A look at upcoming health care changes

Enrollment for enhanced Medicaid and the health insurance marketplace under the federal Affordable Care Act started Tuesday.

New Mexico is participating and has set up a state marketplace, the New Mexico Health Insurance Exchange, through which qualifying individuals, families and small businesses receive health insurance benefits from a variety of established health insurance providers.

Here are some questions and answers about ACA and the health exchange:



Is Insurance Required?

Yes, by Jan. 1, you are required to be enrolled in health insurance, but there are more affordable options than ever and financial assistance may be available. You should start shopping now. Enrollment starts Tuesday. Coverage will start Jan. 1.

(Source: New Mexico Health Insurance Exchange (nmhix.com).)


Is there a deadline?

Yes. You should enroll no later than March 31, 2014.

(Source: nmhix.com)


What is the minimum health care coverage I need?

An individual needs to meet the individual responsibility requirement under the Affordable Care Act, which requires minimum essential coverage.

Minimum essential coverage includes the following:

• Employer-sponsored coverage (including COBRA coverage and retiree coverage).

• Coverage purchased in the individual market, including a qualified health plan offered by the Health Insurance Marketplace (also known as an Affordable Insurance Exchange).

• Medicare Part A coverage and Medicare Advantage plans.

• Most Medicaid coverage.

• Children’s Health Insurance Program (CHIP) coverage.

• Certain types of veterans health coverage administered by the Veterans Administration.


• Coverage provided to Peace Corps volunteers.

• Coverage under the Nonappropriated Fund Health Benefit Program.

• Refugee Medical Assistance supported by the Administration for Children and Families.

• Self-funded health coverage offered to students by universities for plan or policy years that begin on or before Dec. 31, 2014 (for later plan or policy years, sponsors of these programs may apply to HHS to be recognized as minimum essential coverage).

• State high risk pools for plan or policy years that begin on or before Dec. 31, 2014 (for later plan or policy years, sponsors of these program may apply to HHS to be recognized as minimum essential coverage).

(Source: IRS.gov)


Why should I have health insurance?

Accidents and illnesses can happen anytime. And even though you can’t predict when you may need care, at least you can be prepared in how to get it. Thanks to the NMHIX, you can now be covered for checkups, prescriptions, maternity care, hospital visits and more. You get to pick your own doctor and you can’t be denied coverage for a pre-existing health condition.

(Source: NMhix.com)


If my family is already covered under my employer’s plan, do I need to do anything?

No. You should already have the coverage you need. If, however, you are paying more than 9.5 percent of your income for insurance for yourself, you may qualify for financial assistance through the NMHIX.

Source: NMhix.com


What is the New Mexico Health Insurance Exchange (NMHIX)?

The NMHIX is a new way to help you find health insurance that meets your needs and fits your budget. Through the exchange, you can choose from health insurance plans from many top-rated providers, including:

• Blue Cross Blue Shield

• Lovelace

• Molina

• New Mexico Health Connections

• Presbyterian

(Source: NMHix.com)


If I need to buy health insurance, what should I look for?

Please review this checklist before you call or visit with a Health Care Guide, agent or broker. It will help make your application process go more quickly and smoothly.

1. Make a list of any questions you have. For example, “Will any of my current prescriptions be covered by this plan?” or “Will I be able to keep my doctor?”

2. Gather basic information about your household income. To find out if you qualify for financial assistance, have your last two pay stubs, W2’s or last year’s tax return available when applying.

3. Understand how health insurance works, including things like premiums, deductibles, out-of-pocket maximum costs and copayments. Definitions of common insurance and health care terms will be available on this site.

4. Set a budget. There will be a variety of health plans to choose from with different options and prices.

(Source: NMHix.com)


Can I get guidance and assistance in the shopping process?

Yes. To help with any questions or concerns, hundreds of Health Care Guides will be available to you throughout the state. Starting Oct. 1, here is how to reach a health care guide in:


Clovis & Curry County

• La Casa Family Health, Clovis Clinic, (575) 769-5030

• La Casa Family Health, Melrose Clinic, (575) 769-5030

• Plains Regional Medical Center (575) 769-7142

Portales & Roosevelt County

• La Casa Family Health, Portales Clinic, (575) 359-3826

• Roosevelt General Hospital, Portales, (575) 359-1800

Tucumcari & Quay County

• Dr. Dan C. Trigg Memorial Hospital, PMG Clinic, Tucumcari, (575) 461-7100

• Presbyterian Medical Services, Quay County Family Health Center, Tucumcari, (575) 461-2200

Fort Sumner & DeBaca County

• De Baca Family Practice, Fort Sumner, (575) 355-2414

• De Baca School Based, Fort Sumner, (575) 355-7734

• De Baca, Guadalupe Family Dental, Santa Rosa, (575) 472-2414


The NMHIX offers plans from popular commercial providers such as Blue Cross Blue Shield, Lovelace, Molina, New Mexico Health Connections and Presbyterian. Contact an agent for any of these plans for more information.

(Source: NMHix.gov)


Do my spouse and dependent children have to be covered under the same policy or plan that covers me?

