0001| SENATE BILL 770 | 0002| 42ND LEGISLATURE - STATE OF NEW MEXICO - SECOND SESSION, | 0003| 1996 | 0004| INTRODUCED BY | 0005| TIMOTHY Z. JENNINGS | 0006| | 0007| | 0008| | 0009| | 0010| | 0011| AN ACT | 0012| RELATING TO HEALTH INSURANCE; AMENDING A SECTION OF THE | 0013| COMPREHENSIVE HEALTH INSURANCE POOL ACT TO CLARIFY ELIGIBILITY | 0014| PROVISIONS. | 0015| | 0016| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO: | 0017| Section 1. Section 59A-54-12 NMSA 1978 (being Laws 1987, | 0018| Chapter 154, Section 12, as amended) is amended to read: | 0019| "59A-54-12. ELIGIBILITY--POLICY PROVISIONS.-- | 0020| A. Except as provided in Subsection B of this | 0021| section, a person is eligible for a pool policy only if on the | 0022| effective date of coverage or renewal of coverage the person is | 0023| a New Mexico resident, and: | 0024| (1) is not eligible as an insured or covered | 0025| dependent for any health plan that provides coverage for | 0001| comprehensive major medical or comprehensive physician and | 0002| hospital services; | 0003| (2) is only eligible for a health plan that is | 0004| offered at a rate higher than that available from the pool; | 0005| (3) has been rejected for coverage for | 0006| comprehensive major medical or comprehensive physician and | 0007| hospital services; or | 0008| (4) is only eligible for a health plan with a | 0009| rider, waiver or restrictive provision for that particular | 0010| individual based on a specific condition. | 0011| B. A person's eligibility for a policy issued under | 0012| the Health Insurance Alliance Act shall not preclude a person | 0013| from remaining on a pool policy; provided, a self-employed | 0014| person who qualifies for an approved health plan under the | 0015| Health Insurance Alliance Act by using a dependent as the second | 0016| employee may choose a pool policy in lieu of the health plan | 0017| under that act. | 0018| [B.] C. Coverage under a pool policy is in | 0019| excess of and shall not duplicate coverage under any other form | 0020| of health insurance. | 0021| [C.] D. A pool policy shall provide that | 0022| coverage of a dependent unmarried person terminates when the | 0023| person becomes nineteen years of age or, if the person is | 0024| enrolled full time in an accredited educational institution, | 0025| when he becomes twenty-five years of age. The policy shall also | 0001| provide in substance that attainment of the limiting age does | 0002| not operate to terminate coverage when the person is and | 0003| continues to be: | 0004| (1) incapable of self-sustaining employment by | 0005| reason of mental retardation or physical handicap; and | 0006| (2) primarily dependent for support and | 0007| maintenance upon the person in whose name the contract is | 0008| issued. | 0009| Proof of incapacity and dependency shall be furnished to | 0010| the insurer within one hundred twenty days of attainment of the | 0011| limiting age and subsequently as required by the insurer but not | 0012| more frequently than annually after the two-year period | 0013| following attainment of the limiting age. | 0014| [D.] E. A pool policy that provides coverage for | 0015| a family member of the person in whose name the contract is | 0016| issued shall, as to the coverage of the family member or the | 0017| individual in whose name the contract was issued, provide that | 0018| the health insurance benefits applicable for children are | 0019| payable with respect to a newly born child of the family member | 0020| or the person in whose name the contract is issued from the | 0021| moment of coverage of injury or illness, including the necessary | 0022| care and treatment of medically diagnosed congenital defects and | 0023| birth abnormalities. If payment of a specific premium is | 0024| required to provide coverage for the child, the contract may | 0025| require that notification of the birth of a child and payment of | 0001| the required premium shall be furnished to the carrier within | 0002| thirty-one days after the date of birth in order to have the | 0003| coverage continued beyond the thirty-one day period. | 0004| [E.] F. A pool policy may contain provisions | 0005| under which coverage is excluded during a six-month period | 0006| following the effective date of coverage as to a given | 0007| individual for pre-existing conditions, as long as either of the | 0008| following exists: | 0009| (1) the condition has manifested itself within | 0010| a period of six months before the effective date of coverage in | 0011| such a manner as would cause an ordinarily prudent person to | 0012| seek diagnoses or treatment; or | 0013| (2) medical advice or treatment was recommended | 0014| or received within a period of six months before the effective | 0015| date of coverage. | 0016| [F.] G. The pre-existing condition exclusions | 0017| described in Subsection [E] F of this section shall be | 0018| waived to the extent to which similar exclusions have been | 0019| satisfied under any prior health insurance coverage [which] | 0020| that was involuntarily terminated, if the application for pool | 0021| coverage is made not later than thirty-one days following the | 0022| involuntary termination. In that case, coverage in the pool | 0023| shall be effective from the date on which the prior coverage was | 0024| terminated. This subsection does not prohibit pre-existing | 0025| conditions coverage in a pool policy that is more favorable to | 0001| the insured than that specified in this subsection. | 0002| [G.] H. An individual is not eligible for | 0003| coverage by the pool if: | 0004| (1) he is, at the time of application, eligible | 0005| for medicare or medicaid [which] that would provide coverage | 0006| for amounts in excess of limited policies such as dread disease, | 0007| cancer policies or hospital indemnity policies; | 0008| (2) he has terminated coverage by the pool | 0009| within the past twelve months; or | 0010| (3) he is an inmate of a public institution or | 0011| is eligible for public programs for which medical care is | 0012| provided. | 0013| [H.] I. Any person whose health insurance | 0014| coverage from a qualified state health policy with similar | 0015| coverage is terminated because of nonresidency in another state | 0016| may apply for coverage under the pool. If the coverage is | 0017| applied for within thirty-one days after that termination and if | 0018| premiums are paid for the entire coverage period, the effective | 0019| date of the coverage shall be the date of termination of the | 0020| previous coverage." | 0021|  |