13.10.36.9

Premium Assistance and Annual OOP Programs: This rule governs the annual state out-of-pocket assistance and premium assistance programs.

1. 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. (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:

   2. (a) the percentage of an enrollee’s MAGI as computed according to federal standards;

      1. (b) the percentage of enrollee’s MAGI that would be needed to purchase the state benchmark plan as established by the superintendent;
      2. (c) the percentage of New Mexico residents at or below a given the FPL percentage; and
      3. (d) The federal premium sliding scale for marketplace coverage.

   3. (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:

      1. (a) an enrollee’s MAGI as computed according to federal standards;
      2. (b) plan type and metal level tiers that qualify for state out-of-pocket assistance; and
      3. (c) actuarial values for plans that qualify for state out-of-pocket assistance.

2. 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. (1) the income distribution of current marketplace enrollees;
   2. (2) the income distribution of uninsured individuals who qualify for coverage on the New Mexico health insurance exchange; or
   3. (3) health insurance market stability issues and year-over-year trends in premium rate affordability.

3. C. General eligibility requirements.

   1. (1) To qualify for state out-of-pocket and premium assistance, consumers must:

      1. (a) be eligible to purchase a QHP on the exchange;
      2. (b) qualify for federal premium assistance; and
      3. (c) meet income criteria established annually by the superintendent.

   2. (2) The superintendent will issue criteria for premium assistance that is available to members of federally-recognized tribes. To qualify, individuals must:

      1. (a) meet all other criteria for state premium assistance; and
      2. (b) be a member of a federally-recognized tribe.

4. 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. (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.

      1. (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.
      2. (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. (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. (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.

[13.10.36.9 NMAC – N, 5/1/2022]