HomeMy WebLinkAboutBlue Shield HMO 15 Plan Document (SPD)Combined Evidence of Coverage
and Disclosure Form
Custom Access+ HMO 15-0 Inpatient
Public Risk Innovation, Solutions and Management (PRISM) -
Small Group Program
Group Number: W0052149-M0035599 & M0035601
Effective Date: January 1, 2024
Provider Network: Access+
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Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Table of contents
Table of contents .......................................................................................................................................2
Summary of Benefits..................................................................................................................................4
Introduction..............................................................................................................................................10
About this Evidence of Coverage ......................................................................................................10
About this plan ......................................................................................................................................11
How to contact customer service ......................................................................................................11
Your bill of rights.......................................................................................................................................13
Your responsibilities.................................................................................................................................15
How to access care ................................................................................................................................16
Health care professionals and facilities..............................................................................................16
Mental Health Service Administrator (Benefit Administrator) ..........................................................17
Your Primary Care Physician................................................................................................................17
Your Medical Group.............................................................................................................................18
Self-referral for obstetrical/gynecological (OB/GYN) services........................................................19
Specialist referrals..................................................................................................................................19
ID cards ..................................................................................................................................................19
Canceling appointments.....................................................................................................................20
Continuity of care.................................................................................................................................20
Second medical opinion......................................................................................................................21
Care outside of California....................................................................................................................22
Emergency Services..............................................................................................................................22
If you cannot find a Participating Provider........................................................................................23
Other ways to access care..................................................................................................................23
Timely access to care...........................................................................................................................25
Health advice and education ............................................................................................................26
Medical management............................................................................................................................28
Prior authorization and PCP referrals ..................................................................................................28
While you are in the Hospital (inpatient utilization review) ..............................................................29
After you leave the Hospital (discharge planning)...........................................................................29
Using your Benefits effectively (care management)........................................................................29
Your payment information......................................................................................................................31
Paying for coverage.............................................................................................................................31
Paying for Covered Services................................................................................................................31
Claims for Emergency or Urgent Services ..........................................................................................34
Your coverage.........................................................................................................................................36
Eligibility for this plan .............................................................................................................................36
Enrollment and effective dates of coverage....................................................................................36
Plan changes.........................................................................................................................................38
Coordination of benefits......................................................................................................................38
When coverage ends...........................................................................................................................39
Extension of Benefits..............................................................................................................................40
Continuation of group coverage .......................................................................................................40
Your Benefits.............................................................................................................................................45
Allergy testing and immunotherapy Benefits.....................................................................................45
Table of contents 3
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Ambulance services.............................................................................................................................45
Clinical trials for treatment of cancer or life-threatening diseases or conditions Benefits ...........46
Diabetes care services.........................................................................................................................47
Diagnostic X-ray, imaging, pathology, laboratory, and other testing services.............................47
Dialysis Benefits......................................................................................................................................48
Durable medical equipment...............................................................................................................49
Emergency Benefits..............................................................................................................................50
Family planning and Infertility Benefits ...............................................................................................51
Fertility preservation services................................................................................................................52
Home health services ...........................................................................................................................52
Hospice program services....................................................................................................................54
Hospital services....................................................................................................................................55
Medical treatment of the teeth, gums, jaw joints, and jaw bones.................................................55
Mental Health and Substance Use Disorder Benefits........................................................................56
Physician and other professional services..........................................................................................58
PKU formulas and special food products...........................................................................................59
Podiatric services ..................................................................................................................................59
Pregnancy and maternity care ..........................................................................................................59
Preventive Health Services...................................................................................................................60
Reconstructive Surgery Benefits ..........................................................................................................60
Rehabilitative and habilitative services..............................................................................................61
Skilled Nursing Facility (SNF) services...................................................................................................62
Transplant services................................................................................................................................62
Urgent care services.............................................................................................................................64
Exclusions and limitations.......................................................................................................................65
Grievance process..................................................................................................................................70
Submitting a grievance........................................................................................................................70
California Department of Managed Health Care review ...............................................................71
Independent medical review..............................................................................................................71
ERISA review...........................................................................................................................................72
Other important information about your plan ......................................................................................73
Your coverage, continued ..................................................................................................................73
Special enrollment period....................................................................................................................73
Out-of-area services.............................................................................................................................74
Limitation for duplicate coverage......................................................................................................77
Exception for other coverage.............................................................................................................78
Reductions – third-party liability...........................................................................................................78
Coordination of benefits, continued..................................................................................................79
General provisions.................................................................................................................................80
Definitions.................................................................................................................................................83
Notices about your plan.........................................................................................................................97
Acupuncture and Chiropractic Services Rider...................................................................................100
Notice informing individuals about nondiscrimination and accessibility requirements................104
Language access services...................................................................................................................105
A16205 (01/24) 4
Summary of Benefits PRISM/Small Group Program
Effective January 1, 2024
HMO Plan
Custom Access+ HMO 15-0 Inpatient
This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Plan. It
is only a summary and it is included as part of the Evidence of Coverage (EOC).1 Please read both documents carefully
for details.
Medical Provider Network:Access+ HMO Network
This Plan uses a specific network of Health Care Providers, called the Access+ HMO provider network. Medical
Groups, Independent Practice Associations (IPAs), and Physicians in this network are called Participating Providers.
You must select a Primary Care Physician from this network to provide your primary care and help you access
services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access
care under this Plan. You can find Participating Providers in this network at blueshieldca.com.
Calendar Year Deductibles (CYD)2
A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for
Covered Services under the Plan.
When using a Participating Provider3
Calendar Year medical Deductible Individual coverage $0
Family coverage $0: individual
$0: Family
Calendar Year Out-of-Pocket Maximum4
An Out-of-Pocket Maximum is the most a Member will pay for Covered
Services each Calendar Year. Any exceptions are listed in the EOC. No Annual or Lifetime Dollar Limit
When using a Participating Provider3
Individual coverage $1,500
Family coverage $1,500: individual
$3,000: Family
Under this Plan there is no annual or
lifetime dollar limit on the amount Blue
Shield will pay for Covered Services.
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Benefits5 Your payment
When using a Participating
Provider3
CYD2
applies
Preventive Health Services6
Preventive Health Services $0
California Prenatal Screening Program $0
Physician services
Primary care office visit $15/visit
Access+ specialist care office visit (self-referral)$30/visit
Other specialist care office visit (referred by PCP)$15/visit
Physician home visit $15/visit
Physician or surgeon services in an Outpatient Facility $0
Physician or surgeon services in an inpatient facility $0
Other professional services
Other practitioner office visit $15/visit
Includes nurse practitioners, physician assistants, therapists, and
podiatrists.
Teladoc consultation $15/consult
Family planning
•Counseling, consulting, and education $0
•Injectable contraceptive, diaphragm fitting, intrauterine
device (IUD), implantable contraceptive, and related
procedure.
$0
•Tubal ligation $0
•Vasectomy $0
Medical nutrition therapy, not related to diabetes $0
Pregnancy and maternity care
Physician office visits: prenatal and postnatal $0
Abortion and abortion-related services $0
Emergency Services
Emergency room services $50/visit
If admitted to the Hospital, this payment for emergency room
services does not apply. Instead, you pay the Participating
Provider payment under Inpatient facility services/ Hospital
services and stay.
Emergency room Physician services $0
6
Benefits5 Your payment
When using a Participating
Provider3
CYD2
applies
Urgent care center services $15/visit
Ambulance services $50/transport
This payment is for emergency or authorized transport.
Outpatient Facility services
Ambulatory Surgery Center $0
Outpatient Department of a Hospital: surgery $100/surgery
Outpatient Department of a Hospital: treatment of illness or injury,
radiation therapy, chemotherapy, and necessary supplies $0
Inpatient facility services
Hospital services and stay $0
Transplant services
This payment is for all covered transplants except tissue and
kidney. For tissue and kidney transplant services, the payment for
Inpatient facility services/ Hospital services and stay applies.
•Special transplant facility inpatient services $0
•Physician inpatient services $0
Diagnostic x-ray, imaging, pathology, and laboratory services
This payment is for Covered Services that are diagnostic, non-
Preventive Health Services, and diagnostic radiological procedures.
For the payments for Covered Services that are considered
Preventive Health Services, see Preventive Health Services.
Laboratory and pathology services
Includes diagnostic Papanicolaou (Pap) test.
•Laboratory center $0
•Outpatient Department of a Hospital $0
Basic imaging services
Includes plain film X-rays, ultrasounds, and diagnostic
mammography.
•Outpatient radiology center $0
•Outpatient Department of a Hospital $0
Other outpatient non-invasive diagnostic testing
Testing to diagnose illness or injury such as vestibular function
tests, EKG, cardiac monitoring, non-invasive vascular studies,
sleep medicine testing, muscle and range of motion tests, EEG,
and EMG.
•Office location $0
•Outpatient Department of a Hospital $0
Advanced imaging services
Includes diagnostic radiological and nuclear imaging such as CT
scans, MRIs, MRAs, and PET scans.
•Outpatient radiology center $0
•Outpatient Department of a Hospital $0
7
Benefits5 Your payment
When using a Participating
Provider3
CYD2
applies
Rehabilitative and Habilitative Services
Includes physical therapy, occupational therapy, respiratory therapy,
and speech therapy services.
Office location $15/visit
Outpatient Department of a Hospital $15/visit
Durable medical equipment (DME)
DME 20%
Breast pump $0
Orthotic equipment and devices $0
Prosthetic equipment and devices $0
Home health care services $15/visit
Up to 100 visits per Member, per Calendar Year, by a home health
care agency. All visits count towards the limit, including visits during
any applicable Deductible period. Includes home visits by a nurse,
Home Health Aide, medical social worker, physical therapist, speech
therapist, or occupational therapist, and medical supplies.
Home infusion and home injectable therapy services
Home infusion agency services $0
Includes home infusion drugs, medical supplies, and visits by a
nurse.
Hemophilia home infusion services $0
Includes blood factor products.
Skilled Nursing Facility (SNF) services
Up to 100 days per Member, per benefit period, except when
provided as part of a Hospice program. All days count towards the
limit, including days during any applicable Deductible period and
days in different SNFs during the Calendar Year.
Freestanding SNF $0
Hospital-based SNF $0
Hospice program services $0
Includes pre-Hospice consultation, routine home care, 24-hour
continuous home care, short-term inpatient care for pain and
symptom management, and inpatient respite care.
Other services and supplies
Diabetes care services
•Devices, equipment, and supplies 20%
•Self-management training $15/visit
•Medical nutrition therapy $15/visit
Dialysis services $0
PKU product formulas and special food products $0
8
Benefits5 Your payment
When using a Participating
Provider3
CYD2
applies
Allergy serum billed separately from an office visit 50%
Mental Health and Substance Use Disorder Benefits Your payment
Mental health and substance use disorder Benefits are provided
through Blue Shield's Mental Health Service Administrator (MHSA).
When using a MHSA
Participating Provider3
CYD2
applies
Outpatient services
Office visit, including Physician office visit $15/visit
Teladoc mental health $15/consult
Other outpatient services, including intensive outpatient care,
electroconvulsive therapy, transcranial magnetic stimulation,
Behavioral Health Treatment for pervasive developmental disorder
or autism in an office setting, home, or other non-institutional facility
setting, and office-based opioid treatment
$0
Partial Hospitalization Program $0
Psychological Testing $0
Inpatient services
Physician inpatient services $0
Hospital services $0
Residential Care $0
Notes
1 Evidence of Coverage (EOC):
The Evidence of Coverage (EOC) describes the Benefits, limitations, and exclusions that apply to coverage under this
Plan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy
of the EOC at any time.
Capitalized terms are defined in the EOC. Refer to the EOC for an explanation of the terms used in this Summary of
Benefits.
2 Calendar Year Deductible (CYD):
Calendar Year Deductible explained. A Calendar Year Deductible is the amount you pay each Calendar Year before
Blue Shield pays for Covered Services under the Plan.
If this Plan has any Calendar Year Deductible(s), Covered Services subject to that Deductible are identified with a
check mark () in the Benefits chart above.
3 Using Participating Providers:
Participating Providers have a contract to provide health care services to Members. When you receive Covered
Services from a Participating Provider, you are only responsible for the Copayment or Coinsurance, once any Calendar
Year Deductible has been met.
9
Notes
Teladoc. Teladoc mental health and substance use disorder consultations are provided through Teladoc. These
services are not administered by Blue Shield's Mental Health Service Administrator (MHSA).
4 Calendar Year Out-of-Pocket Maximum (OOPM):
Calendar Year Out-of-Pocket Maximum explained. The Out-of-Pocket Maximum is the most you are required to pay
for Covered Services in a Calendar Year. Once you reach your Out-of-Pocket Maximum, Blue Shield will pay 100% of
the Allowed Charges for Covered Services for the rest of the Calendar Year.
Your payment after you reach the Calendar Year OOPM. You will continue to pay all charges for services that are not
covered, charges above the Allowed Charges, and charges for services above any Benefit maximum.
Family coverage has an individual OOPM within the Family OOPM. This means that the OOPM will be met for an
individual with Family coverage who meets the individual OOPM prior to the Family meeting the Family OOPM within
a Calendar Year.
5 Separate Member Payments When Multiple Covered Services are Received:
Each time you receive multiple Covered Services, you might have separate payments (Copayment or Coinsurance)
for each service. When this happens, you may be responsible for multiple Copayments or Coinsurance. For example,
you may owe an office visit payment in addition to an allergy serum payment when you visit the doctor for an allergy
shot.
6 Preventive Health Services:
If you only receive Preventive Health Services during a Physician office visit, there is no Copayment or Coinsurance for
the visit. If you receive both Preventive Health Services and other Covered Services during the Physician office visit,
you may have a Copayment or Coinsurance for the visit.
10
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Introduction
Welcome! We are happy to have you as a Member of our Blue Shield of California (Blue
Shield) health plan.
At Blue Shield, our mission is to ensure all Californians have access to high-quality health
care at an affordable price. To achieve this mission, we pledge to:
•Provide personal service to you that is worthy of our family and friends; and
•Build deep, trusting relationships with providers to improve the quality of
health care and lower the cost.
A Blue Shield health plan will help you pay for medical care and provide you with
access to a network of doctors, Hospitals, and other Health Care Providers. The types of
services that are covered, the providers you can see, and your share of cost when you
receive care may vary depending on your plan.
About this Evidence of Coverage
The Combined Evidence of Coverage and Disclosure Form (Evidence of Coverage)
describes the health care coverage that is provided under the Group Health Service
Contract (Contract) between Blue Shield and your Employer. The Evidence of
Coverage tells you:
•Your eligibility for coverage;
•When coverage begins and ends;
•How you can access care;
•Which services are covered under your plan;
•Which services are not covered under your plan;
•When and how you must get prior authorization for certain services; and
•Important financial concepts, such as Copayment, Coinsurance, Deductible,
and Out-of-Pocket Maximum.
This Evidence of Coverage includes a Summary of Benefits section that lists your Cost
Share for Covered Services. Use this summary to figure out what your cost will be when
you receive care.
Please read this Evidence of Coverage carefully. Some topics in this document are
complex. For additional explanation on these topics, you may be directed to a section
at the back of the Evidence of Coverage called Other important information about
your plan. Pay particular attention to sections that apply to any special health care
needs you may have. Be sure to keep this Evidence of Coverage in your files for future
reference.
Tables and images
In this Evidence of Coverage, you will see the following tables and images to
highlight key information:
Introduction 11
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
This table provides easy access to information
Phone numbers and addresses
Answers to commonly-asked questions
Examples to help you better understand important concepts
This box tells you where to find additional information about a
specific topic.
This box alerts you to information that may require you to take
action.
“You” means the Member
In this Evidence of Coverage, “you” or “your” means any Member enrolled in the
plan, including the Subscriber and all Dependents. “Your Employer” means the
Subscriber’s Employer.
Capitalized words have a special meaning
Some words and phrases in this Evidence of Coverage may be new to you. Key
terms with a special meaning within this Evidence of Coverage are capitalized in this
document and explained in the Definitions section.
About this plan
This is a Health Maintenance Organization (HMO) plan. In an HMO plan, you have
access to a network of providers who collaborate to bring you personal, efficient care.
You will choose a Primary Care Physician (PCP) who is your first point of contact and
manages your care. Your PCP is part of a group of Physicians called a Medical Group.
Your PCP can refer you to Participating Providers in your Medical Group for specialized
care and assist with other care needs. See the How to access care section for
information about Participating Providers.
The Access+ HMO offers a wide choice of Physicians, Hospitals, and other Health Care
Providers and includes special features such as Access+ Specialists.
How to contact customer service
If you have questions at any time, we’re here to help. Blue Shield’s website and app
are useful resources. Visit blueshieldca.com or use the Blue Shield mobile app to:
•Download forms;
•View or print a temporary ID card;
Introduction 12
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
•Access recent claims;
•Find a doctor or other Health Care Provider; and
•Explore health topics and wellness tools.
Blue Shield contact information appears at the bottom of every page.
Contacting Customer Service
If you need information about You should contact
Medical Benefits Customer Service:
1-855-599-2650
Blue Shield of California
P.O. Box 272540
Chico, CA 95927-2540
Mental Health and Substance Use
Disorder services, including prior
authorization
Mental Health Customer Service:
(877) 263-9952
Blue Shield of California
Mental Health Service Administrator
P.O. Box 719002
San Diego, CA 92171-9002
If you are hearing impaired, you may contact Customer Service through Blue Shield’s
toll-free TTY number: 711.
13
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Your bill of rights
As a Blue Shield Member, you have the right to:
1 Receive considerate and courteous care with respect for your right to personal
privacy and dignity.
2 Receive information about all health services available to you, including a clear
explanation of how to obtain them.
3 Receive information about your rights and responsibilities.
4 Receive information about your Blue Shield plan, the services we offer you, and
the Physicians and other Health Care Providers available to care for you.
5 Select a PCP and expect their team to provide or arrange for all the care you
need.
6 Have reasonable access to appropriate medical and mental health services.
7
Participate actively with your PCP in decisions about your medical and mental
health care. To the extent the law permits, you also have the right to refuse
treatment.
8 A candid discussion of appropriate or Medically Necessary treatment options for
your condition, regardless of cost or Benefit coverage.
9
An explanation of your medical or mental health condition, and any proposed,
appropriate, or Medically Necessary treatment alternatives from your PCP, so
you can make an informed decision before you receive treatment. This includes
available success/outcomes information, regardless of cost or Benefit coverage.
10 Receive Preventive Health Services.
11 Know and understand your medical or mental health condition, treatment plan,
expected outcome, and the effects these have on your daily living.
12
Have confidential health records, except when the state law (California) or
federal law requires or permits disclosure. With adequate notice, you have the
right to review your medical record with your PCP.
13 Communicate with, and receive information from, Customer Service in a
language you can understand.
14 Know about any transfer to another Hospital, including information as to why the
transfer is necessary and any alternatives available.
15 Be fully informed about the complaint and grievance process and understand
how to use it without the fear of an interruption in your health care.
16 Voice complaints or grievances about your Blue Shield plan or the care
provided to you.
Your bill of rights 14
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
As a Blue Shield Member, you have the right to:
17 Make recommendations on Blue Shield’s Member rights and responsibilities
policies.
15
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Your responsibilities
As a Blue Shield Member, you have the responsibility to:
1
Carefully read all Blue Shield plan materials immediately after you are enrolled
so you understand how to:
•Use your Benefits;
•Minimize your out-of-pocket costs; and
•Follow the provisions of your plan as explained in the Evidence of
Coverage.
2 Maintain your good health and prevent illness by making positive health choices
and seeking appropriate care when you need it.
3 Provide, to the extent possible, information needed for you to receive
appropriate care.
4 Understand your health problems and take an active role in developing
treatment goals with your PCP, whenever possible.
5
Follow the treatment plans and instructions you and your PCP agree to and
consider the potential consequences if you refuse to comply with treatment
plans or recommendations.
6 Ask questions about your medical or mental health condition and make certain
that you understand the explanations and instructions you are given.
7 Make and keep medical and mental health appointments and inform your
Health Care Provider ahead of time when you must cancel.
8 Communicate openly with your PCP so you can develop a strong partnership
based on trust and cooperation.
9 Offer suggestions to improve the Blue Shield plan.
10
Help Blue Shield maintain accurate and current records by providing timely
information regarding changes in your address, family status, and other plan
coverage.
11 Notify Blue Shield as soon as possible if you are billed inappropriately or if you
have any complaints or grievances.
12 Treat all Blue Shield personnel respectfully and courteously.
13 Pay your Premiums, Copayments, Coinsurance, and charges for non-Covered
Services in full and on time.
16
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
How to access care
PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR
WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED.
Health care professionals and facilities
This plan covers care from Participating Providers within your Medical Group.
Participating Providers
Participating Providers have a contract with a Medical Group in this plan’s network.
With an HMO plan, there is generally no coverage for services from providers outside
of your Medical Group.
If a provider leaves your Medical Group, you will not have coverage for services
received from that provider. See the Continuity of Care section for more information
on how to continue treatment with a Non-Participating Provider.
Visit blueshieldca.com or use the Blue Shield mobile app and
click on Find a Doctor for a list of your plan’s Participating
Providers.
Non-Participating Providers
Non-Participating Providers do not have a contract with Blue Shield to accept Blue
Shield’s Allowed Charges as payment in full for Covered Services. Except for
Emergency Services, Urgent Services, services received at a Participating Provider
facility (Hospital, Ambulatory Surgery Center, laboratory, radiology center, imaging
center, or certain other outpatient settings) under certain conditions, and services
provided by a 988 center, Mobile Crisis Team, or other provider of Behavioral Health
Crisis Services, this plan does not cover services from Non-Participating Providers.
