BROKER CERTIFICATION INTRODUCTION & OVERVIEW: STATE COVERAGE INSURANCE & AGENT OF THE STATE SMALL EMPLOYERS INSU

1. BROKER CERTIFICATION INTRODUCTION & OVERVIEW: STATE COVERAGE INSURANCE & AGENT OF THE STATE SMALL EMPLOYERS INSURANCE PROGRAM NEW MEXIKIDS PREMIUM ASSISTANCE PROGRAMS

2. Insure New Mexico! ProgramsIntro and Overview • INSURE NEW MEXICO! (INM) is a division of the New Mexico Human Services Department’s Medical Assistance Division • GOAL: to address New Mexico’s 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) New Mexico Human Services Depart.

3. State Coverage Insurance (SCI)

4. 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) New Mexico Human Services Depart.

5. 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. New Mexico Human Services Depart.

6. 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), veteran’s administration, worker’s compensation. New Mexico Human Services Depart.

7. 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. New Mexico Human Services Depart.

8. 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 New Mexico Human Services Depart.

9. 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 New Mexico Human Services Depart.

10. 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 New Mexico Human Services Depart.

11. 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 New Mexico Human Services Depart.

12. 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 New Mexico Human Services Depart.

13. 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 applicant’s 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. New Mexico Human Services Depart.

14. 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 New Mexico Human Services Depart.

15. 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). New Mexico Human Services Depart.

16. 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 • Emergency Services $0 $15 per visit $20 per visit, waived if admitted to a hospital within 24 hours • Urgent Care $0 $5 $7 • Prescription Drugs: Generic/Name Brand $3 per prescrip $3 per prescrip $3 per prescrip • Behavioral Health and Substance Abuse: Outpatient $0 $5 $7 Inpatient $0 $25 $30 • Limits on Out-of-Pocket Expenses: limited to 5 percent of countable family income per benefit year. • Pharmacy out-of-pocket charges limited to four (4) prescriptions per month. New Mexico Human Services Depart.

17. 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. New Mexico Human Services Depart.

18. 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 employee’s current certification period. New Mexico Human Services Depart.

19. 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 carrier’s commercial group plan. More details are available by contacting a plan representative. New Mexico Human Services Depart.

20. 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. New Mexico Human Services Depart.

21. SCI and Employer Groups (cont.) HOW SCI BENEFITS THE EMPLOYER: • Because of the cost sharing nature of the plan, the employer’s 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. New Mexico Human Services Depart.

22. TALKING POINTS FOR SELLING SCI TO EMPLOYER GROUPS • How many employees would be eligible for SCI? Is it enough to lower the company’s 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. New Mexico Human Services Depart.

23. 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. New Mexico Human Services Depart.

24. 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. New Mexico Human Services Depart.

25. 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 applicant’s monthly premium amount. New Mexico Human Services Depart.

26. 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. New Mexico Human Services Depart.

27. 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. New Mexico Human Services Depart.

28. 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. New Mexico Human Services Depart.

29. 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. New Mexico Human Services Depart.

30. 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 DRIVER’S 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 STATEWEBSITE. https://www.health.state.nm.us/partners/bc_confirm.phpTHE APPLICANT’S BIRTH NAME, BIRTH DATE, COUNTY OF BIRTH, AND MOTHER’S 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. New Mexico Human Services Depart.

31. BECOMING AN AGENT OF THE STATE (cont.) Agent of the State certification is done through INM’s 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. New Mexico Human Services Depart.

32. 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 New Mexico Human Services Depart.

33. Small Employer Insurance Program (SEIP)

34. 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 New Mexico Human Services Depart.

35. 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 New Mexico Human Services Depart.

36. 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 New Mexico Human Services Depart.

37. NewMexikids New Mexico Human Services Depart.

38. 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. New Mexico Human Services Depart.

39. 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 New Mexico Human Services Depart.

40. NewMexikids (cont.) • Medicaid coverage must be renewed every 12 months. • Applications for NewMexikidsmay be obtained by calling 1-888-997-2583. • Individuals may also go to an ISD office or to a participating clinic, hospital or doctor’s office. Many healthcare providers have staff members who assist families with the Medicaid application process. New Mexico Human Services Depart.

41. Premium Assistance for Kids (PAK)

42. 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. New Mexico Human Services Depart.

43. 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 New Mexico Human Services Depart.

44. 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 New Mexico Human Services Depart.

45. 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 PARENT’S COMMERCIAL PLAN ELIGIBILITY DOES NOT GUARANTEE ENROLLMENT ELIGIBILITY MUST BE ESTABLISHED PRIOR TO BEGINNING THE ENROLLMENT PROCESS WITH THE CARRIER New Mexico Human Services Depart.

46. 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 New Mexico Human Services Depart.

47. 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 POOL’S PREMIUM ASSISTANCE PROGRAM. • ONCE ACCEPTED IN PAK, APPLICANTS ARE ENROLLED IN THE INDIVIDUAL PLAN WITH EITHER PRESBYTERIAN OR LOVELACE New Mexico Human Services Depart.

48. 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 New Mexico Human Services Depart.

49. 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. New Mexico Human Services Depart.

50. Premium Assistance for Maternity (PAM)