A popular benefit of the Blue Shield individual and family plans in California had been the benefits provided by the BlueCard program. For 2019 Blue Shield will trim the benefits apparently making it harder for members to get in-network care out of California in 2019.
BlueCard Benefits Trim
Under the BlueCard program Blue Shield members could seek health care services from doctors and providers in other states. As long as the provider participated in the BlueCard program the member would be billed at in-network cost-sharing levels for the respective plan the member had. From the 2018 Evidence of Coverage (EOC) for the Silver 70 PPO plans,
The BlueCard Program enables you to obtain Covered Services outside of California, as defined, from a healthcare provider participating with a Host Plan, where available. The participating healthcare provider will automatically file a claim for the Covered Services provided to you, so there are no claim forms for you to fill out. You will be responsible for the member copayment and deductible amounts, if any, as stated in this Evidence of Coverage.
The above text for the BlueCard program is essentially the same for the 2019 EOC except there is now an Out-of-Area Services section that precedes the BlueCard Program explanation. Under the Out-of-Area Services section the 2019 EOC states,
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.
This update to the Blue Shield individual and family plans for 2019 eliminates the possibility of receiving services from a specialist in another state unless it is under an emergency or urgent care situation, such as when the member is traveling on vacation. The BlueCard program was a big benefit for people who wanted to see a specific doctor in another state for the diagnosis and treatment of an illness. Blue Shield has essentially closed that benefit for 2019.
Blue Shield Alert To Existing Members
Blue Shield has attempted to alert current members of this change to the benefits of the BlueCard program in an email.
Changes to the BlueCard Program for PPO plans purchased 1/1/2014 and after
The BlueCard® Program enables Blue Shield of California members to access limited care while outside of California, such as when traveling or on vacation.
To control costs, starting January 1, 2019, for our non-grandfathered PPO plans*, Blue Shield will only cover out-of-area healthcare services received for emergency care, urgent care, and any follow-up care resulting from an initial emergency or urgent care visit. Any other services received outside California will no longer be covered unless you receive prior authorization from Blue Shield.
https://www.blueshieldca.com/renewalcenter > News You Need To Know For 2019
The limitations to the BlueCard program for 2019 on PPO plans means the out-of-area health care services are no different than Blue Shield’s Trio HMO plan for individuals and families. Unless the health care services are for emergency or urgent care they won’t be covered unless the member has prior authorization from Blue Shield of California.
Both Blue Shield of California PPO and HMO individual and family plan members will still have access to the BlueCard Program of 2019. How useful this benefit will be depends on how the member expected to use it. It is doubtful that Blue Shield will authorize health care services for an out-of-state provider for a member to get treatment for an illness if there are plenty doctors available in the members home region. However, if you do desperately want to see an out-of-state doctor, and that doctor is in the BlueCard network, you can always request prior authorization for the appointment or treatment.