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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.


Out of Network Coverage?

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Question: I have a Blue Shield of CA Platinum PPO purchased through Covered California. I am confused as to how much I would be responsible for if using a surgeon who is listed as in-network with Blue Shield not purchased through Covered California, but is not listed as in-network for Covered California policies. Would I be responsible for 50% of Blue Shield's contracted amount with the surgeon or 50% of the surgeons non-contracted fee? Also, how is the maximum out-of-pocket work when using in-network and out-of-network providers? I want to have an Anterior Approach total hip replacement, but none of the top surgeons who perform this approach are on my provider list.

Answer: One of our readers, who prefers to remain anonymous, provided the following answer. I believe the information is accurate.

You would be responsible for 50% of Blue Shield's typical contracted fee PLUS anything beyond what Blue Shield allows of the doctor's full bill. This is complicated, so let me explain. When it comes to out of network coverage, the devil is in the details, and the details of Blue Shield's implementation of out of network coverage is hell, where devils belong. Everyone is inevitably surprised by their paltry out of network coverage, because how it works is very obscure.

Blue Shield's policy states that they allow for an out of network doctor what they WOULD HAVE ALLOWED had the doctor been contracted. (This implies that there is just one single fee that they allow all doctors providing a particular service/region- and that is most certainly a fabrication but is another matter.)

Then too, Blue Shield allows its new "Exclusive Provider" network providers much less than it allows its older, full PPO network providers (the network which grandfathered individual plans, and corporate PPO plans, still use). So when Blue Shield says "What we would have paid had the doctor been in network," they mean "in YOUR network, which may be a network that pays doctors very little."

So: If an *in-network* surgeon charges $5,000, since you have Platinum there is no deductible. Let's say Blue Shield only allows $2000 for the surgeon fee. In a platinum plan they would pay 90%, or $1800, and you would pay 10% or $200. The surgeon would be contractually required to write-off (that is, ignore) the remaining $3000 that Blue Shield disallowed.

Out of network, they would allow a surgeon only that same amount - $2000, and would pay just 50% of that $2000, or $1000. You would owe the surgeon your half of the allowed amount, or $1000 - plus another $3000 for the rest of his $5000 bill. (That's the "balance billing" aspect of this.)

Adding insult to injury, what have you paid "out of pocket?" Just $1000, not $4000. Blue Shield - all insurers - ignore anything you pay that is beyond your share of the amount they allow.

FURTHER, if the facility is out of network and you have 1 or more overnight stays the cost is pretty ruinous, because of Blue Shield's extraordinarily stingy allowance for out of network facility charges. They allow no more than $500 per day for out of network hospital charges, and then pay 50% of that - or $250. Since an actual hospital facility can cost thousands of dollars per night, do the math! Stay out of out of network hospitals except for emergencies.

Policies state "out of network, your costs may be higher." That's a very lame warning and it's amazing regulators allow that wording. (Or maybe it's not so amazing - the regulators don't do much in California.) Your costs will not only absolutely be higher, they will absolutely be MASSIVELY higher. All of this is in the Summary of Benefits and Coverage and in the policy documents. I am not making up any of it, but have the Blue Shield plan documents for every word of it.

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