The California Medical Association (CMA) has seen a large increase in calls from physicians confused about the plans/products offered by Blue Shield both on and off the exchange. As you may know, federal law requires that every plan offered in the exchange also be offered off the exchange, using the same network. This has resulted in a number of practices unknowingly seeing patients out-of-network for products that use the insurer's narrower exchange network. It has also created an additional level of confusion for physician practices when checking patients' coverage status.
In the case of Blue Shield, the insurer offers 12 separate products linked to its exchange network, which it calls the "Exclusive PPO Network" or "Exclusive EPO Network." These products, whether purchased on or off the exchange utilize the Blue Shield "Exclusive" (aka exchange) networks. While plans purchased through Covered California will have the CoveredCA logo on them, the "off exchange" versions of these plans will not. However, regardless of whether they were purchased on or off the exchange, these plans will all utilize the insurer's "Exclusive" exchange networks.
When identifying Blue Shield Exclusive Network patients you will need to review both plan and product. Mirror products offered both on and off the exchange may be subject to the lower rate structure. The key in indentifying Exclusive Network products is by verifying the product according to the list in this document. Download the document for a list of all of the various Blue Shield exchange/off-exchange products, a sample eligibility verification and sample member ID cards.
Covered California also announced today that it has taken down its provider directories again due to errors in provider participation information. In the meantime, you can still check your participation status via CMA's quick and easy look-up tool at www.cmanet.org/exchange-lookup (available to members only). If you have any questions about your participation status, please contact the plan(s) directly.
Contact: CMA's reimbursement helpline, (888) 401-5911 or firstname.lastname@example.org.