Health Insurance Benefit Coverage Law Summaries

Health Insurance Benefit Coverage Law Summaries

New Mexico, Health Insurance Benefit Coverage Law Summaries

New Mexico's mandated health benefits law is codified in the New Mexico Statutes Annotated at Chapter 59A, Articles 22, 23, 23C, 46 and 56.

DEFINITIONS

“Mental health benefits” means mental health benefits as described in the group health plan, or group health insurance offered in connection with the plan, but does not include benefits with respect to treatment of substance abuse, chemical dependency or gambling addiction (Sec. 59A-23E-18(F), as added by Ch. 6 (H. 452), L. 2000).

A “small employer” is any person, firm, corporation, partnership, or association actively engaged in business that, on at least 50 percent of its working days during either of the two preceding years, employed no less than two and no more than 50 eligible employees, provided that (Sec. 59A-23C-3, as amended by Ch. 243 (H. 832), L. 1997, effective April 11, 1997):

1. in determining the number of eligible employees, the spouse or dependent of an employee may, at the employer's discretion, be counted as a separate employee;

2. companies that are affiliated companies or that are eligible to file a combined tax return for purposes of state income taxation will be considered one employer; and

3. in the case of an employer that was not in existence throughout a preceding calendar year, the determination of whether the employer is a small or large employer will be based on the average number of employees that it is reasonably expected to employ on working days in the current calendar year.

Concerning small employers, “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 (Sec. 59A-23C-7.1, as amended by Ch. 243 (H. 832), L. 1997, effective April 11, 1997).

"Autism spectrum disorder" means a condition that meets the diagnostic criteria for the pervasive developmental disorders published in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) including autistic disorder, Asperger's disorder, pervasive development disorder not otherwise specified, Rett's disorder and childhood disintegrative disorder (Ch. 74 (S. 39), L. 2009, effective June 19, 2009).

WHAT THE EMPLOYER MUST DO

New Mexico does not require employers to provide health insurance for their employees. However, if an employer does provide insurance, it must be aware of specific coverage required to be included in health insurance policies and contracts. This coverage is summarized below.

Mental health coverage.- A group health plan for a plan year of an employer beginning or renewed on or after October 1, 2000, or group health insurance offered in connection with that plan, must provide both medical and surgical benefits and mental health benefits. The plan may not impose treatment limitations or financial requirements on the provision of mental health benefits if identical limitations or requirements are not imposed on coverage of benefits for other conditions (Sec. 59A-23E-18(A), as added by Ch. 6 (H. 452), L. 2000).

A group health plan for a plan year of an employer beginning on or after October 1, 2000, or group health insurance offered in connection with that plan, may (Sec. 59A-23E-18(B), as added by Ch. 6 (H. 452), L. 2000):

1. require pre-admission screening prior to the authorization of mental health benefits whether inpatient or outpatient; or

2. apply limitations that restrict mental health benefits provided under the plan to those that are medically necessary.

A group health plan for a plan year of an employer beginning or renewed on or after January 1, 2000, or group health insurance offered in connection with that plan, may not be changed through amendment or on renewal to exclude or decrease the mental health benefits existing as of that date (Sec. 59A-23E-18(C), as added by Ch. 6 (H. 452), L. 2000).

An employer, having at least two but not more than 49 employees, that is required by Sec. 59A-23E-18(A) above to provide mental health benefits coverage in a group health plan, or group health insurance offered in connection with that plan on renewal of an existing plan, may, if a premium increase of more than one and one-half percent in the plan year results from the change in coverage (Sec. 59A-23E-18(D), as added by Ch. 6 (H. 452), L. 2000):

1. pay the premium increase;

2. reach agreement with the employees to cost-share that amount of the premium above one and one-half percent;

3. negotiate a reduction in coverage, but not below the coverage existing before the renewal, to reduce the premium increase to no more than one and one-half percent; or

4. after demonstrating to the satisfaction of the insurance division that the amount of the premium increase above one and one-half percent is due exclusively to the additional coverage required by Sec. 59A-23E-18(A) above, receive written permission from the division to not increase coverage.

