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Q.
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What is SCI (State Coverage Insurance)?
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A.
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SCI is low cost health insurance offered primarily through an employer-based benefit
program. Self-employed adults can also participate.
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Q.
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Is SCI a commercial plan or Medicaid?
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A.
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SCI is a hybrid product that combines a commercial style health benefit plan with
low copayments and premiums funded through a Medicaid waiver program.
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Q.
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Who can participate?
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A.
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Uninsured adults ages 19 through 64 with countable household income up to 200 percent
of the federal income guidelines. Adults, 19-64 are eligible through employer-based
coverage or as individuals. Self-employed adults are also eligible.
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Q.
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Do I have to prove my citizenship?
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A.
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Yes, proof of U.S. Citizenship is a program requirement.
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Q.
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What will my employer contribute to the premium? As an employee, what is my contribution?
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A.
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Employers pay either $0 or $75 per employee per month based on income level of the
employee. Employees pay monthly premiums based on household income, ranging from
$0 - $35 per month.
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Q.
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I am self-employed. What premium would I pay?
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A.
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Self-employed individuals pay both the employer and the employee share of the monthly
premium, $0 - $110 per month, depending on countable household income. See Individual Cost Page.
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Q.
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Does SCI have income requirements?
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A.
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Countable household income cannot exceed 200% of the federal income guidelines.
Eligibility is determined by the Income Support Division of Human Services Department.
For State Coverage Insurance (SCI), earned income disregards are applied to household
gross earned income to develop countable income. Countable income will be applied
to the Federal Income Guidelines to determine if the person is eligible. Use the
eligibility wizard to check on your income eligibility.
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Q.
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What is a “voluntary drop or cancellation”?
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A.
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Dropping health insurance within the six months prior to application for reasons
other than legal separation, divorce, change or loss of employment, death, reduction
in hours worked that results in the termination of health coverage, employer contribution
towards coverage is terminated, or terminating a commercial individual plan to enroll
in an SCI group plan constitutes a voluntary drop.
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Q.
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What benefits are covered?
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A.
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The benefit package includes: 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.
For more information see the Summary of Benefits.
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Q.
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What is an “out of pocket” maximum?
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A.
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This is the most you will pay for covered services in a benefit year. 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 of the premium does not apply toward
the out of pocket maximum (even if you pay both portions).
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Q.
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Will I make co-payments for medical and prescription services?
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A.
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Most medical services require 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 with a family of four, the co-pay for a doctor visit would be $5.
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Q.
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Can my family be covered under SCI?
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A.
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There is no family coverage under SCI. SCI is designed to cover individuals, 19
through 64, primarily through an employer. A spouse age 19 and older (up to 65)
could be covered on SCI as an individual. Dependent children age 19-64 could also
be covered. SCI will cover individuals who are self-employed. Children under 19
eligible would probably already be covered for health benefits based on income level
through New MexiKids.
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Q.
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I have health insurance now. Can I qualify for SCI?
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A.
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Probably not, SCI is offered to employees who have not voluntarily dropped health
insurance coverage in the past six months and to employers who have not voluntarily
dropped health insurance for their employees in the last twelve months. However
if your insurance is through your employer and you lose your job or your employer
drops coverage you could qualify.
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Q.
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Who administers the program?
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A.
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SCI is administered through managed care organizations (MCO). The Human Services
Department has contracts with three MCO health plans—Lovelace, Molina and
Presbyterian.
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Q.
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If I am a self-employed individual, how do I apply for SCI coverage?
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A.
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Each individual fills out the eligibility application and chooses one of the three
participating health plans
Lovelace, Molina or Presbyterian
Individual sends the eligibility application and all required documentation to the
SCI centralized unit in Las Cruces (address on application). Proof of citizenship
and identity documentation must be verified and sent with the application.
Eligibility is based on countable household income up to 200% of Federal Poverty
Income Level.
Individuals, if approved, will be enrolled in one of three categories based on income.
There is a 12-month eligibility certification period.
The individual receives eligibility approval notice from the ISD office and contacts
the chosen health plan within 30 days to enroll.
Individual completes the health plan’s enrollment forms and pays the first
month’s premium, if required.
Applicant is enrolled in the SCI benefit plan and 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.
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