NMHIX Healthcare Guide Training
Roswell: Thursday, November 14, 2013
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Who we are
Improving health for over 105 years
Presbyterian was founded in 1908 to serve
tuberculosis patients and has grown to
become the state’s largest healthcare
provider.
Because it is community owned, Presbyterian is dedicated to being a
good steward of local healthcare resources.
Our hospitals, physicians,
caregivers and insurance plans
work together as an integrated
delivery system to serve more than
660,000 New Mexicans.
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Working Together
As the most preferred
healthcare organization
in New Mexico,
Presbyterian offers you
the value that comes
with our integrated
system of physicians,
hospitals, and health
plan – all working
together to keep you
healthy and provide new
and innovative services.
Delivery
System
Medical
Group
Health
Plan
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Presbyterian Hospitals
Our hospitals, physicians, caregivers and insurance
plans serve more than 700,000 New Mexicans.
Delivery
System
Hospitals
Albuquerque
Presbyterian and Presbyterian Kaseman
Hospitals
Clovis
Plains Regional Medical Center
Española
Presbyterian Española Hospital
Rio Rancho
Presbyterian Rust Medical Center
Ruidoso
Lincoln County Medical Center
Socorro
Socorro General Hospital
Tucumcari
Dan C. Trigg Memorial Hospital
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Presbyterian Medical Group
 Offers care at more than
30 different locations
throughout the state.
Medical
Group
 16 clinic locations in the
Albuquerque metro area
 Our clinics handle more
than 1,100,000 patient
visits.
 Fastest growing physician
group, employing nearly
500 practitioners
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Our Health Plan
Presbyterian has the state’s largest health plan,
with approximately 400,000 members.
Health
Plan
We offer a full spectrum of health insurance choices to
meet the diverse needs of all New Mexicans.

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Medicare Advantage Plans
Medicaid (Centennial Care)
Individual Plans
Group Products (fully insured and self-funded (ASO)
Presbyterian Health Plan, Inc.
Presbyterian Insurance Company, Inc.
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Best Health Plan
Presbyterian
Source: Research & Polling, Inc.
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Presbyterian Individual & Family Plans
in the Marketplace
Plans to choose from:
•
•
•
•
•
•
Gold A, B, C
Silver A, B, C, D
Bronze A, B, C
Catastrophic
Native American (on exchange)
Members within 138%-250% of FPL may qualify for benefit subsidies
available in Silver plans. (12 benefit subsidy plans)
All Individual & Family Plans offer:
• A fitness center membership at no charge
• The only Individual & Family Plans in NM that provide access to
Presbyterian’s network
• High-deductible health plans include a health savings account at no
additional charge, administered by HealthEquity®
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Gold Plans
Plans
Gold A
Gold B
Gold C
Benefits with copayments ($) are not subject to deductible
Deductible
$0
$250
$1,000
Primary Care Provider &
Behavioral Health Visit
$15
20%
$0
Specialist Visit
$50
20%
$25
$0
20%
$0
30%
20%
20%
$10
20%
$5
$50
20%
$25
Diagnostic Services
(Lab & X-Ray)
Hospital Inpatient
Rx – Generic
(preferred)
Rx- Brand Name
(preferred)
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Silver Plans
Plans
Silver A
Silver B*
Silver C
Silver D
Benefits with copayments ($) are not subject to deductible
Deductible
$250
$1,300
$2,500
$5,000
Primary Care Provider &
Behavioral Health Visit
50%
25%
$10
$5
Specialist Visit
50%
25%
$60
$50
(Lab & X-Ray)
50%
25%
$0
$0
Hospital Inpatient
50%
25%
20%
20%
50%
25%
$10
$5
50%
25%
$75
$50
Diagnostic Services
Rx – Generic
(preferred)
Rx- Brand Name
(preferred)
* HDHP – Qualified High Deductible Health Plan. See HealthEquity flyer for details.