An employer, having at least 50 employees, that is required by Sec. 59A-23E-18(A) above to provide mental health benefits coverage in a group health plan, or group health insurance offered in connection with that plan on renewal of an existing plan, may, if a premium increase of more than two and one-half percent in the plan year results from the change in coverage (Sec. 59A-23E-18(E), as added by Ch. 6 (H. 452), L. 2000):

1. pay the premium increase;

2. reach agreement with the employees to cost-share that amount of the premium above two and one-half percent;

3. negotiate a reduction in coverage, but not below the coverage existing before applying parity requirements, to reduce the premium increase to no more than two and one-half percent; or

4. after demonstrating to the satisfaction of the insurance division that the amount of the premium increase above two and one-half percent is due exclusively to the additional coverage provided because of the requirements of Sec. 59A-23E-18(A) above, receive written permission from the division to not increase coverage.

Dependent care coverage.- All group health insurance policies delivered or issued for delivery in New Mexico and that provide coverage on an expense-incurred basis for a family member of the insured must, as to such family members' coverage, also provide that the health insurance benefits applicable for children are payable with respect to a newly born child of the insured from the moment of birth (Sec. 59A-22-34).

All group health insurance policies delivered or issued for delivery in New Mexico that do not provide coverage for a family member of the insured must provide for an option to add to the coverage any newly born child of the insured (Sec. 59A-22-34).

The coverage for newly born children must consist of coverage of injury or sickness, including the necessary care and treatment of medically diagnosed congenital defects and birth abnormalities and, where necessary to protect the life of the infant, transportation, including air transport, to the nearest available tertiary care facility for newly born infants (Sec. 59A-22-34).

Immunizations.- Each group health insurance policy, health care plan and certificate of health insurance delivered or issued for delivery in New Mexico must provide coverage for childhood immunizations, as well as coverage for medically necessary booster doses of all immunizing agents used in child immunizations, in accordance with the current schedule of immunizations recommended by the American Academy of Pediatrics (Sec. 59A-22-34.3, as added by H. 979, L. 1997, effective June 20, 1997).

Group health maintenance contracts must also provide coverage for immunizations (Sec. 59A-46-38.2, as added by H. 979, L. 1997, effective June 20, 1997).

Human papillomavirus (HPV) vaccine.- Group insurers and HMOs will be required to provide coverage for the HPV vaccine to females nine to 14 years of age (Secs. 59A-22-40.1 and 59A-46-42.1, as added by Ch. 278 (S. 407), L. 2007).

Disabilities.- A group hospital or medical expense insurance policy delivered or issued for delivery in New Jersey which provides that coverage of a dependent child of an insured, or of an employee or other member of the covered group, terminates upon attainment of the limiting age for dependent children specified in the policy must also provide, in substance, that attainment of the limiting age will not operate to terminate the coverage of a child while the child is, and continues to be both incapable of self-sustaining employment, by reason of mental retardation or physical disability, and chiefly dependent upon the policyholder for support and maintenance (Sec. 59A-22-33).

Adoption.- No group health insurance policy or contract or health care plan may be offered, issued or renewed in New Mexico unless the policy, plan or contract covers adopted children of the insured, subscriber or enrollee on the same basis as other dependents. Coverage is effective from the date of placement for the purpose of adoption and continues unless the placement is disrupted prior to legal adoption and the child is removed from placement. Coverage must include the necessary care and treatment of medical conditions existing prior to the date of placement (Sec. 59A-22-34.1).

Marital status of parents.- An insurer must not deny enrollment of a child under the health plan of the child's parent on the grounds that the child (Secs. 59A-22-34.2 and 59A-23-7.2):

1. was born out of wedlock;

2. is not claimed as a dependent on the parent's federal tax return; or

3. does not reside with the parent or in the insurer's service area.

Circumcisions.- Group insurers and HMOs must provide coverage for circumcision for newborn males (Ch. 122 (S. 502), L. 2004).

Maximum age of dependent.- A group health insurance policy or certificate of insurance delivered, issued for delivery or renewed in New Mexico that provides coverage for an insured's dependent shall not terminate coverage of an unmarried dependent by reason of the dependent's age before the dependent's 25th birthday, regardless of whether the dependent is enrolled in an educational institution. HMOs must also provide this coverage (Sec. 1, Ch. 41 (H. 335), L. 2005; Sec. 59A-46-38.3, as amended by Ch. 41 (H. 335), L. 2005).

