If I go out of State – California or the USA – Country
What does my California Plan or Medicare pay for Emergencies?
Urgent Care?
Regular Doctor Visits?
Colds?
Introduction
How do I know what my coverage is – out of area?
Questions of coverage can be quite confusing, especially what coverage might there be if your California issued coverage, is used out of your HMO local area, network, out of state or out of country. Coverage can differ if it’s for routine care, Urgent Care & Emergency or seeking out specialists at prestigious world famous clinics and hospitals.
We are editing this page in April 2022 and will be putting a lot of the information in the “Historical” section.
For an example – check out the Blue Shield PPO EOC
Please refer to your specific Evidence of Coverage EOC for details of YOUR coverage.
Insubuy Travel Health Insurance
Instant Quotes, Details and ONLINE Enrollment
Steve talks about International Travel Insurance VIDEO
US State Department - Travel - Insurance
Our webpage on Travel Insurance
Definition Urgent Care and #Emergency Services
Emergency Medical Condition
An illness, injury, symptom (including severe pain), or condition severe enough to risk serious danger to your health if you didn’t get medical attention right away. If you didn’t get immediate medical attention you could reasonably expect one of the following:
1) Your health would be put in serious danger; or
2) You would have serious problems with your bodily functions; or
3) You would have serious damage to any part or organ of your body. Health Net Glossary *
Urgent Care
Care for an illness, injury, or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care.
Prior Authorization Preauthorization
A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment (DME) is medically necessary. EOC * Our Webpage * Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost. Health Net Glossary *
The BlueCard® Program links Blue plans across the United States and abroad through a single electronic network for claims processing and reimbursement. When an out-of-state Blue plan member seeks medical care from your office, use the information and tools in this section to submit those claims to Blue Shield of California. As a mission-driven, non-profit health plan, Blue Shield of California is working every day to create a sustainably affordable healthcare system that’s worthy of our family and friends.
BlueCard Program tools | Tutorials and resources | Training and webinars
Be sure to check the definition in YOUR EOC
Travel Guides
- PPO Travel Guide – English (PDF) Health Net
- Policy – Travel Section
- Sorry, under ObamaCare – Blue Cross does not appear to participate in the Blue Card Program unless it’s an emergency or urgent care. Double check this – 2016 might have changed!
- Blue Shield HMO
- SBC – Federal Summary of Benefits
- How to find your Evidence of Coverage
- Kaiser – KP.org Travel Care away from home * 951-268-3900 *
- Provider Finder for all our companies
- US News & World Report 10.2015 – Coverage while outside USA
- Free Quotes, Brochures and complete information on travel coverage and International Medical Plans
- $50k Emergency Coverage in Supplemental & Advantage Plans
- Medicare.Gov/Travel
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Blue Shield Silver 70 PPO Off Exchange Evidence of Coverage EOC
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Medical Info for American’s Traveling Abroad US State Department
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Official Web Site for Canadian Health Care
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Constitutional right to travel 14th Amendment
Specimen Policy #EOC with Definitions
It's often so much easier and simpler to just read your Evidence of Coverage EOC-policy, then look all over for the codes, laws, regulations etc! Plus, EOC's are mandated to be written in PLAIN ENGLISH!
- Find your own Individual EOC Evidence of Coverage
- It' important to use YOUR EOC not just stuff in general!
- Obligation to READ your EOC
- Employer Group Plans
- Medi-Cal HMO – Managed Care Providers
- Our Webpage on Evidence of Coverage
- Plain Meaning Rule - Plain Writing Act
- Our Webpage on OOP Out of Pocket Maximum - Many definitions are explained there.
Steve Explains how to read EOC
All our plans are Guaranteed Issue with No Pre X Clause
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Medicare A & B if you don't #live in USA
Publication 11871
Medicare just visiting Out of County Publication # 11037
- Medicare VIDEO Medicare & You: Traveling Abroad
- Our webpage on Medicare Coverage outside of USA
- FAQ - Buying Medi Gap if you live outside USA
- Get Travel Quotes & Information
*********Social Security*****
Payments if you are living outside of USA # 10137
- What if you work in two or more different Countries?
- International Social Security agreements,“Totalization agreements,” have two main purposes.
- First, they eliminate dual Social Security taxation, the situation that occurs when a worker from one country works in another country and is required to pay Social Security taxes to both countries on the same earnings.
- Second, the agreements help fill gaps in benefit protection for workers who have divided their careers between the United States and another country.
