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
- Website: bewellnm.com
- Phone: (833) 862-3935
beWellnm 2026 Updates
| Feature | Detail |
|---|---|
| Enhanced Subsidies | Extended through 2026 under Inflation Reduction Act |
| Premium Reductions | Average 10-15% reduction for subsidized enrollees |
| Plan Options | Multiple carriers offering QHPs |
| Enrollment Assistance | Free in-person help across the state |
Metal Tier Plans
| Tier | Actuarial Value | Cost Sharing | Best For |
|---|---|---|---|
| Bronze | 60% | Higher out-of-pocket costs | Low healthcare users, want lowest premium |
| Silver | 70% | Moderate cost sharing | Qualify for cost-sharing reductions |
| Gold | 80% | Lower out-of-pocket costs | Regular healthcare users |
| Platinum | 90% | Lowest out-of-pocket costs | High healthcare users |
Cost-Sharing Reductions (CSRs)
Silver plans offer enhanced benefits for lower-income enrollees:
| Income Level (% FPL) | Actuarial Value |
|---|---|
| 100-150% FPL | 94% (enhanced) |
| 150-200% FPL | 87% (enhanced) |
| 200-250% FPL | 73% (enhanced) |
| Above 250% FPL | 70% (standard) |
Exam Tip: Cost-sharing reductions are ONLY available on Silver plans purchased through beWellnm. Advise clients to consider Silver plans if they qualify for CSRs.
Medicaid Expansion
New Mexico expanded Medicaid in 2014 under the ACA:
Centennial Care 2.0
New Mexico's Medicaid program is called Centennial Care 2.0:
| Feature | Detail |
|---|---|
| Income Limit | Up to 138% of Federal Poverty Level |
| Expansion Population | Adults 19-64 without dependent children |
| Managed Care | Delivered through managed care organizations |
| Benefits | Comprehensive coverage including behavioral health |
2026 Medicaid Updates
| Change | Effective |
|---|---|
| Continuous Eligibility | 12-month coverage regardless of income changes |
| Streamlined Enrollment | Simplified application process |
| Behavioral Health | Expanded mental health services |
Medicaid Managed Care Organizations (MCOs)
New Mexico contracts with MCOs to deliver Medicaid services:
- Blue Cross Blue Shield of New Mexico
- Presbyterian Health Plan
- Western Sky Community Care
- UnitedHealthcare Community Plan
Important: Producers selling individual health insurance should screen clients for Medicaid eligibility before enrolling in Marketplace plans.
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
Small Group Health Insurance
New Mexico regulates small group health insurance under NMSA 59A-23C:
Small Group Market Definition
| Definition | Requirement |
|---|---|
| Employer Size | 1-50 employees (fully insured) |
| Rating Factors | Age, tobacco use, geography, family composition |
| Prohibited Factors | Health status, claims history, industry |
Small Group Requirements
| Requirement | Detail |
|---|---|
| Guaranteed Issue | Must accept all eligible small groups |
| Guaranteed Renewal | Cannot refuse renewal except for fraud or non-payment |
| Essential Health Benefits | Must cover all 10 EHB categories |
| Rate Restrictions | Community rating with permitted adjustments |
Individual Health Insurance
New Mexico regulates individual health insurance under NMSA 59A-23E:
Individual Market Protections
| Protection | Requirement |
|---|---|
| Guaranteed Issue | Must accept all applicants |
| No Pre-existing Exclusions | Cannot exclude pre-existing conditions |
| Community Rating | Rates based on age, tobacco, geography |
| Essential Health Benefits | All ACA-required benefits |
Short-Term Limited Duration Insurance
New Mexico regulates short-term health insurance:
| Requirement | New Mexico Rule |
|---|---|
| Maximum Duration | Limited (check current regulations) |
| Renewability | May have restrictions |
| Disclosures | Must clearly state limitations |
| Not ACA-Compliant | Does not satisfy individual mandate |
Important: Short-term plans do not cover pre-existing conditions and are not ACA-compliant. Producers must clearly disclose these limitations.
Health Insurance Rate Review
New Mexico OSI reviews health insurance rates:
| Review Type | Threshold |
|---|---|
| Effective Rate Review | All rate filings reviewed |
| Public Comment | Available for significant increases |
| Justification Required | Insurers must justify rate changes |
Rate Filing Requirements
| Requirement | Detail |
|---|---|
| Advance Filing | Rates filed before implementation |
| Actuarial Certification | Certified by qualified actuary |
| Public Transparency | Major filings available for public review |
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?