Section 7. Definitions

As used in this rule: A. “Authority” means the New Mexico public school insurance authority or its authorized representatives. B. “Authority board” or “board” means the board of directors of the New Mexico public school insurance authority. C. “Appellant” means any party who complains that a coverage determination may be in violation of any law, rule, regulation, or order administered or promulgated by the authority and who initiates a proceeding under this rule by filing a petition for review with the authority. D. “Coverage determination” and “determination” mean any decision, order or disposition by the authority denying coverage, limiting the scope of coverage or limiting the amount of payment of a claim of a member or employee, except for workman’s compensation claims. E. “Document” means, except as otherwise used in the provisions of this rule governing discovery, any written submission in a formal proceeding which is not a pleading or which is required to be filed by authority rule or order outside a formal pleading; this includes items such as reports, exhibits, and studies; at the option of the party or staff making a filing, any document may additionally be presented in a form the hearing officer so orders. F. “Employee” means a person employed by a member school district, charter school or other educational entity, or an employee’s representatives in the event of legal incapacity, and includes volunteers or officials entitled to authority liability coverage pursuant to the Tort Claims Act, Subsection F of Section 41-4-3 NMSA 1978. G. “Final coverage determination by the authority” with respect to a member means a coverage letter from the authority in consultation with general counsel or contracted claims adjuster or with respect to an employee means a coverage letter from the authority’s contracted third party benefits administrator or authorized authority staff member. 6.50.16 NMAC 2 H ection F of Section 41-4-3 NMSA 1978. G. “Final coverage determination by the authority” with respect to a member means a coverage letter from the authority in consultation with general counsel or contracted claims adjuster or with respect to an employee means a coverage letter from the authority’s contracted third party benefits administrator or authorized authority staff member. 6.50.16 NMAC 2 H. “Hearing” means any proceeding that is noticed for “hearing” by the authority or hearing officer and shall include an opportunity for the parties to present such evidence, argument, or other appropriate matters as the presiding officer shall deem relevant and material to the issues; hearings may be conducted by telephone conference call at the discretion of the presiding officer. I. “Hearing officer” means a person appointed by the authority as a hearing examiner, who is designated by the authority to conduct any hearing or investigation which the authority is authorized to conduct, to take testimony in respect to the subject under investigation, report such testimony and provide to the authority a proposed decision with regard to the issues. J. “Member school districts, charter schools and other participating entities” herein referred to collectively as “members” means all public school districts and charter schools mandated by the act to be members of the authority and all other educational entities voluntarily participating in the authority. K. “Party” means any person or entity that initiates or responds to an authority proceeding by filing a petition for review with the authority and includes the authority; unless the context indicates otherwise, the term “party” may also refer to counsel of record for the party d by the act to be members of the authority and all other educational entities voluntarily participating in the authority. K. “Party” means any person or entity that initiates or responds to an authority proceeding by filing a petition for review with the authority and includes the authority; unless the context indicates otherwise, the term “party” may also refer to counsel of record for the party. [6.50.16.7 NMAC - Rp, 6.50.16.7 NMAC, 09/01/2014; A, 12/10/2024] 6.50.16.8 RELATIONSHIP BETWEEN THE AUTHORITY, ITS MEMBERS AND COVERED EMPLOYEES: These findings and policy considerations guide the authority in adopting the following regulations and providing a procedure for administrative appeal of authority coverage determinations: A. The authority is an agency of the state of New Mexico and is endowed only with those powers and duties stated in the New Mexico Public School Insurance Authority Act, Section 22-29-1 et seq. NMSA 1978 (“act”). The relationship between the authority and its members or employees, and any coverage provided by the authority to them, is defined and constrained by the act and by authority rules, regulations and procedures lawfully promulgated under the act. B. The members of the authority participate pursuant to Section 22-29-9, NMSA 1978 of the act, which provides that school districts and charter schools shall participate in the authority unless they are granted a waiver of participation pursuant to the procedures provided in that section of the act. Section 22-2-9 NMSA 1978 also provides that other educational entities may participate in the authority. C. The act does not empower the authority to contract with its members or employees. There is no relationship between the authority and its members or employees based upon or arising out of any contract between the authority and its members or employees. D s provided in that section of the act. Section 22-2-9 NMSA 1978 also provides that other educational entities may participate in the authority. C. The act does not empower the authority to contract with its members or employees. There is no relationship between the authority and its members or employees based upon or arising out of any contract between the authority and its members or employees. D. The insurance protection provided by the authority to its members is provided either by insurance policies contracted through private insurers or through the statutory self-insurance program administered by the authority. E. For the benefit of the authority and its members and their employees, the following regulations provide a formal procedure for members and employees to appeal authority coverage determinations. Therefore, the following procedures for appeal from any coverage determination or ruling of the authority are provided as the exclusive remedy for any person or entity challenging a coverage determination of the authority. [6.50.16.8 NMAC - Rp, 6.50.16.8 NMAC, 09/01/2014] 6.50.16.9 PROCEDURE FOR APPEAL OF A FINAL COVERAGE DETERMINATION OF THE AUTHORITY: An aggrieved member or employee may appeal any final coverage determination of the authority by following the procedures specified herein. Review of any final decision or order of the authority can only be sought as provided by statute or by rules promulgated by the supreme court for appeal of state agency decisions.