No more auths for you!

Posted by Jenn Munson on Jan 16, 2019 1:12:24 PM
Jenn Munson

No More Auths For You

On January 1, 2019 California Blue Shield eliminated the ability for policy holders and their families to seek services outside of the state of California.  This policy change poses substantial obstacles for those seeking mental health and addiction treatment services outside of the state of California.  IF YOU CURRENTLY HAVE CLIENTS IN YOUR PROGRAM THAT HAVE THIS INSURANCE CARRIER, AND YOU ARE OUTSIDE CALIFORNIA – NO MORE AUTHS FOR YOU!  To avoid this, please have your Utilization Review team call and get your single case agreements for impacted patients AS SOON AS POSSIBLE!  There are bound to be some hiccups in this new process.  If you have any questions about this process or how it works, please feel free to phone Elevated Billings’ Revenue Cycle Expert – Kendra Allen at 801-644-4014.

Based on the state of California’s Department of Managed Health Care, Blue Shield of California is the third largest insurer in the state of California, covering an estimated 720,000 people in individual PPO Plans, a fifth of which are in the state’s insurance marketplace, Covered California. At the time of this article, there is still no way to know how many individuals will actually be affected by this change, which went into effect on January 1, 2019.

Citing the need to reduce costs, California Blue Shield decided to scale back participation in the national Blue Card program that has historically allowed Blue Shield members to receive a range of primary and specialty care services out of state since 1994. Downplaying the new restrictions, the insurer claims that policies will still cover out-of-state emergency care, urgent care and some limited primary care, according to company officials.

“We have a large network of providers in California. We’re trying to focus on affordability and part of that is focusing on our provider network in California. We’re able to manage our costs better…” states Amanda Wardell, spokesperson for California Blue Shield. Additionally, she goes on to say that the insurance company will work with patients who are already undergoing a course of treatment in a different state and offer members the opportunity for telephone consultations with out-of-state doctors.

This recent change, however, is causing concern. Dena Mendelsohn, a Senior Attorney for Consumers Union out of San Francisco, said that all insurers need to ensure that their members, including those that live in rural areas, have timely access to both primary care and specialty doctors. While conceding that no law forces insurers to provide non-emergency care outside their regions, Mendelsohn adds that if Blue Shield is trying to get costlier members to drop their coverage, known as “lemon-dropping” in the industry, that “it would be problematic.”

Open enrollment season in California ends on January 15, 2019. “It’s really important for consumers to really shop around and understand their options during open enrollment season, Mendelsohn reminds us.



Sources Cited

"Blue Shield's trims to out-of-state coverage give some Californians the blues" originally appeared in California Healthline, a service of the California Health Care Foundation, which is produced by Kaiser Health News. Kaiser HealthNews, a not-for-profit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.