If I go out of State – California  or the USA – Country –
What does Blue Shield pay for Emergencies?  Urgent Care?  Regular Doctor Visits?  Colds?

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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.  B

Blue Shield for 2019 (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, 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.  ​

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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.

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 Cente 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 Cente”

17 comments on “Blue Shield PPO Out of State & Country

  1. 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?

  2. How does one get medical coverage for travel out of state and out of country? Do you sell annual medical travel insurance plans?

        • 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

  3. 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.

  4. 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.

  5. 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???

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