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Change Request

Add Coverage

What is your qualifying event? All requests to add coverage must be done within 31 days of qualifying event. Involuntarily loss of coverage under another program (employer, Spouse's employer, Medicaid, divorce)? Newly married? (within 31 days) Birth of a child(ren)? Adoption or granted legal guardianship of a child(ren)?

Complete only if you wish to add dependents. See NMRHCA Summary of Benefits or call NMRHCA for definition of eligible dependents. If you add dependent(s) after your initial enrollment, you must attach a loss of coverage letter for each dependent to be added, unless dependent is newly eligible (marriage, birth, involuntarily termination of health care coverage under another program—see Summary of Benefits). Documentation of event causing new eligibility is required (copy of marriage certificate, birth certificate, court decree of adoption or legal guardianship, etc.).

Dependents to Be Covered Spouse Domestic Partner Dependent(s)

Spouse

Does your spouse qualify as an eligible NMRHCA retiree?

If your spouse qualifies as an eligible NMRHCA retiree and wishes to enroll separately, call the NMRHCA and request a General Enrollment Packet. If your spouse qualifies as an eligible NMRHCA retiree and has the same number of credible service years as you, then they may enroll under the same application, but an additional work history form is required by your spouse.

Yes No

What is his / her retirement date?

What is his / her last employer?

Does he / she receive a pension? Yes No

Social Security Number

First Name

Initial

Last Name

Birthdate

Gender Male Female

Relationship to Retiree

Domestic Partner

Social Security Number

First Name

Initial

Last Name

Birthdate

Gender Male Female

Relationship to Retiree

Download the domestic partnership affidavit

Dependent 1 Remove

Social Security Number

First Name

Initial

Last Name

Birthdate

Gender Male Female

Relationship to Retiree
Dependent 2 Remove

Social Security Number

First Name

Initial

Last Name

Birthdate

Gender Male Female

Relationship to Retiree

Medical Coverage

Each enrollee's level of coverage must be the same; unless one party is Medicare eligible. Out-of-state non-Medicare enrollees must select the BCBS Premier plan.

Non-Medicare Plan

Each enrollee's level of coverage must be the same.
Single, two-party or family; spouse/dependent(s) will default to retiree's selection.
Out-of-state Non-Medicare members must select a BCBS PLAN.
Out-of-state Medicare members can select from either BCBS Supplemental, United Healthcare or Humana Medicare.
If neither you nor your dependents carry Medicare:
Select medical carrier and medical plan for Retiree, Spouse, and Dependent(s) in the "Non-Medicare Plans" section.
If you do not carry Medicare but your dependents do:
Select medical carrier and medical plan in the "Non-Medicare Plans" section for yourself. Select medical plan in the "Medicare Plans" section for your Spouse and/or Dependent(s) (as applicable). Please submit copy of Medicare Card showing Parts A and B.

Plans BCBS Premier PPO Presbyterian Premier PPO BCBS Value PPO Presbyterian Value PPO

Medicare Plan

Please select Yes or No for yourself (if applicable)

Do you have End-Stage Renal Disease (ESRD)?

If yes, please contact the NMRHCA at 1-800-233-2576 for further instructions

Yes No

Are you a resident in a long-term care facility, such as a nursing home? Yes No

Are you enrolled under private insurance, TRICARE, Federal employee health benefits, VA Benefits, or State Pharmaceutical Assistance Programs? Yes No

Please select Yes or No for your spouse (if applicable)

Do you have End-Stage Renal Disease (ESRD)?

If yes, please contact the NMRHCA at 1-800-233-2576 for further instructions

Yes No

Are you a resident in a long-term care facility, such as a nursing home? Yes No

Are you enrolled under private insurance, TRICARE, Federal employee health benefits, VA Benefits, or State Pharmaceutical Assistance Programs? Yes No

IMPORTANT: Out-of-state enrollees must select a BCBSNM Supplemental, United Healthcare or Humana Medicare plan.

Medicare Parts A and B are required for all Medicare Plans.
MEDICAL COVERAGE:
Contact individual insurance carriers with questions regarding plan benefits; review carefully the benefits and limitations of the plan(s) you select. If you and/or your dependents are Medicare-eligible but do not carry Medicare Part A and/or Part B, call the NMRHCA to learn about the consequences.
If you do carry Medicare but your dependents do not:
Select plan in the "Medicare Plans" section and submit Medicare Card showing Parts A and B for yourself. Select medical carrier and medical plan in the "Non-Medicare Plans" section for Spouse and/or Dependent(s).
If both you and your dependents carry Medicare:
Select medical plan in the "Medicare Plans" section. Submit Medicare cards showing Parts A and B for all members.

Plans BCBSNM Supplemental Plan

BCBS Advantage Plan I

BCBS Advantage Plan II

Presbyterian Advantage Plan I

Presbyterian Advantage Plan II

United Healthcare Advantage Plan I

United Healthcare Advantage Plan II

Humana Advantage Plan I

Humana Advantage Plan II

Declaration and Signature

By selecting the boxes below, I acknowledge that:

Participation in the New Mexico Retiree Health Care Act is subject to specific eligibility requirements and that benefits offered through the New Mexico Retiree Health Care Authority are subject to legal limitations. Ineligible individuals cannot receive benefits through this program and will benefits or services will not exceed legal limitations. Submitting information on this page is only an application for benefits and does not create any contractual relationship or impose any duties on the part of the New Mexico Retiree Health Care Authority. I must comply with all program requirements, including making timely payments, to enroll and participate. I agree that the New Mexico Retiree Health Care Authority may terminate my participation in this program for noncompliance. I have carefully read and understood all statements on this page and included with this submission, approve all indicated changes, and elect the coverages and benefits selected. I am the actual person applying for benefits whose signature appears below or I am signing on another's behalf under a power of attorney. (If I am signing on another's behalf under a power of attorney, I have attached current authorizing documents or ensured that the New Mexico Retiree Health Care Authority has current authorizing documents on file.)

By typing my name in the space provided below, I hereby declare that all the information I have provided in connection with this application is true and complete to the best of my knowledge.

Type full name in the box below

Today's Date

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