0001| SENATE BILL 571
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0002| 43rd legislature - STATE OF NEW MEXICO - first session, 1997
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0003| INTRODUCED BY
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0004| CARROLL H. LEAVELL
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0005|
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0006|
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0007|
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0008|
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0009|
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0010| AN ACT
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0011| RELATING TO INSURANCE; PERMITTING PERSONS WITH A DISABILITY TO
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0012| ACQUIRE MEDICARE SUPPLEMENT HEALTH INSURANCE UNDER CERTAIN
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0013| CIRCUMSTANCES.
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0014|
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0015| BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF NEW MEXICO:
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0016| Section 1. Section 59A-54-3 NMSA 1978 (being Laws 1987,
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0017| Chapter 154, Section 3, as amended) is amended to read:
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0018| "59A-54-3. DEFINITIONS.--As used in the Comprehensive
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0019| Health Insurance Pool Act:
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0020| A. "board" means the board of directors of the
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0021| pool;
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0022| B. "health care facility" means any entity
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0023| providing health care services that is licensed by the
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0024| department of health;
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0025| C. "health care services" means any services or
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0001| products included in the furnishing to any individual of
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0002| medical care or hospitalization or incidental to the furnishing
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0003| of such care or hospitalization, as well as the furnishing to
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0004| any person of any other services or products for the purpose of
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0005| preventing, alleviating, curing or healing human illness or
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0006| injury;
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0007| D. "health insurance" means any hospital and
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0008| medical expense-incurred policy, nonprofit health care service
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0009| plan contract, health maintenance organization subscriber
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0010| contract, short-term, accident, fixed indemnity, specified
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0011| disease policy or disability income contracts and limited
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0012| benefit or credit insurance, or as defined by Section 59A-7-3
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0013| NMSA 1978. The term does not include insurance arising out of
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0014| the Workers' Compensation Act or similar law, automobile
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0015| medical payment insurance or insurance under which benefits are
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0016| payable with or without regard to fault and which is required
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0017| by law to be contained in any liability insurance policy;
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0018| E. "health maintenance organization" means any
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0019| person who provides, at a minimum, either directly or through
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0020| contractual or other arrangements with others, basic health
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0021| care services to enrollees on a fixed prepayment basis and who
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0022| is responsible for the availability, accessibility and quality
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0023| of the health care services provided or arranged, or as defined
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0024| by Subsection F of Section 59A-46-2 NMSA 1978;
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0025| F. "health plan" means any arrangement by which
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0001| persons, including dependents or spouses, covered or making
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0002| application to be covered under the pool have access to
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0003| hospital and medical benefits or reimbursement, including group
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0004| or individual insurance or subscriber contract; coverage
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0005| through health maintenance organizations, preferred provider
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0006| organizations or other alternate delivery systems; coverage
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0007| under prepayment, group practice or individual practice plans;
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0008| coverage under uninsured arrangements of group or group-type
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0009| contracts, including employer self-insured, cost-plus or other
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0010| benefits methodologies not involving insurance or not subject
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0011| to New Mexico premium taxes; coverage under group-type
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0012| contracts which are not available to the general public and can
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0013| be obtained only because of connection with a particular
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0014| organization or group; and coverage by medicare or other
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0015| governmental benefits. The term includes coverage through
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0016| health insurance;
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0017| G. "insured" means an individual resident of this
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0018| state who is eligible to receive benefits from any insurer or
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0019| other health plan;
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0020| H. "insurer" means an insurance company authorized
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0021| to transact health insurance business in this state, a
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0022| nonprofit health care plan, a health maintenance organization
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0023| and self insurers not subject to federal preemption. "Insurer"
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0024| does not include an insurance company that is licensed under
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0025| the Prepaid Dental Plan Law or a company that is solely engaged
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0001| in the sale of dental insurance and is licensed not under that
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0002| act, but under another provision of the Insurance Code;
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0003| I. "medicare" means coverage under both [Part]
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0004| Parts A and B of Title XVIII of the Social Security Act, [42
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0005| USC 1395 et seq.] as amended;
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0006| J. "medicare supplement" means coverage that
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0007| offers health insurance benefits, pursuant to Chapter 59A,
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0008| Article 24 NMSA 1978, for that portion of health care services
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0009| not covered by Parts A and B of Title XVIII of the Social
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0010| Security Act, as amended;
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0011| [J.] K. "pool" means the New Mexico
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0012| comprehensive health insurance pool;
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0013| [K.] L. "superintendent" means the
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0014| superintendent of insurance; and
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0015| [L.] M. "therapist" means a licensed physical,
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0016| occupational, speech or respiratory therapist."
