NEW MEXICO STATE COVERAGE INITIATIVE

1. NEW MEXICO STATE COVERAGE INITIATIVE New Mexico Human Services Department Medical Assistance Division Mari Spaulding-Bynon, SCI Project Coordinator Insure NM Update 11/16/04

2. Goal of New Mexico’s State Coverage Initiative (SCI) • To address New Mexico’s high rate of uninsured and low rate of employer sponsored health care • To offer affordable health care coverage to low-income working adults through an employer-based system New Mexico Human Services Department

3. Approval for SCI Granted Through a Health Insurance Flexibility and Accountability (HIFA) Federal Waiver • Partially fund program using funds from the State Children’s Health Insurance Program (SCHIP) • 82% federal match rate • More flexibility in health care coverage, cost-sharing and benefit design New Mexico Human Services Department

4. Financing Will Be Shared Between Public and Private Sources FINANCING EXAMPLE: Avg. cost per member/per month (pm/pm) = $300* Less: Premium Sharing Employer $ 75 Employee $ 20 Net Cost $205 Less: Federal Match @ 82% $169 State Share $ 36 * PM/PM provided only as an example not as actual cost New Mexico Human Services Department

5. SCI Targeting Employees Without Insurance ELIGIBILITY: • SCI will be offered to employees who have not voluntarily dropped health insurance coverage in the past six months and to employers who have not voluntarily dropped health insurance for their employees in the last twelve months. • No pre-existing condition limitations • Uninsured employees with family incomes up to 200% of federal poverty level. New Mexico Human Services Department

6. 2004 Federal Poverty Levels (FPL)Hourly Salary/FT employees(40 Hours/week) New Mexico Human Services Department

7. Proposed SCI Benefit Package* Is Similar to a Basic Commercial Plan * BENEFITS INCLUDE: • Hospital—inpatient/outpatient • Emergency and urgent care • Primary care/Specialty care • Women’s health services • Preventive health services • Inpatient physical rehabilitation & skilled nursing facility • Home health services/home intravenous services • Ambulance services $100,000 annual limit New Mexico Human Services Department

8. Proposed SCI Benefit Package* Is Similar to a Basic Commercial Plan(continued) BENEFITS INCLUDE: • Durable medical equipment supplies, orthopedic appliances, & prosthetic devices • Pharmacy • OT/PT/ST • Lab/diagnostics/X-ray • Behavioral health/substance abuse • Reconstructive surgery • Diabetes treatment * $100,000 annual limit New Mexico Human Services Department

9. Proposed SCI Benefit Package Does Not Include Typical Medicaid Benefits INCLUDING:  Optometrists & Eyeglasses  Personal Care Services  Transportation New Mexico Human Services Department

10. New Mexico Human Services Department Cost Sharing Provisions for SCI Premium Example:  Employers pay about $75/person/month  Employees pay premium based on family income from about $0-$35.00/month • 0-100% - employee pays $0/month • 101-150% - employee pays $20/month • 151-200% - employee pays $35/month

11. Employee Co-payments (by FPL) Co-pays for services based on sliding scale with out-of-pocket maximum  Physician/provider visits 0-100% of FPL - $0 101-150% of FPL - $5 151-200% of FPL - $7  Hospital inpatient medical/surgical 0-100% of FPL – $0 101-150% of FPL – $25 151-200% of FPL - $30  Prescription drugs – generic $3 per prescription New Mexico Human Services department

12. New Mexico Human Services Department Limits on Out-of-Pocket Expenses Annual Maximum Co-payments Equal to 5% of maximum gross income standard for given income grouping at time of application disposition  SCI covered individual’s responsibility to track and total amounts paid for SCI premiums and co-payments  Individual must notify Managed Care Organizations (MCO) and provide verification of paid amounts

13. New Mexico Human Services Department Limits on Out-of-pocket Expenses (Continued)  Once verified as paid, individual will not owe further premiums or co-pay amounts for remainder of benefit year (except for pharmacy) Monthly Maximum Co-payment  Individual monthly co-payment maximum for prescriptions of $12

14. New Mexico Human Services Department SCI Administered by Managed Care SCI is a managed care model to be contracted to managed care organizations (MCO) that successfully bid on the program through a request for proposal (RFP).