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Numerous state and federal laws make it easier for people with pre-existing conditions to get or keep health insurance, or to change from one health plan to another. A federal law, known as the Health Insurance Portability and Accountability Act (HIPAA) sets national standards for all health plans. In addition, states can pass different reforms for the health plans they regulate (fully insured group health plans and individual health plans), so your protections may vary if you leave New Mexico. Neither federal nor state laws protect your access to health insurance in all circumstances. So please read this guide carefully.

The following information summarizes how federal and state laws do – or do not – protect you as a New Mexico resident.

How am I protected?
In New Mexico, as in many other states, your health insurance options are somewhat dependent on your health status. Even if you are sick, however the laws protect you in the following ways.

• Coverage under your group health plan (if your employer offers one) cannot be denied or limited, nor can you be required to pay more, because of your health status. This is called nondiscrimination.

• All health plans in New Mexico must limit exclusion of pre-existing conditions. There are rules about what counts as a pre-existing condition and how long you must wait before a new health plan will begin to pay for care for that condition. Generally, if you join a new health plan, your old coverage will be credited toward the pre-existing condition exclusion period, provided you did not have a long break in coverage.

• Your health insurance cannot be canceled because you get sick. Most health insurance is guaranteed renewable.

• If you leave your job, you may be able to remain in your old group health plan for a certain length of time. This is called COBRA continuation coverage or state continuation coverage. It can help when you are between jobs or waiting for a new health plan to cover your pre-existing condition. There are limits on what you can be charged for this coverage.

• If you lose your group health insurance and meet other qualifications, you will be federally eligible and guaranteed access to several types of individual health coverage. You can buy an individual coverage from the New Mexico Medical Insurance Pool (NMMIP) or from the New Mexico Health Insurance Alliance (the Alliance). There are limits on what you can be charged for coverage under NMMIP and the Alliance. You will not have a pre-existing condition exclusion period.

• You may also be able to buy insurance from NMMIP if you have had difficulty obtaining affordable health insurance from private companies because of your health condition. In this case you may face a new pre-existing condition exclusion period. There are limits on what you can be charged for an NMMIP policy.

• If you lose coverage under a fully insured group health plan in New Mexico, you can buy a conversion policy. This is an individual health plan from the company that insured your former group. You will not face a new pre-existing condition exclusion period. There are limits on what you can be charged for a conversion policy.

• If you are a small employer buying a group health plan, you cannot be turned down because of the health status, age, or any factor that might predict the use of health services of those in your group. All health plans for small employers must be sold on a guaranteed issue basis.

• In addition, if you are self-employed with no other workers, you are eligible to obtain coverage through the Alliance if you enroll with a dependent.

• If you are a small employer buying a group health plan, there are limits on what you can be charged due to the health status and other factors of those in your group. Health plans sold in the Alliance cannot charge you more due to the health status of those in your group, however the Alliance can charge you more, within limits, based on age, gender, family size, where you live, and the plan that you choose. This is called modified community rating.

• If you have low or modest household income, you may be eligible for free or subsidized health coverage for yourself or members of your family. The New Mexico Medicaid program offers free or reduced price health coverage for certain families, children, pregnant women, elderly, and disabled individuals.