NEW MEXICO HEALTH
INSURANCE EXCHANGE
QHP Training
BeWellNM.com
New Mexico Has 2 Exchanges!
Both can be accessed
through BeWellNM.com
• New Mexico built its own
SHOP for small employers
and it is currently up and
running.
• For 2014, New Mexico is
using the federal
exchange (also called
marketplace or FFM) for
its individual exchange.
Most health care guide
clients will be signing up
through the individual
exchange.
Apply to Access Plan Information
– The Federally-facilitated Marketplace (FFM) will
allow individuals to compare and buy insurance
plans:
• In person
• On the phone
• Via a web portal
• Via a paper application
– The FFM web portal will display comparative
information about health plans, including benefits
available, cost, and quality information.
Quality Plans Available
–The FFM is only allowed to offer high-quality,
qualified health plans that meet standards set by the
State and Federal Government, and offer at least an
essential benefits package.
–Plans are called Qualified Health Plans
–The FFM will categorize levels of coverage into five
standard tiers:
»Bronze, silver, gold, platinum, and a high
deductible (catastrophic) health plan option
available only to individuals under the age of 30.
Insurance Terms
• Private Insurance Carrier/Issuer: An insurance
company that provides a health plan.
• Examples: Blue Cross Blue Shield, Presbyterian,
Lovelace, Molina, New Mexico Health
Connections
• Provider Network: The set of health care providers
(for example, doctors and hospitals) who have
contracted with the health plan to provide services
to the plan’s members at established rates.
Insurance Terms
• Premium: The premium is the cost of the health
insurance plan for one year. It can usually be made in
one lump sum payment or divided into monthly
payments.
• Cost Sharing: All plans include a out-of-pocket limit,
but may also include copays, deductibles and
coinsurance. Cost sharing arrangements depend on
each plan’s specific design.
Insurance Terms
• Deductible: Certain monetary amount that must be
paid out-of-pocket before the health insurance will
begin to cover health service costs.
• Coinsurance: Consumer’s share of the costs of a
covered health care service, calculated as a percent
of the allowed amount for the service. You pay
coinsurance plus any deductibles you owe.
• Copayment: Set amount that must be paid out-ofpocket for medical services and prescriptions; the
health insurance pays the rest of the amount.
Enrollee Costs
• Enrollee may be responsible for “Out-of-Pocket” costs,
including:
•
•
•
•
Deductible
Copay
Coinsurance
There is an “Out-of-pocket limit,” the maximum amount
of money a consumer would pay for medical services in
a calendar year. The maximum limit for an individual
who buys a QHP plan is $6350/year.
Subsidy Terms
• Monthly Subsidy ($): The total amount that will be
paid by the federal government per month towards
the payment of premiums.
• Percent of FPL (%): A measure of income based on
percentages at and above the Federal Poverty Limit,
the minimum amount of gross income that a family
needs as defined by the government.
• Maximum Annual Premium ($): The total dollar
amount that a non-smoking individual or family is
expected to pay annually in silver-level premiums,
based on income.
QHPS IN NEW MEXICO’S INDIVIDUAL
MARKETPLACE
Carriers Who Have QHPs On The FFM
These carriers are offering certified QHP health plans to
New Mexicans:
• New Mexico Health Connections
• Molina
• Presbyterian
• Blue Cross Blue Shield
These carriers are offering stand-alone dental
plans to New Mexicans:
• Best Life and Health
• Blue Cross Blue Shield
• Delta Dental
• Lincoln National Life
• Guardian Life
• Renaissance L&H
• Lovelace Health System
Actuarial Value
Actuarial value: percentage of total average costs for
covered benefits that a plan will cover.
• Bronze = 60%
• Silver = 70%
• Gold = 80%
• Platinum = 90%
• Catastrophic = high deductible option available
only to individuals under the age of 30.
Actuarial Value, Dental Plans
For dental plans –
Actuarial values are broken out in to low (70%) and
high (85%). Dental plans do not use metal levels.
Tax Credits and Cost Sharing
When consumers get
health coverage through
the Marketplace, they may
be able to save money on
monthly premiums, lower
their out-of-pocket costs, or
get low-cost coverage
starting January 1, 2014.
Advanced Premium Tax Credits
• Premium tax credits offset the cost of the health
plan’s premium to increase affordability.
• Requirements to qualify for tax credits include:
– Household income between 138% and 400% of
the federal poverty level.
– Enroll in a plan offered on the individual
marketplace
– Be legally present in the United States and not
incarcerated
– Not be eligible for other types of coverage, such as
Medicare, Medicaid, or affordable employersponsored coverage.
Advanced Premium Tax Credits
• Amount of the tax credit is capped at the premium
for the plan chosen, cannot receive a credit that is
more than the cost of the plan.
• Credit payment is “advanceable,” made directly to
the health insurance issuer on behalf of the
individual and his or her family.
– Advanced payments are made based on the
family’s income during the previous tax year and
reconciled against the family’s current income
when they file their tax return.
Subsidy Chart – One Person
Advanced Premium Tax Credit
• After the Marketplace determines a person’s
eligibility for APTC/CSR, she will be told the
maximum amount of APTC she can receive.
• She can then shop around for different plans.
• If she chooses a less expensive plan, the APTC will
cover more of the overall costs.
• If she chooses a more expensive plan, the APTC will
cover less of the overall costs, and she will need to
pay more on her own.
Cost-Sharing Reductions
• Consumers may also be eligible for reduced cost
sharing on deductibles, co-insurance, and
copayments.
• Unlike APTCs, the Cost-Sharing Reductions are only
available on Silver level plans.
• Cost sharing reductions make coverage more
affordable for lower income individuals and families
who:
– Enroll in a Silver-level Marketplace plan
– Receive the premium tax credit
– Have income less than or equal to 250% FPL
Tribal Member Cost-Sharing
Tribal members pay zero cost-sharing up to 300% of
FPL. Tribal members under 300% FPL pay no
deductible, co-payments or co-insurance.
Tribal members can use their CSR on any metal
level.
This is why a Bronze plan is sometimes the best
value for a tribal member.
Scenario: Stephanie and Yolanda
• Stephanie makes
$22,000/year, is 30 and
has no children.
• Stephanie is a nonsmoker.
• Stephanie prefers to
have a plan from the
gold level.
• Under 250% FPL
• Yolanda makes
$22,000/year, is 30 and
has no children.
• Yolanda smokes.
• Yolanda prefers to have
a plan from the silver
level.
• Under 250% FPL
Stephanie’s and Yolanda’s APTC
Taken from the Kaiser calculator kff.org
Stephanie’s and Yolanda’s APTC
• Stephanie chooses the
Gold level of the NMHC
HMO $2443/year.
• She applies her credit of
$1067.
• She will owe $1376/yr
or $115/month. She
pays this amount to the
carrier.
• Yolanda chooses the
Silver level of the NMHC
HMO for smokers
$2647/year.
• She applies her credit of
$1067.
• She will owe
$1580/year or $132/mo
• Yolanda will also be
eligible for a costsharing reduction.
Talking to Clients About a Policy
• New Mexico Health Care Guides educate clients
about the differences between policies.
• Ask clients what they are looking for in a policy. (The
least cost? The most coverage? Can see their current
doctor?).
• New Mexico Health Care Guides are not allowed to
recommend one policy over another.
THANK YOU.
BE WELL
BeWellNM.com