Covered CA - Frequently Asked Questions
Covered California & Other Insurance Exchange Networks
2020 Open Enrollment
Sansum Clinic has secured a contract with Blue Shield of California for all individual health insurance plans offered through Covered California. This means that Sansum Clinic should be an in-Network provider for plans sold by Blue Shield or Blue Cross for individuals through Covered California and directly through Blue Shield (On-Exchange) or Blue Cross (On-Exchange) or through a broker/plan directly (Off-Exchange). It is always a good idea to confirm with your insurance broker or with Blue Shield or Blue Cross that the plan you choose will include Sansum Clinic.
Extended hours will be offered by Covered California and locally through the Santa Barbara County Department of Social Services from 8:00 am - 8:00 pm Monday through Friday, although walk-in hours will remain 8:00 am - 4:00 pm Monday through Friday.
Resources:
CoveredCA offers a list of Frequently Asked Questions, which addresses many questions patients may have about Individual or Small Group plans being offered in Region 12 of California.
There is also a link to the insurance brokers licensed to enroll under Covered California on the website CoveredCA.com.
Patients can shop and compare multiple plans at one time for benefits/cost.
To speak with a Covered California representative call:
English (800) 300-1506
TTY (888) 889-4500
Español (Spanish) (800) 300-0213
You may qualify for:
- Premium assistance (only available on exchange)
- Low cost Medi-Cal in which case your application is automatically sent to Santa Barbara County
- Other programs offered by the County of Santa Barbara (i.e. Tobacco Settlement (TS), MADDY, Ryan-White (HIV/Aids related programs, and ICP (Indigent care program))
You may apply for Medi-Cal anytime at the Department of Social Services
Local hospitals also assist their patients if no insurance as they have presumptive eligibility programs in which to enroll patients in need of healthcare coverage.
Frequently Asked Questions:
1. Question: Is Sansum Clinic part of the Covered California Exchange?
Answer: We are part of the Covered California Exchange through Blue Shield of California for Individual plans in Region 12 (for patients living in Santa Barbara, San Luis Obispo, Ventura Counties). For patients living in other Regions of California/States, please check with Blue Shield of California directly to learn whether Sansum Clinic and our providers are considered In Network or Out of Network.
2. Question: Is Sansum part of all of the Blue Shield and Blue Cross of California Exchange plans?
Answer: Sansum Clinic does know we are In Network providers for Blue Shield and Blue Cross of California Individual plans in Region 12 (patients living in Santa Barbara, San Luis Obispo, and Ventura counties) on Covered California (Exchange) or off-Exchange (purchased at health plan directly). For patients living in other Regions of California/States, please check with Blue Shield of California directly to learn whether Sansum Clinic and our providers are considered In Network or Out of Network.
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3. Question: Are Sansum Clinic providers considered In Network or Out of Network for Blue Shield and Blue Cross of California Covered California (On-Exchange) or off-Exchange?
Answer: Sansum Clinic medical providers are In Network providers for Blue Shield and Blue Cross of California. Individual plans sold on Covered California (On-Exchange) or Off-Exchange in Region 12 (purchased through Blue Shield directly) (people who live in Santa Barbara, San Luis Obispo, Ventura counties). For patients living in other Regions of California/States, please check with your broker, Covered CA, or the health plan directly to learn whether Sansum Clinic and our providers are considered In Network or Out of Network.
4. Question: What does Out of Network mean?
Answer: Sansum Clinic medical providers may not be in your particular benefit plans’ network of participating providers, which will likely necessitate you to pay higher costs for Out of Network Coinsurance, Out of Network Deductibles, and Out of Network benefits at a higher out of pocket cost than In Network providers. Generally, there are different accumulators for In Network versus Out of Network benefits as well. It is best you discuss this with your broker, Covered California, or health plan directly to discuss what the Out of Network benefits are for your chosen benefit plan.
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5. Question: Are all Sansum Clinic providers contracted with Blue Shield and Blue Cross Covered California Individual plans?
Answer: Yes, Sansum Clinic medical providers are contracted with Blue Shield and Blue Cross of California Individual plans on Covered California (Exchange) or off-Exchange (those sold directly by the health plans) for people who live in Region 12 (Santa Barbara, San Luis Obispo, Ventura Counties). For Sansum Clinic behavioral health providers - see question 11.
