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.
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.
The health plan line-up includes the standard small group benefit design metal tier plans and a mix of what Oscar calls “Classic” and “Saver” benefit designs. The Classic and Saver benefit designs will have lower premiums because the members have a higher maximum out-of-pocket amount or a coinsurance percentage.
For eligible members, there is no additional cost to participate in this program or for services provided by Landmark. Covered services provided by non-Landmark providers through a referral from Landmark may be subject to cost-sharing based on members’ health plan benefits and coverage.
The question no one can answer for me is if the expanded Medi-Cal HMO capitation rates have been decreasing because there are more healthy people in the Medi-Cal pool? Or are there other factors that are driving down the rates. There must be good money in Medi-Cal as Aetna, Blue Shield, and United Healthcare have all been approved to offer Medi-Cal HMO plans alongside other private health insurance companies such as Anthem Blue Cross, Health Net, Kaiser, and Molina.
Both Health Net and Blue Shield have wasted thousands of hours of time for consumers, agents, and their customer service staff. Tempers have become short and patience has run thin. And as of December 21st, a month after some people have applied for health insurance, 10 days before the plans are to become effective, many families don’t know if they will have insurance on January 1, 2018.
Health insurance companies are smarter than your average house cat. They have reams of data about health care claims and demographics. They can forecast, with reasonable confidence, that altering some of the member cost-sharing benefits may reduce their final exposure to pay member claims. It has also been suggested that consumers who purchase health insurance off-exchange, paying the full premium rate with no subsidy, may be more judicious in how they use health care services. In other word, off-exchange consumer mays tend to file fewer health care expense claims. This results in lower rates to the consumer.
Because of all of the numerous ways a provide network search can give incorrect results, I am now recommending that people print out a list of providers in their area. Usually the list can be created in a PDF format that is searchable with Adobe Acrobat Reader. You can look through the list of doctor names alphabetically. You might see Dr. Balabat and realize that is your doctor when you thought the name was spelled Baladat.
But once you cross the border, some plans can be a little coy in whether they will cover any health care services. For both travel in the United States and abroad, you really need to study the health plan’s member agreement also referred to the Evidence of Coverage (EOC). The EOCs are those big documents that tell you have the plan works, what’s included, and what’s excluded. Some EOCs are specific about foreign travel coverage while others that I have studied make no mention of coverage outside the U.S.
Finally, some folks are considering just enrolling in Medi-Cal because they are eligible. They have very little or no income to report on their taxes because they are living off of savings, interest, and dividends. Here again, Medi-Cal would be used as a containment strategy to an unexpected accident or illness. Medi-Cal is typically a HMO plan which requires a Primary Care Physician to make referrals to specialists, order tests, or imaging.