Key Takeaways
- New Mexico operates its own state-based health exchange called beWellnm
- The Office of Superintendent of Insurance (OSI) regulates health insurance
- Pre-existing condition exclusions are prohibited under ACA-compliant plans
- New Mexico has mental health parity requirements
- New Mexico has expanded Medicaid under the ACA
New Mexico Health Insurance Policy Requirements
New Mexico has health insurance regulations that work alongside federal requirements under Chapter 59A of the New Mexico Statutes Annotated.
Regulatory Structure
New Mexico health coverage is regulated by the Office of Superintendent of Insurance (OSI):
| Agency | Role |
|---|---|
| Office of Superintendent of Insurance (OSI) | Regulates all health insurance, reviews rates and forms |
| beWellnm | Operates the state-based health exchange |
Health Insurance Marketplace
New Mexico operates its own state-based exchange called beWellnm:
- State-based marketplace (one of 18 states with own exchange)
- Provides access to qualified health plans (QHPs)
- Premium tax credits available for eligible residents
- Open enrollment and special enrollment periods apply
- In-person assisters available statewide
Metal Tier Plans
| Tier | Actuarial Value | Cost Sharing |
|---|---|---|
| Bronze | 60% | Higher out-of-pocket costs |
| Silver | 70% | Moderate cost sharing |
| Gold | 80% | Lower out-of-pocket costs |
| Platinum | 90% | Lowest out-of-pocket costs |
Medicaid Expansion
New Mexico has expanded Medicaid under the ACA:
- Covers adults up to 138% of federal poverty level
- Provides coverage to previously uninsured residents
- Administered by New Mexico Human Services Department
Pre-Existing Condition Protections
New Mexico prohibits pre-existing condition exclusions in ACA-compliant plans:
| Market Segment | Pre-Existing Condition Exclusions |
|---|---|
| Individual | Prohibited |
| Small Group | Prohibited |
| Large Group | Limited by federal law |
Guaranteed Issue and Renewal
New Mexico requires:
Guaranteed Issue
- Insurers must accept all applicants for ACA-compliant plans
- Cannot deny coverage based on health status
- Applies to individual and small group markets
Guaranteed Renewal
- Insurers cannot cancel coverage except for:
- Non-payment of premium
- Fraud or misrepresentation
- Plan discontinuation (with proper notice)
Mental Health Parity
New Mexico requires mental health parity:
Coverage Requirements
New Mexico law requires health plans to cover:
- Mental health conditions
- Substance use disorders
- Behavioral health services
Federal MHPAEA Compliance
New Mexico requires compliance with the federal Mental Health Parity and Addiction Equity Act (MHPAEA):
- Financial requirements must be comparable to medical/surgical
- Treatment limitations must be comparable
- Prior authorization requirements must be comparable
- Out-of-pocket costs must be comparable
Exam Tip: New Mexico operates its own state-based exchange (beWellnm) rather than using HealthCare.gov.
Essential Health Benefits
All individual and small group plans must cover:
- Ambulatory patient services
- Emergency services
- Hospitalization
- Maternity and newborn care
- Mental health and substance use disorders
- Prescription drugs
- Rehabilitative services
- Laboratory services
- Preventive and wellness services
- Pediatric services (including dental and vision)
External Review
New Mexico provides external review rights:
- Consumers can appeal denied claims
- Independent external review available
- Binding decision on insurer
Consumer Resources
beWellnm provides consumer assistance:
- Website: bewellnm.com
- Phone: (833) 862-3935
- In-person assistance available
What is the name of New Mexico's state-based health insurance exchange?
Has New Mexico expanded Medicaid under the ACA?
Which agency regulates health insurance in New Mexico?
Can New Mexico health insurers deny coverage based on pre-existing conditions?
What rights do New Mexico consumers have when a health insurance claim is denied?