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Presentation on theme: "QHP Training NEW MEXICO HEALTH INSURANCE EXCHANGE"— Presentation transcript:


2 New Mexico Has 2 Exchanges! 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. Both can be accessed through

3 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.

4 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.

5 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 plans members at established rates.

6 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 plans specific design.

7 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: Consumers 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-of- pocket for medical services and prescriptions; the health insurance pays the rest of the amount.

8 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.

9 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.


11 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

12 These carriers are offering stand-alone dental plans to New Mexicans: Best Life and Health Delta Dental Guardian Life Lovelace Health System Blue Cross Blue Shield Lincoln National Life Renaissance L&H

13 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.

14 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.

15 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.

16 Advanced Premium Tax Credits Premium tax credits offset the cost of the health plans 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 employer- sponsored coverage.

17 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 familys income during the previous tax year and reconciled against the familys current income when they file their tax return.

18 Subsidy Chart – One Person

19 Advanced Premium Tax Credit After the Marketplace determines a persons 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.

20 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

21 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.

22 Scenario: Stephanie and Yolanda Stephanie makes $22,000/year, is 30 and has no children. Stephanie is a non- smoker. 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

23 Stephanies and Yolandas APTC Taken from the Kaiser calculator

24 Stephanies and Yolandas 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 cost- sharing reduction.

25 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.



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