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Difference
Between Blue Cross and Blue Shield |
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Blue
Cross of California and Blue Shield of
California are separate, competing companies
that offer comprehensive plans at the
Individual and Small Group level.
Provider Networks Both companies have
extensive doctor and hospital lists with
48,000 doctors and 400 hospitals up and down
the state. Typically the lists overlap
with doctors/hospitals participating in
both. Occasionally there will be a
doctor who participates with one company but
not the other so it's best to check on your
doctor.
Online
Doctor Listing
Financial Strength This really
is the main reason to go with the
"Blues". Smaller or
less efficient carriers are having
difficulties with some filing for
Bankruptcy. If you are with a smaller
carrier that is offering significantly
reduced costs, they almost definitely raise
rates, lower benefits, and/or leave the
market entirely. If you have developed
health conditions, the other carriers will
not pick you up at that time. Blue
Cross is owned by Wellpoint, named the most
admired health care carrier in the nation
three years in a row. Blue Shield is a
close second.
Plans Both companies offer a wide
range of plans. Take a look at Cross for
their Share PPO plans, Basic 1000 ( low cost
hospital plan). Shield has done well
with the HSA qualified Preferred Savings
plans.
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Difference
between HMO and PPO
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Most
people already have a strong preference
between these two models but in case you a
need a quick summary, here it is.
With a PPO, you have more flexibility
to choose your doctors; you are not locked
into a region or a primary care doctor.
You can self-refer yourself out to
quotes. The trade off is that you
will help share the costs when you get sick
or hurt in the form of a deductible or
co-insurance.
With an HMO, you choose a Primary
Care Physician who has more control over
referral and/or decisions regarding your
care. You must remain within your
medical group and within a geographic
region. The trade off with this more
structured approach is that there will be
less out of pocket when sick or hurt.
For example, for inpatient hospital, you may
be looking at nothing out of pocket.
TIP HMO's have become more
expensive so compare the annual premium
difference with PPO options to make sure you
are not paying too much.
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How
are pre-existing conditions handled
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Getting
Approved When applying for
coverage, the carrier will make their
decision to approve/decline coverage and/or
increase rates based on pre-existing
conditions. They are mainly looking
for current or ongoing situations.
They will also heavily weigh anything that
is open-ended such as a doctor's request for
a check up in the future which has not
happened yet. Medication now weigh
heavily because of the associated cost.
You can run your situation by us first to
see what the probable outcome might be.
The carriers cannot exclude a certain
condition from coverage in order to approve
a person's coverage.
Once Approved If you have not
had coverage in the prior 63 days before
your effective date, there is a 6 month
waiting period for pre-existing conditions.
This means they will not pay out for claims
relating to pre-existing conditions until
you have been on the plan for 6 months.
If you have not lapsed coverage more than 62
days up to your new effective date, the
carrier will take into account your prior
coverage against a 6 month waiting period.
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Is
my doctor on the list
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You
can check for your doctor or hospital below.
Make sure you specify HMO or PPO.
Sometimes, doctors are listed under medical
group or a billing doctor so if you do not
see your doctor on the list, call their
office and ask if they
EXAMPLE..."participate in the Blue
Cross PPO network".
Online
Doctor Listing
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Can
you breakdown the PPO's plans
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This
is a simple breakdown and you should read
through the benefit summary for more detail
but it helps to simplify the plans.
PPO
plans breakdown into three main categories:
Office consultation, Prescriptions,
and...pretty much everything else (hospital,
labs/x-rays, emergency, surgery, etc..)
Most plans offer some type of immediate
coverage for the office consultation and
generic drugs. NOTE Blue
Cross' Basic 1000 PPO does not cover either
and Shield's Preferred Savings makes these
benefits subject to the deductible.
Keep in mind that there is usually a
separate deductible (from $250 up to $750
depending on plan) for Brand Name drugs.
The "everything else" is typically
subject to the main
deductible
($500-$5000 depending on plan). Once
you meet your deductible, you pay a
percentage until you reach your
max-out-of-pocket.
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What
does the deductible mean
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A
deductible is an amount that you will pay
first before the plan kicks in. Keep
in mind that you will still get the
discounted rate (usually 30-60% off) on
covered benefits, in-network even before you
meet your deductible. After the
deductible is met, you typically go into a %
of the discounted rate. Some benefits
such as maternity and brand name
descriptions will have their own, separate
deductible.
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What
does max-out-of-pocket mean
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This
basically lets you know how the plan will
treat large bills. Your
max-out-of-pocket let's you how much you
will pay up to for covered benefits,
in-network in a calendar year.
Usually, the max is per person up to two
people maximum. The Blue Shield
Preferred Savings plans have a family
deductible for 2 or more people on one plan.
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Can
the rates change
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The
rates can change by class (the entire state
of California or county) or when you move up
to a new age band (typically at 5 year
increments such as age 35-39). The
stronger the carrier, the less severe and
less often the rate increases. Once
approved, they cannot change rates based on
your medical health.
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Can
a child have a plan alone
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Yes.
With either carrier, you have a single child
or multiple siblings on one plan if they are
under the age of 18.
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What
is needed to start the process
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We
basically need the completed application
(download
here
or have a
hard
copy sent to you), and the first payment
to the carriers for at least one month's
worth of premium. If there are medical
records needed, they will request them
directly from the doctor. This
completed information can be expedited by
faxing (831-624-2902) us a copy of the app
and check, and then sending the original in
the mail:
Goodacre Insurance Services
316 Mid Valley Center #283
Carmel, Ca 93923
Online applications are available
here
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How
long does it take
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There
are two different scenarios. If the
applicant is in good health and there isn't
much the carrier wants to check into, we
usually hear back in one to two weeks.
If the volume of applications is running
high in underwriting, the time frame can be
longer. If the carrier wants further
information on something listed in the
application, they will request records
directly from the doctor and this can delay
the processing time. It usually adds
another 2-4 weeks depending on how quickly
the doctor responds back to the request.
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Do
I submit payment with the application
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The
first month's premium must be submitted with
the application. This can be done with
a check made out to the carrier or via
credit card (for Blue Cross). If the
application is not approved, this initial
payment will be fully refunded.
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Is
there a fee to apply
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There
is no fee to apply. Only the initial
month's premium is submitted with the
application.
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Is
a physical required
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A
physical is not required...only the
completed application and first months
premium. Blue Shield does require a
physical for applicants over the age of 55
who have not had one in the last two years.
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How
can I expedite the processing
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Blue
Cross has an
online application which tends to process very
quickly. Otherwise, you can fax your
completed application and copy of check (or
credit card section) to 831-624-2902 to
start the process immediately. You
would then mail the original if paying by
check. The credit card option just
requires the faxed copy.
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Am
I locked in for a period of time
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No.
The policy can be cancelled or renewed (by
payment) month to month.
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How
is payment handled
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There
are a few options for payment with either
carrier.
Billing - Shield monthly, quarterly
Blue Cross bi-monthly, quarterly
Credit Card Blue Cross allows
monthly, bi-monthly, quarterly credit card
deduction
Checking account auto-deduction
monthly deduction.
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Can
I change my plan later
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Downgrading
is easy to do within the same kind of plan
such as Share 500 to the Share 1500.
Upgrading is possible if you are in good
health as it is subject to underwriting.
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Why
should I go with Goodacre Insurance Services
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click
here
for a full explanation of what we provide.
Thanks.
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