N.M. Stat. § 59A-23A-4

Current through 2024, ch. 69

Section 59A-23A-4 - Definitions

As used in the Long-Term Care Insurance Law:

A. "applicant" means:

(1) in the case of an individual long-term care insurance policy, the person who seeks to contract for benefits; and

(2) in the case of a group long-term care insurance policy, the proposed certificate holder;

B. "certificate" means any certificate issued under a group long-term care insurance policy;

C. "group long-term care insurance" means a long-term care insurance policy which is delivered or issued for delivery in this state and issued to:

(1) one or more employers or labor organizations established by one or more employers or labor organizations or a combination thereof, for employees or former employees or a combination thereof or for members or former members or a combination thereof of the labor organizations;

(2) any professional, trade or occupational association for its members or former or retired members, or a combination thereof, if the association:

(a) is composed of individuals all of whom are or were actively engaged in the same profession, trade or occupation; and

(b) has been maintained in good faith for purposes other than obtaining insurance;

(3) an association or a trust or the trustees of a fund established, created or maintained for the benefit of members of one or more associations. Prior to advertising, marketing or offering such policy within this state, the association or associations, or the insurer of the association or associations, shall file evidence with the superintendent that the association or associations have at the outset a minimum of twenty-five persons and have been organized and maintained in good faith for purposes other than that of obtaining insurance; have been in active existence for at least one year; and have a constitution and bylaws which provided that:

(a) the association or associations hold regular meetings not less than annually to further purposes of the members;

(b) except for credit unions, the association or associations collect dues or solicit contributions from members; and

(c) the members have voting privileges and representation on the governing board and committees.

Sixty days after such filing the association or associations will be deemed to satisfy such organizational requirements, unless the superintendent finds that the association or associations do not satisfy those organizational requirements; or

(4) a group other than as described in Paragraph (1), (2) or (3) of this subsection, subject to a finding by the superintendent that:

(a) the issuance of the group policy is not contrary to the best interest of the public;

(b) the issuance of the group policy would result in economies of acquisition or administration; and

(c) the benefits are reasonable in relation to the premiums charged;

D. "long-term care insurance" means any insurance coverage advertised, marketed, offered or designed to provide coverage for not less than twelve consecutive months for each covered person on an expense incurred, indemnity, prepaid or other basis for one or more necessary or medically necessary diagnostic, preventive, therapeutic, rehabilitative, maintenance or personal care services, provided in a setting other than an acute care unit of a hospital, including group and individual annuities and life insurance policies or riders which provide directly or which supplement long-term care insurance, and policies or riders which provide for payment of benefits based upon cognitive impairment or the loss of functional capacity. Long-term care insurance may be issued by insurers; fraternal benefit societies; nonprofit health insurers; prepaid health plans; health maintenance organizations or any similar organization to the extent they are otherwise authorized to issue life or health insurance. Long-term care insurance shall not include any insurance policy which is offered primarily to provide basic medicare supplement coverage, basic hospital expense coverage, basic medical-surgical expense coverage, hospital confinement indemnity coverage, major medical expense coverage, disability income or related asset-protection coverage, accident only coverage, specified disease or specified accident coverage or limited benefit health coverage. With regard to life insurance, this term does not include life insurance policies which accelerate the death benefit specifically for one or more of the qualifying events of terminal illness, medical conditions requiring extraordinary medical intervention or permanent institutional confinement, and which provide the option of a lump-sum payment for those benefits and in which neither the benefits nor the eligibility for the benefits is conditioned upon the receipt of long-term care. Notwithstanding any other provision contained herein, any product advertised, marketed or offered as long-term care insurance shall be subject to the provisions of this article;

E. "long-term care insurance policy" means an individual or group policy or an individual or group certificate of health insurance issued pursuant to the provisions of Chapter 59A, Articles 22, 23, 44, 46 and 47 NMSA 1978; and

F. "rider" means any additional long-term care coverage provision added to any type of policy by issuance of an amending document.

NMS § 59A-23A-4

Laws 1989, ch. 136, § 4; 1993, ch. 126, § 9.