Transcript STATE COVERAGE INSURANCE

BROKER CERTIFICATION
INTRODUCTION & OVERVIEW:
•STATE COVERAGE INSURANCE & AGENT OF THE STATE
•SMALL EMPLOYERS INSURANCE PROGRAM
•NEW MEXIKIDS
•PREMIUM ASSISTANCE PROGRAMS
Insure New Mexico! Programs Intro and Overview
• INSURE NEW MEXICO! (INM) is a division of the New Mexico
Human Services Department’s Medical Assistance Division
• GOAL: to address New Mexico’s high rate of uninsured and low rate of
employer-sponsored health coverage
• INM! is responsible for the development and oversight of new health
care initiatives, such as:
• STATE COVERAGE INSURANCE (SCI)
• SMALL EMPLOYER INSURANCE PROGRAM (SEIP)
• PREMIUM ASSISTANCE FOR KIDS (PAK)
• PREMIUM ASSISTANCE FOR MATERNITY (PAM)
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State Coverage Insurance (SCI)
State Coverage Insurance
•
SCI is authorized through a HIFA (Health Insurance Flexibility and Accountability)
waiver approved by Centers for Medicare and Medicaid Services. The state of
of New Mexico receives a match from the federal government of approximately 80%.
•
SCI contracts were awarded through by a procurement process. The program
officially began in July 2005.
The Current SCI health insurance carriers are:
• LOVELACE COMMUNITY HEALTH PLAN
• PRESBYTERIAN HEALTH PLAN and
• MOLINA HEALTHCARE which includes the University of New
Mexico SCI program (note that UNM assists with payment of all
premiums for enrollees in its network)
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Eligibility Requirements
AGE:
• Uninsured persons between the ages of 19
and 64 with no other health insurance
coverage and not eligible for other
government programs.
CITIZENSHIP:
• Must be a U.S. Citizen or Legal
Permanent Resident (LPR) who has met
the 5-year bar.
2007 Annual Guidelines
Household Size
0-100%
FPL
101-150%
FPL
151-200%
FPL
1
$10,210
$15,324
$20,424
2
$13,690
$20,544
$27,384
IDENTITY:
• Must provide original proof of identity.
3
$17,170
$25,764
$34,344
4
$20,650
$30,974
$41,304
RESIDENCY:
• Must be a New Mexico Resident.
5
$24,130
$36,204
$48,264
6
$27,610
$41,424
$55,224
INCOME:
• Earn less than 200% of the federal poverty
level.
7
$31,090
$46,644
$62,184
8
$ 34,570
$51,864
$69,144
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Eligibility Requirements: Income
There are two types of income:
– Earned: consists of the total gross income received by an
individual for services performed as an employee or as a result
of self-employment.
– Unearned: consists of all other income that is not earned in
the course of employment.
Examples of earned income are wages, salaries, commissions, self-employment
income and military pay.
Examples of unearned income are alimony support, disability insurance benefits,
dividends, interest and royalties, rent income from property, pensions and
annuities, reimbursements, social security, unemployment compensation,
supplemental security income (SSI), veteran’s administration, worker’s
compensation.
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Eligibility Requirements: Income
Income Disregards-- SCI applies earned income deductions to the total
gross income as follows (no deductions are applied to unearned income):
TWO PARENT HOUSEHOLD WORK INCENTIVE DEDUCTION
• Start with household gross earned income
• Subtract $225 for each working parent
• Divide the remainder of the income by ½
• Subtract dependent child care (if any)
• Add in unearned income (if any)
• This gives you the net countable income that is compared to the FPL chart.
SINGLE PARENT OR ADULTS WITHOUT CHILDREN HOUSEHOLD WORK
DEDUCTION
• Start with household gross earned income
• Subtract $125 for the single working parent or adult
• Divide the remainder of the income by ½
• Subtract dependent child care (if any)
• Add in unearned income (if any)
• This gives you the net countable income that is compared to the FPL chart.
