Standardized Health Plan Requirements for the 2027 Plan Year
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Governance of required standardized Individual Market Qualified Health Plans (QHPs) to be offered on the New Mexico Health Insurance Exchange in plan year 2027, including required plan designs, networks, specialty drug tiers, DME tiers, actuarial value constraints, and operational directions for BeWell and issuers.
No material clinical or coverage changes in this revision.
Standardized Plan Coverage & Cost-Sharing Rules
Standardized Plan coverage stance and criteria
Coverage stance for Standardized Health Plans and key coverage features defined for 2027:
Standardized cost-sharing by AV tier
Standardized cost-sharing schedules by actuarial value tier and service category for the 2027 plan year as presented in the document pages provided.
AV 70.31%
- Individual deductible (combined medical and drug): $6,250
- Family deductible (combined medical and drug): $12,500
- Individual out-of-pocket maximum: $10,750
- Family out-of-pocket maximum: $21,500
- Preventive care / screening / immunization: $0
- Primary care visit: $50
- Specialist visit: $100
- Imaging (CT/PET, MRI): $100
- Laboratory outpatient and professional services / X-rays: $100
- Urgent care facility: $100
- Basic durable medical equipment: $100–$325 depending on item
- Higher co-pay outpatient facility / outpatient surgery physician & services / ER visit / inpatient per visit: $325
- Complex Rehabilitation Technology Device: $325
- Generics: $35; Preferred brand: $50; Non-preferred brand: $250
- Preferred specialty drugs: $100; Non-preferred specialty drugs: $250
AV 73.15%
- Individual deductible (combined medical and drug): $5,550
- Family deductible (combined medical and drug): $11,100
- Individual out-of-pocket maximum: $8,550
- Family out-of-pocket maximum: $17,100
- Preventive care / screening / immunization: $0
- Primary care visit: $50
- Specialist visit: $100
- Imaging (CT/PET, MRI): $100
- Laboratory outpatient and professional services / X-rays: $100
- Urgent care facility: $100
- Basic durable medical equipment: $100
- Higher co-pay outpatient facility / outpatient surgery physician & services: $255
- Emergency room services (per visit) / inpatient hospital services (per visit): $275
- Complex Rehabilitation Technology Device: (noted in source; specific copay variable),
- Generics: $35; Preferred brand: $50; Non-preferred brand: $225
- Preferred specialty drugs: $96; Non-preferred specialty drugs: $240
AV 87.06%
- Individual deductible (combined medical and drug): $1,350
- Family deductible (combined medical and drug): $2,700
- Individual out-of-pocket maximum: $3,600
- Family out-of-pocket maximum: $7,200
- Preventive care / screening / immunization: $0
- Primary care visit: $15
- Specialist visit: $30
- Imaging (CT/PET, MRI): $30
- Laboratory outpatient and professional services / X-rays: $30
- Urgent care facility: $30
- Basic durable medical equipment: $30
- Higher co-pay outpatient facility: $95; Outpatient surgery physician/surgical services: $105; ER visit / inpatient per visit: $105
- Complex Rehabilitation Technology Device: (referenced in source with specified values)
- Generics: $15; Preferred brand: $30; Non-preferred brand: $100
- Preferred specialty drugs: $65; Non-preferred specialty drugs: $164
AV 94.37%
- Individual deductible (combined medical and drug): $675
- Family deductible (combined medical and drug): $1,350
- Individual out-of-pocket maximum: $1,675
- Family out-of-pocket maximum: $3,350
- Preventive care / screening / immunization: $0
- Primary care visit: $10
- Specialist visit: $25
- Imaging (CT/PET, MRI): $25
- Laboratory outpatient and professional services / X-rays: $25
- Urgent care facility: $25
- Basic durable medical equipment: $25
- Higher co-pay outpatient facility / outpatient surgery physician & services / ER visit / inpatient per visit: $45–$55 per source lines
- Complex Rehabilitation Technology Device: (referenced in source with specified values)
- Generics: $10; Preferred brand: $20; Non-preferred brand: $60
- Preferred specialty drugs: $30; Non-preferred specialty drugs: $75
Appendices, Codes, and Actuarial Thresholds
| AV 99.25% | Plan variant with very high actuarial value and specified copays/out-of-pocket amounts (see Appendix A) |
| AV 95.21% | Plan variant with 95.21% AV and specified copays/out-of-pocket amounts (see Appendix A) |
| AV 90.24% | Plan variant with 90.24% AV and specified copays/out-of-pocket amounts (see Appendix A) |
| AV 80.34% | Plan variant with 80.34% AV and specified copays/out-of-pocket amounts (see Appendix A) |
| AV 70.31% | Standard Silver variant AV = 70.31% with associated deductibles, OOP max, copays and specialty drug tiers |
| No codes listed |
Issuer and Operational Requirements
Issuer obligations for offering Standardized Health Plans
All individual market issuers offering Qualified Health Plans (QHPs) on the New Mexico Health Insurance Exchange during the 2027 Plan Year must offer the Board-adopted Standardized Health Plans and may not alter the adopted plan designs for any covered service. Issuers must use the same statewide network for Standardized Health Plans as they use for their other Exchange plans. Issuers must comply with OSI-required naming conventions and enter the specified cost-sharing amounts into the Plan and Benefits and SOPA templates as provided by OSI and HCA.
- Offer the Board-adopted Standardized Health Plans for 2027 without altering plan design for any covered service.
- Use the same statewide network for Standardized Health Plans as for other plans offered on the Exchange.
- Comply with Office of Superintendent of Insurance (OSI) naming conventions for Standardized Health Plans.
- Enter correct cost-sharing amounts into the Plan and Benefits Template and SOPA templates per OSI/HCA sample template.
Health Benefits Committee authority for limited plan design adjustments
If adopted plan designs do not meet required actuarial value targets when the federal AV Calculator is applied, the Health Benefits Committee is authorized to approve minor plan design adjustments limited to dollar amounts for co-pays, deductibles, and the maximum out-of-pocket limit. Such adjustments may not reorganize co-pay categories or expand the set of services subject to the deductible.
- Adjustments limited to dollar amounts for co-pays, deductibles, and maximum out-of-pocket limits to meet AV targets.
- Adjustments shall not include reorganization of co-pay categories or expansion of services subject to the deductible.
No prior authorization or provider action rules specified
The provided document excerpts do not specify any prior authorization requirements or additional provider action rules.
- No prior authorization or provider action rules are specified in the cited chunks.
Key Terms
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