TITLE 2 PUBLIC
FINANCE
CHAPTER 81 RETIREE
HEALTH CARE FUNDS
PART 6 ELIGIBLE
RETIREE SPOUSE, DOMESTIC PARTNER AND DEPENDENT BENEFIT COVERAGE ENROLLMENT
2.81.6.1 ISSUING
AGENCY: New Mexico Retiree Health Care Authority
("NMRHCA").
[2.81.6.1 NMAC - Rp,
2.81.6.1 NMAC, 1/1/2017]
2.81.6.2 SCOPE:
This rule applies to all eligible retirees, eligible spouses, eligible
domestic partners, and eligible dependents authorized to participate in the
NMRHCA coverages.
[2.81.6.2 NMAC - Rp,
2.81.6.2 NMAC, 1/1/2017]
2.81.6.3 STATUTORY AUTHORITY: This rule is promulgated pursuant to the
Retiree Health Care Act, Sections 10-7C-1 to 16 NMSA 1978.
[2.81.6.3 NMAC - Rp,
2.81.6.3 NMAC, 1/1/2017]
2.81.6.4 DURATION: Permanent.
[2.81.6.4 NMAC - Rp,
2.81.6.4 NMAC, 1/1/2017]
2.81.6.5 EFFECTIVE DATE: January 1, 2017 unless a later date is cited
at the end of a section.
[2.81.6.5 NMAC - Rp,
2.81.6.5 NMAC, 1/1/2017]
2.81.6.6 OBJECTIVE: The objective of this rule is to establish
the enrollment policy for eligible retirees, eligible spouses, eligible
domestic partners, and dependents authorized to participate in the NMRHCA's
coverage. The objective is to establish rules for new eligible retiree, spouse,
domestic partners, and dependent enrollment, change in status enrollment for
eligible dependents and new dependent enrollment. The objective of this rule is to clarify when
proof of medical insurability will be required in these cases, requiring
certain documentation of retirees, spouses, domestic partners, and those
claiming improper loss of coverages.
[2.81.6.6 NMAC - Rp,
2.81.6.6 NMAC, 1/1/2017]
2.81.6.7 DEFINITIONS:
A. “Act” means the Retiree Health Care Act (Sections 10-7C-1 to
16 NMSA 1978).
B. “Domestic partner” means a person at least 18 years of age,
not married or a member of another domestic partnership, who is in an exclusive
committed relationship with and for the benefit of the retiree member, and who
has shared a primary residence with the retiree member for twelve or more
consecutive months, is jointly responsible with the retiree member for each
other’s common welfare, shares joint financial obligations with the retiree
member, and does not have a blood relationship with the retiree member such as
to preclude marriage between them under New Mexico law.
C. “Open enrollment period” means any of the periods commencing January 1, 2017,
and ending January 31, 2017, or commencing on January 1 and ending on January
31 of every odd-numbered year thereafter, in which an eligible retiree,
eligible spouse, eligible domestic partner or dependents authorized to
participate in NMRHCA’s coverage may enroll into NMRHCA programs and outside of
such periods an eligible retiree, eligible spouse, eligible domestic partner or
eligible dependent may enroll into NMRHCA programs only upon the occurrence of
a qualifying event as provided in 26 U.S.C. Section 125, as amended, and the
regulations promulgated thereunder.
D. “Termination of domestic partnership” means the cessation of the joint and
mutually
responsible
financial and exclusive committed relationship required for a domestic
partnership.
[2.81.6.7 NMAC - Rp,
2.81.6.7 NMAC, 1/1/2017]
2.81.6.8 REQUIREMENTS FOR ENROLLMENT IN COVERAGES: An eligible retiree, spouse, domestic partner
or dependent shall be enrolled pursuant to his/her actual status at the time of
enrollment or at any time thereafter when a change in status occurs. A retiree may add eligible dependents at the
time of acquiring them. A retiree may enroll himself/herself only, and any
eligible dependents, or no eligible dependents. Each such enrollee's status must be the same
for all lines of coverage (i.e. single, two party or family). An eligible spouse, domestic partner or
dependent of a retiree may not be enrolled unless the eligible retiree is
enrolled, except as otherwise provided by court order pursuant to the Mandatory
Medical Support Act Sections 40-4C-1 to 14 NMSA 1978. A spouse, domestic partner or dependent of a
deceased eligible retiree receiving a survivor's pension benefit may enroll
separately. Any eligible retiree,
spouse, domestic partner or dependent
desiring to enroll for coverages shall meet the following requirements:
A. Spouse, domestic partner and dependent
enrollment/medical insurability: An eligible retiree, spouse, domestic partner
or dependent may enroll without evidence of medical insurability only during an
open enrollment period.