Non-Participating Providers at a Participating Provider facility
When you receive care at a Participating Provider facility, some Covered
Services may be provided by a Non-Participating Provider. Your Cost Share will
be the same as the amount due to a Participating Provider under similar
circumstances, and you will not be responsible for additional charges above the
Allowed Charges, unless the Non-Participating Provider provides you written
notice of what they may charge and you consent to those terms.
Common types of providers
Primary Care Physicians (PCPs)
How to access care 17
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Common types of providers
Other primary care providers, such as nurse practitioners and physician assistants
Physician Specialists, such as dermatologists and cardiologists
Physical, occupational, and speech therapists
Mental health providers, such as psychiatrists, psychologists, and licensed clinical
social workers
Hospitals
Freestanding labs and radiology centers
Ambulatory Surgery Centers
Mental Health Service Administrator (Benefit Administrator)
Blue Shield contracts with the Mental Health Service Administrator (MHSA) to manage
Mental Health and Substance Use Disorder services through their own network of
providers. The MHSA authorizes services, processes claims, and addresses complaints
and grievances for those Benefits on behalf of Blue Shield. If you receive a Covered
Service from an MHSA Participating Provider, you should interact with the MHSA in the
same way you would otherwise interact with your PCP.
Your Primary Care Physician
In an HMO plan, you are required to have a Primary Care Physician (PCP). Your PCP is
your first point of contact for any health concern and for Preventive Health Services.
Your PCP will also manage other aspects of your care, including:
•Prior authorization requests;
•Health education;
•Specialist referrals;
•Hospital admissions; and
•Hospice program admissions.
Selecting a PCP
Blue Shield will initially choose a PCP for you, but you can change this selection. You
do not need to choose the same PCP for each Member in your family. To change
your PCP, visit blueshieldca.com.
PCPs may be:
•General practitioners;
•Family practitioners;
•Internists;
How to access care 18
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
•Obstetrician/gynecologists; or
•Pediatricians.
Your PCP must be a Participating Provider. If your PCP leaves this plan’s network, Blue
Shield will choose a new PCP for you and notify you.
Your relationship with your PCP
The relationship you have with your PCP is an important element of an HMO plan.
Your PCP has a unique holistic view of your medical care. He or she will know your
health history, which may help identify problems before they become serious. Your
PCP will work with you to ensure you receive Medically Necessary professional
services and accommodate your preferences to the extent possible. This relationship
also allows for more open communication between you and your PCP. If you are
unable to establish a satisfactory relationship with your PCP, you can choose a new
one.
Your Medical Group
Some PCPs contract directly with Blue Shield, but most are part of a Medical Group.
Medical Groups:
•Share administrative responsibilities with your PCP;
•Work with your PCP to authorize Covered Services;
•Ensure that a full panel of Specialists are available to you; and
•Have admission arrangements with Blue Shield’s contracted Hospitals within
the Medical Group Service Area.
Your PCP and Medical Group are listed on your ID card.
Changing your Medical Group
You can change your Medical Group by visiting blueshieldca.com. If your PCP is not
part of your new Medical Group, you will also have to select a new PCP.
Changes to your Medical Group are effective on the first day of the month after Blue
Shield approves the change. Once the change is effective, authorizations for any
services by your old Medical Group are no longer valid. If you still need these
services, they must be reauthorized by your new Medical Group.
You may not change Medical Groups while you are admitted to the Hospital or in
the third trimester of pregnancy. Any requested changes to your Medical Group in
these situations will not be effective until the first day of the month after the date of
your discharge from the Hospital or completion of postpartum care.
A change in Medical Group during an ongoing course of treatment may interrupt
your care. Any requested changes to your Medical Group during an ongoing course
of treatment requires an exception. Exceptions must be approved by a Blue Shield
Medical Director and will be effective when medically appropriate to transfer care.
Call Customer Service for more information.
How to access care 19
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Self-referral for obstetrical/gynecological (OB/GYN) services
You do not need a referral from your PCP for OB/GYN services as long as the
obstetrician, gynecologist, or family practice Physician you see is in your Medical
Group. Your Cost Share for OB/GYN services with that Physician will be the same as if
you received those services from your PCP.
OB/GYN services are female reproductive and sexual health care services. OB/GYN
services include Physician services related to:
•Family planning and contraception;
•Treatment during pregnancy;
•Diagnosis and treatment of disorders of the female reproductive system and
genitalia;
•Treatment of disorders of the breast; and
•HIV testing.
Specialist referrals
You have two options if you need to see a Specialist.
PCP referrals
This option requires a referral from your PCP to see most types of Specialist. Your PCP
will refer you to a Specialist or other appropriate Participating Provider in your
Medical Group.
Self-referral to an Access+ Specialist
With this option, you do not need a referral from your PCP to visit an Access+
Specialist in your Medical Group. You can self-refer to an Access+ Specialist for:
•An examination or other consultation; and
•In-office diagnostic procedures or treatment.
You cannot self-refer to an Access+ Specialist for:
•Allergy testing;
•Endoscopic procedures;
•Advanced imaging, including CT, MRI, or bone density measurement;
•Injectables, chemotherapy, or other infusion Drugs, other than vaccines and
antibiotics;
•Infertility services;
•Inpatient services or any services that result in a facility charge, except for
routine X-ray and laboratory services; or
•Services for which the Medical Group routinely allows you to self-refer without
authorization from your PCP.
ID cards
Blue Shield will provide the Subscriber and any enrolled Dependents with identification
cards (ID cards). Only you can use your ID card to receive Benefits. Your ID card is
How to access care 20
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
important for accessing health care, so please keep it with you at all times. Temporary
ID cards are available at blueshieldca.com or on the Blue Shield mobile app.
Canceling appointments
If you are unable to keep an appointment, you should notify the provider at least 24
hours before your scheduled appointment. Some offices charge a fee for missed
appointments unless it is due to an emergency or you give 24-hour advance notice.
Continuity of care
Continuity of care may be available if:
•Blue Shield, the Medical Group, or the MHSA no longer contracts with your
Former Participating Provider for the services you are receiving;
•You are a newly-covered Member whose coverage choices do not include
out-of-network Benefits; or
•You are a newly-covered Member whose previous health plan was
withdrawn from the market.
Continuity of care may also be available to you when your Employer terminates its
contract with Blue Shield and contracts with a new health plan (insurer) that does not
include your Blue Shield Participating Provider in its network.
If your Former Participating Provider is no longer available to you for one of the reasons
noted above, Blue Shield, the Medical Group, or the MHSA will notify you of the option
to continue treatment with your Former Participating Provider.
You can request to continue treatment with your Former Participating Provider in the
situations described above if you are currently receiving the following care:
Continuity of care with a Former Participating Provider
Qualifying conditions Timeframe
Undergoing a course of institutional or
inpatient care
90 days from the date of receipt of
notice of the termination of the Former
Participating Provider’s contract, the
Employer’s contract, or until the
treatment concludes, whichever is sooner
Acute conditions As long as the condition lasts
Maternal mental health condition 12 months after the condition’s diagnosis
or 12 months after the end of the
pregnancy, whichever is later
Ongoing pregnancy care, including care
immediately after giving birth
Up to 12 months
How to access care 21
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Continuity of care with a Former Participating Provider
Qualifying conditions Timeframe
Recommended surgery or procedure
documented to occur within 180 days
Within 180 days
Ongoing treatment for a child up to 36
months old
Up to 12 months
Serious chronic condition Up to 12 months
Terminal illness The duration of the terminal illness
If a condition falls within a qualifying condition under federal and state law, the more
generous time frames would be followed.
To request continuity of care, visit blueshieldca.com and fill out the Continuity of Care
Application. Blue Shield will confirm your eligibility and may review your request for
Medical Necessity.
Under Federal law, the Former Participating Provider must accept Blue Shield’s, the
Medical Group’s, or the MHSA’s Allowed Charges as payment in full for the first 90 days
of your ongoing care. Once the provider accepts and your request is authorized, you
may continue to see the Former Participating Provider at the Participating Provider Cost
Share.
See the Your payment information section for more information about the Allowed
Charges.
Second medical opinion
You can ask your PCP for a referral to another provider for a second medical opinion in
situations including but not limited to:
•You have questions about the reasonableness or necessity of the treatment
plan;
•There are different treatment options for your medical condition;
•Your diagnosis is unclear;
•Your condition has not improved after completing the prescribed course of
treatment;
•You need additional information before deciding on a treatment plan; or
•You have questions about your diagnosis or treatment plan.
Your Medical Group will work with you to arrange for a second medical opinion.
How to access care 22
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Who provides your second medical opinion
If you want a second opinion on It will come from
A proposed treatment plan from your
PCP
Another PCP in your Medical Group
A proposed treatment plan from a
Specialist
A Participating Provider in the same or
equivalent specialty
Care outside of California
If you need urgent or emergency medical care while traveling outside of California,
you’re covered. Blue Shield has relationships with health plans in other states, Puerto
Rico, and the U.S. Virgin Islands through the BlueCard® Program. The Blue Cross Blue
Shield Association can help you access care in those geographic areas.
See the Out-of-area services section for more information
about receiving care while outside of California. To find
participating providers while outside of California, visit
bcbs.com.
Away from Home Care
You or your Dependent may be able to enroll in Away from Home Care when you
are on an extended stay within the service area of another Blue Cross or Blue Shield
plan outside of California. Away from Home Care may be available for Dependents
who are full-time students, Dependents of Subscribers who are required by court
order to provide coverage, and long-term travelers. For more information on the
program and which states participate, visit blueshieldca.com or call the Blue Shield
of California Away from Home Care coordinators at (800) 622-9402.
Emergency Services
If you have a medical emergency, call 911 or seek immediate
medical attention at the nearest hospital.
The Benefits of this plan will be provided anywhere in the world for treatment of an
Emergency Medical Condition. Emergency Services are covered at the Participating
Provider Cost Share, even if you receive treatment from a Non-Participating Provider.
After you receive care, Blue Shield will review your claim for Emergency Services to
determine if your condition was in fact an Emergency Medical Condition. If you did not
How to access care 23
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
require Emergency Services and did not reasonably believe an emergency existed, you
will be responsible for the entire cost of that non-emergency service.
If you cannot find a Participating Provider
Your PCP will refer you to other providers in your Medical Group for the care you need.
If these services cannot reasonably be obtained from a Participating Provider, you can
ask your Medical Group for authorization to see a Non-Participating Provider. They will
review your request for Medical Necessity, and if approved, your Medical Group will
pay for Covered Services from the Non-Participating Provider. You will only be
responsible for the Participating Provider Cost Share. If the Medical Group cannot
provide the necessary care, you can call Customer Service for help finding a
Participating Provider who can provide the requested services.
Other ways to access care
For non-emergencies, it may be faster and easier to access care in one of the following
ways. For more information, visit blueshieldca.com or use the Blue Shield mobile app.
Teladoc
Teladoc, a Third-Party Corporate Telehealth Provider, provides consultations by
phone or secure online video. Teladoc general medical Physicians can diagnose
and treat basic non-emergency medical conditions, and can also prescribe certain
medication. Teladoc mental health consultations are available for Members age 13
and older. Members under age 13 may obtain telebehavioral health services for
Mental Health and Substance Use Disorders from MHSA Participating Providers.
Teladoc is a supplemental service that is not intended to replace care from your
PCP, care from your MHSA Participating Provider, or your relationship with your PCP.
How to access care 24
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
How to access Teladoc
Teladoc service Ways to access Availability
General medical Phone: 1-800-835-2362
Online:
blueshieldca.com/teladoc
24 hours a day, 7 days
a week by phone or
secure online video
Consultations can be
requested on-demand
or by scheduled
appointment
Mental health Phone: 1-800-835-2362
Online:
blueshieldca.com/teladoc
7 a.m. to 9 p.m., 7
days a week by
scheduled
appointment only
Consultations must be
scheduled online and
cannot be requested
by phone
Telebehavioral health services
Online telebehavioral health services for Mental Health and Substance Use Disorders
are available through MHSA Participating Providers and are a Covered Service
regardless of your age. Telebehavioral health includes counseling services,
psychotherapy, and medication management with a mental health provider. If you
are currently receiving telebehavioral health services for Mental Health and
Substance Use Disorders, you can continue to receive those services with the MHSA
Participating Provider rather than switching to a Third-Party Corporate Telehealth
Provider. Visit blueshieldca.com and click on Find a Doctor to access the MHSA
network.
Urgent care centers
Urgent care centers are free-standing facilities that provide many of the same basic
medical services as a doctor's office, often with extended hours but similar Cost
Share.
If your condition is not an emergency, but you need treatment that cannot be
delayed, you can visit an urgent care center to receive care that is typically faster
and costs less than an emergency room visit.
If you are in your Medical Group Service Area, go to the urgent care center
designated by your Medical Group or call your PCP. If you are outside of your
How to access care 25
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Medical Group Service Area but within California and need urgent care, you may
visit any urgent care center near you.
Ambulatory Surgery Centers
Many of the more common, uncomplicated, outpatient surgical procedures can be
performed at an Ambulatory Surgery Center. Your cost at an Ambulatory Surgery
Center may be less than it would be for the same outpatient surgery performed at a
Hospital.
Evaluations and services under the CARE Act
Blue Shield covers the cost of developing an evaluation and the provision of all
health care services for an enrollee when required or recommended pursuant to a
CARE (Community Assistance, Recovery, and Empowerment) agreement or CARE
plan approved by a court in accordance with the CARE Act. The evaluation and
services, other than prescription Drugs, are covered at no charge whether they are
provided by a Participating or Non-Participating Provider.
Timely access to care
Participating Providers agree to provide timely access to care. This means that when
you call for an appointment, you will see your provider within a reasonable timeframe.
Blue Shield’s access standards are listed below.
When your appointment will occur
Urgent appointments Appointment will occur
Services that do not require prior
authorization
Within 48 hours
Services that do require prior
authorization
Within 96 hours
Non-urgent appointments Appointment will occur
Primary Care Physician office visit Within 10 business days
Specialist office visit Within 15 business days
Mental or substance use disorder health
provider (who is not a Physician) office
visit
Within 10 business days
How to access care 26
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
When your appointment will occur
Follow-up appointments with a mental or
substance use disorder health provider
(who is not a Physician)
Within 10 business days of the prior
appointment for those undergoing a
course of treatment for an ongoing
mental health or substance use disorder
condition
Other services to diagnose or treat a
health condition Within 15 business days
Phone inquiries Appointment will occur
Access to a health care professional for
phone triage or screening services by
calling Customer Service
24 hours a day, seven days a week
Call Customer Service if you need help finding a Participating Provider or if a
Participating Provider is not available. Please see the If you cannot find a Participating
Provider section for more information.
Contact Customer Service to schedule interpreter services for
your appointment. For more information about interpreter
services, see the Language access services notice.
Health advice and education
Blue Shield provides several ways for you to get health advice and access to health
education and wellness services. These resources are available to you at no extra cost.
NurseHelp 24/7SM
You can contact a registered nurse 24 hours a day, seven days a week through the
NurseHelp 24/7SM program. Nurses are available to help you select appropriate care
and answer questions about:
•Symptoms you are experiencing;
•Minor illnesses and injuries;
•Medical tests and medications;
•Chronic conditions; and
•Preventive care.
Call (877) 304-0504 or log in to your account at blueshieldca.com and use the chat
feature to connect with a nurse. This service is free and confidential.
NurseHelp 24/7 SM is not meant to replace the advice and care you receive from your
Physician or other health care professional.
How to access care 27
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
LifeReferrals 24/7SM
The LifeReferrals 24/7 SM program offers you access to support services 24 hours a day,
seven days a week, including assessments and referrals for consultations for health
and psychosocial issues. Professional counselors can provide confidential telephone
or in-person support by approved appointment. You are limited to three
consultations with a professional counselor every six months.
This bundle of services also includes referrals, resources, and support for additional
topics such as:
•Legal services;
•Financial counseling;
•Mediation;
•Child and family care;
•Adult and elder care;
•Chronic conditions and illnesses;
•Income tax preparation; and
•Identity theft assistance.
Call (800) 985-2405 to obtain services or access online tools and resources by visiting
lifereferrals.com and using the code: “BSC”. These services are free and confidential.
Health and wellness resources
Your Blue Shield coverage gives you access to a variety of health education and
wellness services, such as:
•Prenatal and other health education programs;
•Healthy lifestyle programs to help you get more active, quit smoking, lower
stress, and much more; and
•A health update newsletter.
Visit blueshieldca.com to explore these resources.
28
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Medical management
Medical management can help you coordinate your care and treatment. It includes
utilization management and care management. Blue Shield uses utilization
management to help you and your providers identify the most appropriate and cost-
effective way to use the Benefits of this plan. Care management and palliative care
can help you access the care you need to manage serious health conditions and
complex treatment plans.
For written information about Blue Shield’s Utilization
Management Program, visit blueshieldca.com.
Prior authorization and PCP referrals
Coverage for most Benefits requires pre-approval from the Medical Group. This process
is called prior authorization. Prior authorization requests are reviewed for Medical
Necessity, available plan Benefits, and clinically appropriate setting. Your PCP will
manage your prior authorization requests. You do not need prior authorization for
services, other than prescription Drugs, provided under a court-approved CARE
agreement or CARE plan.
A referral from your PCP is usually required when you want to see a Specialist or other
provider, but there are some exceptions. You do not need a referral for:
•Emergency Services;
•Urgent Services;
•Access+ Specialist visits;
•OB/GYN services by an obstetrician, gynecologist, or family practice
Physician within your Medical Group; and
•Office visits with your PCP or for outpatient Mental Health and Substance Use
Disorder services with an MHSA Participating Provider.
When a decision will be made about your prior authorization request
Prior authorization or exception request Time for decision
Routine medical and Mental Health and Substance Use
Disorder requests
Within five business days
Expedited medical and Mental Health and Substance Use
Disorder requests
Within 72 hours
Medical management 29
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Expedited requests include urgent medical requests. Once the decision is made, your
provider will be notified within 24 hours. Written notice will be sent to you and your
provider within two business days.
While you are in the Hospital (inpatient utilization review)
When you are admitted to the Hospital, your stay will be monitored for continued
Medical Necessity. If it is no longer Medically Necessary for you to receive an inpatient
level of care, your Medical Group will send a written notice to you, your provider, and
the Hospital. If you choose to stay in the Hospital past the date indicated in this notice,
you will be financially responsible for all inpatient charges after that date. Exceptions to
inpatient utilization review include maternity and mastectomy care.
For maternity, the minimum length of an inpatient stay is 48 hours for a normal, vaginal
delivery and 96 hours for a C-section. The provider and mother together may decide
that a shorter length of stay is adequate.
For mastectomy, you and your provider determine the Medically Necessary length of
stay after the surgery.
After you leave the Hospital (discharge planning)
You may still need care at home or in another facility after you are discharged from the
Hospital. Your Medical Group will work with you, your provider, and the Hospital’s
discharge planners to determine the most appropriate and cost-effective way to
provide this care.
Using your Benefits effectively (care management)
Care management helps you coordinate your health care services and make the most
efficient use of your plan Benefits. Its goal is to help you stay as healthy as possible while
managing your health condition, to avoid unnecessary emergency room visits and
repeated hospitalizations, and to help you with the transition from Hospital to home. A
Blue Shield care management nurse may contact you to see how we might help you
manage your health condition. You may also request care management support by
calling Customer Service. A case manager can:
•Help you identify and access appropriate services;
•Instruct you about self-management of your health care conditions; and
•Identify community resources to lend support as you learn to manage a
chronic health condition.
Alternative services may be offered when they are medically appropriate and only
utilized when you, your provider, and Blue Shield mutually agree. The availability of
these services is specific to you for a set period of time based on your health condition.
Blue Shield does not give up the right to administer your Benefits according to the terms
of this Evidence of Coverage or to discontinue any alternative services when they are
no longer medically appropriate. Blue Shield is not obligated to cover the same or
similar alternative services for any other Member in any other instance.
Medical management 30
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Managing a serious illness (palliative care services)
Blue Shield covers palliative care services if you have a serious illness. Palliative care
provides relief from the symptoms, pain, and stress of a serious illness to help improve
the quality of life for you and your family.
Palliative care services include access to Physicians and case managers who are
specially trained to help you:
•Manage your pain and other symptoms;
•Maximize your comfort, safety, autonomy, and well-being;
•Navigate a course of care;
•Make informed decisions about therapy;
•Develop a survivorship plan; and
•Document your quality-of-life choices.
31
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Your payment information
Paying for coverage
Your Employer is responsible for a monthly payment to Blue Shield for health care
coverage for the Subscriber and any enrolled Dependents. This monthly payment is a
Premium. Any amount the Subscriber must contribute to the Premium is set by your
Employer.
The contract states the monthly Premiums for this plan for the Subscriber and any
enrolled Dependents.
Paying for Covered Services
Your Cost Share is the amount you pay for Covered Services. It is your portion of the
Blue Shield Allowed Charges.
Your Cost Share includes any:
•Deductible;
•Copayment amount; and
•Coinsurance amount.
See the Summary of Benefits section for your Cost Share for
Covered Services.
Allowed Charges and capitation
Participating Providers agree to accept the Allowed Charges as payment in full for
Covered Services provided or arranged by Blue Shield, except as stated in the
Exception for other coverage and Reductions – third party liability sections. Covered
Services provided or arranged by the Medical Group are paid for by capitation
payments. Every month, Blue Shield pays a set dollar amount to the Medical Group
for each enrolled Member. The capitation payments are available to cover the cost
of services when you need them.
If there is a payment dispute between Blue Shield and a Participating Provider over
Covered Services you receive, the Participating Provider must resolve that dispute
with Blue Shield. You are not required to pay for Blue Shield’s portion of the Allowed
Charges. You are only required to pay your Cost Share for those services.
When you see a Participating Provider, you are responsible for your Cost Share.
Calendar Year Deductible
The Deductible is the amount you pay each Calendar Year for Covered Services
before Blue Shield begins payment. Blue Shield will pay for some Covered Services
before you meet your Deductible.
