Current through Register Vol. 35, No. 18, September 24, 2024
A.
Eligibility as an individual.
(1) An individual is eligible for an
alliance plan outside of a small employer if:
(a) as of the date of application for
coverage the individual is a resident of the state of New Mexico and has an
aggregate of 18 or more months of creditable coverage, as defined in the act,
provided that during this period the individual did not have a break in
creditable coverage lasting 95 days or longer; and either
(i) the individual's most recent coverage was
under a group health plan, governmental plan or church plan, or
(ii) the individual was covered by a group
health plan, governmental plan or church plan less than 95 days prior to the
date the individual applies for coverage through the
alliance;
(b) the individual is a resident of the state
of New Mexico and is entitled to continuation coverage under the act, as
provided in 13.10.11.31 NMAC;
(c)
the individual is a resident of the state of New Mexico and his coverage has
been terminated pursuant to the provisions of Section 59A-23E-14 NMSA 1978
(i.e., when a carrier has withdrawn from the small group market) or Section
59A-23E-19 NMSA 1978 (i.e., when a carrier has withdrawn from the individual
market).
(2) The
alliance may require the individual to provide an affidavit,
signed under oath, stating that the individual is or will be a resident of the
state of New Mexico as of the effective date of coverage.
(3) Notwithstanding the foregoing, an
individual is not eligible for coverage if the coverage is being paid for or
reimbursed by the individual's employer, unless the individual is either
self-employed or employed by his own corporation and in either case has no
other employees, or if on the effective date of coverage the individual:
(a) has or is eligible for coverage under a
group health plan, as defined in the Alliance Act;
(b) is eligible for coverage under medicare
or medicaid;
(c) has other health
insurance coverage as defined by Subsection R of Section 59A-23E-2 NMSA 1978
(which is not terminating);
(d) was
terminated from the most recent coverage within the coverage period described
in Paragraph 1 of Subsection A of 13.10.11.34 NMAC as a result of nonpayment of
premium or fraud; or
(e) has been offered the option of coverage
under a COBRA continuation provision or a similar state program (other than
through the alliance), and either did not elect or did not exhaust
the coverage available under the offered program.
(4) An individual may elect to obtain
coverage for his or her eligible dependents under an individual plan. The
requirements of 13.10.11.29 NMAC shall apply to the eligibility and enrollment
of dependents under individual coverage.
(5) A covered dependent is eligible for
individual continuation coverage under the act only if the dependent has been
continuously covered under an
alliance plan as a dependent of a
covered individual for at least six months, and then only if the dependent
applies for continuation coverage within 31 days of:
(a) the death of the individual;
(b) the divorce, annulment or dissolution of
marriage or legal separation of the spouse from the individual; or
(c) for covered dependent children, upon
attainment of the limiting age of 26, as provided in Subsection C of
13.10.11.29 NMAC.
(6) No
person is eligible to enroll or to remain on continuation coverage if he or she
resides outside of the United States for a period of over six months or, if
continuation coverage under this section became effective after the effective
date of this rule, he or she moves from the state of New Mexico or resides
outside of the state of New Mexico for a period of over six months.
(7) Continuation coverage under the act is
considered to be individual coverage for purposes of state and federal law.
Persons electing to continue coverage under the act shall be subject to the
provisions of 13.10.11.34 NMAC. Premiums for this continuation coverage shall
be calculated at individual coverage rates.
B.
Effective date.
(1) If the documentation required by the
alliance is received by the 15th of the month, coverage shall be
reviewed for an effective as of the first day of the following month. If the
complete documentation required by the alliance is received after
the 15th of the month, coverage shall be not be effective until the first day
of the month after the month following that in which the documentation is
received. (If the 15th of the month falls on a weekend or holiday, the
documentation must be received by the alliance, or delivered to
its post office box, before 5:00 p.m. on the next business day.)
(2) The effective date of a continuee's
individual coverage shall be the first of the month following termination of
the individual's group coverage through the alliance provided the
required documentation is received.
C.
Renewability.
(1) Coverage under an
alliance
plan for an individual can be terminated or non-renewed only in the event of
the following:
(a) the individual loses
eligibility by residing outside of the state of New Mexico for a period of over
six months, and the individual:
(i) obtained
individual coverage through the alliance after the date on which
this residency requirement first became effective; and
(ii) is not covered as a continuee under
state six-month continuation; termination under this paragraph is allowed if
the individual is covered under 13.10.11.31 NMAC.
(b) nonpayment of premium;
(c) fraud; or
(d) termination of the plan.
(2) If coverage under an
alliance plan is terminated or not renewed because of termination
of the plan, the individual shall have the right to transfer to any other
alliance plan. If the individual's coverage terminates for any
reason, covered dependents shall be given the opportunity to obtain conversion
coverage directly from the member.
D.
HMO service area
requirements. In order to be eligible to enroll in an
alliance plan offered by an HMO, an individual must live or work
within the HMO's service area. The HMO may approve exceptions on an individual
basis in accordance with the HMO's usual business practice. If the individual
moves from the service area, the individual may enroll in the HMO's affiliated
indemnity plan offered through the alliance.
E.
Coverage of out-of-country
services. Services provided outside of the United States will be covered
only if they are for emergency treatment.
F.
Pre-existing condition
exclusions. An individual or dependent enrolling for individual coverage
shall not be subject to any pre-existing condition exclusion.
G.
Individual rates. Premium
rates for individuals, including alliance continuees, shall be
based on the age of the individual on the effective date of the individual or
continuation coverage. Rates, excepting age-based increases or tier changes,
shall be guaranteed for 12 months from that effective date and from each annual
anniversary thereafter. Any applicable age-based increase shall not be
considered a violation of the guarantee and shall become effective on the first
of the month following the individual's birthday. Any applicable tier-change
increase shall not be considered a violation of the guarantee and shall become
effective on the first of the month in which the change in dependents becomes
effective. Changes in premiums for renewal periods shall take effect on the
anniversary of the effective date of individual or continuation
coverage.
H.
Plan
selection. Individuals must select a carrier (member) as of the
effective date of individual coverage and may not thereafter change carriers
except on the annual anniversary of the effective date of individual coverage
or if the carrier withdraws from participation in the alliance. An
individual may change plan design, e.g., level of deductible or
co-pay/co-insurance, as of any annual anniversary of the effective date of
individual coverage.