Hearing aids.- Effective July 1, 2007, group insurers and HMOs must provide coverage for a hearing aid and any related service for the full cost of one hearing aid per hearing-impaired ear up to $2,200 every 36 months for hearing aids for insured children under 18 years of age or under 21 years of age if still attending high school. The insured may choose a higher priced hearing aid and may pay the difference in cost above the $2,200 limit without financial or contractual penalty to the insured or to the provider of the hearing aids (Ch. 356 (S. 529), L. 2007, effective July 1, 2007).

Autism spectrum disorder.- Group health insurers and HMOs must provide coverage to eligible individuals 19 years old or younger (or 22 years old or younger, if in high school) for the diagnosis and treatment of autism spectrum disorder. Coverage must include: (1) well-baby and well-child screening for the presence of the disorder; and (2) treatment through speech therapy, occupational therapy, physical therapy and applied behavioral analysis. Maximum benefit amounts apply-$36,000 annually and $200,000 in total lifetime benefits. Beginning January 1, 2011, these limits will be adjusted annually to account for changes in the medical component of the Consumer Price Index. Autism coverage may not be subject to dollar limits, deductibles or coinsurance that are less favorable than those applicable to physical illnesses covered under the policy or contract. However, coverage may be limited to treatment prescribed by the treating physician in accordance with a treatment plan, and may be subject to general plan exclusions and limitations such as coordination of benefits and participating provider requirements. Services received under laws requiring state and local school boards to provide specialized education to children with autism also may be excluded (Ch. 74 (S. 39), L. 2009, effective June 19, 2009).

Substance abuse coverage.- Each insurer that delivers or issues for delivery in New Mexico a group health insurance policy must offer and make available benefits for the necessary care and treatment of alcohol dependency. Such benefits must (Sec. 59A-23-6):

1. be subject to annual deductibles and coinsurance consistent with those imposed on other benefits within the same policy;

2. provide no less than 30 days necessary care and treatment in an alcohol dependency treatment center and 30 outpatient visits for alcohol dependency treatment; and

3. be offered for benefit periods of no more than one year and may be limited to a lifetime maximum of no less than two benefit periods.

Such offer of benefits is subject to the rights of the group health insurance holder to reject the coverage or to select any alternative level of benefits if that right is offered by or negotiated with that insurer. Coverage for substance abuse treatment need not be provided by blanket, short-term travel, accident-only, limited or specified disease, individual conversion policies or policies designed for issuance to persons eligible for Medicare or any other similar coverage under state or federal governmental plans (Sec. 59A-23-6).

If an organization offering group health benefits to its members makes more than one health insurance policy or nonprofit health care plan available to its members on a member option basis, the organization must not require alcohol dependency coverage from one health insurer or health care plan without requiring the same level of alcohol dependency coverage for all other health insurance policies or health care plans that the organization makes available to its members (Sec. 59A-23-6).

Providers.- Within the area and limits of coverage offered an insured and selected by him or her in the application for insurance, the right of any person to exercise full freedom of choice in the selection of any hospital for hospital care or of any practitioner of the healing arts or optometrist, psychologist, podiatrist, certified nurse midwife, registered lay midwife or registered nurse in expanded practice for treatment of any illness or injury within such person's scope of practice must not be restricted under any new policy of health insurance, contract or health care plan issued in New Mexico (Sec. 59A-22-32).

Nurse practitioners.- All group subscriber contracts delivered or issued for delivery in New Mexico that provide for treatment of persons for the prevention, cure or correction of an illness or physical or mental condition must include coverage for the services of a certified nurse practitioner (Sec. 59A-47-28.3, as added by Ch. 39 (S. 37), L. 1998, effective May 20, 1998).

Social workers.- Within the area and limits of coverage offered an insured and selected by him or her in the application for insurance, the right of any person to exercise full freedom of choice in the selection of any independent social worker for treatment within the social worker's scope of practice must not be restricted under any new policy of health insurance, contract or health care plan issued in New Mexico (Sec. 59A-22-32.1).

Preexisting conditions.- Group health insurance plans may deny health benefit coverage because of preexisting conditions if the condition that would cause a prudent person to seek diagnosis, care, treatment, or medical advice first manifested itself within six months immediately before the effective date of coverage or medical advice or treatment was recommended or received within six months immediately before the effective date of coverage. Coverage will not be excluded due to preexisting conditions for longer than six months after the effective date. If the insured is covered within 31 days of having other qualifying coverage, the new policy will credit the time covered under the previous contract or policy toward an exclusion for preexisting conditions (Sec. 59A-22-5).