Learn More
Our Webpages on:
Related Pages
Emergency Room – Balance Billing
Providence Health – Difference between ER and Urgent Care
- Pharmacy
- Provider Finder – Instructions * Exclusive PPO – Trio HMO
- Urgent Care vs ER
- It seems that there are NO companies, even PPO that cover you out of state, unless it’s an Emergency or Urgent Care. We will be checking
Medical Necessity – reasonable and necessary
EOC Evidence of Coverage Value and how to find
Why the restrictions in Coverage?
Going to Urgent Care vs ER Emergency Room
What if you’re out of the area, out of state?
Visiting an urgent care center can cost up to five times less than a visit to the ER and significantly reduce your wait time. While the average wait at a California ER is 4 hours and 34 minutes, urgent care center wait times are usually under an hour*. That means you can bypass the crowds and take your first step on the road to recovery.
- *”Urgent Care or the ER – Which is the Right Choice?” Health Alerts, Johns Hopkins Medicine, January 2011. Read more Accessing Urgent Care
- 49 Ways to stay out of the ER – Emergency Room Kevin MD.com
- The Insurance Company might base the claim payment on final diagnosis, rather than if a reasonable person felt their life was in danger?
Blue Shield INDIVIDUAL Plans
Unauthorized Excerpt of Confidential Agent Guide
Blue Shield BlueCard Program frequently asked questions
Too Many Claims
VIDEO UCSF cardiologist Rita Redberg talks about the negative effects of variation on patients’ health and medical costs and what can be done to change it.
HOLY SMOKES – it worked (at least it looks promising)
Thank you Steve for your clever observation about BS of CA potentially being more liberal about considering out-of-state providers “in network” as of 2022 (even for Covered CA).
Actually I don’t know if this is really new or not – but I wouldn’t have pursued it unless you had sent me the new, updated, benefits guide (where you highlighted info specific to my out of state coverage situation in the 150 page document). This will save me AT LEAST 4 trips back and forth to CA, during a time when I need to be temporarily staying in another state to support a sick family member. YOU ROCK STEVE!!!
Your other customers might be able to benefit from this same thing if they log on to their BS of CA account and go to the section where they can FIND a DOCTOR (across the top of the page)
Scroll down to the VERY bottom of the page, on the left side it says ACCESSING CARE OUTSIDE CA. Two options under that including PROVIDERS OUTSIDE OF CA and COVERAGE OUTSIDE OF THE US. Click on that and it will take them to the “IN NETWORK” providers in the BLUE CARD Network!
FIND a DOCTOR ->ACCESSING CARE OUTSIDE OF CA-> PROVIDERS OUTSIDE OF CA
See attached letter where BS of CA explains it. Apparently the out of state provider (in Washington) will be considered in-network since the provider participates in the BlueCard program.
Feel free to put this on your site – as long as you take all the personal info off.
WELL DONE!!!
I’m traveling to Costa Rica next week.
Will Blue Shield PPO meet the Health Insurance Requirements to get a Visa?
Visitors traveling to Costa Rica will need to provide proof of a medical insurance policy to cover any COVID-19 related medical treatment or quarantine lodging while in Costa Rica.
In the case of international insurance, tourists must request from their insurer a certification issued in English or Spanish, noting:
1) the validity of the policy during the dates of visit to Costa Rica,
2) guarantee of coverage for medicals expenses in cases of COVID-19 related medical treatment in the amount of 50,000 USD and,
3) minimum coverage of 2,000 USD for extended lodging expenses due to COVID-19 related illness. US Embassy in Costa Rica
See webpage above, Blue Shield would be good for Requirement # 1
#2 Blue Shield would only page for urgent and emergency care
#3 I doubt Blue Shield would pay for lodging.
Don’t quote me! See the actual EOC Evidence of Coverage. See the bulletins on COVID coverage.
We are authorized brokers for Insuby where you can get a Costa Rican compliant policy!
We have a Silver PPO from Blue Shield of CA. (the primary coverage). Here’s the evidence of coverage.
It has hefty out of network deductibles, co pays and max out of pocket limits. For illustration purposes, let’s say the annual deductible for out of network is $25K and max out of pocket is $50K.
If we buy an annual travel plan with secondary medical coverage (they all seem to have secondary coverage – your webpage on dual coverage),
will the annual travel policy play pick up the hefty deductible ($25 k in this notional example) and $50K Max out of pocket, etc that Blue Shield of CA won’t pay if we end up hit by a bus in Italy and end up going to an out of network provider?
Please, let’s use the actual #’s and actually read and cite the real 1st hand information.
Are there any PPO Silver plans that don’t have the CALIFORNIA “in-network” requirement?
In other words, in the last year or two Blue Shield of CA has added a requirement that one needs to use a CALIFORNIA provider to have the encounter considered “in-network”.
Are there any Silver PPOs that allow one to go to providers (occasionally) in other states and have the encounters considered “in-network?
