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Health Plans and Provider Networks

What Is a Health Plan?

A health plan is a generic term referring to a specific benefit package offered by an insurer, HMO, PPO or self-funded employer plan.

What Is a Provider Network?

Health plans use select groups of doctors, hospitals and other health care professionals who work together to provide a full range of covered health care services. These are called provider networks. Some provider networks have fewer doctors and hospitals than others. Plans with smaller networks may have lower monthly premiums than plans with larger networks.

Which Health Plan or Network Do You Have?

Your health plan or network is shown on the front of your Blue Cross and Blue Shield of New Mexico (BCBSNM) member ID card. If you have questions about which network you have, call the Customer Service number on the back of your card.

Keep Costs Down. Stay in Network with Provider Finder®

If you visit a doctor outside of your network, you may have to pay more for your care. In some cases, you may have to pay the full cost. For HMOs, if you are referred to a specialist, make sure he or she is in your network.

Search Provider Finder before you see a doctor or go to the hospital.

  • Choose your Network, Plan or Product, and State.
  • Choose Provider Type, Specialty, Name or Location, if you know them.
  • Select Find.

Common Health Plans and Networks

The three most common types of health plans are:



HMOs

An HMO is a type of health plan that often has lower monthly premiums and out-of-pocket costs, like copayments and deductibles. HMOs only cover health care services given by doctors and hospitals in the plan's provider network. Not all HMO plans are the same. Some HMOs may have a smaller network and lower monthly premiums than other HMOs.

Key Things to Remember about HMOs:

  • See your primary care physician (PCP) first. Your PCP is your doctor who directs all of your health care.
  • You don't need a referral for a specialist. Your PCP can give you a referral or you can find a specialist on your own. Either way, check Provider Finder to make sure he or she is in your plan's network.
  • Stay in Network. Check Provider Finder to make sure your doctors, specialists and hospitals are in your plan's network to avoid paying out-of-network costs.
  • In an emergency — when your injury or illness is serious or life-threatening — go to the nearest emergency room. You don't need a referral.

About Your Primary Care Physician (PCP)

When you first sign up for an HMO, you choose — or are assigned — a primary care physician (PCP). These doctors focus on general practice, internal medicine and family practice. An obstetrics-gynecology doctor can serve as a woman's PCP. A pediatrics doctor can serve as a child's PCP.

  • Find your PCP on the front of your BCBSNM member ID card or in Blue Access for MembersSM, our secure member website.
  • You don't need a referral to see a doctor for a specific issue, as long as he or she is in your HMO plan's network. Check Provider Finder to make sure they are in-network.
  • If you're a new patient, see your PCP as soon as possible. Tell him or her you're a new patient when you call to make your first appointment. This will help avoid delays when you are sick or need a referral.
  • You can change your PCP online or by phone.
    • Online
      • Log in to Blue Access for Members
      • Select the Doctors & Hospitals tab
      • Select the Change PCP link
      • Follow the instructions
    • Phone
      Call the Customer Service number on the back of your BCBSNM member ID card.


PPOs

A PPO is a type of health plan that gives you the most flexibility, in most cases, but often has higher monthly premiums and out-of-pocket costs, like deductibles and coinsurance, than other plans. Like HMOs, each PPO uses a certain network of doctors, specialists and hospitals. Some lower-cost PPOs have fewer doctors and hospitals than other more costly PPOs and some HMOs.

Key Things to Remember about PPOs:

  • You don't need a primary care physician (PCP).
  • You don't need a referral to see a specialist. Your specialist must be in your plan's network so you don't pay higher out-of-network costs.
  • You can get care from doctors, hospitals and specialists inside or outside of your plan's provider network. Keep in mind, you'll pay more if you go to an out-of-network provider.
  • You may need pre-authorization (pre-certification) from BCBSNM before certain tests or services. You or your doctor must call the pre-authorization (or pre-certification) number on the back of your member ID card to confirm.
  • In an emergency — when your injury or illness is serious or life-threatening — go to the nearest emergency room or other similar facility, even when traveling out-of-state or abroad. You won't have to pay the higher out-of-network deductible and coinsurance.


CDHPs and the HSA Option

Consumer Directed Health Plans (CDHPs) often involve pairing a high deductible PPO plan with a tax-advantaged account, such as a Health Savings Account (HSA). An HSA is a savings account that you can use to cover a wide range of qualified medical costs. HSAs have special tax advantages and are regulated by the Treasury Department.1

Key Things to Remember about CDHPs

  • To get an HSA, you must have an HSA-qualified high deductible health plan.
  • When a CDHP includes a high deductible health plan, premiums are often lower than other types of health plans. This is because you pay a greater share of your health care costs.
  • If the plan uses a PPO network, you don't have to choose a primary care physician (PCP).
  • You can get care from doctors, hospitals and specialists in the network or outside the network, but know that you'll pay higher out-of network costs.
  • You don't always need a referral to see a specialist.

1 Health Savings Accounts (HSA) have tax and legal ramifications. Blue Cross and Blue Shield of New Mexico does not provide legal or tax advice, and nothing herein should be construed as legal or tax advice. These materials, and any tax-related statements in them, are not intended or written to be used, and cannot be used or relied on, for the purpose of avoiding tax penalties. Tax-related statements, if any, may have been written in connection with the promotion or marketing of the transaction(s) or matter(s) addressed by these materials. You should seek advice based on your particular circumstances from an independent tax advisor regarding the tax consequences of specific health insurance plans or products.