Blue Shield Medicare Advantage Plan
65 Plus (HMO), Inspire, Trio & Choice
Blue Shield has Medicare HMOs with a Medicare Advantage-Prescription Drug Plan MAPD contract. MAPD plans cover the same basic benefits as Original Medicare plus Part D prescription drug coverage.
See actual summary of benefits below and evidence of coverage to make sure everything is up to date for 2022.
#Understanding Medicare Advantage Plans (PDF) #12026
Insurance Companies get a fee from the Federal Government, when you enroll in an MAPD plan.
That's why the premium is very low or ZERO!
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Blue Shield Provider #Finder -
Dentists, Doctors & Hospitals
VIDEOS
- Finding or changing MD with Trio Plan VIDEO
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- How to use the Finding a provider tool above VIDEO
- Understanding Your Plan pdf
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- Use your online account to review claims, copays or deductibles and take advantage of other member benefits.
- Explanatory VIDEOS on everything... from Blue Shield
- Medicare Advantage Provider Print Directories BROKER ONLY
- Late Bloomers – Medicare – VIDEO
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Blue Shield Videos On Medicare
“Medicare Enlightenment” video series out now!
- Medicare Enlightenment – Entire Video 18 minutes
- Different Parts of Medicare
- Original Medicare Parts A& B: What’s Not Covered
- When can I enroll in Medicare
- Your Medicare Coverage Choices at a Glance
- Medicare Advantage Plans – Part C
- Medicare Supplement Plans
- Prescription Drug Plans
- Our Blue Shield Web Pages on Medicare
- Blue Shield 65 Plus – Inspire HMO 2021
- Blue Shield – Medi-Gap – Any Medicare Provider
2022
2022 Blue Shield Inspire (HMO) – Los Angeles and Orange counties, English
2022 Blue Shield Inspire (HMO) – Alameda and San Mateo counties, English
2022 Blue Shield Inspire (PPO) – Alameda County, English
2022 Blue Shield Inspire (HMO) – Fresno and Madera counties, English
2022 Blue Shield Inspire (HMO) – Sacramento County, English
2022 Blue Shield Inspire (HMO) – Santa Clara County, English
2022 Blue Shield Inspire (HMO) – San Joaquin, Stanislaus and Merced counties, English
2022 Blue Shield Vital (HMO) – Los Angeles, Orange, Riverside and San Bernardino counties, English
2022 Blue Shield 65 Plus (HMO) – Los Angeles and Orange counties, English
2022 Blue Shield 65 Plus (HMO) – San Bernardino County, English
2022 Blue Shield 65 Plus (HMO) – Riverside County, English
2022 Blue Shield 65 Plus Plan 2 (HMO) – Los Angeles and Orange counties, English
2022 Blue Shield 65 Plus Choice Plan (HMO) – Riverside and San Bernardino counties, English
2022 Blue Shield 65 Plus (HMO) – San Diego County, English
2022 Blue Shield 65 Plus (HMO) – Ventura County, English
2022 Blue Shield 65 Plus (HMO) – Kern County, English
2022 Blue Shield 65 Plus (HMO) – San Luis Obispo and Santa Barbara counties, English
2022 Blue Shield Balance (HMO) – Los Angeles County, English
2022 Blue Shield AdvantageOptimum Plan (HMO) – Los Angeles and Orange counties, English
2022 Blue Shield AdvantageOptimum Plan 1 (HMO) – San Diego County, English
2022 Blue Shield AdvantageOptimum Plan (HMO) – Fresno County, English
2022 Blue Shield AdvantageOptimum Plan (HMO) – Merced and Santa Clara Counties, English
2022 Blue Shield AdvantageOptimum Plan (HMO) – Stanislaus County, English
2022 Blue Shield AdvantageOptimum Plan (HMO) – San Joaquin County, English
2022 Blue Shield AdvantageOptimum Plan 2 (HMO) – San Diego County, English
2022 Blue Shield TotalDual Plan (HMO D-SNP) – Los Angeles, Orange, San Bernardino & San Diego counties, English
