Health

There are several different ways to get health insurance. Some people buy coverage on their own. Many people get coverage through their job or a family member’s job. Others are covered through public programs like Medicare and Medicaid. State insurance regulators provide oversight for some of these types of health insurance. Different regulatory agencies have responsibility for other types of coverage.

Individual Market—Buying Health Insurance on Your Own

When you or your family purchase health insurance and are not part of a group that gets health coverage together (like an employer), you’re considered to have ‘individual market’ coverage. Many people choose to buy individual market coverage through a health insurance marketplace. Buying through a marketplace allows those who qualify to get premium tax credits to help with the cost of their coverage. An insurance agent or broker can help you choose an individual market plan, or your state may have health insurance ‘navigators’ or other community-based assisters to help you.

While marketplaces only offer health insurance (and dental coverage) that meets certain requirements for benefits and coverage, other types of health insurance are also available to purchase on your own. These other types of insurance cover a more limited set of health care services and may choose not to cover you or charge you more if you have a pre-existing health condition.

Employer-based Coverage

Most non-elderly Americans get health care coverage through employment, either through their own job or family members. Employees and their families usually have a chance to sign up for coverage when starting a new job and once each year during an enrollment period.

State insurance regulators help to oversee insurance plans that employers purchase, often when the employer has fewer than 50 employees. But many employers choose to ‘self-insure’ rather than purchase health insurance. The U.S. Department of Labor generally provides oversight of self-insured employer plans. Other agencies, including the Office of Personnel Management, the Defense Health Agency, and the Centers for Medicare and Medicaid Services, provide oversight when the employer is a government agency.

Public Coverage

Many people get health coverage through public programs like Medicare, Medicaid, and the Children’s Health Insurance Program.

What is Open Enrollment?

Each year there is a specified period when people can enroll in an individual market health plan. New Mexico consumers can obtain coverage through beWellnm.com, for which open enrollment runs Nov. 1 – Dec. 23. Please check with the New Mexico Health Insurance Exchange, beWellnm, here to confirm Open Enrollment and Special Enrollment dates.

Is there a penalty for not having minimum essential coverage?

In the past, consumers would pay a penalty with their federal taxes if they were not enrolled in a health plan. Starting Jan. 1, 2019, that federal tax penalty was reduced to nothing and New Mexico does not impose penalties for going without insurance. If you don’t have major medical health insurance, you’ll be responsible for major health care costs.

Does my Health insurance plan renew automatically?

Most health plans are required to offer you a renewal each year. It’s your option to renew such plans but plans often renew automatically each year unless you take action to cancel. If you buy coverage on your own, there’s a time each year called the Open Enrollment Period when you can select a new plan or renew the one you have. If you get coverage through your employer, there is usually a similar period for changing plans.

Can I opt out of a Health insurance plan?

Yes, you may opt out of an insurance plan. However, you should check with your health insurance provider to see if there is any penalty for canceling your health insurance early.

Can I have more than one Health insurance plan?

Yes, you may be enrolled in more than one plan. Some people are enrolled in employer-sponsored insurance as well as Medicare, or both Medicare and a Medicare supplemental plan. One plan will be considered primary and pay for your health claims. The other plan will be considered secondary and will process any remaining bills under its rules.

What is a Medigap policy?

A Medigap policy is health insurance sold by private insurance companies to fill the “gaps” in Original Medicare Plan coverage. Medigap policies help pay some of the health care costs that the Original Medicare Plan does not cover. If you are in the Original Medicare Plan and have a Medigap policy, then Medicare and your Medigap policy will each pay their share of covered health care costs.

What is Medicare supplemental coverage?

Medicare supplemental coverage is another way to refer to Medigap policies. The federal Medicare program pays most medical expenses for people 65 or older, or for individuals under 65 receiving Social Security disability benefits. However, Medicare does not pay all expenses. As a result, you may want to buy a Medigap policy, also known as Medicare supplemental coverage, that helps pay for certain expenses, including deductibles not covered by Medicare.

How do I know if I’m eligible for a Medigap policy?

To buy a Medigap policy, you generally must have Medicare Part A and Part B. You are guaranteed the right to buy a Medigap policy if you are in your Medigap open enrollment period or covered under Medigap protection. You might not be able to buy a Medigap policy if you are in a Medicare Advantage Plan, have Medicaid, already have a Medigap policy, or are under the age of 65 and you are disabled or have End-Stage Renal Disease.

