New Mexico Health Connections | my connection | Summer 2016

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If you live in an area with outpatient lab, x-ray and high-tech
imaging (CT and MRI) centers and if you are not having an
emergency, talk to your doctor about getting your tests at one
of these nonhospital-based facilities. Be sure the facility is in our provider
network!
When we all work together on lowering costs, we can and will make a
difference.
List of formulary alternatives
now available
To help you get the most out of your prescription drug benefit, we
have created a list of formulary (drug list) alternatives. The list can
help you find alternatives to medications that:
• Are not on our formulary.
• Are nonpreferred drugs.
• Require prior authorization or step therapy.
You can find the list on the “Pharmacy/Formulary” page of our
website:
Summer 2016
MY CONNECTION is published as a health and wellness service for the members of
NEW MEXICO HEALTH CONNECTIONS. Information comes from a wide range of medical experts.
If you have any concerns or questions about specific content that may affect your health,
please contact your primary care provider. Models may be used in photos and illustrations.
2016 © Coffey Communications, Inc. All rights reserved. ID0407-0616
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Message
from
Martin
Martin Hickey, MD, CEO of
New Mexico Health Connections
Iwant to talk frankly with
you about a difficult subject.
You may have heard that
health insurance rates are
going up significantly next year
across the nation. First of all, I
want you to know that as a com-
pany committed to offering New
Mexicans affordable access to
health coverage, we are not happy
about this. The promise of the
Affordable Care Act (ACA) was
that the market would help keep
premiums affordable. However,
many factors have come together
to create a different result.
The rate increases happening
across the country are caused by
several things. One is the financial
impact of millions of previously
uninsured people entering the
healthcare system and receiving
care for the first time. This care
is often costlier because chronic
conditions that have gone un-
treated for so long often need
intensive services. Another is due
to changes that ACA made to
what we call the “three Rs”: risk
adjustment, risk corridors and
reinsurance. The three Rs are a
mechanism within the ACA that
were designed to help ease the
switch to a new healthcare cover-
age model. But mostly they have
led to steep, unintended premium
increases.
I know this is difficult news
to hear. We are working hard to
develop plans that are as afford-
able as possible given the changes
in the industry thus far. Our focus
always will be on helping you and
your family be as healthy as pos-
sible. Therefore, we will continue
to offer plans with $0 copays for
many generic prescription medi-
cations. We are also expanding
our $0 copay to cover all behav-
ioral health visits for most plans.
By law, we must take in enough
money to cover claims. But as a
nonprofit health plan, we put you
first. We have no shareholders to
please or new buildings to pay for.
We entered the New Mexico
market in 2012 to help change
healthcare for the better, and we
are keeping that promise. Let me
say again that we are as unhappy
about the need for these increases
as you are. As you review your
2017 coverage options, we can
help you navigate the system to
make the best choices for yourself
and your family. We value your
membership and will do all we
can to help you stay healthy.
FACING
HARD FACTS
TOGETHER
W hen your
doctor orders
a diagnostic
test—like
lab work, x-rays or high-tech
imaging—he or she wants to get
a more complete picture of your
health. High-tech imaging, such
as an MRI, can detect disease
and guide treatment for many
conditions. And it does this with
less pain and fewer risks than
more invasive methods, such as
biopsies.
However, these tests are
costly. Did you know that where
you have your test can help drive
the cost of healthcare up or down?
Many outpatient or freestanding
testing facilities charge less than
hospitals charge for the same test.
So why are hospital prices
higher? Hospitals are open all the
time. They often charge higher
fees for their availability. This
helps to offset their operating
costs and the need to provide
services around the clock.
Hospital costs often reflect the
extra attention a patient needs
for tests done while an inpatient
due to the severity of the patient’s
condition.
Hospitals also may charge fees
for high-tech tests to support
some other services for which they
receive low reimbursement from
insurance companies.
Hospitals can charge Medicare
and other third-party insurers a
facility fee. This practice leads to
even more price inflation.
Keeping the
cost of diagnostic
tests down
Find freestanding radiology
providers online
To do a general search for in-network providers on our website, visit
On that page, you can find
easy-to-browse sections of our provider directory, including a list
of freestanding radiology providers. Scroll down to the “Radiology
Services–Freestanding Providers” section, and click on the link.
Hospital-based
facility
Nonhospital-
based facility
Examples of differences in average billed amounts
$500
$7,500
$3,700
$40
$440
$360
X-ray of
foot
CT of
abdomen
MRI of
lower limb
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