Oct. 1, 2024
Starting Jan. 1, 2025, members of Blue Preferred PPOSM and Blue Focus POSSM benefit plans with Blue Cross and Blue Shield of Montana who purchased their plans on or off the marketplace exchange will no longer have access to out-of-state care beyond the border counties of Idaho, Wyoming, North Dakota and South Dakota.
Coverage for non-urgent and non-emergent out-of-service area care will only be available if adequate care is not available in the member’s service area. (Check our provider directory for in-area care options.) Beginning Jan. 1, if needed care is not available in the member’s service area, coverage may be available if a waiver is requested and granted.
Remember: Out-of-state care beyond the contiguous counties is not covered and will ONLY BE COVERED by waiver if the services are not available in the member’s service area. A waiver will be denied if adequate care is available in-state or in contiguous counties. Members will be redirected to available, local in-network services.
What’s not changing: Services provided by in-network (BlueCard® contracted) providers within the bordering counties do not require a waiver. In addition, nothing is changing for urgent and emergency services.
Requesting a waiver: Members or providers can request a waiver for care outside Montana and the bordering counties in Idaho, Wyoming, North Dakota and South Dakota when adequate in-state care is not available. The member is responsible for securing the waiver, but you may request it on their behalf.
Out of network providers should call Customer Service at BCBSMT at 855-258-8471 to request a waiver. In network providers may request a waiver using the referral form on the Availity® Essentials Payer Space for BCBSMT.
Members with approved waivers: If members are approved for out-of-state health care services beyond the border counties, those services will be reimbursed at the in-network benefit level.
Members without approved waivers: If members seek care beyond the bordering counties and don’t receive a waiver, their services will not be covered under their benefit plan. The member will be responsible for the full cost.
Out-of-Network Providers: Members with approved waivers to see out-of-state, out-of-network providers will be reimbursed at the in-network benefit level.
More information: Check members’ eligibility and benefits through Availity Essentials or your preferred vendor portal prior to rendering services or recommending care.
To find in-network care, check our provider directory.
Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSMT. BCBSMT makes no endorsement, representations or warranties regarding any products or services provided by third party vendors.