A group health plan and a health insurance issuer offering group health insurance coverage may, with respect to a participant or beneficiary, impose a preexisting condition exclusion only if (Sec. 59A-23E-3, as amended by Ch. 41 (S. 176), L. 1998, effective March 6, 1998):

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, or 18 months in the case of a late enrollee, 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 enrollment date.

A group health plan or a health insurer offering group health insurance may not impose a preexisting condition exclusion (Sec. 59A-23E-4, as amended by Ch. 41 (S. 176), L. 1998, effective March 6, 1998):

1. in the case of an individual who, as of the last day of the 30-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 his or her 18th birthday and who, as of the last day of the 30-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.

Small employers.- A health benefit plan that is offered by a carrier to a small employer may include a preexisting condition exclusion only if (Sec. 59A-23C-7.1, as amended by Ch. 243 (H. 832), L. 1997, effective April 11, 1997):

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, or 18 months in the case of a late enrollee, 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 enrollment date.

A carrier must not impose a preexisting condition exclusion (Sec. 59A-23C-7.1, as amended by Ch. 243 (H. 832), L. 1997, effective April 11, 1997):

1. in the case of an individual who, as of the last day of the 30-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 his or her 18th birthday and who, as of the last day of the 30-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.

Items (1) and (2) directly above do not apply to any individual after the end of the first continuous 63-day period during which the individual was not covered under any creditable coverage (Sec. 59A-23C-7.1, as amended by Ch. 243 (H. 832), L. 1997, effective April 11, 1997).

Prescription drugs.-Contraceptives.- Each group health insurance policy, health care plan and certificate of health insurance delivered or issued for delivery in New Mexico, and which offers a prescription drug benefit, must offer coverage for prescription contraceptive drugs or devices approved by the FDA. A religious entity purchasing group insurance coverage may elect to exclude prescription contraceptive drugs or devices from the health coverage purchased (Sec. 59A-22-42, as added by Ch. 14 (H. 59), L. 2001, effective July 1, 2001).

HMOs must also provide this coverage (Sec. 3, Ch. 14 (H. 59), L. 2001, effective July 1, 2001).

Medical diets for genetic inborn errors of metabolism.- Each group health insurance policy, health care plan, certificate of health insurance and managed health care plan delivered, issued for delivery, renewed, extended or modified in New Mexico shall provide coverage for the treatment of genetic inborn errors of metabolism that involve amino acid, carbohydrate and fat metabolism and for which medically standard methods of diagnosis, treatment and monitoring exist (Sec. 1, Ch. 192 (H. 289), L. 2003).

HMOs must also provide this coverage (Sec. 2, Ch. 192 (H. 289), L. 2003).

Mammograms.- Each group health insurance policy, health care plan and certificate of health insurance delivered or issued for delivery in New Mexico must provide coverage for low-dose screening mammograms for determining the presence of breast cancer. Such coverage must make available one baseline mammogram to persons age 35 through 39, one mammogram biennially to persons age 40 through 49 and one mammogram annually to persons age 50 and over. Coverage is available only for screening mammograms obtained on equipment designed specifically to perform low-dose mammography in imaging facilities that have met American College of Radiology accreditation standards for mammography. Coverage for mammograms may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same policy, plan or certificate. Short-term travel, accident-only or limited or specified disease policies need not provide coverage for mammograms (Sec. 59A-22-39).

Mastectomies.- Each group health insurance policy, health care plan and certificate of health insurance delivered or issued for delivery in New Mexico must provide coverage for not less than 48 hours of inpatient care following a mastectomy and not less than 24 hours of inpatient care following a lymph node dissection for the treatment of breast cancer. The attending physician and patient may determine that a shorter period of hospital stay is appropriate (Sec. 59A-22-39.1, as added by Ch. 249 (S. 964), L. 1997, effective June 20, 1997).

Group health maintenance contracts must also provide this coverage for mastectomies and lymph node dissections (Sec. 59A-46-41.1, as added by Ch. 249 (S. 964), L. 1997, effective June 20, 1997).

