What is the New Mexico Medical Insurance Pool (the Pool)?

The pool was created to provide access to health insurance coverage to all residents of New Mexicans who are denied adequate health insurance and are considered uninsurable.

When was the Pool started?

The New Mexico Medical Insurance Pool (NMMIP) was established by the 1987 New Mexico State Legislature.

Who manages the Pool?

The Pool is administered by BlueCross BlueShield of New Mexico who handles eligibility, enrollment, member services, and claims processing.

How are the operations of the Pool financed?

Financing of the Pool is a four-way partnership: premiums from individuals, assessment of losses to health insurance carriers, State premium tax credits for health insurance carriers (to help offset assessments) and a Federal grant.

Who sets the premiums charged?

The Board of Directors, with approval of the Superintendent of Insurance, is responsible for setting the premium rates. By state law, those rates cannot be above 150% of the “standard risk rate” (the average premium rate charged for healthy individuals in the private market). Premium rates are reviewed at least annually and, currently, the premiums are set at less than 135% of the standard rate.

  Who is eligible for Pool coverage?

There are a couple basic categories of eligibility. The first major category is if you have a qualifying medical condition or have either been rejected for individual coverage or offered insurance with a rate above the Pool’s qualifying rate or with restrictions and limits in coverage due to a health condition. The second major category is if you meet State or Federal criteria under HIPAA (Health Insurance Portability and Accountability Act) of having at least 18 months of previous group coverage that ended within the last 95 days and now you need an individual policy. See Eligibility for details.

How do I apply for coverage?

Complete an application and submit it along with requested documentation and a check for the first month’s premium. Instructions for submission, as well as contact information for questions, are on the application form. [Click Here] to access the Application/Forms page.

How are payments of premiums handled?

Payments are made directly to BCBSNM (Blue Cross Blue Shield New Mexico), who administers the Pool’s insurance plan. You may sign up for payments to be withdrawn automatically from your bank account.  [Click Here] to access the Auto Payment Form.

What are the residency requirements for the Pool?

You must be a resident of New Mexico to be eligible for Pool coverage. However, there is no minimum time limit for residency. But, you must have a physical street address in New Mexico and, if you currently live elsewhere, coverage cannot become effective prior to moving to the state.

What happens if I live part of the year in another state?

As long as you maintain your permanent residence in New Mexico, you can be gone from the state for periods of time for reasons such as contract work, school or to live with family due to illness or other temporary circumstance. Your driver’s license, vehicle registration or other documentation may be required to assist us in determining residency.

Do I have to accept my employer’s insurance instead of the Pool?

You are required to join an employer’s group health insurance as soon as you become eligible. If they apply a waiting period for pre-existing condition, you may keep Pool coverage until their waiting period has ended. You may also keep Pool coverage and not enroll in the group plan if the coverage offered is limited and not comprehensive. In that case, your employer must contribute the same dollar amount for your Pool coverage as he does for other employees on the employer’s plan but you will not be eligible for the Low-Income Premium Program.

Can I get a Pool policy if my current plan has limited benefits?

We will need to review your summary of benefits to determine if the plan is comprehensive or limited. (Note: The policy is not necessarily limited just because it offers fewer benefits or pays less than the Pool policy.) If your current coverage is determined to be limited, you must still meet other eligibility criteria to qualify for Pool coverage. (i.e. have a qualifying medical condition, receive a rejection notice for coverage or offer of coverage with a rider/waiver/exclusion or with a rate above the Pool’s qualifying rate.) The waiting period for pre-existing conditions may be waived, depending on how long you had prior coverage.

Is there a waiting period for pre-existing conditions?

Yes. However, to be considered a pre-existing condition that may be subject to a waiting period of up to six months, the condition must be one for which medical advice or treatment was recommended or received within six months before the effective date of the Pool policy OR be a condition that manifested itself during the previous six months in such a way that would cause an ordinarily prudent person to seek diagnosis or treatment. NOTE: A pre-existing waiting period applies only to pre-existing conditions and not to new conditions, wellness care or prescription drug coverage.

