Transcript Standard (LoboCare) Network

A Division of Health Care Service Corporation, A Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
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Your Health Plan
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Today We Will Cover:
Two Network Options
• Standard & Extended
• Same services available in both networks
• Differences between the two networks

Provider network

Copayments

Bi-monthly premium
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Standard & Extended Network
Similarities
In-network (HMO-type
benefits)
Always verify provider network
status
There is no need to:
•
Obtain referrals for specialist care
You receive the
highest level of benefits:
•
Use providers in specified networks
•
Prior authorization required for certain services
•
Provider files claims
• BlueCard & Away from Home Care
Programs
Out of Network:
•
You pay more of the cost of
out-of-network benefits
- Higher deductibles,
coinsurance
•
You may need to file your own claim
•
You could be balance billed for
amounts over allowed amount
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Standard (LoboCare) Network
• Uses UNMH and First Choice providers
• UNM Hospitals and facilities
• PLUS additional providers and facilities including:
– urgent care centers
– laboratories
– durable medical equipment suppliers
– Pharmacies
– Home health care facilities
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Your Standard (LoboCare) Network Benefits
Benefit Highlights
In-Network
Out-of-Network
Individual Deductible
$250
$1,500
Family Deductible
$500
$3,000
$5,000
$10,000
No Charge
Not Covered
Primary Care Physician
$30
40%*
Specialist Physician
$40
40%*
Individual Out-of-Pocket Max
Preventive Care Services
Inpatient Admission
Emergency Room
Urgent Care
Other Urgent Care
$500 (per admission after
deductible)
40%*
$250 (per visit after deductible)
$75 (per visit after deductible)
$100 (per visit after deductible)
*After deductible you may be responsible for charges over the allowable fee.
N/A
40%*
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Extended Network
Entire BCBSNM HMO network of over 22,000 providers including
University and First Choice providers and UNM Hospitals, PLUS
• Lovelace Hospitals & Facilities
• Independent physicians
• Women’s Hospital
• West Mesa Medical Center
• Lovelace Medical Center
• Kindred Hospital
• Urgent Care Centers
• Heart Hospital of New Mexico
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Your Extended Network Benefits
Benefit Highlights
In-Network
Out-of-Network
Individual Deductible
$250
$1,500
Family Deductible
$500
$3,000
$5,000
$10,000
No Charge
Not Covered
Primary Care Physician
$45
40%*
Specialist Physician
$60
40%*
Individual Out-of-Pocket Max
Preventive Care Services
Inpatient Admission
Emergency Room
Urgent Care
Other Urgent Care
$500 (per admission after
deductible)
40%*
$300 (per visit after deductible)
$75 (per visit after deductible)
$100 (per visit after deductible)
*After deductible you may be responsible for charges over the allowable fee.
N/A
40%*
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Services covered only when received
from Standard & Extended Network
providers
• Preventive care (physicals, routine immunizations,
well-child exams, etc.)
• Infertility services (through UNMH only)
• Allergy testing and injections
• Acupuncture and chiropractic care
• Prescription drugs
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Rx
Pharmacy Benefits
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Prescription Drug Benefit
*Retail Pharmacy:
Maximum
Generic
$10
Brand-Name on Drug List
$40
Brand-Name Not on Drug List
$70
Specialty Medication
*Mail Order:
20% up to maximum copayment of $250
Two copayments for Tiers 1,2 & 3 only (90 day supply)
Maximum
Generic
$20
Brand-Name on Drug List
$80
Brand-Name Not on Drug List
$140
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Urgent Care
• Sudden onset of an illness or injury, not life-threatening
• Unable to see a PCP
• Urgent medical conditions such as sprains, high fever,
minor cuts requiring stitches
• ABQ Health Partners Urgent Care Centers
• Concentra Urgent Care
• UNM Hospital Urgent Care
• Contact PCP for follow-up care
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BlueCard® Travels With You
• Urgent care when you’re away from home less than 90
consecutive days
• Call 1.800.810.BLUE to locate a provider or visit
bcbsnm.com
• Call your PCP to obtain a prior authorization (within 48
hours)
• Simply present your member ID card to a participating
provider and pay the applicable copayment
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Emergency Care
• Definition: A sudden and unexpected
medical condition that a reasonable person
feels could result in death or serious
disability if no medical attention is received
• Call 911
• Go to the nearest emergency room
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Away From Home Care® Privileges
• Reside outside New Mexico longer than 90
consecutive days
• college student
• divorce, dependent children
• work part of year outside of New Mexico
• Call customer service to enroll at 1-800-423-1630
• Choose a PCP and pay applicable copayments for
services