Your payment information 32
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Amounts you pay toward your Deductible count toward your Out-of-Pocket
Maximum.
Some plans do not have a Deductible. For plans that do, there may be separate
Deductibles for an individual Member and an entire Family.
If you have a Family plan, there is an individual Deductible within the Family
Deductible. This means an individual family member can meet the individual
Deductible before the entire Family meets the Family Deductible.
If you have an individual plan and you enroll a Dependent, your plan will become a
Family plan. Any amount you have paid toward the Deductible for your individual
plan will be applied to both the individual Deductible and the Family Deductible for
your new plan.
See the Summary of Benefits section for details on which Covered Services are
subject to the Deductible and how the Deductible works for your plan.
Prior carrier Deductible credit
If you pay all or part of a Deductible for another Employer-sponsored health plan
in the same Calendar Year you enroll in this plan, that amount will be applied to
this plan’s Deductible if:
•You were enrolled in an Employer-sponsored health plan with another
carrier during the same Calendar Year this contract becomes effective
and you enroll as of the original effective date of coverage under this
contract;
•You were enrolled in another Blue Shield plan sponsored by the same
Employer which this plan is replacing; or
•You were enrolled in another Blue Shield plan sponsored by the same
Employer and you are transferring to this plan during open enrollment.
Copayment and Coinsurance
A Covered Service may have a Copayment or a Coinsurance. A Copayment is a
specific dollar amount you pay for a Covered Service. A Coinsurance is a
percentage of the Allowed Charges you pay for a Covered Service.
Your provider will ask you to pay your Copayment or Coinsurance at the time of
service. For Covered Services that are subject to your plan’s Deductible, you are also
responsible for all costs up to the Allowed Charges until you reach your Deductible.
You will continue to pay the Copayment or Coinsurance for each Covered Service
you receive until you reach your Out-of-Pocket Maximum.
Calendar Year Out-of-Pocket Maximum
The Out-of-Pocket Maximum is the most you are required to pay in Cost Share for
Covered Services in a Calendar Year. Your Cost Share includes Deductible,
Copayment, and Coinsurance, and these amounts count toward your Out-of-Pocket
Maximum, except as listed below. Once you reach your Out-of-Pocket Maximum,
Blue Shield will pay 100% of the Allowed Charges for Covered Services for the rest of
the Calendar Year. If you want information about your Out-of-Pocket Maximum, you
can call Customer Service.
Your payment information 33
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
If you have a Family plan, you will have a separate Out-of-Pocket Maximum for each
individual Member and one for the entire Family.
If you have a Family plan, there is an individual Out-of-Pocket Maximum within the
Family Out-of-Pocket Maximum. This means an individual family member can meet
the individual Out-of-Pocket Maximum before the entire Family meets the Family
Out-of-Pocket Maximum.
If you have an individual plan and you enroll a Dependent, your plan will become a
Family plan. Any amount you have paid toward the Out-of-Pocket Maximum for your
individual plan will be applied to both the individual Out-of-Pocket Maximum and
the Family Out-of-Pocket Maximum for your new plan.
The following do not count toward your Out-of-Pocket Maximum:
•Charges for services that are not covered;
•Charges over the Allowed Charges; and
•Charges for services over any Benefit maximum.
You will continue to be responsible for these costs even after you reach your Out-of-
Pocket Maximum.
See the Summary of Benefits section for details on how the Out-of-Pocket Maximum
works for your plan.
Accrual balance
Blue Shield provides a summary of your accrual balances toward your Calendar Year
Deductible, if any, and Out-of-Pocket Maximum for every month in which your
Benefits were used until the full amount has been met. This summary will be mailed to
you unless you opt to receive it electronically or have already opted out of paper
mailings. You can opt back in to receive paper mailings at any time or elect to
receive your balance summary electronically by logging into your member portal
online and updating your communication preferences, or by calling Customer
Service at the number on the back of your ID card. You can also check your accrual
balances at any time by logging into your member portal online, which is updated
daily, or calling Customer Service. Your accrual balance information is updated
once a claim is received and processed and may not reflect recent services.
Your payment information 34
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Cost Share concepts in action
To recap, you are responsible for all costs for Covered Services until you reach your
Deductible. Once you reach your Deductible, Blue Shield will pay the Allowed
Charges for Covered Services, minus your Copayment or Coinsurance amounts, until
you reach your Out-of-Pocket Maximum. Once you reach your Out-of-Pocket
Maximum, Blue Shield will pay 100% of the Allowed Charges for Covered Services.
Exceptions are described above.
EXAMPLE
Cost to visit the doctor
Now that you know the basics, here is an example of how your Cost Share
works. Please note, the DOLLAR AMOUNTS IN THE EXAMPLE ARE EXAMPLES
ONLY AND DO NOT REFLECT ACTUAL DOLLAR AMOUNTS FOR YOUR PLAN.
Example: You visit the doctor for a sore throat. You have received Covered
Services throughout the year and have already met your $500 Deductible.
However, you have not yet met your $1,000 Out-of-Pocket Maximum.
Deductible: $500
Amount paid to date toward Deductible: $500
Out-of-Pocket Maximum: $1,000
Amount paid to date toward Out-of-Pocket Maximum: $500
Participating Provider Copayment: $30
Blue Shield Allowed Charges for the doctor’s visit: $100
Participating Provider
You pay $30
($30 Copayment)
Blue Shield pays $70
(Allowed Charges
minus
your Cost Share)
Total payment to the
doctor
$100
(Allowed Charges)
In this example, because you have already met your Deductible, you are only
responsible for the Participating Provider Copayment.
Claims for Emergency or Urgent Services
If you receive Emergency or Urgent Services from a Non-Participating Provider, you may
be required to pay the charges in full and submit a claim to Blue Shield to request
Your payment information 35
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
reimbursement. Blue Shield may send the payment to the Subscriber or directly to the
Non-Participating Provider.
Claim forms are available at blueshieldca.com. Please submit your claim form and
medical records within one year of the service date.
See the Out-of-area services section in the Other important information about your plan
section for more information on claims for Emergency or Urgent Services outside of
California.
36
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Your coverage
This section explains eligibility and enrollment for this plan. It also describes the terms of
your coverage, including information about effective dates and the different ways your
coverage can end.
Eligibility for this plan
To be eligible for coverage as a Subscriber, you must meet all of your Employer’s
eligibility requirements and complete any waiting period established by your Employer.
Dependent eligibility
To be eligible for coverage as a Dependent, you must:
•Be listed on the enrollment form completed by the Subscriber; and
•Be the Subscriber’s spouse, Domestic Partner, or be under age 26 and the
child of the Subscriber, spouse, or Domestic Partner.
o For the Subscriber’s spouse to be eligible for this plan, the Subscriber and
spouse must not be legally separated.
o For the Subscriber’s Domestic Partner to be eligible for this plan, the
Subscriber and Domestic Partner must have a registered domestic
partnership (except as otherwise permitted by your Employer).
o “Child” includes a stepchild, newborn, child placed for adoption, child
placed in foster care, and child for whom the Subscriber, spouse, or
Domestic Partner is the legal guardian. It does not include a grandchild
unless the Subscriber, spouse, or Domestic Partner has adopted or is the
legal guardian of the grandchild.
o A child age 26 or older can remain enrolled as a Dependent if the child is
disabled, incapable of self-support because of a mental or physical
disability, and chiefly dependent on the Subscriber for economic support.
▪The Dependent child’s disability must have begun before the period
he or she would become ineligible for coverage due to age.
▪Blue Shield will send a notice of termination due to loss of eligibility 90
days before the date coverage will end.
▪The Subscriber must submit proof of continued eligibility for the
Dependent at Blue Shield’s request. Blue Shield may not request this
information again for two years after the initial determination. Blue
Shield may request this information no more than once a year after
that. The Subscriber’s failure to provide this information could result in
termination of a Dependent’s coverage.
Enrollment and effective dates of coverage
As the Subscriber, you can enroll in coverage for yourself and your Dependents during
your initial enrollment period, your Employer’s annual open enrollment period, or if you
qualify for a special enrollment period.
You are eligible for coverage as a Subscriber on the day following the date you
complete any applicable waiting period established by your Employer. Coverage starts
at 12:01 a.m. Pacific Time on the effective date of coverage. The Benefits of this plan
Your coverage 37
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are not available before the effective date of coverage. This Contract has a 12-month
term that begins on your Employer’s effective date of coverage.
Open enrollment period
The open enrollment period is the time when most people apply for coverage or
change coverage. You will have an annual open enrollment period set by your
Employer. Your Employer will notify its Employees of the open enrollment period each
year.
Special enrollment period
A special enrollment period is a time outside open enrollment when you can apply
for coverage or change coverage. A special enrollment period begins with a
Qualifying Event.
A special enrollment period gives you at least 30 days from a Qualifying Event to
apply for or change coverage for yourself or your Dependents. See the Special
enrollment period section for more information. You should notify your Employer as
soon as possible if you experience a Qualifying Event that requires a change in your
coverage.
Common Qualifying Events
Change in Dependents
Loss of coverage under another employer health plan or other health
insurance
Loss of eligibility in a government program
For a complete list of Qualifying Events, see Special enrollment
period on page 73 in the Other important information about
your plan section.
Effective date of coverage for most special enrollment periods
If enrolled during initial enrollment or open enrollment, a Dependent will have
the same effective date of coverage as the Subscriber. However, a Dependent
may have a different effective date of coverage if added during a special
enrollment period. Generally, if the Employee or Dependents qualify for a special
enrollment period, coverage will begin no later than the 1st of the month
following the date Blue Shield receives the request for special enrollment from
your Employer.
Effective date of coverage for a new Dependent child
Coverage starts immediately for a:
Your coverage 38
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2650.
•Newborn;
•Adopted child;
•Child placed for adoption;
•Child placed in foster care; or
•Child for whom the Subscriber, spouse, or Domestic Partner is the court-
appointed legal guardian.
For coverage to continue beyond 31 days for a newborn,
adopted child, or child placed for adoption, the Subscriber
must notify the Employer within 31 days of birth, adoption, or
placement for adoption and request that the child be added
as a Dependent.
If both partners in a marriage or Domestic Partnership are eligible Employees and
Subscribers, both are eligible for Dependent Benefits. You may enroll a child as a
Dependent of either or of both parents.
A child will be considered adopted for the purpose of Dependent eligibility when
one of the following happens:
•The child is legally adopted;
•The child is placed for adoption and there is evidence of the Subscriber,
spouse, or Domestic Partner’s right to control the child’s health care; or
•The Subscriber, spouse, or Domestic Partner is granted legal authority to
control the child’s health care.
The child’s eligibility as a Dependent will continue while waiting for a legal
decree of adoption unless the child is removed from the Subscriber, spouse, or
Domestic Partner’s home before the decree is issued.
Plan changes
Blue Shield has the right to change the Benefits and terms of this plan as the law
permits. This includes, but is not limited to, changes to:
•Terms and conditions;
•Benefits;
•Cost Shares;
•Premiums; and
•Limitations and exclusions.
Blue Shield will give your Employer written notice of Premium or coverage changes. We
will send this notice at least 60 days prior to plan renewal or the effective date of the
Benefit change. Your Employer is responsible for letting you know of any changes.
Benefits provided after the effective date of any change will be subject to the change.
There is no vested right to obtain the original Benefits.
Coordination of benefits
When you are covered by more than one group health plan, payments for allowable
expenses will be coordinated between the two plans. Coordination of benefits
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2650.
determines which plan will pay first when both plans have responsibility for paying the
medical claim. For more information, see the Coordination of benefits, continued
section.
When coverage ends
Your coverage will end if:
•Your Employer cancels or does not renew coverage;
•The Subscriber cancels coverage; or
•Blue Shield cancels or rescinds coverage.
There is no right to receive the Benefits of this plan after coverage ends, except as
described in the Extension of Benefits, Continuity of care, and Continuation of group
coverage sections.
If your Employer cancels coverage
Your Employer may cancel coverage at any time. To cancel coverage, Your
Employer must provide written notice to Blue Shield and its Employees.
If the Subscriber cancels coverage
If the Subscriber decides to cancel coverage, coverage will end at 11:59 p.m.
Pacific Time on a date determined by your Employer.
Reinstatement
If the Subscriber voluntarily cancels coverage, the Subscriber can contact the
Employer for reinstatement options.
If Blue Shield cancels coverage
Blue Shield can cancel coverage if:
•You are no longer eligible for coverage in this plan;
•Your Employer fails to meet Blue Shield’s Employer eligibility, participation,
and contribution requirements;
•Blue Shield terminates this plan; or
•You or your Employer commit fraud or intentional misrepresentation of
material fact.
Blue Shield will provide 30 days’ advance written notice of cancellation of coverage
to your Employer if your Employer fails to meet Blue Shield’s Employer eligibility,
participation, and contribution requirements. It is your Employer’s responsibility to
provide a copy of the notice to its Employees.
Cancellation for Employer’s nonpayment of Premiums
Blue Shield can cancel coverage if your Employer does not pay the required
Premiums in full and on time. Your Employer is responsible for all Premiums during the
term of coverage, including the 60-day grace period. If Blue Shield cancels
coverage due to nonpayment of Premiums, Blue Shield will send a Notice of End of
Coverage to you and your Employer no later than five calendar days after the date
coverage ends.
Your coverage 40
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2650.
Cancellation or rescission for fraud or intentional misrepresentation of material
fact
Blue Shield may cancel or rescind your coverage if you, your Dependent, or your
Employer commit fraud or intentional misrepresentation of material fact. Blue Shield
will send the Notice of Cancellation, Rescission or Nonrenewal to your Employer prior
to any rescission. Your Employer must provide you with a copy of the Notice of
Cancellation, Rescission or Nonrenewal. Rescission voids the Contract as if it never
existed. Cancellation is effective on the date specified in the Notice of Cancellation,
Rescission or Nonrenewal and the Notice of End of Coverage.
Extension of Benefits
If you become Totally Disabled while covered under this plan and continue to be
Totally Disabled on the date the Contract terminates, Blue Shield will extend Benefits
directly related to the condition, illness, or injury causing your Total Disability until one of
the following occurs:
•12 months from the effective date of termination;
•The date you are no longer Totally Disabled; or
•The date on which a replacement carrier provides coverage for your Total
Disability.
Your extension of Benefits will be subject to all the limitations and restrictions of this plan.
You will not receive an extension of Benefits unless a Physician provides Blue Shield with
written certification of your Total Disability within 90 days of the effective date of
termination. After that, the Physician must continue to provide written certification of
your Total Disability at reasonable intervals Blue Shield determines.
Continuation of group coverage
Please examine your options carefully before declining this coverage.
You can continue coverage under this group plan when your Employer is subject to
either Title X of the Consolidated Omnibus Budget Reconciliation Act (COBRA), as
amended, or the California Continuation Benefits Replacement Act (Cal-COBRA).
Your benefits under the group continuation of coverage provisions will be identical to
the Benefits you would have received as an active Employee if the qualifying event
had not occurred. Any changes in the coverage available to active Employees will also
apply to group continuation coverage.
COBRA
You may elect to continue group coverage under this plan if you would otherwise
lose coverage because of a COBRA qualifying event. Please contact your Employer
for detailed information about COBRA continuation coverage, including eligibility,
election of coverage, and Premiums.
Cal-COBRA
If you enroll in COBRA and exhaust the time limit for COBRA group continuation
coverage, you may be able to continue your group coverage under Cal-COBRA for
a combined total (COBRA plus Cal-COBRA) of 36 months.
Your coverage 41
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2650.
You will not be eligible for benefits under Cal-COBRA if, at the time of the Cal-COBRA
qualifying event, you are entitled to benefits under Medicare or are covered under
another group health plan. Medicare entitlement means that you are eligible for
Medicare benefits and enrolled in Part A only.
Cal-COBRA qualifying event
A Cal-COBRA qualifying event is an event that, except for the election of
continuation coverage, would result in a loss of coverage for the Subscriber or
eligible Dependents:
•The death of the Subscriber;
•Termination of the Subscriber’s employment (except termination for gross
misconduct which is not a qualifying event);
•Reduction in hours of the Subscriber’s employment;
•Divorce or legal separation of the Subscriber from the covered spouse;
•Termination of the Subscriber’s domestic partnership with a covered
Domestic Partner;
•Loss of Dependent status by a covered Dependent;
•The Subscriber’s entitlement to Medicare (This only applies to a covered
Dependent); and
•With respect to any of the above, such other qualifying event as may be
added to Cal-COBRA.
A child born to or placed for adoption with a covered Subscriber or Domestic
Partner during the Cal-COBRA group coverage continuation period may be
immediately added as a Dependent provided the Employer is properly notified
of the birth or placement for adoption, and the child is enrolled within 31 days of
the birth or placement for adoption.
Your coverage 42
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2650.
Notification of a qualifying event
You are responsible for notifying Blue Shield in writing of the Subscriber’s death or
Medicare entitlement, of divorce, legal separation, termination of a domestic
partnership, or a Dependent’s loss of Dependent status under this plan. This
notice must be given within 60 days of the date of the qualifying event. Failure to
provide such notice within 60 days will disqualify you from receiving continuation
coverage under Cal-COBRA.
Your Employer is responsible for notifying Blue Shield in writing of the Subscriber’s
termination or reduction of hours of employment within 30 days of the qualifying
event.
When Blue Shield is notified that a qualifying event has occurred, Blue Shield will,
within 14 days, provide you with written notice of your right to continue group
coverage under this plan. You must then give Blue Shield notice in writing of your
election of continuation coverage within 60 days of the date of the notice of
your right to continue group coverage, or the date coverage terminates due to
the qualifying event, whichever is later. The written election notice must be
delivered to Blue Shield by first-class mail or other reliable means.
If you do not notify Blue Shield within 60 days, your coverage will terminate on
the date you would have lost coverage because of the qualifying event.
If this plan replaces a previous group plan that was in effect with your Employer,
and you had elected Cal-COBRA continuation coverage under the previous
plan, you may continue coverage under this plan for the balance of your Cal-
COBRA eligibility period. To begin Cal-COBRA coverage with Blue Shield, you
must notify us within 30 days of the date you were notified of the termination of
your previous group plan.
Duration and extension of group continuation coverage
COBRA enrollees who reach the maximum coverage period available under
COBRA may elect to continue coverage under Cal-COBRA for a combined
maximum period of 36 months from the date continuation of coverage began
under COBRA. You must notify Blue Shield of your Cal-COBRA election at least 30
days before COBRA termination. Your Cal-COBRA coverage will begin
immediately after the COBRA coverage ends.
You must exhaust all available COBRA coverage before you can become
eligible to continue coverage under Cal-COBRA.
Cal-COBRA enrollees will be eligible to continue Cal-COBRA coverage under this
plan for up to a maximum of 36 months, regardless of the type of qualifying
event.
In no event will continuation of group coverage under COBRA, Cal-COBRA, or a
combination of COBRA and Cal-COBRA be extended for more than 36 months
Your coverage 43
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2650.
from the date of the qualifying event that originally entitled you to continue your
group coverage under this plan.
Payment of Premiums
Premiums for continuing coverage will be 110 percent of the applicable group
Premium rate, except if you are eligible to continue Cal-COBRA coverage
beyond 18 months because of a Social Security disability determination. In that
case, the Premiums for months 19 through 36 will be 150 percent of the
applicable group Premium rate.
Cal-COBRA enrollees must submit Premiums directly to Blue Shield. The initial
Premiums must be paid within 45 days of the date you provided written
notification to Blue Shield of your election to continue coverage and must be
sent to Blue Shield by first-class mail or other reliable means. You must pay the
entire amount due within the 45-day period or you will be disqualified from Cal-
COBRA continuation coverage.
Effective date of the continuation of group coverage
If your initial group continuation coverage is Cal-COBRA rather than COBRA,
your Cal-COBRA coverage will begin on the date your coverage under this plan
would otherwise end due to a qualifying event. Your coverage will continue for
up to 36 months unless terminated due to an event described in the Termination
of group continuation coverage section.
Termination of group continuation coverage
The continuation of group coverage will cease if any one of the following events
occurs prior to the expiration of the applicable period of continuation of group
coverage:
•Termination of the Contract (if your Employer continues to provide any group
benefit plan for Employees, you may be able to continue coverage with
another plan);
•Failure to pay Premiums in full and on time to Blue Shield. Coverage will end
as of the end of the period for which Premiums were paid;
•You become covered under another group health plan;
•You become entitled to Medicare; or
•You commit fraud or deception in the use of the services of this Plan.
Continuation of group coverage while on leave
Employers are responsible to ensure compliance with state and federal laws
regarding leaves of absence, including the California Family Rights Act, the Family
and Medical Leave Act, the Uniformed Services Employment and Re-employment
Rights Act, and Labor Code requirements for Medical Disability.
Family leave
The California Family Rights Act of 1991 and the federal Family & Medical Leave
Act of 1993 allow you to continue your coverage under this plan while you are
Your coverage 44
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2650.
on family leave. Your Employer is solely responsible for notifying their Employee of
the availability and duration of family leaves.
Military leave
The Uniformed Services Employment and Re-employment Rights Act of 1994
(USERRA) allows you to continue your coverage under this plan while you are on
military leave. If you are planning to enter the Armed Forces, you should contact
your Employer for information about your rights under the (USERRA).
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2650.
Your Benefits
This section describes the Benefits your plan covers. They are listed in alphabetical order
so they are easy to find.
Blue Shield provides coverage for Medically Necessary services and supplies only.
Experimental or Investigational services and supplies are not covered.
All Benefits are subject to:
•Your Cost Share;
•Any Benefit maximums;
•The provisions of the medical management section; and
•The terms, conditions, limitations, and exclusions of this Evidence of
Coverage.
You can receive many outpatient Benefits in a variety of settings, including your home,
a Physician’s office, an urgent care center, an Ambulatory Surgery Center, or a
Hospital. Blue Shield’s medical management helps your provider ensure that your care
is provided safely and effectively in a setting that is appropriate to your needs. Your
Cost Share for outpatient Benefits may vary depending on where you receive them.
