2006 New Mexico Statutes - Section 59A-56-3 — Definitions.

59A-56-3. Definitions.

As used in the Health Insurance Alliance Act [ 59A-56-1 NMSA 1978]:   

A.     "alliance" means the New Mexico health insurance alliance;   

B.     "approved health plan" means any arrangement for the provisions of health insurance offered through and approved by the alliance;   

C.     "board" means the board of directors of the alliance;   

D.     "child" means a dependent unmarried individual who is less than twenty-five years of age;   

E.     "creditable coverage" means, with respect to an individual, coverage of the individual pursuant to:   

(1)     a group health plan;   

(2)     health insurance coverage;   

(3)     Part A or Part B of Title 18 of the federal Social Security Act;   

(4)     Title 19 of the federal Social Security Act except coverage consisting solely of benefits pursuant to Section 1928 of that title;   

(5)     10 USCA Chapter 55;   

(6)     a medical care program of the Indian health service or of an Indian nation, tribe or pueblo;   

(7)     the Medical Insurance Pool Act [ 59A-54-1 NMSA 1978];   

(8)     a health plan offered pursuant to 5 USCA Chapter 89;   

(9)     a public health plan as defined in federal regulations; or   

(10)     a health benefit plan offered pursuant to Section 5(e) of the federal Peace Corps Act;   

F.     "department" means the insurance division of the commission;   

G.     "director" means an individual who serves on the board;   

H.     "earned premiums" means premiums paid or due during a calendar year for coverage under an approved health plan less any unearned premiums at the end of that calendar year plus any unearned premiums from the end of the immediately preceding calendar year;   

I.     "eligible expenses" means the allowable charges for a health care service covered under an approved health plan;   

J.     "eligible individual":   

(1)     means an individual who:   

(a)     as of the date of the individual's application for coverage under an approved health plan, has an aggregate of eighteen or more months of creditable coverage, the most recent of which was under a group health plan, governmental plan or church plan as those plans are defined in Subsections P, N and D of Section 59A-23E-2 NMSA 1978, respectively, or health insurance offered in connection with any of those plans, but for the purposes of aggregating creditable coverage, a period of creditable coverage shall not be counted with respect to enrollment of an individual for coverage under an approved health plan if, after that period and before the enrollment date, there was a sixty-three-day or longer period during all of which the individual was not covered under any creditable coverage; or   

(b)     is entitled to continuation coverage pursuant to Section 59A-56-20 or 59A-23E-19 NMSA 1978; and   

(2)     does not include an individual who:   

(a)     has or is eligible for coverage under a group health plan;   

(b)     is eligible for coverage under medicare or a state plan under Title 19 of the federal Social Security Act or any successor program;   

(c)     has health insurance coverage as defined in Subsection R of Section 59A-23E-2 NMSA 1978;   

(d)     during the most recent coverage within the coverage period described in Subparagraph (a) of Paragraph (1) of this subsection was terminated from coverage as a result of nonpayment of premium or fraud; or   

(e)     has been offered the option of coverage under a COBRA continuation provision as that term is defined in Subsection F of Section 59A-23E-2 NMSA 1978, or under a similar state program, except for continuation coverage under Section 59A-56-20 NMSA 1978, and did not exhaust the coverage available under the offered program;   

K.     "enrollment date" means, with respect to an individual covered under a group health plan or health insurance coverage, the date of enrollment of the individual in the plan or coverage or, if earlier, the first day of the waiting period for that enrollment;   

L.     "gross earned premiums" means premiums paid or due during a calendar year for all health insurance written in the state less any unearned premiums at the end of that calendar year plus any unearned premiums from the end of the immediately preceding calendar year;   

M.     "group health plan" means an employee welfare benefit plan to the extent the plan provides hospital, surgical or medical expenses benefits to employees or their dependents, as defined by the terms of the plan, directly through insurance, reimbursement or otherwise;   

N.     "health care service" means a service or product furnished an individual for the purpose of preventing, alleviating, curing or healing human illness or injury and includes services and products incidental to furnishing the described services or products;   

O.     "health insurance" means "health" insurance as defined in Section 59A-7-3 NMSA 1978; any hospital and medical expense-incurred policy; nonprofit health care plan service contract; health maintenance organization subscriber contract; short-term, accident, fixed indemnity, specified disease policy or disability income insurance contracts and limited health benefit or credit health insurance; coverage for health care services under uninsured arrangements of group or group-type contracts, including employer self-insured, cost-plus or other benefits methodologies not involving insurance or not subject to New Mexico premium taxes; coverage for health care services under group-type contracts that are not available to the general public and can be obtained only because of connection with a particular organization or group; coverage by medicare or other governmental programs providing health care services; but "health insurance" does not include insurance issued pursuant to provisions of the Workers' Compensation Act [ 52-1-1 NMSA 1978] or similar law, automobile medical payment insurance or provisions by which benefits are payable with or without regard to fault and are required by law to be contained in any liability insurance policy;   

P.     "health maintenance organization" means a health maintenance organization as defined by Subsection M of Section 59A-46-2 NMSA 1978;   

Q.     "incurred claims" means claims paid during a calendar year plus claims incurred in the calendar year and paid prior to April 1 of the succeeding year, less claims incurred previous to the current calendar year and paid prior to April 1 of the current year;   

R.     "insured" means a small employer or its employee and an individual covered by an approved health plan, a former employee of a small employer who is covered by an approved health plan through conversion or an individual covered by an approved health plan that allows individual enrollment;   

S.     "medicare" means coverage under both Parts A and B of Title 18 of the federal Social Security Act;   

T.     "member" means a member of the alliance;   

U.     "nonprofit health care plan" means a "health care plan" as defined in Subsection K of Section 59A-47-3 NMSA 1978;   

V.     "premiums" means the premiums received for coverage under an approved health plan during a calendar year;   

W.     "small employer" means a person that is a resident of this state, has employees at least fifty percent of whom are residents of this state, is actively engaged in business and that on at least fifty percent of its working days during either of the two preceding calendar years, employed no fewer than two and no more than fifty eligible employees; provided that:   

(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 shall 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 shall be based on the average number of employees that it is reasonably expected to employ on working days in the current calendar year;   

X.     "superintendent" means the superintendent of insurance;   

Y.     "total premiums" means the total premiums for business written in the state received during a calendar year; and   

Z.     "unearned premiums" means the portion of a premium previously paid for which the coverage period is in the future.