When should I apply for a Medigap policy?

When you elect coverage under Medicare Part B either due to age or disability, you have a 6-month open enrollment for a Medigap policy, which guarantees you coverage with a plan and company of your choice. You may choose from a list of standardized plans – listed as A through L (New enrollees cannot buy Plans C, F or F High Deductible after January 1, 2020. Find out more here.) If you do not purchase a plan within your 6-month open enrollment, any company you apply to can deny coverage based on your health conditions. There are some limited additional open enrollment periods available if you’re unenrolling from a Medicare Advantage plan.

What isn’t covered in Medicare that is covered by Medigap?

You may want to buy a Medigap policy because Medicare does not pay for all your health care. There are “gaps” or “out-of-pocket” costs that you must pay in the Original Medicare Plan. Some examples of costs not covered are hospital stays, skilled nursing facility stays, blood, Medicare Part B yearly deductible and Medicare Part B covered services. A Medigap policy will not cover long-term care, vision or dental care, hearing aids, and private-duty nursing.

What are my rights with Medigap?

Under Federal law, you have rights and protections regarding your Medigap coverage. These include your right to buy Medigap coverage, protections if you lose or drop your health care plan, and protections for people with Medicare under the age of 65. It is illegal for anyone to pressure you into buying a Medigap policy, lie or mislead you to switch to another company or sell you a second Medigap policy when they know that you already have one. It is also illegal to sell you a policy that cannot be sold in your state. Call your State Health Insurance Assistance Program to better understand these rights and protections.

What are Medicare Advantage plans?

Medicare Advantage plans are private managed care plans that provide the standard Medicare benefits plus additional supplemental benefits for a monthly fee. These plans may include prescription drug coverage. Medicare Advantage participants may receive a subsidy for their prescription drug benefits in most cases.

What are Medicare Select plans?

Medicare Select plans are Medicare supplemental coverage plans that provide benefits through a network of providers similar to a Preferred Provider Organization (PPO). If the participant receives care from a provider under contract with the insurer, the cost will be lower.

What is COBRA?

Under COBRA, if you leave your current job you have the option to continue your health care coverage for up to 18 months. You are required to pay the full premium yourself, even if your employer paid part of your premium while you were employed, and the employer may charge an additional, limited administrative fee.

You can find out more about COBRA continuation of group health benefits from the Federal Department of Labor Office of Employee Benefits Security Administration website.

Shopping for health insurance?

For comprehensive coverage, visit the New Mexico Health Insurance Exchange beWellnm at www.beWellnm.com. You can also contact a certified agent or broker to help you with your insurance coverage needs.

Actual Charge – means the amount actually paid by or on behalf of the insured and accepted by a provider for services provided. Insurance policies that use these terms must use them as defined in this section.

Affordable Care Act (ACA)Legislation signed by President Obama on March 23, 2010, that made historic changes in the availability and delivery of health insurance, Medicaid and health policy nationwide. Commonly referred to as the health reform law, Patient Protection and Affordable Care Act (PPACA), the Affordable Care Act (ACA) and Obamacare. The final provisions of the law went into effect on January 1, 2014, providing a place where individuals and small business owners can shop and compare health insurance plans before enrolling. This law requires all eligible individuals and certain size businesses to have health insurance or pay a fee or tax.

Approved Charge – The dollar amount on which a health carrier bases its payments and your co-payments. This may be less than the actual charge.

Benefit Maximum – The most a health insurance policy will pay for a specified loss or covered service. The benefit can be expressed as either a period of time, a dollar amount or a percentage of the approved amount. Benefits may be paid to the policyholder or a third party.

Certificate Holder – An employee or other insured named to receive benefits under a group health insurance policy.

Chronic Condition – A continuous or prolonged illness or condition. Examples: asthma, diabetes, varicose veins.

Claim – A request for payment for services.

COBRA – Federal law requiring that workers who end employment for specified reasons have the option of purchasing group insurance through the employer for a limited period of coverage (usually 18 months, but in some cases 29 months or 36 months).

Conditionally Renewable – An insurance policy that the company will renew with each premium payment, as long as you meet certain conditions.

