California Based Health Insurance
Emergency and Urgent Care, ONLY? when Traveling?

Introduction
How does my California Coverage work out of Area?

• What coverage is there under a California issued Health Policy, when you need:
  • • Emergency or Urgent Care
      • Medi Cal Emergency Coverage
      •  
    • Out of CA – Not an Emergency or Urgent?  Like if you want to seek out specialists at prestigious world famous clinics and hospitals
      • • Find the EOC Evidence of Coverage for YOUR Insurance Company
        • Blue Shield PPO Table of Contents

      

    •  
    • Out of your HMO Service Area?
      • Blue Shield HMO Table of Contents
      • 
    • Outside of USA?
      • Learn more and enroll in  International Travel Insurance.
      • Medicare outside of USA 
    • Note – Employer Group Plans appear MUCH more liberal!

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} *   Our webpage on Prior Authorization *

Be sure to check the definition in YOUR EOC

Links related to Urgent & Emergency Care Definition

• Urgent Care vs ER
  • Emergency Room – Obligation to treat uninsured patients
  • Emergency Room – Balance Billing
  • Health Net Provider Networks & Search
  • Definitions – Glossary
    • OOP -Out of Pocket Maximum – Participating or Not? Deductibles & Co- Pays
  • Providence Health – Difference between ER and Urgent Care
  • Viewpoints: Insurance Companies Can Drop Patients Whenever; Choosing Between Doctor Vs. Urgent Care  KFF

BlueCard Program for Doctors & Hospitals

& Inter plan Arrangements - 

for members traveling out of state & outside of the united states

Excerpt from Typical EOC Evidence of Coverage   

Out-of-area services

• Blue Shield has a variety of relationships with other Blue Cross and/or Blue Shield licensees. Generally, these relationships are called Inter-Plan Arrangements and they work based on rules and procedures issued by the Blue Cross Blue Shield Association.  Whenever you receive health care services outside of California, the claims for those  services may be processed through one of these Inter-Plan Arrangements described below.
• When you access health care services outside of the Plan Service Area,  you will receive the care from one of two kinds of providers.
  • Most providers are participating providers and contract with the local Blue Cross and/or Blue Shield licensee in that other geographic area (Host Blue). S
  • home providers are non-participating providers because they do not contract with the Host Blue. Blue Shield’s payment practices in both instances are described below and in the Introduction section of this Agreement.
• 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,
  • 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. Please see the Medical Management Programs section for additional information on prior authorization and the Emergency Benefits section for information on emergency admission notification.

• View YOUR actual EOC - It's YOUR EOC Policy that rules, not what you read on the Internet
  • • Here's the  Individual Blue Shield Silver PPO   It's a lot of material, so we won't just copy and paste, nor summarize it.  It's mandated to be in plain English.
  • Please note that Employer Group Plans may have MUCH better coverage than Individual, namely they may cover out of state Non Emergency, Non Urgent.   Here's a Blue Cross Group EOC.
• Co Pays, Deductibles, OOP In vs Out of Network 
  • Hospitals must post pricing and Insurance Companies must post negotiated rates
• Appoint us as your Covered CA broker, no extra charge
• Get Instant California Health Quotes 
  • Instant Foreign Travel Quotes
• Get a Blue Shield Member Portal

• Prior Authorization
  • Medical Necessity
  • Clinically Appropriate Setting