In New Mexico, small employers can buy small group health plans through the New Mexico Health Insurance Alliance.  The Alliance was organized to improve access to health insurance coverage for small employers.  It has been expanded to include access to health insurance coverage for individuals who meet eligibility criteria, including HIPAA eligible individuals (see Chapter 3).

When can I get group coverage from the Alliance?

• If you are an employer with 2 to 50 eligible employees, you can buy health insurance from the Alliance.
• If you are self-employed and want to buy coverage for yourself and at least one other family member, you can buy health insurance from the Alliance.
• You must meet other eligibility standards listed below:
• o At least 50% of all employees (eligible for health benefits or not) must live within New Mexico.
• o At least 50% of eligible employees must enroll. (Note: When counting eligible employees, subtract those who have coverage already, those subject to an employer waiting or probationary period, seasonal employees, and those working fewer than 20 hours per week.)
• o Employer must not already offer other health insurance to employees.
• o Employer premium contributions are not required.
• o Employees must work at least 20 hours per week to qualify as full-time.
• Family coverage is available in the Alliance. Dependent coverage ends when children reach 19 years of age or, if full-time students, 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 the Alliance cover?

• The Alliance offers HMO, PPO, and indemnity plans. Benefits are the same under these options, but cost sharing varies.

Indemnity plans offer a choice of annual deductibles, ranging from $500 to $10,000, a choice of coinsurance (the plan pays either 50%, 70%, or 100% of covered charges after the deductible is met), and a choice of out-of-pocket limits, ranging from $5,000 to $10,000.  All indemnity plans have a lifetime maximum of $2 million on covered benefits.

You can also choose from three PPO options: (1) a plan with a $1,000 annual deductible, 50% coinsurance, and a $10,000 out-of-pocket limit; (2) a plan with a $2,500 annual deductible, 50% coinsurance, and a $10,000 out-of-pocket limit; or (3) a plan with a $10,000 annual deductible and no coinsurance (this means that the plan pays 100% of covered charges after the deductible is met).  All PPO plans have a lifetime maximum of $2 million on covered benefits.

The HMO plan requires no deductible and there is no maximum lifetime benefit.  The maximum out-of-pocket for per calendar year for covered services is $2,500 for individuals and $5,000 for family.  The copayments vary based on the services received - $30 copayment for physician services and $100 for emergency care.

• Alliance plans cover hospital care, physician services, wellness care, prescription drugs, maternity care, mental health services, and other services. Alcohol and substance abuse services are covered in the HMO plan but is offered as an optional coverage in the indemnity plans.

What about coverage for my pre-existing condition?

• If you are a small employer or if self-employed enrolling with at least one other family member, the Alliance can exclude coverage for your pre-existing condition for 6 months. The Alliance will look back 6 months before you enroll to see if you had a condition for which you actually received a diagnosis or medical advice or treatment. The Alliance will give you credit for prior continuous coverage if your break in coverage is not 63 days or more. Pregnancy and genetic information cannot count as pre-existing conditions.

What can I be charged for alliance group coverage?

• If you are buying a small group health plan through the Alliance, you cannot be charged higher premiums because of the health status of those in your group. However, you can be charged more, within limits, based on age, gender, family size, where you live, and the plan that you choose. This is called modified community rating.
• Contact the New Mexico Health Insurance Alliance for the most current information about premium and coverage options.

How long does Alliance group coverage last?

• Alliance group policies are guaranteed renewable as long as you pay your premiums and meet other eligibility requirements.