New Mexico Administrative Code
Title 13 - INSURANCE
Chapter 10 - HEALTH INSURANCE
Part 11 - HEALTH INSURANCE ALLIANCE PLAN OF OPERATION AND ELIGIBILITY CRITERIA
Section 13.10.11.30 - PRE-EXISTING CONDITION EXCLUSIONS
Universal Citation: 13 NM Admin Code 13.10.11.30
Current through Register Vol. 35, No. 18, September 24, 2024
A. Definitions. As used in this section:
(1)
pre-existing
condition 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;
(2)
creditable coverage means,
with respect to an individual, coverage of the individual pursuant to:
(a) an employment-based group health
plan;
(b) health insurance
coverage;
(c) Part A or Part B of
Title 18 of the Social Security Act (medicare);
(d) Title 19 of the Social Security Act
(medicaid) except coverage consisting solely of benefits pursuant to section
1928 of that title;
(e) 10 USCA
Chapter 55 (military benefits);
(f)
a medical care program of the Indian Health Service or of an Indian nation,
tribe or pueblo;
(g) the
Comprehensive Health Insurance Pool Act (CHIP);
(h) a health plan offered pursuant to 5 USCA
Chapter 89;
(i) a public health
plan as defined in federal regulations; or
(j) a health benefit plan offered pursuant to
section 5(e) of the federal Peace Corps Act; and
(3)
enrollment date means the
date of enrollment of the individual in the alliance plan or, if
earlier, the first day of the waiting period for that enrollment.
B. Allowable provisions.
(1) An
alliance indemnity plan may include a pre-existing condition
exclusion only if the exclusion relates to a physical or mental condition,
regardless of the cause of the condition, for which medical advice, diagnosis,
care or treatment was actually recommended or received within the six-month
period ending on the enrollment date.
(a) The
pre-existing condition exclusion cannot extend for more than six months from
the enrollment date.
(b) The period
of the pre-existing condition exclusion must be reduced on a day-for-day basis
by the aggregate of the periods of creditable coverage applicable to the
employee or dependent as of the enrollment date.
(2) An HMO plan issued through the
alliance may not include a pre-existing condition
exclusion.
C. Prohibited applications. No pre-existing condition exclusion may be imposed:
(1) on a child who, as of the last
day of the 30-day period beginning with the date of birth, is covered under
creditable coverage; or
(2) on a
child who is adopted or placed for adoption before his 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.
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