See the Exclusions and limitations section for more information about Benefit exclusions
and limitations.
See the Summary of Benefits section for your Cost Share for
Covered Services.
Allergy testing and immunotherapy Benefits
Benefits are available for allergy testing and immunotherapy services.
Benefits include:
•Allergy testing on and under the skin such as prick/puncture, patch and
scratch tests;
•Preparation and provision of allergy serum; and
•Allergy serum injections.
This Benefit does not include:
•Blood testing for allergies.
Ambulance services
Benefits are available for ambulance services provided by a licensed ambulance or
psychiatric transport van.
Benefits include:
•Emergency ambulance transportation (surface and air) when used to
transport you from the place of illness or injury to the closest medical facility
that can provide appropriate medical care; and
Your Benefits 46
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2650.
•Non-emergency, prior-authorized ambulance transportation (surface and air)
from one medical facility to another.
Air ambulance services are covered at the Participating Provider Cost Share, even if
you receive services from a Non-Participating Provider.
Clinical trials for treatment of cancer or life-threatening diseases or
conditions Benefits
Benefits are available for routine patient care when you have been accepted into an
approved clinical trial for treatment of cancer or a life-threatening disease or condition.
A life-threatening disease or condition is a disease or condition that is likely to result in
death unless its progression is interrupted.
The clinical trial must have therapeutic intent and the treatment must meet one of the
following requirements:
•Your Participating Provider determines that your participation in the clinical
trial would be appropriate based on either the trial protocol or medical and
scientific information provided by you; or
•You provide medical and scientific information establishing that your
participation in the clinical trial would be appropriate.
Coverage for routine patient care received while participating in a clinical trial requires
prior authorization. Routine patient care is care that would otherwise be covered by the
plan if those services were not provided in connection with an approved clinical trial.
The Summary of Benefits section lists your Cost Share for Covered Services. These Cost
Share amounts are the same whether or not you participate in a clinical trial. Routine
patient care does not include:
•The investigational item, device, or service itself;
•Drugs or devices not approved by the U.S. Food and Drug Administration
(FDA);
•Travel, housing, companion expenses, and other non-clinical expenses;
•Any item or service that is provided solely to satisfy data collection and
analysis needs and that is not used in the direct clinical management of the
patient;
•Services that, except for the fact that they are being provided in a clinical
trial, are specifically excluded under the plan;
•Services normally provided by the research sponsor free for any enrollee in
the trial; or
•Any service that is clearly inconsistent with widely accepted and established
standards of care for a particular diagnosis.
Approved clinical trial means a phase I, phase II, phase III, or phase IV clinical trial
conducted in relation to the prevention, detection, or treatment of cancer or other life-
threatening diseases or conditions, and the study or investigation meets one of the
following requirements:
•It is a drug trial conducted under an investigational new drug application
reviewed by the FDA;
•It is a drug trial exempt under federal regulations from a new drug
application; or
•It is federally funded or approved by one or more of the following:
Your Benefits 47
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2650.
o One of the National Institutes of Health;
o The Centers for Disease Control and Prevention;
o The Agency for Health Care Research and Quality;
o The Centers for Medicare & Medicaid Services; or
o A designated Agency affiliate or research entity as described in the
Affordable Care Act, including the Departments of Veterans Affairs,
Defense, or Energy if the study has been reviewed and approved
according to Health and Human Services guidelines.
Diabetes care services
Benefits are available for devices, equipment, supplies, and self-management training
to help manage your diabetes. Services will be covered when provided by a Physician,
registered dietician, registered nurse, or other appropriately-licensed Health Care
Provider who is certified as a diabetes educator.
Devices, equipment, and supplies
Covered diabetic devices, equipment, and supplies include:
•Blood glucose monitors, including continuous blood glucose monitors and
those designed to help the visually impaired, and all related necessary
supplies;
•Insulin pens, syringes, pumps, and all related necessary supplies;
•Disposable hypodermic needles and syringes needed for administration of
insulin and glucagon;
•Blood and urine testing strips and tablets;
•Lancets and lancet puncture devices;
•Podiatric footwear and devices to prevent or treat diabetes-related
complications;
•Medically Necessary foot care; and
•Visual aids, excluding eyewear and video-assisted devices, designed to help
the visually impaired with proper dosing of insulin.
Your plan also covers the replacement of a covered item after the expiration of its life
expectancy. Insulin and glucagon may be covered under the Prescription Drug Rider, if
your Employer selected it as an optional Benefit.
Self-management training and medical nutrition therapy
Benefits are available for outpatient training, education, and medical nutrition
therapy when directed or prescribed by your Physician. These services can help you
manage your diabetes and properly use the devices, equipment, and supplies
available to you. With self-management training, you can learn to monitor your
condition and avoid frequent hospitalizations and complications.
Diagnostic X-ray, imaging, pathology, laboratory, and other testing
services
Benefits are available for imaging, pathology, and laboratory services for preventive
screening or to diagnose or treat illness or injury.
Your Benefits 48
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2650.
Benefits include:
•Basic diagnostic imaging services, such as plain film X-rays, ultrasounds, and
mammography;
•Advanced diagnostic radiological and nuclear imaging, including CT, PET,
MRI, and MRA scans;
•COVID-19 diagnostic testing, screening testing, and related healthcare
services. Medical Necessity requirements do not apply for COVID-19
screening testing;
•Reimbursement for over-the-counter at-home COVID-19 tests. The
reimbursement is allowed for up to 8 tests per Member per month. See the
Claims section for information about how to submit a claim for repayment for
this Benefit;
•Sexually transmitted disease home testing kits, including any laboratory costs
of processing the kit. A Physician or other Health Care Provider’s order must
be provided for coverage;
•Clinical pathology services;
•Laboratory services;
•Other areas of non-invasive diagnostic testing, including respiratory,
neurological, vascular, cardiological, genetic, cardiovascular, and
cerebrovascular; and
•Prenatal diagnosis of genetic disorders of the fetus in cases of high-risk
pregnancy.
Laboratory or imaging services performed as part of a preventive health screening are
covered under the Preventive Health Services Benefit.
For services provided by Participating Providers, Blue Shield will waive Cost Shares for
COVID-19 diagnostic testing, screening testing, and related services.
Blue Shield encourages Members to seek services from Participating Providers to avoid
paying extra fees. Some Non-Participating Providers may charge extra fees that are not
covered by Blue Shield. Any fees not covered by Blue Shield will be the Member’s
responsibility. See the How to access care section for information about Participating
and Non-Participating Providers.
Dialysis Benefits
Benefits are available for dialysis services at a freestanding dialysis center, in the
Outpatient Department of a Hospital, in a physician office setting, or in your home.
Benefits include:
•Renal dialysis;
•Hemodialysis;
•Peritoneal dialysis; and
•Self-management training for home dialysis.
Benefits do not include:
•Comfort, convenience, or luxury equipment; or
•Non-medical items, such as generators or accessories to make home dialysis
equipment portable.
Your Benefits 49
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2650.
Durable medical equipment
Benefits are available for durable medical equipment (DME) and supplies needed to
operate the equipment. DME is intended for repeated use to treat an illness or injury, to
improve the function of movable body parts, or to prevent further deterioration of your
medical condition. Items such as orthotics and prosthetics are only covered when
necessary for Activities of Daily Living.
Benefits include:
•Mobility devices, such as wheelchairs;
•Peak flow meter for the self-management of asthma;
•Glucose monitor including continuous blood glucose monitor, and all related
necessary supplies for the self-management of diabetes;
•Apnea monitors for the management of newborn apnea;
•Home prothrombin monitor for specific conditions;
•Oxygen and respiratory equipment;
•Disposable medical supplies used with DME and respiratory equipment;
•Required dialysis equipment and medical supplies;
•Medical supplies that support and maintain gastrointestinal, bladder, or
bowel function, such as ostomy supplies;
•DME rental fees, up to the purchase price; and
•Breast pumps.
Benefits do not include:
•Environmental control and hygienic equipment, such as air conditioners,
humidifiers, dehumidifiers, or air purifiers;
•Exercise equipment;
•Routine maintenance, repair, or replacement of DME due to loss or misuse,
except when authorized;
•Self-help or educational devices;
•Speech or language assistance devices, except as specifically listed;
•Wigs;
•Adult eyewear;
•Video-assisted visual aids for diabetics;
•Generators;
•Any other equipment not primarily medical in nature; or
•Backup or alternate equipment.
See the Diabetes care services section for more information about devices, equipment,
and supplies for the management and treatment of diabetes
Orthotic equipment and devices
Benefits are available for orthotic equipment and devices you need to perform
Activities of Daily Living. Orthotics are orthopedic devices used to support, align,
prevent, or correct deformities or to improve the function of movable body parts.
Benefits include:
•Shoes only when permanently attached to orthotic devices;
•Special footwear required for foot disfigurement caused by disease, disorder,
accident, or developmental disability;
Your Benefits 50
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2650.
•Knee braces for postoperative rehabilitation following ligament surgery,
instability due to injury, and to reduce pain and instability for patients with
osteoarthritis;
•Custom-made rigid orthotic shoe inserts ordered by a Physician or podiatrist
and used to treat mechanical problems of the foot, ankle, or leg by
preventing abnormal motion and positioning when improvement has not
occurred with a trial of strapping or an over-the-counter stabilizing device;
•Device fitting and adjustment;
•Device replacement at the end of its expected lifespan; and
•Repair due to normal wear and tear.
Benefits do not include:
•Orthotic devices intended to provide additional support for recreational or
sports activities;
•Orthopedic shoes and other supportive devices for the feet, except as listed;
•Backup or alternate items; or
•Repair or replacement due to loss or misuse.
Prosthetic equipment and devices
Benefits are available for prosthetic appliances and devices used to replace a part
of your body that is missing or does not function, and related supplies.
Benefits include:
•Tracheoesophageal voice prosthesis (e.g. Blom-Singer device) and artificial
larynx for speech after a laryngectomy;
•Artificial limbs and eyes;
•Internally-implanted devices such as pacemakers, intraocular lenses,
cochlear implants, osseointegrated hearing devices, and hip joints, if surgery
to implant the device is covered;
•Contact lenses to treat eye conditions such as keratoconus or keratitis sicca,
aniridia, or to treat aphakia following cataract surgery when no intraocular
lens has been implanted;
•Supplies necessary for the operation of prostheses;
•Device fitting and adjustment;
•Device replacement at the end of its expected lifespan; and
•Repair due to normal wear and tear.
Benefits do not include:
•Speech or language assistance devices, except as listed;
•Dental implants;
•Backup or alternate items; or
•Repair or replacement due to loss or misuse.
Emergency Benefits
Benefits are available for Emergency Services received in the emergency room of a
Hospital or other emergency room licensed under state law. The Emergency Benefit
also includes Hospital admission when inpatient treatment of your Emergency Medical
Condition is Medically Necessary. You can access Emergency Services for an
Emergency Medical Condition at any Hospital, even if it is a Non-Participating Hospital.
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If you have a medical emergency, call 911 or seek immediate
medical attention at the nearest hospital.
Benefits include:
•Physician services;
•Emergency room facility services; and
•Inpatient Hospital services to stabilize your Emergency Medical Condition.
After your condition stabilizes
Once your Emergency Medical Condition has stabilized, it is no longer considered an
emergency. Upon stabilization, you may:
•Be released from the emergency room if you do not need further treatment;
•Receive additional inpatient treatment at the Participating Hospital; or
•Transfer to a Participating Hospital for additional inpatient treatment if you
received treatment of your Emergency Medical Condition at a Non-
Participating Hospital.
Stabilization is medical treatment necessary to assure, with reasonable medical
probability, that no material deterioration of the condition is likely to result from, or
occur during, your release from medical care or transfer from a facility. With respect
to a pregnant woman who is having contractions, when there is inadequate time to
safely transfer her to another Hospital before delivery or the transfer may pose a
threat to the health or safety of the woman or unborn child, stabilize means delivery,
including the placenta. Post-stabilization care is Medically Necessary treatment
received after the treating Physician determines the Emergency Medical Condition is
stabilized.
If you are admitted to the Hospital for Emergency Services, you should notify your
PCP within 24 hours or as soon as possible after your condition has stabilized.
Family planning and Infertility Benefits
Family planning
Benefits are available for family planning services without illness or injury.
Benefits include:
•Counseling, consulting, and education;
•Office-administered contraceptives;
•Physician office visits for office-administered contraceptives;
•Clinical services related to the provision or use of contraceptives, including
consultations, examinations, procedures, device insertion, ultrasound,
anesthesia, patient education, referrals, and counseling;
•Follow-up services related to contraceptive Drugs, devices, products, and
procedures, including but not limited to management of side effects,
counseling for continued adherence, and device removal;
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•Voluntary tubal ligation and other similar sterilization procedures; and
•Vasectomy services and procedures.
Infertility Benefits
Benefits are provided for the diagnosis and treatment of the cause of Infertility,
including professional, Hospital, Ambulatory Surgery Center, and related services to
diagnose and treat the cause of Infertility, with the exception of what is excluded in
the Exclusions and limitations section.
Fertility preservation services
Fertility preservation services are covered for Members undergoing treatment or
receiving Covered Services that may directly or indirectly cause iatrogenic Infertility.
Under these circumstances, standard fertility preservation services are a Covered
Service and do not fall under the scope of Infertility Benefits described in the Family
Planning and Infertility Benefits section.
Home health services
Benefits are available for home health services. These services include home health
agency services, home infusion and injectable medication services, and hemophilia
home infusion services.
Home health agency services
Benefits are available from a Participating home health care agency for diagnostic
and treatment services received in your home under a written treatment plan
approved by your Physician.
Benefits include:
•Intermittent home care for skilled services from:
o Registered nurses;
o Licensed vocational nurses;
o Physical therapists;
o Occupational therapists;
o Speech and language pathologists;
o Licensed clinical social workers; and
o Home Health Aides.
•Related medical supplies.
Intermittent home care is for skilled services you receive:
•Fewer than seven days per week; or
•Daily, for fewer than eight hours per day, up to 21 days.
Benefits are limited to a visit maximum as shown in the Summary of Benefits section
for home health agency visits. For this Benefit, coverage includes:
•Up to four visits per day, two hours maximum per visit, with a registered nurse,
licensed vocational nurse, physical therapist, occupational therapist, speech
and language pathologist, or licensed clinical social worker. A visit of two
hours or less is considered one visit. Nursing visits cannot be combined to
provide Continuous Nursing Services.
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•Up to four hours maximum per visit with a Home Health Aide. A visit of four
hours or less is considered one visit.
Benefits do not include:
•Continuous Nursing Services provided by a registered nurse or a licensed
vocational nurse, on a one-to-one basis, in an inpatient or home setting.
These services may also be described as “shift care” or “private duty nursing.”
Home infusion and injectable medication services
Benefits are available through a Participating home infusion agency for home
infusion, enteral, and injectable medication therapy.
Benefits include:
•Home infusion agency Skilled Nursing visits;
•Infusion therapy provided in an infusion suite associated with a Participating
home infusion agency;
•Administration of parenteral nutrition formulations and solutions;
•Administration of enteral nutrition formulas and solutions;
•Medical supplies used during a covered visit; and
•Medications injected or administered intravenously.
See the PKU formulas and special food products section for more information.
There is no Calendar Year visit maximum for home infusion agency services.
This Benefit does not include:
•Insulin;
•Insulin syringes; and
•Services related to hemophilia, which are described below.
Hemophilia home infusion services
Benefits are available for hemophilia home infusion products and services for the
treatment of hemophilia and other bleeding disorders. Benefits must be prior
authorized and provided in the home or in an infusion suite managed by a
Participating Hemophilia Home Infusion Provider.
Benefits include:
•24-hour service;
•Home delivery of hemophilia infusion products;
•Blood factor product;
•Supplies for the administration of blood factor product; and
•Nursing visits for training or administration of blood factor products.
There is no Calendar Year visit maximum for hemophilia home infusion agency
services.
Benefits do not include:
•In-home services to treat complications of hemophilia replacement therapy;
or
•Self-infusion training programs, other than nursing visits to assist in
administration of the product.
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Most Participating home health care and home infusion agencies are not
Participating Hemophilia Home Infusion Providers. A list of Participating Hemophilia
Home Infusion Providers is available at blueshieldca.com.
Hospice program services
Benefits are available through a Participating Hospice Agency for specialized care if
you have been diagnosed with a terminal illness with a life expectancy of one year or
less. When you enroll in a Hospice program, you agree to receive all care for your
terminal illness through the Hospice Agency. Hospice program enrollment is prior
authorized for a specified period of care based on your Physician’s certification of
eligibility. The period of care begins the first day you receive Hospice services and ends
when the specified timeframe is over or you choose to receive care for your terminal
illness outside of the Hospice program.
The authorized period of care is for two 90-day periods followed by unlimited 60-day
periods, depending on your diagnosis. Your Hospice care continues through to the next
period of care when your Physician recertifies that you have a terminal illness. The
Hospice Agency works with your Physician to ensure that your Hospice enrollment
continues without interruption. You can change your Participating Hospice Agency only
once during each period of care.
A Hospice program provides interdisciplinary care designed to ease your physical,
emotional, social, and spiritual discomfort during the last phases of life, and support
your primary caregiver and your family. Hospice services are available 24 hours a day
through the Hospice Agency.
While enrolled in a Hospice program, you may continue to receive Covered Services
that are not related to the care and management of your terminal illness from the
appropriate Health Care Provider. However, all care related to your terminal illness must
be provided through the Hospice Agency. You may discontinue your Hospice
enrollment when an acute Hospital admission is necessary, or at any other time. You
may also enroll in the Hospice program again when you are discharged from the
Hospital, or at any other time, with Physician recertification.
Benefits include:
•Pre-Hospice consultation to discuss care options and symptom management;
•Advance care planning;
•Skilled Nursing Services;
•Medical direction and a written treatment plan approved by a Physician;
•Continuous Nursing Services provided by registered or licensed vocational
nurses, eight to 24 hours per day;
•Home Health Aide services, supervised by a nurse;
•Homemaker services, supervised by a nurse, to help you maintain a safe and
healthy home environment;
•Medical social services;
•Dietary counseling;
•Volunteer services by a Hospice agency;
•Short-term inpatient, Hospice house, or Hospice care, if required;
•Drugs, medical equipment, and supplies;
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•Physical therapy, occupational therapy, and speech-language pathology
services to control your symptoms or help your ability to perform Activities of
Daily Living;
•Respiratory therapy;
•Occasional, short-term inpatient respite care when necessary to relieve your
primary caregiver or family members, up to five days at a time;
•Bereavement services for your family; and
•Social services, counseling, and spiritual services for you and your family.
Benefits do not include:
•Services provided by a Non-Participating Hospice Agency, except in certain
circumstances where there are no Participating Hospice Agencies in your
area and services are prior authorized.
Hospital services
Benefits are available for inpatient care in a Hospital.
Benefits include:
•Room and board, such as:
o Semiprivate Hospital room, or private room if Medically Necessary;
o Specialized care units, including adult intensive care, coronary care,
pediatric and neonatal intensive care, and subacute care;
o General and specialized nursing care; and
o Meals, including special diets.
•Other inpatient Hospital services and supplies, including:
o Operating, recovery, labor and delivery, and other specialized
treatment rooms;
o Anesthesia, oxygen, medicines, and IV solutions;
o Clinical pathology, laboratory, radiology, and diagnostic services and
supplies;
o Dialysis services and supplies;
o Blood and blood products;
o Medical and surgical supplies, surgically implanted devices,
prostheses, and appliances;
o Radiation therapy, chemotherapy, and associated supplies;
o Therapy services, including physical, occupational, respiratory, and
speech therapy;
o Acute detoxification;
o Acute inpatient rehabilitative services; and
o Emergency room services resulting in admission.
Medical treatment of the teeth, gums, jaw joints, and jaw bones
Benefits are available for outpatient, Hospital, and professional services provided for
treatment of the jaw joints and jaw bones, including adjacent tissues.
Benefits include:
•Treatment of odontogenic and non-odontogenic oral tumors (benign or
malignant);
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•Stabilization of natural teeth after traumatic injury independent of disease,
illness, or any other cause;
•Surgical treatment of temporomandibular joint syndrome (TMJ);
•Non-surgical treatment of TMJ;
•Orthognathic surgery to correct a skeletal deformity;
•Dental and orthodontic services directly related to cleft palate repair;
•Dental services to prepare the jaw for radiation therapy for the treatment of
head or neck cancers; and
•General anesthesia and associated facility charges during dental treatment
due to the Member’s underlying medical condition or clinical status when:
o The Member is younger than seven years old; or
o The Member is developmentally disabled; or
o The Member’s health is compromised and general anesthesia is
Medically Necessary.
Benefits do not include:
•Diagnostic dental services such as oral examinations, oral pathology, oral
medicine, X-rays, and models of the teeth, except when related to surgical
and non-surgical treatment of TMJ;
•Preventive dental services such as cleanings, space maintainers, and habit
control devices except as covered under the Preventive Health Services
Benefit;
•Periodontal care such as hard and soft tissue biopsies and routine oral surgery
including removal of teeth;
•Reconstructive or restorative dental services such as crowns, fillings, and root
canals;
•Orthodontia for any reason other than cleft palate repair;
•Dental implants for any reason other than cleft palate repair;
•Any procedure to prepare the mouth for dentures or for the more
comfortable use of dentures;
•Alveolar ridge surgery of the jaws if performed primarily to treat diseases
related to the teeth, gums, or periodontal structures, or to support natural or
prosthetic teeth; or
•Fluoride treatments for any reason other than preparation of the oral cavity
for radiation therapy or for Benefits covered under Preventive Health Services.