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Eligibility Requirements: Citizenship and Identity
U.S. CITIZENSHIP AND IDENTITY
CAN BE VERIFIED WITH:
• U.S. PASSPORT
• CERTIFICATE OF NATURALIZATION
• CERTIFICATE OF U. S. CITIZENSHIP
IF SOMEONE DOES NOT HAVE THE ABOVE DOCUMENTS, THEN
MUST HAVE AN ORIGINAL BIRTH CERTIFICATE AND ONE OF
THE FOLLOWING:
•
•
•
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STATE DRIVERS LICENSE
GOVERNMENT MILITARY ID OR DRAFT RECORD
NEW MEXICO STATE IDENTIFICATION CARD
CERTIFICATE OF INDIAN BLOOD OR NATIVE AMERICAN TRIBAL
DOCUMENT
LEGAL PERMANENT RESIDENTS MUST SHOW ORIGINAL
DOCUMENTATION FROM INS (Form I-94) AND PHOTO ID
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Eligibility Requirements: the Role of ISD
THE INCOME SUPPORT DIVISION (ISD) IS A STATE ENTITY UNDER
THE HUMAN SERVICES DEPARTMENT (HSD). A CENTRAL ISD UNIT IS
RESPONSIBLE FOR REVIEWING THE SCI APPLICATIONS AND
APPROVING THOSE APPLICANTS WHO QUALIFY.
ELIGIBILITY DETERMINATION IS BASED ON:
• HOUSEHOLD INCOME - MUST BE UNDER 200% OF FPL
(DISREGARDS APPLY)
• HOUSEHOLD SIZE - DETERMINES THE AMOUNT OF INCOME A
HOUSEHOLD CAN MAKE UNDER THE GUIDELINES
• CITIZENSHIP - MUST BE A CITIZEN OR LEGAL PERMANENT
RESIDENT FOR 5 OR MORE YEARS
• IDENTITY - MUST SHOW A GOVERNMENT ISSUED ID OR DRIVERS
LICENSE.
• RESIDENCY - MUST BE A RESIDENT OF NEW MEXICO
• NO VOLUNTARY DROP IN COVERAGE IN THE LAST 6 MONTHS
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Eligibility Requirements: Crowd Out Provisions
• AN INDIVIDUAL CANNOT HAVE VOLUNTARILY DROPPED
OTHER HEALTH INSURANCE IN THE 6 MONTHS PRIOR TO
APPLICATION
(QUALIFYING EVENTS SUCH AS AGING OFF OF PARENTS PLAN,
DIVORCE, DEATH, LAYOFF, COBRA, I-PLAN TO SCI GROUP ARE NOT
CONSIDERED A VOLUNTARY DROP OF COVERAGE)
• AN INDIVIDUAL WHO WAS TERMED FROM THE SCI PLAN FOR
NON-PAYMENT WILL HAVE A 6 MONTH PENALTY IMPOSED
• EMPLOYER GROUPS CANNOT HAVE VOLUNTARILY DROPPED
HEALTH INSURANCE IN THE LAST 12 MONTHS PRIOR TO
APPLICATION
• GROUPS WHO ARE TERMINATED FOR NON-PAYMENT WILL
HAVE A 12-MONTH PENALTY IMPOSED
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Eligibility Requirements: Crowd Out Provisions (cont.)
EXCEPTIONS TO CROWD OUT ARE:
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•
•
•
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LEGAL SEPARATION
DIVORCE
CHANGE OR LOSS OF EMPLOYMENT
DEATH
REDUCTION IN HOURS WORKED THAT RESULTS IN
TERMINATION OF HEALTH COVERAGE
• EMPLOYER CONTRIBUTION TOWARDS COVERAGE IS
TERMINATED
• TERMINATING FROM AN INDIVIDUAL PLAN TO ENROLL IN
AN SCI GROUP PLAN
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Eligibility Requirements: Income
HOUSEHOLD COMPOSITION: WHO IS COUNTED?
The applicant, his/her spouse and all dependents under age 19.
Children living in the household who are 19 years of age and older are considered to be
adults and NOT members of the household.
Parenthood also determines the household– whether or not the parents are
legally married.
