Blue Shield of California
The network contract between Blue Shield of California and Sutter Health has expired; negotiations continue
Blue Shield of California and Sutter Health have been engaged in discussions on rates and terms for a new network contract (HMO/PPO and in some cases, Group Medicare Advantage). Though we are still actively involved in negotiations, the current contract expired at 11:59 p.m. on December 31, 2016 and Sutter Health is no longer Blue Shield’s in-network provider effective January 1, 2017.
We continue to work diligently and in good faith to complete a new contract that is fair and sustainably affordable for our customers. Blue Shield and Sutter Health have agreed to a six-month transition period (through June 30, 2017) to help ensure uninterrupted care for our members as we continue to negotiate.
For members who have questions about Sutter Health and their access to care, Blue Shield has set up a dedicated phone line (888) 852-5345 from 8:00 a.m. to 5:00 p.m. Monday through Friday to address their concerns.
Important information
While our contract negotiations continue, we are taking steps to ensure members have access to uninterrupted care in their area.
PPO members have a six-month transition period
In order to ensure an orderly transition of care to participating providers, Blue Shield and Sutter Health have agreed to a six-month transition period beginning on January 1, 2017. During this transition period, Blue Shield will continue to offer in-network benefit levels to renewing members who receive care from Sutter Health providers. However, even though members’ percentage cost-share will be honored at the in-network benefit level, Sutter Health’s allowed charges will be higher, and members should be aware that this may result in higher out-of-pocket expense for services received from Sutter Health providers depending on plan design.
If a new agreement is not reached before June 30, 2017, services received from Sutter Health after that date will be paid at the out-of-network benefit level in most cases based on reasonable and customary area rates and the terms of the Evidence of Coverage (EOC).
HMO members will receive a 60-day notice if we cannot reach an agreement
If we are unable to reach an agreement with Sutter Health, affected HMO members will be provided sixty (60) days advance written notice of any medical group/PCP change.
Members in an ongoing course of treatment can apply for Continuity of Care
Eligibility for Continuity of Care (COC) depends on factors outlined in the member’s EOC and will be considered by Blue Shield’s COC Department on a case-by-case basis. When a case is approved, the claim(s) is/are processed at in-network benefit levels.
Our commitment to affordably priced health coverage
Blue Shield continues its provider contract discussions with Sutter Health in hopes that a new agreement will soon be reached. We appreciate your patience while we work to secure the best possible outcome for our customers. Our goal is to provide our members with access to quality healthcare at an affordable price.
Emergency services
Blue Shield members who need emergency services should call 911 or seek care at the nearest emergency room including Sutter Health.
Blue Shield will provide the full emergency care level of benefits for these services. Blue Shield encourages members to make informed decisions about when to use urgent care as opposed to emergency room care. Urgent care is appropriate when a member needs a physician’s attention for a condition that is non-life threatening. Any member needing urgent care, but whose physician or network provider is unavailable, should go to the nearest immediate or urgent care facility. Members can access a list of nearby urgent care facilities using the Find a Doctor tool.