Is the six-month waiting period ever waived?

If you had prior coverage of at least six months and you apply for Pool coverage within 95 days of prior coverage ending, the waiting period will be waived. (In that case, Pool coverage will be effective on the date prior coverage ended, which may require payment of additional premiums to fill any gap of up to 95 days.) If you had prior coverage of less than six months, and apply for Pool coverage within 95 days of termination, you will be given credit toward the waiting period equivalent to the months of previous coverage. There is no waiting period for pre-existing conditions if your previous coverage did not have a six-month pre-existing condition clause (i.e. SCI or Medicaid) or was terminated involuntarily less than 95 days prior to applying for Pool coverage.

What is HIPAA and how does it affect Pool eligibility?

There is both federal and state law (Health Insurance Portability and Accountability Act) that has provisions to assure access to individual health insurance coverage if you have had at least 18 months of continuous coverage, the last of which was group coverage, without any single gap of more than 95 days. If you had group coverage through your employer, or certain other groups, you are usually offered the ability to continue that group coverage (COBRA) for a period of time (usually 18 months) but you pay the full premium – both what your employer previously contributed as well as the portion you paid. If your family members were also covered, then each of you individually has the option of continued coverage under COBRA. Following the exhaustion of COBRA, if you or your family members had 18 months of continuous coverage, you/they are eligible for coverage in the Pool without a pre-existing waiting period and without the need to meet medical eligibility or get a rejection notice.

Do I have to take COBRA after insurance through my job ends?

If you are offered COBRA coverage, you do not have to elect it and can apply to the Pool instead. However, if you do enroll in COBRA coverage you may have to exhaust that coverage before being eligible for the Pool, depending on certain circumstances. However, if the rates of your COBRA plan are higher than the Pool’s qualifying rates, you will qualify for Pool coverage and can switch at any time. NOTE: We advise that you do not drop current COBRA coverage until you have been assured of approval for Pool coverage

How does “qualifying rate” differ from the premium?

The qualifying rate is determined twice a year (January and July) and is equal to 125% of the “Standard Risk Rate,” which is the average rate for insurance in the private market for a healthy individual. The premium for Pool coverage is separately set by the Board of Directors and, at present, is a little higher than the qualifying rate. If the premium rate or quote for your current or applied-for insurance is above the Pool’s qualifying rate, you are eligible for Pool coverage.

How do I qualify for the Low Income Premium Program?

Income level alone does not qualify you for Pool coverage. You must meet other eligibility criteria and then, if you meet the household income guidelines, you may apply for the LIPP. NOTE: If you have current health coverage you cannot drop it just so that you can enroll in the Pool and take advantage of the LIPP. If you voluntarily terminate other comprehensive coverage, even if you meet medical eligibility criteria and have had coverage more than six months, you will be subject to a six-month waiting period for pre-existing conditions. The only exceptions are if your current premium is higher than the Pool’s qualifying rates or if you meet HIPAA eligibility criteria.

Can/must my employer help pay my Pool premiums?

If you are employed, but cannot obtain health coverage under your employer’s program because of health reasons, your employer may make a payroll deduction for your portion of the Pool premium. If your employer contributes to health coverage for others, he must contribute the same dollar amount for the Pool policy as he contributes for other similar employees. Employers must also offer and make available to dependent family members of an employee covered by the Pool the same group plan, at the same cost, offered to dependent family members of other employees. The employer must contribute in total, between Pool contribution on behalf of the employee and group family coverage, the same amount as he would have paid for family coverage for another similar employee/family. NOTE: If your employer contributes to your premium, you are not eligible for the LIPP.

If I drop/lose Pool coverage can I re-enroll?

If you fail to pay the premium by the due date, or within the allowed grace period, or if you voluntarily leave the Pool program, you will not be eligible to re-apply for 12 months, unless you drop coverage because you become eligible for group coverage or a public program (i.e. Medicaid) and then involuntarily lose or exhaust that coverage.