For individuals and families who were mourning the loss of Blue Shield’s BlueCard program, it is back for 2022. Blue Shield of California’s PPO plans off-exchange and through Covered California will include the BlueCard program. Curiously, Blue Shield reinstated the BlueCard benefits just as Anthem Blue Cross expanded their EPO plans in California that also includes the BlueCard feature.
BlueCard Program Back for 2022
The BlueCard program allows members to receive some health care services outside of California. This is an important feature for individuals who routinely spend weeks or months outside of California on business. With the exception of emergency services, if an individual needed small health care service in another state, they were almost forced to buy two health plans; one for California and one for the other state.
Why did Blue Shield discontinue the BlueCard program several years ago for individuals and families? Costs. I’ve heard various accounts involving excessive utilization of BlueCard services coupled with unrelated in-patient drug treatment fraud. The fraud issues have been addressed with additional information centered on California residency and verification of who is actually paying for the health plan. With the expansion of health insurance to more people, the carriers have seen claims become less volatile and more predictable.
Anthem Blue Cross EPO BlueCard
Since the inception of the Affordable Care Act and Covered California, Blue Shield of California has offered health plans throughout the entire state. Anthem Blue Cross serviced most of California until health care claims increased too much, then they jumped ship. Blue Cross kept a small presence in the California individual and family market to placate Covered California. Now that the health insurance market has stabilized, Blue Cross is expanding their EPO plans in California. The EPO plans have the BlueCard program.
Anthem Blue Cross and Blue Shield of California are two separate insurance companies in California. They are affiliated with the larger Blue Cross/Blue Shield family of health plans nationwide. This nationwide association allows them to include the BlueCard benefit in their health plans…if they chose to. The BlueCard program will only be available with the individual and family Blue Shield PPO plans and the Anthem Blue Cross EPO plans.
While most of Northern California will have access to the BlueCard through either of the Blue plans, Los Angeles and Orange Counties will only have the Blue Shield PPO plans. Anthem Blue Cross is only offering their HMO products in those two counties. A quick review of the rates shows that the Blue Cross EPO plans will generally be less than Blue Shield PPO plans. Because of the way the Covered California subsidies are calculated, the difference between the Blue Cross and Blue Shield plans premiums may be very large or very small.
Both plans include text in their Evidence of Coverage that stipulate, excluding emergency services, health care services involving the BlueCard should receive prior authorization or precertification. Below are snippets of the text from each carrier’s Evidence of Coverage for 2022 regarding the BlueCard program.
With the reemergence of the BlueCard with Blue Shield and the expansion of the Blue Cross EPO plans, there will certainly be more people taking advantage of the out-of-state benefit. It is the bane of California health of insurance consumers that most plans offer no coverage outside of California. I have to believe that both Blue Shield and Blue Cross will be carefully monitoring the use of the BlueCard program. It is a benefit they are not mandated to include in their plans, and as we have seen, can be stripped out of the benefit structure.
Blue Shield PPO BlueCard Evidence of Coverage Text
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.
Under the BlueCard® Program, when you receive Out-of-Area Covered Health Care Services within the geographic area served by a Host Blue, Blue Shield will remain responsible for the provisions of this Agreement. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating healthcare providers, including direct payment to the provider.
The BlueCard® Program enables you to obtain Out-of-Area Covered Health Care Services, as defined above, from a health care provider participating with a Host Blue, where available. The participating health care provider will automatically file a claim for the Out-of-Area Covered Health Care Services provided to you, so there are no claim forms for you to fill out. You will be responsible for your Cost Share, if any, as stated in the Summary of Benefits.
When you receive Out-of-Area Covered Health Care Services and the claim is processed through the BlueCard® Program, your Member share of cost for these services, if not a flat dollar Copayment, is calculated based on the lower of:
- The billed charges for your Out-of-Area Covered Health Care Services; or
- The negotiated price that the Host Blue makes available to Blue Shield.
Often, this negotiated price will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price.
Estimated pricing and average pricing, going forward, also take into account adjustments to correct for over- or underestimation of modifications of past pricing as noted above. However, such adjustments will not affect the price Blue Shield uses for your claim because these adjustments will not be applied retroactively to claims already paid.
Anthem Blue Cross EPO BlueCard Evidence of Coverage Text
- Member must get Precertification when required (call Member Services)
- Member may be financially responsible for charges/costs related to the service and/or setting in whole or in part if the service and/or setting is found not to be Medically Necessary.
Under the BlueCard® Program, when You receive Covered Services within the geographic area served by a Host Blue, We will still fulfill Our contractual obligations. But, the Host Blue is responsible for: a) contracting with its Providers; and b) handling its interactions with those Providers.
When You receive Covered Services outside of California and the claim is processed through the BlueCard® Program, the amount You pay is calculated based on the lower of:
- The billed charges for Covered Services or
- The negotiated price that the Host Blue makes available to Us.
Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to the Provider. Sometimes, it is an estimated price that takes into account special arrangements with that Provider. Sometimes, such an arrangement may be an average price, based on a discount that results in expected average savings for services provided by similar types of Providers. Estimated and average pricing arrangements may also involve types of settlements, incentive payments and/or other credits or charges.
Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price We used for Your claim because they will not be applied after a claim has already been paid.