Basically, one needs to get their routine care done in CA. If it’s urgent or emergency, then you can go out of network out of state. See our “Blue Card” webpage.
2021 Rates and Benefits will be on our quote engine on the 15th http://www.quotit.net/eproIFP/webPages/infoEntry/InfoEntryZip.asp?license_no=0596610
IMHO it would be better to wait till November 1st to really look as then we will have information from all plans.
Then, you’ll want to check the summary of benefits and EOC Evidence of Coverage to verify the technical questions you are asking.
Here’s our page showing all the carrier pages, administrative and provider networks.
Here’s a master provider finder for all companies https://www.quotit.net/eproIFP/webpages/providers/providers_v20.asp?license_no=0596610
Plan Comparison PPO
Health Net
Enhanced Care PPO Disclosures https://ifp.healthnetcalifornia.com/content/dam/centene/healthnet/pdfs/general/ca/ifp/2021-ca-ifp-ecppo-disclosure.pdf
Note: EnhancedCare PPO insurance plans do not cover health care services outside of the state of California, except for emergency and urgent care. https://individuals.healthreformquotes.com/international/blue-shield-ppo-state-country/#emergency
Our webpage for finding Health Net Providers https://individuals.healthreformquotes.com/companies/health-net/portal/provider-networks-search/
At an agent meeting today, HN said their enhanced care PPO has over 10k doctors and medical groups like Facey & Scripps
Blue Shield PPO Providers Search https://individuals.healthreformquotes.com/companies/blue-shield/member-portal/provider-finder/
Blue Shield has 56K doctors and 325 hospitals in CA in Exclusive PPO Network https://www.blueshieldca.com/bsca/bsc/public/broker/PortalComponents/StreamDocumentServlet?fileName=A49537-OL_1-21.pdf
Please note, it’s confusing keeping track of all these names. Health Care Reform didn’t really allows us to keep our doctor.
Our webpage on narrow networks
Blue Cross of CA
Out-of-state protection: benefits that travel with you
When you are out of California for work, school or on vacation, you should not have to worry about health surprises. Through the BlueCard® program, https://www.blueshieldca.com/bluecard our exclusive provider organization (EPO) plans cover nonemergency, emergency and urgent care, while our health maintenance organization (HMO) plans cover medically necessary emergency and urgent care visits. The program applies to all 50 states.
Exclusive provider organization (EPO):
With our EPO plans, you will be able to see any in network doctor. It is a good idea to have a primary care doctor to coordinate your care, so we will pick one close to your home and let you know your assignment in the beginning of the year. You do not need to see this doctor for services or referrals, and you can change your assigned primary care doctor at any time. EPO plans do not offer out of network benefits, except for emergency and urgent care, ambulance services or when a service is preapproved. If you see a doctor not in your plan for any other reason, you will have to pay 100% out of pocket.
EPO plans are available in
Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Kern, Lake, Lassen, Mariposa, Mendocino, Merced, Modoc, Mono, Monterey, Nevada, Plumas, San Benito, San Joaquin, San Luis Obispo, Santa Barbara, Santa Clara, Santa Cruz, Shasta, Sierra, Siskiyou, Stanislaus, Sutter, Tehama, Trinity, Tulare, Tuolumne, Ventura and Yuba counties
I’ve been searching and searching… I found this on Blue Shield’s website
BlueCard® Program and Blue Shield Global Core
Covered services and urgent and emergency care while traveling in the United States or abroad.
HMO and EPO plan members: Coverage for emergency and urgent care services.
PPO, POS, and Active Choice® members: Same as above plus access to covered benefits (except dental, vision care, and prescription drugs).
If in the United States: Call (800) 810-BLUE or visit provider.bcbs.com.
If overseas: Call (804) 673-1177 or visit bcbsglobalcore.com.
This sounds good, BUT the benefits provided are in your EOC Evidence of Coverage, the actual contract that you have with the insurance company.
Blue Card is simply stating that if your EOC says so, then you can have these benefits. There might be a difference between Individual and Employer Group plans on this benefit.
Here’s the evidence of coverage for Blue Shield Silver 70 PPO Exclusive Network
So, now this question is getting beyond my pay grade as it’s my recollection that the contract – agreement has priority and not some ancillary benefit on some other page, that doesn’t really apply to the actual policy that an Individual can purchase in CA.
See our webpage on how to read and interpret a contract.
Coverage out of the state of California due to COVID travel restrictions???
I have Blue Shield of CA, Silver PPO, on-exchange (Covered California).
