Fact Sheet Number 322
INSURANCE POOL (NMMIP)
- WHAT IS NMMIP?
- WHO IS ELIGIBLE FOR NMMIP?
- WHAT DOES THE POLICY PAY?
- ANNUAL DEDUCTIBLE
- OUT-OF-POCKET MAXIMUM
- PRE-EXISTING CONDITIONS
- WHAT SERVICES ARE COVERED?
- HOW MUCH DOES IT COST?
- RENEWAL AND TERMINATION
- PREMIUM CHANGES
- RE-STARTING YOUR POLICY
- HOW TO APPLY FOR A POLICY
- EMPLOYER RESPONSIBILITIES
- GRIEVANCE PROCEDURE
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The New Mexico Legislature developed the New Mexico Medical Insurance
Pool (NMMIP) to provide health insurance coverage to all residents
of New Mexico who are denied adequate health insurance and are
considered uninsurable. The administrator for the NMMIP is Blue
Cross Blue Shield of New Mexico (BCBSNM), PO Box 27630, Albuquerque,
NM 87125-7630. Telephone 1-800-432-0750.
Please refer to the actual insurance policy for a detailed
explanation of the rights and obligations of the NMMIP program
and policyholders.
FOR NMMIP?
Coverage is available to residents of New Mexico who are unable
to obtain health insurance. You may be eligible if you have received:
- A notice or rejection for substantially similar health insurance.
- A notice of health insurance being available ONLY with a
rider, waiver, or restrictive provision for you, specifically
based on a health condition.
- A notice with a premium rate that will exceed the rate of
the NMMIP $500 deductible for the applicant’s age and sex.
- A certificate of prior comprehensive medical/surgical group
coverage (including COBRA continuation), that was terminated
within the last 63 days prior to your date of application.
- Involuntary termination of coverage because the insurer stopped
issuing coverage in New Mexico, or your coverage in another state’s
high risk pool ended due to non-residency.
Important: Coverage is not available if you are
eligible for and/or covered by Medicare, Medicaid, or another
health insurance benefit plan through an employer or your own
policy.
Your spouse and unmarried children may be covered under an
NMMIP family policy if they each satisfy all eligibility requirements.
POLICY PAY?
There are four plans offered under the NMMIP program.
Under Plans 1, 2, and 3, the NMMIP program pays 80% of the maximum
allowable fee for covered charges after you pay the annual deductible
amount. After you have paid your out-of-pocket maximum for the
year, the program pays 100% of covered charges. Under Plan 4,
the NMMIP program pays 100% of the maximum allowable fee for covered
charges after you have paid the annual deductible amount.
Lifetime maximum benefit is unlimited, except for certain benefits
specifically described.
The annual deductible is the amount you must pay each calendar
year before the NMMIP program begins to pay benefits. There are
four choices for deductibles:
- Plan 1: $500 per person per year
- Plan 2: $1,000 per person per year
- Plan 3: $2,000 per person per year
- Plan 4: $7,500 per person per year.
MAXIMUM
The out-of-pocket maximum is the total amount you will pay each
year before the NMMIP program starts to pay 100% of covered expenses.
Your deductible amount, plus your 20% share of covered expenses
after the deductible (called “co-pay” or “coinsurance”)
count toward your annual out-of-pocket maximum. The out-of-pocket
maximums are:
- Plan 1: $2,500 per person/$5,000 per family
- Plan 2: $3,500 per person/$7,000 per family
- Plan 3: $5,000 per person/$10,000 per family
- Plan 4: $7,500 per person.
You will not receive any benefits during the first six months
you have an NMMIP policy for any health condition if, during the
six months before you got the policy,
- You got medical advice or treatment for the condition, or
- Medical advice or treatment was recommended for a condition.
This 6-month waiting period may be waived if,
- You have 18 months of creditable coverage with no more than
a 63-day break and your last coverage was group coverage, or
- You had an involuntarily termination of coverage or your
coverage in another state’s high risk pool ended due to non-residency,
and apply within 31 days and have no lapse in coverage.
This 6-month waiting period may not apply if you apply for
NMCHIP insurance because your prior health insurance was cancelled.
ARE COVERED?
Contact BCBSNM for detailed information about covered services.
Maternity benefits are available for an additional premium.
IT COST?
NMMIP premiums are reviewed twice each year. Ask your case manager
or the BCBSNM for current premium rates. You might qualify for
a reduced premium from NMMIP if your income is below 200% of the
federal poverty level, or $17,720 annually. A reduced premium
is not available if a third party, who is not a family member,
pays your premium. You may also be eligible for the Insurance
Assistance Program, which can help you pay for health insurance
if your income is below 300% of the federal poverty level, or
$2,215 monthly. Your case manager can give you more information
on how to pay for NMMIP insurance.
The NMMIP policy is renewed each time you pay the required premium,
until one of the following occurs:
- You stop being eligible for NMMIP
- You stop being a resident of New Mexico
- You become eligible for other health insurance (other than
Medicare or Medicaid)
- You ask to cancel your policy
- You do not provide a written response regarding an inquiry
about your place of residence within 30 days.
Your premium is based on your sex and age. It will increase as
you get older. It may also change for everyone in a certain age
and sex group, based on the actual benefits paid by the NMMIP
program. You will be notified at least 30 days before any premium
changes.
POLICY
If your policy is cancelled for nonpayment, or because you ask
to have the policy cancelled, you can’t reapply for coverage for
12 months.
A POLICY
You can apply for an NMMIP policy through your case manager, from
BCBSNM (see the first paragraph on this page) or through any licensed
health insurance agent or agency in New Mexico.
If you are employed, your employer may have to help pay for your
NMMIP policy. In general, an employer must pay the same dollar
amount for your health insurance as they do for similar employees.
Your employer has to offer your family members the same group
health insurance that is available to other employees in your
group. If your employer saves money because you get your policy
from NMMIP instead of through the employer’s group plan, they
have to contribute an equal amount to help pay for insurance for
your family members under the employer’s group plan.
There is a procedure to follow if you think a mistake was made
in deciding that you do not qualify for a policy under NMMIP,
or in deciding how much you should be paid in benefits. You can
find information on this procedure in your NMMIP policy, or in
the notice that tells you that your application for a policy was
turned down.
Revised February 22, 2002
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