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0017| Section 2. Section 59A-54-12 NMSA 1978 (being Laws 1987,
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0018| Chapter 154, Section 12, as amended) is amended to read:
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0019| "59A-54-12. ELIGIBILITY--POLICY PROVISIONS.--
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0020| A. A person is eligible for a pool policy only if
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0021| on the effective date of coverage or renewal of coverage the
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0022| person is a New Mexico resident, and:
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0023| (1) is not eligible as an insured or covered
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0024| dependent for any health plan, except as provided in
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0025| Subsection G of this section, that provides coverage for
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0001| comprehensive major medical or comprehensive physician and
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0002| hospital services;
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0003| (2) is only eligible for a health plan that is
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0004| offered at a rate higher than that available from the pool;
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0005| (3) has been rejected for coverage for
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0006| comprehensive major medical or comprehensive physician and
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0007| hospital services; or
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0008| (4) is only eligible for a health plan with a
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0009| rider, waiver or restrictive provision for that particular
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0010| individual based on a specific condition.
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0011| B. Coverage under a pool policy is in excess of and
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0012| shall not duplicate coverage under any other form of health
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0013| insurance.
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0014| C. A pool policy shall provide that coverage of a
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0015| dependent unmarried person terminates when the person becomes
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0016| nineteen years of age or, if the person is enrolled full time
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0017| in an accredited educational institution, when he becomes
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0018| twenty-five years of age. The policy shall also provide in
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0019| substance that attainment of the limiting age does not operate
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0020| to terminate coverage when the person is and continues to be:
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0021| (1) incapable of self-sustaining employment by
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0022| reason of mental retardation or physical handicap; and
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0023| (2) primarily dependent for support and
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0024| maintenance upon the person in whose name the contract is
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0025| issued.
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0001| Proof of incapacity and dependency shall be furnished to
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0002| the insurer within one hundred twenty days of attainment of the
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0003| limiting age and subsequently as required by the insurer but
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0004| not more frequently than annually after the two-year period
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0005| following attainment of the limiting age.
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0006| D. A pool policy that provides coverage for a
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0007| family member of the person in whose name the contract is
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0008| issued shall, as to the coverage of the family member or the
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0009| individual in whose name the contract was issued, provide that
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0010| the health insurance benefits applicable for children are
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0011| payable with respect to a newly born child of the family member
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0012| or the person in whose name the contract is issued from the
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0013| moment of coverage of injury or illness, including the
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0014| necessary care and treatment of medically diagnosed congenital
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0015| defects and birth abnormalities. If payment of a specific
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0016| premium is required to provide coverage for the child, the
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0017| contract may require that notification of the birth of a child
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0018| and payment of the required premium shall be furnished to the
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0019| carrier within thirty-one days after the date of birth in order
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0020| to have the coverage continued beyond the thirty-one day
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0021| period.
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0022| E. A pool policy may contain provisions under which
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0023| coverage is excluded during a six-month period following the
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0024| effective date of coverage as to a given individual for
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0025| preexisting conditions, as long as either of the following
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0001| exists:
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0002| (1) the condition has manifested itself within
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0003| a period of six months before the effective date of coverage in
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0004| such a manner as would cause an ordinarily prudent person to
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0005| seek diagnoses or treatment; or
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0006| (2) medical advice or treatment was
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0007| recommended or received within a period of six months before
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0008| the effective date of coverage.
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0009| F. The preexisting condition exclusions described
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0010| in Subsection E of this section shall be waived to the extent
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0011| to which similar exclusions have been satisfied under any prior
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0012| health insurance coverage which was involuntarily terminated,
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0013| if the application for pool coverage is made not later than
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0014| thirty-one days following the involuntary termination. In that
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0015| case, coverage in the pool shall be effective from the date on
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0016| which the prior coverage was terminated. This subsection does
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0017| not prohibit preexisting conditions coverage in a pool policy
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0018| that is more favorable to the insured than that specified in
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0019| this subsection.
