The New Mexico Health Insurance Alliance (the Alliance) is a state-run program that offers private health insurance coverage to HIPAA eligible individuals as well as to those individuals who lost their group coverage through the Alliance.  The Alliance also offers group health plans to small businesses and self-employed that meet specified requirements (see page 27).

When can I get individual health insurance from the Alliance?

• If you are HIPAA eligible, you are guaranteed the right to buy an approved health plan through the Alliance without limits on coverage for pre-existing conditions. You can buy coverage for yourself and your dependents.

If you are HIPAA eligible, you have a choice between buying coverage through the Alliance or the New Mexico Medical Insurance Pool (see page 22).  Compare the options to see which is best for you.

• If you had group coverage through the Alliance and lost it, you can continue in your plan as an individual indefinitely.

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 annual 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 offered as optional coverage in the indemnity and PPO plans.
• Once you enroll in an Alliance plan as an individual, you can change your benefit options annually on the anniversary date of your coverage. (For example, you can choose a higher or lower deductible.) However, you will not be allowed to switch to a different insurance company or HMO except in two circumstances. If your insurer stops offering coverage through the Alliance you can choose another insurer. In addition, if you are enrolled in an HMO and you are moving out of the service area, including out of state, you can buy coverage from an indemnity or PPO insurer in the Alliance.

What about coverage for my pre-existing condition?

• If you are HIPAA eligible, you will not have a pre-existing condition exclusion period.
• If you lose your group coverage that you had through an Alliance plan and elect to continue coverage through that plan as an individual, you will not have a new pre-existing condition exclusion period.

What can I be charged for Alliance individual coverage?

• Premiums will not vary because of your health status. However, they may vary, within limits, based on your age, gender, family size, where you live, and the plan that you choose. This is called modified community rating.
• Discounted premiums are available to people within low to modest incomes (see Chapter 5).

How long does Alliance individual coverage last?

• You can remain enrolled in the Alliance as long as you pay your premiums.
• Unlike COBRA, continuation coverage in the Alliance lasts indefinitely. You can remain with your plan as long as you need it, even if you move to another state, as long as you continue to pay your premiums. Each year, you will have an opportunity to change benefit packages, but you will not be allowed to change insurance companies except in limited circumstances.