2022 Blue Shield Inspire (HMO D-SNP) – Fresno, Merced, San Joaquin & Stanislaus counties, English
2022 Blue Shield CoordinatedChoice Plan (HMO) – Los Angeles, Orange, San Bernardino, Riverside, San Diego, Fresno, Santa Clara, Merced, San Joaquin & Stanislaus counties, English
Summary of Benefits SOB
for Blue Shield Medicare Advantage Plans
- 2021 Blue Shield Inspire (HMO) Los Angeles and Orange Counties (PDF, 619KB)
- Inspire Highlights 2021 LA & Orange
- 2021 Blue Shield Inspire (HMO) Alameda County (PDF, 311KB)
- 2021 Blue Shield Inspire (PPO) Alameda County (PDF, 765KB)
- 2021 Blue Shield Inspire (HMO) San Mateo County (PDF, 321KB)
- 2021 Blue Shield Inspire (HMO) Fresno and Madera Counties (PDF, 297KB)
- 2021 Blue Shield Inspire (HMO) Sacramento County (PDF, 304KB)
- 2021 Blue Shield Inspire (HMO) Santa Clara County (PDF, 303KB)
- 2021 Blue Shield Inspire (HMO) San Joaquin, Stanislaus & Merced counties (PDF, 565KB)
- 2021 Blue Shield Vital (HMO) Los Angeles and Orange counties (PDF, 320KB)
- 2021 Blue Shield Vital (HMO) Riverside and San Bernardino counties (PDF, 586KB)
- 2021 Blue Shield 65 Plus (HMO) Los Angeles and Orange counties (PDF, 387KB)
- 2021 Blue Shield 65 Plus (HMO) San Bernardino County (PDF, 351KB)
- 2021 Blue Shield 65 Plus (HMO) Riverside County (PDF, 599KB)
- 2021 Blue Shield 65 Plus Plan 2 (HMO) Los Angeles and Orange counties (PDF, 389KB)
- 2021 Blue Shield 65 Plus Choice Plan (HMO) Riverside and San Bernardino counties (PDF, 648KB)
- 2021 Blue Shield 65 Plus (HMO) San Diego County (PDF, 406KB)
- 2021 Blue Shield 65 Plus (HMO) Ventura County (PDF, 466KB)
- 2021 Blue Shield 65 Plus (HMO) Kern County (PDF, 394KB)
- 2021 Blue Shield 65 Plus (HMO) San Luis Obispo and Santa Barbara counties (PDF, 295KB)
- 2021 Blue Shield AdvantageOptimum Plan (HMO) Los Angeles & Orange counties (PDF, 256KB)
- 2021 Blue Shield AdvantageOptimum Plan 1 (HMO) San Diego County (PDF, 258KB)
- 2021 Blue Shield AdvantageOptimum Plan (HMO) Santa Clara County (PDF, 256KB)
- 2021 Blue Shield AdvantageOptimum Plan (HMO) Fresno County (PDF, 252KB)
- 2021 Blue Shield AdvantageOptimum Plan (HMO) Merced County (PDF, 442KB)
- 2021 Blue Shield AdvantageOptimum Plan (HMO) Stanislaus County (PDF, 252KB)
- 2021 Blue Shield AdvantageOptimum Plan (HMO) San Joaquin County (PDF, 464KB)
- 2021 Blue Shield AdvantageOptimum Plan 2 (HMO) San Diego County (PDF, 259KB)
- 2021 Blue Shield TotalDual Plan (HMO D-SNP) Los Angeles, Orange, San Bernardino & San Diego counties (PDF, 423KB)
- 2021 Blue Shield Inspire (HMO D-SNP) Fresno, San Joaquin & Stanislaus counties (PDF, 254KB)
- 2021 Blue Shield Coordinated Choice Plan (HMO) Los Angeles, Orange, San Bernardino, Riverside, San Diego, Fresno, Santa Clara, Merced, San Joaquin & Stanislaus counties (PDF, 244KB)
Rather than posting the Summary of Benefits, we are posting the Full Evidence of Coverage, which includes that information. If you would like the SOB Email us
Permission to have a Zoom, Phone or Skype Meeting – Scope of Appointment – English
Blue Shield Medicare
Resources & Links
Member Services 800.766.4466
Medicare Advantage Prescription Drug (MA-PD) Plan Customer Care: (800) 776-4466 (TTY: 711), 8 a.m. to 8 p.m., seven days a week, year-round -Effective 10/01/2021
Blue Shield Balance: (888) 802-4423 (TTY: 711), 8 a.m. to 8 p.m., seven days a week, year round
Individual Medicare Prescription Drug Plan (PDP): 888) 239-6469 (TTY: 711), 8 a.m. to 8 p.m., seven days a week, year round
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Blue Shield of California is an HMO and PDP plan with a Medicare contract. Enrollment in Blue Shield of California depends on contract renewal.
