PART 36 HEALTH
CARE AFFORDABILITY FUND
13.10.36.1 ISSUING
AGENCY:
New Mexico Office of Superintendent of Insurance (“OSI”).
[13.10.36.1 NMAC –
N, 5/1/2022]
13.10.36.2 SCOPE:
These rules govern the establishment and
provision of a Health Care Affordability Plan and administration of the Health
Care Affordability Fund (the “Fund”).
[13.10.36.2 NMAC –
N, 5/1/2022]
13.10.36.3 STATUTORY
AUTHORITY:
Section 59A-23F-12 NMSA 1978 (the “Health Care Affordability Plan”).
[13.10.36.3 NMAC –
N, 5/1/2022]
13.10.36.4 DURATION: Permanent.
[13.10.36.4 NMAC –
N, 5/1/2022]
13.10.36.5 EFFECTIVE
DATE:
May 1, 2022, unless a later date is cited at the end of a section.
[13.10.36.5 NMAC –
N, 5/1/2022]
[13.10.36.6 NMAC –
N, 5/1/2022]
13.10.36.7 DEFINITIONS: Terms
are as defined in the Insurance Code, and as supplemented below.
A. “Advance
state payments” means marketplace affordability program payments by the
fund to a participating health insurance issuer on a monthly
basis to lower premium and state out-of-pocket assistance for consumers.
B. “Affordability
criteria” means the factors used to determine the amount of premium
assistance or state out-of-pocket assistance that will be provided from the
fund on behalf of an eligible individual.
C. "Eligible plan” means a health plan sold on the New
Mexico health insurance exchange (the “exchange” or “marketplace”) that meets
the requirements for the state premium assistance program.
D. “Federal poverty level or FPL”
means the federal poverty level issued annually by the U.S department of health
and human services at aspe.hhs.gov/poverty-guidelines/.
E. “Income
criteria” means parameters to establish eligibility for marketplace
affordability programs.
F. “Modified adjusted gross income
or MAGI” means modified adjusted gross income as defined in 42 CFR §
435.60.
G. “Marketplace
affordability program” means a fund program that reduces premiums and OOP
costs for individuals and families who purchase individual or family coverage
on the exchange.
H. “OOP” means out-of-pocket.
I. “Participating health insurance
issuer” means a health insurance issuer who is authorized to sell a QHP on
the exchange or in the fully-insured small group
market who has confirmed in writing its intention to participate in a specified
fund program prior to the commencement of the plan year.
J. “Plan year” means the year
for which a participating health insurance issuer underwrites qualifying health
insurance coverage.
K. “Premium assistance” means a
fund program that pays a participating health insurance issuer to cover a
portion of the premium obligation of a person who meets premium assistance
affordability criteria.
L. “QHP” means a qualified
health plan.
M. “Small business health insurance
premium relief initiative”
means a program to reduce premiums for small businesses that purchase QHPs in the
small group health insurance market.
N. “Small
group QHP purchaser” means an employer who purchases one or more QHPs for
any of its employees or owners through the small business health options
program or directly from a health insurance issuer selling QHPs in the small
group health insurance market.
O. “State benchmark plan” means a qualified health plan that has been approved for sale on the exchange and that is identified by the superintendent as the plan to be used in developing affordability criteria.
P. “State out-of-pocket assistance
program” means a fund program that reduces OOP costs for households that
meet eligibility and income criteria established by the superintendent.
[13.10.36.7 NMAC –
N, 5/1/2022; E/A, 6/1/2022; A, 9/1/2022]
13.10.36.8 APPROPRIATIONS REQUESTS: This rule governs appropriation requests.
A. Annually, the superintendent will
submit appropriation requests to the legislative finance committee for each
fund program. OSI will post proposed program parameters associated with the
budget request on the agency’s website upon submission to the legislative
finance committee.
B. The request for each fund program
shall meet these minimum standards:
(1) for the marketplace affordability
program, sufficient funding to provide premium reductions for individuals under
four hundred percent of the FPL and OOP cost reductions for individuals under
three hundred percent of the FPL;
(3) for the uninsured program,
sufficient funding to expand coverage to eligible individuals under two hundred
percent of the FPL before expanding further up the income scale.
[13.10.36.8 NMAC –
N, 5/1/2022; A/E, 6/1/2022, A, 9/1/2022]
13.10.36.9 Premium Assistance and Annual OOP Programs: This rule governs the annual state out-of-pocket
assistance and premium assistance programs.
