Blue Community Silver HMO℠ 203
75605NM0390110
Silver
HMO
Blue Community Silver HMO℠ 203 is a Silver HMO plan by Blue Cross and Blue Shield of New Mexico.
Locations
Blue Community Silver HMO℠ 203 is offered in the following counties.
Plan Overview
This is a plan overview for 2022 version of Blue Community Silver HMO℠ 203 75605NM0390110.
| Insurer: | Blue Cross and Blue Shield of New Mexico |
| Network Type: | HMO |
| Metal Type: | Silver |
| HSA Eligible?: | No |
| Plan ID: | 75605NM0390110 |
Cost-Sharing Overview
Blue Community Silver HMO℠ 203 offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Blue Community Silver HMO℠ 203 includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | 8700 | 8700 per person | $17400 per group |
| Deductible: | 2500 | 2500 per person | $7500 per group |
| Coinsurance: | 2500 per person | $7500 per group | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Blue Community Silver HMO℠ 203 will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | ||
| Out-of-Network Deductible: |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | 2500 |
| Copayment: | 900 |
| Coinsurance: | 3600 |
| Limit: | 60 |
| Deductible: | 3600 |
| Copayment: | 300 |
| Coinsurance: | 0 |
| Limit: | 20 |
| Deductible: | 2400 |
| Copayment: | 400 |
| Coinsurance: | 0 |
| Limit: | 0 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Blue Community Silver HMO℠ 203?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
Blue Community Silver HMO℠ 203 offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Asthma, Heart Disease, Depression, Diabetes, Pain Management, Pregnancy, Low Back Pain, High Blood Pressure & High Cholesterol |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Blue Community Silver HMO℠ 203 covers when you are out of the service area or out of the country.
| Out of Country Coverage: | Yes |
| Out of Country Coverage Description: | This plan does not cover any services and/or supplies provided to a member outside of the United States, if the member traveled to the location for the purposes of receiving medical services, supplies, or drugs. |
| Out of Service Area Coverage: | Yes |
| Out of Service Area Coverage Description: | Coverage outside our service area is available for Emergency and Urgent Care services only. |
| National Network: | No |
Additional Benefits and Cost-Sharing
Blue Community Silver HMO℠ 203 includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Dialysis Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Hearing Aids Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 1 Item(s) per 3 Years Limit is per hearing impaired ear and limited to covered members up to age 21. |
| Chemotherapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| X-rays and Diagnostic Imaging Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
| Non-Preferred Brand Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. Tier 1 (Preferred Network) and Tier 2 (Non-Preferred Network) share the same maximum out of pocket or deductible and maximum out of pocket, as applicable. |
| Generic Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Certain generic drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. See benefit book for details. Tier 1 (Preferred Network) and Tier 2 (Non-Preferred Network) share the same maximum out of pocket or deductible and maximum out of pocket, as applicable. |
| Basic Dental Care – Child Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Emergency Transportation/Ambulance Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Emergency Transportation/Ambulance is covered when your condition is such that an ambulance is necessary. Benefits will not be provided for long distance trips or for use of an ambulance because it is more convenient than other transportation when rendered in connection with a covered Inpatient admission or covered Emergency Accident Care or covered Emergency Medical Care or if it does not meet the definition of Medically Necessary for non-emergency medical situations. Benefits will not be provided for long distance trips. See benefit book for details. |
| Specialist Visit Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Outpatient Surgery Physician/Surgical Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Abortion for Which Public Funding is Prohibited Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Covered in the instances of rape, incest, and life endangerment. |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. Member will be responsible for copay per outpatient surgery admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details. |
| Bariatric Surgery Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Bariatric surgery is Covered for patients with a Body Mass Index (BMI) of 35 kg/m2 or greater who are at high risk for increased morbidity due to specific obesity related comorbid medical conditions. |
| Weight Loss Programs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dietary evaluations and counseling for the medical management of morbid obesity and obesity are covered |
| Home Health Care Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 100 Visit(s) per Benefit Period Substantially Equal |
| Inpatient Physician and Surgical Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Treatment for Temporomandibular Joint Disorders Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Accidental Dental Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Prosthetic Devices Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Mental/Behavioral Health Inpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Imaging (CT/PET Scans, MRIs) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
| Durable Medical Equipment Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Routine Eye Exam (Adult) Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Orthodontia – Child Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Habilitation Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Emergency Room Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Member will be responsible for copay per emergency room admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details. |