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2022
Blue Shield 65 Plus (HMO), Blue Shield 65 Plus Plan 2 (HMO), Blue Shield 65 Plus Choice Plan (HMO), Blue Shield AdvantageOptimum Plan (HMO), Blue Shield AdvantageOptimum Plan 1 (HMO), Blue Shield AdvantageOptimum Plan 2 (HMO), Blue Shield Inspire (HMO), Blue Shield Inspire (PPO), and Blue Shield Vital (HMO)
Blue Shield Balance (HMO)
Blue Shield Coordinated Choice Plan (HMO), Blue Shield Inspire (HMO D-SNP), and Blue Shield TotalDual Plan (HMO D-SNP)
<<<<<<<<<<<<<<<HISTORICAL>>>>>>>>>>>>>>>>>>>>>>>>>>
2021
2021 Pharmacy List
<<<<<<<<<<<<<<<HISTORICAL>>>>>>>>>>>>>>>>>>
Blue Shield 65 Plus (HMO), Blue Shield 65 Plus Plan 2 (HMO), Blue Shield 65 Plus Choice Plan (HMO), Blue Shield AdvantageOptimum Plan (HMO), Blue Shield AdvantagOptimum Plan 1 (HMO), Blue Shield Advantage Optimum Plan 2 (HMO), Blue Shield Inspire (HMO), Blue Shield Inspire (PPO), and Blue Shield Vital (HMO)
Blue Shield Coordinated Choice Plan (HMO), Blue Shield Inspire (HMO D-SNP), and Blue Shield TotalDual Plan (HMO D-SNP)
*Available only in certain ZIP codes. See the Evidence of Coverage or Summary of Benefits for details.
Blue Shield has a program that helps members with certain chronic conditions better manage their drug therapy. Learn more about the program
Learn more about appeals and grievances
Find prior authorization request forms
Learn about exceptions if you find our plan does not cover your medication and how you can ask us to make an exception to our coverage rules. Learn more about coverage determinations
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Pharmacy Directory
2019 Blue Shield 65 Plus HMO and Blue Shield 65 Plus Choice Plan HMO
#Dental?
Blue Shield offers two optional supplemental dental plans to Blue Shield of California Medicare Advantage Prescription Drug plan members. Members can choose between an
Optional
These plans offer a wide range of dental benefits, including many diagnostic and preventive services at no charge to you.
Be Sure to email your completed application to us [email protected] so that we are coded as your broker. No extra charge.
See the EOC’s Evidences of Coverage for details & pricing
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Related & Child Blue Shield MAPD Pages
11 comments on “Provider Directories, Search Tools & Instructions”
HI Steve:
Why can’t I find my specialist doctors listed when I search Blue Shield 65 plus site?
I do find primary care doctors at UCLA Health in Santa Clarita but not my specialists Donin (Urology) and Smith (Pulmonology) who I see at the UCLA Health Santa Clarita Primary and Specialty Care clinic.
I see them as a traditional Medicare patient, which I switched to from Blue Shield 65 plus because at the time UCLA would not accept Blue Shield 65 plus.
I understand from your video that now they do.
My concern is whether the primary care physician is going to direct me to see some other doctor at that clinic who also practices the same specialty but not the doctors I have been seeing because I am a ” UCLA Medicare Advantage” patient instead of a traditional medicare patient.
What is your view about this?
Thanks so much for your help, Steve.
Neil R
Please when stating facts, provide the screen shots, exact URL’s, etc. It takes us time to duplicate what you are referring to.
I’m surprised that you can search for 2021 MD’s, as it’s my understanding that 2021 information can’t be released to the public until October 1st. https://medicare.healthreformquotes.com/mapd/regulations/
It often seems that Medicare Advantage rules are there, just so that agents can go to jail at the Federal Governments whim.
We do see Blue Shield 65 Plus, Vital & Inspire on UCLA’s list of accepted Health Plans, but don’t know if that’s for 2021.
Which facility are you using?
When using Blue Shield Provider Finder
https://www.blueshieldca.com/fad/home
you can set the filter to which MD’s accept Blue Shield
Working “backwards” UCLA shows Dr. Donin MD as accepting Blue Shield. Give me a couple of days to see why he doesn’t show on Blue Shield’s provider finder.
He does show in their print directory on page 640
https://www.uclahealth.org/nicholas-donin
Is it Malcolm Smith you’re going to?
https://www.uclahealth.org/malcolm-smith
He’s on page 632 of the pdf directory
Reply from Blue Shield broker support
I can confirm Dr. Nicholas Donin is constructed with 65 plus / Inspire under UCLA Medicare Advantage ( Medical Group).
Practioner id showing contracted with UCLA Medicare Advantage & 65 Plus/Inspire : 100323139008.
If your member’s Primary Care physician is attached to UCLA Medicare Advantage then the member can request this Urologist.
If its not, I would recommend speaking with your member as for HMO Policies, most procedures and specialists need to be authorized by medical group and they always refer out from their own doctors.
See page 42 of EOC for more details on getting referred to specialists.
2nd reply from Blue Shield broker services:
[we will] request for the Find a Provider page to be updated.
Thanks for the information.
After spending a lot of time talking to UCLA and Blue Shield, I decided that if I wanted someone else to manage my care and didn’t care about how they did or didn’t do that, I should go back to the Medicare Advantage plan I was on for 4 years before I switched to original Medicare! [Parts A Hospital & B Doctor Visits]
Thanks for your help.