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0020| G. A person under the age of sixty-five who meets
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0021| the criteria established in Subsection A of this section and
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0022| who is eligible for and receiving medicare because of a
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0023| disability is eligible for a medicare supplement pool policy.
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0024| [G.] H. Except as provided in Subsection G of
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0025| this section, an individual is not eligible for coverage by
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0001| the pool if:
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0002| (1) he is, at the time of application,
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0003| eligible for medicare or medicaid which would provide coverage
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0004| for amounts in excess of limited policies such as dread
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0005| disease, cancer policies or hospital indemnity policies;
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0006| (2) he has terminated coverage by the pool
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0007| within the past twelve months; or
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0008| (3) he is an inmate of a public institution or
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0009| is eligible for public programs for which medical care is
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0010| provided.
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0011| [H.] I. Any person whose health insurance
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0012| coverage from a qualified state health policy with similar
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0013| coverage is terminated because of nonresidency in another state
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0014| may apply for coverage under the pool. If the coverage is
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0015| applied for within thirty-one days after that termination and
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0016| if premiums are paid for the entire coverage period, the
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0017| effective date of the coverage shall be the date of termination
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0018| of the previous coverage."
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0019| Section 3. Section 59A-54-13 NMSA 1978 (being Laws 1987,
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0020| Chapter 154, Section 13, as amended) is amended to read:
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0021| "59A-54-13. BENEFITS.--
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0022| A. The health insurance policy issued by the pool
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0023| shall pay for medically necessary eligible health care services
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0024| rendered or furnished for the diagnoses or treatment of illness
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0025| or injury that [exceeds] exceed the deductible and
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0001| coinsurance amounts applicable under Section 59A-54-14 NMSA
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0002| 1978 and are not otherwise limited or excluded. Eligible
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0003| expenses are the charges for the health care services and items
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0004| for which benefits are extended under the pool policy. The
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0005| coverage to be issued by the pool and its schedule of
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0006| benefits, exclusions and other limitations shall be established
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0007| by the board and shall, at a minimum, reflect the levels of
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0008| health insurance coverage generally available in New Mexico for
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0009| small group policies. The superintendent shall approve the
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0010| benefit package developed by the board to ensure its compliance
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0011| with the Comprehensive Health Insurance Pool Act. The benefit
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0012| package shall include therapy services and hearing aids.
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0013| B. The pool shall make available medicare
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0014| supplement coverage for individuals under the age of sixty-five
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0015| who meet the criteria established in Subsection A of Section
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0016| 59A-54-12 NMSA 1978 and who are eligible for and receive
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0017| medicare because of a disability.
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0018| [B.] C. The Comprehensive Health Insurance Pool
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0019| Act shall not be construed to prohibit the pool from issuing
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0020| additional types of health insurance policies with different
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0021| types of benefits which in the opinion of the board may be of
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0022| benefit to the citizens of New Mexico.
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0023| [C.] D. The board may design and employ cost
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0024| containment measures and requirements, including preadmission
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0025| certification and concurrent inpatient review, for the purpose
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0001| of making the pool more cost effective."
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0002| Section 4. Section 59A-54-14 NMSA 1978 (being Laws 1987,
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0003| Chapter 154, Section 14, as amended) is amended to read:
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0004| "59A-54-14. DEDUCTIBLES--COINSURANCE--MAXIMUM OUT-OF-
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0005| POCKET PAYMENTS.--
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0006| A. Except for medicare supplement coverage
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0007| authorized by Subsection B of Section 59A-54-13 NMSA 1978, and
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0008| subject to the limitation provided in Subsection C of this
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0009| section, a pool policy offered in accordance with the
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0010| Comprehensive Health Insurance Pool Act shall impose a
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0011| deductible on a per-person calendar-year basis. Deductible
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0012| plans of five hundred dollars ($500) and one thousand dollars
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0013| ($1,000) shall initially be offered. The board may authorize
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0014| deductibles in other amounts. The deductible shall be applied
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0015| to the first five hundred dollars ($500) or one thousand
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0016| dollars ($1,000) of eligible expenses incurred by the covered
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0017| person.