| Diabetes Education Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Allergy Testing Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Specialty Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Certain specialty drugs may have a higher cost share amount than is listed on this page. Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. Tier 1 (Preferred Network) and Tier 2 (Non-Preferred Network) share the same maximum out of pocket or deductible and maximum out of pocket, as applicable. |
| Delivery and All Inpatient Services for Maternity Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details. |
| Chiropractic Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 20 Visit(s) per Benefit Period Unless for Habilitative and Rehabilitative ServicesSubstantially Equal |
| Routine Foot Care Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Acupuncture Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 20 Visit(s) per Year |
| Routine Eye Exam for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 1 Visit(s) per Benefit Period When purchasing Out of Network, reimbursements are available. See benefit book for details.Substantially Equal |
| Preferred Brand Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Out of Network Pharmacy coverage is only available in emergency situations. You may be responsible for paying the difference between the cost of a brand name drug and generic drug, if a generic was also available. See benefit book for details. Tier 1 (Preferred Network) and Tier 2 (Non-Preferred Network) share the same maximum out of pocket or deductible and maximum out of pocket, as applicable. |
| Transplant Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Major Dental Care – Child Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Well Baby Visits and Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Routine Dental Services (Adult) Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Major Dental Care – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Outpatient Rehabilitation Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Mental/Behavioral Health Outpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Radiation Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Nutritional Counseling Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Covered: The following are covered benefits: Nutritional supplements for prenatal care when prescribed by a practitioner/provider are covered for pregnant women.; Nutritional counseling as medically necessary; Nutritional supplements that require a prescription to be dispensed are covered when prescribed by a Practitioner/Provider and when medically necessary to replace a specific documented deficiency.; Nutritional supplements administered by injection at the practitioner’s/provider’s office are covered when medically necessary.; Enteral formulas or products, as nutritional support, are covered only when prescribed by a practitioner/provider and administered by enteral tube feedings.; Total Parenteral Nutrition (TPN) is the administration of nutrients through intravenous catheters via central or peripheral veins and is covered when ordered by a practitioner/provider.; Special medical foods as listed as covered benefits in the Genetic Inborn Errors of Metabolism (IEM) benefit or as medically necessary.; Not Covered: The following are not covered: Baby food (including baby formula or breast milk) or other regular grocery products that can be blenderized and used with the enteral system for oral or tube feedings.; Nutritional supplements prescribed by an attending practitioner/provider not due to a deficiency or as the sole source of nutrition. |
| Dental Check-Up for Children Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Hospice Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Substance Abuse Disorder Inpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Private-Duty Nursing Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Laboratory Outpatient and Professional Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
| Infertility Treatment Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Covers diagnosis and medically indicated treatments for physical conditions causing infertility. |
| Prenatal and Postnatal Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | First prenatal visit is subject to the Office Visit charge. All subsequent prenatal care is covered under delivery for maternity care. |
| Skilled Nursing Facility Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 60 Days per Benefit Period Preauthorization may be required. See benefit booklet for details.Substantially Equal |
| Primary Care Visit to Treat an Injury or Illness Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Rehabilitative Speech Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Urgent Care Centers or Facilities Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Long-Term/Custodial Nursing Home Care Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Infusion Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Member cost share may increase when using a Hospital-based facility for these services. See benefit booklet for details. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Member will be responsible for copay per inpatient admission before and after meeting the plan deductible. The remainder of the eligible charge will be subject to plan deductible and coinsurance. See benefit book for details. |
| Basic Dental Care – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Orthodontia – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Reconstructive Surgery Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Preventive Care/Screening/Immunization Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Substance Abuse Disorder Outpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Eye Glasses for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | 1 Item(s) per Benefit Period Provider-designated frames are covered. An allowance may apply to non-provider-designated frames. Coinsurance may apply to non-provider-designated frames on the remaining balance over the allowance. See benefit book for details.Substantially Equal |
| Cosmetic Surgery Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No |
Free Preventive Services
There is no copayment or coinsurance for any of the following Blue Community Silver HMO℠ 203 preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Ready to sign up for Blue Community Silver HMO℠ 203?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904