| Identification cards | We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter. If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at (800) 880-8086. You may also request cards through our website www.blueshieldca.com |
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| Where you get covered care | You get care from “Plan providers” and “Plan facilities.” You will only pay co-payments and/or coinsurance, and you will not have to file claims, except for your annual eye examination. |
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Balance Billing Protection | FEHB Carriers must have clauses in their in-network (participating) providers agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract. |
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Plan providers | Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. All Plan providers are credentialed, according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is also on our website, www.blueshieldca.com/federal.
This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.
This plan provides Care Coordinators for complex conditions and can be reached at www.blueshieldca.com/federal for assistance. |
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Plan facilities
| Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website, www.blueshieldca.com/federal. |
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What you must do to get covered care
| It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. You must complete a Primary Care Physician Selection Form. |
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Primary care | Your primary care physician can be a general practitioner, family practitioner, internist, pediatrician, or an OB/GYN. Your primary care physician will provide most of your healthcare, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care physician or IPA/Medical Group leaves the Plan, call us at (800) 880-8086. We will help you select a new one. |
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Specialty care | Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral.
The exceptions to this are:
- for true medical emergencies;
- when another physician is on call for your physician;
- when you self-refer to an Access+ HMO participating specialist (not applicable to infertility, emergency and urgent care and allergy services; mental health and substance use Access+ HMO specialist care must be provided by a provider in Blue Shield's Mental Health Services Administrator (MHSA) network. (see page 57 for details.);
- OB/GYN services provided by an obstetrician/gynecologist or family practitioner within the same IPA/Medical Group as your primary care physician.
In all other instances, referral to a specialist is done at the primary care physician’s direction; if non-Plan specialists or consultants are required, the primary care physician will arrange appropriate referrals.
Here are other things you should know about specialty care:
- If you need to see a specialist frequently because of a chronic, complex or serious medical condition, your primary care physician will develop a treatment plan with you that allows an adequate number of direct access visits with that specialist. Your primary care physician will use our criteria when creating your treatment plan.
- Your primary care physician will create your treatment plan. The physician may have to get an authorization or approval from us beforehand. If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. If they decide(s) to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. We will not pay for you to see a specialist who does not participate with our Plan, unless your primary care physician refers you to a non-Plan specialist for a second opinion.
- If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
- If you have a chronic or disabling condition and lose access to your specialist because we:
- terminate our contract with your specialist for other than cause;
- drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan; or
- reduce our service area and you enroll in another FEHB plan;
You may be able to continue seeing your specialist for up to 90 days or when clinically appropriate after you receive notice of the change. Contact us or, if we drop out of the program, contact your new Plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days. Contact us to coordinate care for these types of cases.
If you are a new Blue Shield of California Access+ HMO member and are currently receiving treatment for a qualifying medical condition from a provider who is not in our network, you may be eligible to complete treatment of your condition with the provider. Or, if you are an existing member and are currently receiving treatment for a qualifying medical condition from a provider who is leaving our network, you may be eligible to complete treatment of your condition with the provider. In order to receive more information about continuity of care and qualifying medical conditions and situations, please contact us at (800) 880-8086 and we will assist you.
