Transparency
Transparency in Coverage Reporting for Individual On-Exchange Members
The U.S. Health and Human Services Department (HHS) requested that all Qualified Health Plan issuers collect, and provide information publicly, on transparency provisions in connection with section 1311(e)(3) of the Affordable Care Act (ACA), consistent with the requirements of section 3506(c)(2)(A) of the Paperwork Reduction Act of 1995 (PRA).
New Mexico Health Connections is a Qualified Health Plan issuer that participates in federally facilitated Exchanges and state-based Exchanges that rely on the federal IT platform HealthCare.gov. We have collected the required information in response to the HHS request. If you have questions about the information below, please call Customer Service toll-free: 1-855-7MY-NMHC (1-855-769-6642).
Out-of-network liability and balance-billing
Definition: Balance-billing occurs when an out-of-network provider bills an enrollee/member for charges other than copayments, coinsurance, or any amounts that may remain on a deductible.
Will I have financial liability for out-of-network services?
If you are a member of an NMHC HMO plan and receive care, services, and/or supplies from an out-of-network (non-participating) provider, those services/supplies will not be covered unless prior approval is obtained from NMHC before the services occur. If you do not receive prior approval, you may be responsible for the charges.
When will I be balance-billed?
When receiving care from an out-of-network provider, payment from the plan will be limited to the usual, customary, and reasonable (UCR) charges of the covered service. You will be responsible for your deductible and coinsurance amounts, and for charges that exceed UCR rate. The out-of-network provider may choose to balance-bill you for the charges that exceed the UCR rate.
Are there any exceptions to out-of-network liability, such as emergency services?
Definition of medical emergency: Healthcare procedures, treatments, or services delivered to a covered person after the sudden onset of what reasonably appears to be a medical condition that manifests itself by symptoms of sufficient severity, including severe pain. The absence of immediate medical attention could reasonably be expected by a reasonable layperson to result in: danger to the person’s health, serious harm to bodily functions and any bodily organ or part, or disfigurement to the person.
If you reasonably believe that you have an emergency medical condition, the initial treatment of that condition is paid at the in-network benefit level, even if care is provided by an out-of-network provider.
For follow-up care (which is no longer considered an emergency), you will need to visit an in-network provider in order to receive in-network benefits.
For more information, please refer to the Evidence of Coverage book for your plan (also called a member handbook).
Enrollee claims submission
Definition: An enrollee/member, instead of the provider, submits a claim to the health plan, requesting payment for services received.
How can I submit a claim in lieu of a provider, if the provider failed to submit the claim?
If the provider or facility is in-network, it must file claims on the member's behalf. Claims for benefits or services rendered by an out-of-network provider must be submitted to NMHC within one year (365 days) from the date of service. If your out-of-network provider does not file a claim for you, you are responsible for filing the claim within the one-year deadline. Claims submitted after the deadline are not eligible for reimbursement. If a claim is returned to you because we need additional information, you must resubmit it, with the information requested, within 90 days of receipt of the request.
Mail your claim forms and itemized bills to:
Claims Department
New Mexico Health Connections
P.O. Box 3828
Corpus Christi, TX 78463
Once received, reviewed, and approved, NMHC will reimburse you for covered benefits and services, less any required deductibles and coinsurance or copayment amounts that you are required to pay as stated in the Summary of Benefits and Coverage. You will be responsible for services not specifically covered by the Plan.
Grace periods and claims pending policies during the grace period
Definition: NMHC will grant a grace period of ninety (90) days to enrollees/members who have paid at least one month’s worth of premiums, and are receiving advance payments of the Premium Tax Credit. If NMHC does not receive payment of premium within that grace period, NMHC will terminate coverage as of the last day of the first month during the grace period.
NMHC will continue to pay all appropriate claims for covered services provided during the first month of the grace period, and will pend (halt) claims for covered services provided in the second and third month of the grace period. Pending claims halts the process of reviewing and paying submitted claims.
NMHC will notify the Exchange and you of the non-payment of your premiums. NMHC also will notify providers of the possibility of denied claims when you are in the second and third month of the grace period. NMHC will continue to collect Advance Premium Tax Credits on your behalf from the Department of the Treasury, and will return the Advance Premium Tax Credits on your behalf for the second and third month of the grace period if you exhaust your grace period as described above.
Retroactive denials
Definition: The reversal of a previously paid claim, in which case the enrollee/member then becomes responsible for payment. Retroactive denials can occur if there is a correction or change made to an enrollee/member’s eligibility, causing coverage to be terminated as of an effective date that is in the past. Any claims from the period after the termination effective date will be denied.
The Exchange may start the termination of your coverage in a Qualified Health Plan (such as your NMHC plan) and must allow NMHC to terminate such coverage in the following circumstances:
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You are no longer eligible for coverage in a Qualified Health Plan;
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You have not paid your premiums;
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You perform an act, practice, or omission that constitutes fraud, or you make an intentional misrepresentation of material fact.
To avoid retroactive denials of claims, you should tell NMHC immediately about any changes to your eligibility and pay your premiums on time.
Enrollee recoupment of overpayments
Definition: The refund of a premium overpayment by the enrollee/member due to the over-billing by the issuer.
If you believe NMHC has billed you for the wrong premium amount, our Customer Service department will help you by starting a reconciliation of your statements. If we identify a refund amount, you will see it reflected on the next invoice and/or we will mail the difference to you.
For help, please contact NMHC.
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By phone: (505) 633-8020 or 1-855-7MY-NMHC (1-855-769-6642)
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In writing: NMHC, P.O. Box 36719, Albuquerque, NM 87176
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In person: NMHC, 2440 Louisiana Blvd. NE, Suite 601, Albuquerque, NM 87110