Off-Exchange Health Plan Submission Information
FAQs for Qualified Dental Plan submission
Information about the next meeting of the New Mexico Health Insurance Exchange is available on the Health Insurance
Exchange website http://www.nmhix.com.
Carrier questions about the New Mexico Health Insurance Exchange can be e-mailed to: CarrierQuestions@nmhix.com
Qualified Health Plan Submission information
- For Consumers:
Office of Superintendent of Insurance has the regulatory responsibility for licensing Qualified Health Plan (QHP) issuers and reviewing and approving/disapproving QHP policies. The upcoming enrollment period of the New Mexico Health Insurance Exchange begins October 1, 2013. As we draw nearer to that date, we will post updated consumer access information. Please see this NAIC FAQ for an overview of general health insurance exchange information.
- For issuers who are submitting Qualified Heath Plans for review:
Step 1 – Submit the Intent to Participate form.
Step 2 – Become licensed with Office of Superintendent of Insurance, Company Licensing Bureau. Additionally, all issuers who submit QHP policies for review will need to have the QHP Line of Business attached to their licenses. Line of Business requests can be submitted at the same time as the QHP policy submission. Please see instructions here.
Step 3 – Submit QHP policies (via SERFF). The submission date for the 2014 plan year is April 30, 2013. Guidelines are available here.
Please note: For additional assistance, please see the Frequently Asked Questions.
New Mexico Qualified Health Plan Submission Guide Final :: Submission Guide Changes
DEADLINE FOR PLANS OUTSIDE THE EXCHANGE – Submission of plans to be sold outside the exchange will have a deadline of August 15, 2013. We strongly encourage carriers to submit their outside the exchange plans separately from their QHPs for the exchange and we are working with SERFF to make the separate submission process clear. More guidance on submission of outside the exchange plans will be forthcoming.
Frequently Asked Questions About QHP Submissions in New Mexico
- Will carriers be required to participate in both the individual and small group markets? No, carriers can offer policies in just the individual exchange or just the SHOP exchange. Additionally carriers will not be required to offer the same plan in the individual and the SHOP exchange.
- Will carriers participating in the exchange be required to offer plans at more than the two levels of coverage required by the ACA (Silver and Gold)? No, carriers will only be required to offer two levels of coverage.
- Will carriers be required to offer more than one plan at any one metal level? Issuer must offer three silver plan variations for each silver QHP, and one zero cost sharing plan variation and one limited cost sharing plan variation for each metal level QHP. Silver plan variations must have a reduced annual limitation on cost sharing, cost sharing requirements and AVs that meet the required levels within a de minimis range. Benefits, networks, non-EHB cost sharing, and premiums cannot change. All cost sharing must be eliminated for the zero cost sharing plan variation. Cost sharing for certain services must be eliminated for the limited cost sharing.
- Will carriers have a limitation on the timeframe to decide if they want to participate in the Exchange? For the 2014 plan year, QHPs must be submitted to Office of Superintendent of Insurance by April 30, 2013. Information about plan submission is available on Office of Superintendent of Insurance website. Subsequent limitations will be decided by the Exchange, but the next opportunity to participate will be for the 2016 plan year.
Please note, stand alone dental and vision plans must be submitted by May 30, 2013.
- How will provider network adequacy be determined? Except for the new Essential Community Providers requirements, network adequacy will be evaluated by the same standards currently in use by Office of Superintendent of Insurance.
New Mexico has chosen to follow the federal guidelines for Essential Community Provider requirements. This ECP Supporting Documentation Instructions form outlines the requirements.
- How extensively must a QHP cover the geographical area? The ACA requires that the geographic region must be at least an entire county. New Mexico requires that carriers must offer at least one statewide plan at the metal level of any other plan submitted at a given metal level. (For example, if Carrier A has submitted a plan available at all the metal levels, then they need 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 they only need provide statewide plans at the Silver and Gold Levels.)
- Will carriers be allowed to apply area rating factors? New Mexico has chosen to define the number of rating areas in New Mexico as being four Metropolitan Service Areas (MSAs) plus one. See map. The value of the factors applied to each rating area will be determined by each carrier as would be appropriate given their unique contractual arrangements within that area. The cap on a maximum differential between the highest and lowest rated area is 40%.
- Will the maximum small group size be expanded from 50 to 100 in 2014? Will it include groups of one? The small group size will not be expanded in 2014. Groups of one will not be allowed.
- Will risk pools of the individual and small group markets be combined? The risk pools will not be combined for the 2014 plan year.
- What will the final assessment fees/taxes be for participating carriers? Due to the recent legislative action and federal proposals still in the comment stage, we do not yet have an answer to that.
- What will the rating factor be for tobacco? The maximum ratio will be 1:1.5.
How must pediatric dental and vision be submitted? It is a federal requirement that pediatric vision be embedded into the QHP health plans sold on the exchange.
Office of Superintendent of Insurance does not support the federal requirement to include pediatric vision and dental in childless adult health plans. Therefore, Office of Superintendent of Insurance will allow either embedded pediatric dental benefits at a minimum Actuarial Value level of 70% or the health plan can opt out of embedding. Office of Superintendent of Insurance has received Notices of Intent to Participate from dental plans. We therefore feel reasonably assured that pediatric dental stand alone insurance plans will be available. If embedding, please submit dental as a rider in SERFF.
From the Patient Protection and Affordable Care Act:
SEC. 1302. Essential Health Benefit Requirements (b) Essential Health Benefits (4) Required Elements for Consideration
“(F) provide that if a plan described in section 1311 (b)(2)(B)(ii) (relating to stand-alone dental benefits plans) is offered through an Exchange, another health plan offered through such Exchange shall not fail to be treated as a qualified health plan solely because the plan does not offer coverage of benefits offered through the standalone plan that are otherwise required under paragraph (1)(J);
When must stand-alone dental and vision plans be submitted? Recent guidance indicates that stand-alone vision plans will not be allowed on the exchange. : http://cciio.cms.gov/resources/files/ancillary-product-faq-03-29-2013.pdf Stand-alone dental plans must be submitted through SERFF no later than May 30, 2013.
Please note, guidelines for plan submission for plans outside the Exchange are forthcoming.