A. Affordability criteria: Annually, the superintendent shall publish a
bulletin specifying affordability criteria for the ensuing plan year. Absent extenuating circumstances that mandate
an earlier rate filing, the superintendent shall allow issuers at least 15 days
from publication of the bulletin to make an initial QHP rate filing. If the federal
government changes policies that will affect the cost of the program to the
state or the cost to enrollees after the issuance of the bulletin, the
superintendent may adjust the affordability criteria.
(1) These are the affordability
criteria that the superintendent may consider to determine premium assistance
eligibility for a plan year. The superintendent
will use these criteria to establish a premium sliding scale based on household
income:
(a) the
percentage of an enrollee’s MAGI as computed according to federal standards;
(b) the percentage of enrollee’s MAGI
that would be needed to purchase the state benchmark plan as established by the
superintendent;
(c) the percentage of New Mexico
residents at or below a given the FPL percentage; and
(d) The federal premium sliding scale
for marketplace coverage.
(2) These are the affordability criteria
that the superintendent may consider to determine state out-of-pocket
assistance eligibility. The
superintendent will use these criteria to establish state cost sharing
reduction variants that improve the actuarial value of certain QHPs offered on
the exchange:
(a) an enrollee’s MAGI as computed
according to federal standards;
(b) plan type and metal level tiers that
qualify for state out-of-pocket assistance; and
(c) actuarial values for plans that
qualify for state out-of-pocket assistance.
B. Income eligibility parameters. Annually, the superintendent shall publish a
bulletin specifying income eligibility parameters for the ensuing plan
year. Absent extenuating circumstances
that mandate an earlier rate filing, the superintendent shall allow
participating health insurance issuers at least 15 days from publication of the
bulletin to make an initial QHP rate filing.
If the federal government changes policies that will affect the cost of
the program to the state or the cost to enrollees after the issuance of the
bulletin, the superintendent may adjust the income eligibility parameters. The income eligibility parameters may differ
for the premium assistance program, state out-of-pocket assistance program or
premium assistance for state residents who are members of federally-recognized
tribes. In developing the criteria, the
superintendent may consider the following factors:
(1) the income distribution of current
marketplace enrollees;
(2) the income distribution of
uninsured individuals who qualify for coverage on the New Mexico health
insurance exchange; or
(3) health insurance market stability
issues and year-over-year trends in premium rate affordability.
C. General eligibility requirements.
(1) To qualify for state out-of-pocket
and premium assistance, consumers must:
(a) be eligible to purchase a QHP on
the exchange;
(b) qualify for federal premium
assistance; and
(c) meet income criteria established
annually by the superintendent.
(2) The superintendent will issue
criteria for premium assistance that is available to members of
federally-recognized tribes. To qualify,
individuals must:
(a) meet all other criteria for state
premium assistance; and
(b) be a member of a federally-recognized
tribe.
D. Premium
and state out-of-pocket assistance payment
disbursements. Disbursements for
premium assistance or state out-of-pocket assistance to a participating health insurance
issuer of an eligible enrollee who purchases an eligible plan are governed by
this rule. Monthly, by the 15th of each
month, the exchange shall report to the superintendent the total amount due to
each participating health insurance issuer for premium assistance and state
out-of-pocket assistance for coverage of its eligible enrollee(s) for the
preceding calendar month.
(1) The monthly
payment amount due to a participating health insurance issuer for premium
assistance shall be the monthly aggregate amount of premium assistance for all
eligible enrollees of the health insurance issuer for the month.
(a) Monthly
state premium assistance amounts shall be calculated using the following
formula: gross monthly premium for state benchmark plan
minus monthly federal premium tax credit minus applicable percentage of income
established by superintendent multiplied by expected annual household income as
outlined in 45 C.F.R. § 155.305(f)(i) divided by 12.
(b) Within
10 days of receiving the monthly accounting from the exchange, the
superintendent will, by voucher, request that the secretary of finance and
administration issue warrants as necessary to ensure payment to each
participating health insurance issuer for the monthly amount determined to be
due by the superintendent.
(2) The monthly
payment amount to a participating health insurance issuer for state
out-of-pocket assistance shall be determined as a percentage set by the
superintendent of gross monthly premiums for enrollees of an eligible plan in a
specified income tier, aggregated across all qualifying income tiers.
