New Mexico Register / Volume XXXIII, Issue 15 / August 9, 2022
This is an
amendment to 13.10.36 NMAC, amending Sections 7, 8, 10 and 11, effective
9/1/2022
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] 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.
[F] 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/.
[G] E. “Income criteria”
means parameters to establish eligibility for marketplace affordability
programs.
[H] F. “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.] means
modified adjusted gross income as defined in 42 CFR § 435.60.
[I] 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.
[J] H. “OOP” means out-of-pocket.
[K] 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.
[L] J. “Plan
year”
means the year for which a participating health insurance issuer underwrites
qualifying health insurance coverage.
[M] 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.
[N] L. “QHP” means a qualified health plan.
[O] M. [“Reinsurance
payment” means an amount
paid to a participating health insurance issuer under the small group
reinsurance program.] “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.
[P] N. [“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.] “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.
[Q] 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.
[R] 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 [two
hundred fifty] 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]
13.10.36.10 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]