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Bronze Plans
Plans
Bronze A*
Bronze B*
Bronze C
Benefits with copayments ($) are not subject to deductible
Deductible
$2,500
$4,000
$6,350
Primary Care Provider &
Behavioral Health Visit
50%
20%
$45
Specialist Visit
50%
20%
0%
Diagnostic Services
50%
20%
0%
Lab - $0
50%
20%
0%
50%
20%
0%
50%
20%
0%
(Lab & X-Ray)
Hospital Inpatient
Rx – Generic
(preferred)
Rx- Brand Name
(preferred)
* HDHP – Qualified High Deductible Health Plan. See HealthEquity flyer for details.
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Catastrophic and Native American Plans
Plans
Catastrophic
< 30 years of age
Native American
On Exchange Only
Benefits with copayments ($) are not subject to deductible
Deductible
$6,350
$0
Primary Care Provider &
Behavioral Health Visit
0%
Plan pays 100%
Specialist Visit
0%
Plan pays 100%
0%
Plan pays 100%
0%
Plan pays 100%
0%
Plan pays 100%
0%
Plan pays 100%
Diagnostic Services
(Lab & X-Ray)
Hospital Inpatient
Rx – Generic
(preferred)
Rx- Brand Name
(preferred)
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Free Gym Membership
• All Individual Plan members (18
and over) will be enrolled in a
fitness center membership for no
additional cost
• There are over 8,000 fitness
center locations nationwide
• Locations near Roswell include
Curves (Alamogordo) and Ruidoso
Physical Therapy
• Additional locations can be found
online at
https://phcprime.healthways.com/
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Premium Comparison
Roswell Area
Gold A
$0
Deductible
Silver C
$2,500
Deductible
Bronze C
$6,350
Deductible
Catastrophic
< 30 years of
age
Age 0-20
$173.49
$140.29
$111.50
$79.91
Age 40
$349.16
$282.34
$224.40
n/a
Age 60
$741.49
$599.59
$476.54
n/a
Plans
Same rate for smoker and non-smoker
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Advance Premium Tax Credit
Savings depends on income and family size
The amount you save depends on your family size and how much money your
family earns. In general, if your income falls within the following ranges you'll
qualify to save money on your premiums in 2014. The lower your income within
these ranges, the more you'll save. (The amounts below are based on 2013
numbers and are likely to be slightly higher in 2014.)
• $11,490 to $45,960 for individuals
• $15,510 to $62,040 for a family of 2
• $19,530 to $78,120 for a family of 3
• $23,550 to $94,200 for a family of 4
• $27,570 to $110,280 for a family of 5
• $31,590 to $126,360 for a family of 6
• $35,610 to $142,440 for a family of 7
• $39,630 to $158,520 for a family of 8
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Coverage Connector
An interactive tool that helps determine where to
start looking for health insurance, either through a
commercial insurance plan, Medicaid or Medicare
programs, or on New Mexico's new health insurance
exchange.
www.phs.org/coverageconnector
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How to apply?
To apply for coverage directly with Presbyterian:
Premium tax credits or benefit subsidies will not apply
• Online at www.phs.org – coming soon
• With a paper application – download online at
http://docs.phs.org/idc/groups/public/documents/communication/pel_00
169987.pdf
To apply for Presbyterian coverage in the Marketplace:
• Online at www.healthcare.gov
• With a paper application – download online at
http://marketplace.cms.gov/getofficialresources/publications-andarticles/marketplace-application-for-family.pdf
• By phone or with an in-person assister by calling 1-800-318-2596, 24
hours a day, 7 days a week.
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Presbyterian Resources
• Presbyterian Website – www.phs.org
• Online Provider Directory -
https://presbyterianproviderfinder.ipf.vitals.com/search
• Coverage Connector (Our Health Insurance Decision Tool) -
https://www.phs.org/insurance-plans/all-about-health-care/coverageconnector/Pages/default.aspx
• Individual & Family Plan Information - https://www.phs.org/insurance-
plans/our-plans/individual-and-family/Pages/default.aspx
• Formulary (Prescription Drug Coverage) -
https://www.phs.org/insurance-plans/our-plans/individual-andfamily/Pages/individual-and-family.aspx
• Call for a Quote: 1-866-869-7737, Weekdays, 8:00 a.m. – 5:00 p.m.
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Questions?
505-Ask-Pres
505-875-7737
1-866-869-7737
iplan@phs.org
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