Benefits and Eligibility
Benefits & Eligibility Requirements
Summary of Benefits
Our Summary of Benefits and Coverage documents describe what each plan covers and what it costs for coverage.
Find our Summary of Benefits here.
Eligibility
New Mexico High Risk Pool Eligibility Requirements:
- You can qualify for the Pool if:
- You are a resident of New Mexico with a permanent street address; and
- Have a rejection notice for comprehensive healthcare coverage; or
- Have a quote for, or in-force, premium rate that is higher than the Pool’s qualifying rate; or
- Have a rider, waiver or limitation on current or offered coverage that reduces or limits your coverage due to a health condition; or
- You are/will be involuntarily terminated from an individual plan because the carrier stopped selling such coverage in New Mexico; or
- You are moving to New Mexico and were covered by a High Risk Pool in another state; or
- You are currently covered by a plan under the New Mexico Health Insurance Alliance and wish to transfer to the Pool; or
- You have reached the maximum allowable coverage limit of your current health insurance plan; or
- You meet HIPAA eligibility criteria.
Not Eligible
You are NOT eligible for the Pool if:
- You have other comprehensive coverage;
- You are, or become, eligible for other comprehensive coverage, including insurance from an employer either as yourself or as a family member;
- You are eligible for Medicaid;
You are 65 or older and have, or are eligible for, Medicare; - You voluntarily dropped your most recent coverage and it was within the last 12 months;
- You are in prison;
- You have military health coverage under Tricare.
HIPAA Eligibility
To be eligible under Health Insurance Portability & Accountability Act (HIPAA) criteria, you must:
- Have had a minimum of 18 months of continuous coverage with no single gap of more than 95 days, the last of which was group coverage; and
- Apply to the Pool within 95 days of your prior coverage ending; and
- You do not have, nor are eligible for, other group insurance. (Eligibility for individual insurance does not disqualify you under HIPAA.)
COBRA
If you are offered group continuation coverage through COBRA or some other continuation coverage, you do not have to accept such coverage prior to being eligible for the Pool. Exceptions to the requirement that COBRA be exhausted, if elected, include:
- The premium rate for COBRA/continuation coverage is above the Pool’s qualifying rate.
- COBRA/continuation coverage is no longer offered where you live (Coverage for that area is no longer available OR you have moved out of the coverage area.)
- Some other special circumstances. Contact the Pool if you have COBRA/continuation coverage, and don’t wish to exhaust such coverage, to discuss your circumstances. Type your paragraph here.
Medicare Carve Out Plan Information
Summary of Benefits
Our Summary of Benefits and Coverage documents describe what each plan covers and what it costs for coverage.
Find our Summary of Benefits here.
Eligibility
The NMMIP Medicare Carve-Out Plan is available to individuals under the age of 65 who are enrolled in Medicare due to a disability. You must have both Medicare Part A and Part B to be eligible for the Carve-Out Plan.
Coordination of Benefits
The NMMIP Carve-Out Plan is designed to “coordinate” benefits with Medicare and usually pays benefits only after Medicare has paid its portion of your covered health care services. Medicare is called the “primary” coverage or carrier and pays its benefits first.
The NMMIP is the “secondary” coverage or carrier. You may not elect to change NMMIP to be the primary carrier and may not elect to bypass Medicare. If services are among those normally covered by Medicare, you or your doctor or hospital (your health care “provider”) must submit a claim for those services first to Medicare. Medicare will calculate its benefits and will send you an Explanation of Medicare Benefits (EOMB) form. This form must be attached to any claim you send to the NMMIP Administrator. Note: You will usually not have to submit claims.
Services Covered Only by NMMIP
A service covered under this Policy may not be covered by Medicare either because it is not a covered type of service under Medicare (such as acupuncture) or because it is from a provider that is not covered by Medicare (such as a nonparticipating hospital). When such services are covered under this NMMIP Policy, you can choose to visit any eligible health care provider you want and still receive benefits as listed. However, there are advantages to choosing a health care provider that has a participating provider agreement with the Administrator. These providers will not bill you for amounts that are over the Administrator’s maximum allowable fee (or covered charge).
Note: Some services not covered by Medicare will be denied or benefits for them reduced if you do not obtain prior approval from the Administrator.
Services Covered Only By Medicare
This Carve-Out Plan will cover Medicare-eligible services that are also listed as covered in the Summary of Benefits on pages iv and v. However, some benefits are limited under the NMMIP Policy and benefit payments cannot exceed those limits – even if Medicare covers the service.
If you are needing help finding the best plan for you, please see the following list of brokers approved for NMMIP.