New Mexico Register / Volume XXXIII,
Issue 9 / May 3, 2022
This is an
emergency amendment to 13.10.36 NMAC, which went into effect on May 1, 2022, Sections
7, 8, 10, and 11. These amendments will be effective on June 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; A/E, 6/1/2022]
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] 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]
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 Subsection 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 2022 plan
year.
C. Duration. The program shall be available beginning on
a date established by the superintendent and continue until the marketplace affordability
program begins.
[13.10.36.10 NMAC – N/E, 6/1/2022]
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 fully-insured small group health benefit plans
that meet QHP standards and are sold on or off the exchange.
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 Subsection 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]