health care guides introducing new mexico health connections 11/6/2013new mexico health connections
TRANSCRIPT
Health Care GuidesIntroducing New Mexico Health Connections
11/6/2013 New Mexico Health Connections
New Mexico Health Connections• 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 DifferentNon-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 ConnectGold $500 PPO
Choice ConnectSilver $2,000 PPO
Care Connect Gold $750 HMO
CareConnect Silver $2,000 HMO
Care Connect Bronze HMO
UNM CareConnect $2,000 HMO (HIX ONLY)
Care Connect Catastrophic HMO(HIX ONLY)
In-Network
Out-of-Network
In-Network
Out-of-Network
Preventive Care Services(1) No Charge
50% after deductible
No Charge
50% after deductible
No Charge
No Charge
No Charge
No Charge No Charge
Primary Care $20/visit
50% after deductible
$30/visit
50% after deductible
$30/visit $25/visit
50% after deductible
$25/visit No Charge(2)
Specialist Care $40/visit
50% after deductible
$60/visit
50% after deductible
$60/visit $75/visit
50% after deductible
$75/visit0% after deductible
Behavioral Health Visits(2) No Charge
50% after deductible
No Charge
50% after deductible
No Charge
No Charge
No Charge
No Charge No Charge
Urgent Care $50/visit $50/visit $50/visit $50/visit $50/visit $50/visit
50% after deductible
$50/visit0% after deductible
Emergency Room Services $250/visit
$250/visit
$250/visit$250/visit
$250/visit
$250/visit
50% after deductible
$250/visit0% after deductible
Preferred Generic Drugs(3)
No ChargeNot Covered
No ChargeNot Covered
No Charge
No Charge
No Charge
No Charge No Charge
Generic Drugs $10/RxNot Covered
$25/RxNot Covered
$15/Rx $25/Rx
50% after deductible
$25/Rx0% after deductible
Brand Name Drugs $30/Rx
Not Covered
$75/RxNot Covered
$45/Rx $75/Rx
50% after deductible
$75/Rx0% after deductible
Non-Preferred Brand Drugs $60/Rx
Not Covered
$150/RxNot Covered
$75/Rx $150/Rx
50% after deductible
$150/Rx0% after deductible
Specialty Drugs30% to max of $250/Rx
Not Covered
$250/RxNot Covered
$150/Rx $250/Rx
50% after deductible
$250/Rx0% after deductible
Individual Plans
MRI/CT/PET $250/test
50% after deductible
$250/test
50% after deductible
$250/test
$250/test
50% after deductible
$250/test0% after deductible
PT/OT/ST $40/visit
50% after deductible
$60/visit
50% after deductible
$60/visit $75/visit
50% after deductible
$75/visit0% after deductible
Outpatient Hospital
30% after deductible
50% after deductible
40% after deductible
50% after deductible
20% after deductible
30% after deductible
50% after deductible
30% after deductible
0% after deductible
Inpatient Hospital
30% after deductible
50% after deductible
40% after deductible
50% after deductible
$1,000/admission
$2,500/ admission
50% after deductible
$2,500/ admission
0% after deductible
Lab & X-ray Services(4)
No Charge
50% after deductible
No Charge
50% after deductible
No Charge
No Charge
50% after deductible
No Charge0% 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 deductible
30% 50% 40% 50% 20% 30% 50% 30% 0%
Annual Out-of-Pocket Maximum
$5,000 $10,000 $6,350 $12,700 $6,000 $6,350 $6,350 $6,350 $6,350
Choice ConnectGold $500 PPO
Choice ConnectSilver $2,000 PPO Care
Connect Gold $750 HMO
CareConnect Silver $2,000 HMO
Care Connect Bronze HMO
UNM CareConnect $2,000 HMO (HIX ONLY)
Care Connect Catastrophic HMO(HIX ONLY)In-
NetworkOut-of-Network
In-Network
Out-of-Network
Generic Medications• $0 Co-pay for these Chronic Conditions:– 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• 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
2440 Louisiana Blvd., NE, Suite 601Albuquerque, NM 87110