Current through Register Vol. 35, No. 18, September 24, 2024
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.