Mental Health and Substance Use Disorder Benefits
Blue Shield’s Mental Health Service Administrator (MHSA) administers Mental Health and
Substance Use Disorder services from MHSA Participating Providers for Members in
California. See the Out-of-area services section for an explanation of how Benefits are
administered for out-of-state services. Mental health services provided through Teladoc
are administered by Blue Shield, not the MHSA. See the Teladoc section for more
information.
The MHSA Participating Provider must get prior authorization from the MHSA for all non-
emergency Hospital admissions for Mental Health and Substance Use Disorder services,
and for certain outpatient Mental Health and Substance Use Disorder Services. See the
Medical management section for more information about prior authorization.
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The MHSA Participating Providers network is separate from Blue Shield’s Participating
Provider network. Visit blueshieldca.com and click on Find a Doctor to access the MHSA
Participating Provider network.
Office visits
Benefits are available for professional office visits, including Physician office visits, for
the diagnosis and treatment of Mental Health and Substance Use Disorders in an
individual, Family, or group setting.
Benefits are also available for telebehavioral health online counseling services,
psychotherapy, and medication management with a mental health or substance
use disorder provider.
Other Outpatient Mental Health and Substance Use Disorder Services
In addition to office visits, Benefits are available for other outpatient services for the
diagnosis and treatment of Mental Health and Substance Use Disorders. You can
receive these other outpatient services in a facility, office, home, or other non-
institutional setting.
For Behavioral Health Crisis Services rendered by a Non-Participating Provider, you
will pay the same Cost Share for Covered Services received from a Participating
Provider. Prior authorization is not required for the Medically Necessary Treatment of
a Mental Health or Substance Use Disorder provided by a 988 center, Mobile Crisis
Team, or other Behavioral Health Crisis Services.
Other Outpatient Mental Health and Substance Use Disorder Services include, but
are not limited to:
•Behavioral Health Treatment – professional services and treatment programs,
including applied behavior analysis and evidence-based intervention
programs, prescribed by a Physician or licensed psychologist and provided
under a treatment plan approved by the MHSA to develop or restore, to the
maximum extent practicable, the functioning of an individual with pervasive
developmental disorder or autism;
•Behavioral Health Crisis Services and other services provided by a 988 center,
a Mobile Crisis Team, or other provider of Behavioral Health Crisis Services,
regardless of whether the service is rendered by a Participating or Non-
Participating Provider;
•Electroconvulsive therapy – the passing of a small electric current through the
brain to induce a seizure, used in the treatment of severe depression;
•Intensive Outpatient Program – outpatient care for mental health or
substance use disorders when your condition requires structure, monitoring,
and medical/psychological intervention at least three hours per day, three
days per week;
•Office-based opioid treatment – substance use disorder maintenance
therapy, including methadone maintenance treatment;
•Partial Hospitalization Program – an outpatient treatment program that may
be in a free-standing or Hospital-based facility and provides services at least
five hours per day, four days per week when you are admitted directly or
transferred from acute inpatient care following stabilization;
•Psychological Testing – testing to diagnose a mental health condition; and
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•Transcranial magnetic stimulation – a non-invasive method of delivering
electrical stimulation to the brain for the treatment of severe depression.
Benefits do not include:
•Treatment for the purposes of providing respite, day care, or educational
services, or to reimburse a parent for participation in the treatment.
Inpatient Services
Benefits are available for inpatient facility and professional services for the treatment
of Mental Health and Substance Use Disorders in:
•A Hospital; or
•A free-standing residential treatment center that provides 24-hour care when
you do not require acute inpatient care.
Medically Necessary inpatient substance use disorder detoxification is covered
under the Hospital services Benefit.
Physician and other professional services
Benefits are available for services performed by a Physician, surgeon, or other Health
Care Provider to diagnose or treat a medical condition.
Benefits include:
•Office visits for examination, diagnosis, counseling, education, consultation,
and treatment;
•Specialist office visits;
•Urgent care center visits;
•Second medical opinions;
•Administration of injectable medications;
•Administration of radiopharmaceutical medications;
•Outpatient services;
•Inpatient services in a Hospital, Skilled Nursing Facility, residential treatment
center, or emergency room;
•Home visits;
•Telehealth consultations, provided remotely via communication
technologies, for examination, diagnosis, counseling, education, and
treatment. Coverage for these services will be on the same basis and to the
same extent as a service conducted in person; and
•Teladoc general medical consultations.
See the Mental Health and Substance Use Disorder Benefits section for information on
Mental Health and Substance Use Disorder office visits and Other Outpatient Mental
Health and Substance Use Disorder services.
Medical nutrition therapy
Benefits are provided for office visits for medical nutrition therapy for conditions other
than diabetes. Treatment must be prescribed by a Physician and provided by a
Registered Dietitian Nutritionist or other appropriately-licensed or certified Health
Care Provider. You can continue to receive medical nutrition therapy as long as your
treatment is Medically Necessary. Blue Shield may periodically review the provider’s
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treatment plan and records for Medical Necessity. See the Diabetes care services
section for information about medical nutrition therapy for diabetes.
PKU formulas and special food products
Benefits are available for formulas and special food products if you are diagnosed with
phenylketonuria (PKU). The items must be part of a diet prescribed and managed by a
Physician or appropriately-licensed Health Care Provider.
Benefits include:
•Enteral formulas;
•Parenteral nutrition formulations; and
•Special food products for the dietary treatment of PKU.
Benefits do not include:
•Grocery store foods including shakes, snack bars, used by the general
population;
•Additives such as thickeners, enzyme products; or
•Food that is naturally low in protein, unless specially formulated to have less
than one gram of protein per serving.
Podiatric services
Benefits are available for the diagnosis and treatment of conditions of the foot, ankle,
and related structures. These services, including surgery, are generally provided by a
licensed doctor of podiatric medicine.
Pregnancy and maternity care
Benefits are available for maternity care services.
Benefits include:
•Prenatal care;
•Postnatal care;
•Involuntary complications of pregnancy;
•Inpatient Hospital services including labor, delivery, and postpartum care;
•Elective newborn circumcision within 18 months of birth; and
•Abortion and abortion-related services, including preabortion and followup
services.
See the Diagnostic X-ray, imaging, pathology, and laboratory services and Preventive
Health Services sections for information about coverage of genetic testing and
diagnostic procedures related to pregnancy and maternity care.
The Newborns’ and Mothers’ Health Protection Act requires health plans to provide a
minimum Hospital stay for the mother and newborn child of 48 hours after a normal,
vaginal delivery and 96 hours after a C-section. The attending Physician, in consultation
with the mother, may determine that a shorter length of stay is adequate. If your
Hospital stay is shorter than the minimum stay, you can receive a follow-up visit with a
Health Care Provider whose scope of practice includes postpartum and newborn care.
This follow-up visit may occur at home or as an outpatient, as necessary. This visit will
include parent education, assistance and training in breast or bottle feeding, and any
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necessary physical assessments for the mother and child. Prior authorization is not
required for this follow-up visit.
Preventive Health Services
Benefits are available for Preventive Health Services such as screenings, checkups, and
counseling to prevent health problems or detect them at an early stage.
Benefits include:
•Evidence-based items, drugs, or services that have a rating of A or B in the
current recommendations of the United States Preventive Services Task Force
(USPSTF), such as:
o Screening for cancer, such as colorectal cancer, cervical cancer,
breast cancer, and prostate cancer;
o Screening for HPV;
o Screening for osteoporosis; and
o Health education;
•Immunizations recommended by either the Advisory Committee on
Immunization Practices of the Centers for Disease Control and Prevention, or
the most current version of the Recommended Childhood Immunization
Schedule/United States, jointly adopted by the American Academy of
Pediatrics, the Advisory Committee on Immunization Practices, and the
American Academy of Family Physicians;
•Evidence-informed preventive care and screenings for infants, children, and
adolescents as listed in the comprehensive guidelines supported by the
Health Resources and Services Administration, including screening for risk of
lead exposure and blood lead levels in children at risk for lead poisoning;
•Adverse Childhood Experiences screenings;
•California Prenatal Screening Program; and
•Additional preventive care and screenings for women not described above
as provided for in comprehensive guidelines supported by the Health
Resources and Services Administration. See the Family planning Benefits
section for more information.
If there is a new recommendation or guideline in any of the resources described above,
Blue Shield will have at least one year to implement coverage. The new
recommendation will be covered as a Preventive Health Service in the plan year that
begins after that year. However, for COVID-19 Preventive Health Services and
Preventive Health Services for a disease for which the Governor of the State of
California has declared a public health emergency, a new recommendation will be
covered within 15 business days.
Visit blueshieldca.com/preventive for more information about
Preventive Health Services.
Reconstructive Surgery Benefits
Benefits are available for Reconstructive Surgery services.
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Benefits include:
•Surgery to correct or repair abnormal structures of the body caused by
congenital defects, developmental abnormalities, trauma, infection, tumors,
or disease to:
o Improve function; or
o Create a normal appearance to the extent possible;
•Dental and orthodontic surgery services directly related to cleft palate repair;
and
•Surgery and surgically-implanted prosthetic devices in accordance with the
Women’s Health and Cancer Rights Act of 1998 (WHCRA).
Benefits do not include:
•Cosmetic surgery, which is surgery that is performed to alter or reshape
normal structures of the body to improve appearance;
•Reconstructive Surgery when there is a more appropriate procedure that will
be approved; or
•Reconstructive Surgery to create a normal appearance when it offers only a
minimal improvement in appearance.
In accordance with the WHCRA, Reconstructive Surgery, and surgically implanted and
non-surgically implanted prosthetic devices (including prosthetic bras), are covered for
either breast to restore and achieve symmetry following a mastectomy, and for the
treatment of the physical complications of a mastectomy, including lymphedemas. For
coverage of prosthetic devices following a mastectomy, see the Durable medical
equipment section. Medically Necessary services will be determined by your attending
Physician in consultation with you.
Benefits will be provided in accordance with guidelines established by Blue Shield and
developed in conjunction with plastic and reconstructive surgeons, except as required
under the WHCRA.
Rehabilitative and habilitative services
Benefits are available for outpatient rehabilitative and habilitative services.
Rehabilitative services help to restore the skills and functional ability you need to
perform Activities of Daily Living when you are disabled by injury or illness. Habilitative
services are therapies that help you learn, keep, or improve the skills or functioning you
need for Activities of Daily Living.
These services include physical therapy, occupational therapy, and speech therapy.
Your Physician or Health Care Provider must prepare a treatment plan. Treatment must
be provided by an appropriately-licensed or certified Health Care Provider. You can
continue to receive rehabilitative or habilitative services as long as your treatment is
Medically Necessary.
Blue Shield may periodically review the provider’s treatment plan and records for
Medical Necessity.
See the Hospital services section for information about inpatient rehabilitative Benefits.
See the Home health services and Hospice program services sections for information
about coverage for rehabilitative and habilitative services provided in the home.
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Physical therapy
Physical therapy uses physical agents and therapeutic treatment to develop,
improve, and maintain your musculoskeletal, neuromuscular, and respiratory systems.
Physical agents and therapeutic treatments include but are not limited to:
•Ultrasound;
•Heat;
•Range of motion testing;
•Targeted exercise; and
•Massage as a component of a multimodality rehabilitative treatment plan or
physical therapy treatment plan.
Occupational therapy
Occupational therapy is treatment to develop, improve, and maintain the skills you
need for Activities of Daily Living, such as dressing, eating, and drinking.
Speech therapy
Speech therapy is used to develop, improve, and maintain vocal or swallowing skills
that have not developed according to established norms or have been impaired by
a diagnosed illness or injury. Benefits are available for outpatient speech therapy for
the treatment of:
•A communication impairment;
•A swallowing disorder;
•An expressive or receptive language disorder; and
•An abnormal delay in speech development.
Skilled Nursing Facility (SNF) services
Benefits are available for treatment in the Skilled Nursing unit of a Hospital or in a free-
standing Skilled Nursing Facility (SNF) when you are receiving Skilled Nursing or
rehabilitative services. This Benefit also includes care at the Subacute Care level.
Benefits must be prior authorized and are limited to a day maximum per benefit period,
as shown in the Summary of Benefits section. A benefit period begins on the date you
are admitted to the facility. A benefit period ends 60 days after you are discharged
from the facility or you stop receiving Skilled Nursing services. A new benefit period can
only begin after an existing benefit period ends.
Transplant services
Benefits are available for tissue and kidney transplants and special transplants.
Tissue and kidney transplants
Benefits are available for facility and professional services provided in connection
with human tissue and kidney transplants when you are the transplant recipient.
Benefits include services incident to obtaining the human transplant material from a
living donor or a tissue/organ transplant bank.
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Special transplants
Benefits are available for special transplants only if:
•The procedure is performed at a special transplant facility contracting with
Blue Shield, or if you access this Benefit outside of California, the procedure is
performed at a transplant facility designated by Blue Shield; and
•You are the recipient of the transplant.
Special transplants are:
•Human heart transplants;
•Human lung transplants;
•Human heart and lung transplants in combination;
•Human liver transplants;
•Human kidney and pancreas transplants in combination;
•Human bone marrow transplants, including autologous bone marrow
transplantation (ABMT) or autologous peripheral stem cell transplantation
used to support high-dose chemotherapy when such treatment is Medically
Necessary and is not Experimental or Investigational;
•Pediatric human small bowel transplants; and
•Pediatric and adult human small bowel and liver transplants in combination.
Donor services
Transplant Benefits include coverage for donation-related services for a living donor,
including a potential donor, or a transplant organ bank. Donor services must be
directly related to a covered transplant for a Member of this plan.
Donor services include:
•Donor evaluation;
•Harvesting of the organ, tissue, or bone marrow; and
•Treatment of medical complications for 90 days after the evaluation or
harvest procedure.
Travel expense reimbursement for transplant services
You may be eligible for reimbursement of your travel expenses for transplant
services, including preoperative and postoperative visits, if you live at least 100
miles away from the nearest transplant services Participating Provider.
For travel expense reimbursement, you must submit receipts, claim forms, and
any other documentation required by Blue Shield. You must also have a claim for
the transplant service for which you traveled on file with Blue Shield prior to
reimbursement. When you see a Participating Provider for transplant services,
your provider submits the claim for those services to Blue Shield.
Blue Shield’s maximum travel expense reimbursement will not exceed $5,000 per
Member, per lifetime. Expenses must be reasonably necessary. Reimbursable
expenses include, if appropriate:
o Transportation to and from the facility to receive transplant services;
o Hotel accommodations if one or more overnight stays are required to
obtain transplant services. Limited to 1 double-occupancy room up to
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$200/day. Only the room is covered. All other hotel expenses are
excluded;
o Meals. Limited to $100/day. Expenses for tobacco, alcohol, drugs, phone,
television, delivery, and recreation are excluded; and
o Companion expenses for reimbursable expenses as listed above.
Certain travel expense reimbursements may be tax reportable. When required,
Blue Shield will issue a Form 1099-MISC to you, reporting travel expense
reimbursements. Blue Shield does not provide tax advice. If you have tax
questions about travel expense reimbursements, you should consult with your tax
advisor.
You will be assigned a case manager who can help you coordinate your health
care services and submit your travel expense reimbursement forms. See the Using
your Benefits effectively (care management) section for more information on
care management. For additional questions, contact Blue Shield Customer
Service.
Urgent care services
Benefits are available for urgent care services you receive at an urgent care center or
during an after-hours office visit. You can access urgent care instead of going to the
emergency room if you have a medical condition that is not life-threatening but
prompt care is needed to prevent serious deterioration of your health.
If you need to visit an urgent care center and you are in your Medical Group Service
Area, go to the urgent care center designated by your Medical Group or call your PCP.
If you are outside of your Medical Group Service Area but within California and need
urgent care, you may visit any urgent care center near you.
See the Out-of-area services section for information on urgent care services outside
California.
65
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2650.
Exclusions and limitations
This section describes the general exclusions and limitations that apply to all your plan
Benefits.
General exclusions and limitations
1
This plan only covers services that are Medically Necessary. A Physician or other
Health Care Provider’s decision to prescribe, order, recommend, or approve a
service or supply does not, in itself, make it Medically Necessary. This exclusion
does not apply to services which Blue Shield is required by law to cover for
Reconstructive Surgery.
2
Routine physical examinations solely for:
•Immunizations and vaccinations, by any mode of administration, for
the purpose of travel; or
•Licensure, employment, insurance, court order, parole, or probation.
This exclusion does not apply to services deemed Medically Necessary
Treatment of a Mental Health or Substance Use Disorder.
3 Hospitalization solely for X-ray, laboratory or any other outpatient diagnostic
studies, or for medical observation.
4
Routine foot care items and services that are not Medically Necessary,
including:
•Callus treatment;
•Corn paring or excision;
•Toenail trimming;
•Over-the-counter shoe inserts or arch supports; or
•Any type of massage procedure on the foot.
This exclusion does not apply to items or services provided through a
Participating Hospice Agency or covered under the diabetes care Benefit.
5
Home services, hospitalization, or confinement in a health facility primarily for
rest, custodial care, or domiciliary care.
Custodial care is assistance with Activities of Daily Living furnished in the home
primarily for supervisory care or supportive services, or in a facility primarily to
provide room and board.
Domiciliary care is a supervised living arrangement in a home-like environment
for adults who are unable to live alone because of age-related impairments or
physical, mental, or visual disabilities.
6 Continuous Nursing Services, private duty nursing, or nursing shift care, except
as provided through a Participating Hospice Agency.
Exclusions and limitations 66
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2650.
General exclusions and limitations
7
Prescription and non-prescription oral food and nutritional supplements. This
exclusion does not apply to services listed in the Home infusion and injectable
medication services and PKU formulas and special food products sections, or as
provided through a Participating Hospice Agency. This exclusion does not
apply to services deemed Medically Necessary Treatment of a Mental Health
or Substance Use Disorder.
8 Unless selected as an optional Benefit by your Employer, hearing aids, hearing
aid examinations for the appropriate type of hearing aid, fitting, and hearing
aid recheck appointments.
9
Eye exams and refractions, lenses and frames for eyeglasses, lens options,
treatments, and contact lenses, except as listed under the Prosthetic
equipment and devices section.
Video-assisted visual aids or video magnification equipment for any purpose, or
surgery to correct refractive error.
10
Any type of communicator, voice enhancer, voice prosthesis, electronic voice
producing machine, or any other language assistive device. This exclusion does
not apply to items or services listed under the Prosthetic equipment and
devices section.
11
Dental services and supplies for treatment of the teeth, gums, and associated
periodontal structures, including but not limited to the treatment, prevention, or
relief of pain or dysfunction of the temporomandibular joint and muscles of
mastication. This exclusion does not apply to items or services provided under
the Medical treatment of the teeth, gums, or jaw joints and jaw bones and
Hospital services sections.
12
Surgery that is performed to alter or reshape normal structures of the body to
improve appearance. This exclusion does not apply to Medically Necessary
treatment for complications resulting from cosmetic surgery, such as infections
or hemorrhages.
13
Unless selected as an optional Benefit by your Employer, any services related to
assisted reproductive technology (including associated services such as
radiology, laboratory, medications, and procedures) including but not limited
to the harvesting or stimulation of the human ovum, in vitro fertilization, Gamete
Intrafallopian Transfer (GIFT) procedure, Zygote Intrafallopian Transfer (ZIFT),
Intracytoplasmic sperm Injection (ICSI), pre-implantation genetic screening,
donor services or procurement and storage of donor embryos, oocytes, ovarian
tissue, or sperm, any type of artificial insemination, services or medications to
treat low sperm count, services incident to or resulting from procedures for a
surrogate mother who is otherwise not eligible for covered pregnancy and
maternity care under a Blue Shield health plan, or services incident to reversal
Exclusions and limitations 67
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2650.
General exclusions and limitations
of surgical sterilization, except for Medically Necessary treatment of medical
complications of the reversal procedure.
14
Home testing devices and monitoring equipment. This exclusion does not apply
to COVID-19 at-home testing kits, sexually transmitted disease home testing kits,
or items specifically described in the Durable medical equipment or Diabetes
care services sections.
15 Preventive Health Services performed by a Non-Participating Provider, except
laboratory services under the California Prenatal Screening Program.
16 Services performed in a Hospital by house officers, residents, interns, or other
professionals in training without the supervision of an attending Physician in
association with an accredited clinical education program.
17 Services performed by your spouse, Domestic Partner, child, brother, sister, or
parent.
18
Services provided by an individual or entity that:
•Is not appropriately licensed or certified by the state to provide
health care services;
•Is not operating within the scope of such license or certification; or
•Does not maintain the Clinical Laboratory Improvement
Amendments certificate required to perform laboratory testing
services.
This exclusion does not apply to Behavioral Health Treatment Benefits listed
under the Mental Health and Substance Use Disorder Benefits section or to
services deemed Medically Necessary Treatment of a Mental Health or
Substance Use Disorder provided by an individual trainee, associate or
applicant for licensure who is supervised as required by applicable law.
19
Select physical and occupational therapies, such as:
•Massage therapy, unless it is a component of a multimodality
rehabilitative treatment plan or physical therapy treatment plan;
•Training or therapy for the treatment of learning disabilities or
behavioral problems;
•Social skills training or therapy;
•Vocational, educational, recreational, art, dance, music, or reading
therapy; and
•Testing for intelligence or learning disabilities.
This exclusion does not apply to services deemed Medically Necessary
Treatment of a Mental Health or Substance Use Disorder.
20 Weight control programs and exercise programs. This exclusion does not apply
to nutritional counseling provided under the Diabetes care services section, or
Exclusions and limitations 68
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2650.
General exclusions and limitations
to services deemed Medically Necessary Treatment of a Mental Health or
Substance Use Disorder, or Preventive Health Services.
21 Services or Drugs that are Experimental or Investigational in nature.
22
Services that cannot be lawfully marketed without approval of the U.S. Food
and Drug Administration (FDA), including, but not limited to:
•Drugs;
•Medicines;
•Supplements;
•Tests;
•Vaccines;
•Devices; and
•Radioactive material.
