Health care in by Jan. 1


Editor’s note: This is Part 1 of a two part story to be continued in the Oct. 10 edition of El Defensor Chieftain.

Oct. 1 kicked off the health insurance enrollment mandate required by the 2010 federal Patient Protection and Affordable Care Act, also known as “Obamacare.” If you are confused, don’t feel bad. Over half of Americans feel they don’t know enough about ACA, according to a September 2013 Kaiser Family Foundation poll.

Between now and Jan. 1, 2014, all Americans have to sign up for health insurance or pay federal penalties. Many New Mexicans will be making some tough decisions in the next three months.

“About 400,000 New Mexicans, or one fourth of the state’s population, is uninsured,” said Michael Olguin, owner of Michael Olguin Insurance Associates insurance agency and a registered New Mexico health insurance exchange agent for Socorro County.

Those who already have health insurance through their employer don’t have to do anything. But those who are uninsured, are low wage earner, or pay for individual health insurance coverage will want to find out more about the new health insurance options offered by the Affordable Care Act.

NMHIX began accepting health insurance applications online Oct. 1. If you apply by Dec. 1 your insurance coverage will start Jan. 1, 2014. You will be able to choose plans offered by many insurance companies.

“All insurance companies that have plans in New Mexico will offer plans within the exchange,” Olguin said. He didn’t expect the New Mexico exchange to be fully up and running on Oct. 1, so don’t be dismayed if you can’t get enrolled immediately.

According to the Kaiser Family Foundation, if those with income between 138 and 400 percent of the federal poverty level will want to investigate NMHIX because state and federal subsidies and tax credits could reduce or eliminate all of health insurance premium costs.

Exchange plans vary by premium charges and benefits offered. The platinum plan costs the most per year in premiums, but covers more expenses. Using the Kaiser Family Foundation subsidy calculator, a single nonsmoker 35 years of age making $16,000 a year (just above New Mexico’s Medicaid cutoff) can sign up for a silver insurance plan through the exchange. He or she will have to pay only 18 per cent of the cost of health insurance, $539 per year ($45 per month). A government tax credit will pay the rest of the overall annual premium cost.

The most a silver plan enrollee will ever have to pay out of pocket for health services is $2,250 in a calendar year, excluding premiums.

At press time, complete information about the bronze plan was not available, but tax credits and subsidies reduce the yearly premium cost for a person making up to 400 percent of the federal poverty level, or $45,000 per year for a single adult, according to a NMHIX navigator. But the bronze plan would require people to pay 60 percent of all covered medical expenses. It would be a plan appropriate for healthy adults who just desire coverage for catastrophic medical events, Olguin said.

Preventative services will be paid for in full by all plans as required by ACA, he said.

Over 170,000 New Mexicans are expected to sign up for Medicaid in New Mexico, also known as Centennial Care, said N. M. Human Services Department Director of External Affairs Matt Kennicott. Governor Susanna Martinez supported expanding Medicaid in New Mexico to provide free or low cost health benefits for all adults and families earning 138 per cent or below of the federal poverty income, he said. Single adults earning less than $15,288 per year now qualify for Medicaid in New Mexico. A family of four qualifies at $31,000 per year.

“Medicaid in New Mexico covers a very rich benefits program,” Kennicott said. “It’s a no-cost program, with only a few co-pays. It’s like most traditional health plans. It covers doctor’s appointments, urgent care, dental visits, necessary surgeries, and eyeglasses.”

But Medicaid recipients at the higher income levels will pay for part of their emergency room visits.

Kennicott said New Mexicans applying for Medicaid can choose from four insurance companies: Blue Cross, United Health Group, Presbyterian, and Molina Health Care. They will make their choices during an open enrollment period.

If you aren’t sure you can qualify for Medicaid and you don’t want to enroll online, Kennicott recommends stopping by or calling the local New Mexico Human Services Office on California Street next door to Socorro Springs Brewing Company.

“Even if people have health care through their work place, if they would like, they can visit one of our income support offices,” he said.

If you still don’t want to sign up for health insurance by the January 1 deadline, you’ll probably end up paying a federal penalty, according to the Kaiser Family Foundation website. If you’re under 65 and earning more than $9,350 in taxable income ($18,700 per couple) per year, you will pay a $95 fine or 1.0 per cent of annual taxable income, whichever is greater, in 2014. (Single adults making less than $15,288 qualify for state Medicaid health insurance coverage free of charge.) The penalty amount goes up yearly until 2016, when the fine will be $695 per year or 2.5 per cent of taxable income.

Besides very low income earners, certain other uninsured people won’t be assessed the tax penalty for not signing up, including American Indians, those with religious objections, people in jail, and illegal aliens. You also won’t pay the penalty if you have been without insurance for three months or less, or if the cost of the lowest priced insurance available on the exchange exceeds 8 per cent of your income.

“How and when that penalty will be assessed in anybody’s guess,” said Michael Olguin. The U.S. Internal Revenue Service will collect the penalties.

Kaiser Family Foundation

New Mexico Health Insurance Exchange – NMHI

1-855-99NMHIX (bilingual)


575-835-1331 (Socorro County’s registered NMHIX agent)

Federal health insurance information website

New Mexico Medicaid websites

Medicaid expansion hotline

1-855-637-6574 for New Mexico

New Mexico Income Support Division Socorro Office (for Medicaid)

1014 North California Street



• All adult children may remain on their parents’ health plan until age 26 regardless of marital or student status.

• Preventative services covered, including those for women

October 1, 2013

• State and Federal health insurance exchanges open

December 1, 2013

• Last day to sign up for New Mexico’s health insurance exchange plan to get coverage started by Jan. 1

January 1, 2014

• Most American citizens must have health insurance. Uninsureds will be liable for a federal fine

• All certified insurance plans must offer essential benefits (co-pays and co-insurance may apply):

Ambulatory care, including doctor’s visit


Mental health and substance abuse treatment

Rehabilitative and habilitative services

Laboratory services

Emergency care services

Maternal and newborn care


Preventative and wellness services, such as mammograms, immunizations, and colonoscopies

Chronic disease management

Pediatric services, including oral and vision coverage

• Insurance companies must cover everyone; no denials or penalties for pre-existing conditions

• No annual or lifetime maximums on costs insurance companies must pay (excluding annual deductible, co-pays, and co-insurance costs below annual caps)

• Out of pocket expenses

What you have to pay.

• Deductible

Amount you pay out of pocket before your plan starts paying for services

• In Network

Doctors and other providers belonging to a list whose services the insurance company discounts for you. You pay a higher percentage or all of the costs of out-of-network providers

• Co-insurance

The percentage of major medical services, such as hospitalizations, you pay out of pocket. Your co-insurance cost is capped at a maximum amount per calendar year, depending on your plan.

• Co-pay

What you pay for certain expenses, such as doctor’s office visits, emergency room visits, prescriptions, specialist visits, and out-patient procedures. For example, a co-pay amount for a doctor’s visit might be $10. Co-pays are not applied to your maximum out-of-pocket expense cap in most commercial policies.

• Navigator

A person contracted by the New Mexico health exchange to help consumers compare health insurance plans. There is no charge for a navigator’s services.

Why bother with insurance?

“If I have to go to the hospital, they have to pay for it.”

Michael Olguin answers:

“This is called uncompensated care. They’ll navigate with you to get you on a (payment) program.”

The cost of uncompensated health care currently is paid for by those who do buy health insurance plans, he said. Part of everyone’s health care bills cover uncompensated health care costs incurred by uninsured people. After January 1, 2014, people without health insurance making over $9,350 in taxable income will pay a $95 fine.


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