HERE ARE SOME EXAMPLES:
•
•
•
•
•
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UNMARRIED COUPLE WITH 7 YEAR OLD CHILD = FAMILY OF 3
UNMARRIED COUPLE - GIRLFRIEND APPLIES = FAMILY OF 1
GRANDPARENTS AND 16 YEAR OLD = FAMILY OF 3
MARRIED COUPLE WITH 21 YEAR OLD CHILD = FAMILY OF 2
UNMARRIED MALE AGE 18 = NOT ELIGIBLE FOR SCI, WOULD BE
ELIGIBLE FOR NewMexikids
UNMARRIED COUPLE, MALE HAS 1 CHILD, FEMALE HAS 1 CHILD AND
FEMALE IS APPLYING = FAMILY OF 2
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SCI BENEFIT OVERVIEW
3 Different Premiums/3 Co-Pay Ranges
SCI is a cost sharing plan. The premiums and copays are based on the applicant’s household income.
Each applicant is approved based on the information
submitted with his/her application. The benefits,
limitations, and exclusions are the same across the
board. The co-pays and premiums are the only items
that differ.
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SCI BENEFIT OVERVIEW (CONT.)
3 different premium categories and 3 co-pay ranges:
•
0% - 100% FPL= $0.00 premium; $0.00 copays
•
101% - 150% FPL= $95.00 premium (employer pays $75/employee pays $20*)
– Mostly $5.00 copays
– Inpatient service is $25.00 copay; Emergency Care is $15.00 copay
•
151%- 200% FPL= $110.00 premium (employer pays $75/employee pays $35*)
– Mostly $7.00 copays
– Inpatient service is $30.00 copay; Emergency Care is $20.00 copay
*Individuals not affiliated with an employer group pay both the employer and
employee share of the premiums.
All categories: $3.00 Rx copays; capped at $12.00 per month
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SCI BENEFIT OVERVIEW (CONT.)
Comprehensive benefit plan: Primary and specialty
care, inpatient and outpatient hospitalization,
pharmacy, lab, X-ray, physical, occupational, speech
therapy, behavioral health and substance abuse
services.
Benefits are limited to $100,000.00 per benefit year. Inpatient services
are limited to 25 days (cumulative) per benefit year. Patients who
meet their benefit maximums are assisted to transition to other
health plans including New Mexico Medical Insurance Pool (the
Pool).
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SCI BENEFIT OVERVIEW (CONT.)
Service
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
0% – 100%
101% – 150%
151% - 200% FPL
Physician/Provider Visits)
$0
$5
$7
Pre/Post Natal Care
$0
$0
$0
Preventive Services
$0
$0
$0
Hospital Inpatient
Medical/Surgical**
$0/per admission $25/per admission $30/per admission
Hospital Inpatient
Maternity**
$0/per admission $25/per admission $30/per admission
Hospital Outpatient Surgery
$0
$5
$7
Home Health**
$0
$5
$7
Physical Therapy, Occupational
& Speech Therapy
$0
$5
$7
Diagnostics
(excluding routine lab and X-ray)
$0
$0
$0
Durable Medical Equipment/Supp
$0
$5
$7
Diabetes Treatment
Equipment and Supplies
$3
$3
$3
Diabetes Management
$0
$5
$7
Emergency Services
$0
$15 per visit
$20 per visit, waived if admitted to a hospital within 24 hours
Urgent Care
$0
$5
$7
Prescription Drugs:
Generic/Name Brand
$3 per prescrip $3 per prescrip $3 per prescrip
Behavioral Health and Substance Abuse:
Outpatient
$0
$5
$7
Inpatient
$0
$25
$30
Limits on Out-of-Pocket Expenses: limited to 5 percent of countable family income per benefit year.
Pharmacy out-of-pocket charges limited to four (4) prescriptions per month.
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SCI and Employer Groups
• An SCI group consists of 50 or fewer eligible employees. SCI is not
offered to larger groups who have 50 or more eligible employees. Eligible
means able to participate in insurance coverage.
• An SCI group can consist of one member. This is called a Group of One.
Self-employed persons can be a Group of One.