Continuity of care is also available if you are currently receiving services for a serious mental health condition. To obtain further information, please contact our Mental Health Services Administrator (MHSA) directly by calling their Member Services at (877) 263-9952. |
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| Second Opinions | If there is a question about your diagnosis or if additional information concerning your condition would be helpful in determining the most appropriate plan of treatment, your primary care physician will, upon request, refer you to another physician for a second medical opinion. If you are requesting a second opinion about care you received from your primary care physician, a physician within the same Medical Group/IPA as your primary care physician will provide the second opinion. If you are requesting a second opinion about care received from a specialist, any Plan specialist of the same equivalent specialty may provide the second opinion. We must authorize all second opinion consultations. |
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| Urgent Care | We have made arrangements for an added benefit for you and your family for your urgent care needs when you or your family are temporarily traveling outside of your primary care physician’s service area. When you are traveling outside of California, you can get urgent care services across the country and around the world through the BlueCard® Program. While traveling within the United States, you can locate a BlueCard provider any time by calling 1-800-810-BLUE (2583) or by going to www.blueshieldca.com/federal. If you are traveling outside of the United States you can call (804) 673-1177 collect 24 hours a day to locate BlueCard Worldwide® Network Provider. If you need urgent care while in your primary care physician's service area, you must first call your primary care physician. If your primary care physician (or your assigned medical group) has provided instructions to seek in-area urgent care at a local urgent care clinic you may do so without calling your primary care physician first. When you are traveling within California but you are outside of your primary care physician’s service area, you should call Blue Shield Member Services at (800) 880-8086 for assistance in receiving Urgent Care through a Blue Shield of California Plan provider. You may also locate a Plan provider by visiting our web site at www.blueshieldca.com/federal. Remember that when you are within your primary care physician’s service area, Urgent Care must be provided or authorized by your primary care physician just like all other non-emergency services of the Plan. |
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| Hospital Care | Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility. |
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| If you are hospitalized when your enrollment begins | We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our plan begins, call our member service department immediately at (800) 880-8086. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage. If you changed from another FEHB Plan to us, your former Plan will pay for the hospital stay until: - you are discharged, not merely moved to an alternative care center;
- the day your benefits from your former Plan run out; or
- the 92nd day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. If your Plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such case, the hospitalized family member's benefits under the new benefit Plan begin on the effective date of enrollment. |
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| The Plan provides coverage for Medically Necessary services for the treatment of gender dysphoria. This includes medical and mental health benefits, as well as benefits for surgical procedures related to gender reassignment with prior authorization. Travel and lodging expenses may also be covered when necessary to obtain Covered Services and authorized in advance by Blue Shield of California. |
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| You need prior Plan approval for certain services | Since your primary care physician arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services. |
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| Inpatient hospital admission | Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. |
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Other services | Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain prior approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.
Your primary care physician must obtain a preauthorization from us for: (1) selected drugs and drug dosages which require prior authorization for medical necessity, including most specialty drugs, (2) growth hormone therapy (GHT) (3) organ transplants (4) bone marrow transplants (5) cancer clinical trials (6) skilled nursing facility care and hospice care and (7) mental health and substance use disorder services.
Refer to Section 5(b) for the preauthorization process for organ and bone marrow transplants.
Refer to Section 5(c) for preauthorization process for extended care/skilled nursing care facility and hospice care benefits.
Refer to Section 5(e) for preauthorization process for mental health and substance use disorder benefits.
Refer to Section 5(f) for preauthorization process for drugs and drug dosages including home self-administered injectable drugs. |
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| How to request precertification for an admission or get prior authorization for Other services | First, your physician, your hospital, you, or your representative, must call us at (800) 880-8086 before admission or services requiring prior authorization are rendered. Next, provide the following information: - enrollee’s name and Plan identification number;
- patient’s name, birth date, identification number and phone number;
- reason for hospitalization, proposed treatment, or surgery;
- name and phone number of admitting physician;
- name of hospital or facility; and
- number of days requested for hospital stay
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Non-urgent care claims | For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.
If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information. |
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Urgent care claims | If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.
If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of time frame, whichever is earlier.
We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.
You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at (800) 880-8086. You may also call OPM's FEHB 2 at (202) 606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at (800) 880-8086. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim). |
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Concurrent care claims | A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.
If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, then we will make a decision within 24 hours after we receive the claim. |
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| Emergency inpatient admission | If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. |
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If your treatment needs to be extended | If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim. |
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Circumstances beyond our control
| Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care. |
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If you disagree with our pre-service claim decision | If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.
If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8. If your claim is in reference to a contraceptive, call 800-880-8086. |
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To reconsider a non-urgent care claim | Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.
In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to
1. Pre-certify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
3. Write to you and maintain our denial. |
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| To reconsider an urgent care claim | In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by telephone, electronic mail, facsimile, or other expeditious methods. |
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| To file an appeal with OPM | After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure. |
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The Federal Flexible Spending Account Program – FSAFEDS | Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26).
FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.
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