N.M. Admin. Code § 13.10.36.7

Current through Register Vol. 35, No. 21, November 5, 2024

Section 13.10.36.7 - DEFINITIONS

Terms are as defined in the Insurance Code, and as supplemented below.

A. "Advance state payments" means marketplace affordability program payments by the fund to a participating health insurance issuer on a monthly basis to lower premium and state out-of-pocket assistance for consumers.

B."Affordability criteria" means the factors used to determine the amount of premium assistance or state out-of-pocket assistance that will be provided from the fund on behalf of an eligible individual.

C."Eligible plan" means a health plan sold on the New Mexico health insurance exchange (the "exchange" or "marketplace") that meets the requirements for the state premium assistance program.

D."Federal poverty level or FPL" means the federal poverty level issued annually by the U.S department of health and human services at aspe.hhs.gov/poverty-guidelines/.

E."Income criteria" means parameters to establish eligibility for marketplace affordability programs.

F."Modified adjusted gross income or MAGI" means modified adjusted gross income as defined in 42 CFR § 435.60.

G."Marketplace affordability program" means a fund program that reduces premiums and OOP costs for individuals and families who purchase individual or family coverage on the exchange.

H."OOP" means out-of-pocket.

I."Participating health insurance issuer" means a health insurance issuer who is authorized to sell a QHP on the exchange or in the fully-insured small group market who has confirmed in writing its intention to participate in a specified fund program prior to the commencement of the plan year.

J."Plan year" means the year for which a participating health insurance issuer underwrites qualifying health insurance coverage.

K. "Premium assistance" means a fund program that pays a participating health insurance issuer to cover a portion of the premium obligation of a person who meets premium assistance affordability criteria.

L."QHP" means a qualified health plan.

M."Small business health insurance premium relief initiative" means a program to reduce premiums for small businesses that purchase QHPs in the small group health insurance market.

N."Small group QHP purchaser" means an employer who purchases one or more QHPs for any of its employees or owners through the small business health options program or directly from a health insurance issuer selling QHPs in the small group health insurance market.

O."State benchmark plan" means a qualified health plan that has been approved for sale on the exchange and that is identified by the superintendent as the plan to be used in developing affordability criteria.

P."State out-of-pocket assistance program" means a fund program that reduces OOP costs for households that meet eligibility and income criteria established by the superintendent.

N.M. Admin. Code § 13.10.36.7

Adopted by New Mexico Register, Volume XXXIII, Issue 08, April 19, 2022, eff. 5/1/2022, Amended by New Mexico Register, Volume XXXIII, Issue 09, May 3, 2022, eff. 6/1/2022, Amended by New Mexico Register, Volume XXXIII, Issue 15, August 9, 2022, eff. 9/1/2022