A deductible is the amount of covered charges a member must pay each calendar year before Blue Cross and Blue Shield of New Mexico (BCBSNM) begins to pay its share of the applicable covered charges the member incurs during the rest of the same calendar year. If you have selected a PPO plan, there is a separate higher deductible for using Non-Preferred Providers (out-of-network providers).
Jesse has PPO coverage with a $500 deductible and 20% coinsurance. His plan pays 80% after the deductible is satisfied. Jesse didn't have any health care services until he began to experience severe pain in his lower back. He went to the ER for treatment. They found he had kidney stones and admitted him for surgery. Jesse was in the hospital for 4 days. He used BCBSNM Preferred Providers (in-network). His total hospital bill was $18,680. BCBSNM covered $11,800.
Note: The covered charge is usually less than the billed charged. BCBSNM contracted providers will write off the difference. Noncontracted providers may not write off the difference and the member may be responsible for paying the difference in charges.
For example only. Amounts used are not real and do not reflect a total description of benefits.
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, coinsurance, copay, and/or penalty amount), 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 percentage of covered charges that members must pay for certain covered services after the deductible has been met. With most plans, after the deductible has been met, members will pay a percentage of covered charges for services from a Preferred Provider and a percentage of covered charges for services from a Nonpreferred Provider. Check the Summary of Benefits for the specific percentage of covered charges you and your employees will have to pay for different services.
A copayment is a fixed dollar amount members pay for a service at the time they receive care.
For PPO plans, an out-of-pocket limit is the maximum amount of coinsurance that members will pay for covered services in a calendar year. After the out-of-pocket limit is reached, the PPO plan will pay 100 percent of most of your Preferred Provider and Nonpreferred Provider covered charges for the rest of that 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 of most covered charges for the calendar year, not to exceed any benefit limits. Refer to your benefit information or call Customer Service for more information.
A provider is a physician, hospital, or other health care professional or facility, licensed when required, that provides medical services and care, and performs within their scope of licensure.
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 facility that has contracted with BCBSNM, a BCBSNM contractor or subcontractor, or with a Blue Cross and Blue Shield (BCBS) company in another state.
A Nonpreferred Provider (out-of-network provider) has not contracted with BCBSNM or a Blue Cross and Blue Shield (BCBS) company, either directly or indirectly, to be part of the preferred or PPO provider network.
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.
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.
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.
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.
Certain services require approval from BCBSNM. If approval is not obtained, BCBSNM may not pay for them. This approval is called prior authorization. The list of services that require prior authorization is in the Benefit Booklet. To request prior authorization, the member or the member's provider must call BCBSNM Health Services. Call 1-505-291-3585 in Albuquerque, or toll-free at 1-800-325-8334, Monday through Friday, from 8 a.m. to 5 p.m. MT.
Note: If your plan includes behavioral health and substance abuse services, prior authorization is required for inpatient, residential treatment, partial hospitalization and some outpatient services. Request prior authorization 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.
Yes. Not all radiology and imaging centers offer mammography services. To find a BCBSNM provider that performs mammography services, members can call Customer Service at the number listed on their BCBSNM member ID card.
Covered preventive services include routine annual physicals, gynecological exams, related testing (includes routine Pap tests, mammograms, cholesterol tests, urinalysis, etc.), well child care, immunizations, routine testing, and routine vision or hearing screenings (through age 17).
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 Blue National Doctor and Hospital Information Line toll-free at 1-800-810-2583, or search the Blue National 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 1-800-810-2583 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.
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.
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:
Note: Services are reviewed and if they are determined to be nonemergency services, coverage may be denied.
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 1-800-810-2583. The operator will provide the name and phone 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.
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.
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. 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 1-800-810-2583. The operator will give the name and phone number of a local provider who will be able to treat them.
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.
If a member and his or her spouse are covered under each other's 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 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.
Generally, eligible dependents for group or individual plans include:
* 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.
To add a dependent to their health insurance coverage, members can call us at the number on their BCBSNM member ID card.
Only the suscriber's name is listed on a member ID card. However, any dependent listed in the subscriber's health care benefits plan will be covered according to the policy, and the dependent will receive a member ID card that includes the subscriber's (main policyholder) name.
Members can log in to Blue Access for MembersSM 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.
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.