2019 New Mexico Statutes
Chapter 59A - Insurance Code
Article 23 - Group and Blanket Health Insurance Contracts
Section 59A-23-11 - Private health insurance cooperatives; incorporation.
A. A person may form a cooperative to purchase employer health benefit plans. A cooperative shall be organized as a nonprofit corporation and has the rights and duties provided by the Nonprofit Corporation Act [Chapter 53, Article 8 NMSA 1978].
B. Two or more large employers or small employers or any combination of large employers and small employers with an aggregate of fifty or more full-time-equivalent employees may purchase group health benefit plans pursuant to Chapter 59A, Article 23 NMSA 1978.
C. A carrier shall not form, or be a member of, a cooperative. A carrier may associate with a sponsoring entity, such as a business association, chamber of commerce or other organization representing employers or serving an analogous function, to assist the sponsoring entity in forming a cooperative.
D. A cooperative shall:
(1) arrange for group health benefit plan coverage for employer groups that participate in the cooperative by contracting with carriers pursuant to Chapter 59A, Article 23 NMSA 1978;
(2) collect premiums to cover the cost of:
(a) group health benefit plan coverage purchased through the cooperative; and
(b) the cooperative's administrative expenses;
(3) establish administrative and accounting procedures for the operation of the cooperative;
(4) establish procedures under which an applicant for or participant in group health benefit plan coverage issued through the cooperative may have a grievance reviewed by an impartial person;
(5) contract with carriers to provide services to employers covered through the cooperative; and
(6) develop and implement a plan to maintain public awareness of the cooperative and publicize the eligibility requirements for, and the procedures for enrollment in, group health benefit plan coverage through the cooperative.
E. A cooperative may negotiate the premiums paid by its members.
F. Notwithstanding the provisions of Subsections B and C of this section, a cooperative may restrict membership to employers within a single industry grouping as defined by the most recent edition of the United States census bureau's North American Industry Classification System.
G. A carrier shall issue health benefit plan coverage for the cooperative through a licensed agent marketing the coverage in accordance with the provisions of Chapter 59A, Article 23 NMSA 1978.
H. The members of a cooperative shall be considered a single risk pool.
I. A cooperative may make available to its members more than one group health benefit plan, but each plan shall be made available to all employees covered by the cooperative.
J. The provisions of this section do not limit or restrict a small or large employer's access to health benefit plans pursuant to the Insurance Code [Chapter 59A NMSA 1978].
K. A group health benefit plan provided through a cooperative shall provide coverage for diabetes equipment, supplies and services.
L. A carrier may elect not to participate in a cooperative. The carrier may elect to participate in one or more cooperatives and may select the cooperatives in which the carrier will participate.
M. A cooperative shall not self-insure or self-fund any health benefit plan or portion of a plan.
N. A cooperative may contract only with a carrier that demonstrates that the carrier:
(1) is in good standing with the division;
(2) has the capacity to administer health benefit plans;
(3) is able to monitor and evaluate the quality and cost-effectiveness of care and applicable procedures;
(4) is able to conduct utilization management and establish applicable procedures and policies;
(5) is able to ensure that enrollees have adequate access to health care providers, including adequate numbers and types of providers;
(6) has a satisfactory grievance procedure and is able to respond to enrollees' calls, questions and complaints; and
(7) has financial capacity, either through satisfying financial solvency standards that the superintendent shall set or through appropriate reinsurance or other risk-sharing mechanisms.
O. A cooperative is not a carrier or an insurer, and an employee of the cooperative shall not be required to be licensed as an agent or broker pursuant to the provisions of the Insurance Code. This exemption from licensure includes a cooperative that acts to provide information about and to solicit membership in the cooperative.
P. A cooperative shall register as a cooperative with the insurance division in accordance with division rules.
Q. For the purposes of this section:
(1) "carrier" means a person that is subject to licensure by the superintendent or subject to the provisions of the Insurance Code and that provides one or more health benefit or insurance plans in the state;
(2) "large employer" means a person, firm, corporation, partnership or association actively engaged in business that, on at least fifty percent of its working days during either of the two preceding years, employed no fewer than fifty-one employees eligible for employer-sponsored coverage; provided that:
(a) 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;
(b) 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;
(c) 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; and
(d) the employer does not self-insure; and
(3) "small employer" means a person, firm, corporation, partnership or association actively engaged in business that, on at least fifty percent of its working days during either of the two preceding years, employed no less than two and no more than fifty employees eligible for employer-sponsored coverage; provided that:
(a) 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;
(b) 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;
(c) 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; and
(d) the employer does not self-insure.
History: Laws 2011, ch. 34, § 2.
ANNOTATIONSEffective dates. — Laws 2011, ch. 34 contained no effective date provision, but, pursuant to N.M. Const., art. IV, § 23, was effective June 17, 2011, 90 days after the adjournment of the legislature.