• A group can have SCI in combination with a commercial plan. This is
referred to as a Combo Group.
• The SCI plan and Commercial plan can have different renewal dates.
• Each employee must qualify based on his/her own household income and
family size. No one is automatically qualified.
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SCI and Employer Groups (cont.)
•
The employer must submit all required documents for its group to INM for
review. INM facilitates the group application process and notifies the broker or
employer if information is missing or additional documentation is needed.
•
The centralized ISD unit processes all of the group applications and issues
approval/denial notices.
•
Employees are responsible for notifying the employer when they receive their ISD
notices.
•
Employee certification dates may be different from the employer enrollment date.
•
Employee certification dates will be different from the group renewal date.
•
Employees may have a lapse in coverage if recertification is not approved prior to
the end of the employee’s current certification period.
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SCI and Employer Groups (cont.)
• An SCI only group is a group which offers SCI for medical coverage and
there is no other group coverage available.
• The group must not have voluntarily terminated a commercial group
policy in the last 12 months.
• An SCI only group can be a group of one.
• The group size is based on eligible employees.
• The group must meet participation requirements.
• A Combo Group can consist of a SCI group and a carrier’s commercial
group plan. More details are available by contacting a plan representative.
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SCI and Employer Groups (cont.)
To submit a group application packet to INM, employers should send the following:
•
•
•
Employer Group Information Sheet
SUTA or Census (payroll ledger)
Employee(s) ISD application(s) with required documents (information is placed
in sealed envelopes and kept confidential)
SEND Group Applications To:
Insure New Mexico
P.O. Box 27117
Santa Fe, NM 87502
For group enrollment information, call the Solutions Center at 1-888-997-2583 and ask
for the group enrollment center.
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SCI and Employer Groups (cont.)
HOW SCI BENEFITS THE EMPLOYER:
• Because of the cost sharing nature of the plan, the employer’s health care
costs are reduced significantly for those employees who qualify.
• Offering health coverage helps with employee retention.
• Having a combo group allows the employer to offer health insurance to
more employees.
• Having a combo group allows the employer to offer health insurance to an
employee group who had not previously been offered coverage.
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TALKING POINTS FOR SELLING SCI TO EMPLOYER GROUPS
• How many employees would be eligible for SCI? Is it enough to lower the
company’s health insurance costs?
• How many other groups in the same industry offer health coverage?
Offering coverage can help the company attract and retain the best
employees.
• A portion of employees will frequently be approved at the $0.00 dollar
premium. How will that impact your employees and the company?
• Regarding limitations to the plan, how many employees had significant
medical needs, and would have exceeded either the $100,000 limit or the
25-day inpatient limit in the last two years?
• It usually takes three meetings with a group. The first to sell the idea, the
second to enroll the employees, and the third to gather missing
information and additional applications.
• Once the initial paperwork is completed, the group can look forward to a
plan that offers a wide variety of services at an affordable price.
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SCI and INDIVIDUALS
• Although originally created for small groups, SCI helps low income
individuals who otherwise would not have access to health care insurance.
• SCI for individuals can also help groups. Employees who are exempt
from being offered health care insurance through their employer can
enroll in SCI.
• Because the premiums and co-pays are based on income, the individual
SCI member has a greater opportunity to receive needed health care and
preventive services.
• A self-employed person is considered an Individual or a Group of One.
Either enrollment process will work for those persons.
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SCI INDIVIDUAL ENROLLMENT
•
•
•
SCI applications are processed by a centralized Income Support Division Unit.
SCI applications are available through INM, participating carriers, participating
Brokers and ISD offices.
Applicants are responsible for attaching the required documentation which
includes having citizenship verified by ISD or by an agent of the state.
The Applicant is responsible for attaching required documentation to the SCI
application:
– VERIFICATION OF CITIZENSHIP AND IDENTIFICATION
– PROOF OF INCOME FROM THE PAST 30 DAYS
Broker-Sponsored Individual Applications Are Mailed To:
Insure New Mexico
P.O. Box 27117
Santa Fe, NM 87502
Insure New Mexico will review for completion and forward to ISD.
