Kevin Knauss: Health, History, Travel, Insurance
Posts related to Blue Shield of California for individuals, families, small groups, Medicare, Medi-Cal, Covered California.
Blue Shield of California, as well as other health plans, would like to break away from the large Pharmacy Benefit Managers and some of their distorted incentive and pricing structures. Unfortunately, the Pharmacy Benefit Managers perform many tasks involving price negation, handling the payments process from pharmacy to health plan, and managing the pharmacy network.
The virtual PCP can refer to an in-person specialist. The goal for Blue Shield’s virtual PCP implementation is to reduce wait times to see a physician and reduce costs to the plan and member. Behavioral health will also be a part of the Accolade Care virtual system as well as a health coach. PPO plan members will also be able to select an Accolade Care virtual PCP.
The Stanford Health Care hospitals and facilities contract with Blue Shield ended on June 28, 2024. Despite many months of good faith negotiations with Stanford Health, we have not been able to reach a reasonable agreement on reimbursement rates and contractual terms that are beneficial for both parties and keep care sustainably affordable for our members.
Had you been near this family’s home, it would have sounded like an explosion as the Blue Shield member vented to me about the incompetent billing system of Blue Shield.
In March of 2021, Blue Shield approved the plan member to receive gender dysphoria health care services from an out-of-network provider. Unfortunately, Blue Shield, according to the press release, inappropriately adjusted several of claims submitted by the health care professional. The payment dispute led to the health care professional suspending continued treatment until the claims dispute was resolved.
Blue Shield PPO members can schedule a visit by calling the Blue Shield Nurse Hotline or contacting Dispatchealth directly via website or telephone. Blue Shield HMO members must call their Primary Care Physician for a referral for an in-home visit to treat a medical condition. In-home visits are grouped into 5-hour windows corresponding to morning, afternoon or evening. Appointments can be as early as 7 AM or as late as 10 PM, sometimes on the same day as the request. Care is available in English and Spanish.
Where households realize a dramatic increase in Blue Shield PPO Covered California premiums is when the SLCSP has a small increase or negative rate change. Consumers in regions 2, 3, 4, 6, 7, 15, 16 and 18, where the SLCSP rate increases were in the low single digits will see a smaller subsidy. In other words, the Blue Shield PPO plan rate increases in those areas was greater than the SLCSP that the subsidy is based upon. The subsidy did not keep pace with the Blue Shield PPO rate increase like they did in regions 1 and 10.
While prior authorization is not required, Blue Shield of California members should become familiar with all of the conditions of the program for proper reimbursement. The abortion services must be provided by a licensed practitioner in a state other than the member’s residence where pregnancy termination can be lawfully provided.
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.
Many people want predictable copayments for routine services and are willing to accept a large deductible and maximum out-of-pocket amount for the rare and unexpected hospitalization. Blue Shield of California has come pretty close to designing such a plan with their 2022 Bronze 7500 HMO individual and family plan. Services with a set copayment and not subject to the medical deductible are:
