Presbyterian State Coverage Insurance (SCI)

State Coverage Insurance (SCI) offers affordable healthcare coverage to low-income working adults, who meet the SCI eligibility criteria, either through their employer or as an individual.

Eligibility Requirements

To become eligible for a State Coverage Insurance (SCI) Plan you must:

• Not have voluntarily dropped insurance coverage for 6 months (individual) or 12 months (group)
• Be a New Mexico resident between the ages of 19 and 64
• Earn a family income of up to 200% of the federal poverty level (see chart)
• Not be eligible for certain government health insurance benefits, such as Medicaid (Title XIX), Medicare, CHAMPUS, and do not have other public or private health insurance  

State Coverage Insurance Benefits

Once you enroll in the Presbyterian State Coverage Insurance Plan, you will enjoy affordable health insurance that provides coverage for services such as:

• Preventive care visits
• Visits to your doctor (see the SCI Provider Directory (.pdf))
• Prescription Drugs (see Salud Pharmacy Benefits (.pdf))
• Prenatal care
• Hospital visits, urgent care or emergency services
• Lab tests and x-rays
• No pre-existing condition limitations
• Out-of-pocket maximums that help protect you
• Medical benefits up to $100,000 per year
• And more  

Please refer to the Benefit Summary and the Member Handbook (.pdf) [also available in Spanish as the Manual para Los Miembros del Plan del Seguro de Cobertura Estatal [SCI] de Presbyterian (.pdf)] for more information about covered services with the SCI Plan.

SCI Plan Costs

The cost of the SCI Plan depends on the total household income of the individual applying for coverage. Depending on which Federal Poverty Level (FPL) category of the total family income and if you are participating in the program through an employer or on your own the following monthly premiums apply. See chart below.

If the SCI Plan is purchased through an employer, the employer is responsible for paying the employer share of the premium as indicated above.  If a person is self-employed, they would pay the portion of the premium that an employer would otherwise pay.  However, based on a person's income level, there may be no cost associated with their SCI Plan. 
 
Once approved for the Plan the employee pays any amount over $75 toward the premium due each month. Again, based on a person's income level, there may be no cost associated with their SCI Plan.

The above chart is for illustration purposes only.

Total household incomes may be reduced by "income disregards." When an individual purchases an SCI Plan, they are required to pay both the employer and employee share of the premium, if any, based on income level. Employers may elect to pay any portion of the employee premium and may also elect to pay any portion of the Adult Spouse premium.

What are the SCI benefits?

SCI is a limited insurance plan that will cover up to $100,000 per benefit year of medical services. There are three different plan designs, based on the FPL of the qualified individual.

• View a summary of those benefits
• SCI Provider Directory

How do I qualify and enroll in an SCI plan?

• I want more information about enrolling as an individual
• I am an employer, and wish to offer an SCI Group Plan to my employees

Fraud and Abuse

The Presbyterian Health Plan and Presbyterian Insurance Company's Special Investigative Unit (SIU) is responsible for the detection, investigation and reporting of potential fraud and abuse activity. We are required to cooperate with regulatory and law enforcement agencies in reporting any activity that appears to be suspicious in nature. According to the law, any information that we have concerning such matters must be turned over to the appropriate governmental agencies. Find out more.

Other Resources

• New Mexico State Coverage Insurance website