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.