Oct. 1, 2024
Starting Jan. 1, 2025, members with Blue Preferred PPOSM and Blue Focus POSSM Individual and Family Market benefit plans purchased from Blue Cross and Blue Shield of Montana 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 when adequate care is available in-state and or in its contiguous counties. This change does not apply to members with group coverage.
Coverage for non-urgent and non-emergent out-of-service area care will only be available if adequate care is not available in the IFM 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 IFM member’s service area. A waiver will be denied if adequate care is available in-state or in contiguous counties. IFM 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: IFM 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 state providers should call Customer Service at BCBSMT at 855-258-8471 to request a waiver. In state or out of network providers should request a waiver by submitting a Referral request in Availity® Essentials, which is accessible in the main navigation menu under Patient Registration.
IFM 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.
IFM 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: IFM 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.