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Health Care Guides Introducing New Mexico Health Connections 11/6/2013New Mexico Health Connections.

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Presentation on theme: "Health Care Guides Introducing New Mexico Health Connections 11/6/2013New Mexico Health Connections."— Presentation transcript:

1 Health Care Guides Introducing New Mexico Health Connections 11/6/2013New Mexico Health Connections

2 Affordable Care Act (ACA) – Section 1322 Consumer Operated and Oriented Health Plan (CO-OP) New Mexico’s only non-profit health plan February Licensed as Certified Qualified Health Plan by NM Office of the Superintendent of Insurance Required to hold 2.5 times the normal financial reserves needed for health plans All brought about by Nandini Kuehn, PhD and other concerned New Mexicans

3 NMHC - What Makes Us Different Non-profit health plan Mission-driven, not profit-driven – Profits will be reinvested back to New Mexicans to improve quality of health care Lower Premiums Improve Benefits Collaboration with Community Organizations – Investing in the community health infrastructure Serving as connector between members and community resources

4 NMHC - What Makes Us Different Consumer Operated and Oriented Health Plan (CO-OP) – Governed with consumer control – By 2016, majority of our Board of Directors will be NMHC members – Members will help drive health plan direction and decisions

5 NMHC - What Makes Us Different NMHC is committed to a model of coordinated care – Focused on keeping members and their families healthy – Closely partnering with Clinicians, Community Health Workers and Promotoras – Incentivizing prevention, health, and wellness

6 Philosophy of Benefit Plans Less is more – Fewer plans = Less confusion – Our benefit plans on the Exchange are the same as those off the Exchange Choice to use co-pay model – The cost the member pays is defined and clear – Encourages use of preventive care and wellness services

7 Individual Plans Choice Connect Gold $500 PPO Choice Connect Silver $2,000 PPO Care Connect Gold $750 HMO Care Connect Silver $2,000 HMO Care Connect Bronze HMO UNM Care Connect $2,000 HMO (HIX ONLY) Care Connect Catastrophic HMO (HIX ONLY) In-Network Out-of- Network In-Network Out-of- Network Preventive Care Services (1) No Charge 50% after deductible No Charge 50% after deductible No Charge Primary Care $20/visit 50% after deductible $30/visit 50% after deductible $30/visit$25/visit 50% after deductible $25/visitNo Charge (2) Specialist Care $40/visit 50% after deductible $60/visit 50% after deductible $60/visit$75/visit 50% after deductible $75/visit 0% after deductible Behavioral Health Visits (2) No Charge 50% after deductible No Charge 50% after deductible No Charge Urgent Care $50/visit 50% after deductible $50/visit 0% after deductible Emergency Room Services $250/visit 50% after deductible $250/visit 0% after deductible Preferred Generic Drugs (3) No Charge Not Covered No Charge Not Covered No Charge Generic Drugs $10/Rx Not Covered $25/Rx Not Covered $15/Rx$25/Rx 50% after deductible $25/Rx 0% after deductible Brand Name Drugs $30/Rx Not Covered $75/Rx Not Covered $45/Rx$75/Rx 50% after deductible $75/Rx 0% after deductible Non-Preferred Brand Drugs $60/Rx Not Covered $150/Rx Not Covered $75/Rx$150/Rx 50% after deductible $150/Rx 0% after deductible Specialty Drugs 30% to max of $250/Rx Not Covered $250/Rx Not Covered $150/Rx$250/Rx 50% after deductible $250/Rx 0% after deductible

8 Individual Plans MRI/CT/PET $250/test 50% after deductible $250/test 50% after deductible $250/test 50% after deductible $250/test 0% after deductible PT/OT/ST $40/visit 50% after deductible $60/visit 50% after deductible $60/visit$75/visit 50% after deductible $75/visit 0% after deductible Outpatient Hospital 30% after deductible 50% after deductible 40% after deductible 50% after deductible 20% after deductible 30% after deductible 50% after deductible 30% after deductible 0% after deductible Inpatient Hospital 30% after deductible 50% after deductible 40% after deductible 50% after deductible $1,000/ admission $2,500/ admission 50% after deductible $2,500/ admission 0% after deductible Lab & X-ray Services (4) No Charge 50% after deductible No Charge 50% after deductible No Charge 50% after deductible No Charge 0% after deductible Annual In-Network Deductible (5) $500$1,000$2,000$4,000$750$2,000$2,500$2,000$6,350 Coinsurance after deductible 30%50%40%50%20%30%50%30%0% Annual Out-of-Pocket Maximum $5,000$10,000$6,350$12,700$6,000$6,350 Choice Connect Gold $500 PPO Choice Connect Silver $2,000 PPO Care Connect Gold $750 HMO Care Connect Silver $2,000 HMO Care Connect Bronze HMO UNM Care Connect $2,000 HMO (HIX ONLY) Care Connect Catastrophic HMO (HIX ONLY) In-Network Out-of- Network In-Network Out-of- Network

9 Generic Medications $0 Co-pay for these Chronic Conditions: – Hypertension – Depression – Bipolar Disorder – Diabetes – Hypercholesterolemia – Chronic Obstructive Pulmonary Disease – Coronary Artery Disease – Congestive Heart Failure – Asthma

10 Behavioral Health Services Behavioral Health Services are a key focus for NMHC Addressing Behavioral Health issues leads to better overall health – Behavioral Health Provider network – $0 co-pay for the first 3 outpatient visits – $0 co-pay for most generic Behavioral Health medicines

11 NMHC State-Wide Provider Network Nearly 5,500 practitioners, hospitals, and facilities Primary Care and Specialty Close partnerships with FQHCs Centers of Excellence Out of State Network Community Health Worker program Please refer to website for a more detailed list of providers

12 NMHC Website: Easy to Navigate

13 NMHC Website: Getting Started

14 NMHC Website: Quote and Compare

15 NMHC Website: Quote Comparison

16 NMHC Website: Provider Network

17 NMHC Website: Rx Formulary

18 Questions to help guide your clients How often do you / your family go to the doctor How many times did you visit the emergency room last year What prescription medications are taken on a regular basis Who are your doctors Do you have any chronic conditions Are you eligible for subsidies

19 Things to Consider How much did you spend last year – The least expensive plan is not always the most cost effective – Consider deductibles, co-pays and coinsurance as well as the monthly premium Example: The story of Mr. Sanchez and his health plan selection journey

20 Mr. Sanchez & His Health Plan Selection Health NeedsThings to ConsiderHow NMHC Can Assist Type I DiabetesLocate a PCPState-wide provider network Doctor VisitsLow co-pays Medication Costs$0 co-pay for generic medications Subsidy Eligible?Subsidy Calculator on website

21 NMHC Summary NMHC adds value to the insurance market – Member Driven – Community Focused – Co-pays clarify member costs – Easy to use website – Profits reinvested in New Mexico – Built by New Mexicans, for New Mexicans

22 New Mexico Health Connections MY-NMHC 2440 Louisiana Blvd., NE, Suite 601 Albuquerque, NM 87110


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