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SCI INDIVIDUAL ENROLLMENT (cont.)
ISD will send either a denial or approval notice with a CERTIFICATION
date.
• Certification Period:
– Certification period begins on the date listed on the ISD certification
letter.
– Certification period is for 12 months.
• Enrollment Period:
– Enrollment period begins on the month after the first premium
payment is made.
– The ISD approval letter lists the applicant’s monthly premium
amount.
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SCI RECERTIFICATION PROCESS
• Applicants must be recertified by the end of the 12 month eligibility
period.
• Enrollment does not continue if the member is not recertified by the end
of the certification period.
• Recert applications are not reviewed by ISD until the month of
recertification. Applications may be received up to 45 days earlier but will
not be processed until the month of certification.
• A lapse of coverage may occur if the recertification paperwork is not
received by the carrier by the cut off date. The member may re-enroll
once the required paperwork is received.
• When the enrollment is updated for new certification period, the Benefit
Max, Premiums, Copay Max will start over again.
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SCI RECERTIFICATION (CONT.)
TWO STEP RECERTIFICATION PROCESS:
• Step 1 - - Re-Apply to ISD
– ISD sends a recertification notice to the member 30 days prior to end of the
current ISD certification period.
– The carrier sends a recertification packet to the member or group 45 - 60 days
prior to the end of the current ISD certification period.
– The member or group submits all documents AND has citizenship verified, if not
previously done.
– It takes about the same amount of time to recertify as to apply, 45 - 60 days.
• Step 2 - - Re-Enroll with Your Carrier
– The ISD office sends the member a Recertification Approval Notice if the member
is recertified.
– ISD will send a copy of the recert approval notice to the carrier, which is usually
proof to continue coverage if a lapse has not already occurred.
– The individual member may be required to send in the recertification approval
notice with the re-enrollment documents, especially if banking information is
needed.
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BECOMING AN AGENT OF THE STATE
• Brokers can assist clients with SCI eligibility applications by becoming
agents of the state.
• Agents of the state are able to validate citizenship documents for clients.
• The best way to validate citizenship documents for clients is to have an
agent of the state in your office.
• If your office does not have an agent, INM can help. INM maintains a
database of agents throughout the state who are able to verify citizenship.
All ISD offices can also validate citizenship documents.
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WHAT DOCUMENTS MUST BE WITNESSED?
VALID CITIZENSHIP DOCUMENTS INCLUDE:
• U.S. PASSPORT* - THIS WILL WORK FOR VERIFYING BOTH
IDENTITY AND CITIZENSHIP. AN EXPIRED PASSPORT IS ACCEPTED.
• OTHER RECORDS OF CITIZENSHIP - CERTIFICATE OF
NATURALIZATION*, CERTIFICATE OF U.S. CITIZENSHIP*,
REPORT OF BIRTH ABROAD, CERTIFICATE OF INDIAN BLOOD,
ADOPTION DECREE
*U.S. PASSPORT, CERTIFICATE OF U.S. CITIZENSHIP AND THE CERTIFICATE OF
NATURALIZATION ARE THE ONLY DOCUMENTS THAT WILL PROVE BOTH
CITIZENSHIP AND IDENTITY.
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WHAT DOCUMENTS MUST BE WITNESSED (cont.)
IF APPLICANT DOES NOT HAVE A U.S. PASSPORT, THEN MUST
PROVIDE TWO DOCUMENTS-- GENERALLY A BIRTH
CERTIFICATE AND A DRIVER’S LICENSE
• STATE ISSUED BIRTH CERTIFICATE -THE VERIFIED DOCUMENT
MUST BE THE ORIGINAL. THE BIRTH CERTIFICATE FROM THE HOSPITAL IS
CONSIDERED A SOUVENIR AND IS NOT AN ACCEPTABLE FORM OF
CITIZENSHIP. A BAPTISMAL CERTIFICATE IS NOT AN ACCEPTABLE FORM OF
CITIZENSHIP
VERIFICATION OF A NEW MEXICO BIRTH CAN BE ACCESSED THROUGH THE
STATE WEBSITE. https://www.health.state.nm.us/partners/bc_confirm.php THE
APPLICANT’S BIRTH NAME, BIRTH DATE, COUNTY OF BIRTH, AND MOTHER’S
MAIDEN FIRST AND MAIDEN LAST NAME ARE NEEDED. A PRINT OUT OF
THIS SCREEN IS ACCEPTABLE DOCUMENTATION FOR PROOF OF BIRTH.