I have no changes planned for my supplement (F extra) so it will automatically renew
Did you see our video and pdf # 12026 on Understanding Advantage Plans on our Blue Shield Advantage Plan Page?
The Introduction to Medi Gap Publication # 02110on our Blue Shield Medi Gap Page?
IMHO those video’s and official Government brochures explain how Medicare Advantage tries to save $$$ by “managing” your care.
We are authorized Blue Shield Medi Gap brokers and can assist you with anything that comes up. When you appoint us as your Broker, Blue Shield compensates us at no additional charge to you, as it saves them time on the phone with you not having to call them. Here’s the form to appoint us. How much time did we spend helping you?
We can get you enrolled in Blue Shield Medicare Advantage starting on October 15th for a January 1st effective date.
Informational Materials will be released to the public on October 1st. If an agent is able to see anything before that time, it’s more secret that anything else I know of.
Check our Blue Shield MAPD webpage for 2021 information and enrollment then. There is no extra charge for our services. The Federal Government provides for agent compensation from the fees they pay the Insurance Companies to take care of you.
Medicare Advantage plans must cover Medicare A & B https://www.medicare.gov/what-medicare-covers/what-medicare-health-plans-cover/medicare-advantage-plans-cover-all-medicare-services
Steve,
you have mentioned to me in my san mateo county, part c will be available to me with out any premium
How about other neighboring counties like santa clara, alameda etc in bay area.
How can I verify the same?
I am thinking of moving to low cost counties.
See our information and enrollment link above for Blue Shield
Blue Cross
Email us [email protected] for United Health Care, they don’t really let agents post anything.
Watch the video we just made to guide you through the process. Blue Cross navigation would be very similar.
tier one medication for ucla medical inspire hmo
if there a charge for 90 days mail orders for my medicine
zolpidem 5mg ,
trazodone 50mg and
lisinopril 2.5 mg ?
what pharmacy will process orders?
See the Blue Shield provider finder above to find participating pharmacies https://medicare.healthreformquotes.com/mapd/65-plus/#comment-25680
Here’s a print pdf list of pharmacies
You can also use Medicare’s tool to check Rx co pays https://medicare.healthreformquotes.com/part-d-rx/donut-hole/shop-compare-tools/
Blue Shield’s tool is in their enrollment portal https://medicare.healthreformquotes.com/mapd/65-plus/#enroll
We’ll do more research, later in the day.
What is your Zip Code???
We can be your broker, no extra charge, if you use the enrollment link above or sign this form https://steveshorr.com/steveshorr/individual_and_family/blue.shield/Off%20Exchange%20IFP%20%26%20Med%20Supp%20POR%20Change%20Request%20Form.pdf
I’ve heard that Blue Shield has PPO here in Santa Barbara can you send me the link or info for these?
I never liked HMO.
Please, we are not allow to go by hearsay – that is what someone told you. We only go by what is in writing.
We’ve listed all of Blue Shield’s California Plans above. You can also go to Blue Shield’s website logo above, search & double check.
Blue Shield Medi Gap Plans are PPO or even better as you can use ANY Medicare Provider! Blue Shield is having a UNDERWRITING HOLIDAY, so you can enroll now, without doing Health Questions https://medicare.healthreformquotes.com/medi-gap/blue-shield/#comment-25630 Use the logo above to get quotes or use the rate sheet above.
We are NOT aware of any PPO MAPD plans in Santa Barbara. We even checked with Medicare.Gov https://medicare.healthreformquotes.com/part-d-rx/donut-hole/shop-compare-tools/
We’ve answered similar questions at
Blue Shield’s HMO MAPD rate is zero vs UHC of $89/month – See above for Blue Shield details. UHC doesn’t allow agents to post anything meaningful. We can email you their information by request.
https://medicare.healthreformquotes.com/mapd/uhc/#comment-25661
If you would like to review the pros & cons in more detail, please set a Zoom meeting https://steveshorr.com/intro/set-a-meeting/ and sign & return a scope of appointment – permission slip https://steveshorr.com/steveshorr/medi_gap_medicare_advantage/aarp/2019/Scope%20of%20Appointment%20-%20pdf%20fillable%20Generic%20Form.pdf
See our You Tube video explaining all this https://youtu.be/720-ovAfQF0
Video Links to follow along
Detailed answer to inquiry about Medicare Advantage PPO availability in Santa Barbara County.