However, drugs and medicines that have received FDA approval for marketing
for one or more uses will not be denied on the basis that they are being
prescribed for an off-label use if the conditions set forth in California Health &
Safety Code Section 1367.21 have been met.
23
The following non-prescription (over-the-counter) medical equipment or
supplies:
•Oxygen saturation monitors;
•Prophylactic knee braces; and
•Bath chairs.
24 Member convenience items or services, such as internet, phones, televisions,
guest trays, personal hygiene items, and food delivery services.
25 Disposable supplies for home use except as provided under the Durable
medical equipment, Home health services, and Hospice program services
sections.
26
Services incident to any injury or disease arising out of, or in the course of,
employment for salary, wage, or profit if such injury or disease is covered by any
workers’ compensation law, occupational disease law, or similar legislation.
However, if Blue Shield provides payment for such services, we will be entitled to
establish a lien up to the amount paid by Blue Shield for the treatment of such
injury or disease.
27 Transportation by car, taxi, bus, gurney van, wheelchair van, and any other
type of transportation (other than a licensed ambulance or psychiatric
transport van).
28 Drugs dispensed by a Physician or Physician’s office for outpatient use.
29 Outpatient prescription Drugs.
Exclusions and limitations 69
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2650.
General exclusions and limitations
30
Hospital care programs or services provided in a home setting (Hospital-at-
home programs).
70
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2650.
Grievance process
Blue Shield has a formal grievance process to address any complaints, disputes,
requests for reconsideration of health care coverage decisions made by Blue Shield, or
concerns with the quality of care you received from a provider. Blue Shield will receive,
review, and resolve your grievance within the required timeframes.
Submitting a grievance
If you have a question about your Benefits or any action taken by Blue Shield (or a
Benefit Administrator), your first step is to make an inquiry through Customer Service. If
Customer Service is not able to fully address your concerns, you can then submit a
grievance or ask the Customer Service representative to submit one for you. If Blue
Shield denies authorization or coverage for health care services, you can appeal the
denial and Blue Shield will reconsider your request.
You have 180 days after a denial or other incident to submit your grievance to Blue
Shield. Your provider, or someone you choose to represent you, can also submit a
grievance on your behalf.
The fastest way to submit a grievance is online at blueshieldca.com. You can also
submit the form by mail or begin the grievance process by calling Customer Service.
Where to mail grievances
Type of grievance Address
Medical Benefits, and prescription Drug
Benefits if selected as an optional Benefit
by your Employer
Blue Shield of California
Customer Service Appeals and Grievance
P.O. Box 5588
El Dorado Hills, CA 95762
Mental Health and Substance Use Disorder
services from an MHSA Participating
Provider
Blue Shield of California
Mental Health Service Administrator
P.O. Box 719002
San Diego, CA 92171
Once Blue Shield or the MHSA receives your grievance, they will send a written
acknowledgment within five calendar days.
Blue Shield will resolve your grievance and provide a written response within 30
calendar days. The response will explain what action you can take if you are not
satisfied with how your grievance is resolved.
If your Employer selected the optional Prescription Drug Benefits Rider, and Blue Shield
denies an exception request for coverage of a non-Formulary Drug or step therapy, you
may request an external exception request review. Blue Shield will ensure a decision
within 72 hours. Blue Shield will make a decision within 24 hours when there are exigent
Grievance process 71
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2650.
circumstances related to denial of an exception request for a non-Formulary Drug or
step therapy.
Expedited grievance request
You can submit an expedited grievance request to Blue Shield when the routine
grievance process might seriously jeopardize your life, health, or recovery, or when
you are experiencing severe pain.
Blue Shield will make a decision within three calendar days for expedited grievance
requests related to medical Benefits and Mental Health and Substance Use Disorder
services.
Once a decision is made, Blue Shield will notify you and your provider as soon as
possible to accommodate your condition.
California Department of Managed Health Care review
The California Department of Managed Health Care is responsible for regulating health
care service plans. If you have a grievance against your health plan, you should first
telephone your health plan at 1-855-599-2650 and use your health plan’s grievance
process before contacting the Department. Utilizing this grievance procedure does not
prohibit any potential legal rights or remedies that may be available to you. If you need
help with a grievance involving an emergency, a grievance that has not been
satisfactorily resolved by your health plan, or a grievance that has remained unresolved
for more than 30 days, you may call the Department for assistance. You may also be
eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR
process will provide an impartial review of medical decisions made by a health plan
related to the Medical Necessity of a proposed service or treatment, coverage
decisions for treatments that are Experimental or Investigational, and payment disputes
for emergency or urgent medical services.
The Department also has a toll-free telephone number (1-888-466-2219) and a TDD line
(1-877-688-9891) for the hearing and speech impaired. The Department’s internet
website (www.dmhc.ca.gov) has complaint forms, IMR application forms, and
instructions online.
If you feel Blue Shield improperly cancels, rescinds, or does not renew coverage for you
or your Dependents, you can submit a request for review to Blue Shield or to the
Director of the California Department of Managed Health Care. Any request for review
submitted to Blue Shield will be treated as an expedited grievance request.
Independent medical review
You may be eligible for an independent medical review if your grievance involves a
claim or service for which coverage was denied on the grounds that the service is:
•Not Medically Necessary; or
•Experimental or Investigational (including the external review available under
the Friedman-Knowles Experimental Treatment Act of 1996).
You can apply to the Department of Managed Health Care (DMHC) for an
independent medical review of the denial. For a Medical Necessity denial, you must
first submit a grievance to Blue Shield and wait for at least 30 days before requesting an
Grievance process 72
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2650.
independent medical review. However, if the request qualifies for an expedited review
as described above, or if it involves a determination that the requested service is
Experimental or Investigational, you may request an independent medical review as
soon as you receive a notice of denial from Blue Shield. The DMHC’s application for
independent medical review is included with your appeal outcome letter.
The DMHC will review your application. If the request qualifies for independent medical
review, the DMHC will select an independent review organization to conduct a clinical
review of your medical records. You can submit additional records for consideration as
well. There is no cost to you for this independent medical review. You and your provider
will receive copies of the independent medical review determination. The decision of
the independent review organization is binding on Blue Shield. If the reviewer
determines that the requested service is clinically appropriate, Blue Shield will arrange
for the service to be provided or the disputed claim to be paid.
The independent medical review process is in addition to any other procedures or
remedies available to you to resolve coverage disputes. It is completely voluntary. You
are not required to participate in the independent medical review process, but if you
do not, you may lose your statutory right to pursue legal action against Blue Shield
regarding the disputed service.
ERISA review
If your Employer’s health plan is governed by the Employee Retirement Income Security
Act (“ERISA”), you may have the right to bring a civil action under Section 502(a) of
ERISA if all required reviews of your claim have been completed and your claim has not
been approved. Additionally, you and your Employer-sponsored plan may have other
voluntary alternative dispute resolution options, such as mediation.
73
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2650.
Other important information about your plan
This section provides legal and regulatory details that impact your health care
coverage. This information is a supplement to the information provided in earlier
sections of this document and is part of the contractual agreement between the
Subscriber and Blue Shield.
Your coverage, continued
Special enrollment period
For more information about special enrollment periods, see
Special enrollment period on page 37 in the Your coverage
section.
A special enrollment period is a timeframe outside of open enrollment when an
eligible Subscriber or Dependent can enroll in, or change enrollment in, a health
plan. The special enrollment period is 30 days following the date of a Qualifying
Event except as otherwise specified below. The following are examples of Qualifying
Events. For complete details and a determination of eligibility for special enrollment,
please consult your Employer.
•Loss of eligibility for coverage, including the following:
o The eligible Employee or Dependent loses coverage under another
Employer health benefit plan or other health insurance and meets all
of the following requirements:
▪The Employee or Dependent was covered under another
employer health benefit plan or had other health insurance
coverage at the time the Employee was initially offered
enrollment under this Plan;
▪If required by the Employer, the Employee certified, at the time
of the initial enrollment, that coverage under another employer
health benefit plan or other health insurance was the reason for
declining enrollment provided that the Employee was given
notice that such certification was required and that failure to
comply could result in later treatment as a Late Enrollee;
o The Employee or Dependent was eligible for coverage under the
Healthy Families Program or Medi-Cal and such coverage was
terminated due to loss of such eligibility, provided that enrollment is
requested no later than 60 days after the termination of coverage;
o The eligible Employee or Dependent loses coverage due to legal
separation, divorce, loss of dependent status, death of the Employee,
termination of employment, or reduction in the number of hours of
employment;
o In the case of coverage offered through an HMO, loss of coverage
because the eligible Employee or Dependent no longer resides, lives,
or works in the service area (whether or not within the choice of the
Other important information about your plan 74
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2650.
individual), and if the previous HMO coverage was group coverage,
no other benefit package is available to the Employee or Dependent;
o Termination of the employer health plan or contributions to Employee
or Dependent coverage;
o Exhaustion of COBRA group continuation coverage; or
•The Employee or Dependent is eligible for coverage under the Healthy
Families Program or Medi-Cal premium assistance program, provided that
enrollment is within 60 days of the notice of eligibility for these premium
assistance programs;
•A court has ordered that coverage be provided for a spouse or Domestic
Partner or minor child under a covered Employee’s health benefit plan. The
health plan shall enroll a Dependent child effective the first day of the month
following presentation of a court order by the district attorney, or upon
presentation of a court order or request by a custodial party or the Employee,
as described in Sections 3751.5 and 3766 of the Family Code; or
•An eligible Employee acquires a Dependent through marriage, establishment
of domestic partnership, birth, or placement for adoption. Applies to both the
Employee and the Dependent.
Cancellation for Employer’s nonpayment of Premiums
Premium grace period
After payment of the first Premium, your Employer has a 60-day grace period
from the due date to pay all outstanding Premiums before coverage is canceled
due to nonpayment of Premiums. Coverage will continue through the grace
period. However, if your Employer does not pay all outstanding Premiums within
the grace period, coverage will end the day following the 60-day grace period.
Your Employer will be liable for all Premiums owed, even if coverage is canceled.
This includes Premiums for coverage during the 60-day grace period. Blue Shield
will send a Notice of End of Coverage to you and your Employer no later than
five calendar days after the day coverage ends.
Out-of-area services
Overview
Blue Shield has a variety of relationships with other Blue Cross and/or Blue Shield Plans
and their Licensed Controlled Affiliates (Licensees). Generally, these relationships are
called Inter-Plan Arrangements. These Inter-Plan Arrangements work based on rules
and procedures issued by the Blue Cross Blue Shield Association. Whenever you
obtain health care services outside of California, the claims for these services may be
processed through one of these Inter-Plan Arrangements.
When you access services outside of California, you may obtain care from one of
two kinds of providers. Most providers are participating providers and contract with
the local Blue Cross and/or Blue Shield Licensee in that other geographic area (Host
Blue). Some providers are non-participating providers because they don’t contract
with the Host Blue. Blue Shield’s payment practices in both instances are described in
this section.
Other important information about your plan 75
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2650.
The Blue Shield Access+ HMO plan provides limited coverage for health care services
received outside of California. 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 authorized by Blue Shield.
See the Care outside of California section for more
information about receiving care while outside of California.
To find participating providers while outside of California, visit
bcbs.com.
Inter-Plan Arrangements
Emergency Services
Members who experience an Emergency Medical Condition while traveling
outside of California should seek immediate care from the nearest Hospital. The
Benefits of this plan will be provided anywhere in the world for treatment of an
Emergency Medical Condition.
BlueCard® Program
Under the BlueCard® Program, when you receive Out-of-Area Covered Health
Care Services within the geographic area served by a Host Blue, Blue Shield will
remain responsible for the provisions of this Evidence of Coverage. However, the
Host Blue is responsible for contracting with and generally handling all
interactions with its participating healthcare providers, including direct payment
to the provider.
The BlueCard® Program enables you to obtain Out-of-Area Covered Health Care
Services outside of California, as defined above, from a health care provider
participating with a Host Blue, where available. The participating health care
provider will automatically file a claim for the Out-of-Area Covered Health Care
Services provided to you, so there are no claim forms for you to fill out. You will
be responsible for the Member Copayment, Coinsurance, and Deductible
amounts, if any, as stated in the Summary of Benefits.
When you receive Out-of-Area Covered Health Care Services outside of
California and the claim is processed through the BlueCard® Program, the
amount you pay for covered health care services, if not a flat dollar Copayment,
is calculated based on the lower of:
•The billed charges for your Out-of-Area Covered Health Care Services; or
•The negotiated price that the Host Blue makes available to Blue Shield.
Often, this negotiated price will be a simple discount that reflects an actual price
that the Host Blue 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
Other important information about your plan 76
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2650.
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 of claims as noted above. However, such adjustments will not affect the
price Blue Shield used for your claim because these adjustments will not be
applied retroactively to claims already paid.
Federal or state laws or regulations may require a surcharge, tax, or other fee
that applies to fully-insured accounts. If applicable, Blue Shield will include any
such surcharge, tax, or other fee as part of the claim charges passed on to you.
Claims for covered Emergency Services are paid based on the Allowed Charges
as defined in this Evidence of Coverage.
Non-participating providers outside of California
Coverage for health care services provided outside of California and
within the BlueCard® Service Area by non-participating providers is limited
to Out-of-Area Covered Health Care Services. The amount you pay for
such services will normally be based on either the Host Blue’s non-
participating provider local payment or the pricing arrangements
required by applicable state or federal law. In these situations, you will be
responsible for any difference between the amount that the non-
participating provider bills and the payment Blue Shield will make for Out-
of-Area Covered Health Care Services as described in this paragraph.
If you do not see a participating provider through the BlueCard® Program,
you will have to pay the entire bill for your medical care and submit a
claim to the local Blue Cross and/or Blue Shield plan, or to Blue Shield of
California for reimbursement. Blue Shield will review your claim and notify
you of its coverage determination within 30 days after receipt of the
claim; you will be reimbursed as described in the preceding paragraph.
Remember, your share of cost is higher when you see a non-participating
provider.
Your Cost Share for out-of-network Emergency Services will be the same
as the amount due to a Participating Provider for such Covered Services,
as listed in the Summary of Benefits.
Blue Shield Global® Core
If you are outside the United States, the Commonwealth of Puerto Rico
and the U.S. Virgin Islands (BlueCard® Service Area), you may be able to
take advantage of Blue Shield Global® Core when accessing Out-of-Area
Covered Health Care Services. Blue Shield Global® Core is not served by a
Host Blue. As such, you will typically have to pay the providers and submit
the claims yourself to obtain reimbursement for these services.
If you need assistance locating a doctor or hospital outside the BlueCard®
Service Area you should call the service center at (800) 810-BLUE (2583) or
call collect at (804) 673-1177, 24 hours a day, seven days a week. Provider
Other important information about your plan 77
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2650.
information is also available online at www.bcbs.com: select “Find a
Doctor” and then “Blue Shield Global Core.”
Submitting a Blue Shield Global® Core claim
When you pay directly for Out-of-Area Covered Health Care Services
outside the BlueCard® Service Area, you must submit a claim to obtain
reimbursement. You should complete a Blue Shield Global® Core claim
form and send the claim form with the provider’s itemized bill to the
service center at the address provided on the form to initiate claims
processing. The claim form is available from Blue Shield Customer Service,
the service center or online at www.bcbsglobalcore.com. If you need
assistance with your claim submission, you should call the service center at
(800) 810-BLUE (2583) or call collect at (804) 673-1177, 24 hours a day,
seven days a week.
Limitation for duplicate coverage
Medicare
Blue Shield will provide Benefits before Medicare when:
•You are eligible for Medicare due to age, if the Subscriber is actively working
for a group that employs 20 or more employees (as defined by Medicare
Secondary Payer laws);
•You are eligible for Medicare due to disability, if the Subscriber is covered by
a group that employs 100 or more employees (as defined by Medicare
Secondary Payer laws); or
•You are eligible for Medicare solely due to end-stage renal disease during the
first 30 months you are eligible to receive benefits for end-stage renal disease
from Medicare.
Blue Shield will provide Benefits after Medicare when:
•You are eligible for Medicare due to age, if the Subscriber is actively working
for a group that employs less than 20 employees (as defined by Medicare
Secondary Payer laws);
•You are eligible for Medicare due to disability, if the Subscriber is covered by
a group that employs less than 100 employees (as defined by Medicare
Secondary Payer laws);
•You are eligible for Medicare solely due to end-stage renal disease after the
first 30 months you are eligible to receive benefits for end-stage renal disease
from Medicare; or
•You are retired and age 65 or older.
When Blue Shield provides Benefits after Medicare, your combined Benefits from
Medicare and Blue Shield may be lower than the Medicare allowed amount but will
not exceed the Medicare allowed amount. You do not have to pay any Blue Shield
Deductibles, Copayments, or Coinsurance.
Medi-Cal
Medi-Cal always pays for Benefits last when you have coverage from more than one
payor.
Other important information about your plan 78
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2650.
Qualified veterans
If you are a qualified veteran, Blue Shield will pay the reasonable value or the
Allowed Charges for Covered Services you receive at a Veterans Administration
facility for a condition that is not related to military service. If you are a qualified
veteran who is not on active duty, Blue Shield will pay the reasonable value or the
Allowed Charges for Benefits you receive at a Department of Defense facility. This
includes Benefits for conditions related to military service.
Coverage by another government agency
If you are entitled to receive Benefits from any federal or state governmental
agency, by any municipality, county, or other political subdivision, your combined
Benefits from that coverage and Blue Shield will equal but not be more than what
Blue Shield would pay if you were not eligible for Benefits under that coverage. Blue
Shield will provide Benefits based on the reasonable value or the Allowed Charges.
Exception for other coverage
A Participating Provider may seek reimbursement from other third-party payors for the
balance of their charges for services you receive under this plan.
If you recover from a third party the reasonable value of Covered Services received
from a Participating Provider, the Participating Provider is not required to accept the
fees paid by Blue Shield as payment in full. You may be liable to the Participating
Provider for the difference, if any, between the fees paid by Blue Shield and the
reasonable value recovered for those services.
Reductions – third-party liability
If you are injured or become ill due to the act or omission of another person (a “third
party”), Blue Shield shall, with respect to services required as a result of that injury,
provide the Benefits of the plan and have an equitable right to restitution,
reimbursement, or other available remedy to recover the amounts Blue Shield paid for
services provided to you on a fee-for-service basis from any recovery (defined below)
obtained by or on your behalf, from or on behalf of the third party responsible for the
injury or illness, and you must agree to the provisions below. In addition, if you are
injured and no other person is responsible but you receive (or are entitled to) a recovery
from another source, and if Blue Shield paid Benefits for that injury, you must agree to
the following provisions.
•All recoveries you or your representatives obtain (whether by lawsuit,
settlement, insurance, or otherwise), no matter how described or designated,
must be used to reimburse Blue Shield in full for Benefits Blue Shield paid. Blue
Shield’s share of any recovery extends only to the amount of Benefits it has
paid or will pay you or your representatives. For purposes of this provision, your
representatives include, if applicable, your heirs, administrators, legal
representatives, parents (if you are a minor), successors, or assignees. This is
Blue Shield’s right of recovery.
•Blue Shield’s right to restitution, reimbursement, or other available remedy is
against any recovery you receive as a result of the injury or illness. This
includes any amount awarded to you or received by way of court judgment,
arbitration award, settlement, or any other arrangement, from any third party
Other important information about your plan 79
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2650.
or third-party insurer, related to the illness or injury (the “Recovery”), whether
or not you have been “made whole” by the Recovery. The amount Blue
Shield seeks as restitution, reimbursement, or other available remedy will be
calculated in accordance with California Civil Code Section 3040.
•Blue Shield will not reduce its share of any Recovery unless, in the exercise of
our discretion, Blue Shield agrees in writing to a reduction (1) because you do
not receive the full amount of damages that you claimed or (2) because you
had to pay attorneys’ fees.
•You must cooperate in doing what is reasonably necessary to assist Blue
Shield with its right of recovery. You must not take any action that may
prejudice Blue Shield’s right of recovery.
•You must tell Blue Shield promptly if you have made a claim against another
party for a condition that Blue Shield has paid or may pay Benefits for. You
must seek recovery of Blue Shield’s payments and liabilities, and you must tell
us about any recoveries you obtain, whether in or out of court. Blue Shield
may seek a first priority lien on the proceeds of your claim in order to be
reimbursed to the full amount of Benefits Blue Shield has paid or will pay.
Blue Shield may request that you sign a reimbursement agreement consistent with this
provision. Your failure to comply with the above shall not in any way act as a waiver,
release, or relinquishment of the rights of Blue Shield.
Further, if you received services from a Participating Hospital for such injuries or illness,
the Hospital has the right to collect from you the difference between the amount paid
by Blue Shield and the Hospital’s reasonable and necessary charges for such services
when payment or reimbursement is received by you for medical expenses. The
Hospital’s right to collect shall be in accordance with California Civil Code Section
3045.1.
IF THIS PLAN IS PART OF AN EMPLOYEE WELFARE BENEFIT PLAN SUBJECT TO THE EMPLOYEE
RETIREMENT INCOME SECURITY ACT OF 1974 (“ERISA”), YOU ARE ALSO REQUIRED TO DO
THE FOLLOWING:
•Ensure that any recovery is kept separate from and not comingled with any
other funds or your general assets;
•Agree in writing that the portion of any recovery required to satisfy the lien or
other right of recovery of Blue Shield is held in trust for the sole benefit of Blue
Shield until such time it is conveyed to Blue Shield; and
•Direct any legal counsel retained by you or any other person acting on your
behalf to hold that portion of the recovery to which Blue Shield is entitled in
trust for the sole benefit of Blue Shield and to comply with and facilitate the
reimbursement to Blue Shield of the monies owed.
