Coverage and Eligibility

The Biden administration announced that it intends to end the COVID-19 national and public health emergency (PHE) declarations on May 11, 2023. Due to the OSI rule, BCBSNM fully insured groups will continue with the coverage that was available during the PHE.

Blue Cross and Blue Shield of New Mexico (BCBSNM) health plans cover medically necessary health benefits, including physician services, hospitalization and emergency services.

In addition, we have put in place working solutions to help you and your members get the care they need during these uncertain times.

With a BCBSNM health plan, our members have access to care for COVID-19 related health issues. Members can use doctors, labs and facilities in their BCBSNM health plan’s provider network for:

• Tests to diagnose COVID-19
• COVID-19 testing-related doctor’s visits
• COVID-19 treatment

In response to the pandemic, BCBSNM made some temporary changes impacting coverage for various services. Some of these changes will end with the end of the public health emergency. Some may end sooner, depending on the member’s plan. To understand what is currently in effect, please view effective coverage dates.

COVID-19 Vaccines

With a BCBSNM health plan, members have access to COVID-19 vaccines at no cost to them. Members should talk with their doctors about when they should get vaccinated once available and discuss any questions they have about the vaccines.

While most plans cover COVID-19 vaccines at no cost, some self-funded groups do not cover preventive services, including COVID-19 vaccines. Members who are unsure what their plan covers should contact their company’s benefits administrator or call BCBSNM Customer Service at the number listed on their member ID card.

Cost-Sharing Waived

To make it easier for our members to get the care and treatment they need amid the COVID-19 outbreak, we are waiving member cost-sharing,  including copays, deductibles and coinsurance, related to testing and treatment for COVID-19.

Cost-sharing waivers end with the end of HHS public health emergency. For fully insured and IBAC plan members, there is currently no end date for the State of New Mexico’s rule requiring cost-sharing waivers for COVID-19-related testing and treatment.

Telemedicine Expanded

Members insured by BCBSNM, including Medicare (excluding Part D plans) and Medicare Supplement members, can access provider visits for covered services through telemedicine as outlined in their benefit plan.

The state’s COVID-19 cost-sharing rules will continue to apply to COVID-19-related testing and treatment delivered by telemedicine for fully insured and IBAC plan members.

For non-COVID-19 testing and treatment, cost-share waivers for fully insured group, retail, Medicare (not Part D) and Medicare Supplement plans ended on Dec. 31, 2020. That means copays, deductibles and coinsurance apply after Dec. 31.

Telemedicine services may be available for members with plans that include MDLIVE^®*, our telemedicine service provider, or any in-network provider who offers the service through two-way, live interactive telephone and/or digital video consultations.

Telemedicine benefits may differ based on the plan. 

Self-funded customers have some choices about how we administer COVID-19 related treatment coverage for their employees.

Prescription Coverage

Members with pharmacy benefits through Prime Therapeutics^®** are encouraged to keep refills current and ask for new prescriptions before the last refill runs out.

Many drug stores may offer delivery options. If part of plan benefits, members can sign up for mail-order delivery (up to a 90-day supply of covered non-specialty medications) with the home delivery program. Members with Group Medicare Advantage and Group MedicareRx (PDP) plans can also get 90-day fills through mail order.

Prior Authorization

We temporarily extended approvals on existing prior authorizations for most non-emergent elective surgeries, procedures, therapies and home visits, if the service was provided by Dec. 31, 2020. This applies to services that were originally approved or scheduled between Jan. 1, 2020 and June 30, 2020.

Relaxed Eligibility Requirements

You can maintain employees who were enrolled as of March 20, 2020 through Sept. 30, 2020, regardless of the eligibility definition stated in their plan or the BPA. This includes reduced work hours, furlough, leave of absence or layoffs. This flexibility does not apply to those who are newly electing coverage via a special enrollment period.

See what is being communicated directly to our members about these coverage changes.