Health and Welfare Summary Plan Description

Health and Welfare SPD / Article VIII / Self-Funded PPO Option >>

8.3 Blue Shield Out of State Programs

General Rules. Benefits will be provided for Covered Charges received outside of California within the United States, Puerto Rico and the U.S. Virgin Islands. The Plan calculates the Covered Individual's coinsurance as a percentage of the allowable amount, as provided in Section 8.6(b). When Covered Charges are incurred in another state, the Covered Individual's coinsurance will be based on the local Blue Cross and/or Blue Shield plan's arrangement with its providers under the BlueCard program described in subsection (e). Blue Shield has a variety of relationships with other Blue Cross and/or Blue Shield Plans and their licensed controlled affiliates ("Licensees"). Whenever you obtain healthcare services outside of California, the claims for these services may be processed through one of these inter-plan programs, which includes the BlueCard Program. When you incur Covered Charges outside of California you may obtain care from participating providers with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (the "Host Plan").
Services Obtained from Non-Preferred Providers. In some instances, you may obtain care from out-of-state non-preferred healthcare providers within the U.S., Puerto Rico or the U.S. Virgin Islands. If you do not see a participating provider through the BlueCard Program, you must pay the entire bill for your medical care and submit a claim form to the local Blue Cross and/or Blue Shield plan or to the Plan Office for payment. The Plan Office will notify you of its determination within 30 days after receipt of the claim. The Plan Office will pay you at the non-Preferred Provider benefit level. Remember, your coinsurance is higher when you use a non-Preferred Provider. You will be responsible for paying the entire difference between the amount paid by the Plan and the amount billed. Charges for services that are not covered, and charges by non-Preferred Providers in excess of the amount covered by the Plan, are the Participant's responsibility and are not included in coinsurance calculations.
How to Access Out-of-State Services in U.S., Puerto Rico and U.S. Virgin Islands. When you require covered services while traveling outside of California, but within the U.S., Puerto Rico and the U.S. Virgin Islands:
1. call BlueCard Access ® at (800) 810-BLUE (2583) to locate Physicians and Hospitals that participate in the local Blue Cross and/or Blue Shield plan, or go online at bcbs.com and select the "Find a Doctor or Hospital" tab; and
2. visit the participating Physician or Hospital and present your membership card.
The participating Physician or Hospital will verify your eligibility and coverage information by calling BlueCard Eligibility at (800) 676-BLUE. Once verified and after services are provided, a claim is submitted electronically and the participating Physician or Hospital is paid directly. You may be asked to pay for your applicable coinsurance and deductible at the time you receive the service. You will receive an Explanation of Benefits which will show your payment responsibility. You are responsible for the coinsurance and deductible amounts shown in the Explanation of Benefits. Prior authorization is required for all non-emergency in-patient Hospital services and notification is required for in-patient emergency services. Prior authorization is required for selected in-patient and out-patient services; however, only notification is required for in-patient emergency services. Prior authorization is required for selected in-patient and out-patient services, supplies and durable medical equiptment. To receive prior authorization from the Plan, the out-of-area provider should call the customer service number noted on the back of your identification card. If you need emergency services, you should seek immediate care from the nearest medical facility. Plan benefits will be provided for covered services received anywhere in the world for emergency care of an illness or injury.
Care for Covered Urgent Care and Emergency Services Outside the United States. Benefits will also be provided for covered urgent and emergent services received outside of the United States, Puerto Rico, and U.S. Virgin Islands. If you need urgent care while out of the country, call the BlueCard Worldwide Service Center at either the toll-free BlueCard Access number (800) 810-2583 or collect (804) 673-1177, 24 hours a day, seven days a week. In an emergency, go directly to the nearest hospital. If your coverage requires precertification or prior authorization, you should also call the Plan at the customer service number noted on the back of your identification card. For in-patient hospital care, contact the BlueCard Worldwide Service Center to arrange cashless access. If cashless access is arranged, you are responsible for the usual out-of-pocket expenses (non-Covered Charges, deductibles, and coinsurance). If cashless access is not arranged, you will have to pay the entire bill for your medical care and submit a claim to the BlueCard Worldwide Service Center. When you receive services from a physician, you will have to pay the doctor and then submit a claim. Before traveling abroad, call your local Customer Service office for the most current listing of providers world-wide or you can go on-line at bcbs.com and select "Find a Doctor or Hospital" and "BlueCard Worldwide."
BlueCard Program. Under the BlueCard Program, when you obtain covered services within the geographic area served by a Host Plan, the Plan will remain responsible for any payment due, excluding the Participant's liability (such as coinsurance and deductibles). However, the Host Plan is responsible for contracting with and generally handling all interactions with its participating healthcare providers. The BlueCard Program enables you to obtain covered services outside of California, as defined, from a healthcare provider participating with the Host Plan, where available. The participating healthcare provider will automatically file a claim for the covered services provided to you, so there are no claim forms for you to fill out. You will be responsible for any member coinsurance and deductibles, if any, as stated in this document. Whenever you incur Covered Charges outside of California and the claim is processed through the BlueCard Program, the amount you pay is calculated based on the lower of (i) the billed Covered Charges for your covered services or (ii) the negotiated price that the Host Plan makes available to Blue Shield. Often, this "negotiated price" will be a simple discount that reflects an actual price that the Host Plan pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcare provider or provider group that may include types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average savings for similar types of healthcare providers after taking into account the same types of transactions as with an estimated price. Estimated pricing and average pricing, going forward, also take into account adjustments to correct for over- or underestimation of modifications of past pricing for the types of transaction modifications noted above. However, such adjustments will not affect the price the Plan uses for your claim because they will not be applied retroactively to claims already paid. Laws in a small number of states may require the Host Plan to add a surcharge to your calculation. If any state laws mandate other liability calculation methods, including a surcharge, we would then calculate your liability for any Covered Charges according to applicable law. Claims for covered services are paid based on the Reasonable and Customary amount. See Appendix D for details.