Covered California enrollee fights Blue Shield plan to limit out-of-state care

Jan. 02--Blue Shield of California is unfairly targeting hundreds of thousands of Covered California enrollees with a coverage change that would prevent them from getting routine care when they are working outside of California, one enrollee told The Sacramento Bee.

Philip Martin has been trying to get Blue Shield to reverse its decision to limit out-of-state medical coverage for PPO members whose policies didn't go into effect before Jan. 1, 2014, the date when coverage under the Affordable Care Act went into effect. Blue Shield is limiting out-of-state coverage to urgent care, emergency care or follow-up related to those events.

"They are specifically discriminating against this demographic for more profit," Martin said, "not even allowing people who have been with them since the beginning to be grandfathered in."

Roughly 360,000 Covered California enrollees were covered through the Blue Shield PPO by mid-2018, according agency spokesman James Scullary, and about 6,000 of those enrollees had sought out-of-state medical care.

Given that the Blue Shield provisions are changing, Scullary urged Martin and other Covered California enrollees who need a plan offering routine care outside of California to study all the insurer networks because some plans have physicians in other states. Open enrollment continues in California through Jan. 15.

Martin, a 32-year-old Laguna Nigel resident, said he works regularly in California, New York and Florida, and his sister goes to college out of state. They both have routine care needs that can't always wait until they are in California, he said.

"I have relationships with primary care physicians in New York and Los Angeles," Martin said. "I've had specialists that I've been working on knee issues that I've had. I have an orthopedic surgeon and an acupuncturist who have helped with some of those injuries. Also, I have a therapist in New York, one in Florida and one in L.A. that I work with when I'm back there. And, then also, I have chiropractor needs because my work is very demanding with clients. I work out a lot with them. They want to work out with me. We do a lot of physical activity."

Martin said that he called Blue Shield customer service to discuss his care needs, and the representative suggested he come back to California for appointments with medical professionals. He does not make enough money with his work to make such trips cost-effective.

"I work as a recovery coach. I work with people who have addiction issues and mental illness issues, usually diagnosed as bipolar or alcohol addiction or meth and depression," he said. "For me, sometimes I can get a case in another state for two months. Basically, I am with that client 24/7, or I'm with that client 12 hours out of the day to help them with their 12-step program or help them start a job."

The coverage change is also alarming for Martin's sister, who is a student at New York University but covered under their mother's Blue Shield PPO plan, he said.

Martin said he enrolled in Covered California prior to the Jan. 1 date, but coverage didn't start until that date. He appealed the coverage change with Blue Shield and shared the response letter with The Bee. It read: "This change is being made to help us fulfill our goal of keeping coverage costs down for all PPO members."

In a statement emailed to The Bee, Blue Shield said that its PPO would cover only non-emergency care that receives prior authorization and suggested members contact Blue Shield customer service with questions.

Martin shared a letter from Blue Shield that lists non-emergency services that it will cover without prior authorization. They are CAT and MRI scans, and mental health outpatient services.

Martin said he also filed a complaint with the California Department of Managed Health Care, but a department spokesperson told The Bee that state legislation does not require plans to provide non-emergency or non-urgent services outside the state of California, so the DMHC does not have any jurisdiction in the matter.

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