Maternity benefits.-Medical transport.- All group health insurance policies delivered or issued for delivery in New Mexico that provide maternity coverage on an expense-incurred basis must also provide, where necessary to protect the life of the infant or mother, coverage for transportation, including air transport, for the medically high-risk pregnant woman with an impending delivery of a potentially viable infant to the nearest available tertiary care facility for newly-born infants (Sec. 59A-22-35).

Alpha-fetoprotein IV screenings.- Group insurers and HMOs must provide coverage for an alpha-fetoprotein IV screening test for pregnant women, generally between 16 and 20 weeks of pregnancy, to screen for certain genetic abnormalities in the fetus (Ch. 122 (S. 502), L. 2004).

Smoking cessation treatment.- A group health insurance policy, health care plan or certificate of health insurance that is delivered or issued for delivery in New Mexico and that offers maternity benefits shall offer coverage for smoking cessation treatment (Sec. 59A-22-44, as added by Ch. 337 (S. 743), L. 2003, effective July 1, 2003).

HMOs must also provide this coverage (Sec. 4, Ch. 337 (S. 743), L. 2003, effective July 1, 2003).

Clinical trials.- A health care plan must provide coverage for routine patient care costs incurred as a result of the patient's participation in a phase I, II, III or IV cancer clinical trial if specified conditions are met (Sec. 1, Ch. 27 (S. 240), L. 2001, effective June 15, 2001, and repealed effective July 1, 2009; Ch. 70 (S. 73), L. 2004).

Domestic abuse victims.- A health insurer may not engage in an unfair discriminatory act or practice against a person on the basis of domestic abuse, including (Sec. 4, Ch. 141 (H. 346), L. 1997, effective July 1, 1997):

1. denying, refusing to issue, renew or reissue or canceling or otherwise terminating a policy, restricting or excluding coverage or benefits of a policy or charging a higher premium for a policy on the basis of domestic abuse status;

2. terminating group health coverage for a victim of domestic abuse because coverage was originally issued in the name of an alleged abuser who has divorced, separated from or lost custody of a victim of domestic abuse or because the alleged abuser's coverage has terminated voluntarily or involuntarily.

Diabetes.- Each group health insurance policy, health care plan, certificate of health insurance and managed health care plan delivered or issued for delivery in New Mexico must provide coverage for individuals with insulin-using diabetes, with non-insulin-using diabetes and with elevated blood glucose levels induced by pregnancy. This coverage will entitle each individual to the medically accepted standard of medical care for diabetes and benefits for diabetes treatment as well as diabetes supplies (Sec. 59A-22-41(A), as added by H. 571 and S. 682, L. 1997, effective January 1, 1998).

These requirements will also apply to HMOs (Sec. 59A-46-43(A), as added by H. 571 and S. 682, L. 1997, effective January 1, 1998).

Cervical cancer/human papillomavirus screenings.- Each group health insurance policy, health care plan and certificate of health insurance delivered or issued for delivery in New Mexico must provide coverage for cytologic and human papillomavirus screening for determining the presence of precancerous or cancerous conditions and other health problems. The coverage must make available cytologic screening, as determined by the health care provider in accordance with national medical standards, for women who are 18 years of age or older and for women who are at risk of cancer or at risk of other health conditions that can be identified through cytologic screening. The coverage shall make available human papillomavirus screening once every three years for women aged 30 and older. Coverage for cytologic and human papillomavirus screening may be subject to deductibles and coinsurance consistent with those imposed on other benefits under the same policy, plan or certificate. Such coverage need not be provided by short-term travel, accident-only or limited or specified-disease policies (Sec. 59A-22-40, as amended by Ch. 133 (H. 477), L. 2005). HMOs are also required to provide this coverage (Sec. 59A-46-42, as amended by Ch. 133 (H. 477), L. 2005).

Colorectal cancer screenings.- A group health insurance policy, health care plan and certificate of health insurance that is delivered, issued for delivery or renewed in New Mexico shall provide coverage for colorectal screening for determining the presence of precancerous or cancerous conditions and other health problems (Sec. 1, Ch. 17 (H. 510), L. 2007). These provisions also apply to group HMOs (Sec. 3, Ch. 17 (H. 510), L. 2007).