Please see the back of the Medicaid Tracking Log for other acceptable documents to
prove citizenship and identity.
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BECOMING AN AGENT OF THE STATE (cont.)
Agent of the State certification is done through INM’s Group Enrollment Center.
•
During the Agent of the State Certification, you will:
– Receive an Agent of the State Informational Guide.
– Review the requirements for verifying citizenship and identity documents and
learn about fraudulent documents.
– Enter into an agreement with HSD.
– Learn how to complete the Medicaid Citizen and Identity Tracking Log,
which is the ISD required form.
Certifications may be scheduled through the group enrollment center: 505-827-3130.
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SCI COMMISSIONS/BROKER REIMBURSEMENT
SCI commissions are determined and paid by the carrier.
A broker must be certified in Insure New Mexico! programs and appointed
with the carrier.
Carriers can discuss specifics of commissions with brokers.
Health Plan Contacts:
Lovelace: Gloria Vigil- 1-505-232-1791
Molina: Sharon Huerta- 1-505-348-1543
Presbyterian: Agnes Gallegos- 1-505-923-8171
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Small Employer Insurance Program
(SEIP)
PROGRAM OVERVIEW
•
STATE ADMINISTERED SELF-FUNDED PROGRAM
•
AUTHORIZED BY THE GENERAL SERVICES DEPARTMENT
•
SELF-FUNDED EMPLOYER POOL CONCEPT
•
ALLOWS FOR COMBINATION WITH OTHER PROGRAMS:
– Group New Mexico Medical Insurance Pool (NMMIP)
– State Coverage Insurance (SCI)
– Premium Assistance for Kids (PAK)
– NewMexiKids (MEDICAID)
•
LOWER-COST, COMPLETE HEALTH INSURANCE PACKAGE FOR SMALL
EMPLOYERS
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ELIGIBILITY AND ENROLLMENT
• ELIGIBILITY
– Small employers and sole-proprietors who have not offered health insurance
for the past 12 months
– Any interested non-profit organization (no crowd out provisions apply)
– Groups with 50 or fewer eligible employees
– All eligible employees (those eligible to participate in insurance) and their
dependents
– 75% participation requirement
• ENROLLMENT
– Enrollment is handled through Insure New Mexico! Solutions Center
1-888-997-2583
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BENEFITS, PREMIUMS AND ADMINISTRATION
BENEFIT PLAN - Similar to SCI with two plan options:
• PLAN A - No deductible / $20 co-pays
• PLAN B - $1000 deductible / $30 co-pays
Primary and specialty care, inpatient and outpatient hospitalization, pharmacy,
lab, X-ray, physical, occupational and speech therapy, behavioral health and
substance abuse services.
ANNUAL BENEFIT MAXIMUM OF $100,000
AVERAGE MONTHLY PREMIUMS
• PLAN A - $360.14 per employee
• PLAN B - $234.61 per employee
Employer must contribute at least 50% of the employee premium
Monthly premiums are determined by age, gender and geographic location
THIS PROGRAM IS ADMINSTERED BY:
BLUE CROSS/BLUE SHIELD OF NEW MEXICO
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NewMexikids
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NewMexikids
• NewMexikids is no-cost or low-cost health coverage for eligible families
with children from birth to age 19 and with incomes up to 235% of the
Federal Poverty Level.
• Expanded income disregards apply to children ages 0-5.
• Covered services include preventive and specialty care.
• Some categories of eligibility require minimal co-payments for doctor
visits and prescriptions.
• Children who qualify at 185% FPL or below receive full coverage Medicaid
and do not have co-payments.
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NewMexikids (cont.)
