N.M. Admin. Code § 13.10.11.30 - PRE-EXISTING CONDITION EXCLUSIONS

A. Definitions. As used in this section:

(1) pre-existing condition means a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for coverage for the benefits whether or not any medical advice, diagnosis, care or treatment was recommended or received before that date, but genetic information is not included as a preexisting condition for the purposes of limiting or excluding benefits in the absence of a diagnosis of the condition related to the genetic information;

(2) creditable coverage means, with respect to an individual, coverage of the individual pursuant to:

(a) an employment-based group health plan;

(b) health insurance coverage;

(c) Part A or Part B of Title 18 of the Social Security Act (medicare);

(d) Title 19 of the Social Security Act (medicaid) except coverage consisting solely of benefits pursuant to section 1928 of that title;

(e) 10 USCA Chapter 55 (military benefits);

(f) a medical care program of the Indian Health Service or of an Indian nation, tribe or pueblo;

(g) the Comprehensive Health Insurance Pool Act (CHIP);

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

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

(j) a health benefit plan offered pursuant to section 5(e) of the federal Peace Corps Act; and

(3) enrollment date means the date of enrollment of the individual in the alliance plan or, if earlier, the first day of the waiting period for that enrollment.

B. Allowable provisions.

(1) An alliance indemnity plan may include a pre-existing condition exclusion only if the exclusion relates to a physical or mental condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was actually recommended or received within the six-month period ending on the enrollment date.

(a) The pre-existing condition exclusion cannot extend for more than six months from the enrollment date.

(b) The period of the pre-existing condition exclusion must be reduced on a day-for-day basis by the aggregate of the periods of creditable coverage applicable to the employee or dependent as of the enrollment date.

(2) An HMO plan issued through the alliance may not include a pre-existing condition exclusion.

C. Prohibited applications. No pre-existing condition exclusion may be imposed:

(1) on a child who, as of the last day of the 30-day period beginning with the date of birth, is covered under creditable coverage; or

(2) on a child who is adopted or placed for adoption before his 18th birthday and who, as of the last day of the 30-day period beginning on and following the date of the adoption or placement for adoption, is covered under creditable coverage; or

(3) that relates to or includes pregnancy as a preexisting condition.

Notes

N.M. Admin. Code § 13.10.11.30

13.10.11.30 NMAC - N, 6-1-01