B. Eligible retiree, spouse, domestic partner,
dependent change in status/enrollment: Where an
eligible retiree, spouse, domestic partner or dependent was receiving or
eligible to receive group health benefit coverages through a third party and
because of a change in status they lose the coverage and become ineligible for
the coverage the eligible retiree, spouse, domestic partner or dependent may be
enrolled without evidence of medical insurability if enrolled during an open
enrollment period. If the loss of
coverage due to the change in status was not caused by any neglect or wrong
doing by the eligible retiree, spouse, domestic partner or dependent, they may
enroll at any time so long as they do so within 31 calendar days of the change
of status. If an eligible retiree is
employed by an employer offering its employees a basic plan of benefits, the
coverage provided by the NMRHCA plan shall be secondary regardless of whether
the retiree enrolls in his employer's plan.
C. Domestic partner enrollment: An eligible domestic partner may enroll upon
the submittal of sworn statements of domestic partnership executed by both
domestic partners on a form approved by the board.
D. Prohibition against duplicate coverage: An
eligible retiree, spouse, domestic partner or dependent is prohibited from
having duplicate coverage from the NMRHCA for any line of coverage. An eligible retiree, spouse, domestic partner
or dependent is also prohibited from having retiree coverage and dependent
coverage at the same time from the NMRHCA for any line of coverage.
E. More than one eligible retiree in a family:
Where an eligible retiree, spouse, domestic partner or dependent are all
three or two of them eligible retirees, either may enroll into coverage as the
eligible retiree and the other be treated as an eligible spouse, domestic
partner or dependent.
F. Participation requirements for eligible
retiree, spouse, domestic partner or dependent enrollment: An
eligible retiree, spouse, domestic partner or dependent is not permitted to
enroll for a particular line of coverage unless the minimum participation level
as determined by the NMRHCA is met.
G. Switching coverage: The
eligible retiree, spouse, domestic partner or dependent shall all select the
same line or lines of coverage and shall only be permitted to switch, add or
delete coverages during an open enrollment period.
H. Dropping coverage: An
eligible retiree, spouse, domestic partner or dependent (except for dental or
vision coverages) may drop any line of coverage at any time at their
discretion. If they drop a line of
coverage, they cannot re-enroll except as this rule permits. Members of the same family shall not be
allowed to carry different lines of coverage.
I. Dental or vision/dropping coverage:
Once enrolled in dental or vision coverages an eligible retiree, spouse,
domestic partner or dependent may drop such coverages any time after
enrollment. However, once a NMRHCA
participant drops dental or vision coverage, that individual may not reenroll
in that line of coverage until the open enrollment period immediately following
the fourth anniversary of such dropped coverage. The four year waiting period does not apply
to an involuntary loss of coverage and such eligible retiree, spouse, domestic
partner or dependent may reenroll in that line of coverage during the next open
enrollment period.
J. Proper documentation:
Proper documentation, including evidence of medical insurability where
required, must be provided by the eligible retiree, spouse, domestic partner or
dependent seeking coverage within thirty-one days of the application for
coverage. Coverage may be rejected where
adequate proof and documentation satisfactory to the NMRHCA is not submitted in
a timely manner. In the event such documentation is not timely submitted, the
coverage shall not be effective and any contribution paid by the retiree, spouse,
domestic partner or dependent shall be returned without interest.
K. Eligible spouse, domestic partner dependent/open
enrollment: During an open enrollment period of eligible
spouses, domestic partners, and dependents may be enrolled without evidence of
medical insurability. A new spouse,
domestic partner or newborn dependent of an eligible retiree is eligible for coverage
from date of birth, the date of marriage or date of submission of affidavit of
domestic partnership, respectively, without providing evidence of medical
insurability if the eligible retiree submits the required contribution and
proper documentation within 31 calendar days of the birth, marriage or commencement
of domestic partnership. Newly eligible
dependents are also eligible for coverage from the date that a court order
establishes their dependent status without providing evidence of medical
insurability, if the eligible retiree submits the required contribution and
proper documentation within 31 calendar days of the court order. In the event they fail to enroll within this
period of time, they may not do so without providing evidence of medical
insurability unless they subsequently enroll during an open enrollment period. Those persons considered to be a new eligible
spouse, domestic partner or dependent are persons becoming related to the
eligible retiree by marriage, establishment of a domestic partnership, the
birth of a child, establishment of legal guardianship status and other similar
situations where he or she becomes a new family member and is otherwise an
eligible spouse, domestic partner or dependent under these rules.
L. Eligible retiree, dependent, domestic
partner or spouse/same coverage as eligible retiree: The
eligible spouse, domestic partner or dependent has no greater coverage than the
eligible retiree participant and the eligible spouse, domestic partner or
dependent can maintain coverage only to the extent that the eligible retiree
participant maintains his/her coverage.
