• What is a deductible?
• What is a billed charge?
• What is a covered charge?
• What is coinsurance?
• What is a copayment?
• What is an out-of-pocket limit?
• What is a provider?
• What is a participating provider?
• What is a Preferred Provider?
• Where can my employees find a Preferred Provider?
• What is a Nonpreferred Provider?
• What does "in-network" mean?
• What does "out-of-network" mean?
• Can my employees get a second opinion?
• Do members need a referral to see a specialist?
• What is prior approval/authorization?
• Are mammograms covered under my plan?
• What preventive services are covered?
• Are my employees covered when traveling?
• What is a medical emergency and what services are covered?
• What do members do in an emergency?
• How can my employees get emergency care when traveling?
• What is urgent care and what services are covered?
• What do members do to get urgent care?
• How does Coordination of Benefits work?
• What is an eligible dependent?
• How do members add an eligible dependent to their health insurance coverage?
• Why isn't a dependent's name listed on the member's ID card?
• What should my employees do if they lose their ID card?
• How does the prescription drug plan work?
A deductible is the amount a member must pay each year before BCBSNM begins to pay for services. Members can check their BCBSNM member ID card for the amount of their deductible. If you have selected a PPO plan, there is a separate higher deductible for using Nonpreferred Providers (out-of-network providers).
The billed charge is the amount a provider bills for a service. Sometimes the billed charge is more than the covered charge (amount BCBSNM will pay to contracted providers). Preferred Providers (in-network providers) will "write off" the balance, but Nonpreferred Providers (out-of-network providers) may bill the member for the difference between the covered charge and the billed charge.
The covered charge is the amount that BCBSNM determines is a fair and reasonable allowance for a particular covered service. After the member's share of a covered charge has been calculated (deductible and coinsurance), BCBSNM pays the remaining amount of the covered charge, up to maximum benefit limitations, if any. The covered charge may be less than the billed charge for a covered service. Preferred Providers will "write off" this balance, but Nonpreferred Providers may bill the member for the difference between the covered charge and the billed charge.
Coinsurance is the percent of covered charges that members must pay for covered services after the deductible has been met. With most plans, after the deductible has been met, members will pay 20 percent of covered charges for services from a Preferred Provider and 40 percent of covered charges for services from a Nonpreferred Provider. Check the Summary of Benefits for the percentage of covered charges you and your employees will have to pay for different services.
A copayment is a fixed dollar amount members are required to pay for a service at the time they receive care.
What is an out-of-pocket limit?
For PPO plans, an out-of-pocket limit is the total amount of coinsurance ONLY that members will pay for covered services in a calendar year. The amounts you and your employees may pay for deductibles, drug plan copayments, penalty amounts, or noncovered charges are not included in this out-of-pocket limit. After the out-of-pocket limit is reached, the PPO plan will pay 100 percent for most covered charges for the calendar year. See the Summary of Benefits or Benefit Booklet for more information.
For HMO plans, an out-of-pocket limit is usually twice (2X) the annual premium. After the out-of-pocket limit is reached, the HMO plan will pay 100 percent for most covered charges for the calendar year. Refer to your benefit information or call Customer Service for more information.
A provider is a licensed health care facility, program, agency, ambulance company, doctor (including Doctor of Medicine, Doctor of Osteopathy, Doctor of Oriental Medicine, Doctor of Chiropractic, and Doctor of Podiatric Medicine), or other health professional that delivers health care services.
What is a participating provider?
A participating provider is a provider that has a written agreement with BCBSNM or another Blue Cross and Blue Shield company to provide services to members through a designated health plan. Participating providers are sometimes called contracting providers.
A Preferred Provider (in-network provider) is a health care professional or a facility that has a "preferred" or "PPO" contract with BCBSNM or a Blue Cross and Blue Shield (BCBS) company in another state.
Where can my employees find a Preferred Provider?
To find a Preferred Provider, check the printed network directory or search the Provider Finder®. Your employees may also call BCBSNM Customer Service at the number on the back of their ID card for help looking for Preferred Providers. For Preferred Providers outside New Mexico, call 1-800-810-BLUE (2583).
What is a Nonpreferred Provider?
A Nonpreferred Provider (out-of-network provider) does not have a "preferred" or "PPO" contract with BCBSNM or a Blue Cross and Blue Shield (BCBS) company in another state.
