New Mexico Register / Volume XXXIII,
Issue 8 / April 19, 2022
TITLE 13 INSURANCE
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. "Attachment
range" means
the amount of claims costs incurred by a participating health insurance issuer
for a covered person's covered benefits in a plan year, above and below which
the claims costs for benefits are eligible for reinsurance payments under the
small group reinsurance program.
D. "Coinsurance
rate" means
the reimbursement percentage paid by the fund to a health insurance issuer
participating in the small group reinsurance program for claims incurred for a
covered person's covered benefits in a plan year which are in the attachment
range.
E. "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.
F. “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/.
G. “Income
criteria” means parameters to establish eligibility for marketplace
affordability programs.
H. “Modified adjusted gross income
or MAGI” means household size and income calculated to determine
eligibility for financial assistance on the New Mexico health insurance
exchange.
I. “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.
J. “OOP” means out-of-pocket.
K. “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.
L. “Plan year” means the year for which a participating health
insurance issuer underwrites qualifying health insurance coverage.
M. “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.
N. “QHP” means a qualified
health plan.
O. “Reinsurance
payment” means an
amount paid to a participating health insurance issuer under the small group
reinsurance program.
P. “Small group
reinsurance program” means a program to reduce premium rates for small
businesses that purchase coverage in the fully-insured small group market
through the purchase of reinsurance for claim costs that fall in the attachment
range.
Q. “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.
R. “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]
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 affordability program, sufficient funding to provide premium
reductions for individuals under four hundred percent of the FPL and OOP cost
reductions for individuals under two hundred-fifty 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]
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]
History of
13.10.36 NMAC: [RESERVED]