Blue Shield of California is the only health insurance carrier that will be offering PPO plans throughout California in 2019. Blue Shield has also expanded the availability of their Trio HMO health insurance plans to many parts of California. Blue Shield’s plans will be offered through Covered California and off-exchange with no tax credit subsidies.
PPO (Preferred Provider Organization) plans offer coverage for health care services provided by non-network providers. However, there is a separate out-of-network deductible and maximum out-of-pocket amount (MOOP). These amounts are different than the in-network member cost-sharing. With most of the Blue Shield PPO plans you will have to spend $5,000 in health care services before the plan covers any of the cost. You don’t really want to go out of network.
PPO Out of Network Deductible and MOOP 2019
Per individual, family amounts are usually twice the individual.
Bronze HDHP: $12,000*/ $20,000
Bronze: $12,600/ $20,000
Silver 70, 73, 87, 94: $5,000/ $20,000
Gold: $5,000/ $20,000
Platinum: $5,000/ $20,000
*Increased from 2018
Blue Shield offers a provider finder tool for network doctors and also a treatment cost estimator for getting an average cost projection for many health care services such as out-patient surgery.
Blue Shield Trio HMO 2019 Plans
The Trio HMO plans from Blue Shield offer no out-of-network coverage. You must select a primary care physician (PCP) if you have a HMO plan. The medical group your PCP is in is very important. Your PCP will refer you to specialists within the medical group network. If you have a specialist doctor, you need to determine which medical group that specialist is in so you can select a PCP from that medical group for a referral.
Another issue to consider, as Blue Shield notes in their 2019 Disclosures document, is that not all hospitals or providers offer services for family planning, contraceptive services, sterilization, tubal ligation, infertility treatments, or abortion. So if any of the health care services maybe on the horizon in 2019, carefully select a plan that has providers and hospitals that will support family planning services.
In most regions of California, Blue Shield’s HMO plans will be less expensive than their PPO plans. But this is not always the case. However, the Blue Shield Trio plan is very competitively priced in many regions and sometimes is less than Kaiser HMO plans.
Covered California vs. Off-Exchange Enrollment
All the member cost-sharing elements are virtually identical between the Blue Shield plans offered through Covered California and off-exchange with a couple of exceptions. The Blue Shield off-exchange Silver 70 plans have an ambulance copayment $5 more than the Silver 70 purchased through Covered California. However, the off-exchange Silver 70 PPO and HMO plans have premium approximately 8% less than through Covered California. If you are not eligible for a tax credit subsidy through Covered California, or very little tax credit, then you need to consider the off-exchange Silver 70. Blue Shield will also offer their Silver 1850 PPO health plan off-exchange only and those rates are lower than the standard Silver 70 plans.
While the Blue Shield standard benefit design off-exchange plans virtually mirror the Covered California plan, the administration can be slightly different. If you purchase a plan through Covered California, all changes (new address, adding family member, termination, etc.) must go through Covered California. Covered California has a modified reinstatement period if the plan is cancelled for nonpayment. Consequently, there are separate Evidence of Coverage documents for Covered California and off-exchange plans that reflect the differences.
Blue Shield individual and family plans also come with Teladoc for phone call consultations, NursesHelp 24/7 online chat, and the BlueCard program that allows member’s access to providers when they are travelling out-of-network. The plans also include a physician home visit. The home visit, Heal on-demand house calls, is subject to the member’s location. There is also Telebehavioral health benefit that helps members with mental or substance abuse challenges access therapy online with mental health professionals.
At the time of this post Blue Shield had not released their 2019 IFP drug formulary. If you take prescription medications you should always check to see if the drug is on the formulary and at what pricing tier for each of the health plans under consideration.
Blue Shield Rates, Documents, Forms