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0018| B. Except for medicare supplement coverage
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0019| authorized by Subsection B of Section 59A-54-13 NMSA 1978, and
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0020| subject to the limitations provided in Subsection C of this
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0021| section, a mandatory coinsurance requirement shall be imposed
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0022| at the rate of twenty percent of eligible expenses in excess of
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0023| the mandatory deductible.
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0024| C. The maximum aggregate out-of-pocket payments for
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0025| eligible expenses by the insured shall be determined by the
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0001| board."
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0002|
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0003|
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0004| FORTY-THIRD LEGISLATURE
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0005| FIRST SESSION, 1997
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0006|
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0007|
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0008|
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0009| February 28, 1997
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0010|
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0011| Mr. President:
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0012|
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0013| Your PUBLIC AFFAIRS COMMITTEE, to whom has been
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0014| referred
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0015|
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0016| SENATE BILL 571
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0017|
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0018| has had it under consideration and reports same with
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0019| recommendation that it DO PASS, and thence referred to the
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0020| CORPORATIONS & TRANSPORTATION COMMITTEE.
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0021|
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0022| Respectfully submitted,
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0023|
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0024|
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0025|
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0001|
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0002| __________________________________
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0003| Shannon Robinson, Chairman
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0004|
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0005|
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0006|
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0007| Adopted_______________________ Not
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0008| Adopted_______________________
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0009| (Chief Clerk) (Chief Clerk)
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0010|
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0011|
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0012| Date ________________________
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0013|
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0014|
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0015| The roll call vote was 5 For 0 Against
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0016| Yes: 5
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0017| No: 0
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0018| Excused: Boitano, Garcia, Ingle, Smith
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0019| Absent: None
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0020|
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0021|
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0022| S0571PA1
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0023|
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0024|
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0025|
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0001| FORTY-THIRD LEGISLATURE
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0002| FIRST SESSION, 1997
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0003|
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0004|
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0005| March 4, 1997
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0006|
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0007| Mr. President:
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0008|
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0009| Your CORPORATIONS & TRANSPORTATION COMMITTEE, to
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0010| whom has been referred
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0011|
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0012| SENATE BILL 571
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0013|
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0014| has had it under consideration and reports same with
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0015| recommendation that it DO PASS.
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0016|
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0017| Respectfully submitted,
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0018|
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0019|
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0020|
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0021|
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0022| __________________________________
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0023| Roman M. Maes, III, Chairman
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0024|
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0025|
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0001|
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0002| Adopted_______________________ Not
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0003| Adopted_______________________
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0004| (Chief Clerk) (Chief Clerk)
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0005|
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0006|
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0007|
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0008| Date ________________________
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0009|
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0010|
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0011| The roll call vote was 8 For 0 Against
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0012| Yes: 8
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0013| No: 0
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0014| Excused: Fidel, Robinson
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0015| Absent: None
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0016|
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0017|
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0018| S0571CT1
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0019| State of New Mexico
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0020| House of Representatives
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0021|
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0022| FORTY-THIRD LEGISLATURE
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0023| FIRST SESSION, 1997
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0024|
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0025|
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0001| March 22, 1997
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0002|
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0003|
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0004| Mr. Speaker:
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0005|
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0006| Your BUSINESS AND INDUSTRY COMMITTEE, to whom has
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0007| been referred
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0008|
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0009| SENATE BILL 571
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0010|
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0011| has had it under consideration and reports same with
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0012| recommendation that it DO PASS.
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0013|
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0014| Respectfully submitted,
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0015|
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0016|
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0017|
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0018|
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0019| Fred Luna, Chairman
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0020|
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0021|
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0022| Adopted Not Adopted
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0023|
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0024| (Chief Clerk) (Chief Clerk)
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0025|
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0001| Date
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0002|
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0003| The roll call vote was 7 For 1 Against
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0004| Yes: 7
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0005| No: Lutz
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0006| Excused: Alwin, Chavez, Getty, Gubbels, Varela
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0007| Absent: None
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0008|
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0009|
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0010| G:\BILLTEXT\BILLW_97\S0571
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