PPO Blue Shield?
https://medicare.healthreformquotes.com/mapd/65-plus/#comment-25674
Better plan than UHC AARP?
https://medicare.healthreformquotes.com/mapd/uhc/#comment-25661
Blue Shield Medi Gap Underwriting Holiday
https://medicare.healthreformquotes.com/medi-gap/blue-shield/#comment-25630
Blue Shield Medi Gap Plans
https://medicare.healthreformquotes.com/medi-gap/blue-shield/
Plans at a glance
https://steveshorr.com/steveshorr/medi_gap_medicare_advantage/blue.shield/2021/2021%20Blue%20Shield%20Medicare%20Supplement%20-%20Health%20Plans%20at%20a%20Glance.pdf
Summary of benefits Medi Gap
https://contentserver.destinationrx.com/ContentServer/DRxProductContent/Medigap_PDFs/128_0/2021_Medicare%20Supplement_Summary%20of%20Benefits_EN%20v2.pdf#page=17
Medi Gap Rate Sheet
https://www.blueshieldca.com/bsca/bsc/public/broker/PortalComponents/StreamDocumentServlet?fileName=2021_MedicareSupplement_OpenPlanRateSheets_EN.pdf#page=4
Blue Shield MAPD California
https://medicare.healthreformquotes.com/mapd/65-plus/
Blue Shield Print Directories
https://medicare.healthreformquotes.com/mapd/65-plus/provider-directories/
Blue Cross PPO Orange County
https://medicare.healthreformquotes.com/mapd/anthem-mediblue-plus/
Blue Cross Evidence of Coverage
https://file.anthem.com/MED2021/Y0114_21_123039_U_C_0315.pdf
Blue Cross Summary of Benefits
https://steveshorr.com/steveshorr/medi_gap_medicare_advantage/Anthem/MAPD/2021/Y0114_21_123777_U_M_0065_H8552_020-000_CA_LPPO.pdf
Set a Zoom meeting
https://steveshorr.com/intro/set-a-meeting/
UCLA accepted plans
https://www.blueshieldca.com/bsca/bsc/public/broker/PortalComponents/StreamDocumentServlet?fileName=2021_MedicareSupplement_OpenPlanRateSheets_EN.pdf#page=4
How to use Medicare Shop & Compare tools – Don’t buy there – come back to us to enroll
https://medicare.healthreformquotes.com/part-d-rx/donut-hole/shop-compare-tools/
Costs to provide health services
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NHE-Fact-Sheet
Online Seminar
https://medicare.healthreformquotes.com/seminar/
FAQ’s from prior webpage
I Just got off the phone with the Social Security Dept. as I needed clarification on some of the questions asked in the online application for Medicare.
This woman “Tracy” states that I am not eligible as I don’t have enough credits and won’t be eligible until Bruce turns 62 this coming October, then apply under him as he does have the credits.
She told me that I wouldn’t be able to apply until open enrollment, Jan-March 2017.
This seems odd to me but need your take on this.
Thanks,
Jackie
A yearly dental cleaning and exam is included. How do I get the list of in network dentists in Riverside County, CA?
thank youJoan V
Any notions about when the 2021 Medicare Advantage details and provider lists might be available?
Thanks for a very informative website.
Sorry that my PCP doesn’t take the Blue insurance so I could give you some business.
Plan information will be available October 1st and you can enroll or change plans October 15th. CMS.gov
We represent not only Blue Shield, but UHP and Blue Cross. What is your PCP’s name and we can check those provider finders:
https://www.blueshieldca.com/fad/home
https://www.anthem.com/ca/find-doctor/?dplid=sso.dpl.providerdirectory.search-criteria
https://connect.werally.com/county-plan-selection/uhc.mnr/zip
Why do I need blue shield Medicare Advantage with medicare A & B?
It’s a nightmare to see doctors and get the necessary treatment while my friend has only medicare A & B and can go to any doctor
Medicare A Hospital & B Doctor visits, pay a lot, but not everything.
It doesn’t pay for out of hospital Rx Drugs. If you don’t have a Medicare Advantage Plan, you can get Part D Rx separately.
See the video above about your Medicare Choices.
The Inspire Summary of Benefits – shows that you pay NO EXTRA premium for the plan! It also shows, what you pay for various services. What it doesn’t show… is what you would pay, if you didn’t have a plan. See the screen shot’s below. The first is the MAPD inspire plan. The 2nd is a Medi Gap plan, which does have a premium and then you will also need a Part D Rx plan.
Blue Shield Medi Gap Summary of Benefits
Hosptial
Part B
Foreign Travel
Please explain “Nightmare?” Here’s the provider finder
Here’s the procedure to make a complaint in the Evidence of Coverage for Inspire.
So, the choices are,
pay for a separate Part D plan,
premium for a Medi Gap plan that allows you to see ANY Medicare MD and will even pay the part that Medicare doesn’t if your MD charges more – see details in the evidence of coverage or our assignment page.
or pay out of pocket what Medicare doesn’t pay… don’t forget the 80% never ends. There is NO OOP Out of Pocket Maximum
I am signing up for medicare this month and want to know about doctors, in particular, urologists and GI doctors, in the Blue Shield Inspire Network.
My family doc is already in this network.
I live in the Redondo Beach/Torrance, CA 90277 area.
