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Health Care Guides
Introducing New Mexico Health Connections
11/6/2013
New Mexico Health Connections
New Mexico Health Connections
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Affordable Care Act (ACA) – Section 1322
Consumer Operated and Oriented Health Plan (CO-OP)
New Mexico’s only non-profit health plan
February 2013 - Licensed as Certified Qualified Health
Plan by NM Office of the Superintendent of Insurance
• Required to hold 2.5 times the normal financial
reserves needed for health plans
• All brought about by Nandini Kuehn, PhD and other
concerned New Mexicans
NMHC - What Makes Us Different
Non-profit health plan
• Mission-driven, not profit-driven
– Profits will be reinvested back to New Mexicans to
improve quality of health care
• Lower Premiums
• Improve Benefits
• Collaboration with Community Organizations
– Investing in the community health infrastructure
• Serving as connector between members and
community resources
NMHC - What Makes Us Different
• Consumer Operated and Oriented Health Plan
(CO-OP)
– Governed with consumer control
– By 2016, majority of our Board of Directors will be
NMHC members
– Members will help drive health plan direction and
decisions
NMHC - What Makes Us Different
• NMHC is committed to a model of coordinated
care
– Focused on keeping members and their families
healthy
– Closely partnering with Clinicians, Community
Health Workers and Promotoras
– Incentivizing prevention, health, and wellness
Philosophy of Benefit Plans
• Less is more
– Fewer plans = Less confusion
– Our benefit plans on the Exchange are the same
as those off the Exchange
• Choice to use co-pay model
– The cost the member pays is defined and clear
– Encourages use of preventive care and wellness
services
Individual Plans
Choice Connect
Gold $500 PPO
Choice Connect
Silver $2,000 PPO
In-Network Out-ofNetwork
In-Network Out-ofNetwork
Care
Connect
Gold $750
HMO
Care
Connect
Silver
$2,000
HMO
Care
Connect
Bronze
HMO
UNM Care
Connect
$2,000 HMO
(HIX ONLY)
Care Connect
Catastrophic
HMO
(HIX ONLY)
Preventive Care
Services(1)
No Charge
50% after
50% after
No Charge
No Charge No Charge No Charge No Charge
deductible
deductible
No Charge
Primary Care
$20/visit
50% after
$30/visit
deductible
50% after
$30/visit
deductible
$25/visit
50% after
$25/visit
deductible
No Charge(2)
Specialist Care
$40/visit
50% after
$60/visit
deductible
50% after
$60/visit
deductible
$75/visit
50% after
$75/visit
deductible
0% after
deductible
50% after
50% after
Behavioral Health
No Charge
No Charge
No Charge No Charge No Charge No Charge
Visits(2)
deductible
deductible
No Charge
Urgent Care
$50/visit
$50/visit
$50/visit
$50/visit
$50/visit
$50/visit
50% after
$50/visit
deductible
0% after
deductible
Emergency
Room Services
$250/visit
$250/visit
$250/visit
$250/visit
$250/visit
$250/visit
50% after
$250/visit
deductible
0% after
deductible
Preferred
Generic Drugs(3)
No Charge
Not
Covered
No Charge
Not
Covered
No Charge No Charge No Charge No Charge
Generic Drugs
$10/Rx
Not
Covered
$25/Rx
Not
Covered
$15/Rx
$25/Rx
50% after
$25/Rx
deductible
0% after
deductible
Brand Name
Drugs
$30/Rx
Not
Covered
$75/Rx
Not
Covered
$45/Rx
$75/Rx
50% after
$75/Rx
deductible
0% after
deductible
Non-Preferred
Brand Drugs
$60/Rx
Not
Covered
$150/Rx
Not
Covered
$75/Rx
$150/Rx
50% after
$150/Rx
deductible
0% after
deductible
Specialty Drugs
30% to max Not
of $250/Rx Covered
$250/Rx
Not
Covered
$150/Rx
$250/Rx
50% after
$250/Rx
deductible
0% after
deductible
No Charge
Individual Plans
Choice Connect
Gold $500 PPO
Choice Connect
Silver $2,000 PPO
In-Network Out-ofNetwork
In-Network Out-ofNetwork
Care
Connect
Gold $750
HMO
Care
Connect
Silver
$2,000
HMO
Care
Connect
Bronze
HMO
UNM Care
Connect
$2,000 HMO
(HIX ONLY)
Care Connect
Catastrophic
HMO
(HIX ONLY)
MRI/CT/PET
$250/test
50% after
$250/test
deductible
50% after
$250/test
deductible
$250/test
50% after
$250/test
deductible
0% after
deductible
PT/OT/ST
$40/visit
50% after
$60/visit
deductible
50% after
$60/visit
deductible
$75/visit
50% after
$75/visit
deductible
0% after
deductible
Outpatient
Hospital
30% after
deductible
50% after 40% after
deductible deductible
50% after 20% after 30% after 50% after 30% after
deductible deductible deductible deductible deductible
0% after
deductible
Inpatient Hospital 30% after
deductible
50% after 40% after
deductible deductible
50% after $1,000/
$2,500/
50% after $2,500/
deductible admission admission deductible admission
0% after
deductible
Lab & X-ray
Services(4)
No Charge
50% after
50% after No
No Charge
deductible
deductible Charge
No
Charge
50% after
No Charge
deductible
0% after
deductible
Annual
In-Network
Deductible(5)
$500
$1,000
$2,000
$4,000
$750
$2,000
$2,500
$2,000
$6,350
Coinsurance after
30%
deductible
50%
40%
50%
20%
30%
50%
30%
0%
Annual
Out-of-Pocket
Maximum
$10,000
$6,350
$12,700
$6,000
$6,350
$6,350
$6,350
$6,350
$5,000
Generic Medications
• $0 Co-pay for these Chronic Conditions:
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Hypertension
Depression
Bipolar Disorder
Diabetes
Hypercholesterolemia
Chronic Obstructive Pulmonary Disease
Coronary Artery Disease
Congestive Heart Failure
Asthma
Behavioral Health Services
• Behavioral Health Services are a key focus for
NMHC
• Addressing Behavioral Health issues leads to
better overall health
– Behavioral Health Provider network
– $0 co-pay for the first 3 outpatient visits
– $0 co-pay for most generic Behavioral Health
medicines
NMHC State-Wide Provider Network
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Nearly 5,500 practitioners, hospitals, and facilities
Primary Care and Specialty
Close partnerships with FQHCs
Centers of Excellence
Out of State Network
Community Health Worker program
Please refer to website for a more detailed list of
providers
NMHC Website: Easy to Navigate
NMHC Website: Getting Started
NMHC Website: Quote and Compare
NMHC Website: Quote Comparison
NMHC Website: Provider Network
NMHC Website: Rx Formulary
Questions to help guide your clients
• How often do you / your family go to the doctor
• How many times did you visit the emergency room
last year
• What prescription medications are taken on a
regular basis
• Who are your doctors
• Do you have any chronic conditions
• Are you eligible for subsidies
Things to Consider
• How much did you spend last year
– The least expensive plan is not always the most
cost effective
– Consider deductibles, co-pays and coinsurance as
well as the monthly premium
Example: The story of Mr. Sanchez and his health
plan selection journey
Mr. Sanchez & His Health Plan Selection
Health Needs
Things to Consider
How NMHC Can Assist
Type I Diabetes
Locate a PCP
State-wide provider network
Doctor Visits
Low co-pays
Medication Costs
$0 co-pay for generic
medications
Subsidy Eligible?
Subsidy Calculator on
website
NMHC Summary
• NMHC adds value to the insurance market
– Member Driven
– Community Focused
– Co-pays clarify member costs
– Easy to use website
– Profits reinvested in New Mexico
– Built by New Mexicans, for New Mexicans
New Mexico Health Connections
www.mynmhc.org
info@mynmhc.org
1-855-7MY-NMHC
2440 Louisiana Blvd., NE, Suite 601
Albuquerque, NM 87110

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