If I go out of State – California or the USA – Country
What does Blue Shield pay for Emergencies?
Urgent Care?
Regular Doctor Visits?
Colds?
Care for Covered Urgent Care and Emergency Services
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 *
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.
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.
Blue Shield Flyer
Urgent Care preferred to ER Emergency Room
Additional Reading
*”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?
Travel Guides
Members can download claim forms at www.healthnet.com. Claim forms can also be found under the Applications and Forms section on this page.
PPO Travel Guide – English (PDF) Health Net
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
Kaiser – KP.org Travel Care away from home * 951-268-3900 *
Provider Finder for all our companies
BLUE (Shield & Cross) CARD PROGRAM
US News & World Report 10.2015 – Coverage while outside USA
Free Quotes, Brochures and complete information on travel coverage and International Medical Plans
Medicare Coverage Outside of USA # 11037
$50k Emergency Coverage in Supplemental & Advantage Plans
Steve Shorr
Website Introduction Video
Instant Health Quotes & Enroll
15 Reasons to appoint us as your broker – No extra charge
Our Webpage on Insurance Coverage for
COVID 19
To get an #authoritative answer to most any question on Insurance Coverage
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.
Blue Shield for 2019 & beyond (Silver PPO EOC page 19) will only have Urgent & emergency coverage out of state!
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,
Definitions
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.
Alternatives for Blue Card Changes
for Blue Shield INDIVIDUAL Plans
Unauthorized Excerpt of Confidential Agent Guide
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
No charge for our complementary services
Detailed Video Instructions on using our Quote Engine
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.
If you qualify for tax credits - subsidies and want them in advance (Pros-Cons) of filing your taxes click on "Health On Exchange" - Covered CA, illustrated below.
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
Blue Shield Silver 70 PPO Off Exchange Evidence of Coverage EOC
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.
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
6 comments on “Blue Card Program”
With the 2020 Blue Shield 1950 PPO plan, is there a blue card coverage while travelling in Canada.
If so, is there the payment more limited than in network emergency service?
Is travel insurance advisable in addition to Blue card coverage?
We have a web page just for Blue Shield’s decision to restrict out of state coverage to urgent care & emergency coverage – see that page and if you have further questions, ask there.
Evidence of Coverage for Silver 1950 PPO Plan See page 27 for out of area coverage
Check out Teledoc Services https://member.teladoc.com/bsc
How about appointing us as your agent so that we can get paid for helping you? Does your current agent do this kind of research for you?
Here’s the form, no extra charge for our services. Blue Shield pays us.
Click here for travel quotes
I have a small employer Blue Cross HMO group health plan, in CA. My child will be going to school in New York.
Will she be covered under our plan?
If not, what do we do?
I’m double checking on the definition of service area. If that means Blue Cross of CA or if that includes anywhere BC/BS has a list of MD’s. See our page on residency.
Normally for visits and travel, it’s not a problem.
Here’s the reply from Blue Cross Broker Support:
Because you are on a Select HMO plan, coverage out of the state of CA is limited to emergency services only.
If you were on a PPO plan, she would be subject to in network doctors in NY through the “blue card” program regardless if the services are for emergency or not.
Unfortunately, her going to school isn’t a qualifying event to change your plan to a PPO.
I have attached a flyer for more information on the “Anthem Guest Membership Program“, for further information you can call 800-827-6422. Please note, that in very tiny print on the flyer it does indicate that applicants can still be declined if a region within a guest states does not have providers.
New York is on the list.
This link will allow you to search based on the 3 letter Alpha Pre-Fix that is on the member’s card. Or you can just select the BlueCard PPO/EPO network option under browse plans.
the blue card network does not apply to HMO’s.
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 https://individuals.healthreformquotes.com/provider-finder/narrow-lists/
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 https://steveshorr.com/steveshorr/individual_and_family/blue_cross/2021/2021-Product-Guide-OFF_HIX_CA_KIT_2021.pdf#page=6
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
http://www.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/
See our page on the Blue Card Program to find a provider out of country.
The travel policy with secondary coverage will pay what your primary Blue Shield doesn’t. Did you see this page on the travel site, which explains it?
Basically, it says secondary coverage will pay, after they review the bill and the explanation of benefits from Blue Shield and pick up the patient responsibility – co pays, co-insurance, etc.
Get quotes here https://steve.brokersnexus.com/
When you talk of secondary coverage, are you talking about 3rd party liability, if you hurt someone else?
When I checked with Broker Services, they suggested that you get a trip policy, not multi trip. If you find a secondary clause in those, please send me the exact URL internet address.
Please note that ACA Obamacare requires you have coverage, even if there is no mandate penalty. These policies don’t comply with ACA and they can’t sell them as a substitute.
VIDEO – Patriot International https://youtu.be/LnwH7azEnx0
Thank you for the comprehensive reply and links to info for more info. Your site is truly a one-stop shop!
How does one get medical coverage for travel out of state and out of country? Do you sell annual medical travel insurance plans?
Yes, click this link for our travel website. This is mainly for foreign travel. I’m checking on USA travel. USA citizens are still mandated to have minimum essential coverage, even if there is no monetary penalty for 2019.
What is the purpose of your travel outside of California, but in the USA? Vacation, business, specialized medical treatment like Mayo Clinic?
Information on Travel & Trip coverage, which you should qualify for – for travel out of CA but within USA
The purpose of travel in the USA, outside of California (and therefore Blue Shield Of California’s coverage network) is to care for sick parents or vacation – not to seek medical coverage out of state.
You’re not leaving Blue Shield’s network, there is the Blue Card Program. See link above. The issue is, if you want to get treated for something, it has to be “Urgent” or an “Emergency.”
Urgent Services — those Covered Services rendered outside of the Plan Service Area (other than Emergency Services) which are Medically Necessary to prevent serious deterioration of a Member’s health resulting from unforeseen illness, injury, or complications of an existing medical condition, for which treatment cannot reasonably be delayed until the Member returns to the Plan Service Area.
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.
Emergency Services — the following services provided for an Emergency Medical Condition:
1) A medical screening examination that is within the capability of the emergency department of a hospital, including ancillary services
routinely available to the emergency department to evaluate the Emergency Medical Condition; and
2) Such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available
at the hospital, to stabilize the Member.
Copied from EOC
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???
This new restriction is only if you are out of state.
Apparently too many adults were getting elective procedures done out of state.
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. https://youtu.be/rBia7wbnaz4