Here’s the Blue Shield Provider Finder
We found 67 doctors with 10 miles for urology and gastroenterology. The list has been emailed to you.
What medical group is your family doctor in. You’ll want the specialist to be in the same group.
See page 40 of the Inspire Evidence of Coverage for how referrals to specialist work in the same network – group.
We have print directories on this page
Here’s how to enroll in Inspire. No extra charge for our website and our help.
Here’s instructions and the link to enroll in Medicare A Hospital and B Doctor Visits
I have Blue Shield 65 Plus (HMO), Santa Barbara County, CA …
is it possible to get PPO?
Blue Shield doesn’t have a Medicare Advantage PPO that I’m aware of.
Blue Cross does, but it’s only in Orange County.
At Open Enrollment you can qualify for a Medi Gap plan if “any” of the benefits change. Blue Shield at all the Broker meetings state they will do this for anyone, on a MAPD plan, but I really like to have something in writing before I say it.
There is also a MA OEP Open Enrollment Period – the name gets confusing as Open Enrollment is now called AEP – Annual Election Period. The dates of this MA OEP is January 1 to March 31. Agents are not allowed to promote this. We can only tell you if you ask, which you did.
Are you in your first year of a Medicare Advantage Plan? There is a one year “test drive” aka trial period.
Please send us your zip code and we can check the Medicare Plan Finder and see if there are any PPO’s that we are not readily familiar with.
What is it that your looking for, that the plan you have isn’t keeping you 100% happy?
Do you have a chronic illness? There may be plans that better fit your needs? SNP Special Needs Plans.
Have you used the Blue Shield provider finder above? Can you find a provider there that will make you happy?
One problem with a MAPD PPO, is that there is still a doctor list and you’ll want to look at the coverage if you go out of network. It’s not that terrific. Also, the premium is $159/month.
If you would like to discuss further, via phone, skype, face time, etc., click here to set a time.
On your Inspire program, what are considered “over-the-counter” items?
Does it include vitamins?
Click here for orders and to view catalog
Yes, Vitamins & Minerals are included
Page 83 of evidence of coverage
Do you have to have a doctors note to buy the vitamins?
No. I don’t find a definition in the EOC, thus let’s go by the FDA’s definition:
Over-the-counter medicine is also known as OTC or nonprescription medicine. All these terms refer to medicine that you can buy without a prescription. They are safe and effective when you follow the directions on the label and as directed by your health care professional.
Just follow the links above to view the catalog and to place your order.
To enroll and have us as your agent, no extra charge, click on the links in the body of the webpage above.
I’m enrolled in BlueShield +65 HMO in San Luis Obispo.
Where can I find the on-line catalog for over-the-counter meds, supplements, etc?
And how do I place an order?
I can’t find any info on-line about the benefit.
Isn’t our website the greatest thing since sliced bread? We’ve already answered your question above. One just has to go through the Q & A.
How about appointing us as your agent, no extra charge whenever you might make a change to your program?
How do I enroll in Inspire or any other Blue Shield MAPD?
Online with our Blue Shield Affliate Link – No extra charge for agent support
Paper Application
Transfer Application if you already have a Blue Shield Plan
We can help you via Phone, Skype or Face to Face
See our scheduling calendar below to set a meeting.
Please explain Blue Shield inspire 2020 to me.
I had Medicare Supplement Blue Shield extra F Plan 2019,
My doctors all in UCLA Medical Group. Next year UCLA accept Blue Shield Inspire HMO.
Shall I change to HMO from Medicare Supplement?
I’m not sure what you mean by explain Inspire 2020 to you? Here’s the Summary of Benefits for Los Angeles & Orange County. Did you have a more specific question?
Here’s the summary of benefits for Plan F Extra Medi Gap – Our webpage on Plan F Extra
Yes, UCLA will accept Inspire in 2020.
The difference between HMO Medicare Advantage and Medicare Supplement is, I’m not sure of the right word, but it’s the main decision to make, once one has Medicare Parts A & B. Here’s our webpage on which way to go.
If you decide to remain on your Medi Gap plan, here’s the form to appoint us as your agent, no extra charge and allows us to get paid for helping you.
Official Medicare Video on understanding your choices
If I want to switch back to the Medi Gap plan in 2021, can I do that?
Let me review Blue Shield Guaranteed Acceptance Guide
https://www.blueshieldca.com/bsca/bsc/public/broker/PortalComponents/StreamDocumentServlet?fileName=MSP17149.pdf and get back to you tomorrow.
These “situations” might allow that
# 17 You enrolled in a Medicare Advantage Plan and that plan either:
• Reduced any of its benefits;
• Increased the amount of cost-sharing or premium; or;
• Discontinued (for other than quality of care) a contract with a provider currently furnishing services to you.
