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Policy Book

This Policy is issued to you by the “Pool”, which was created by the New Mexico State Legislature in 1987. The Pool is a non-profit program that offers health care policies to eligible residents of New Mexico who are denied coverage in the private or public markets as well as individuals eligible under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). The Pool is governed by a board of directors consisting of consumer, industry, medical, and health planning representatives. It is funded through premiums from the enrollees, assessments to health insurance companies, a federal assistance grant, and a premium tax credit from the state. The Pool contracts with Value Health Benefit Administrator, LLC for administrative services.

Your Policy Book will contain the following nine (9) sections:

  • Your Health Care Policy
  • How Your Plans Works
  • Covered Services
  • General Limitations and Exclusions
  • Coordination of
  • Benefits/Reimbursement
  • Claims Payable and Appeals
  • Enrollment and Termination
  • Information
  • General Provisions; and
  • Definitions

It is very important that you read this Policy! It explains what benefits the Pool will provide. Following the procedures of this Policy can save you money.

If you ever have a question, it is best to call Customer Service at 1-866-306-1882, and they can assist you in understanding this Policy.