Healthcare costs and claims

Healthcare costs are made up of two parts:

1. Your monthly premium to pay for your coverage.
2. Your out-of-pocket expenses that you pay for the services you receive from a healthcare provider. These can be copayments, coinsurance, and deductibles.

See an example of how your health plan works.

If you’re a PPO member, you can use our Treatment Cost Estimator to help you estimate the cost for more than 400 treatments. Log in to your account and click Treatment Cost Estimator under “Popular tasks.”

Every year, rates are evaluated based on an individual’s household size, income, and region. Additionally, the difference in premiums may be due to one or more of the following:

• You or your dependents had a birthday since your enrollment date: As a member, you are given a rate based on your age at the time of enrollment. Upon renewal (on January 1), we recalculate the rate based on each member's age at the renewal date. For example, if you were 35 when you enrolled and turned 36 before the renewal date (January 1), we will recalculate your rate. Additionally, when members turn 21, they are considered adults, and their rate is recalculated.
• You moved to a different rating (geographic) region: There are 19 rating regions in California, and the prices of the plans available vary by region. If you move to a different rating region, we recalculate your rate based on your new address. For example, if you move from Sacramento to San Francisco, we will recalculate your rate based on your new address, and the rate for the same plan may change.
• Changes in family status: All members of the family who are enrolled for coverage are factored into the overall rate: the subscriber, spouse, the first three children under 21, and every member over 21. Adding or removing dependents from the plan may impact the monthly rate.
• Rising medical costs: These include general costs associated with the administration and delivery of health benefits, hospital, physician, and drug costs, as well as the cost of medical technology. Your premium payments are used to pay these costs.
• Changes to benefits offered in your plan: Some benefit changes include changes in the law, coverage for certain services, authorization requirements, or changes that affect which providers participate in our networks. Changes to coverage will affect rates.
• If you haven't updated your information with Covered California for next year: Your premium and premium tax credit may not reflect the most accurate information. You should always report income and family size changes to Covered California when they happen throughout the year. This will help make sure you get the proper type and amount of premium assistance and will help you avoid getting too much or too little in advance, which can affect your premium.

Blue Shield strongly encourages you to see provider's in your plan's network, so you receive the best value and do not have to pay more out of pocket for care in the form of deductibles or out-of-pocket maximums.

Your doctor or hospital will bill Blue Shield for most services. We will determine what you are charged based on our negotiated rates, or the allowable amount for each covered service. If you have a deductible, you will be responsible for paying the negotiated rate for these services up to the deductible limit. After you have met the deductible limit, we will share most costs with you. This means you will pay a certain percentage of costs for covered services received from Blue Shield providers, and Blue Shield will pay the rest.

There is a limit to how much you must spend out of your pocket each year before Blue Shield begins paying 100% for most covered medical services. This is called your plan's out-of-pocket maximum.

PPO plan

With a PPO plan you have the flexibility to receive covered services from providers that are not in your plan's network, but your costs will be higher because we do not have negotiated rates with those providers. Blue Shield will pay a percentage of our allowed amount for covered services, and you will be responsible for all other costs up to the billed amount. If the service isn’t covered, you may be responsible for all billed charges.

Non-network benefits have separate and higher deductibles and out-of pocket maximums than network benefits. Therefore, you will pay more out of pocket for covered services received from non-network providers. PPO networks and participating providers may be different from plan to plan.

To find a provider in your network, use our Find a Doctor tool. All the search results will list providers that are currently participating in the plan you selected. We work hard to make sure our list of providers is current and accurate. However, because providers leave networks from time to time, you are encouraged to check with the provider before using their services.

HMO plan

If you have an HMO plan, you must visit your primary care physician (PCP) to receive health care. Your PCP must be part of the Trio ACO HMO Network and will refer you to specialists that are part of the same medical group. Services from non-network providers are only covered in the case of emergency treatment; or, if a specialist for the care you need is not in your plan's network, then your PCP will refer you to one outside the network. Please review your Evidence of Coverage for more details.

After you've logged in to blueshieldca.com, click Claims from your Dashboard to see a summary. Click View claims to see your most recent claims and detailed information for each claim including total billed amount, patient responsibility, and more.*

You can also see claim status. Your claim status will be one of the following:
Finalized: Claim has been processed.
Pending: Claim is in process. Claim details are not available while your claim is pending.
Adjustment pending: A change to the original claim is being processed. You will not see the details of the claim while the adjustment is pending.
Adjustment finalized: Claim has been processed and there was an adjustment to the original claim. Details of the claim are available online.

If you need to see a claim that's more than two years old, or if you have other questions, you can call the customer service number listed on your Blue Shield member ID card.

* If you’re a Trio HMO member, you may not be able to view all claims online. For details about claims not available online, please contact your doctor’s medical group or IPA.