Coordination of benefits, continued
When you are covered by more than one group health plan, payments for allowable
expenses will be coordinated between the two plans. Coordination of benefits ensures
that benefits paid by multiple group health plans do not exceed 100% of allowable
expenses. The coordination of benefits rules also determine which group health plan is
primary and prevent delays in benefit payments. Blue Shield follows the rules for
coordination of benefits as outlined in the California Code of Regulations, Title 28,
Other important information about your plan 80
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2650.
Section 1300.67.13 to determine the order of benefit payments between two group
health plans:
•When a plan does not have a coordination of benefits provision, that plan will
always provide its benefits first. Otherwise, the plan covering you as an
Employee will provide its benefits before the plan covering you as a
Dependent.
•Coverage for Dependent children:
o When the parents are not divorced or separated, the plan of the parent
whose date of birth (month and day) occurs earlier in the year is primary.
o When the parents are divorced and the specific terms of the court
decree state that one of the parents is responsible for the health care
expenses of the child, the plan of the responsible parent is primary.
o When the parents are divorced or separated, there is no court decree,
and the parent with custody has not remarried, the plan of the custodial
parent is primary.
o When the parents are divorced or separated, there is no court decree,
and the parent with custody has remarried, the order of payment is as
follows:
▪The plan of the custodial parent;
▪The plan of the stepparent; then
▪The plan of the non-custodial parent.
•If the above rules do not apply, the plan which has covered you for the
longer period of time is the primary plan. There may be exceptions for laid-off
or retired Employees.
•When Blue Shield is the primary plan, Benefits will be provided without
considering the other group health plan. When Blue Shield is the secondary
plan and there is a dispute as to which plan is primary, or the primary plan
has not paid within a reasonable period of time, Blue Shield will provide
Benefits as if it were the primary plan.
•Anytime Blue Shield makes payments over the amount they should have paid
as the primary or secondary plan, Blue Shield reserves the right to recover the
excess payments from the other plan or any person to whom such payments
were made.
These coordination of benefits rules do not apply to the programs included in the
Limitation for Duplicate Coverage section.
General provisions
Independent contractors
Providers are neither agents nor employees of Blue Shield but are independent
contractors. In no instance shall Blue Shield be liable for the negligence, wrongful
acts, or omissions of any person providing services, including any Physician, Hospital,
or other Health Care Provider or their employees.
Assignment
The Benefits of this plan may not be assigned without the written consent of Blue
Shield. Participating Providers are paid directly by Blue Shield or the Medical Group.
Other important information about your plan 81
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2650.
When you are authorized to receive Covered Services from a Non-Participating
Provider, Blue Shield, at its sole discretion, may make payment to the Subscriber or
directly to the Non-Participating Provider. If Blue Shield pays the Non-Participating
Provider directly, such payment does not create a third-party beneficiary or other
legal relationship between Blue Shield and the Non-Participating Provider.
Plan interpretation
Blue Shield shall have the power and authority to construe and interpret the
provisions of this plan, to determine the Benefits of this plan, and to determine
eligibility to receive Benefits under the Contract. Blue Shield shall exercise this
authority for the benefit of all Members entitled to receive Benefits under this plan.
Public policy participation procedure
Blue Shield allows Members to participate in establishing the public policy of Blue
Shield. Such participation is not to be used as a substitute for the grievance process.
Recommendations, suggestions or comments should be submitted in writing to:
Sr. Manager, Regulatory Filings
Blue Shield of California
601 12th Street
Oakland, CA 94607
Phone: (510) 607-2065
Please include your name, address, phone number, Subscriber number, and group
number with each communication. Please state the public policy issue clearly.
Submit all relevant information and reasons for the policy issue with your letter.
Public policy issues will be heard as agenda items for meetings of the Board of
Directors. Minutes of Board meetings will reflect decisions on public policy issues that
were considered. Members who have initiated a public policy issue will be furnished
with the appropriate extracts of the minutes.
At least one third of the Board of Directors is comprised of Subscribers who are not
employees, providers, subcontractors or group contract brokers and who do not
have financial interests in Blue Shield. The names of the members of the Board of
Directors may be obtained from the Sr. Manager, Regulatory Filings as listed above.
Access to information
Blue Shield may need information from medical providers, from other carriers or other
entities, or from the Member, in order to administer the Benefits and eligibility
provisions of this plan and the Contract. By enrolling in this health plan, each
Member agrees that any provider or entity can disclose to Blue Shield that
information that is reasonably needed by Blue Shield. Members also agree to assist
Blue Shield in obtaining this information, if needed, (including signing any necessary
authorizations) and to cooperate by providing Blue Shield with information in the
Member’s possession. Failure to assist Blue Shield in obtaining necessary information
or refusal to provide information reasonably needed may result in the delay or denial
of Benefits until the necessary information is received. Any information received for
this purpose by Blue Shield will be maintained as confidential and will not be
Other important information about your plan 82
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2650.
disclosed without the Member’s consent, except as otherwise permitted or required
by law.
Right of recovery
Whenever payment on a claim is made in error, Blue Shield has the right to recover
such payment from the Subscriber or, if applicable, the provider or another health
benefit plan, in accordance with applicable laws and regulations. With notice, Blue
Shield reserves the right to deduct or offset any amounts paid in error from any
pending or future claim to the extent permitted by law. Circumstances that might
result in payment of a claim in error include, but are not limited to, payment of
benefits in excess of the benefits provided by the health plan, payment of amounts
that are the responsibility of the Subscriber (Cost Share or similar charges), payment
of amounts that are the responsibility of another payor, payments made after
termination of the Subscriber’s coverage, or payments made on fraudulent claims.
83
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Definitions
Activities of Daily
Living
Activities related to independence in normal everyday living.
Recreational, leisure, or sports activities are not considered
Activities of Daily Living.
Adverse Childhood
Experiences
An event, series of events, or set of circumstances that is
experienced by an individual as physically or emotionally
harmful or threatening and that has lasting adverse effects on
the individual’s functioning and physical, social, emotional, or
spiritual well-being.
Allowed Charges
•For a Participating Provider: the amounts a
Participating Provider agrees to accept as
payment from Blue Shield.
•For a Non-Participating Provider: (1) the amounts
paid by Blue Shield when services from a Non-
Participating Provider are covered and are paid as
a Reasonable and Customary amount, or (2) if
applicable, the amount determined under state
and federal law.
Ambulatory Surgery
Center
An outpatient surgery facility that meets both of the following
requirements:
•Is a licensed facility accredited by an ambulatory
surgery center accrediting body; and
•Provides services as a free-standing ambulatory
surgery center, which is not otherwise affiliated with
a Hospital.
ASH Participating
Provider
A Physician or Health Care Provider under contract with ASH
Plans to provide Covered Services to Members.
Behavioral Health
Crisis Services
The continuum of services to address crisis intervention, crisis
stabilization, and crisis residential treatment needs of those
with a mental health or substance use disorder crisis that are
wellness, resiliency, and recovery oriented. These include, but
are not limited to, crisis intervention, including counseling
provided by 988 centers, Mobile Crisis Teams, and crisis
receiving and stabilization services.
Behavioral Health
Treatment (BHT)
Professional services and treatment programs that develop or
restore, to the maximum extent practicable, the functioning
of an individual with pervasive developmental disorder or
autism. BHT includes applied behavior analysis and evidence-
based intervention programs.
Definitions 84
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2650.
Benefits (Covered
Services)
Medically Necessary services and supplies you are entitled to
receive pursuant to the Contract.
Benefit Administrator Administrator for specialized Benefits such as Mental Health
and Substance Use Disorder Benefits.
Blue Shield of
California
California Physicians' Service, d/b/a Blue Shield of California, is
a California not-for-profit corporation, licensed as a health
care service plan. It is referred to throughout this Evidence of
Coverage as Blue Shield.
BlueCard® Service
Area
The United States, Commonwealth of Puerto Rico, and U.S.
Virgin Islands.
Calendar Year The 12-month consecutive period beginning on January 1
and ending on December 31 of the same year.
Care Coordination
Organized, information-driven patient care activities intended
to facilitate the appropriate responses to a Member’s
healthcare needs across the continuum of care.
Care Coordinator An individual within a provider organization who facilitates
Care Coordination for patients.
Care Coordinator
Fee
A fixed amount paid by a Blue Cross and/or Blue Shield
Licensee to providers periodically for Care Coordination
under a Value-Based Program.
Coinsurance The percentage amount that a Member is required to pay for
Covered Services after meeting any applicable Deductible.
Continuous Nursing
Services
Nursing care provided on a continuous hourly basis, rather
than intermittent home visits for Members enrolled in a
Hospice Program. Continuous home care can be provided by
a registered or licensed vocational nurse, but is only available
for brief periods of crisis and only as necessary to maintain the
terminally ill patient at home.
Copayment
The specific dollar amount that a Member is required to pay
for Covered Services after meeting any applicable
Deductible.
Cost Share Any applicable Deductibles, Copayment, and Coinsurance.
Covered Services
(Benefits)
Medically Necessary services and supplies you are entitled to
receive pursuant to the Contract.
Deductible
The Calendar Year amount you must pay for specific
Covered Services before Blue Shield pays for Covered
Services pursuant to the Contract.
Definitions 85
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2650.
Dependent
The spouse, Domestic Partner, or child of an eligible
Employee, who is determined to be eligible.
•A spouse who is legally married to the Subscriber
and who is not legally separated from the
Subscriber.
•A Domestic Partner to the Subscriber who meets the
definition of Domestic Partner as defined in this
Evidence of Coverage.
•A child who is the child of, adopted by, or in legal
guardianship of the Subscriber, spouse, or Domestic
Partner, and who is not covered as a Subscriber. A
child includes any stepchild, child placed for
adoption, or any other child for whom the
Subscriber, spouse, or Domestic Partner has been
appointed as a non-temporary legal guardian by a
court of appropriate legal jurisdiction. A child is an
individual less than 26 years of age. A child does
not include any children of a Dependent child
(grandchildren of the Subscriber, spouse, or
Domestic Partner), unless the Subscriber, spouse, or
Domestic Partner has adopted or is the legal
guardian of the grandchild.
Domestic Partner
An individual who is personally related to the Subscriber by a
domestic partnership that meets all the following
requirements:
•Both partners are 18 years of age or older, except
as provided in Section 297.1 of the California Family
Code;
•The partners have chosen to share one another’s
lives in an intimate and committed relationship of
mutual caring;
•The partners are:
o not currently married to someone else or a
member of another domestic partnership,
and
o not so closely related by blood that legal
marriage or registered domestic partnership
would otherwise be prohibited;
•Both partners are capable of consenting to the
domestic partnership; and
•The partners have filed a Declaration of Domestic
Partnership with the Secretary of State. (Note, some
Employers may permit partners who meet the
above criteria but have not filed a Declaration of
Domestic Partnership with the Secretary of State to
be eligible for coverage as a Domestic Partner
under this Plan. If permitted by your Employer, such
Definitions 86
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individuals are included in the term “Domestic
Partner” as used in this Evidence of Coverage;
however, the partnership may not be recognized
by the State for other purposes as the partners do
not meet the definition of “Domestic Partner”
established under Section 297 of the California
Family Code).
The domestic partnership is deemed created on the date
when both partners meet the above requirements.
Emergency Medical
Condition
A medical condition, including a psychiatric emergency,
manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that you reasonably believe the
absence of immediate medical attention could result in any
of the following:
•Placing your health in serious jeopardy (including
the health of a pregnant woman or her unborn
child);
•Serious impairment to bodily functions;
•Serious dysfunction of any bodily organ or part;
•Danger to yourself or to others; or
•Inability to provide for, or utilize, food, shelter, or
clothing, due to a mental disorder.
Emergency Services
The following services provided for an Emergency Medical
Condition:
•Medical screening, examination, and evaluation by
a Physician and surgeon, or other appropriately
licensed persons under the supervision of a
Physician and surgeon, to determine if an
Emergency Medical Condition or active labor exists
and, if it does, the care, treatment, and surgery
necessary to relieve or eliminate the Emergency
Medical Condition, within the capability of the
facility;
•Additional screening, examination, and evaluation
by a Physician, or other personnel within the scope
of their licensure and clinical privileges, to
determine if a psychiatric Emergency Medical
Condition exists, and the care and treatment
necessary to relieve or eliminate the psychiatric
Emergency Medical Condition, within the capability
of the facility; and
•Care and treatment necessary to relieve or
eliminate a psychiatric Emergency Medical
Condition may include admission or transfer to a
psychiatric unit within a general acute care
Hospital or to an acute psychiatric Hospital; and
Definitions 87
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•Solely to the extent required under the federal law,
Emergency Services also include any additional
items or services that are covered under the plan
and furnished by a Non-Participating Provider or
emergency facility, regardless of the department
where furnished, after stabilization and as part of
outpatient observation or inpatient or outpatient
stay.
Employee An individual who meets the eligibility requirements set forth in
the Contract between Blue Shield and theEmployer.
Employer
(Contractholder)
Any person, firm, proprietary or non-profit corporation,
partnership, public agency, or association that has at least
101 employees and that is actively engaged in business or
service, in which a bona fide employer-employee relationship
exists, in which the majority of employees were employed
within this state, and which was not formed primarily for
purposes of buying health care coverage or insurance.
Experimental or
Investigational
Any treatment, therapy, procedure, drug or drug usage,
facility or facility usage, equipment or equipment usage,
device or device usage, or supplies that are not recognized in
accordance with generally accepted professional medical
standards as being safe and effective for use in the treatment
of the illness, injury, or condition at issue.
Services that require approval by the Federal government or
any agency thereof, or by any State government agency,
prior to use and where such approval has not been granted
at the time the services or supplies were rendered, shall be
considered experimental or investigational in nature.
Services or supplies that themselves are not approved or
recognized in accordance with accepted professional
medical standards, but nevertheless are authorized by law or
by a government agency for use in testing, trials, or other
studies on human patients, shall be considered experimental
or investigational in nature.
Family The Subscriber and all enrolled Dependents.
Former Participating
Provider
A Former Participating Provider is a provider of services to the
Member under any of the following conditions:
•A provider who is no longer available to you as a
Participating Provider or an MHSA Participating
Provider, but at the time of the provider's contract
termination with Blue Shield or the MHSA, you were
receiving Covered Services from that provider for one
of the conditions listed in the Continuity of care with a
Definitions 88
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2650.
Former Participating Provider table in the Continuity of
care section.
•A Non-Participating Provider to a newly-covered
Member whose health plan was withdrawn from the
market, and at the time your coverage with Blue Shield
became effective, you were receiving Covered
Services from that provider for one of the conditions
listed in the Continuity of care with a Former
Participating Provider table in the Continuity of care
section.
•A provider who is a Participating Provider with Blue
Shield or the MHSA but no longer available to you as a
Participating Provider or an MHSA Participating
Provider because:
o The Employer has terminated its contract with
Blue Shield; and
o The Employer currently contracts with a new
health plan (insurer) that does not include the
Blue Shield Participating Provider or the MHSA
Participating Provider in its network; and
o At the time of the Employer’s contract
termination you were receiving Covered
Services from that provider for one of the
conditions listed in the Continuity of care with a
Former Participating Provider table in the
Continuity of care section.
Generally Accepted
Standards of Mental
Health and
Substance Use
Disorder Care
Standards of care and clinical practice that are generally
recognized by Health Care Providers practicing in relevant
clinical specialties such as psychiatry, psychology, clinical
sociology, addiction medicine and counseling, and
behavioral health treatment. Valid, evidence-based sources
establishing generally accepted standards of Mental Health
and Substance Use Disorder care include:
•Peer-reviewed scientific studies and medical literature;
•Clinical practice guidelines and recommendations of
nonprofit health care provider professional associations;
•Specialty societies and federal government agencies;
and
•Drug labeling approved by the United States Food and
Drug Administration.
Group Health Service
Contract (Contract)
The contract for health coverage between Blue Shield and
the Employer (Contractholder) that establishes the Benefits
that Subscribers and Dependents are entitled to receive.
Health Care Provider
An appropriately licensed or certified professional who
provides health care services within the scope of that license,
including, but not limited to:
Definitions 89
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•Acupuncturist;
•Associate clinical social worker;
•Associate marriage and family therapist or
marriage and family therapist trainee;
•Associate professional clinical counselor or
professional clinical counselor trainee;
•Audiologist;
•Board certified behavior analyst (BCBA);
•Certified nurse midwife;
•Chiropractor;
•Clinical nurse specialist;
•Dentist;
•Hearing aid supplier;
•Licensed clinical social worker;
•Licensed midwife;
•Licensed professional clinical counselor (LPCC);
•Licensed vocational nurse;
•Marriage and family therapist;
•Massage therapist;
•Naturopath;
•Nurse anesthetist (CRNA);
•Nurse practitioner;
•Occupational therapist;
•Optician;
•Optometrist;
•Pharmacist;
•Physical therapist;
•Physician;
•Physician assistant;
•Podiatrist;
•Psychiatric/mental health registered nurse;
•Psychologist;
•Psychology trainee or person supervised as required
by law;
•Qualified autism service provider or qualified autism
service professional certified by a national entity;
•Registered dietician;
•Registered nurse;
•Registered psychological assistant;
•Registered respiratory therapist;
•Speech and language pathologist.
Hemophilia Home
Infusion Provider
A provider that furnishes blood factor replacement products
and services for in-home treatment of blood disorders such as
hemophilia.
A Participating home infusion agency may not be a
Participating Hemophilia Infusion Provider if it does not have
an agreement with Blue Shield to furnish blood factor
replacement products and services.
Definitions 90
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2650.
Home Health Aide
An individual who has successfully completed a state-
approved training program, is employed by a home health
agency or Hospice program, and provides personal care
services in the home.
Hospital
An entity that meets one of the following criteria:
•A licensed and accredited facility primarily
engaged in providing medical, diagnostic, surgical,
or psychiatric services for the care and treatment of
sick and injured persons on an inpatient basis,
under the supervision of an organized medical staff,
and that provides 24-hour a day nursing service by
registered nurses;
•A psychiatric health care facility as defined in
Section 1250.2 of the California Health and Safety
Code.
A facility that is principally a rest home, nursing home, or
home for the aged, is not included in this definition.
Host Blue
The local Blue Cross and/or Blue Shield licensee in a
geographic area outside of California, within the BlueCard®
Service Area.
Infertility
May be either of the following:
•A demonstrated condition recognized by a
licensed Physician or surgeon as a cause for
Infertility; or
•The inability to conceive a pregnancy or to carry a
pregnancy to a live birth after a year of regular
sexual relations without contraception.
Intensive Outpatient
Program
An outpatient treatment program for mental health or
substance use disorders that provides structure, monitoring,
and medical/psychological intervention at least three hours
per day, three times per week.
Inter-Plan
Arrangements
Blue Shield’s relationships with other Blue Cross and/or Blue
Shield licensees, governed by the Blue Cross Blue Shield
Association.
Late Enrollee
An eligible Employee or Dependent who declined enrollment
in this coverage at the time of the initial enrollment period,
and who subsequently requests enrollment for coverage,
provided that the initial enrollment period was a period of at
least 30 days. Coverage is effective for a Late Enrollee the
earlier of 12 months from the date a written request for
coverage is made or at the Employer’s next open enrollment
period.
Definitions 91
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Medical Group
An organization of Physicians who are generally located in
the same facility and provide Benefits to Members, or an
independent practice association (a group of Physicians in
individual offices who form an organization to contract,
manage, and share financial responsibilities for providing
Benefits to Members).
Medical Group
Service Area
The geographic area served by the Medical Group.
Medical Necessity
(Medically
Necessary)
Benefits are provided only for services that are Medically
Necessary.
Services that are Medically Necessary include only those
which have been established as safe and effective, are
furnished under generally accepted professional standards to
treat illness, injury, or medical condition, and which, as
determined by Blue Shield, are:
•Consistent with Blue Shield medical policy;
•Consistent with the symptoms or diagnosis;
•Not furnished primarily for the convenience of the
patient, the attending Physician or other provider;
•Furnished at the most appropriate level that can be
provided safely and effectively to the patient; and
•Not more costly than an alternative service or
sequence of services at least as likely to produce
equivalent therapeutic or diagnostic results as to the
diagnosis or treatment of the Member’s illness, injury, or
disease.
Hospital inpatient services that are Medically Necessary
include only those services that satisfy the above
requirements, require the acute bed-patient (overnight)
setting, and could not have been provided in a Physician’s
office, the Outpatient Department of a Hospital, or in another
lesser facility without adversely affecting the patient’s
condition or the quality of medical care rendered.
Inpatient admission is not Medically Necessary for certain
services, including, but not limited to, the following:
•Diagnostic studies that can be provided on an
outpatient basis;
•Medical observation or evaluation;
•Personal comfort;
•Pain management that can be provided on an
outpatient basis; and
•Inpatient rehabilitation that can be provided on an
outpatient basis.
Blue Shield reserves the right to review all services to
determine whether they are Medically Necessary, and may
Definitions 92
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use the services of Physician consultants, peer review
committees of professional societies or Hospitals, and other
consultants.
This definition does not apply to services which Blue Shield is
required by law to cover for Reconstructive Surgery or to
Mental Health and Substance Use Disorders. Medically
Necessary Treatment of a Mental Health or Substance Use
Disorder is defined separately.
Medically Necessary
Treatment of a
Mental Health or
Substance Use
Disorder
A Covered Service or product addressing the specific needs
of a Member, for the purpose of preventing, diagnosing, or
treating an illness, injury, condition, or its symptoms, including
minimizing the progression of an illness, injury, condition, or its
symptoms, in a manner that is all of the following:
•In accordance with the Generally Accepted
Standards of Mental Health and Substance Use
Disorder care;
•Clinically appropriate in terms of type, frequency,
extent, site, and duration; and
•Not primarily for the economic benefit of the disability
insurer and Members or for the convenience of the
patient, treating Physician, or other Health Care
Provider.