No. You, your spouse and your dependent children do not have to be covered under the same policy or plan. However, you, your spouse and each dependent child for whom you may claim a personal exemption on your federal income tax return must have minimum essential coverage or qualify for an exemption, or you will owe a payment when you file.

(Source: IRS.gov)


If I have insurance for myself through my employer but it doesn’t cover the rest of my family, may I buy insurance through the exchange?

If you qualify based on household income, you may insure others in your household through the exchange.

(Source: NMHix.com)


Is financial assistance available?

Yes. Depending on your income, you may qualify for assistance to cover your costs. If you qualify for expanded Medicaid under the ACA, you might even receive health insurance free.

(Source: NMHix.com)




Who qualifies for expanded Medicaid, including free health insurance, through ACA and the Exchange?

According to the New Mexico Center on Law and Poverty, an additional 150,000 more New Mexicans will qualify for free health care coverage after Jan. 1 than qualify now.

To qualify for Medicaid expansion, an adult must be between the ages of 19 and 64 and must be a citizen of the U.S. or a lawfully present immigrant, and live in New Mexico, and household income must be less than the following levels, according to household size.

Adults age 19 to 64 qualify on the basis of household size with incomes per month/year of:

• 1 person, less than $1,232 per month/ $15,856 per year

• 2 persons, less than $1,785 / $21,404

• 3 persons, less than $2,247 / $26,951

• 4 persons, less than $2,709 / $32,499

• 5 persons, less than $3,172 / $38,047

• 6 persons, less than $3,634 / $43,594

If an adult cannot get Medicaid, children in the household may qualify. Qualifying children of immigrants who do not qualify are also eligible for the Medicaid program. While qualifying income levels are likely to change on Jan. 1, here are the current qualifying income levels for children:

Household size, yearly household income

• 1 person, less than $27,000

• 2 persons, less than $36,499

• 3 persons, less than $45,896

• 4 persons, less than $55,342

• 5 persons, less than $64,790

Low cost health insurance at low cost or free is available if your monthly household income is below:

• 1 person, $3,830

• 2-persons, $5,170

• 3 persons, $6,510

• 4 persons, $7,850

(Source: NM Center on Law and Poverty)


Who should get insurance through the NMHIX?

• Those without health insurance.

• People who can’t afford health insurance offered at their job.

• Small businesses with 50 employees or fewer.

• Those currently buying their own insurance but would like more options and affordability.

(Source: NMHix.com)


How do I sign up?

You can sign up online at www.BeWellNM.com, beginning Oct. 1, or set up an appointment with one of NMHIX’s Health Care Guides or insurance brokers near you.

(Source: NMHix.com)


If I think I qualify for enhanced Medicaid, but I’m having trouble proving it, what should I do?


Health Action New Mexico’s Joe Martinez says, “don’t give up.” There is a group of “You’re Not AloneTeams” of advocacy groups who can help.

Participating organizations and their websites and phone numbers include Center on Law and Poverty, http://nmpovertylaw.org; Southwest Women’s Law, www.swwomenslaw.org, (505) 244-0502; Health Action New Mexico, www.healthactionnm.org, (505) 867-1095; VOICES for Children, www.nmvoices.org; and the New Mexico Office of the Supervisor of Insurance Ombudsman Program at (855) 857-0972.

(Source: Health Action New Mexico, healthactionnm.org)


Where can I get more information about the Affordable Care Act?

• The New Mexico Health Insurance Exchange, www.nmhix.com

• The federal ACA website, www.Healthcare.gov.

• Health Action New Mexico, www.healthactionnm.org


Small Business

(Source: Affordable Care Act: Key Small Business Provisions, author: Small Business Administration)


What is the small business tax credit?

Businesses that have fewer than 25 full-time equivalent employees, pay average annual wages below $50,000 and contribute 50 percent or more toward employees’ self-only health insurance premiums, may qualify for a credit of up to 35 percent to offset the costs of insurance. In 2014, this tax credit goes up to 50 percent and is available to qualified small businesses who participate in the Small Business Health Options Program (SHOP). Eligible small employers can claim the current cedit through 2013, and the enhanced credit can be claimed for any two consecutive taxable years beginning in 2014 through the SHOP.


What is the Small Business Health Options Program (SHOP)?

Beginning Jan. 1, Small businesses with generally 50 or fewer employees will have access to marketplaces through SHOP. SHOP will offer small business increased purchasing power to obtain a better choice of high-quality coverage at a lower cost. Currently, small businesses pay on average 18 percent more than big business for health care because of administrative costs. SHOP will also pool risks for small groups and reduce administrative complexity, thereby reducing costs. More information is available by calling 1-800-706-7893.

Businesses with fewer than 50 full-time equivalent employees are generally not affected by the new employer shared responsibility rules. These smaller employers do not have to pay an assessment if their full-time employees receive premium tax credits to purchase coverage in one of the new Marketplaces.


What information does a business have to provide employees about health care coverage?

