2023 New Mexico Statutes › Chapter 59A - Insurance Code › Article 23C - Small Group Rate and Renewability › Section 59A-23C-3 - Definitions.

As used in the Small Group Rate and Renewability Act:
A. "actuarial certification" means a written statement by a member of the American academy of actuaries or another individual acceptable to the superintendent that a small employer carrier is in compliance with the provisions of Section 59A-23C-5 NMSA 1978, based upon the person's examination, including a review of the appropriate records and of the actuarial assumptions and methods used by the carrier in establishing premium rates for applicable health benefit plans;
B. "base premium rate" means, for each class of business as to a rating period, the lowest premium rate charged under a rating system for that class of business by the small employer carrier to small employers with similar case characteristics for health benefit plans with the same or similar coverage;
C. "carrier" means any person who provides health insurance in this state. For the purposes of the Small Group Rate and Renewability Act, "carrier" or "insurer" includes a licensed insurance company, a licensed fraternal benefit society, a prepaid hospital or medical service plan, a health maintenance organization, a nonprofit health care organization, a multiple employer welfare arrangement or any other person providing a plan of health insurance subject to state insurance regulation;
D. "case characteristics" means demographic or other relevant characteristics of a small employer, as determined by a small employer carrier, that are considered by the carrier in the determination of premium rates for the small employer, but "case characteristics" does not include claim experience, health status and duration of coverage since issue;
E. "class of business" means all small employers as shown on the records of the small employer carrier. A separate class of business may be established by the small employer carrier on the basis that the applicable health benefit plans have been acquired from another small employer carrier as a distinct grouping of plans;
F. "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 Social Security Act;
(4) Title 19 of the 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 Comprehensive Health Insurance Pool Act [Medical Insurance Pool Act] [Chapter 59A, Article 54 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;
G. "department" means the department of insurance;
H. "group health plan" means an employee welfare benefit plan as defined Section 3(1) of the Employee Retirement Income Security Act of 1974 to the extent that the plan provides medical care and including items and services paid for as medical care to employees or their dependents as defined under the terms of the plan directly or through insurance, reimbursement or otherwise;
I. "health benefit plan" or "plan" means any hospital or medical expense incurred policy or certificate, hospital or medical service plan contract or health maintenance organization subscriber contract. "Health benefit plan" does not include accident-only, credit, dental or disability income insurance, medicare supplement coverage, coverage issued as a supplement to liability insurance, workers' compensation or similar insurance or automobile medical-payment insurance;
J. "index rate" means, for each class of business for small employers with similar case characteristics, the arithmetic average of the applicable base premium rate and the corresponding highest premium rate;
K. "late enrollee" means, with respect to coverage under a group health plan, a participant or beneficiary who enrolls under the plan other than during:
(1) the first period in which the individual is eligible to enroll under the plan; or
(2) a special enrollment period pursuant to Sections 8 and 9 [59A-23A-8 and 59A-23A-9 NMSA 1978] of the Health Insurance Portability Act;
L. "new business premium rate" means, for each class of business as to a rating period, the premium rate charged or offered by the small employer carrier to small employers with similar case characteristics for newly issued health benefit plans with the same or similar coverage;
M. "rating period" means the calendar period for which premium rates established by a small employer carrier are assumed to be in effect, as determined by the small employer carrier;
N. "small employer" means any person, firm, corporation, partnership or association actively engaged in business who, 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 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;
O. "small employer carrier" means any insurer that offers health benefit plans covering the employees of a small employer; and
P. "superintendent" means the superintendent of insurance.
History:
Laws 1991, ch. 153, § 3; 1994, ch. 75, § 30; 1997, ch. 243, § 22.
ANNOTATIONS
Bracketed material.
— The bracketed material was inserted by the compilerand is not part of the law. The name of the Comprehensive Health Insurance Pool Act was changed to the Medical Insurance Pool Act by Laws 2001, ch. 352, § 1.
Cross references.
— For Titles 18 and 19 of the federal Social Security Act, referred to in Paragraphs F(3) and F(4),
see
42 U.S.C. § 1395 et seq. and 42 U.S.C. § 1396 et seq., respectively.
For Section 1928 of Title 19,
see
42 U.S.C. § 1396s.
For Section 5(e) of the federal Peace Corps Act,
see
22 U.S.C. 2504(e).
For Section 3(1) of the federal Employee Retirement Income Security Act (ERISA),
see
29 U.S.C. § 1002(1).
The 1997 amendment,
effective April 11, 1997, added Subsections F, H, and K, redesignated the former subsections accordingly, and in Subsection N, substituted "either of the two preceding years" for "the preceding year" and added Paragraph (3).
The 1994 amendment,
effective January 1, 1995, substituted "59A-23C-5 NMSA 1978" for "5 of the Small Group Rate and Renewability Act" in Subsection A; deleted "are not case characteristics for the purposes of the law" at the end of Subsection D, and in the same subsection inserted "but 'case characteristics' does not include"; rewrote Subsection E; inserted "medicare supplement coverage," in Subsection G; rewrote and redesignated the provisions of Subsection K; and substituted "that" for "which" in Subsection L.
Applicability.
— Laws 1994, ch. 75, § 36 makes the provisions of §§ 26 to 34 of the act applicable to all plans and policies delivered, issued for delivery or renewed on or after January 1, 1995.