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Medicaid, SCHIP, & Federal Authority

  • Health Insurance Flexibility and Accountability (HIFA) Demonstration - In 2002, New Mexico received a HIFA waiver to expand coverage to low-income uninsured working adults with incomes up to 200 percent of the federal poverty level (FPL).  Under that program, coverage was purchased with a combination of state, federal, employer and employee funds. 

    In July 2005, the state implemented the New Mexico State Coverage Insurance (SCI).  This is a public-private partnership resulting in the creation of a new employer-sponsored insurance program.  The state contracts with managed care organizations to provide the product.  The target population is low-income, uninsured, adults working for small employers with family income below 200 percent of the federal poverty level (FPL). An individual may enroll through his or her employer, as a self-employed individual, or as an individual without employer-sponsored insurance.  The premium is paid through contributions from the employer and employee in combination with state and federal funds.  Individuals and the self-employed must pay the employer as well as the employee portion of the premium. The benefit package is a comprehensive health care benefit with a claims benefit maximum.  The SCI plan features cost-sharing designed to ensure that low-income participants would have access to care. Enrollment in the program began in July 2005 and, as of November 2007, 11,489 participants were enrolled.

    Section 1115 Waiver - In 1998, New Mexico received approval for a State Children’s Health Insurance Program (SCHIP) demonstration for implementation of co-payment requirements and a six-month period of SCHIP ineligibility in instances where an applicant’s health insurance was voluntarily dropped.  New Mexico SCHIP covers children up to age 19 in families with income between 185 percent and 235 percent of the FPL.


  • New Mexico Health Insurance Alliance (Alliance) was created in 1994 by the state legislature to provide increased access to health insurance for small businesses, self-employed individuals, and other qualified individuals. The Alliance consists of independent health insurers and operates without medical or industry underwriting, sets yearly rates, and simplifies participation for employers. Carriers in the state are assessed an annual administrative fee withheld from gross premiums.  Costs not paid via premium assessments are collected from the carriers proportionately by market share.

    Legislation passed in 2005 (HB 294) reduced premiums for small businesses by changing the Alliance premium structure.  The bill also expanded the Alliance’s responsibility for outreach, public awareness, and assistance to employers in obtaining and maintaining health insurance.

    The Alliance is part of the Insure New Mexico! model.  It offers three types of broker-assisted comprehensive plans: PPO, Indemnity, and HMO through 11 participating commercial carriers. Employee and dependent share of premiums depend on employer contribution. Alliance policies are available to those who currently offer insurance coverage. It is available for employees and dependents of small businesses (2-50 employees), self-employed persons with at least one dependent, and individuals.

High-Risk Pools

  • The New Mexico Medical Insurance Pool  became operational in 1988 and is financed by premiums and assessments to insurers. High-risk individuals previously rejected by commercial carriers, those having received a rate increase or rate quote exceeding certain limits based on health status, those who have specific pre-existing conditions, or who have received notice of a rider, waiver, or restrictive provision are eligible to participate. The premium cap is set at 140 percent of the standard risk rate.  New Mexico operates a 75 percent premium subsidy for recipients who earn between 0 percent and 200 percent FPL and a 50 percent premium reduction for recipients between 200 percent FPL and 399 percent FPL.  The subsidy program is called the Low Income Premium Program (LIPP).  At the end of January 2008, over 5,000 persons were enrolled in the Pool.

Dependent Coverage

  • An individual or group health policy may not terminate coverage of an unmarried dependent before the dependent's 25th birthday. This applies regardless of whether the dependent is enrolled in an educational institution. (59A-22-30.1)

Group Purchasing Arrangements

  • In 2005, the New Mexico legislature created the Small Employer Insurance Program (SEIP).  SEIP is one of the Insure New Mexico! initiatives that addresses the problem of the high number of uninsured working adults in New Mexico.  SEIP is specifically tailored towards helping small employers and non-profits, with 50 or fewer employees, to voluntarily buy into a state-administered pool if the firm has not offered insurance for twelve months.  The pool is self-funded by premium contributions paid by employers and employees and backed by a stop-loss insurance policy.  To maintain the integrity of the risk pool, high-risk SEIP members become members of the high-risk pool.  The SEIP program and the Pool will use the same administrator so the individuals within the group will not know if they are drawing coverage from SEIP or from the Pool.  The benefit package will be similar to the New Mexico State Coverage Insurance program.


State Specific Strategies

  • New Mexico has created a portal to facilitate insurance coverage called the Insure New Mexico! SolutionsCenter. This initiative features health insurance products custom-designed for each small employer, based on employee demographics and the needs of a specific employer group.  The custom product will incorporate coverage for each employee through publicly administered products including New Mexico State Coverage Insurance (NMSCI), New Mexico Medical Insurance Pool (the Pool), the New Mexico Health Insurance Alliance and the Small Employers Insurance Pool (SEIP).

    Premium Assistance for Maternity (PAM) covers pregnancy-related services for women who are ineligible for Medicaid maternity services due to income. The enrollee pays a one-time enrollment fee per pregnancy depending on the trimester in which she enrolls. Enrollment cost during the first 20 weeks of pregnancy is $150. Enrollment cost during the second 20 weeks of pregnancy is $300. 

    Under the Insure New Mexico initiative, the state expanded access to care through innovative premium assistance programs for children and pregnant women who are not eligible for Medicaid due to income.  This public/private program not only helps more uninsured children receive the healthcare coverage they need, it also helps assure that children receive healthier starts by encouraging pregnant women to begin receiving healthcare services early in pregnancy.

    Premium Assistance for Kids (PAK) covers children ages 0 to 12, or up to 18 years old if part of a sibling group with a child under age 12, who are ineligible for the New Mexikids program due to income. The state assists with 50 percent of the costs of the premium. Premiums range from $70 to $180 per month. The PAK benefit package (an individual commercial benefit package)includes preventive, primary and specialty care, inpatient and outpatient hospitalization, pharmacy, lab, x-ray and physical, occupational and speech therapy.