6. Question: Is PDL (Pacific Diagnostic Laboratories) contracted with Blue Shield or Blue Cross Covered California?
Answer: You will need to ask your broker, specific health plan or Covered California for laboratory providers covered by your Individual plan.
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7. Question: Is Sansum's Prescription Pharmacy located at 215 Pesetas Lane and at 317 West Pueblo Street taking Blue Shield of California Individual plan pharmacy plans?
Answer: Yes. However, it is always best to ask your broker, specific health plan or Covered California for pharmacy providers covered by your specific Individual or Small Group benefit plan.
8. Question: What other providers in Santa Barbara County are contracted with Blue Shield or Blue Cross of California Covered California (Exchange) or off-Exchange Individual plans?
Answer: You will need to ask your broker, specific health plan or Covered California for information regarding whether the provider in question is considered In Network or Out of Network for any Individual plan.
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9. Question: Will Sansum Clinic be able to tell me my out of pocket cost before proceeding with recommended procedures/treatment?
Answer: Yes, if we have confirmed your eligibility with your chosen health plan, and you have a plan that includes Sansum Clinic as an In Network provider, we should be able to if services/procedures are known when your out of pocket costs are estimated.
10. Question: Will Sansum Clinic accept health plans from out of state Exchange programs?
Answer: Yes. However, you will have to verify if care at Sansum Clinic or with Sansum Clinic medical providers will be considered In Network or Out of Network. Out of Network means that the provider is not participating in your particular plan even though we may have an agreement/contract with the plan for other plan types (Group plans, for example).
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11. Question: Will behavioral/mental health benefits be carved out through other plans affiliated with Blue Shield of California?
Answer: Yes. Sansum behavioral/mental health providers are Out-of-Network for Blue Shield's behavioral health plan, Magellan.
12. Question: What other Covered California insurances are contracted with Sansum Clinic?
Answer: Sansum Clinic has an agreement with Blue Shield and Blue Cross of California for Individual Plans on Covered California (Exchange) and off-Exchange for Region 12 (if you live within Santa Barbara, San Luis Obispo, Ventura counties). We are also a Blue Shield HMO/PPO Small Group and Health Net PPO Small Group Plan participating provider on Covered California (Exchange) and off-Exchange. We also participate in Off-Exchange small group plans with Blue Cross PPO (Off-Exchange).
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13. Question: Will I be able to keep my Sansum Clinic doctors if I get insurance under Covered California for Individual plans?
Answer: Yes, if you live in Region 12 (Santa Barbara, San Luis Obispo, Ventura counties) and sign up with Blue Shield of California Individual plan on Covered California (Exchange) or off-Exchange (sign up directly with Blue Shield of California). For patients living in other Regions of California/States, please check with your broker, Covered California or health plan directly to learn whether Sansum Clinic and our medical providers are considered In Network or Out of Network.
14. Question: Where do I go to get insurance under Covered California?
Answer: Go to CoveredCa.com or consult a local broker (coveredCA.com lists licensed brokers who are able to sell Individual and Small Group Exchange/off-Exchange Metal plans). Covered California marketplace must be used if you qualify for a subsidy.
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15. Question: Are there any insurance brokers that can sign me up?
Answer: You can visit CoveredCa.com for a list of licensed brokers authorized to sell Individual and Small Group On-Exchange Metal plans, check with Blue Shield of California directly; or visit www.blueshieldca.com for Off-Exchange plans.
16. Question: Does the new Insurance Exchange affect my Medicare benefits?
Answer: No. But once qualified for Medicare, individual exchange plans are typically terminated. Medicare is a Federal Insurance Program for disabled patients and/or people 65 years of age and over.
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17. Question: Will I be able to get insurance even though I have a pre-existing condition?
Answer: Yes, the Accountable Care Act (ACA) has included this provision in all Individual and Small Group Plans in California and most, if not all, of the United States (depending on the State).
