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The goal of New Mexico's State Coverage Insurance (SCI) is to address New Mexico's high rate of uninsured and low rate of employer-sponsored health care. State Coverage Insurance (SCI) offers affordable health care coverage to low-income working adults primarily through an employer-based system. You may enroll through your employer group or as an individual.

Availability

SCI is available to uninsured, low-income adults, ages 19 through 64, with countable family incomes of up to 200% of federal poverty level and who are not eligible for certain government health insurance benefits, such as Medicaid, Medicare, CHAMPUS, and do not have other public or private health insurance programs. There is no asset test for eligibility. There are no pre-existing health condition limitations.
Description

SCI is an innovative insurance product. The employer and employee pay part of the premium and state and federal funds pay the remainder.

If self employed individuals wish to enroll, they pay the employer and employee portion of the premium. Employees or individual enrollees cannot have voluntarily cancelled health insurance in the past six months, and employers cannot have voluntarily cancelled health insurance for their employees in the last twelve months.

What is SCI (State Coverage Insurance)?

SCI is a new health plan initiative designed to decrease the number of uninsured adults in New Mexico by providing low cost basic health insurance through an employer based benefit program.

Is SCI a commercial plan or Medicaid?

Neither. SCI is a hybrid that combines a commercial style basic health benefit plan offered through an employer with partial funding through the state and federal governments.

Who can participate?

Uninsured adults ages 19 through 64 with family incomes up to 200 percent of the federal poverty level. Adults are eligible through employer-based coverage. Self-employed adults are also eligible. Adults with or without children may participate.

What will my employer contribute to the premium? As an employee, what is my contribution?

Employers pay $75 per person per month. Employees pay monthly premiums based on household income, ranging from $0 - $35 per month.

I am self-employed. What premium would I pay?

Self-employed individuals pay the employer share of $75 per month and the employee share, $0 - $35 per month, depending on countable household income.

Does SCI have income requirements?

Countable household income cannot exceed 200% of the federal poverty level. An individual's countable income can be approximately $19,600 per year (or $9.42 hr). The countable income for a family of four can be approximately $40,000 per year (or $19.23 hr).

What benefits are covered?

The benefit package is similar to a basic commercial plan-including primary and specialty care, inpatient and outpatient hospitalization, prescription drugs, lab, X-ray, physical, occupational, speech therapy, behavioral health and substance abuse services. Annual benefits are capped at $100,000. Maximum out of pocket costs are also capped on a sliding scale basis.

What is an “out of pocket” maximum?

Out of pocket maximum is 5% of your annual countable household income per benefit year. Only the employee portion ($0 - $35) of the SCI premium and your co-payments apply towards the out of pocket maximum. The employer portion ($75) does not apply towards the out of pocket maximum.

Will I make co-payments for medical and prescription services?

SCI is based on a commercial model and each medical and prescription service will have a co-payment. Co-payments are on a sliding scale based on household income. For example, for an individual with a household income of $25,000 per year and has a family of four, the co-pay for a doctor visit would be $5.

Can my family be covered under SCI?

There is no family coverage under SCI. SCI is designed to cover individuals, 19 through 64, through an employer. SCI will also cover individuals who are self-employed. Children would already be covered for health benefits based on income level through Medicaid and New Mexikids

I have health insurance now. Can I qualify for SCI?

No, SCI is offered to employees who have not voluntarily cancelled health insurance coverage in the past six months and to employers who have not voluntarily cancelled health insurance for their employees in the last twelve months. There are no pre-existing condition limitations.

Who administers the program?

SCI is a managed care model. Human Services Department has contracted with three MCO health plans - Lovelace, Molina, or Presbyterian.

If I am an employer, how do I apply for SCI coverage for my employees?

1. Employer groups must choose one of the three participating health plans (Lovelace, Molina, or Presbyterian) and contact that plan to start the eligibility and enrollment process.
2. The health plan will send the employer forms for his/her employees to enroll in the health plan and forms to determine SCI eligibility.
3. Each employee fills out the eligibility form.
4. Each employee returns the eligibility form to the employer for submission to the SCI centralized unit in Las Cruces (All addresses on application). Citizenship and Identification documentation must be verified. Please call the Income Support Division’s SCI Unit at toll free 866-765-4148.
5. Eligibility is based on countable income up to 200% of Federal Poverty Income Level.
6. Employees, if approved, will be enrolled in one of three categories based on income. There is a 12-month eligibility certification period.
7. The employee receives eligibility approval notice from the ISD office and gives a copy of it to the employer within 30 days of receiving it.
8. The employer collects approval notices from all of the employees and sends enrollment forms and approval notices in to the health plan.
9. The health plan carrier approves the enrollment application and bills employer group.
10. When health plan receives premium payment, the employer group is enrolled in the SCI benefit plan and the benefits start the month following the date of enrollment, unless the date of enrollment is the 24th of the month or later, then benefits start the first day of the second month.

If I am a self-employed individual, how do I apply for SCI coverage?

1. A self-employed individual must choose one of the three participating health plans (Lovelace, Molina, or Presbyterian) and contact that plan to start the eligibility and enrollment process.
2. The health plan will send the individual a form for enrolling in the health plan and a form to determine SCI eligibility.
3. Each individual fills out the eligibility form.
4. Individual sends the eligibility form to the SCI centralized unit in Las Cruces (All addresses on application). Citizenship and Identification documentation must be verified. Please call the Income Support Division’s SCI Unit at toll free 866-765-4148.
5. Eligibility is based on countable income up to 200% of Federal Poverty Income Level.
6. Individuals, if approved, will be enrolled in one of three categories based on income. There is a 12-month eligibility certification period.
7. The individual receives eligibility approval notice from the ISD office and sends eligibility letter and enrollment form to the chosen health plan within 30 days after receiving it.
8. The health plan approves the enrollment application and bills the applicant.
9. When health plan receives premium payment, the applicant is enrolled in the SCI benefit plan and the benefits start the month following the date of enrollment, unless the date of enrollment is the 24th of the month or later, then benefits start the first day of the second month.