In-network services are services provided by doctors and hospitals that have contracted with BCBSNM or with other Blue Cross and Blue Shield companies. For most benefits, after members meet the deductible for services from a Preferred Provider, they will usually pay a percentage of covered charges for services received from Preferred Providers. If the covered charge is less than the amount a provider bills, the provider will "write off" the difference. Preferred Providers will file a member's claims, and in New Mexico, will obtain any needed prior approvals for the member.
What does "out-of-network" mean?
Out-of-network services are services provided by doctors and hospitals that have not contracted with BCBSNM or with other Blue Cross and Blue Shield companies. Out-of-network providers may have other contracts with their local BCBS, but not "preferred" or "PPO" contracts. For most benefits, after members meet the deductible for services from a Nonpreferred Provider, they will pay a percentage of covered charges for services received from Nonpreferred Providers. If the covered charge is less than the amount a Nonpreferred Provider bills, the provider may bill the member for the balance. (Some Nonpreferred Providers may have other types of contracts with BCBSNM and will also write off the amount over the covered charge.) Some BCBSNM plans do not cover services from Nonpreferred Providers, except for emergency services. See the Summary of Benefits.
Can my employees get a second opinion?
Yes, you and your employees may request a second opinion about any procedure or course of treatment recommended. A physician can recommend a specialist, or contact BCBSNM Customer Service for assistance.
Do members need a referral to see a specialist?
No. However, members should verify that the specialist is in the health plan network and that the services are covered under their plan before making an appointment. Otherwise, they will be responsible for costs of services not covered. Even if members don't need a referral for some services with specialists, they may need prior approval. We recommend members see their primary care physician – their family doctor knows their medical history and is best qualified to coordinate all medical care, including visits to specialists.
What is prior approval/authorization?
Certain services require approval from BCBSNM before being received; if approval is not obtained before the services are received, the services will be denied. The list of services that require prior approval is in the Benefit Booklet. To request prior approval, the member or the member's provider must call BCBSNM Health Services (505-291-3585 in Albuquerque, or toll-free at 1-800-325-8334), Monday through Friday, from 8 a.m. to 5 p.m. Mountain Time.
Note: If the plan you selected includes mental health, alcoholism, and drug abuse services, prior approval must be requested from the BCBSNM behavioral health services administrator. Call 505-816-6790 in Albuquerque, or toll-free at 1-800-583-6372. Phones are open 7 days a week, 24 hours a day.
Are mammograms covered under my plan?
Yes, but not all radiology and imaging centers offer mammography services. Members can search under Ancillary Services – Mammography Centers on our Provider Finder®, or check the Mammography Provider List (PDF) to locate a BCBSNM provider in their area that performs mammography services.
What preventive services are covered?
Covered preventive services include: routine adult physicals, gynecological exams, related testing (includes routine Pap tests, mammograms, cholesterol tests, urinalysis, etc.) and well child care, immunizations, routine testing, routine vision or hearing screenings (through age 17).
Are my employees covered when traveling?
Yes; with the BlueCard® program, you and your employees have help accessing physicians and hospitals contracted as providers with Blue Cross and Blue Shield companies across the country. If BCBSNM members are traveling in the U.S. and need to find a provider when out of the area that BCBSNM serves, they can contact the local Blue Cross and/or Blue Shield company, call the BlueCard Doctor and Hospital Information Line toll-free at 1-800-810-BLUE (2583), or search the BlueCard Doctor and Hospital Finder. If they are outside the U.S. and need emergency medical care, they should go to the nearest hospital; call the BlueCard Worldwide® Service Center at 1-800-810-BLUE (2583) or call collect at 1-804-673-1177 if they're admitted. Members should always carry their BCBSNM member ID card, as it contains important information the provider will need to file claims correctly.
What is a medical emergency and what services are covered?
An emergency is the sudden onset of a medical condition with symptoms of sufficient severity, including severe pain, whereby the absence of immediate medical attention could result in jeopardy to the member's health; serious impairment of bodily functions; serious dysfunction of any bodily organ or part; or disfigurement. Examples of emergency conditions are heart attack, poisoning, severe allergic reaction, convulsions, unconsciousness, and uncontrolled bleeding.
Members must seek initial treatment within 48 hours of the accidental injury, or onset of the condition, for the visit to qualify as an emergency. Services received in an emergency room or other trauma center must meet the definition of "emergency" to be covered. Services received in a doctor's office or urgent care facility are not considered emergencies.
What do members do in an emergency?
