State Marketplace Profiles: New Mexico

Final update made on October 25, 2013 (no further updates will be made)

Establishing the Marketplace

On March 28, 2013, Governor Susana Martinez (R) signed legislation creating the New Mexico Health Insurance Exchange (NMHIX). Governor Martinez had vetoed previous legislation that would have established a Marketplacein 2011; however, the state had moved forward with a plan to create the New Mexico Health Insurance Exchange within the New Mexico Health Insurance Alliance.¹ The Alliance was created in 1994 to provide small employer groups and qualifying individuals with access to health insurance.² The new legislation creates a Board of Directors for the Marketplace,  requires the establishment of strong conflict of interest policies, and allows the creation of a Native American Service Center to help with outreach to Native American populations.^3,4 The Board of Directors of the Marketplace will also oversee the Alliance until all the individuals and employers currently receiving coverage through the Alliance, along with enrollees in the New Mexico medical insurance pool, the state’s high risk pool, are transitioned into the Marketplace. On October 1, 2013, NMHIX launched its consumer-facing web portal, “Be Well New Mexico.” The website is available in English and Spanish. New Mexico is running its Small Business Health Options Program (SHOP) Marketplace, but will work with the federal government to run the individual Marketplace until October 2014. Under this arrangement, the state will maintain plan management and consumer assistance functions, while the federal government will operate the IT system.

Prior to enactment of Marketplace authorizing legislation, a 15-member Health Insurance Exchange Advisory Task Force was created by the Human Services Department to advise the state regarding development of a Marketplace. The Task Force consisted of eight workgroups focused on specific topics: Essential Health Benefits; outreach, education, adoption, and enrollment; legislation; market regulation; Native Americans; program integration; financial sustainability; and employer participation.⁵ Based in part on the insight collected by these workgroups, the Task Force released final recommendations on April 9, 2013.⁶

Structure: ExchangeBe Well New Mexico is a quasi-governmental organization, specifically a non-profit public corporation.

Governance: ExchangeBe Well New Mexico is governed by a Board of Directors consisting of thirteen voting members. These members include: the state Superintendent of Insurance; six members appointed by the Governor, including the Secretary of Human Services, a health insurance issuer, and a consumer advocate; and six members appointed by the state Legislature, including one health care provider and one health insurance issuer.⁷

In April 2013 the board members were selected and include:⁸

• Dr. James R. Damron (Chair), University of New Mexico School of Medicine
• Jason Sandel (Vice Chair), New Mexico Medical Insurance Pool
• Terriane Everhart, Property Consultants
• John Franchini, New Mexico Superintendent of Insurance
• Teresa Gomez, Futures for Children
• Dr. Martin Hickey, New Mexico Health Connections
• Dr. Larry Leaming, Roosevelt General Hospital
• Gabriel Parra, Presbyterian Healthcare Services
• Patsy Romero, Easter Seals El Mirador
• David Shaw, Nor-Lea General Hospital
• Ben Slocum, Lovelace Health Plan
• Sidonie Squier, Secretary, New Mexico Human Services Department
• Dr. J. Deane Waldman, University of New Mexico Health Sciences Center

The board named Mike Nunez, Executive Director of the New Mexico Health Insurance Alliance, to be the interim CEO of Be Well New Mexico at least through the first quarter of 2014, when the board hopes to hire a long-term CEO.

Contracting with Plans: The New Mexico Division of Insurance (DOI) has the regulatory responsibility for licensing Qualified Health Plan (QHP) issuers and reviewing and approving QHP policies. On April 15, 2013, DOI released its submission guidelines for qualified health plans (QHPs).⁹  Carriers are required to offer Silver and Gold levels of coverage, and must offer at least one statewide plan at each metal level for which the carrier submits a plan. (For example, if Carrier A has submitted a plan available at all the metal levels, then it needs to provide at least one statewide plan at all the metal levels. If Carrier A has only submitted plans at the Silver and Gold levels, then it only needs to provide statewide plans at the Silver and Gold Levels.) A carrier must offer three silver plan variations for each silver QHP to reflect the cost-sharing subsidies, and one zero cost sharing plan variation and one limited cost sharing plan variation for each metal level QHP. Benefits, networks, non-essential health benefits (EHB) cost sharing, and premiums must be the same across the silver plan variations. Carriers can offer plans in either the individual Marketplace or SHOP, and will not be required to offer the same plan in both Marketplaces. Plans that do not participate in the Marketplace initially will not be able to participate until the 2016 plan year.¹⁰

Be Well New Mexico will use geographic and tobacco rating. It is defining the number of geographic rating areas in New Mexico as four Metropolitan Service Areas (MSAs) plus one. The cap on a maximum differential between the highest and lowest rated area is 40%. The maximum ratio for tobacco rating will be 1:1.5.

