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Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.

PPO in One Region, EPO in Another ?

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Question: I live in San Diego, and have been leaning towards Blue Shield (PPO) versus Anthem (EPO) since I don’t like the idea of NO out of network coverage. However, my daughter will be going off to college at UC Santa Cruz in the Fall, and I notice that in Santa Cruz’s region, it is reversed, i.e. Blue Shield is an EPO whereas Anthem is a PPO. Does this have any unusual implications in my situation? My interpretation (assuming we have Blue Shield as a family) would be that in Santa Cruz, she would need to use a provider who was in-network for Blue Shield in Santa Cruz. Is this correct, or would she be able to transfer the “PPO-ness” of our San Diego Blue Shield policy up to school with her? I realized that this only matters if she really needs to see someone who is not in-network for Blue Shield up in that region. Is this an important enough reason to purchase her own policy vs. being part of the family ? And, in general, how will it work for ANYONE who travels to a different region (or out of state, for that matter) where the type of policy that your provider offers is different in the area that you are visiting ? I hope the question is clear, thanks for the service that you are providing.

Answer: The solution is for the family to buy the Blue Shield PPO because PPO members can access EPO providers, but EPO members are unable to access PPO providers. EPO members can only access other EPO providers in other counties. You are correct, no out-of-network coverage for EPO members except for emergencies. PPO members will have out-of-state coverage through BlueCard. EPO members will not.

1 Comment

The different-region EPO/PPO breakdown is really messy. I mean, if I declare my primary residence in one region, I can get the provider I want with PPO coverage, and pay $20-$30 more. But, if I declare my primary residence where I want to, I’m limited to EPO.

It’s the same carrier. Why in the world should it matter if I’m in one region or another. I think Covered California made a huge mistake letting different regions cherry pick between PPO and EPO, so long as there was one in each region.

It really encourages people to get creative about where they’re primary residence is located. And that hurts everyone, the exchange, the system, and the insurance company’s metrics.

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