New Mexico has a high-risk pool program, called the New Mexico Medical Insurance Pool (NMMIP), which provides access to health insurance coverage to all residents of New Mexico who are denied adequate health insurance and are considered uninsurable and for people who are HIPAA eligible.
When can I get coverage from nmmip?
- If you are HIPAA eligible, you can buy health insurance from the NMMIP without limits on coverage for pre-existing conditions. You also can buy coverage from the New Mexico Health Insurance Alliance. Compare the options to see which is best for you (see page 20).
To be HIPAA eligible, you must meet certain criteria
If you are HIPAA eligible in New Mexico, you are guaranteed the right to buy individual health insurance from the New Mexico Health Insurance Alliance or the New Mexico Medical Insurance Pool (NMMIP) and are exempted from pre-existing condition exclusion periods. To be HIPAA eligible, you must meet all of the following:
- You must have had 18 months of continuous creditable coverage, at least the last day of which was under a group health plan.
- You also must have used up any COBRA or state continuation coverage for which you were eligible.
- You must not be eligible for Medicare, Medicaid or a group health plan.
- You must not have health insurance. (Note, however, if you know your group coverage is about to end, you can apply for coverage for which you will be HIPAA eligible.)
- You must apply for health insurance for which you are HIPAA eligible within 63 days of losing your prior coverage.
HIPAA eligibility ends when you enroll in the NMMIP, the Alliance or individual health insurance, because the last day of your continuous health coverage must have been in a group plan. You can become HIPAA eligible again by maintaining continuous coverage and rejoining a group health plan.
- If you are not HIPAA eligible, you can buy insurance from NMMIP if you are a New Mexico resident and can demonstrate proof of uninsurability. You are considered uninsurable if you have been turned down for comprehensive health insurance coverage, offered health insurance that excludes coverage for your pre-existing condition, offered individual health insurance at a premium higher than NMMIP premiums, or have been diagnosed with one of NMMIP’s pre-qualifying medical conditions.
You are also eligible for NMMIP coverage if your health plan is terminated involuntarily because the insurer stopped issuing coverage in New Mexico, your coverage in another state’s high-risk pool ended due to non-residency, or your current coverage in another state is not valid in New Mexico.
In addition, if you have a policy from the Alliance, you can transfer into NMMIP.
- You are not eligible for NMMIP coverage if you have terminated NMMIP coverage within the past 12 months, if you are an inmate of a public institution, or if other coverage has been terminated because of nonpayment or fraud.
- Family coverage is available in the NMMIP. Dependent coverage ends when children reach 19 years of age or, if a full-time student, when they reach 25 years of age. Adult dependents who are incapable of self-sustaining employment because of developmental disability or physical handicap and are primarily dependent on the policyholder can remain covered after the limiting age. Proof of incapacity and dependency must be provided within 120 days of reaching the limiting age and may be required subsequently in the future.
What will nmmip cover?
- The NMMIP offers coverage with a choice of annual deductibles ($500, $1,000, $2,000, $5,000, $7,500, or $10,000). After the deductible is met, the NMMIP will pay 80% of the claims until your out-of-pocket limit for the plan is met. The maximum out-of-pocket limits for the different deductible options are $2,500, $3,500, and $5,000, respectively. There is no out-of-pocket maximum for the $5,000, $7,500 and $10,000 deductible options and NMMIP pays 100% for most covered services once the annual deductible has been met.
- Benefits are the same under these options. NMMIP plans cover hospital and physician care, prescription drugs, and other services. Limited home health visits and organ transplant coverage are available. There is no lifetime maximum per member except for certain benefits (e.g., $250,000 lifetime maximum per member for organ transplant). Maternity coverage is available for an additional premium.
What about coverage for my pre-existing condition?
- You will not have a pre-existing condition exclusion when you enroll in NMMIP if any of the following applies to you:
- o You are HIPAA eligible;
- o Your prior coverage was terminated involuntarily and you apply for coverage within 31 days of termination;
- o You have individual health insurance that has been in effect for at least six months at a premium higher than NMMIP premiums;
- o Pre-existing condition exclusions have been satisfied under prior policies; or
- o You have been covered by another state’s high-risk pool and it ended due to non-residency.
- If you are not HIPAA eligible or none of the above applies to you, NMMIP can exclude coverage for your pre-existing condition for 6 months. NMMIP follows the rules of other individual health insurers for pre-existing conditions. It will look back 6 months, using the prudent person rule, for evidence of a pre-existing condition. Pregnancy can be counted as a pre-existing condition and is subject to special rules.
NMMIP will credit prior continuous coverage toward your pre-existing condition exclusion if you apply for NMMIP coverage within 31 days of losing your prior coverage.
What can I be charged for pool coverage?
- Premiums will vary based on the plan you choose. In addition, the NMMIP charges enrollees different rates based on their age and gender. Under New Mexico law, the NMMIP rates cannot be more than 50% higher than the average premium a healthy person would pay if he or she bought a similar plan sold by a private insurer in New Mexico.
The monthly NMMIP premium for a 24-year-old male ranges from $82 to $174, depending on which plan option is selected. By contrast, the monthly premium for a 64-year-old male ranges from $257 to $543, depending on which plan option is selected.
Contact the New Mexico Medical Insurance Pool for the most current information about premium and coverage options at (800) 432-0750 or visit their website at http://www.nmmip.com/.
How long does pool coverage last?
- NMMIP policies are renewable as long as you pay your premiums, continue to reside in New Mexico, and meet other eligibility requirements.