New Mexico Department of Health
Our mission is to promote health and wellness, improve health outcomes, and assure safety net services for all people in New Mexico.

Children & Youth with Special Health Care Needs Program

This program provides comprehensive medical care and care coordination for children with chronic medical conditions, birth to 21 years of age, who are uninsured or underinsured and are not eligible for Medicaid. Clients must have an eligible medical diagnosis (“medical eligibility”) and also meet income guidelines of family income under 200% of poverty level (“financial eligibility”). CMS has almost 60 medical social workers housed in 32 health offices throughout the state.

Financial Eligibility

General financial eligibility is based on a family’s gross income and assets. In general, family income must be less than 200% of the Federal Poverty Level. Other factors taken into account include family size and the number of children in the family with special health care needs.

Families whose income exceeds the financial eligibility criteria may still attend specialty outreach clinics, are still eligible for care coordination provided by social workers throughout the state, and are also eligible for diagnostic services to rule out eligible medical conditions.

CMS serves as the last payer after insurance and does not provide financial coverage for Medicaid clients.

Medical Eligibility

Covered Conditions

CMS provides payment for medical care, up to $15,000 per year, for clients with a wide range of chronic conditions, including, but not limited to, cleft lip and/or palate, congenital heart conditions, asthma, cerebral palsy, diabetes, immune deficiencies, cystic fibrosis, childhood cancer, epilepsy, renal disease, endocrine disorders and rheumatic disease. In addition to specialty care related to their diagnosis, clients with eligible conditions also receive primary care visits, general dental care, general vision care, medications and nutrition counseling.

Diagnostics

Children who may have an eligible medical diagnosis are provided with diagnostic services for that condition, regardless of financial status.

Not Covered

Acute injuries or disease processes, breast or cervical cancer, experimental treatment or medication, psychiatric disorders (unless related to underlying eligible medical diagnosis). Most orthopedic conditions are not covered by CMS, as care for these may be provided by the University of New Mexico through Carrie Tingley Hospital.

High Risk Insurance

For children who meet income guidelines and have certain high-cost conditions such as cancer, cerebral palsy, renal failure, heart failure, or cystic fibrosis, CMS will cover the cost of the premium for the New Mexico Medical Insurance Pool to ensure comprehensive insurance coverage.

Care Coordination

Licensed medical social workers around the state provide care coordination to children with eligible medical conditions and assist the family in obtaining needed services and accessing community resources. Care coordination also plays a critical role in providing transition services to adolescents ages 15-21 with chronic illnesses, assisting the youth in transitioning from pediatric to adult health care and in obtaining educational support and community services.

Multidisciplinary Pediatric Specialty Clinics

CMS provides approximately 128 community-based pediatric specialty clinics around the state, in conjunction with UNM and community providers. These clinics provide multidisciplinary, coordinated diagnostic services and/or ongoing medical care to children and youth with special health care needs. Current specialty clinics include: asthma, endocrine, genetic, metabolic, nephrology, neurology, and cleft lip and palate. Clinics are held in each region of the state, in order to ensure access to care for families who may find it difficult to travel to Albuquerque. There is no financial eligibility requirement for the clinics. Payer sources include private insurance, Medicaid, and CMS.

Cystic Fibrosis and Metabolic Disease

CMS provides lifelong care coordination for these diseases, regardless of financial status.