N.M. Admin. Code § 13.10.11.21

Current through Register Vol. 35, No. 23, December 10, 2024

Section 13.10.11.21 - ELIGIBILITY OF EMPLOYEES OF SMALL EMPLOYERS

A. Eligible employees.

(1) An employee of a small employer (or a self-employed person who is eligible under Subparagraph (b) of Paragraph (3) of Subsection A of 13.10.11.20 NMAC) is eligible to enroll in an approved health plan if:

(a) the employee (or the self-employed person) has completed the employer's waiting period;

(b) the employee (and any self-employed person) is working at least 20 hours per week on a regular basis (other than as a volunteer); and

(c) the employee (or the self-employed person) does not come within one of the categories of ineligible employees described in Subsection B of 13.10.11.21 NMAC.

(2) An individual already covered under an approved health plan may retain coverage after he or she first becomes eligible for medicare as primary coverage. If an individual who has a family coverage policy elects to terminate his or her coverage through the alliance when he or she becomes eligible for medicare, the family coverage under the approved health plan shall continue for any person in the family who is not eligible for medicare. The family rate shall be based on the age of the employee, unless the employee has terminated coverage, in which case the rate shall be based on the age of the eldest enrolled member of the family. The rate shall be adjusted to reflect the number of persons actually enrolled in the approved health plan.

B. Ineligible employees. An employee of a small employer, or a self-employed person, is not eligible to enroll in an approved health plan if:

(1) at the time of application, he is eligible for medicare and the group has fewer than 20 employees;

(2) if he is an inmate of a public institution; or

(3) if he or she previously was terminated by the carrier for cause under any plan.

C. Participation requirement. As of the date of the group's enrollment or renewal, at least 50 percent of the employer's eligible employees who are not otherwise covered under another comprehensive health plan or program must elect to be covered under the alliance plan. For purposes of this subsection, comprehensive health insurance coverage includes coverage sponsored by any recognized labor union and any group health insurance or individual health insurance coverage that is not paid for or reimbursed by the employer. If the employer is deemed to be a small group by virtue of having one employee and a dependent, then at least two persons must be covered under the alliance plan. Management or class subsets or carve-outs cannot be used to satisfy or circumvent participation requirements for the employer group.

N.M. Admin. Code § 13.10.11.21

13.10.11.21 NMAC - N, 6-1-01