Medical Plans

  • Blue Shield Point-of-Service (POS) Medical - Through the vast Blue Shield provider network, the Blue Shield Classic and Lite plans combine the cost savings of HMO plans with the flexibility of traditional Fee-For-Service plans. Each time you need medical care, you decide who provides your care: your Personal Physician, a Preferred Provider in the Blue Shield network, or any other licensed medical care provider. This plan gives you freedom of choice and puts you in control of your health care needs. Both CAPE Blue Shield plans include prescription drug, mental health, vision, a medical premium disability plan, a $10,000 survivor benefit, and chiropractic and acupuncture coverage.
  • Plan year 2014 CAPE/Blue Shield plan highlights: enhanced vision benefits (including provider network change from MES to VSP), enhanced DME/orthotic/prosthetic coverage, acupuncture and chiropractic benefits continue through ASHP’s provider network (using your CAPE/Blue Shield medical ID card).  IMPORTANT REMINDER!  Take a moment to complete and submit the Beneficiary Designation Form for the $10,000 Survivor Benefit.
  • Chiropractic and Acupuncture - Provided with CAPE Blue Shield coverage, extensive chiropractic and acupuncture benefits are available without a referral from your Personal Physician. Depending on which Blue Shield plan you choose, you will either have a $10 or $15 co-pay per visit with the new benefit of  unlimited visits in a calendar year (based on medical necessity). Provider network through American Specialty Health Plans.
  • Healthy Lifestyle Rewards is changing its look and will now be known as Wellvolution!  In 2014, CAPE’s wellness rewards program, through Wellvolution, will continue to provide health-wise activities, which can earn you up to $175 (subscribers only). Join the well-volution in 2014 (with the utmost confidentiality), by following these three easy steps at Wellvolution.
  • CAPE Blue Shield Discounts!  CAPE Blue Shield participants (and covered dependents) may also enjoy discounts on a variety of Health & Wellness programs such as Weight Watchers, 24 Hour Fitness, Club Sport and Renaissance Club Sport facilities.  Participants may also find additional discount savings after using their vision, acupuncture and chiropractic benefits (includes providers outside of the above networks).

Follow Blue Shield on Twitter and Facebook – for latest Blue Shield updates and health news at www.twitter.com/BlueShieldCA. Visit www.facebook.com/blueshieldca and click on the "like" button to become a fan and receive even more Blue Shield updates, including health tips, videos, and photos.

 

Blue Shield Point-of-Service (POS) Medical Insurance

Blue Shield of California
P.O. Box 272540
Chico, CA 95927-2540
www.blueshieldca.com

Member Services 1-800-642-6155

Blue Shield Frequently Asked Questions

Lite: group # ZH5105
Classic: group # ZH5106

Levels of Care
The CAPE/Blue Shield Point-of-Service Lite and Classic plans combine typical HMO and PPO coverage with an Out-of-Network option, giving you provider choice and flexibility. While you must select a Personal Physician upon enrollment, you decide who provides your care when seeking medical services. There are three levels of benefits under each plan, as outlined below:

Level I: The HMO Option
When you receive care through your Blue Shield HMO Personal Physician:

  • You receive the highest level of benefits.

  • There are no deductibles and virtually no claim forms.

  • You pay fixed co-payments for most covered services.

  • Preventive care services are covered at no charge.

  • There is no lifetime dollar maximum.

Level II: The Preferred Plan Option
If you self-refer your care to a Blue Shield Preferred Provider:

  • You can choose from more than 51,000 physicians, 380 hospitals, and 40,000 allied health professionals throughout California.

  • You rarely have to pay at the time of your visit or bother with claim forms.

  • Once you meet your plan's calendar year deductible, you pay only the applicable co-payment for covered services.

  • You're not responsible for provider charges above the amount Blue Shield allows for covered services.

Level III: The Non-Preferred Plan Option
If you self-refer your care to a Non-Preferred Provider:

  • You may visit any licensed provider.

  • You receive the lowest level of benefits, and your Co-payment Maximum will be higher than when you choose a Blue Shield Preferred Provider.

  • You may have to pay for services at the time of your visit or be billed afterwards for the entire amount.

  • You'll have to file claim forms with Blue Shield.

  • You are responsible for paying any difference between the amount Blue Shield allows and the amount billed by the provider.

