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Covered California Q&A

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 see a holistic medical doctor who is not in any Covered California networks. It is very hard to find information about out of network coverage. I was looking at Blue Shield PPO plans. Am I correct they will cover only 50% out of network?

Answer: Out-of-network benefits are reimbursed at a level much lower than 50% of the provider charges. The plan pays 50% of the carrier’s allowable amount, not the provider’s bill. For example: if your doctor charges $250. The Blue Shield’s in-network allowable amount for this treatment could be as low as $75. Your benefit amount would be half of $75, not half of $250. In addition, out-of-network coverage has a separate deductible, usually 150% to 200% of the in-network deductible. Don’t look for out-of-network benefits to help much if at all on minor medical expenses.

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