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AN ACT

RELATING TO HEALTH INSURANCE; EXPANDING THE HEALTH INSURANCE

ALLIANCE COVERAGE TO EMPLOYERS WHOSE EMPLOYEES PARTICIPATE IN

PUBLICLY OFFERED PROGRAMS BASED ON EMPLOYEES' INCOME.

BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:

Section 1. Section 59A-56-14 NMSA 1978 (being Laws

1994, Chapter 75, Section 14, as amended) is amended to read:

"59A-56-14. ELIGIBILITY--GUARANTEED ISSUE--PLAN

PROVISIONS.--

A. A small employer is eligible for an approved

health plan if on the effective date of coverage or renewal:

(1) at least fifty percent of its employees

not otherwise insured elect to be covered under the approved

health plan;

(2) the small employer has not terminated

coverage with an approved health plan within three years of

the date of application for coverage except to change to

another approved health plan; and

(3) the small employer does not offer other

general group health insurance coverage to its employees. For

the purposes of this paragraph, general group health insurance

coverage excludes coverage that:

(a) is offered by a state or federal

agency to a small employer's employee whose eligibility for

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alternative coverage is based on the employee's income; or

(b) provides only a specific limited

form of health insurance such as accident or disability income

insurance coverage or a specific health care service such as

dental care.

B. An individual is eligible for an approved

health plan if on the effective date of coverage or renewal

the individual meets the definition of an eligible individual

under Section 59A-56-3 NMSA 1978.

C. An approved health plan shall provide in

substance that attainment of the limiting age by an unmarried

dependent individual does not operate to terminate coverage

when the individual continues to be incapable of self-

sustaining employment by reason of developmental disability or

physical handicap and the individual is primarily dependent

for support and maintenance upon the employee. Proof of

incapacity and dependency shall be furnished to the alliance

and the member that offered the approved health plan within

one hundred twenty days of attainment of the limiting age.

The board may require subsequent proof annually after a two-

year period following attainment of the limiting age.

D. An approved health plan shall provide that the

health insurance benefits applicable for eligible dependents

are payable with respect to a newly born child of the family

member or the individual in whose name the contract is issued

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from the moment of birth, including the necessary care and

treatment of medically diagnosed congenital defects and birth

abnormalities. If payment of a specific premium is required

to provide coverage for the child, the contract may require

that notification of the birth of a child and payment of the

required premium shall be furnished to the member within

thirty-one days after the date of birth in order to have the

coverage from birth. An approved health plan shall provide

that the health insurance benefits applicable for eligible

dependents are payable for an adopted child in accordance with

the provisions of Section 59A-22-34.1 NMSA 1978.

E. Except as provided in Subsections G, H and I of

this section, an approved health plan offered to a small

employer may contain a preexisting condition exclusion only

if:

(1) the exclusion relates to a condition,

physical or mental, regardless of the cause of the condition,

for which medical advice, diagnosis, care or treatment was

recommended or received within the six-month period ending on

the enrollment date;

(2) the exclusion extends for a period of

not more than six months after the enrollment date; and

(3) the period of the exclusion is reduced

by the aggregate of the periods of creditable coverage

applicable to the participant or beneficiary as of the

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enrollment date.

F. As used in this section, "preexisting condition

exclusion" means a limitation or exclusion of benefits

relating to a condition based on the fact that the condition

was present before the date of enrollment for coverage for the

benefits whether or not any medical advice, diagnosis, care or

treatment was recommended or received before that date, but

genetic information is not included as a preexisting condition

for the purposes of limiting or excluding benefits in the

absence of a diagnosis of the condition related to the genetic

information.

G. An insurer shall not impose a preexisting

condition exclusion:

(1) in the case of an individual who, as of

the last day of the thirty-day period beginning with the date

of birth, is covered under creditable coverage;

(2) that excludes a child who is adopted or

placed for adoption before the child's eighteenth birthday and

who, as of the last day of the thirty-day period beginning on

and following the date of the adoption or placement for

adoption, is covered under creditable coverage; or

(3) that relates to or includes pregnancy as

a preexisting condition.

H. The provisions of Paragraphs (1) and (2) of

Subsection G of this section do not apply to any individual

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after the end of the first continuous sixty-three-day period

during which the individual was not covered under any

creditable coverage.

I. The preexisting condition exclusions described

in Subsection E of this section shall be waived to the extent

to which similar exclusions have been satisfied under any

prior health insurance coverage if the effective date of

coverage for health insurance through the alliance is made not

later than sixty-three days following the termination of the

prior coverage. In that case, coverage through the alliance

shall be effective from the date on which the prior coverage

was terminated. This subsection does not prohibit preexisting

conditions coverage in an approved health plan that is more

favorable to the covered individual than that specified in

this subsection.

J. An approved health plan issued to an eligible

individual shall not contain any preexisting condition

exclusion.

K. An individual is not eligible for coverage by

the alliance under an approved health plan issued to a small

employer if the individual:

(1) is eligible for medicare; provided,

however, if an individual has health insurance coverage from

an employer whose group includes twenty or more individuals,

an individual eligible for medicare who continues to be

employed may choose to be covered through an approved health

plan;

(2) has voluntarily terminated health

insurance issued through the alliance within the past twelve

months unless it was due to a change in employment; or

(3) is an inmate of a public institution.

L. The alliance shall provide for an open

enrollment period of sixty days from the initial offering of

an approved health plan. Individuals enrolled during the open

enrollment period shall not be subject to the preexisting

conditions limitation.

M. If an insured covered by an approved health

plan switches to another approved health plan that provides

increased or additional benefits such as lower deductible or

co-payment requirements, the member offering the approved

health plan with increased or additional benefits may require

the six-month period for preexisting conditions provided in

Subsection E of this section to be satisfied prior to receipt

of the additional benefits." HB 24

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