Health insurance rates for individuals have now been approved and plan summaries and premiums can be viewed online.¹¹ Five insurers are participating in the Marketplace statewide.

In addition to ACA requirements, carriers offering QHPs will be required to report New Mexico-specific quality information to Be Well New Mexico and DOI. Quality reporting will not be required for dental carriers; however dental-specific quality measures may be created by DOI for future plan years.¹²

Dental and Vision Benefits: DOI will allow either embedded pediatric dental benefits at a minimum actuarial value level of 70% or the health plan can opt out of embedding.  DOI has adopted the reasonable limit of annual cost sharing for stand-alone pediatric dental plans to be at or below $700 for a single child enrollee plan, and $1400 for two or more children enrolled in a plan. Plans sold through the SHOP Marketplace are not required to embed pediatric dental benefits, but stand-alone pediatric policies will be available on the SHOP Marketplace.¹³

Risk adjustment, Reinsurance, and Risk corridors: Governor Martinez stated in her letter to Secretary Sebelius that New Mexico intends to administer a risk adjustment and reinsurance program during the first year of the Marketplace, but noted that the State would not be able to come to a final determination until it has an opportunity to examine the federal risk adjustment methodology.  Governor Martinez also noted New Mexico’s intention to use the federal service for Advance Premium Tax Credit/Cost-Sharing Reduction eligibility determinations.¹⁴

Consumer Assistance and Outreach: On July 9, 2013 the New Mexico Human Services Department received a Level One Establishment grant of $18.6 million. This award will be used to support comprehensive outreach, education, and marketing activities, as well as the state’s “Healthcare Guide” program (Navigators and In-person Assisters). The state will partner with nonprofit organizations, counties, schools and universities, faith communities, providers, and business organizations to provide extensive outreach at local events.  The State will also provide targeted outreach and education to tribal sovereign Nations at health fairs and events, and create an educational website and hotlinks for Native Americans.¹⁵

On June 18, 2013, Be Well New Mexico issued an RFP for advertising and marketing assistance, educational content, and public relations services, to be funded by the state’s Level One grant award. In August, the Marketplace awarded a $6-$7 million contract,¹⁶ and on September 17^th launched its “Be Well New Mexico” marketing and outreach campaign. The campaign features radio, print and TV ads, billboards, a website and social media. It also features an original “Be Well New Mexico” song, performed by six Albuquerque-area musicians. However, due to issues that individuals have faced with using healthcare.gov, Be Well New Mexico decided to postpone its advertising campaign, including television commercials and other paid advertising, until the federal website is working better and it is easier for individuals to enroll.¹⁷

On June 28, 2013 Be Well New Mexico released a Request for Information (RFI) for “Healthcare Guides,” which is how the Marketplace will refer to Navigators and Assisters.¹⁸ The Marketplace is contracting with two umbrella entities to develop Navigator/Assister programs and implement comprehensive outreach, education, and enrollment strategies. In August, the Marketplace selected these two umbrella entities: New Mexico Primary Care Association and Native American Professional Parenting Resources. These umbrella entities have subcontracted with community organizations throughout the state to provide Healthcare Guide services. Individual Healthcare Guides must complete a training and certification program, as well as a criminal background check. Healthcare Guides will deliver education, outreach, and in-person assistance to result in enrollment in the Marketplace, and connect customers to the Customer Service Center, Be Well New Mexico website, or certified and licensed brokers if additional support is needed. Targeted Native American assistance programs will also be developed to serve New Mexico’s Native American population.¹⁹

Be Well New Mexico is using the federal call center for its individual Marketplace and creating its own call center for the SHOP Marketplace. There is one phone number that all customers can call to receive assistance (1-855-99-NMHIX). That call center will connect customers to either: 1) the state Medicaid program’s call center for Medicaid-related calls; 2) contracted Healthcare Guide entities and/or certified Healthcare Guides; 3) the federal call center for customers seeking health insurance on the individual market; 4) New Mexico’s SHOP Marketplace; or 5) referrals to agents and brokers as requested.

