BROKER CERTIFICATION

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• BROKER CERTIFICATION
• INTRODUCTION OVERVIEW
• STATE COVERAGE INSURANCE AGENT OF THE STATE
• SMALL EMPLOYERS INSURANCE PROGRAM
• NEW MEXIKIDS
• PREMIUM ASSISTANCE PROGRAMS

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Insure New Mexico! Programs Intro and Overview

• INSURE NEW MEXICO! (INM) is a division of the
  New Mexico Human Services Departments Medical
  Assistance Division
• GOAL to address New Mexicos 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)

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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.
• IDENTITY
• Must provide original proof of identity.
• RESIDENCY
• Must be a New Mexico Resident.
• INCOME
• Earn less than 200 of the federal poverty level.

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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), veterans
  administration, workers 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
• 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
• 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
• 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
  co-pays are based on the applicants 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

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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 employees 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
  carriers 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 employers 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 companys 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 applicants
  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 DRIVERS 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 APPLICANTS BIRTH NAME, BIRTH DATE,
  COUNTY OF BIRTH, AND MOTHERS 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
  INMs 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)

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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 doctors
  office. Many healthcare providers have staff
  members who assist families with the Medicaid
  application process.

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• Premium Assistance for Kids (PAK)

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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 PARENTS 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 POOLS 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)

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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 POSTNATAL CARE, DELIVERY AND OTHER
  PREGNANCYRELATED 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
• [phone] or mari.spaulding-bynon_at_state.nm.u
  s
• Nancy Smith-Leslie, Programs Manager (505)
  827-7704 or
• nancy.smith-leslie_at_state.nm.us
• Claudia Wilson, Group Enrollment Center Manager
  [phone] or claudia.wilson_at_state.nm.us
• Toni Atencio, Outreach Coordinator (505)
  827-7248 or toni.atencio_at_state.nm.us
• Insure NM Solutions Center (Santa Fe)
  1-888-997-2583