I am presently in WASHINGTON state caring for a very sick family member and will be in WASHINGTON for another 90 +/- days. I had planned to go back to CA, (to my normal providers) for a few days, to have some tests and procedures done for continuing care conditions (Breast Cancer follow up concerns, migraine management) among other things. {NOTE: these procedures and tests have already been been “pre-authorized by BS of CA}
Given the COVID travel restrictions / stay at home / quarantine orders in both states I am not able to make it to my home providers in California to have these tests/procedures. Some things I can postpone (like my annual dermatology check – other things I can not postpone (like a recently ordered breast Ultrasound and mammogram, etc).
QUESTION:
Can I go to providers in WASHINGTON state that accept Blue Shield, for those things I can’t postpone AND have them considered “in-network” – OR – will going to a WASHINGTON State Blue Shield provider be considered out-of-network on my “on-exchange” CALIFORNIA Silver PPO?
If I can go to WASHINGTON state provider (in the Blue Shield Network) to have these continuing care tests / procedures, what is the process for doing so?
How do I document or get approvals or whatever, so that it is considered “in network” and I don’t have to pay out of network rates or completely out of pocket?
I need to get these procedures re-scheduled in WASHINGTON in the next couple weeks.
Thank you!
IMHO the first place to go, would be the Blue Shield member portal and ask them to accommodate you. https://individuals.healthreformquotes.com/companies/blue-shield/member-portal/
Here’s an example of Blue Shield accommodating people with a similar situation
Blue Cross and Blue Shield of Oklahoma will authorize any member who was receiving treatment outside of Oklahoma prior to March 15 to continue receiving care closer to home if they prefer not to travel during the COVID-19 crisis through July 31. This date is an extension from the original end date of June 30. Members can transition to an in-network provider in Oklahoma or BCBSOK will cover the costs to see an out-of-network provider in Oklahoma at the in-network rate. AHIP.org
Public Health Emergency?
The purpose of the 1135 waiver authority is to ensure that sufficient healthcare services are available to meet the needs of individuals enrolled in SSA programs when and where an emergency is experienced.
the secretary can waive or modify specific requirements to match the particular needs of the emergency event and service providers. Section 1135 allows the secretary to waive or modify the following reimbursement requirements:
Out-of-Network Payments—Limitations on payments to permit …enrollees to use out-of-network providers in an emergency situation.
Social Security Act, Section 1135 Waiver Authority in National Emergencies
Forcing you to use out of network providers might be considered to be AGAINST PUBLIC POLICY!
https://www.upcounsel.com/what-contracts-are-considered-to-be-contrary-to-public-policy
duhaime.org/LegalDictionary/P/PublicPolicy.aspx
See our webpage on how Insurance Companies are covering COVID https://employers.healthreformquotes.com/corona-virus-how-does-insurance-cover-it/
Thanks for your answers. Is it fair to say that, in 2019, both PPO options, available in my zip code (San Diego County), Blue Shield of California and Health Net, classify (hence reinburse) non emergency treatment OUTSIDE of CALIFORNIA as out of network / non preferred providers.
It’s my understanding they won’t pay at all. See comment below.
Please read the excerpt 3 times, then when you think you understand it, read it again. Justice Frankfurter. If you disagree, then you should probably talk to someone who actually completed law school, passed the bar and specializes in Insurance Contracts. My bio is here.
In 2019, Are there any PPOs in California, that provide services considered in network, our of state or out of the country. Blue shield used to but apparently will stop in 2019
First try our quote engine and see.
Here’s a sample proposal. Please note that this is for San Pedro, CA. Different plans are offered in different counties, zip codes. 19 rating areas in CA.
Health Net Enhanced Care PPO is the only other one.
HN Covered CA information
30 page disclosure
Evidence of Coverage Silver 87 Enhanced Care PPO
Page 7 :
THIS BENEFIT PLAN PROVIDES BOTH PREFERRED PROVIDER AND OUT-OF-NETWORK PROVIDER BENEFITS FOR SERVICES (INCLUDING BEHAVIORAL HEALTH TREATMENT) ONLY WITHIN CALIFORNIA.
THIS BENEFIT PLAN DOES NOT PROVIDE BENEFITS FOR SERVICES (INCLUDING SERVICES FOR BEHAVIORAL HEALTH TREATMENT) OUTSIDE OF CALIFORNIA, EXCEPT FOR URGENT CARE AND EMERGENCY CARE.
OUTSIDE THE UNITED STATES, COVERAGE IS LIMITED TO URGENT CARE AND EMERGENCY CARE, AS DESCRIBED BELOW UNDER “FOREIGN TRAVEL OR WORK ASSIGNMENT” IN THIS “MISCELLANEOUS PROVISIONS” SECTION.
If Blue Shield of California PPO plans ( either on or off the exchange ) no longer cover non – emergency coverage – then are they any better than an HMO?
What am I paying the extra for???