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Frequently Asked Questions
Do you have questions about our individual and family plans? The answers below may help. If you don't see your question listed, please contact us.
What's the difference between a PPO and an HMO?
There are many differences between them, but the most significant difference is how you access care. If you're covered by a PPO plan, you may visit any licensed doctor. In an HMO plan, you need to access non-emergency care through an HMO plan; you need to access non-emergency care through a designated Personal Physician to be covered. You can choose your own Personal Physician or we can assign one to you.
Is my doctor or hospital part of the Blue Shield network?
We offer an extensive network of physicians throughout California. To see if you're doctor, hospital or other provider is part of our network
Which plan qualifies for use with a Health Savings Account?
The Shield Spectrum PPOSM Savings Plans 2400/4800 and 4000/8000 are HSA-eligible, high-deductible health plans. Since high-deductible health plan monthly dues/premiums are generally less than health plans with a lower deductible, you can put the money you might save (along with any additional HSA contributions) in a tax-advantaged any additional HSA contributions) in a tax-advantaged personal savings or investment account. You can then use these funds to pay for qualified, non-covered services and major medical expenses - expenses that would otherwise come out of your after-tax income. This could help extend your healthcare budget.
How soon can I get coverage?
It can take four to six weeks to review your application. If you need coverage sooner, Blue Shield of California Life & Health Insurance Company offers short-term health insurance that can be effective almost immediately if you qualify. Please note that if you currently have group coverage, enrolling in a short-term health insurance plan may cause you to be term health insurance plan may cause you to be ineligible for a guaranteed issue individual plan in the future.
Is there an exclusion for pre-existing conditions?
For our Blue Shield PPO plans, benefits will not be provided for pre-existing conditions in the first six months of coverage. This exclusion may be waived if you have prior creditable coverage. You may have prior creditable coverage if your previous health plan covered the services in question and we received your application for Blue Shield coverage within 63 days of terminating your previous plan coverage.
Is pregnancy a waivered condition?
A waivered condition is excluded from coverage for charges and expenses incurred six months from the effective date of coverage. A waivered condition only applies to a condition for which medical advice, diagnosis, care or treatment (including prescription drugs) was recommended or received from a licensed health practitioner during the six months immediately preceding the effective date of coverage.
With Access+ Value HMOSM and Access+ HMO®, pregnancy is a waivered condition. Therefore, benefits for pregnancy and maternity services are not covered for the six-month period from the effective date of coverage, with the exception of services required to treat involuntary complications of pregnancy.
However, if you have prior creditable coverage and you apply for coverage within 63 days after termination of prior coverage, Blue Shield will credit the length of time you were covered on your previous health plan toward the six-month period.
Please note that for Active Start Plans 25 and 35 and Shield Spectrum PPO Savings Plan 4000/8000, pregnancy and maternity benefits are not covered.
Am I covered while traveling?
Yes. With all Blue Shield health plans, benefits will be provided anywhere in the world in the case of an emergency. Blue Shield PPO members are also covered for care worldwide through the Blue Card program. Check your Evidence of Coverage or Policy for specific provisions.
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