Dental surgery.- Effective July 1, 2007, group insurers and HMOs must provide coverage for hospitalization and general anesthesia provided in a hospital or ambulatory surgical center for dental surgery for the following (Ch. 218 (S. 776), L. 2007, effective July 1, 2007):

1. insureds exhibiting physical, intellectual or medically compromising conditions for which dental treatment under local anesthesia, with or without additional adjunctive techniques and modalities, cannot be expected to provide a successful result and for which dental treatment under general anesthesia can be expected to produce superior results;

2. insureds for whom local anesthesia is ineffective because of acute infection, anatomic variation or allergy;

3. insured children or adolescents who are extremely uncooperative, fearful, anxious or uncommunicative with dental needs of such magnitude that treatment should not be postponed or deferred and for whom lack of treatment can be expected to result in dental or oral pain or infection, loss of teeth or other increased oral or dental morbidity;

4. insureds with extensive oral-facial or dental trauma for which treatment under local anesthesia would be ineffective or compromised; or

5. other procedures for which hospitalization or general anesthesia in a hospital or ambulatory surgical center is medically necessary.

Home health care benefits.- Each insurer that delivers or issues for delivery in New Mexico an individual or group hospital expense or major medical expense insurance policy must make available to the policyholder the option of home health care coverage that includes benefits for the following services (Sec. 59A-22-36):

1. services provided by a registered nurse or a licensed practical nurse;

2. health services provided by physical, occupational and respiratory therapists and speech pathologists;

3. health services provided by a home health aide; and

4. medical supplies, drugs and medicines and laboratory services, to the extent they would have been covered if provided to the insured on an in-patient basis.

Home health care coverage may be limited to (Sec. 59A-22-36):

1. services provided on the written order of a licensed physician, provided such order is renewed at least every 60 days;

2. services provided, directly or through contractual agreements, by a home health agency licensed in the state in which the home health services are delivered; and

3. services, as set forth in items (1)-(4) above, without which the insured would have to be hospitalized.

Coverage must be provided for at least 100 home visits per insured per year, with each home visit including up to four hours of home health care services (Sec. 59A-22-36).

Small employers.- The New Mexico Health Insurance Alliance Act contains special health insurance provisions for small employers. A small employer is eligible for an “approved health plan” under the law if, on the effective date of coverage or renewal (Sec. 59A-56-14, as amended by Ch. 3 (H. 24), L. 2006, enacted February 24, 2006):

1. at least 50 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 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.

Dependent care coverage.- An approved health plan must 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 (Sec. 59A-56-14, as amended by Ch. 3 (H. 24), L. 2006, enacted February 24, 2006).

An approved health plan must also 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 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 must be furnished to the member within 31 days after the date of birth in order to have the coverage from birth. The health insurance benefits applicable for eligible dependents are likewise payable for an adopted child (Sec. 59A-56-14, as amended by Ch. 3 (H. 24), L. 2006, enacted February 24, 2006).

Exceptions.- An individual is not eligible for coverage under the special small employer provisions if he or she (Sec. 59A-56-14, as amended by Ch. 3 (H. 24), L. 2006, enacted February 24, 2006):

1. is eligible for Medicare; provided, however, if an individual has health insurance coverage from an employer whose group includes 20 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 New Mexico Health Insurance Alliance within the past 12 months unless it was due to a change in employment; or

3. is an inmate of a public institution.

Part-time employees.- An insurer that provides group health insurance pursuant to Ch. 59A, Art. 22 or 23, shall make available, upon an employer's request prior to issuance, delivery or renewal, coverage for regular part-time employees who work or are expected to work an average of at least 20 hours per week over a six-month period. Nothing in this section shall be construed to require an employer to offer or provide coverage for regular part-time employees. HMOs must also comply with these provisions (Ch. 42 (H. 289), L. 2005).

Employer utilization and loss data availability.- Claims information, including utilization and loss experience under group health insurance, shall be made available only upon the request of and to employers of employees with such coverage within 60 days of an employer's written request for such information, provided the employer's coverage extends to no less than 25 individual employees, regardless of whether family coverage is included. In providing such utilization data, carriers shall not reveal information that allows identification of an individual employee or the employee's family or the specific conditions for which coverage was provided (Ch. 252 (S. 829), L. 2003).

<p>Employer utilization and loss data availability.— Claims information, including utilization and loss experience under group health insurance, shall be made avai</p>

New Mexico, Health Insurance Benefit Coverage Law Summaries

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