CAPE/Blue Shield Lite

Benefits Summary 2014

Benefits

Level I -
HMO Option

Level II -
Preferred Plan Option

Level III -
Non-Preferred
Plan Option

Calendar Year Deductible

None

$400 individual $800 family
(combined in - and out of network)

$400 individual $800 family
(combined in - and out of network)

Annual Out-of-Pocket Maximum

$1,500/person; $3,000/family

After deductible, $4,000/person; $8,000/family
(combined in - and out of network)

After deductible, $6,000/person; $12,000/family
(combined in - and out of network)

Lifetime Maximum Benefit

Unlimited

Unlimited

Unlimited


Preventive Care

Immunizations

100%

100% (not subject to deductible)

100% of allowable amount (not subject to deductible)

Periodic Health Exams

100% (including well woman exam, pap smear and mammography)

100% (including well baby/well woman exam, pap smear and mammography – not subject to deductible)

100% of allowable amount (including well baby/well woman exam, pap smear and mammography – not subject to deductible)


Medically Necessary Care

Ambulance

100% after $50 co-pay

80% after deductible

80% of allowable amount (after deductible)

Doctor Office Visits

100% after $10 co-pay

100% after $25 co-pay (for consultation only, not subject to deductible)

70% of allowable amount (after deductible)

Emergency Room

100% after $50 co-pay (waived if admitted)

100% after $50 co-pay (waived if admitted)

100 % after $50 co-pay (waived if admitted)

Hospital Care

100%

80% after deductible

70% of allowable amount (after deductible), up to $360 carrier max per day

Maternity

100%

100% after $25 co-pay (for consultation only, not subject to deductible)

70% of allowable amount (after deductible)

Surgery

100% (outpatient $75 co-pay)

80% after deductible

70% of allowable amount (after deductible); Outpatient: up to $360 carrier max per day

X-ray & Lab Tests

100%

80% after deductible

70% of allowable amount (after deductible)

Prescription Drugs

$5 generic; $15 brand; $30 non-formulary (non-formulary must be preapproved by Blue Shield); Mail Order (90 day supply): $10 generic; $30 brand; $60 non-formulary

$5 generic; $15 brand; $30 non-formulary (non-formulary must be preapproved by Blue Shield); Mail Order (90 day supply): $10 generic; $30 brand; $60 non-formulary

Covered for emergencies only--co-pay applies


Mental Health Care

Mental Health Outpatient

HMO

In-Network

Out-of-Network

100% after $10 co-pay

100% after $25 co-pay for consultation only (not subject to deductible)

70% of allowable amount (after deductible)

Provided by Magellan. Must be arranged through MHSA.

Mental Health Inpatient

HMO

In-Network

Out-of-Network

100%

80% after deductible

70% of allowable amount (after deductible), up to $360 carrier max per day

Provided by Magellan. Must be arranged through MHSA.


Other Plan Benefits

Chiropractic Care

100% after $15 co-pay

100% after $15 co-pay

Not covered

Includes acupuncture, unlimited visits per calendar year per calendar year (based on medical necessity.) Provided through American Specialty Health Plans

Home Health Care

100% after $10 co-pay (up to 100 combined visits per calendar year)

80% after deductible (up to 100 combined visits per calendar year)

70% of allowable amount (after deductible) (up to 100 combined visits per calendar year)

Hospice Care

100% (when provided by authorized hospice agency)

100% (when provided by authorized hospice agency)

100% (when provided by authorized hospice agency)

 

Physical Therapy

100% after $10 co-pay

80% after deductible

70% of allowable amount (after deductible)

Skilled Nursing Facility

100%

80% after deductible

70% of allowable amount (after deductible)

(up to 100 combined days per calendar year)

Vision Care

100% (up to age 18 for screenings only); Through VSP providers: one eye exam every 12 months after $10 co-pay; After $10 material co-pay lenses every 12 months; frames every 12 months up to $120, elective contacts up to $120 every 12 months

100% (up to age 18 for screenings only); Through VSP providers: one eye exam every 12 months after $10 co-pay; After $10 material co-pay lenses every 12 months; frames every 12 months up to $120, elective contacts up to $120 every 12 months

For Non-VSP providers reimbursement up to $60 for one ophthalmologist exam or an optometrist exam up to $50 reimbursement every 12 months; lenses reimbursement of $43-$200 every 12 months; frames up to $40 reimbursement every 12 months; elective contacts reimbursement up to $100 every 12 months

Evidence of Coverage
Lite Plan (PDF download)

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This information is extracted from the Blue Shield POS Plan Member Handbook and the Los Angeles County Choices 2014 Annual Benefits Enrollment Guide. Please refer to your Evidence of Coverage booklet for specific plan details. If you have further questions regarding Coverage Levels or covered services, please contact Blue Shield Member Services at 1-800-642-6155. And, you may always contact our benefits consultants, with dedicated staff to serve you, at 1-800-487-3092.

