Health Insurance: Get the Facts, Make an Informed Decision
Looking for essential information on the Patient Protection and Affordable Care Act – also known as the Affordable Care Act, ACA, Obamacare, and healthcare reform? Visit our Healthcare Reform page.
If you are thinking about buying an individual or family health plan from New Mexico Health Connections, please see our Plans for Individuals & Families page for information on what benefits and services are and are not covered and what out-of-pocket costs you can expect to pay.
If you are an employer considering a New Mexico Health Connections health plan for your employees, please visit our Plans for Employers & Organizations page. You will find information on what benefits and services are and are not covered and what out-of-pockets you can expect to pay.
Choosing a health plan is an important decision. We want to provide you with all the information you need to choose the best plan for you. Click on the link below for an overview of:
- The availability of the providers and practitioners in our network.
- Our utilization management guidelines (how we make decisions on medical necessity and appropriateness of care).
- Any limitations on our services or covered benefits.
- Information on our formulary – also called a drug list – and your prescription drug benefits.
- How we keep your Protected Health Information (PHI) safe.
View a PDF that gives you information on our procedures and policies that can affect your healthcare.
Health insurance has its own set of commonly used terms. Learn what these terms are below.
- What is a copay? A set amount that you pay when you visit the doctor, pick up your medicines at the pharmacy, and use other services that are included in your health plan.
- How do I know what to pay? Your member ID card and plan information state exactly how much the copay is for each type of service. You’ll know what to expect when you use these healthcare services.
- What’s in the fine print? Copays are set for the year, but may change in a new plan year.
- What is a deductible? A set amount that you must pay each year before your health insurance company begins to cover the cost of services that you use.
- How do I know what to pay? Your member ID card and plan information state the amount of your deductible. This is a yearly amount. At the beginning of a new year, you will start your deductible over again. You’ll pay as you use services before you meet the deductible and your health insurance company begins to cover the costs.
- What’s in the fine print? Each health insurance company sets up its plans differently. With one plan, you may be required to pay all costs of services you use until you reach the plan’s deductible amount. With other plans, certain services you use regularly may require only a copay.
- What is coinsurance? A percentage amount that you pay for covered services you use. Your health insurance pays the rest. This goes into effect after you have paid the deductible amount required by your plan.
- How do I know what to pay? Your plan information describes the coinsurance amount that you are required to pay. This will appear as a percentage amount, for example, “20% after deductible.”
- What’s in the fine print? Coinsurance may be required for all services you use, or only for some services. Because it is a percentage of the cost of the service, you will not know how much you are required to pay until you use the service.
- What is an out-of-pocket limit? The most you will need to pay in a one-year period. If you reach this amount, the health insurance company will cover 100% costs of the services you use for the rest of the year.
- How do I know? Your plan information describes the out-of-pocket limit for your coverage plan.
- What’s in the fine print? This does not include your monthly premium payments! There may be other payments, such as copays or out-of-network payments, that are not included in this amount either.
In-Network vs. Out-of-Network
- What is in-network? The doctors, hospitals, clinics, pharmacies, and medical equipment suppliers that your health insurance company has agreements with to provide services to their subscribers, like you.
- What is out-of-network? This refers to the doctors, hospitals, clinics, pharmacies and medical equipment suppliers that DO NOT have agreements with your health insurance company. You may still use services at these locations and providers, but your costs will be higher.
- How do I know? Your plan will provide a list of doctors, hospitals, clinics, pharmacies, and medical equipment suppliers that are in-network. Your plan information will also describe the costs of in-network vs. out-of-network services and providers.
- What’s in the fine print? Services that you need may not be covered at all by your plan if you are using out-of-network providers. If they are covered, your copayment amounts and coinsurance percentages will likely be higher than if you were using in-network providers.
Click here to download this list of commonly used insurance terms to your computer.