For children who qualify under the SCHIP category (185-235%
FPL), copayments are as follows:
– $5 per doctor, dentist, outpatient and urgent care
visits;
– $2 per prescription;
– $15 per emergency room visit; and
– $25 per inpatient hospital admission.
Native American children who are eligible for SCHIP do not make co-payments
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NewMexikids (cont.)
• Medicaid coverage must be renewed every 12 months.
• Applications for NewMexikids may be obtained by
calling 1-888-997-2583.
• Individuals may also go to an ISD office or to a
participating clinic, hospital or doctor’s office. Many
healthcare providers have staff members who assist
families with the Medicaid application process.
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Premium Assistance for Kids (PAK)
PAK PROGRAM OVERVIEW
For children who DO NOT qualify for NewMexikids due to
income, Premium Assistance for Kids (PAK) program is
available.
PAK PROVIDES ELIGIBLE CHILDREN WITH A
COMPREHENSIVE COMMERCIAL HEALTH PLAN.
THE STATE GENERALLY PAYS 50% OF THE MONTHLY
PREMIUM FOR EACH ELIGIBLE CHILD.
THE PROGRAM IS ENTIRELY STATE FUNDED-NO FEDERAL DOLLARS ARE USED.
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PAK ELIGIBILITY
PAK COVERAGE IS AVAILABLE TO:
• CHILDREN 0 THROUGH 11 UNLESS IN A SIBLING GROUP,
THEN UP TO 18 YEARS
• CHILDREN WHO DO NOT QUALIFY FOR MEDICAID OR
SCHIP BASED ON INCOME
• CHILDREN WHO HAVE NO OTHER TYPE OF HEALTH
INSURANCE
• CHILDREN WHOSE PARENTS HAVE NOT VOLUNTARILY
DROPPED INSURANCE COVERAGE FOR THEIR CHILDREN
WITHIN THE LAST SIX MONTHS
• CHILDREN MUST BE U.S. CITIZENS AND NEW MEXICO
RESIDENTS
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PAK OVERVIEW
• HUMAN SERVICES DIVISION IS THE REGULATORY AGENCY
FOR PAK ELIGIBILITY
• DOI IS THE REGULATORY AGENCY FOR THE PLAN ITSELF
• PAK ELIGIBILITY IS DETERMINED BY INM! - NOT THE
INCOME SUPPORT DIVISION
• FAMILIES WHO HAVE BEEN DENIED MEDICAID ELIGIBILITY
DUE TO INCOME ARE CONTACTED
• A MODIFIED INCOME APPLICATION IS USED FOR ELIGIBILITY
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PAK OVERVIEW (CONT.)
INSURE NEW MEXICO ISSUES APPROVAL LETTERS TO QUALIFIED
APPLICANTS
ELIGIBILITY IS VALID FOR 12 MONTHS UNLESS THE CHILD :
• QUALIFIES FOR MEDICAID
• IS ADDED TO A PARENT’S COMMERCIAL PLAN
ELIGIBILITY DOES NOT GUARANTEE ENROLLMENT
ELIGIBILITY MUST BE ESTABLISHED PRIOR TO BEGINNING THE
ENROLLMENT PROCESS WITH THE CARRIER
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PAK ENROLLMENT
PRESBYTERIAN AND LOVELACE ARE THE CURRENT PAK
CARRIERS
APPLICANTS MUST CONTACT THE CARRIER TO RECEIVE AN
ENROLLMENT APPLICATION
THE APPLICANT IS SUBJECT TO ALL STANDARD INDIVIDUAL
PLAN RULES, REGULATIONS, PROCEDURES AND
LIMITATIONS, SUCH AS:
• SERVICE AREA LIMITATIONS- IF ANY
• MEDICAL UNDERWRITING
• TERMINATION CLAUSES
• RATE INCREASES
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PAK ENROLLMENT (CONT.)
• EVERY APPLICANT IS SUBJECT TO MEDICAL
UNDERWRITING
• SOME APPLICANTS WILL BE DENIED
• UNDERWRITING DENIALS ARE REFERRED BACK
TO INM!