 

CAPE/Blue Shield Classic

Benefits Summary 2014

Benefits

Level I -
HMO Option

Level II -
Preferred Plan Option

Level III -
Non-Preferred
Plan Option

Calendar Year Deductible

None

$300 individual $600 family
(combined in - and out of network)

$300 individual $600 family
(combined in - and out of network)

Annual Out-of-Pocket Maximum

$1,500/person; $3,000/family

After deductible, $4,000/person; $8,000/family
(combined in - and out of network)

After deductible, $6,000/person; $12,000/family
(combined in - and out of network)

Lifetime Maximum Benefit

Unlimited

Unlimited

Unlimited


Preventive Care

Immunizations

100%

100% (not subject to deductible)

100% of allowable amount (not subject to deductible)

Periodic Health Exams

100% (including well woman exam, pap smear and mammography)

100% (including well baby/well woman exam, pap smear and mammography – not subject to deductible)

100% of allowable amount (including well baby/well woman exam, pap smear and mammography – not subject to deductible)


Medically Necessary Care

Ambulance

100% after $50 co-pay

90% after deductible

90% of allowable amount (after deductible)

Doctor Office Visits

100% after $10 co-pay

100% after $20 co-pay (for consultation only, not subject to deductible)

 

70% of allowable amount (after deductible)

Emergency Room

100% after $50 co-pay (waived if admitted)

100% after $50 co-pay (waived if admitted)

100% after $50 co-pay (waived if admitted)

Hospital Care

100%

90% after deductible

70% of allowable amount (after deductible), up to $360 carrier max per day

Maternity

100%

100% after $20 co-pay (for consultation only, not subject to deductible)

70% of allowable amount (after deductible)

Surgery

100% (outpatient $50 co-pay)

90% after deductible

70% of allowable amount (after deductible) Outpatient: up to $360 carrier max per day

X-ray & Lab Tests

100%

90% after deductible

70% of allowable amount (after deductible)

Prescription Drugs

$5 generic; $15 brand; $30 non-formulary (non-formulary must be preapproved by Blue Shield); Mail Order (90 day supply): $10 generic; $30 brand; $60 non-formulary

$5 generic; $15 brand; $30 non-formulary (non-formulary must be preapproved by Blue Shield; Mail Order (90 day supply): $10 generic; $30 brand; $60 non-formulary

Covered for emergencies only--co-pay applies


Mental Health Care

Mental Health Outpatient

HMO

In-Network

Out-of-Network

100% after $10 co-pay

100% after $20 co-pay for consultation only (not subject to deductible)

70% of allowable amount (after deductible)

Provided by Magellan. Must be arranged through MHSA.

Mental Health Inpatient

HMO

In-Network

Out-of-Network

100%

90% after deductible

70% of allowable amount (after deductible), up to $360 carrier max per day

Provided by Magellan. Must be arranged through MHSA.


Other Plan Benefits

Chiropractic Care

100% after $10 co-pay

100% after $10 co-pay

Not covered

Includes acupuncture, unlimited visits/calendar year (based on medical necessity). Provided through American Specialty Health Plans

Home Health Care

100% after $10 co-pay

90% after deductible

70% of allowable amount (after deductible)

(up to 100 combined visits per calendar year)

Hospice Care

100% (when provided by authorized hospice agency)

100% (when provided by authorized hospice agency)

100% (when provided by authorized hospice agency)

Physical Therapy

100% after $10 co-pay

90% after deductible

70% of allowable amount (after deductible)

Skilled Nursing Facility

100%

90% after deductible

70% of allowable amount (after deductible)

(up to 100 combined visits per calendar year)

Vision Care

100% (up to age 18 for screenings only); Through VSP providers: one eye exam every 12 months after $10 co-pay; After $10 material co-pay lenses every 12 months; frames every 12 months up to $120, elective contacts up to $120 every 12 months

100% (up to age 18 for screenings only); Through VSP providers: one eye exam every 12 months after $10 co-pay; After $10 material co-pay lenses every 12 months; frames every 12 months up to $120, elective contacts up to $120 every 12 months

For Non-VSP providers reimbursement up to $60 for one ophthalmologist exam or an optometrist exam up to $50 reimbursement every 12 months; lenses reimbursement of $43-$200 every 12 months; frames up to $40 reimbursement every 12 months; elective contacts reimbursement up to $100 every 12 months

Evidence of Coverage
Classic Plan (PDF download)

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This information is extracted from the Blue Shield POS Plan Member Handbook and the Los Angeles County Choices 2014 Annual Benefits Enrollment Guide. Please refer to your Evidence of Coverage booklet for specific plan details. If you have further questions regarding Coverage Levels or covered services, please contact Blue Shield Member Services at 1-800-642-6155. And, you may always contact our benefits consultants, with dedicated staff to serve you, at 1-800-487-3092.