# 9
You terminated enrollment in a Medicare Supplement plan and subsequently enrolled, for the first time, in any of the following:
• A Medicare Advantage Plan
• A Medicare Cost Plan or similar organization operating under demonstration project authority before April 1, 1999;
• A PACE provider; or
• A Medicare Select policy.
You then disenrolled within the first 12 months.
Why do I need blue shield Medicare Advantage with medicare A & B?
It’s a nightmare to see doctors and get the necessary treatment while my friend has only medicare A & B and can go to any doctor
Medicare A Hospital & B Doctor visits, pay a lot, but not everything.
It doesn’t pay for out of hospital Rx Drugs. If you don’t have a Medicare Advantage Plan, you can get Part D Rx separately.
See the video above about your Medicare Choices.
The Inspire Summary of Benefits – shows that you pay NO EXTRA premium for the plan! It also shows, what you pay for various services. What it doesn’t show… is what you would pay, if you didn’t have a plan. See the screen shot’s below. The first is the MAPD inspire plan. The 2nd is a Medi Gap plan, which does have a premium and then you will also need a Part D Rx plan.
Blue Shield Medi Gap Summary of Benefits
Hosptial
Part B
Foreign Travel
Please explain “Nightmare?” Here’s the provider finder
Here’s the procedure to make a complaint in the Evidence of Coverage for Inspire.
So, the choices are,
pay for a separate Part D plan,
premium for a Medi Gap plan that allows you to see ANY Medicare MD and will even pay the part that Medicare doesn’t if your MD charges more – see details in the evidence of coverage or our assignment page.
or pay out of pocket what Medicare doesn’t pay… don’t forget the 80% never ends. There is NO OOP Out of Pocket Maximum
How can I find a list of participating doctors & hospitals?
Scroll up the page and use our Provider Finder
Check this page for pdf print directories
Click on Blue Shield link above to enroll in a plan. No extra charge for our services. Blue Shield pays us to help you enroll.
What do I have to do to see a specialist?
I’ve cut and pasted this from the Evidence of Coverage
Section 2.2 What kinds of medical care can you get without getting approval in advance from your PCP?
You can get the services listed below without getting approval in advance from your PCP.
Routine women’s health care, which includes breast exams, screening mammograms (xrays of the breast), Pap tests, and pelvic exams as long as you get them from a network provider.
Flu shots, Hepatitis B vaccinations, and pneumonia vaccinations as long as you get them from a network provider. Emergency services from network providers or from out-of-network providers.
Urgently needed services from network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible (e.g., when you are temporarily outside of the plan’s service area).
Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area. (If possible, please call Member Services before you leave the service area so we can help arrange for you to have maintenance dialysis while you are away. Phone numbers for Member Services are printed on the back cover of this booklet.)
Section 2.3 How to get care from specialists and other network providers
A specialist is a doctor who provides health care services for a specific disease or part of the body. There are many kinds of specialists. Here are a few examples:
Oncologists care for patients with cancer.
Cardiologists care for patients with heart conditions.
Orthopedists care for patients with certain bone, joint, or muscle conditions.
When your PCP thinks that you need specialized treatment, they will request a referral (approval in advance) to see a plan specialist or certain other providers. For some types of referrals, your PCP may need to get approval in advance from our plan (this is called getting “prior authorization”). For more information about which services require prior authorization, see Chapter 4, Section 2.1 of this booklet.
It is very important to get a referral (approval in advance) from your PCP before you see a plan specialist or certain other providers (there are a few exceptions, including routine women’s health care that we explain later in this section). If you don’t have a referral (approval in advance) before you get services from a specialist, you may have to pay for these services yourself.
If the specialist wants you to come back for more care, check first to be sure that the referral (approval in advance) you got from your PCP for the first visit covers more visits to the specialist.
When you choose your PCP, you are also choosing the hospital and specialty network associated with your PCP.
If there are specific specialists you want to use, find out whether your PCP sends patients to these specialists. Each network PCP has certain plan specialists they use for referrals. This means that the PCP you select may determine the specialists you may see. You may generally change your PCP at any time if you want to see a plan specialist that your current PCP can’t refer you to. Earlier in this chapter, in Section 2.1 under “Changing your PCP”, we tell you how to change your PCP. If there are specific hospitals you want to use, you must first find out whether your PCP uses these hospitals. Note that changing your PCP may result in being limited to specific specialists or hospitals to which that PCP refers (i.e., sub-networks, referral circles).
What if my PCP won’t give me a referral?
See Chapter 9 of EOC about if you have a problem
See our webpage on appeals & grievances
Our webpage on IMR Independent Medical Review
I live in Orange County and have Blue Shield 65 Plus.
I got an outpatient X-ray done at my doctor’s, St Jude Heritage.
On my summary of benefits
https://www.blueshieldca.com/bsca/bsc/public/broker/PortalComponents/StreamDocumentServlet?fileName=2019_MAPD-LAOR-SOB.pdf
it clearly states that I pay nothing.