Employers are required to provide employees with a standard summary of benefits and coverage form explaining what their plan covers and what it costs. The purpose of the SBC form is to help employees better understand and evaluate their health insurance options. Penalties may be imposed for non-compliance The Dept. of Labor has provided a sample completed SBC that employers may reference. It is available at www.dol.gov/ebsa/pdf/CorrectedSampleCompletedSBC2.pdf.


What is a Medical Loss Ratio Rebate and how could it apply to my business?

If an insurance company spends more than 20 percent of premium dollars on administrative costs, it must provide rebates to its policy holders, typically employers that provide a group health plan. Employers who receive premium rebates must then determin whether the rebates constitute plan assets. If they are treated plan assets, employers have discretion to determine a reasonable and fair allocation of the rebate. More information is available at www.irs.gov/uac/Medical-Loss-Ratio-%28MLR%29-FAQs.


Does my business have to report health care costs on employee W-2 forms?

Beginning with their 2012 tax returns, most employers must report the aggregate annual cost of employer-provided health coverage for each employee on Form W-2. The new W-2 is for information only and does not require taxation on any health plan coverage. The requirement does not apply to employers required to file fewer than 250 W-2 forms in the prior calendar year. More information is available from the IRS at www.irs.gov/uac/Form-W-2-Reporting-of-Employer-Sponsored-Health-Coverage.


What is the limit on flexible spending account contributions?

Beginning this year, the maximum amount an employee may elect to contribute to health care flexible spending arrangements for any year will be capped at $2,500, subject to cost-of-living adjustments. The limit only applies to elective employee contributions and does not extend to employer contributions. More information is available from the IRS at www.irs.gov/publications/p969/ar02.html.


Who has more taxes withheld from wages for Medicare, starting in 2013?

The ACA increases the employee portion of the Medicare Part A Hospital Insurance withholding by nine-tenths of 1 percent—from 1.45 percent to 2.35 percent for employees with incomes of more than $200,000 for single filers and $250,000 for married joint filers. It is the employer’s obligation to withhold this additional tax, which applies only to wages in excess of these amounts. The employer portion of the tax remains at 1.45 percent.


How much is the new Medicare Assessment on Net Investment Income?

Since Jan.1, there has been a 2.8 percent tax assessed on net investment income, including capital gains, dividends, rent, royalties and interest for taxpayers with modified adjusted gross income over $200,000 for single filers and $250,000 for married joint filers. Common types of income that are not investment income include wages, unemployment compensation, operating income from a non-passive business, Social Security benefits, alimony, tax-exempt interest and self-employment income.


What are the employer shared responsibility provisions that go into effect next year?

A small business does not have to insure employees, but beginning in 2014, employers with 50 or more full-time equivalent employees who do not offer affordable health insurance that provides minimum value to their full-time employees and dependents may be required to pay an assessment. The assessment will be charged if at least one full-time employee is qualified to receive a premium tax credit to purchase coverage in an individual Marketplace (See “For Individuals” questions). A full-time employee is one who is employed an average of at least 30 hours a week. If a business has 50 full-time or full-time equivalent employees, or is close to it, it’s important to understand how these rules may apply and how the payment amounts could be calculated. More information is available from the IRS at www.irs.gov/uac/Newsroom/Questions-and-Answers-on-Employer-Shared-Responsibility-Provisions-Under-the-Affordable-Care-Act


How will a business be required to report health insurance coverage requirements?

Beginning Jan. 1, employers subject to the employer shared responsibility rules must provide the IRS with information about full-time employees’ coverage under the health plans and the cost of benefits provided. Likewise, employers that sponsor self-insured plans must submit reports detailing information for each covered individual. The first of these reports must be filed in 2015. The IRS is expected to provide more information to clarify these rules next year.


What is the 90-day maximum waiting period requirement?

Beginning Jan. 1, individuals who are eligible for health coverage will not have to wait more than 90 days to begin coverage. The IRS has provided temporary guidance on how employers should apply the 90-day rule and is expected to provide more information in the near future clarifying these rules. More is available at http://www.irs.gov/pub/irs-drop/n-12-59.pdf.


Is there an incentive for employers to offer workplace wellness programs?

Beginning Jan. 1, an employer’s maximum reward for promoting “health-contingent wellness programs,” which generally require individuals to meet specific standards related to their health to earn a reward, will increase from 20 percent to 30 percent of the cost of health coverage. The maximum reward for programs designed to prevent or reduce tobacco use will be as much as 50 percent. The text of the newest regulations that apply to wellness programs are available at webapps.dol.gov/FederalRegister/PdfDisplay.aspx?DocId=26880

Where can I find more information about how the Affordable Care Act applies to businesses?

The U.S. Small Business Administration heath care web page, www.sba.gov/healthcare, is dedicated to education small business owners about the ACA.

Another helpful site is at Healthcare.gov. Click on “Small Businesses” in the banner at the top of the page.

A glossary of key terms is available at https://www.healthcare.gov/glossary/.

The IRS website, at irs.gov, includes summaries of tax-related ACA provisions, frequently asked questions and eligibility worksheets.

More employer-related information on HCA is available throughout the U.S. Dept. of Labor at www.dol.gov/ebsa/healthreform.


— Compiled by CMI staff writer Steven Hansen

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