If I go out of State – California or the USA – Country
What does Blue Shield pay for Emergencies?
Regular Doctor Visits?
Outside the United States
Benefits will also be provided for Covered Services received while temporarily traveling outside of the United States, Puerto Rico and U.S. Virgin Islands for emergency care of an illness or injury. If you need urgent care while out of the country, contact the Blue Cross Blue Shield Global™ (BCBS Global™) Service Center through the toll-free BlueCard Access number at 1-800-810-2583 or call collect at 1-804-673-1177, 24 hours a day, and seven days a week. In an emergency, go directly to the nearest hospital. If your coverage requires pre-certification or prior authorization, you should also call Blue Shield of California at the Customer Service telephone number indicated on the back of the Member’s identification card. For inpatient hospital care, contact the Blue Cross Blue Shield Global™ (BCBS Global™) Service Cente to arrange cashless access. If cashless access is arranged, you are responsible for the usual out-of-pocket expenses (non-covered charges, Deductibles, and copayments). If cashless access is not arranged, you will have to pay the entire bill for your medical care and submit a claim. When you receive services from a physician, you will have to pay the doctor and then submit a claim. Before traveling abroad, call your local Customer Service office for the most current listing of providers or you can go on-line at www.bcbs.com and select “Find a Doctor or Hospital” and “Blue Cross Blue Shield Global™ (BCBS Global™) Service Center”
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 *
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.
Out of Area Programs
Benefits will be provided for Covered Services received by Subscribers and their Dependent(s) who are temporarily traveling outside of California within the United States, Puerto Rico and U.S. Virgin Islands. (Temporarily traveling is defined as a Subscriber or Dependent(s) who spends in the aggregate not more than 180 days each Calendar Year outside the State of California.) Blue Shield of California calculates the Subscriber’s copayment as a percentage of the Allowable Amount, as defined in this booklet. When Covered Services are received in another state, the Subscriber’s copayment will be based on the local Blue Cross and/or Blue Shield plan’s arrangement with its providers.ee the BlueCard Program section in this booklet.
If you do not see a Participating Provider through the BlueCard Program, you will have to pay for the entire bill for your medical care and submit a claim to the local Blue Cross and/or Blue Shield plan or to Blue Shield of California for payment. Blue Shield of California will notify you of its determination within thirty (30) days after the receipt of the claim. Blue Shield of California will pay you at the Non-Participating Provider benefit level. Remember that your copayment is higher when you see a Non-Participating Provider. You will be responsible for paying the entire difference between the amount paid by Blue Shield of California and the amount billed.
Charges for services which are not covered, and charges by Non-Participating Providers in excess of the amount covered by the plan, are the Subscriber’s responsibility and are not included in copayment calculations.
To receive the maximum benefits of your plan, please follow the procedure below. When you require Covered Services while temporarily traveling outside of California:
1) call BlueCard Access® at 1-800-810-BLUE (2583) to locate physicians and hospitals that participate with the local Blue Cross and/or Blue Shield plan, or go on-line at www.bcbs.com and select the “Find a Doctor or Hospital” tab; and,
2) visit the participating physician or hospital and present your membership card.
The participating physician or hospital will verify your eligibility and coverage information by calling BlueCard Eligibility at 1-800-676-BLUE. Once verified and after services are provided, a claim is submitted electronically and the participating physician or hospital is paid directly. You may be asked to pay for your applicable copayment and plan Deductible at the time you receive the service.
You will receive an Explanation of Benefits, which will show your payment responsibility. You are responsible for the copayment and plan Deductible amounts shown in the Explanation of Benefits. Pre-admission review is required for all inpatient hospital services and notification is required for inpatient emergency services. Prior Authorization is required for selected inpatient and outpatient services, supplies, and durable medical equipment. To receive pre-admission review from Blue Shield of California, the out-of-area provider should call the Customer Service telephone number indicated on the back of the Member’s identification card.
If you need Emergency Services, you should seek immediate care from the nearest medical facility. The Benefits of this plan will be provided for Covered Services received anywhere in the world for the emergency care of an illness or injury.
The Blue Card Program for
International & Domestic Travel
The Blue Card program worldwide 1-800-810-BLUE (2583) gives Blue Cross/Blue Shield PPO members access to doctors and hospitals in participating local Blue plan networks throughout the nation. The program features assistance in locating these participating providers from a roster including more than 70 percent of doctors and 80 percent of hospitals in America. Blue Card extends “Power of Blue” cost savings and the security of access to quality health care, wherever you travel within the U.S. Blue Cross GROUP Sales Brochure Page 12 Blue Shield GROUP – Blue Card Brochure Blue Shield International Claim Form
Read your specific EOC – Don’t trust general information on the Internet. Even OUR prestigious site!
Resources & Links
Blue Shield CA on Blue Card Program for providers
Find a doctor in New York
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?
Members can download claim forms at www.healthnet.com. Claim forms can also be found under the Applications and Forms section on this page.
Blue Cross – Specimen Platinum PPO –
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!
- SBC – Federal Summary of Benefits
- Evidence of Coverage
BLUE (Shield & Cross) CARD PROGRAM
US News & World Report 10.2015 – Coverage while outside USA
Medicare Coverage Outside of USA # 11037
Steve talks about International Travel Insurance
1st – Find the actual Evidence of Coverage for the plan you have or are thinking of getting.
Here’s Blue Shield’s webpage with all the EOC’s and summary of benefits. Here’s our webpage with Benefit Summaries, which IMHO are easier to read than the Federal Summary of Benefits, but neither one will really answer the technical question posed here.
Be sure to use the CURRENT EOC for the plan that you have or are thinking of getting.
If you want the short and quick answer (which might be wrong, as you really should follow the instructions below) click on the link to jump to our Sample EOC for Emergency Services or here for Oscar EPO.
This Blue Shield plan provides limited coverage for health care services received outside of the Plan Service Area. Out-of-Area Covered Health Care Services are restricted to Emergency Services,
Emergency Medical Condition (including a psychiatric emergency) — a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following:
1) placing the Member’s health in serious jeopardy;
2) serious impairment to bodily functions;
3) serious dysfunction of any bodily organ or part. EOC *
Click on link for definition of Emergency Services
Urgent Services, and Out-of-Area Follow-up Care. Any other services will not be covered when processed through an Inter-Plan Arrangement unless prior authorized by Blue Shield. Prior authorization is required for non-emergency services. Please see the Benefits Management Program section for additional information on prior authorization and emergency admission notification.
In an effort to reduce costs, Blue Shield has quietly decided to scale back participation in the national Blue Card program that since 1994 has allowed Blue Shield’s members to receive a range of primary and specialty care services out of state. That could be a big problem for frequent travelers, college students, snowbirds and other people who divide their time between states – and for rural patients who live close to state borders.
The change applies only to members with individual market preferred provider health plans,- not those with group coverage or Medicare. The restrictions appear to be confined to California.
“Consumers are price-sensitive to premiums,” Under the ACA, “there is a more limited set of tools for insurers to lower premiums. They can’t discriminate against people based on their health status.” CA Healthline 12.11.2018 *
Let’s use the Silver PPO Off Exchange for an example. I imagine that all the PPO plans have the same relevant out of area clauses, but you must check yours. Let’s scroll down to the Table of Contents.
Guaranteed Issue - No Pre X Clause
Quote & Subsidy Calculation
Find out your premium with Covered CA
or Direct without Subsidies
Missed Open Enrollment?
See our Special Enrollment page
How to use our FREE Quote Engine, Subsidy Calculator and get the MOST from the experience.
When you get a FREE quote, you can also see the benefits, view actual brochures, MD and Hospital Lists all ONE easy process with no obligation & it can be anonymous. Enter your zip code, date of birth, family - household taxation relationships (MAGI - Definition), Estimated MAGI - Modified Adjusted Gross Income for the upcoming - current year. Last years tax return only gives an idea so that Covered CA can approve your advance tax credit to help pay premiums.
This website and are individual consultation are provided to you FREE of Charge! We are paid by Covered CA and/or the Insurance Companies to help you. When you fill out the Covered CA ONLINE Application, just appoint us as your agent under Find Help in the Upper Right Hand Corner so that we get paid for helping you. Click here for screen shots for more detail of how to do it. If you prefer, you can pay us a consultation fee in lieu of appointing us as your agent, for educational services only.
You can then see all the quotes on the exchange, showing the Cost Share Reduction - Enhanced Silver if available, subsidy - tax credit amount and your net premium. If you click "Off Exchange" you will see more plans and companies which may have larger provider lists. Scroll down for more screen shots.
Then click on "View Plan Details" - "View Doctor's & Providers" - to compare and get more information. Please note that the quote engine does not show enhanced silver, but shows silver at 70%. Check our chart for the better silver coverage.
Learn more about the right to change plans when Silver Level Enhanced Changes
To apply, click on apply now or use the links in the right hand column, ON THIS PAGE, but it will have you redo the quote for that specific company. The price is the SAME, no matter if you use us, go direct to Covered CA or the Insurance Company, as mandated by law! If applying through Covered CA, be sure to sign the form to appoint us as your agent. It's not all the easy to figure out how to do it on their website.
If you have any questions email [email protected] or call us 310.519.1335
Links & References
Medical Info for American’s Traveling Abroad US State Department
Official Web Site for Canadian Health Care
Constitutional right to travel 14th Amendment
Covered CA Certified Agent
No extra charge for complementary assistance
- Appoint us as your broker
- Set Consultation Meeting via Phone, Skype or Zoom
- Instant Health Quotes & Enroll including subsidy calculation
Videos on how great agents are
Enrolling in health plans has helped people focus on their families and careers, and feel protected against unexpected medical issues.
Our webpage on Medicare Coverage outside of USA
- USA Policies – Out of Area Coverage & Worldwide
Providence Health – Difference between ER and Urgent Care
- 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
- USA Policies – Out of Area Coverage & Worldwide
- Blue Cross Provider Lists – Definitions HMO, Tiered – PPO, PPO, EPO
- Blue Shield Provider Finder – Instructions * Exclusive PPO – Trio HMO
- Urgent Care vs ER
- Quotit Provider Finder – All Companies
- Kaiser Provider Search
- Oscar Pharmacy, Doctor & Provider Finder
- Definitions – Glossary