However, Blue Shield is telling me that because my doctor ordered 2 views it now becomes a “complex X-ray” to quote them and therefore I have to pay a $40 co-pay as if it was a ct scan etc,
What is going on?
Sorry, your question is beyond my pay grade. Here’s the answer, but I don’t understand nor have say 10 hours to review the material to answer the question for you. Somehow you’ve gone over a basic test and into the realm of radiology services.
Medicare Learning Network
Medicare Claims Processing Manual Radiology Services
United Health Care MAPD Manual
https://www.medicare.gov/coverage/x-rays
Image is from the Evidence-of-Coverage above.
Does blue shield 65 plus 2019 cover any chiropractor care as basic medicare does?
We gone into that pretty thoroughly on this page. See exhibits 13 & 14 on that page. If you have further questions, please post in the ask a question section on that page.
Click here to enroll in Blue Shield for 2019. No extra charge for our help.
How do I find a Chiropractor for the Inspire Plan?
call ASH American Specialty Health Network customer service at (800) 678-9133
Verified with Blue Shield reference number 200270024298
My doctor doesn’t take any HMO’s. What else might I look at?
Here’s some thoughts & suggestions:
Medicare Advantage offers Part D Rx at no additional charge
You might just pay cash for the entire MD visit, Medicare wouldn’t pay, as when you have Medicare Advantage, the Insurance Company takes care of everything.
See our webpage on the pros & cons of Medi Gap vs Medicare Advantage and what’s best for each person.
Just get a Part D plan and leave what Medicare doesn’t pay as something you pay out of pocket, like you’re doing now. Note, if you didn’t buy Part D when first eligible, there might be a late enrollment penalty.
Get a Medi Gap plan. Look at High F from Blue Shield, sure it has a deductible, but that doesn’t stop Medicare from paying first. The price is right. Here’s where we explained to another web visitor how to figure out the rate chart. Or, just send an email, with zip code and date of birth and we can send you your specific rate.
If you want to discuss this on the phone, face to face, video conference, etc. see above for our appointment scheduler.
I moved from Orange County to Redlands in San Bernardino County. Since there is a change in residency, I have to change plans and have a special enrollment period to do so.
My question is, can I keep my same MD:
Norman J Rosen M.D. 2501 Chapman Ave, Orange, CA
IMHO the simplest is to call your MD and ask. However, CMS rules require that an agent call the Insurance Company or check the provider directory. ONLINE is best, as the printed directories get outdated quickly.
Here’s the Blue Shield provider directory. It’s also listed above. Here’s more detail and instruction on how to use the Blue Shield provider search.
We do find Dr. Rosen listed, see below. There is a rule somewhere about a doctor having to be within 20 miles. Let me check that.
Here’s a screen shot showing the Dr. Rosen is listed. The Plus plan has more MD’s than the choice plan, so that stands to reason
The rules for picking a provider start on page 40 of the Evidence of Coverage. I don’t see any rule about 20 miles… However, the print edition of the San Bernardino doctor list for 2017 doesn’t show Dr. Rosen. So it may be that he’s not a provider for San Bernardino County. Let me check further.
If you click enrollment links above, we can do the transfer for you and thus get paid for helping you.
Here’s a rule about 30 minutes or 15 miles:
If you really want Dr. Rosen, you do have a guaranteed right to get a Medi Gap plan. We can help you with that.
Can I file an appeal based on continuity of service?
He’s treating an ongoing problem
Review our page on continuity of care SB 133. Double check if it applies to MAPD. Even if it doesn’t specifically, there must be similar legislation for MAPD plans.
Review the appeals procedures in the evidence of coverage.
Review the appeals procedure on our website.
When you appoint us as your broker, no charge, we can help you with this.
If the appeal fails, what if I just go outside of the Insurance and pay cash?
What is my deadline to change plans after a move?
Right, you would have to pay cash, as the Insurance since you have a MAPD plan would not pay anything. Medicare would not pay, as they are paying your MAPD plan to take care of you. You basically trade in your Medicare Card for a MAPD plan. There are certain times that you can get out of an MAPD plan and get regular Medicare. You would also have an enrollment period into a Part D Rx plan.
It’s Sunday. Give me a few days to research. Of course, the best place to look is probably your evidence of coverage page 48 cited above.
Deadline to change plans after a move. Check our residency page and the evidence of coverage Page 8, 181, 244, 246, Service Area definition page 263, special enrollment 263, , .
If you drop the MAPD plan because of the move, you can do that now. You wouldn’t have to wait till MAPD open enrollment. At 2019 open enrollment you could select a new MAPD plan. As we said above, you can get a Medi Gap plan now, to pay what Medicare doesn’t pay. You can also get an Rx plan now, during special enrollment.