Agents and brokers who wish to sell Marketplace products will be required to meet licensing requirements and take additional training on Be Well New Mexico protocols. They will be required to register with the Marketplace, receive training on QHP options and other publicly subsidized insurance programs and comply with Marketplace privacy and security standards. Web brokers will be delayed until the 2015 operational year.²⁰

Small Business Health Options Program (SHOP) Marketplace: In New Mexico’s SHOP Marketplace, employers must cover a minimum of 50% of their employees’ health care costs. If a business has less than 25 full-time employees, offers coverage to all full-time employees, has an average annual salary for all employees of less than $50,000, and contributes at least 50% of premium costs for employee plans, the business may be eligible to receive a tax credit. Employers select a health plan metal level (bronze, silver, gold, or platinum) to offer employees, and select a reference plan on which to base their contribution for each employee. Employees can select any plan within the metal level offered by their employer, although they may have to pay more or less, based on the plan they choose compared to the reference plan.²¹

Financing: The Exchange Advisory Task Force made several recommendations related to the financing of the Marketplace.  It recommended that an assessment be placed on insurers both inside and outside of the Marketplace to remove the potential disincentive for Marketplace participation, and that an assessment be placed on self-insured plans to contribute to financing the Marketplace’s administrative costs. In addition, the Task Force recommended that if/when the High Risk Pool and the Health Insurance Alliance are absorbed into the Marketplace, the assessments currently placed on plans for their administrative support be transferred to support the Marketplace.²²

Basic Health Program (BHP): New Mexico has explored establishing an optional coverage program available through the Affordable Care Act (ACA) which allows states to use federal funding to offer subsidized health insurance to adults with incomes between 139 and 200% of the federal poverty level (FPL) who would otherwise be eligible to purchase subsidized coverage through a Marketplace. The state selected a subcontractor to create a health care reform fiscal model, which includes the estimated impact of a BHP.²³ In its final recommendations, the Advisory Task Force recommended that the BHP continue to be studied as the Marketplace moves forward. Workgroup members believe the BHP is necessary to mitigate the effects of churn and avoid possible loss of coverage.²⁴

Essential Health Benefits (EHB): The ACA requires that all non-grandfathered individual and small-group plans sold in a state, including those offered through the Marketplace, cover certain defined health benefits.  On October 17, 2012, the Public Regulation Commission’s Insurance Division recommended that New Mexico’s EHB benchmark be the Lovelace Classic Preferred Provider Organization, a small group plan.²⁵

Marketplace Funding

The New Mexico Department of Human Services received a federal Exchange Planning grant of $1 million in 2010.  The Office of Health Care Reform requested and was granted a 12-month budget extension on the Planning grant funds for a new project end date of September 29, 2012.²⁶ On November 29, 2011, the New Mexico Human Services Department received a federal Level One Establishment grant of almost $35 million.²⁷ The grant funding will be used to refine the vision and objectives of the Marketplace, continue stakeholder engagement, develop a multi-year business and operational plan, and examine the information technology infrastructure and functionality necessary to operate the Marketplace by 2014. In October 2012, New Mexico requested an extension of the Level One grant. On July 9, 2013 the New Mexico Human Services Department received an additional Level One Establishment grant of $18.6 million. This award will be used to support comprehensive outreach, education, and marketing activities, establishing the state’s Navigator program, and supporting the state’s in-person assistance personnel.²⁸

In addition, New Mexico, along with nine other states, is receiving technical assistance from the Robert Wood Johnson Foundation through the State Health Reform Assistance Network; this assistance includes help with setting up health insurance Marketplaces, expanding Medicaid to newly eligible populations, streamlining eligibility and enrollment systems, instituting insurance market reforms and using data to drive decisions.²⁹

Next Steps

On January 3, 2013, New Mexico received conditional approval from the U.S. Department of Health and Human Services (HHS) to establish a state-based Marketplace.³⁰ However, due to time constraints in implementing an IT system, on May 17, the Board of Directors voted to work with the federal government to run the individual Marketplace until October 2014. Under this arrangement, the state will maintain plan management and consumer assistance functions, while the federal government will operate the IT system. The state will also run the SHOP Marketplace.^{31 32} The Be Well New Mexico Marketplace portal opened on October 1, 2013. The state’s SHOP Marketplace has begun to sign up small businesses to buy coverage and help them select plans for their businesses. Employees will be able to sign up for plans starting November 1. Be Well New Mexico directs individuals to HealthCare.gov, the federal health insurance Marketplace portal to apply for and enroll in coverage.

Additional information about Be Well New Mexico can be found at the state’s back office Marketplace website (NMHIX) and its customer portal (Be Well New Mexico). You can also obtain information from Be Well New Mexico’s Facebook page, Twitter feed, and You Tube site.