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How to Find a PPO Provider
From your
computer OR
mobile phone,
log on to
bcbsnm.com
and click on
‘Find a Doctor’
Call Customer Service at the
number on the back of your
BCBSNM ID card
800-423-1630
OR Contact your
physicians and ask
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Blue Access
for Members
SM
Secure member site
A new member subscribes to
Blue Access for Members every
minute
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Blue Access for MEMBERS
SM
Access the
Provider Finder
to locate doctors
& hospitals
®
My Health tab links
you to health and
wellness content,
articles, videos, and
My Care Profile
My Coverage
includes benefit
highlights, spending
accounts, as well as
deductibles and outof-pocket and copay
summaries
My Claim Activity
displays recent
claims, or go to the
Claims Center for
all your claim details
Quick Links for
easy access to
Health Assessment,
Fitness Program,
Member Discounts,
or to get an ID card
Form Finder easier
to view and find
specific forms for
members
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Blue Access Mobile
SM
More than
20,000
Blue Access for Members
• Digital ID Card
• Pay My Bill
• Benefits / eligibility
• Health and Wellness Articles
– Diabetes, Maternity Care,
• Claims Status
• User Profile
Public Site
•
•
•
•
SM
Find a Doctor / Hospital
Health Care 101
Shop for Insurance
Log in or register for Blue
Access for Members
• Contact Us
mobile page
views per day
More than
Five
text messages
sent per minute
Nutrition, Obesity, Fitness, My
Care Profile, Metabolic Syndrome
Text Messaging
Static – One-Way Alerts
• Rx Reminders, Diabetes, CAD, Diet Tips,
Claim Status, Exercise & Fitness Tips
Dynamic – Two-Way
• ID Card Management, Coverage Management
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Health
Services
and Programs
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Blue365 Member Discount Program
®
Member discounts simply
for being a BCBS member
Exclusive health and wellness deals
from national and local retailers
Save money on gym memberships,
vision exams and services, hearing
aids and diet-related services
Share deals with friends and family
and receive cash rewards on future offers
SM
Log on to Blue Access for Members for
updates and to register for weekly emails
Under the My Coverage tab
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Expectant mothers and babies
get off to a healthy start with prenatal and
postnatal education and support
Enroll in the Special Beginnings®΄ program to receive
guidance from pregnancy to six weeks after delivery
•
•
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Pregnancy risk assessment
Frequent, personal contact based on risk
Educational materials
Coordinated care with your physician
Screening for depression
WEB
TEXT
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Your Blue Care Connection®
Condition Management
Personalized
Outreach and
integrated support
by certified clinical
professionals
If you are identified as being at-risk or having
one of the managed chronic conditions, such
as asthma, high blood pressure, or
diabetes, a Blue Care Advisor will contact
you.
Call Back!
This is a completely confidential service offered
at no cost to you. Your participation is voluntary,
but Blue Care Connection will help you better
manage your condition and stay healthier.
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24/7 Nurseline
Advice anytime.
Advice isn’t just needed from 9 to 5.
Round-the-clock health and the wellness advice
from licensed professionals
More than 1,200 AudioHealth Library topics
800-973-6329
Available in English and Spanish
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What if I Have Questions?
Call your BCBSNM customer service team for:
•
•
•
•
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Claim questions or status
Medical benefit coverage questions
Help with finding network providers
Membership and eligibility
Help with navigating online tools
ID card requests
Transition of care
800.423.1630
Toll-free
Enter your ID Number
Monday-Friday 6 AM – 8 PM
Saturday & most holidays
8 AM – 5 PM
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Select a Network:
Standard or Extended
• You must note your selection of either
the Standard (LoboCare) Network or
Extended Network when enrolling
• You cannot change your Network
selection except during Open Enrollment,
regardless of any qualifying event during
the plan year (August 1 through July 31)
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Rates 2014/2015
Standard & Extended Networks
Standard (LoboCare) Network
COVERAGE TYPE
EE COST
Full Time
EE COST
Part Time
Employee
$
0.00
$ 108.00
Employee + Spouse/DP
$ 285.00
$ 393.00
Employee + Child(ren)
$ 136.00
$ 244.00
Employee + Family
$ 312.00
$ 420.00
Extended Network
COVERAGE TYPE
EE COST
Full Time
EE COST
Part Time
Employee
$ 488.00
$ 556.00
Employee + Spouse/DP
$1,200.00
$1,308.00
Employee + Child(ren)
$ 805.00
$ 913.00
Employee + Family
$ l,273.00
$ 1,381.00
UNMH pays $540.00
per month for health
plan coverage for each
enrolled full time
employee. ($324.00 for
part time)
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Questions?
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