Blue Shield released information and documents relating to their California individual and family plans (IFP) for 2016. They have dropped their 2015 Exclusive Provider Organization (EPO) plans that offered no out-of-network coverage. All Blue Shield of California IFPs will be PPO with their Exclusive PPO Network of providers. Blue Shield will also be expanding coverage areas to offer plans in the counties of Alpine, Monterey, Sutter and Yuba counties in 2016.
New for 2016, Blue Shield will offer three off-exchange plans that do not mirror the standard benefit designs offered through Covered California.
- Silver Seven 3750 PPO – $7 primary office visit copay, $7 lab copay, $7 Tier 1 generic prescriptions, $70 urgent care with a $3,750 medical deductible.
- Silver 1850 PPO – $1,850 medical deductible with lab and X-ray of 30% coinsurance after deductible.
- Bronze 5550 PPO – Combined medical and pharmacy deductible of $5,500, with many benefits offered at 30% after the deductible.
Blue Shield members in current 2015 EPO plans will be automatically renewed to an equivalent PPO plan in their region. For example, a Silver 70 EPO will become a Silver 70 PPO. Eleven grandfather plans are being withdrawn and no longer available after December 31, 2015. Affected members will be offered an equivalent ACA compliant metal tier plan. Letters of plan closures and suggested replacement plans are being sent out in early October.
Current EPO members, and some grandfathered plans, that are being withdrawn from the market will also have their current Easy$Pay premium payments cancelled. Members that enroll in a new PPO plan will have to re-establish their online premium payments through Easy$Pay. Members will receive a paper bill in lieu of the Easy$Pay if they don’t renew the online payment process. Members whose Easy$Pay is being terminated can call member services or re-enroll online by December 15th to avoid receiving a paper bill for January.
The new Exclusive PPO Network of providers will include more hospitals throughout California that are in-network for members. Blue Shield has added the following hospitals to their network. The number in parenthesis indicates the health plan region.
- Cedars Sinai Medical Center – Los Angeles (16)
- Community Memorial Hospital of San Buenaventura – Ventura (12)
- Medical Center at UCSF – San Francisco (4)
- Ronald Reagan UCLA Medical Center – Los Angeles (16)
- Santa Monica UCLA Medical Center – Los Angeles (16)
- UC Davis Medical Center – Sacramento (3)
- UCSD La Jolla Thornton Hospital – San Diego (19)
- UCSD Medical Center – San Diego (19)
- UCSF Medical Center at Mission Bay – San Francisco (4)
- UCSF Medical Center at Mount Zion – San Francisco (4)
- University of California Irvine Medical Center – Orange (18)
Consistent with the new Covered California standard benefit design, Blue Shield plans will include a prescription drug cost cap per medication per month. The cost cap will vary by metal tier plan and generally apply to high cost Tier 4 drugs.
Dental and Vision Plans
- Covered diagnostic and preventive services (such as X-rays and routine cleanings) will no longer count toward the annual coverage limit for DentalPPO and Specialty Duo Dental Plans.
- Blue Shield has added more HMO and PPO dental providers for greater access for members.
- Blue Shield is offering a new Ultimate Vision 15/25/120 plan, in addition to their current Ultimate Vision 15/25/150. The new plan will have lower frame allowance and specialty lens options with a lower premium than the existing vision plan with higher benefits.
For Uniform Health Plan Benefits & Coverage Matrix, Summary of Benefits, Evidence of Coverage, Plan Guide, Disclosure and Regional Rate Table documents for Blue Shields on and off exchange plans, in addition to Native Alaskan and American Indian health plans please visit Blue Shield of California ACA Plans.