Coordination of Benefits (COB) – Provisions and procedures used by health carriers to avoid duplicate payments when a person is covered by more than one policy/contract.

Co-payment (co-insurance) – A specified dollar amount or percentage of covered expenses which a health care policy/contract or Medicare requires a covered person to pay toward eligible medical bills.

Covered Period – The time period for which covered services will be paid.

Covered Person – A person who receives benefits of a health care policy/contract.

Covered Services – Services for which a health care policy/contract will pay.

Deductible – A specified dollar amount of medical expenses which the covered person must pay before a health care policy/contract will pay.

Enrollment Period – Period during which individuals or group members may enroll for coverage under a health care policy/contract

Exclusion – A procedure, service, or condition which a health care policy/contract does not cover.

Experimental/Investigational – Medical treatment/procedures that are not generally accepted as the standard of care in the medical profession. Health care policies/contracts often do not cover these treatments/procedures. Often there is disagreement between doctors and health carriers whether a specific treatment/procedure is experimental/investigational.

Explanation of Benefits (EOB) – A statement from a health carrier showing payments or denials for claims for health care services.

Fee For Service – Health care coverage that does not place restrictions on which doctor one can use. The health carrier pays for the health care expenses you incur.

Free Look – The period during which you may reconsider the purchase of an insurance policy, cancel and get a full refund. Individual health policies have a free look of at least 10 days; Medicare supplement and long-term care policies have 30-day free look periods.

Grace Period – A specified period, usually 30 days, for the payment of a renewal premium after the original premium due date. The coverage remains in effect during the grace period if the premium is paid before the grace period expires.

Group Insurance/Coverage – A contract between an insurer and an employer or other group.

Guaranty Issue – An insurance policy that is issued to anyone, regardless of health.

Guaranteed Renewable – An agreement by an insurance company to insure a person for as long as premiums are paid.

Health Insurance Portability and Accountability Act (HIPAA) – Federal statute that among other things, people who move from one group health care plan to another or who move from a group plan to an individual plan will not have to satisfy a new preexisting condition exclusion period. HIPAA was effective on July 1, 1997.

HIPAA Eligible Individual – A person who meets federal standards for continuing or obtaining health care coverage under the Federal HIPAA.

Health Savings Account (HSA) – A new health coverage option that is similar to a Medical Savings Account (MSA). A major advantage to an HSA is that savings may be carried over from calendar year to another.

Hospital Indemnity Policy – Pays a fixed dollar amount for each day you are in the hospital, regardless of actual hospital bills.

Individual Health Care Coverage – A policy/contract between a health carrier and a covered person.

Individual Mandate – Under the ACA, starting January 1, 2014, consumers and their dependents including children were required to have “minimum essential coverage” or pay a penalty, unless they fit within an exemption. This requirement is commonly known as the “individual mandate.”

Inpatient – A person who has been admitted to a hospital or other health care facility to receive diagnosis, treatment or other health services.

Insured – An individual or organization protected by an insurance policy.

Lifetime Maximum – The total amount a policy/contract will pay during the covered person’s lifetime.

Long-term Care (LTC) – The medical and social care given to one who has a severe chronic impairment over a long period of time.

Loss – The basis for a claim under a policy/contract. In health insurance, loss can refer to medical expenses, resulting from illness or injury.

Loss Ratio – The dollar amount a health carrier pays in claims compared to the amount it collects in premiums. Loss ratio is usually shown as a percentage of claims for every dollar collected.

Maximum Amount – The most a health carrier will pay for a specified loss or covered service. The amount can be expressed as either a period of time, a dollar amount or a percentage of the approved amount. Payment may be made to the covered person or the provider.

Medically Necessary – Treatments or services a health care policy/contract will pay for as defined in the contract. Each policy/contract should define medically necessary.

Medical Savings Account (MSA) – A special kind of account that is eligible for a tax credit when combined with catastrophic care insurance that has high deductibles.

Multiple Employer Welfare Arrangement (MEWA) – An organization of employers who “jointly self-insure” and pool funds to provide health care benefits for their employees.

Open Enrollment – A period of time when new applicants may enroll in a health care plan regardless of their health condition.

Out-of-State Group Policies – A group policy/contract that is sold outside of Oklahoma to a group domiciled in another state.

Outpatient – A patient who receives care at a hospital or other health facility without being admitted to the facility. Outpatient care also refers to care given in other locations such as outpatient clinics.

