2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 23E - Health Insurance Portability › Section 59A-23E-13 - Health insurance issuers; guaranteed availability of coverage; exceptions for network plans, insufficient financial capacity and bona fide associations; employer contribution rules.

A. Except as provided in Subsections C through E of this section, a health insurance issuer that offers health insurance coverage in the individual or small group markets shall:
(1) accept every individual or employer that applies for coverage;
(2) accept for enrollment under the offered coverage an eligible individual who applies for enrollment during the period in which the individual first becomes eligible to enroll under the terms of the group health plan or during an open or special enrollment period as specified in rules of the office of superintendent of insurance; and
(3) not place a restriction on an eligible individual being a participant or a beneficiary that is inconsistent with Sections 59A-23E-11 and 59A-23E-12 NMSA 1978.
B. The superintendent shall adopt and promulgate rules relating to enrollment periods.
C. A health insurance issuer that offers health insurance coverage in the group or individual markets through a network plan may:
(1) limit the employers or individuals that may apply for the coverage to those with eligible individuals who live, work or reside in the service area for the network plan; and
(2) within the service area of the network plan, deny coverage to individuals or employers within the service area for the network plan if the issuer has demonstrated to the superintendent that it:
(a) will not have the capacity to deliver services adequately to enrollees of any additional groups or any additional individuals because of its obligations to existing individuals, group contract holders and enrollees; and
(b) is applying this exception uniformly to all employers and individuals without regard to the claims experience of those individuals or those employers, their employees and their dependents or any health status related factor relating to those individuals, employees and dependents.
D. A health insurance issuer, upon denying insurance coverage in any service area pursuant to the provisions of Subsection C of this section, shall not offer coverage in the group market or individual market within the service area for a period of one hundred eighty days after the date coverage is denied.
E. A health insurance issuer may deny health insurance coverage in the individual and group markets if the issuer has demonstrated to the superintendent that it:
(1) does not have the financial reserves necessary to underwrite additional coverage; and
(2) is applying this exception uniformly to all individuals, employers and their employees in the individual and group markets in the state consistent with state law and without regard to the claims experience of those individuals, employers, their employees and their dependents or any health status related factor relating to those individuals, employees and dependents.
F. A health insurance issuer, upon denying health insurance coverage in accordance with Paragraphs (1) and (2) of Subsection E of this section, shall not offer coverage in the group or individual markets in the state for a period of one hundred eighty days after the date the coverage is denied or until the issuer has demonstrated to the superintendent that the carrier has sufficient financial reserves to underwrite additional coverage, whichever is later. The superintendent may provide for the application of this subsection on a service-area-specific basis.
G. As used in this section, "eligible individual" means, with respect to a health insurance issuer offering an individual or group health plan, an individual whose eligibility shall be determined:
(1) in accordance with the terms of the plan;
(2) as provided by the issuer under the rules of the issuer that are uniformly applicable in the state to the individual and group markets; and
(3) in accordance with New Mexico Insurance Code provisions governing the issuer and the small group market.
History:
Laws 1997, ch. 243, § 13; 1998, ch. 41, § 17; 2019, ch. 259, § 12.
ANNOTATIONS
Cross references.
— For the Insurance Code,
see
59A-1-1 NMSA 1978 and notes thereto.
The 2019 amendment,
effective June 14, 2019, provided that health insurance issuers that offer health insurance coverage in the individual or small group market must accept every individual that applies for coverage during open or special enrollment periods, and provided that a health plan that did not have capacity or financial reserves necessary to take more enrollees may not enroll additional members for at least 180 days; in the section heading, deleted "for employers in small group market"; in Subsection A, Paragraph A(1), after "accept", deleted "a small" and added "every individual or", and after "group health plan", added "or during an open or special enrollment period as specified in rules of the office of superintendent of insurance"; added a new Subsection B and redesignated former Subsections B through D as Subsections C through E, respectively; in Subsection C, Paragraph C(2), in the introductory clause, added "within the service area of the network plan"; deleted former Subsections E through G; added a new Subsection F and redesignated former Subsection H as Subsection G; and in Subsection G, in the introductory clause, after "health insurance issuer", deleted "that offers health insurance coverage to a small employer in connections with a group health plan in the small group market" and added "offering an individual or group health plan".
The 1998 amendment,
effective March 6, 1998, inserted "guaranteed availability of" and "for employers" in the section heading, substituted "59A-23E-11 and 59A-23E-12 NMSA 1978" for "11 and 12 of the of the Health Insurance Portability Act" near the end of Paragraph A(3), and added Subsection H.