Member
An individual who is enrolled and maintains coverage in the
plan pursuant to the Contract as either a Subscriber or a
Dependent. Use of “you” in this document refers to the
Member.
Mental Health and
Substance Use
Disorder(s)
A mental health condition or substance use disorder that falls
under any of the diagnostic categories listed in the mental
and behavioral disorders chapter of the most recent edition
of the International Statistical Classification of Diseases or
listed in the most recent version of the Diagnostic and
Statistical Manual of Mental Disorders (DSM).
Mental Health
Service Administrator
(MHSA)
The MHSA is a specialized health care service plan licensed
by the California Department of Managed Health Care. Blue
Shield contracts with the MHSA to administer Blue Shield’s
Mental Health and Substance Use Disorder services through a
separate network of MHSA Participating Providers.
MHSA Non-
Participating Provider
A provider who does not have an agreement in effect with
the MHSA for the provision of mental health or substance use
disorder services.
MHSA Participating
Provider
A provider who has an agreement in effect with the MHSA for
the provision of mental health or substance use disorder
services.
Definitions 93
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Mobile Crisis Team
A multidisciplinary team of trained behavioral health
professionals who provide Behavioral Health Crisis Services in
the least restrictive setting 24 hours a day, 7 days a week, 365
days per year.
Non-Participating
(Non-Participating
Provider)
Any provider who does not participate in this plan’s network
and does not contract with Blue Shield to accept Blue Shield’s
payment, plus any applicable Member Cost Share, or
amounts in excess of specified Benefit maximums, as
payment in full for Covered Services. Also referred to as an
out-of-network provider.
Other Outpatient
Mental Health and
Substance Use
Disorder Services
Outpatient Facility and professional services for the diagnosis
and treatment of Mental Health and Substance Use Disorders,
including but not limited to the following:
•Partial Hospitalization;
•Intensive Outpatient Program;
•Electroconvulsive therapy;
•Office-based opioid treatment;
•Transcranial magnetic stimulation;
•Behavioral Health Treatment; and
•Psychological Testing.
These services may also be provided in the office, home, or
other non-institutional setting.
Out-of-Area Covered
Health Care Services
Medically Necessary Emergency Services, Urgent Services or
Out-of-Area Follow-up Care provided outside the Plan Service
Area.
Out-of-Area Follow-
up Care
Non-emergent Medically Necessary services to evaluate your
progress after Emergency or Urgent Services are provided
outside the Plan Service Area.
Out-of-Pocket
Maximum
The highest Deductible, Copayment, and Coinsurance
amount an individual or Family is required to pay for
designated Covered Services each year as indicated in the
Summary of Benefits section. Charges for services that are not
covered, charges in excess of the Allowed Charges or
contracted rate do not accrue to the Calendar Year Out-of-
Pocket Maximum.
Outpatient
Department of a
Hospital
Any department or facility integrated with the Hospital that
provides outpatient services under the Hospital’s license,
which may or may not be physically separate from the
Hospital.
Outpatient Facility
A licensed facility that provides medical and/or surgical
services on an outpatient basis but is not a Physician’s office
or a Hospital.
Definitions 94
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Partial Hospitalization
Program (Day
Treatment)
An outpatient treatment program that may be free-standing
or Hospital-based and provides services at least five hours per
day, four days per week. You may be admitted directly to this
level of care or transferred from inpatient care following
stabilization.
Participating Hospice
or Participating
Hospice Agency
An entity that has either contracted with Blue Shield or has
received prior approval from Blue Shield to provide Hospice
service Benefits.
Participating
(Participating
Provider)
A provider who participates in this plan’s network and has an
agreement to accept Blue Shield’s payment, plus any
applicable Member Cost Share, as payment in full for
Covered Services. Also referred to as an in-network provider.
Physician An individual licensed and authorized to engage in the
practice of medicine.
Plan Service Area A geographical area designated by the plan within which a
plan shall provide health care services.
Premium (Dues)
The monthly prepayment amount made to Blue Shield on
behalf of each Member by the Contractholder for coverage
under the Contract.
Preventive Health
Services
Preventive medical services for early detection of disease,
including related laboratory services, as specifically described
in the Preventive Health Services section.
Primary Care
Physician (PCP)
A general or family practitioner, internist,
obstetrician/gynecologist, or pediatrician. Your PCP will
provide your primary care and refer, authorize, supervise, and
coordinate the provision of your Benefits.
Psychological Testing Testing to diagnose a mental health condition when referred
by an MHSA Participating Provider.
Qualifying Event A change in your life that can make you eligible for a special
enrollment period to enroll in health coverage.
Reasonable and
Customary
In California: the lower of the provider’s billed charge or the
amount established by Blue Shield pursuant to applicable
state and federal law to be the reasonable and customary
value for the services rendered by a Non-Participating
Provider.
Outside of California: the lower of the provider’s billed charge
or the Participating Provider Cost Share for Emergency
Services as shown in the Summary of Benefits or if applicable,
the amount determined under state and federal law.
Definitions 95
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Reconstructive
Surgery
Surgery to correct or repair abnormal structures of the body
caused by congenital defects, developmental abnormalities,
trauma, infection, tumors, or disease to do either of the
following:
•Improve function; or
•Create a normal appearance to the extent
possible, including dental and orthodontic services
that are an integral part of surgery for cleft palate
procedures.
Skilled Nursing Services performed by a licensed nurse who is either a
registered nurse or a licensed vocational nurse.
Skilled Nursing
Facility (SNF)
A health facility or a distinct part of a Hospital with a valid
license issued by the California Department of Public Health
that provides continuous Skilled Nursing care to patients
whose primary need is for availability of Skilled Nursing care
on a 24-hour basis.
Specialist
Specialists include Physicians with a specialty as follows:
•Allergy;
•Anesthesiology;
•Dermatology;
•Cardiology and other internal medicine specialists;
•Neonatology;
•Neurology;
•Oncology;
•Ophthalmology;
•Orthopedics;
•Pathology;
•Psychiatry;
•Radiology;
•Any surgical specialty;
•Otolaryngology;
•Urology; and
•Other designated as appropriate.
Subacute Care
Skilled Nursing or skilled rehabilitation provided in a hospital or
Skilled Nursing Facility to patients who require skilled care such
as nursing services, physical, occupational or speech therapy,
a coordinated program of multiple therapies or who have
medical needs that require daily registered nurse monitoring.
A facility that is primarily a rest-home, convalescent facility, or
home for the aged is not included.
Subscriber An eligible Employee who is enrolled and maintains coverage
under the Contract.
Definitions 96
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Third-Party
Corporate
Telehealth Provider
A corporation directly contracted with Blue Shield that
provides health care services exclusively through a telehealth
technology platform and has no physical location at which a
Member can receive services.
Total Disability
(Totally Disabled)
In the case of an Employee, or Member otherwise eligible for
coverage as an Employee, a disability which prevents the
individual from working with reasonable continuity in the
individual’s customary employment or in any other
employment in which the individual reasonably might be
expected to engage, in view of the individual’s station in life
and physical and mental capacity.
In the case of a Dependent, a disability which prevents the
individual from engaging with normal or reasonable
continuity in the individual’s customary activities or in those in
which the individual otherwise reasonably might be expected
to engage, in view of the individual’s station in life and
physical and mental capacity.
Value-Based
Program
An outcomes-based payment arrangement and/or a
coordinated care model facilitated with one or more local
providers that is evaluated against cost and quality
metrics/factors and is reflected in Provider payment.
Urgent Services
Those Covered Services rendered outside of the Medical
Group Service Area (other than Emergency Services) which
are Medically Necessary to prevent serious deterioration of
your health resulting from unforeseen illness, injury or
complications of an existing medical condition, for which
treatment cannot reasonably be delayed until you return to
the Medical Group Service Area.
97
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Notices about your plan
Notice about this group health plan: Blue Shield makes this health plan available to
Employees through a contract with the Employer. The Contract includes the terms in this
Evidence of Coverage, as well as other terms. A copy of the Contract is available upon
request. A Summary of Benefits is provided with, and is incorporated as part of, the
Evidence of Coverage. The Summary of Benefits sets forth your Cost Share for Covered
Services under this plan.
Notice about plan Benefits: Benefits are only available for services and supplies you
receive while covered by this plan. You do not have the right to receive the Benefits of
this plan after coverage ends, except as specifically provided under the Extension of
Benefits section and, when applicable, the Continuity of care and Continuation of
group coverage sections. Blue Shield may change Benefits during the term of coverage
as specifically stated in this Evidence of Coverage. Benefit changes, including any
reduction in Benefits or elimination of Benefits, apply to services or supplies you receive
on or after the effective date of the change.
Notice about Medical Necessity: Benefits are only available for services and supplies
that are Medically Necessary. Blue Shield reserves the right to review all claims to
determine if a service or supply is Medically Necessary. A Physician or other Health Care
Provider’s decision to prescribe, order, recommend, or approve a service or supply
does not, in itself, make it Medically Necessary.
Notice about reproductive health services: Some Hospitals and providers do not
provide one or more of the following services that may be covered under your plan
and that you or your family member might need:
•Family planning;
•Contraceptive services, including emergency contraception;
•Sterilization, including tubal ligation at the time of labor and delivery;
•Infertility treatments; or
•Abortion.
You should obtain more information before you enroll. Call your prospective doctor,
medical group, independent practice association, or clinic, or contact Customer
Service to ensure that you can obtain the health care services you need.
Notice about Participating Providers: Blue Shield contracts with Hospitals and Physicians
to provide services to Members for specified rates. This contractual agreement may
include incentives to manage all services for Members in an appropriate manner
consistent with the Contract. To learn more about this payment system, contact
Customer Service.
Notice about telehealth: You have the right to access your medical records. The
records of any services provided to you through a Third-Party Corporate Telehealth
Provider will be shared with your PCP, unless you object.
You can receive Covered Services on an in-person basis or via telehealth, if available,
from your PCP, treating specialist, or from another contracting individual health
professional, contracting clinic, or contracting health facility consistent with existing
timeliness and geographic access standards. See the Timely access to care section for
more information.
If your plan includes Covered Services from Non-Participating Providers, you can
receive the Covered Service either on an in-person basis or via telehealth.
Notices about your plan 98
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Please see the Health care professionals and facilities section for additional information.
Notice about Manifest MedEx participation: Blue Shield participates in the Manifest
MedEx health information exchange (HIE). Blue Shield makes its Members’ health
information available to Manifest MedEx for access by their authorized Health Care
Providers. Manifest MedEx is an independent, not-for-profit organization that maintains
a statewide database of electronic patient records that includes health information
contributed by doctors, health care facilities, health care service plans, and health
insurance companies. Authorized Health Care Providers may securely access their
patients’ health information through the Manifest MedEx HIE to support the provision of
care.
Manifest MedEx respects Members’ right to privacy and follows applicable state and
federal privacy laws. Manifest MedEx uses advanced security systems and modern
data encryption techniques to protect Members’ privacy and the security of their
personal information. The Manifest MedEx notice of privacy practices is posted on its
website at manifestmedex.org.
You have the right to direct Manifest MedEx not to share your health information with
your Health Care Providers. Although opting out of Manifest MedEx may limit your
Health Care Provider’s ability to quickly access important health care information about
you, your Blue Shield coverage will not be affected by an election to opt-out of
Manifest MedEx. No doctor or Hospital participating in Manifest MedEx will deny
medical care to a patient who chooses not to participate in the Manifest MedEx HIE.
If you do not wish to have your health care information displayed in Manifest MedEx,
you should fill out the online form at manifestmedex.org/opt-out or call Manifest MedEx
at (888) 510-7142.
Notice about organ and tissue donation: Thousands of people in the United States need
an organ or tissue transplant. Each person on the transplant waiting list faces death
while waiting for an available organ or tissue.
Many Californians are eligible to become organ and tissue donors. To learn more about
organ and tissue donation, or to register as a donor, visit Donor Network West
(donornetworkwest.org) or Donate Life California (donatelifecalifornia.org). You may
also call the nearest city’s regional organ procurement agency for additional
information.
Notice about confidentiality of personal and health information: Blue Shield protects the
privacy of individually-identifiable personal information, including protected health
information. Individually-identifiable personal information includes health, financial,
and/or demographic information - such as name, address, and Social Security number.
Blue Shield will not disclose this information without authorization, except as permitted or
required by state or federal law.
A STATEMENT DESCRIBING BLUE SHIELD’S POLICIES AND PROCEDURES FOR PRESERVING
THE CONFIDENTIALITY OF MEDICAL RECORDS IS AVAILABLE AND WILL BE FURNISHED TO
YOU UPON REQUEST.
Blue Shield’s “Notice of Privacy Practices” can be obtained either by calling Customer
Service or by visiting blueshieldca.com.
Notices about your plan 99
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Members who are concerned that Blue Shield may have violated their privacy rights, or
who disagree with a decision Blue Shield made about access to their individually-
identifiable personal information, may contact Blue Shield at:
Blue Shield of California Privacy Office
P.O. Box 272540
Chico, CA 95927-2540
Notice about confidential communication requests: A health plan shall notify
Subscribers and enrollees that they may request a confidential communication
pursuant to the following and how to make the request.
A health plan shall permit Subscribers and enrollees to request, and shall
accommodate requests for, confidential communication in the form and format
requested by the individual, if it is readily producible in the requested form and format,
or at alternative locations.
A health plan may require the Subscriber or enrollee to make a request for a
confidential communication in writing or by electronic transmission.
The confidential communication request shall be valid until the Subscriber or enrollee
submits a revocation of the request or a new confidential communication request is
submitted.
The confidential communication request shall apply to all communications that disclose
medical information or provider name and address related to receipt of medical
services by the individual requesting the confidential communication.
A confidential communication request may be submitted in writing to Blue Shield of
California at the mailing address, email address, or fax number at the bottom of this
page. A confidential communication form, available by going to
blueshieldca.com/privacy and clicking on “privacy forms,” may be used when
submitting a confidential communication request in writing, but it is not required.
Once in place, a valid confidential communication request prevents Blue Shield from:
1. Requiring the protected individual to obtain the primary Subscriber’s or other
enrollee’s authorization to receive sensitive services or submit a claim for sensitive
services if the protected individual has the right to consent to care; and 2. Disclosing
medical information relating to sensitive health services provided to a protected
individual to the primary Subscriber or any plan enrollees other than the protected
individual receiving care, absent an express written authorization of the protected
individual receiving care.
You may return this completed and signed form via any of these options:
Mail: Blue Shield of California Privacy Office, P.O. Box 272540, Chico CA, 95927-2540
Email: privacy@blueshieldca.com
Fax: 1-800-201-9020
Notices about your plan 100
A16205 (01/24)100
Acupuncture and Chiropractic Services Rider
Group Rider
Effective January 1, 2024
HMO/POS
PRISM/Small Group Program Chiropractic and Acupuncture Benefits
Summary of Benefits
This Summary of Benefits shows the amount you will pay for Covered Services under this acupuncture and chiropractic
services Benefit.
Benefits Your Payment
Covered Services must be determined as
Medically Necessary by American Specialty
Health Plans of California, Inc. (ASH Plans).
Up to 30 visits per Member, per Calendar Year.
The 30 visit maximum is for acupuncture and
chiropractic services combined.
Services are not subject to the Calendar Year
Deductible and do count towards the
Calendar Year Out-of-Pocket Maximum.
When using an ASH Participating
Provider
When using a Non-Participating
Provider
Acupuncture Services
Office visit $10/visit Not covered
Chiropractic Services
Office visit $10/visit Not covered
Chiropractic Appliances All charges above $50 Not covered
Benefit Plans may be modified to ensure compliance with State and Federal Requirements.
PENDING REGULATORY APPROVAL
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A17273 (1/24) Plan ID: 30749 101
Introduction
In addition to the Benefits listed in your Evidence of Coverage, your rider provides coverage for acupuncture
and chiropractic services as described in this supplement. The Benefits covered under this rider must be
received from an American Specialty Health Plans of California, Inc. (ASH Plans) Participating Provider. These
acupuncture and chiropractic Benefits are separate from your health Plan, but the general provisions,
limitations, and exclusions described in your Evidence of Coverage do apply. A referral from your Primary
Care Physician is not required.
All Covered Services, except for (1) the initial examination and treatment by an ASH Participating Provider;
and (2) Emergency Services, must be determined as Medically Necessary by ASH Plans.
Note: ASH Plans will respond to all requests for Medical Necessity review within five business days from receipt
of the request.
Covered Services received from providers who are not ASH Participating Providers will not be covered
except for Emergency Services and in certain circumstances, in counties in California in which there are no
ASH Participating Providers. If ASH Plans determines Covered Services from a provider other than a
Participating Provider are Medically Necessary, you will be responsible for the Participating Provider
Copayment amount.
Benefits
Acupuncture Services
Benefits are available for Medically Necessary acupuncture services for the treatment of Musculoskeletal
and Related Disorders.
Benefits include an initial examination, acupuncture and adjunctive therapy, and subsequent office visits for
the treatment of:
•headaches (tension-type and migraines);
•hip or knee joint pain associated with osteoarthritis (OA);
•other extremity joint pain associated with OA or mechanical irritation;
•other pain syndromes involving the joints and associated soft tissues;
•back and neck pain; and
•nausea associated with pregnancy, surgery, or chemotherapy.
Chiropractic Services
Benefits are available for Medically Necessary chiropractic services for the treatment of Musculoskeletal and
Related Disorders.
Benefits include an initial examination, subsequent office visits and the following services:
•spinal and extra-spinal joint manipulation (adjustments);
•adjunctive therapy such as electrical muscle stimulation or therapeutic exercises;
•plain film x-ray services; and
•chiropractic supports and appliances.
Visits for acupuncture and chiropractic services are limited to a per Member per Calendar Year maximum as
shown on the Summary of Benefits. Benefits must be provided in an office setting. You will be referred to your
102
Primary Care Physician for evaluation of conditions not related to a Musculoskeletal and Related Disorder
and for other services not covered under this rider such as diagnostic imaging (e.g. CAT scans or MRIs).
Note: You should exhaust the Benefits covered under this rider before accessing the same services through
the "Alternative Care Discount Program," which is a wellness discount program. For more information about
the Alternative Care Discount Program, visit www.blueshieldca.com.
See the Grievance Process portion of your EOC for information on filing a grievance, your right to seek
assistance from the Department of Managed Health Care, and your rights to independent medical review.
Member Services
For all acupuncture and chiropractic services, Blue Shield of California has contracted with ASH Plans to act
as the Plan’s acupuncture and chiropractic services administrator. Contact ASH Plans with questions about
acupuncture and chiropractic services, ASH Participating Providers, or acupuncture and chiropractic
Benefits.
Contact ASH Plans at:
1-800-678-9133
American Specialty Health Plans of California, Inc.
P.O. Box 509002
San Diego, CA 92150-9002
ASH Plans can answer many questions over the telephone.
Exclusions
Acupuncture services do not include:
•treatment of asthma;
•treatment of addiction (including without limitation smoking cessation); or
•vitamins, minerals, nutritional supplements (including herbal supplements), or other similar products.
See the Grievance Process portion of your EOC for information on filing a grievance, your right to seek
assistance from the Department of Managed Health Care, and your rights to independent medical review.
Definitions
American Specialty
Health Plans of
California, Inc. (ASH
Plans)
ASH Plans is a licensed, specialized health care service plan that has entered into
an agreement with Blue Shield of California to arrange for the delivery of
acupuncture and chiropractic services.
ASH Participating
Provider
An acupuncturist or a chiropractor under contract with ASH Plans to provide
Covered Services to Members.
Musculoskeletal and
Related Disorders
Musculoskeletal and Related Disorders are conditions with signs and symptoms
related to the nervous, muscular, and/or skeletal systems. Musculoskeletal and
Related Disorders are conditions typically categorized as: structural, degenerative,
or inflammatory disorders; or biomechanical dysfunction of the joints of the body
and/or related components of the muscle or skeletal systems (muscles, tendons,
fascia, nerves, ligaments/capsules, discs and synovial structures) and related
manifestations or conditions. Musculoskeletal and Related Disorders include
Myofascial/Musculoskeletal Disorders, Musculoskeletal Functional Disorders and
subluxation.
103
Please be sure to retain this document. It is not a contract but is a part of your EOC.
104
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Notice informing individuals about nondiscrimination and
accessibility requirements
Discrimination is against the law
Blue Shield of California complies with applicable state laws and federal civil rights laws,
and does not discriminate on the basis of race, color, national origin, ancestry, religion,
sex, marital status, gender, gender identity, sexual orientation, age, or disability. Blue Shield
of California does not exclude people or treat them differently because of race, color,
national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual
orientation, age, or disability.
Blue Shield of California:
•Provides aids and services at no cost to people with disabilities to communicate
effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (including large print, audio, accessible
electronic formats and other formats)
•Provides language services at no cost to people whose primary language is not English,
such as:
- Qualified interpreters
- Information written in other languages
If you need these services, contact the Blue Shield of California Civil Rights Coordinator.
If you believe that Blue Shield of California has failed to provide these services or
discriminated in another way on the basis of race, color, national origin, ancestry,
religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability,
you can file a grievance with:
Blue Shield of California Civil Rights Coordinator
P.O. Box 629007
El Dorado Hills, CA 95762-9007
Phone: (844) 831-4133 (TTY: 711)
Fax: (844) 696-6070
Email: BlueShieldCivilRightsCoordinator@blueshieldca.com
You can file a grievance in person or by mail, fax, or email. If you need help filing a
grievance, our Civil Rights Coordinator is available to help you. You can also file a civil
rights complaint with the U.S. Department of Health and Human Services, Office for Civil
Rights electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW.
Room 509F, HHH Building
Washington, DC 20201
(800) 368-1019; TTY: (800) 537-7697
Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.
105
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Language access services
106
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
Questions? Visit blueshieldca.com, use the Blue Shield mobile app, or call Customer Service at 1-855-599-
2650.
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