Pre-existing Condition – An illness or medical condition for which an individual received medical advice, diagnosis, care or treatment.

Effective January 1, 2014, ACA Compliant plans must include new consumer protections. Health insurers can no longer deny applicants or refuse to renew coverage because of a pre-existing medical condition. They also can’t charge a higher premium due to a person’s gender or health condition.

Non-ACA compliant plans continue to medically underwrite, apply pre-existing exclusions and waiting periods and can out-right deny coverage during the claim process.

Pre-certification/Pre-authorization – A requirement that you obtain the health carrier’s approval before a medical service is provided or before services by an out-of-network provider are received. Pre-certification/Pre-authorization is not a guarantee of claim payment however; failure to obtain pre-certification/pre-authorization may result in denial of the claim or reduction in payment of the claim.

Primary Carrier – Health care coverage that pays first when a person is covered by more than one policy/contract.

Provider – A person or organization that provides medical services, such as a doctor, hospital, x-ray company, home health agency, pharmacy, etc.

Rider – A legal document that modifies a health care coverage policy/contract. Riders may extend or decrease coverage or add or exclude specific conditions.

Secondary Carrier – Health care coverage that pays second when a person is covered by more than one policy/contract. The secondary carrier cannot determine its payment until after the primary carrier has made its payment determination.

Self-funded/Self-insured Health Care Plan – A health care plan created to pay benefits from a fund established by an employer or organization. Self-funded/Self-insured plans may be administered by third-party administrators or insurance companies but are not considered products under the authority of OID with an exception in some situation for prescription benefits processed by Oklahoma licensed PBM’s.

Specific Disease Policy – A health insurance policy that covers the expenses incurred only for a specific disease named in the policy. The most common type is cancer insurance. Also known as Dread Disease policy.

Underwriting – The process by which a health carrier determines whether or not and on what basis it will accept an application for coverage.

Usual, Customary and Reasonable (UCR) – The dollar amount a health carrier has determined to be appropriate for a particular medical service that is received from an non-PPO network provider. This amount is often less than the actual charge. Each carrier determines its own UCR amount and not all health carriers use this method for determining payments.

Waiting Period – The time that must pass after coverage begins and before the policy/contract will pay claims for a pre-existing condition. It may also refer to the time you must wait before obtaining health care coverage from a new employer group health care plan.

Waiver – A voluntary surrender of a right or privilege known to exist.

You may not be able to enroll in another plan until the Open Enrollment Period unless you qualify for a Special Enrollment Period. Check your policy first though, to see if there are any limitations on canceling your plan. If you are not enrolled in any health plan, you’ll be responsible for major health expenses, but you won’t face a federal tax penalty.

Starting July 1, 2021, New Mexico law protects low-income people from medical debt collection. The law is called the Patient’s Debt Collection Protection Act.

Debt collection can be selling the debt to a third party, and it can be filing a lawsuit against the patient. Debt collection also can be placing a lien on the patient’s property or garnishing wages. If you are low-income, medical providers cannot take certain debt collection actions against you. Low-income also is called “indigent.” Under New Mexico law, “indigent” means your household income is at or below 200% of the federal poverty guidelines. You can ask your medical provider or the debt collector to decide if you are indigent. You can also check the federal income guidelines to see if you may qualify.

See the Debt Collection Notice below to learn more about your rights. You can fill out the “OSI Attestation of Indigency Form” to claim indigency.

Consumer Resources

Provider Resources

Supplement – 21-07

Recursos del Consumidor

Read the Law: Patients’ Debt Collection Protection Act

Read OSI’s Rules: Title 13 Chapter 10 Part 39

Access Indigency Tool

What is Long Term Care Insurance?

Long-term care insurance pays for skilled, intermediate, and custodial care in a nursing home, as well as care in other settings, such as the home, adult daycare center, or assisted living facility. The policy pays a fixed amount per day while a person is receiving care.

Should I purchase long-term care insurance?

Before purchasing long-term care insurance, educate yourself about the pros and cons. Find an agent that you trust and ask questions about coverage, premiums, and how premiums have changed over time for different products. For more information about Long Term Care Insurance, and tips for finding the right product, please download the

NAIC Shopper’s Guide to Long Term Care

Health Insurance

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