What your Blue Shield of California contract says

In short

This is a health insurance policy with Blue Shield of California, one of the state's largest health insurers covering roughly 4.8 million members. Blue Shield offers HMO, PPO, and EPO plans through employers, the individual market, and Covered California. With an HMO plan, you need a referral from your primary care physician (PCP) to see a specialist. PPO plans let you see any provider but cost less if you stay in-network. Under the Affordable Care Act and California law, Blue Shield must cover essential health benefits including preventive care, mental health, prescription drugs, and maternity care with no annual or lifetime dollar limits. The California Department of Managed Health Care (DMHC) regulates Blue Shield and handles consumer complaints.

What you agree to do

• You must pay your monthly premium by the due date to keep your coverage active.
• You must use in-network providers for full benefits under HMO and EPO plans (out-of-network care is generally not covered except in emergencies).
• You must obtain a referral from your PCP before seeing a specialist if you have an HMO plan.
• You must get prior authorization for certain procedures, medications, and hospital stays.

What you can ask for

• You can appeal any claim denial through Blue Shield's internal grievance process, and then to the DMHC for an independent medical review.
• You have the right to receive emergency care at any hospital (Blue Shield must cover it at in-network rates regardless of the hospital's network status).
• You can request an Independent Medical Review (IMR) from the DMHC if Blue Shield denies a treatment as not medically necessary.
• You can cancel your individual plan during Open Enrollment or during a qualifying life event (job loss, marriage, birth).

Points worth knowing

• Prior authorization delays or denialsBlue Shield requires prior authorization for many procedures and medications. If authorization is denied, you either pay out of pocket or delay treatment while you appeal. California's SB 250 requires timely decisions, but the process can still take weeks.
• Annual premium increasesBlue Shield adjusts premiums annually. For individual and family plans, rate increases must be filed with the DMHC but are not subject to prior approval (Blue Shield can implement them after a review period). Increases of 5-15% per year are common.
• Out-of-network cost exposureIf you see an out-of-network provider (other than in an emergency), you may owe the full billed amount. California's AB 72 protects you from surprise bills at in-network facilities, but only for certain specialties.
• Formulary changes to prescription drugsBlue Shield can change its drug formulary (the list of covered medications) during the plan year. A medication you rely on could be moved to a higher cost tier or removed from coverage entirely.
• Coverage termination for non-paymentIf you don't pay your premium within the grace period (31 days for Covered California plans), Blue Shield will terminate your coverage retroactively, and you could owe the full cost of any care received during the grace period.

Dates and deadlines

Open Enrollment period

November 1 through January 31 annually for individual plans

Premium payment grace period

31 days for Covered California enrollees, 30 days for other individual plans

Annual plan renewal

Plans renew January 1 each year (review your benefits and premium changes in the fall)