Frequently Asked Questions

What happens if I don't choose a Personal Physician?
If you don't choose a Personal Physician when you enroll in the Blue Shield POS Plan, Blue Shield will choose one for you. Blue Shield will notify you of the selection and let you choose another Personal Physician if you're not satisfied. Remember, Personal Physician changes are effective the first of the month after Blue Shield is notified.

Do I need to choose the same Personal Physician as other members of my family?
In most instances, each covered family member may choose his or her own Personal Physician within Blue Shield's network. The exception is newborns and children placed for adoption. A newborn that is a mother's natural child must be in the same Medical Group/IPA as the mother. If the mother of the newborn is not enrolled as a member, or if the child has been placed with the subscriber for adoption, the Personal Physician selected must be in the same Medical Group/IPA as the subscriber.

Can I change Personal Physicians?
In general, you may change Personal Physicians at any time for any reason. Just call Blue Shield Member Services. In most cases, the change will be effective the first day of the month following notice of approval by Blue Shield.

What should I do if I want to see a specialist?
If you feel you need to see a specialist, you should discuss this with your Personal Physician. If you Personal Physician believes your medical condition or concerns are best treated by a specialist, they will submit a request to their Medical Group or IPA recommending that you be sent to a specialist. If the referral is approved, you will usually be sent to a specialist in your Personal Physican's Medical Group or IPA, and you will be charge your usual office visit co-payment. You always have the option to self-refer to a Preferred Provider within the Blue Shield network or a Non-Preferred Provider outside the network, but your financial responsibility will be more under these options (see Level of Care summaries).

Can I request a second opinion?
Yes. If there is a question about your diagnosis or you would like additional information regarding your condition in order to help determine the most appropriate course of treatment, you can ask your Personal Physician to refer you to another physician for a second opinion. If you request a second opinion about care received from your Personal Physician, the second opinion will be provided by a physician within the same Medical Group/IPA as your Personal Physician. If you request a second opinion about care received from a specialist, this second opinion can be provided by any Plan specialist of the same or equivalent specialty. All second opinion consultations must be authorized by the Plan. Your Personal Physician might also decide to offer a second opinion referral even if you do not request it. You always have the option to self-refer to a Preferred Provider within the Blue Shield network or a Non-Preferred Provider outside the network, but your financial responsibility will be more under these options (see Level of Care summaries).

Are preexisting conditions covered?
Yes, covered services for preexisting conditions are covered.

What should I do if I get a bill from an HMO provider?
Normally, you should not receive a bill when your Personal Physician provides or coordinates your care. You are responsible only for paying your co-payment at the time of your visit. Sometimes bills for covered services may be sent to you in error. If this should happen to you, call Blue Shield Member Services at 1-800-642-6155 as soon as possible. Blue Shield will need your subscriber number, a brief explanation of the circumstances surrounding the bill and information about whether or not your Personal Physician provided or approved the services. If you paid for or receive a bill for emergency care, call Member Services for assistance.


Chiropractic and Acupuncture

American Specialty Health Plans

10221 Wateridge Circle
San Diego, CA 92121
www.ashcompanies.com

Member Services
(800) 848-3555

Alternative health coverage through American Specialty Health Plans is automatically included when you participate in one of the CAPE/Blue Shield Point-of-Service medical plans. This benefit is available without a referral from your physician and includes chiropractic and acupuncture services.

With ASHP, you have direct access to more than 2,200 credentialed chiropractors and nearly 700 credentialed acupuncturists servicing California. ASHP is designed for your convenience. You simply pay your co-payment at each visit; there are no deductibles to meet or claim forms to fill out.

Members may simply call a Participating Chiropractor or Participating Acupuncturist to schedule an initial examination. After the initial examination, the Chiropractor or Acupuncturist must obtain pre-authorization for any additional Covered Services to a Member.

Summary of Benefits

CAPE/Blue Shield POS Plan Type

Lite Classic
Co-Payment per Visit $15 $10

Calendar-year Chiropractic Appliance Benefit

$50

$50

Office Visit Annual Maximum

Unlimited

Unlimited

 

This information is extracted from the American Specialty Health Plans of California, Inc. and from the ASHP Chiropractic & Acupuncture Schedule of Benefits and is only a summary. Combined Evidence of Coverage and Disclosure Form and from the ASHP Chiropractic & Acupuncture with Traditional Chinese Herbal Supplements Schedule of Benefits and is only a summary. Please refer to the Evidence of Coverage for specific and complete plan details. If you have further questions regarding covered services, please contact ASHP Member Services at (800) 848-3555 between 8:00 a.m. and 5:00 p.m., Monday through Friday. And, you may always contact us at benefits@capeunion.org or (800) 487-3092.

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