Whether at home, out-of-state, or abroad, Blue Cross and Blue Shield of New Mexico wants to ensure our members receive proper care in an emergency.
Here's what members need to know about their emergency medical care coverage:
- In an emergency, go to the nearest hospital or trauma center.
- Members can call 911 or other community emergency resources to obtain assistance in life-threatening situations.
- Members must call BCBSNM within 48 hours of the admission or benefits for covered facility services may be reduced. They can check the back of their member ID card and call for admission/prior approval requirements; failing to do so can affect their benefits.
- Members do not need authorization for out-of-network emergency services; however, they should call their doctor as soon as reasonably possible after receiving emergency room care or being admitted as an inpatient in order to arrange for follow-up care.
Note: Services are reviewed and if they are determined to be nonemergency services, coverage may be denied.
How can my employees get emergency care when traveling?
If you or your employees are traveling outside the service area and need emergency care, go to the nearest participating facility or call the BlueCard® Hotline at 1-800-810-BLUE (2583). The operator will provide the name and telephone number of a local provider who will be able to treat you, call BCBSNM Customer Service for eligibility information, and submit a claim to the local affiliated BCBS Plan. You and your employees will also call the BlueCard program to arrange follow-up care needed as a result of the sudden illness or injury; approved care is also covered through the BlueCard program.
What is urgent care and what services are covered?
Urgent care refers to a necessary medical treatment or service for an unforeseen condition that is not life threatening. The condition does, however, require prompt medical attention to prevent a serious deterioration in your health (e.g., sprains, high fever, cuts that require stitches).
See the Summary of Benefits or Benefit Booklet for guidelines on urgent care coverage.
What do members do to get urgent care?
If members don't have an emergency condition but feel that they need prompt medical attention, they should go to an urgent care center in our network. If you and your employees have coverage for out-of-network services, you will pay higher out-of-pocket costs at a noncontracted urgent care center than you would at a contracted urgent care center. Note: The wait time/treatment time may be shorter at an urgent care center than at an emergency room. It's important to save the emergency room for emergencies.
If members are traveling and need urgent care, they can call the BlueCard® Hotline at 1-800-810-BLUE (2583). The operator will give the name and telephone number of a local provider who will be able to treat them. Note: If your plan does not have benefits for out-of-network coverage (e.g., you and your employees are BlueNet or HMO Blue members), you must use network providers to receive benefits for nonemergency services.
How does Coordination of Benefits work?
If a member and his or her spouse are covered under each other's group plans, the member's plan is always primary for the member's claims, and the spouse's plan is primary for the spouse's claims. The primary plan will pay first. The secondary plan may then pay an additional amount toward the claim, depending on its rules. If dependent children are covered under both the member's group plan and the spouse's, the plan of the parent whose birthday (month and day) occurs first in the calendar year will be considered primary.
What is an eligible dependent?
Generally, eligible dependents for group or individual plans include:
- The member's spouse*
- The member's and/or the spouse's unmarried, dependent children who are under the limiting age specified on the Summary of Benefits or in the medical/surgical plan Benefit Booklet
- Children who are under the member's legal guardianship**
- Children who are in the member's custody under an interim court order prior to finalization of adoption or placement of adoption vesting temporary care, whichever comes first
*The spouse of a covered employee is an eligible dependent. Typically, if there is a divorce, the spouse no longer meets the previously stated description of an eligible dependent. His or her coverage will end as of the date of the divorce.
**Typically, children who are also employees of your group are not eligible dependents under the parent employee's coverage. Coverage for unmarried children will end on the last day of the calendar month in which the limiting age birthday falls or on their date of marriage, whichever occurs first.
How do members add an eligible dependent to their health insurance coverage?
To add a dependent to their health insurance coverage, members can call us at the number on their BCBSNM member ID card.
Why isn't a dependent's name listed on the member's ID card?
As a subscriber, only the member's name is listed on an ID card. However, any dependent listed in the member's health care benefits plan will be covered according to the policy, and the dependent will receive an ID card that includes the member's name as the subscriber (main policyholder).
What should my employees do if they lose their ID card?
Members can log in to Blue Access® for Members and request a new member ID card. It will take up to two weeks to receive a new card. If members need a new card immediately, they can print a temporary ID card to use until their permanent card arrives.
How does the prescription drug plan work?
If you have selected prescription drug coverage through BCBSNM for you and your employees, please see the medical plan-specific FAQs and the separately issued Prescription Drug Plan Rider for more information.
