If you get treated by a provider who is out of your health plan’s network for substance use disorder, BCBSNM will adjust your cost sharing (deductible, copay or coinsurance) to the in-network levels described below. This applies to both in-person care and telemedicine. Remember that out-of-network services may still result in balance billing – see important note below.
Here’s how your out-of-network cost sharing will apply:
- Treatment for a substance use disorder that DOES NOT require a 24-hour stay will be the same as an in-network primary care doctor visit.
- Treatment for a substance use disorder that DOES require a stay of 24 hours or more, will be the same as an in-network medical/surgical inpatient service.
- Emergency care for a substance use disorder will be covered without cost sharing.
- Urgent Care visits for a substance use disorder will be the same as an in-network specialist visit.
IMPORTANT: Even though your cost sharing for substance use disorder treatment will be adjusted to in-network levels, this doesn't change how much BCBSNM pays your provider. BCBSNM pays out-of-network claims at the out-of-network rates listed in your benefit booklet. An out-of-network doctor or facility may still bill you for the difference between what they charge and what BCBSNM pays for those services (this is called “balance” billing).
To avoid these bills, it’s best to stay within your BCBSNM network when possible.
- There are no changes to your cost-sharing for in-network substance use services.
- To see how services are covered at the in-network level, you can check your benefit booklet or call the number on your Member ID card.
Prior Authorization Changes
BCBSNM won’t require prior authorization to use an out-of-network provider for substance use services. This applies unless we require prior authorization for the same services from an in-network provider.
- For example, BCBSNM requires prior authorization for admissions to in-network residential treatment centers. If you want to go to an out-of-network residential treatment center, you will still need prior authorization from BCBSNM to do so. However, if you want to go to an out-of-network psychiatrist for an office visit, you will not need prior authorization, because BCBSNM does not require it to visit an in-network psychiatrist.
BCBSNM won’t require prior authorization for admitting or transferring into a facility for detox, acute or long-term care for substance use disorder.
- You MUST let BCBSNM know within three days if either you or your dependent are admitted or transferred into a facility for detox, acute or long-term care for substance use disorder. We may begin our care management functions after we receive notice.
BCBSNM won’t require prior authorization to use an out-of-network provider for substance use services whether it is in-person care or telemedicine. This applies unless we require prior authorization for the same services from an in-network provider.
- For example, BCBSNM requires prior authorization for admissions to in-network residential treatment centers. If you want to go to an out-of-network residential treatment center, you will still need prior authorization from BCBSNM to do so. However, if you want to go to an out-of-network psychiatrist for an office visit, you will not need prior authorization, because BCBSNM does not require it to visit an in-network psychiatrist.
BCBSNM won’t require prior authorization for admitting or transferring into a facility for detox, acute or long-term care for substance use disorder.
- You MUST let BCBSNM know within three days if either you or your dependent are admitted or transferred into a facility for detox, acute or long-term care for substance use disorder. We may begin our care management functions after we receive notice.
IMPORTANT: BCBSNM pays out-of-network claims at the out-of-network rates listed in your benefit booklet. An out-of-network doctor or facility may still bill you for the difference between what they charge and what BCBSNM pays for those services (this is called “balance” billing).
To avoid these bills, it’s best to stay within your BCBSNM network when possible.
- There are no changes to your cost-sharing for in-network substance use services.
