Frequently Asked Questions about BlueEdge HCA^SM

BlueEdge HCA is a consumer-driven health plan that works with a Health Care Account (HCA) that the employer funds. BlueEdge HCA gives the employee control over how the health care dollars are spent and includes four major components:

1. HCA funds from the employer are used to pay for covered health care expenses. Money spent from this account, for covered services, counts toward the deductible.
2. PPO benefits begin after the employee meets the deductible. The employee has the freedom to see any doctor without a referral.
3. Preventive care and wellness visits are covered – nothing is deducted from the spending account and the employee doesn't need to meet the deductible to enjoy these benefits.
4. Online decision resources help increase awareness and knowledge of health issues and help keep track of the HCA and health care expenses.

Most traditional plans pay a percentage of the charges for covered medical expenses only after the employee satisfies a plan deductible or copayment. With BlueEdge HCA, the preventive care and wellness services are covered without first meeting the deductible. The employer may also set aside a specific amount of money for the employee each benefit year in an HCA. The HCA funds pay for covered health care expenses that are applied to your deductible. The employee pays the remaining deductible amount and then PPO benefits begin. Unused HCA funds roll over year to year, as long as the employee remains in the plan.

A Health Care Account is a spending account with an amount of money set aside for the employee to use for covered health care expenses. The HCA is funded by the employer. Charges for covered medical care services are first paid from this account. Money spent from the HCA is also applied toward the annual deductible. Unspent funds roll over from year to year. If the employee leaves the plan, the funds return to the employer.

Like most other PPO plans, BlueEdge includes an annual deductible. A deductible is a fixed amount the employee is required to pay before health care benefits begin. The HCA pays a portion of the deductible and the employee is responsible for paying the other portion.

The family HCA can be used to pay for any covered services received by any family member covered under the plan. The deductible works like most other Blue Cross and Blue Shield of New Mexico PPOs – no family member has to satisfy more than the individual deductible before receiving PPO benefits, and the PPO benefits will be paid for the whole family once the family deductible is met.

No. Most preventive medical services (e.g., routine physical exams, age-based testing, and vaccinations) are covered under the BlueEdge HCA Plan when care is received from in-network doctors. The employee can check the group plan documents for specific coverage details.

There are three circumstances when the employee will have out-of-pocket expenses:

1. The employee has used all of the HCA funds, but has not yet met the deductible. The employee is responsible for paying for health care services until the deductible is satisfied.
2. The employee has met the deductible, so PPO benefits are available. If the plan includes coinsurance, the employee will be responsible for paying a percentage of the charges. There is an out-of-pocket maximum, so the employee won't pay more than this amount during the benefit year as long as he/she stays in network. The employee can check the plan documents for specific coverage details.
3. Non-covered services, additional coinsurance (until the employee meets the higher out-of-pocket limit), and charges in excess of our allowed amount when the employee receives services out of network.

When the employee uses an in-network provider, the provider will submit the claim. Blue Cross and Blue Shield of New Mexico's integrated claim process automatically deducts funds from the HCA and/or pays the claim from the PPO. There is no paperwork for the employee to file.

If the employee receives care from an out-of-network doctor or hospital, the provider will most likely also file the claim with Blue Cross and Blue Shield of New Mexico. However, if the employee needs to file a claim, he/she can download a form from online and send it to the address on the back of the member ID card.

The eligible expenses are deducted from the HCA first. When that account is depleted, health care expenses can then be reimbursed from the FSA. That is, the funds in the FSA can be used to satisfy the remaining portion of the deductible, or coinsurance payments after the deductible is met, or non-covered eligible charges.

If the employee uses all of the employer's HCA contribution, he/she is responsible for any remaining balance of the deductible before the PPO benefits begin.

If there is a remaining balance in the HCA at the end of the benefit year, it automatically rolls over to the next year and is added to the annual contribution made by the employer (up to the maximum HCA balance specified the employer's plan). The total balance remains available to the employee as long as he/she participates in the plan. The greater the balance in the HCA, the less the employee has to pay out-of-pocket.

If the employee chooses another plan or leaves the company without continuing coverage (e.g., under COBRA), the balance in the HCA returns to the employer.

Blue Preferred EPO offers a 5-tier prescription drug plan with a separate prescription drug out of pocket limit.

Your clients should review their summary of benefits and coverage and their Benefit Booklet for further details.

For more information about our plans for groups, please contact BCBSNM Customer Service toll-free at 1-800-432-0750.