Standardized Health Plan Requirements for the 2027 Plan Year
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Governance and required plan design specifications for individual market Qualified Health Plans (QHPs) offered on the New Mexico Health Insurance Exchange for the 2027 plan year; applies to all individual market issuers offering QHPs on the Exchange.
No material clinical or coverage changes in this revision.
Standardized Plan Coverage Requirements
inv-01: Standardized Plan Coverage Criteria
Issuers must offer Board-adopted Standardized Health Plans on the Exchange and implement the exact benefits and cost‑sharing in the adopted designs; statewide network must match other plans offered by the issuer on the Exchange.
inv-02: Coverage cost-sharing matrix (extracted items)
Standardized copays, deductibles, out‑of‑pocket maxima, and drug tier copays for multiple actuarial value tiers as presented in the document.
Cost-Sharing Schedules, Codes, and Actuarial Value Rules
| 99.25% | Numerous standardized cost-sharing amounts (co-pays, deductibles, out-of-pocket maxima) including $0 individual deductible, $250 individual out-of-pocket maximum, $500 family out-of-pocket maximum and service-level copays as detailed in Appendix A for the 99.25% AV tier. |
| 95.21% | Standardized cost-sharing amounts including $400 individual deductible, $1,400 individual out-of-pocket maximum and service-level copays as detailed in Appendix A for the 95.21% AV tier. |
| 90.24% | Standardized cost-sharing amounts including $1,350 individual deductible, $3,600 individual out-of-pocket maximum and service-level copays as detailed in Appendix A for the 90.24% AV tier. |
| 80.34% | Standardized cost-sharing amounts including $3,850 individual deductible, $6,850 individual out-of-pocket maximum and service-level copays as detailed in Appendix A for the 80.34% AV tier. |
| 70.31% | Standardized cost-sharing amounts including $6,250 individual deductible, $10,750 individual out-of-pocket maximum and service-level copays (e.g., Primary Care $50, Specialist $100, Emergency Room $325, Complex Rehabilitation Technology Device $325, Generics $35, Preferred Brand $50) as detailed in Appendix A for the 70.31% AV tier. |
| 73.15% | Standardized cost-sharing amounts including $4,500 individual deductible, $7,500 individual out-of-pocket maximum and service-level copays (e.g., Primary Care $50, Specialist $100, Emergency Room $275) as detailed in Appendix A for the 73.15% AV tier. |
| 87.06% | Standardized cost-sharing amounts including $1,350 individual deductible, $6,500 individual out-of-pocket maximum and service-level copays (e.g., Primary Care $15, Specialist $30, Emergency Room $105, Complex Rehabilitation Technology Device noted) as detailed in Appendix A for the 87.06% AV tier. |
| 94.37% | Standardized cost-sharing amounts including $675 individual deductible, $1,675 individual out-of-pocket maximum and service-level copays (e.g., Primary Care $10, Specialist $25, Emergency Room $55) as detailed in Appendix A for the 94.37% AV tier. |
| No codes listed |
Operational Authorities and Cost-Sharing Guidance for Issuers
Health Benefits Committee may approve limited dollar adjustments to cost‑sharing
Because the federal AV Calculator for 2027 was not available at adoption, the Health Benefits Committee is authorized to approve only minor dollar adjustments to plan cost-sharing to meet AV targets. Any approved adjustments are limited to dollar amounts for co-pays, deductibles, and the maximum out-of-pocket (MOOP) limit and may not reorganize co-pay categories or expand the set of services subject to the deductible.
- Authority applies only when adopted plan designs do not meet required AV targets using the federal AV Calculator.
- Permitted changes: dollar amount changes to co-pays, deductibles, and MOOP.
- Prohibited changes: reorganization of co-pay categories or expansion of deductible‑subject services.
Summary of cost‑sharing categories and amounts (no authorization rules present)
The standardized plan designs specify cost‑sharing categories (co‑pays and facility fees) across services such as specialist visits, imaging (CT/PET/MRI), emergency room, inpatient hospital, outpatient facility and surgical services, skilled nursing, urgent care, durable medical equipment, rehabilitation therapies, and prescription drug tiers; this document window contains the cost‑sharing amounts for the 70.31% variant (e.g., Specialist Visit $100; Imaging $100; Emergency Room $325; Inpatient Hospital $325; Outpatient Facility/Surgery $325; Basic DME $100; Complex Rehabilitation Technology Device $325; Generics $35; Preferred Brand drugs $50). No prior authorization requirements are indicated in this section.
- Specialist visit co-pay (70.31%): $100
- Imaging (CT/PET/MRI) co-pay (70.31%): $100
- Emergency room (per visit) co-pay (70.31%): $325
- Inpatient hospital (per visit) co-pay (70.31%): $325
- Outpatient facility / ambulatory surgery co-pay (70.31%): $325
- Outpatient surgery physician/surgical services co-pay (70.31%): $325
- Skilled nursing facility co-pay (70.31%): $100
- Urgent care facility co-pay (70.31%): $100
- Basic durable medical equipment co-pay (70.31%): $100
- Complex Rehabilitation Technology Device co-pay (70.31%): $325
- Generics copay (70.31%): $35
- Preferred brand drug copay (70.31%): $50
Key Definitions and Plan Variants
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