18. Question: What do the plans cover?
Answer: There are five types of plans – Platinum, Gold, Silver, Bronze, and Catastrophic (minimum coverage) – and all plans under the Metal plan being offered on Covered California (Exchange) or off-Exchange (direct through the health plan) must offer actuarially similar benefits. However, the cost of the plan may vary and Out of Network costs/benefits may vary by Metal plan type and health plan (carrier).
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19. Question: What plan is better for me as a Sansum Clinic patient?
Answer: Sansum can only tell you that if you want to keep your Sansum Clinic medical doctor, you need to buy an Individual Plan for you and your family that we are currently contracted with to serve you for In Network benefits. The only plan at this time that Sansum Clinic is contracted with for Individual plans is the Blue Shield of California Individual plan through Covered California (Exchange) and Off-Exchange (directly through Blue Shield of California) for patients who live in Region 12 (Santa Barbara, San Luis Obispo, and Ventura counties). For patients living in other Regions of California/States, please check with your broker, Covered California or health plan directly to learn whether Sansum Clinic and our medical providers are considered In Network or Out of Network. We are also In-Network medical providers for patients who live in Region 12 (Santa Barbara, San Luis Obispo, Ventura counties) with Blue Shield PPO and Health Net PPO for their Small Group Plan on Covered California (Exchange) and off-Exchange.
20. Question: Which plans have more coverage?
Answer: Patients can use the Shop and Compare tool of the Metal plans on the CoveredCA.com website. In general, Platinum plans offer the highest level of benefits, but are more expensive. In addition, Bronze plans offer the lowest level of benefits and are the least expensive. Gold and Silver Metal plans are somewhere in between Platinum and Bronze plans.
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21. Question: Can I still have a secondary insurance with Covered California?
Answer: It is always best to ask your broker, specific health plans or Covered California.
22. Question: Where can I get information about whether or not my Sansum Clinic provider is participating in the Individual or Small Group Covered California (Exchange) or off-Exchange (directly through the health plan)?
Answer: Sansum Clinic and all our medical providers are participating with Blue Shield and Blue Cross of California Individual plans On/Off-Exchange and Blue Shield and Blue Cross PPO and Health Net PPO Small Group plans On/Off-Exchange. We may be considered Out of Network for any other Individual/Small Group plans sold in Region 12 of California (Santa Barbara, Ventura and San Luis Obispo counties); other regions of California; other states/federal On/Off-Exchange products sold in other States.
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23. Question: How do I find out if Sansum Clinic providers are participating in my Individual plan purchased through a non-Blue Shield and Blue Cross of California Individual PPO plan?
Answer: Sansum Clinic and our medical providers will not always know if we are In Network or Out of Network for many of these exclusive provider (EPO, EPPO, etc.) plans and it is best if you call the specific health plan or Covered California to get this confirmation. Sansum Clinic and our medical providers will require you to sign a Notice regarding In Network or Out of Network status, which will also indicate that you may be responsible for your plan’s Out of Network copay, coinsurance and maximum out of pocket costs, which are different than In Network benefits on many plans being sold on and off the Exchange. This waiver is designed to inform you about the possibility that higher out of pocket costs may be levied by your plan if you see Sansum Clinic providers on an Out of Network basis.
24. Question: Are Blue Shield and Blue Cross of California Individual plans (on or off-Exchange and sold in Region 12 - Santa Barbara, Ventura, San Luis Obispo counties), either on Covered California or obtained through a broker or at the health plan directly, accepted at Sansum Clinic by all of Sansum Clinic medicalproviders?
Answer: Yes. However, there are a few exceptions, including PDL (as PDL labs are not billed by Sansum Clinic to any insurance company); as well as Dr. Richard Chung and Dr. John Park (neurosurgeon), Sansum Radiologists, and Retina Ophthalmologists, all of whom Sansum Clinic bills for only when patients are seen within Sansum Clinic provider offices. In addition, behavioral health services are carved out to another plan affiliated with Blue Shield, Magellan. Sansum Clinic is Out of Network for any Magellan behavioral health services or plan. See Question 11 for behavioral/mental health providers.
DISCLAIMER: This document was created to assist Sansum Clinic patients and as of December 11, 2019. this information is accurate to the best of our knowledge. We are getting new information all the time and will update this as material information changes.
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