Cost and Coverage of Medicaid in New Mexico

How much is Medicaid, and what is covered by Medicaid in New Mexico? The Medicaid cost estimates in New Mexico vary in comparison to other states, as each state makes its own determinations regarding Medicaid services handled on behalf of the government. Your Medicaid coverage depends on the different types of Medicaid insurance offered in your state. And, since New Mexico accepted Medicaid expansion, there are Medicaid types of insurance available to patients that other states do not allow.

Review more information on Medicaid cost estimates and Medicaid coverage in NM by reading through the following topics:

  • How much does Medicaid cost in New Mexico?

  • What services are covered by Medicaid in New Mexico?

  • What does Medicaid not cover in New Mexico?

  • Types of Medicaid insurance in New Mexico

How much does Medicaid cost in New Mexico?

How much is Medicaid in New Mexico? It can be difficult to estimate Medicaid costs in NM, since there are many different patient groups that receive varying types of Medicaid insurance.

The Children’s Health Insurance Program (CHIP) is part of NM Medicaid. Through this program, enrollees 19 years or below that are living with eligible families receive health care for free or at an extremely low cost.

Members eligible for Medicaid services through the Working Disabled Individuals (WDI) program have to pay copayments for various services. The estimate Medicaid costs of copayments are indicated on the membership handbook. For any medical services not covered by NM Medicaid coverage, you will have to pay the provider’s full charges.

The Medicaid cost estimates depend on the Medicaid services that an enrollee requires. Some healthcare services that are associated with copayments through New Mexico Medicaid include prescriptions, inpatient hospital visits, outpatient medical visits, and office/urgent care visits. The medical assistance copayment amounts differ depending on the services, and may be reviewed over time. Confirm the current Medicaid cost estimates in terms of copay rates with your primary care provider (PCP). Note that the majority of medical services attract copayments of less than $30.

What services are covered by Medicaid in New Mexico?

New Mexico Medicaid coverage means that low-income patients of the state are entitled to full benefits or low-cost Medicaid services. When it comes to what is covered by Medicaid in New Mexico, eligible patients can rest easy knowing there is a plethora of health services taken care of on their behalves, including:

Preventive Services – These health services include Well-Child Visits, which are offered to members 21 years of age and below. The Medicaid services cover health, growth and development checks of your child, and also include immunization.

Early and Periodic Screening, Diagnostic and Treatment (EPSDT) – These Medicaid services are provided to members that are 21 years old or younger and include checkups and preventive services through your child’s PCP. Children are required to have periodic examinations, which may include shots or vaccinations.Adult Health Screenings – Under this program, women ages 40 to 74 are offered a mammogram every one to two years. Both men and women above 50 years of age are screened for colon cancer.

Medical and Surgical Services – Prior authorization is required for a number of medical and surgical services. New Mexico Medicaid coverage applies to the following services when they are medically necessary: breast pumps and replacement supplies, ground and air ambulance, maternity and pregnancy-related services.

Family Planning Services – Family planning services are covered by NM Medicaid, whether they are provided by in or out-of-network providers. The Medicaid services do not require prior authorization, and include pregnancy testing and counseling, birth control pills and other contraceptives.Pregnancy-related and Maternity Services – NM Medicaid coverage includes all medically necessary hospitalizations, including inpatient care after delivery. If you need emergency services and have to see an out-of-network provider, request for authorization. Prenatal care services are also covered.

Urgent Care Services – Sudden injuries or illnesses that are not life-threatening are covered under urgent care services. NM Medicaid only covers medical care services offered by an in-network provider.

Any health services offered by a provider from out-of-network requires prior authorization.

What does Medicaid not cover in New Mexico?

Although there are many Medicaid services included in your government-sponsored health care policy in New Mexico, there are several that are not covered. When it comes to services deemed what is not covered by Medicaid, be prepared to pay partial or full medical expenses. New Mexico Medicaid coverage does not include the following health services and items:

  • Non-emergency medical services offered by out-of-network providers or outside of New Mexico without prior authorization

  • Amounts that would have been paid by Medicare as the primary carrier if you were entitled to Medicare or paid out by other valid coverage

  • Services for which you have no legal obligation to pay for (e.g. voluntary services or those offered at a discount)

  • Services that are not considered medically necessary (i.e.: they are not clinical, rehabilitative, behavioral or physical health services)

  • Treatment procedures, supplies, devices, drugs, equipment or facilities that are unproven, considered investigational or experimental

  • Personal comfort items you may want in the hospital, e.g. TV or telephone

  • Weight loss programs and equipment that have not been authorized by your PCP

Types of Medicaid Insurance in New Mexico

There are various types of NM Medicaid insurance for which enrollees can apply. The medical insurance plans are offered by four managed care plans that have been contracted by the state of New Mexico to provide Medicaid services. The Medicaid coverage plans are through: Blue Cross Blue Shield, Molina Health Care, Presbyterian Health Plan and UnitedHealthcare Community Plan.

The types of Medicaid insurance in New Mexico in which members enroll determine the amount of coverage for which they qualify. The health plans offer the full array of Medicaid services, including community-based long-term services, institutional behavioral health, acute services and support services.

After signing up for NM Medicaid coverage, you will have to choose a health plan. If you do not, one will be automatically assigned to you. The Medicaid health policy you choose will determine the network of providers from which you can obtain services. NM Medicaid services are only covered if they are provided by health centers, facilities, clinics, providers or doctors that are in a plan’s network.



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