(3) To facilitate
reconciliation, a health insurance issuer must track or accurately estimate
claim costs in accordance with guidance published by the superintendent to
allow for the determination of actual utilization of out-of-pocket assistance.
[13.10.36.9 NMAC –
N, 5/1/2022]
13.10.36.10 MINIMIZING COVERAGE DISRUPTIONS AFTER
THE FEDERAL MEDICAID CONTINUOUS COVERAGE REQUIREMENT EXPIRES: This rule
governs the agency’s efforts to ensure a smooth transition into a QHP offered
on the New Mexico health insurance exchange for individuals who no longer
qualify for medicaid after the expiration continuous
coverage requirement in the federal “families first coronavirus response act”.
A. Temporary medicaid transition
premium relief program. The superintendent may issue a bulletin
establishing a program that fully covers the cost of the first month’s premium
for any QHP sold on the individual health insurance exchange for eligible
individuals and families. The premium relief will be available to all members
of a household that meet the eligibility requirements in Paragraph B of this
section. The payment may be used to effectuate coverage.
B. Eligibility for medicaid
transition premium relief program. To qualify, a person must:
(1) be a resident of the state of New
Mexico who is eligible to purchase a QHP on the New Mexico health insurance exchange;
(2) have lost medicaid
coverage or expect to lose medicaid coverage within
60 days of submitting an application to the New Mexico health insurance exchange;
(3) no longer be enrolled in medicaid at the time their QHP coverage begins;
(4) be eligible for federal premium
tax credits; and
(5) have an expected household income
below four hundred percent of the federal poverty level during the plan year in which the federal coronavirus disease
(COVID-19) public health emergency ends.
C. Duration. The program shall be available on January
1, 2023, or on the day the COVID-19 public health emergency ends, whichever is
later. The program shall continue in accordance with legislative
appropriations.
[13.10.36.10 NMAC – N/E, 6/1/2022,
A, 9/1/2022]
13.10.36.11 SMALL BUSINESS HEALTH INSURANCE
PREMIUM RELIEF INITIATIVE: This rule
governs the agency’s small business health insurance premium relief initiative,
which applies to QHPs sold through the small business health options program or
purchased directly from a health insurance issuer selling QHPs in the small group
health insurance market.
A. Premium reduction percentage
bulletin. Annually, based on available funding, the
superintendent will issue a bulletin establishing a premium reduction
percentage that will apply to all QHPs sold in the small group health insurance
market. Health insurance issuers participating in the market shall discount
charges to small group QHP purchasers by the percentage established by the
superintendent and show the amount of the discount in all invoices to the
purchaser. The superintendent may allow issuers to apply the discount directly
or through a credit on the following month’s premium. The bulletin will
establish the percentage reduction, reporting requirements, timetable and
process for issuer reimbursement, and other requirements. The superintendent
may issue additional guidance, if needed.
B. Reporting requirements and annual
verification of accurate payments. Health insurance
issuers selling QHPs in the small group health insurance market must report
data related to enrollment, premiums, and reimbursement from the health care
affordability fund to the office of superintendent of insurance on a regular
basis, based on the requirements of the bulletin. Following each calendar year,
on a date established by the superintendent, issuers must report annualized
data requested by the agency to verify the accuracy of payments made from the
fund. The superintendent will require issuers to replenish the fund if it is
determined that any overpayment has been issued.
C. Payments to participating issuers. On a regular basis, as established in the bulletin, the office of superintendent of insurance will make payments from the health care affordability fund to issuers for the remainder of the gross premium that that would otherwise by owed by small group QHP purchasers if the small business health insurance premium relief initiative were not in effect. The data received by OSI pursuant to Paragraph B of Section 10 of this rule serves as the basis for OSI’s regular payments to issuers from the health care affordability fund. Issuers must invoice the agency according to the bulletin’s instructions in order to receive payment.
D. Notification of small group QHP
purchasers. The superintendent will specify a date before the initiative
goes into effect by which health insurance issuers must notify their small
group QHP purchasers about the premium reductions provided by the initiative.
Issuers subject to the rule should reflect the premium reduction amount in all
invoices.
E. Treatment as third-party payment. For
the purposes of the federal risk adjustment program and federal medical loss
ratio requirements, the state payment under this section should be considered a
third-party payment that is part of the gross premium.
[13.10.36.11 NMAC – N/E, 6/1/2022,
A, 9/1/2022]
History of
13.10.36 NMAC: [RESERVED]