M. Re-enrollment of eligible dependent student: In
those situations in which the eligible retiree maintains dependent coverage on
an eligible dependent child under Paragraph (3) of Subsection F of Section 10-7C
-4 NMSA 1978 and the child student loses coverage because the child no longer
qualifies as a full time student and at some later time the child again becomes
a full time student and the student otherwise qualifies as an eligible
dependent, the child may re-enroll at a time other than during an open
enrollment period an eligible dependent, without evidence of medical
insurability if notification and proper documentation is provided within 31
days of the change in status.
N. Certificate of eligibility: On
certification by the executive director of the public schools insurance
authority, the executive director of the public employees retirement
association, the executive director of the educational retirement association
or the certifying official designated by board rule of an independent public
employer or other public entity, eligible retirees, spouses, domestic partners
and dependents will be permitted to enroll in coverages within 31 days without
proof of medical insurability. Certification
shall be on a form approved by the executive director of the NMRHCA.
O. Retirement documentation: Employees contemplating retirement are
responsible for submitting documentation prior to retirement so as to assure no
break in coverage occurs.
P. Prohibition of split coverages: Retirees who have spouses or domestic
partners who are employed by employers who offer or provide an employer
benefits plan may choose to be covered by the spouses or domestic partner’s
employers' plan of benefits or the retiree may choose to be covered by the plan
of benefits offered by the NMRHCA. Provided,
however, the entire family shall be required to select to be covered under
either the NMRHCA or the spouse’s employer.
Any responsibility for continued coverage under the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA) shall be the responsibility of either
the NMRHCA or the spouse or domestic partner employer coverage selected.
Q. Coverage after marriage dissolution: Where
there is a dissolution of marriage by decree which results in either of the
former spouses no longer being eligible for coverage, that spouse shall be
eligible only for such continuation of coverage as is required by COBRA.
R. Termination of domestic
partnership: Eligibility for benefit
coverage shall terminate for the non-retiree member of the domestic partnership
upon the termination of the domestic partnership. The retiree member must notify the NMRHCA of
the termination of his/her domestic partnership in writing, which must include
the name of the former domestic partner and the effective date of the termination
of the partnership, within 31 days of the termination.
[2.81.6.8 NMAC - Rp,
2.81.6.8 NMAC, 1/1/2017]
2.81.6.9 ENROLLMENT AND ELIGIBILITY/ CONFLICT
BETWEEN NMRHCA-CARRIER AGREEMENTS, NMRHCA RULES AND REGULATIONS, INDEMNITY
POLICIES, HMO INDIVIDUAL SUBSCRIBER AGREEMENTS AND NMRHCA POLICY
MISCOMMUNICATIONS:
A. Carrier contracts: As to questions of enrollment and
eligibility, in the event there is a conflict between the carrier contract with
the NMRHCA and this rule the rule will prevail.
B. Miscommunication: As to questions of enrollment and
eligibility, if miscommunication occurred, the party negligently communicating
shall initiate action to correct the error.
C. Dispute resolution: As to questions of enrollment and
eligibility, disputes not resolved between the retiree and the NMRHCA or its
contractors shall be submitted to and resolved by the NMRHCA executive
director. Any aggrieved person may
within 30 days of the executive director's decision, appeal such to the NMRHCA
board and its decision shall be final, except as otherwise provided by law.
[2.81.6.9 NMAC - Rp,
2.81.6.9 NMAC, 1/1/2017]
2.81.6.10 ENROLLMENT
IN OPTIONAL, VOLUNTARY, OR SUPPLEMENTAL PLANS: Eligible
retirees, and their spouses, domestic partners, and dependents, may enroll in
optional, voluntary, or supplemental plans such as dental, vision, and life
without enrolling in an NMRHCA medical plan of benefits. The eligible retirees and their spouses,
domestic partners, and dependents enrolling in such optional, voluntary, and
supplemental plans shall pay a monthly premium which will cover the total cost
for each benefit plan they elect to receive.
[2.81.6.10 NMAC - Rp,
2.81.6.10 NMAC, 1/1/2017]
HISTORY OF 2.81.6 NMAC:
Pre-NMAC History: The material
in this part was derived from that previously filed with the State Records
Center and Archives under:
RHCA Rule 90-6,
Retiree, Spouse and Dependent Benefit Coverage Enrollment, 6/5/1990.
History of Repealed Material:
2.81.6 NMAC, Eligible
Retiree, Spouse, Domestic Partner and Dependent Benefit Coverage Enrollment,
filed 12/12/2002 - Repealed effective 1/1/2017.
Other History:
2 NMAC 81.6,
Retiree Spouse and Dependent Benefit Coverage Enrollment, filed 6/02/1998 is
renumbered, reformatted and amended to 2.81.6 NMAC, effective 12/30/2002.