New Mexico Health Exchange Profile
Establishing the Exchange
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 an Exchange in 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. The Alliance was created in 1994 to provide small employer groups and qualifying individuals with access to health insurance. The new legislation creates a Board of Directors for the Exchange, 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. The Board of Directors of the Exchange 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 Exchange.
Prior to enactment of exchange 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 an Exchange. 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. Based in part on the insight collected by these workgroups, the Task Force released final recommendations on April 9, 2013.
Structure: The New Mexico Health Insurance Exchange is a quasi-governmental organization, specifically a non-profit public corporation.
Governance: The New Mexico Health Insurance Exchange 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.
In April 2013 the board members were selected and include:
- 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 the New Mexico Health Insurance Exchange at least through the first quarter of 2014, when the board hopes to hire a long-term CEO. The Exchange plans to issue bids for a national firm, which should be hired by November 1, to conduct a search for 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). Carriers have submitted plans and preliminary rates to DOI, which are currently being reviewed. 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 Exchange or SHOP, and will not be required to offer the same plan in both Exchanges. Plans that do not participate in the Marketplace initially will not be able to participate until the 2016 plan year.
The New Mexico Health Insurance Exchange (NMHIX) 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.
In addition to ACA requirements, carriers offering QHPs will be required to report New Mexico-specific quality information to the New Mexico Health Insurance Exchange 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.
At least five companies have filed with DOI to sell health insurance on New Mexico’s Exchange, including Lovelace Health Plan, Presbyterian Health Plan, Blue Cross Blue Shield of New Mexico, New Mexico Health Connections, and Molina Healthcare of New Mexico. The Marketplace has not yet defined its assessment fees for participating carriers.
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 received Notices of Intent to Participate from dental plans, and therefore expects that pediatric dental stand-alone plans will be available. 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 exchange are not required to embed pediatric dental benefits, but stand-alone pediatric policies will be available on the SHOP exchange.
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 Exchange, 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.
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.
On June 18, 2013, the New Mexico Health Insurance Exchange 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. Through this RFP, the Exchange is seeking contractors to design and implement a comprehensive advertising and marketing campaign aimed at reaching uninsured and insured individuals and small employer populations that will be impacted by health reform. The purpose of this campaign is to educate these populations on the availability and benefits of health insurance to be offered through the Exchange beginning on January 1, 2014. Applications are due July 3, and the award is estimated to be announced the week of July 15. The New Mexico Health Insurance Alliance offered recommendations to the board on marketing channels, PR, and advertising messaging for specific populations.
On June 28, 2013 the Exchange released a Request for Information (RFI) for “Healthcare Guides,” which is how NMHIX will refer to Navigators and Assisters. The Exchange envisions contracting with two or more umbrella entities to develop Navigator/Assister programs and implement comprehensive outreach, education, and enrollment strategies. It is assumed that these umbrella entities will utilize subcontractor organizations to provide a Healthcare Guide program. Separate contracts may be needed to provide services to specialized populations or certain geographic areas. The Exchange is encouraging partnerships and coalitions of organizations to submit applications together. Some partner organizations may propose to do outreach and education and some may propose to do enrollment and application assistance, but the overall proposal must include comprehensive services of outreach, education, and enrollment. These programs will hire individual Healthcare Guides, who 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 NMHIX, and connect customers to the Customer Service Center, NMHIX 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. Applications are due July 15.
Agents and brokers who wish to sell Exchange products will be required to meet licensing requirements and take additional training on NMHIX protocols. They will be required to register with the Exchange, receive training on QHP options and other publicly subsidized insurance programs and comply with Exchange privacy and security standards. Web brokers will be delayed until the 2015 operational year.
NMHIX is working towards a “triage” call center to address unresolved federal call center issues during the interim period in which New Mexico will rely on federal platform functions. The Exchange is also investigating the possibility of developing its own SHOP call center or obtaining those services through outsourcing.