• THOSE APPLICANTS ARE ELIGIBLE TO APPLY
FOR THE POOL AND MAY QUALIFY FOR THE
POOL’S PREMIUM ASSISTANCE PROGRAM.
• ONCE ACCEPTED IN PAK, APPLICANTS ARE
ENROLLED IN THE INDIVIDUAL PLAN WITH
EITHER PRESBYTERIAN OR LOVELACE
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PAK PREMIUM BILLING
• THE STATE PAYS 50% OF THE ENTIRE MONTHLY PREMIUM
• THE MEMBER IS RESPONSIBLE FOR THE REMAINING
PORTION OF THE MONTHLY PREMIUM
• PRE-PAYMENT IS REQUIRED PRIOR TO ENROLLMENT
• FAILURE TO PAY THE PREMIUM TIMELY WILL RESULT IN
LOSS OF ELIGIBILITY FOR THE PAK PROGRAM AND
TERMINATION FROM THE PLAN
• INDIVIDUALS WHO ARE TERMINATED FOR NON-PAYMENT
ARE INELIGIBLE FOR THE PAK PROGRAM FOR 12 MONTHS
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BROKER INVOLVEMENT
• CHILDREN OF PARENTS IN SCI GROUPS WILL
LIKELY QUALIFY FOR NEWMEXIKIDS AND SHOULD
NOT APPLY FOR PAK UNLESS THEY RECEIVE A
DENIAL FROM MEDICAID.
• BROKERS ARE ENCOURAGED TO PARTICIPATE IN
PAK.
• CONTACT INSURE NEW MEXICO SOLUTIONS
CENTER AT 1-888-997-2583.
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Premium Assistance for Maternity
(PAM)
PREMIUM ASSISTANCE FOR MATERNITY (PAM)
• TO BE ELIGIBLE FOR PAM, YOU MUST BE:
– A NEW MEXICO RESIDENT
– A U.S. CITIZEN OR LEGAL PERMANENT RESIDENT (LPR)
WHO HAS MET THE 5- YEAR BAR (APPLICABLE FOR LPRS
WHO ENTERED THE U.S. AFTER AUGUST 16, 1996),
– UNINSURED OR HAVE INSURANCE WITHOUT MATERNITY
COVERAGE AND INELIGIBLE FOR MEDICAID DUE TO
INCOME.
• PAM BENEFIT:
– PREGNANCY-ONLY COVERAGE THROUGH ANY PROVIDER
THAT ACCEPTS MEDICAID REIMBURSEMENT. INCLUDES
PRE– AND POST–NATAL CARE, DELIVERY AND OTHER
PREGNANCY–RELATED HEALTH SERVICES.
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PREMIUM ASSISTANCE FOR MATERNITY (CONT.)
• ENROLLMENT:
–
INSURE NEW MEXICO! OFFICE PROCESSES ALL ELIGIBILITY
APPLICATIONS.
– ONE TIME ENROLLMENT FEE BASED ON TRIMESTER OF
PREGNANCY TO ENCOURAGE EARLY ENROLLMENT:
- $150 IF APPLICANT ENROLLS DURING FIRST 20 WEEKS
(MONTHS 1- 5 OF PREGNANCY)
- $300 IF APPLICANT ENROLLS DURING SECOND 20 WEEKS
(MONTHS 6-9 OF PREGNANCY)
THERE ARE NO DEDUCTIBLES OR CO-PAYS FOR THE PROGRAM.
CONTACT INSURE NEW MEXICO SOLUTIONS CENTER
AT 1-888-997-2583.
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INSURE NEW MEXICO CONTACTS:
• Mari Spaulding -Bynon, Insure New Mexico! Program Director
(505) 827-7788 or [email protected]
• Nancy Smith-Leslie, Programs Manager (505) 827-7704 or
[email protected]
• Claudia Wilson, Group Enrollment Center Manager (505) 827-3130 or
[email protected]
• Toni Atencio, Outreach Coordinator (505) 827-7248 or
[email protected]
• Insure NM Solutions Center (Santa Fe) 1-888-997-2583
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