Much to the displeasure of many Californians who frequently travel, most individual and family health plans have dropped any coverage for routine or elective health care services outside of California. This has been particularly irritating for residents who live near the border where the neighboring state has more health care providers. The exceptions to out-of-state coverage are emergency, urgent, and some post stabilization health care services.
The only individual and family health plan that still offers out-of-state coverage is the Anthem Blue Cross EPO plans that offer the Blue Card program. The Blue Cross EPO plans are only offered in certain Northern California counties and Santa Clara County. With the Blue Card program, a member can receive health care services, such as an office visit with a doctor, and pay an amount similar to their plan benefits. If you are a Blue Cross EPO member, contact member services to ensure they are still offering this benefit.
Emergency Care Outside of California
Unbeknownst to many people, most California health plans cover emergency care anywhere in the United States and treat it as if it were in-network. This means that if you have a Silver 70 plan and are rushed to the emergency room of the nearest hospital while on vacation in upstate New York, your copayment will be $400 just as if the emergency services were performed at your local home office.
If you are admitted to the hospital because of the emergency situation, those costs will also be subject to the cost-sharing limitations of your health plan. Once you are discharged from the hospital, but the doctor has ordered some special durable medical equipment, that should also be covered. If you cannot travel back home because of your condition, and need additional follow-up treatment, those health care services may also be covered, but you need to get prior authorization from the health plan.
From the Blue Shield Silver 70 Evidence of Coverage, 2021
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.
Urgent Care Outside of California
Similar to emergency room services, urgent care is almost always covered. Health plans want you to seek urgent care whenever possible for non-emergency conditions.
From the Kaiser Member Agreement, 2021
Out-of-Area Urgent Care: If you need Urgent Care due to an unforeseen illness, unforeseen injury, or unforeseen complication of an existing condition (including pregnancy), we cover Medically Necessary Services to prevent serious deterioration of your (or your unborn child’s) health from a Non–Plan Provider if all of the following are true:
• You receive the Services from Non–Plan Providers while you are temporarily outside your Home Region Service Area
• A reasonable person would have believed that your (or your unborn child’s) health would seriously deteriorate if you delayed treatment until you returned to your Home Region Service Area
You do not need prior authorization for Out-of-Area Urgent Care. We cover Out-of-Area Urgent Care you receive from Non–Plan Providers if the Services would have been covered under this EOC if you had received them from Plan Providers.
What I have not been able to discern, as posed by a client, was if a Kaiser facility in another state is available for routine medical treatment. You might be needing an office visit to get a prescription refilled or a nagging injury you received while hiking. If you are a Kaiser member, you will need to call member services to learn if they will honor the health care costs at an out-of-state Kaiser facility as in-network under your California plan.
For the vast majority of Californians who travel, their health plans travel with them in case of an emergency or urgently needed care. It is unfortunate that the U.S. does not have a nationwide network of providers similar to Original Medicare that can be tapped into for individual and family plans. This forces people who live in other states, outside of California, for considerable time periods to go without access to routine care. The current situation also forces some California residents to travel considerable distances to access routine care when they can see a competent provider just over the state line.