The Affordable Care Act (ACA) was passed in 2010 and states began to create exchanges, or marketplaces, for health insurance. The New Mexico Health Insurance Exchange (NMHIX) is New Mexico’s marketplace, and Be Well NM is the website for the program. Be Well NM helps those who are uninsured, unable to buy their employer insurance plans, or who are buying their own insurance.
NMHIX offers plans from the following providers:
- Blue Cross and Blue Shield of New Mexico
- New Mexico Health Connections
- Presbyterian Health Plan
All plans must offer the following essential services:
- physician office visits
- emergency medical services
- inpatient hospital services
- labor and delivery care
- newborn care
- mental healthcare
- prescription drugs
- rehabilitative and habilitative care (includes speech, occupational, or physical therapy)
- diagnostic laboratory services
- preventive care
- chronic disease management
- pediatric services
There are four basic plans available through the exchange. These have varying coverage levels. They include:
- bronze (60 percent of expenses paid)
- silver (70 percent)
- gold (80 percent)
- platinum (90 percent)
Lower plans have lower premiums (the baseline cost for coverage), but higher out-of-pocket costs (including deductible, copays, and coinsurance). A catastrophic plan, with a high deductible, is available for those under the age of 30.
Many people will want to know how much of a subsidy they qualify for, but the real question is, how much will you pay? Your ultimate decision should be based on your income versus how often you might need to use the coverage.
For example, the silver plan for a 40-year-old nonsmoker in Bernalillo County that earns $35,000 a year ranges from $167 to $302 a month.
The challenge is to compare the costs of each plan and decide which offers the best value. There are several tools that can help you estimate the monthly cost of health care in New Mexico, including this calculator, sponsored by BeWellNM, and this calculator, sponsored by the Kaiser Family Foundation.
As of 2015, the annual maximum out-of-pocket is $6,600 for individuals and $13,200 for families. Capping out-of-pocket costs will help consumers pay medical bills that aren’t covered by insurance, reducing the chances of bankruptcy.
Depending on your income, you may qualify for financial aid to help offset the costs of coverage. This may come in the form of:
- Medicaid coverage
- tax credits
Adults livings at or below 133 percent of the federal poverty level (FPL) may qualify for Medicaid in New Mexico. Pregnant women living at or below 250 percent of the FPL may also qualify.
The FPL for 2015, according to the health insurance marketplace, is:
- $11,770 in individual annual wages
- $15,930 for those in families of two
- $24,250 for a family of four
- $40,890 for a family of eight
There are also two kinds of subsidies people may use for healthcare costs. Federal poverty levels from 2014 are used to calculate eligibility for subsidies in 2015. The first is a cost-sharing subsidy. This subsidy is for silver plans only and reduces the total out-of-pocket cost of a plan. People who have household incomes between 100 and 250 percent of the 2014 poverty level may be eligible.
The second type of subsidy is the premium tax credit. If your income is less than 400 percent of the 2014 federal poverty level but you do not qualify for Medicaid, you may qualify for this credit. This is a subsidy that would help pay for part of your insurance. On average, individuals who earn about $46,680 a year or less qualify. For a family of four, the eligible income level increases to about $95,400 or less.
The percentage of your costs that this subsidy would cover depends on income level and the cost of a second-tier silver plan where you live. This silver plan is used as a baseline because the ACA was designed so everyone could afford a silver plan, regardless of how expensive the healthcare rates may be where you live.
For example, if your income is $33,000 a year (283 percent of the poverty level), the most you’ll have to pay for a second-tier silver plan is about 9 percent of your income. This averages to about $2,972 a year, or $248 a month. You can choose a plan other than the second-tier silver plan and use your tax credit but the subsidy amount will stay the same. This means a gold plan would cost you more, even if you use a subsidy to cover some of the cost.
For 2016, the open enrollment period begins November 1, 2015 and ends January 31, 2016. Those who experience a life-changing event, such as birth of a child or loss of employer coverage, may purchase health insurance outside of the open enrollment period.
Getting the right insurance plan for you and your family is easier, and more important, than you may think. Healthcare guides can help you with any issues you have during the search and enrollment process. You can also consult an insurance agent or broker. The NMHIX call center is live 24 hours a day, seven days a week.