The current New Mexico Health Insurance Alliance staff will undergo Navigator, IPA, federal call center, and SHOP training. They will become Triage Center Representatives (TCRs) for escalated federal call center calls and will be responsible for carrier and federal subsidy reconciliations. The Exchange website will provide a premium calculator and employer decision tool, and will route member information to either SHOP or the federal individual Exchange.
Small Business Health Options Program (SHOP) Exchange: The Advisory Task Force adopted the Employer Participation Workgroup’s recommendations regarding the SHOP Exchange in April 2013. Generally, the Workgroup emphasized the importance of affordability, simplicity, and education in attracting small businesses to the Exchange. The Workgroup recommended that state wait until 2016, when federal mandates go into effect, to change its definition of “small employer” to 100 or fewer employees.
The Workgroup recommended that in addition to its minimum bronze-level plans, every employer in a defined contribution exchange should be required to offer plans from one other actuarial value level. The same recommendation applies if an employer offers more than one plan in a traditional defined-benefit setting. In addition, the Exchange (not employers) should be responsible for premium aggregation.
Financing: The Exchange Advisory Task Force made several recommendations related to the financing of the Exchange. It recommended that an assessment be placed on insurers both inside and outside of the Exchange to remove the potential disincentive for Exchange participation, and that an assessment be placed on self-insured plans to contribute to financing the Exchange’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 Exchange, the assessments currently placed on plans for their administrative support be transferred to support the Exchange.
Information Technology (IT): The New Mexico Health Insurance Exchange Board selected an IT vendor and project manager at its May 2013 board meeting. The project manager will provide support and oversight of the IT vendor, business analysis and testing, and technical architecture review of the Exchange. The IT vendor contract includes shopping and comparison of IT systems, quality assurance and user acceptance testing, website development, and functionality related to the Small Business Health Options Program (SHOP) Exchange. The IT vendor has developed a roadmap and timeline for getting the Exchange IT systems up and running by October 2013.
The IT vendor is expected to coordinate with the Medical Assistance Division and Income Support Division of the New Mexico Human Services Department, such that eligibility determinations for Medicaid and the Children’s Health insurance Program (CHIP) can be transmitted to ASPEN (Automated System Program and Eligibility Network), the state’s current Medicaid eligibility system. The ASPEN system and the Medicaid Management Information System (MMIS) will coordinate enrollment activities for individuals found eligible for Medicaid or CHIP. The state is in the process of replacing ASPEN, which is approximately 25 years old. Integration of the Exchange and ASPEN is expected to be functional in 2015. To assist in financing the information technology upgrades of the state’s Medicaid eligibility systems, New Mexico applied for and received CMS approval of an Advanced Planning Document for the enhanced federal match.
New Mexico is also participating in the Enroll UX 2014 project, which is a public-private partnership creating design standards for exchanges that all states can use.
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 an Exchange. The state selected a subcontractor to create a health care reform fiscal model, which includes the estimated impact of a BHP. In its final recommendations, the Advisory Task Force recommended that the BHP continue to be studied as the Exchange moves forward. Workgroup members believe the BHP is necessary to mitigate the effects of churn and avoid possible loss of coverage.
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 Exchange, 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.
The New Mexico Human Services Department 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. On November 29, 2011, the New Mexico Department of Human Services received a federal Level One Establishment grant of almost $35 million. The grant funding will be used to refine the vision and objectives of the Exchange, continue stakeholder engagement, develop a multi-year business and operational plan, and examine the information technology infrastructure and functionality necessary to operate the Exchange 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.
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 exchanges, expanding Medicaid to newly eligible populations, streamlining eligibility and enrollment systems, instituting insurance market reforms and using data to drive decisions.
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 Exchange. However, due to time constraints in implementing an IT system, on May 17, 2013, the Board of Directors voted to work with the federal government to run the individual Exchange 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 Exchange.
Additional information about the New Mexico Health Insurance Exchange can be found at http://www.nmhix.com/