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HMO General Information
 Your Access to Health Care
Blue Cross of California Health Maintenance Organization (HMO) Plans cover more of the costs of your health care than any other plan type. With HMO plans, you choose a Participating Medical Group (PMG) or Independent Practice Association (IPA) from the Blue Cross HMO Network listed in your directory. You also choose a doctor within the group to serve as your Primary Care Physician (PCP), and you can select a different Primary Care Physician for each family member enrolled in your HMO Plan.
Your HMO plan coverage applies only when you receive health care services through your Primary Care Physician. He or she will coordinate all of your health care, either by treating you directly, or by referring you to a specialist.
For more information on accessing doctors and the referral process, be sure to read about the DirectAccessSM and SpeedyReferralSM programs.
Blue Cross of California — HMO Quality
The Blue Cross HMO plans featured in this brochure were awarded a “Commendable” status from the National Committee for Quality Assurance (NCQA). The status of “Commendable” is granted to managed care organization plans that deliver high-quality care and service, and whose systems for consumer protection and quality improvement meet or exceed NCQA’s rigorous requirements.
NCQA is an independent, not-for-profit organization that evaluates managed care organizations. Its mission is to provide information that enables purchasers and consumers of managed health care to distinguish among plans based on quality, so they can make more informed decisions.
HMO Plan Highlights
In a Blue Cross of California HMO, you get:
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Low out-of-pocket costs |
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Comprehensive health care coverage |
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Unlimited lifetime benefits for covered services |
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Mimial copays for office visits |
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Self-referral for OB/GYN (women's health specialists) |
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Blue Cross DirectAccess |
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Blue Cross SpeedyReferral |
Taking Care of Your Health with Blue Cross HMO Plans
Staying Healthy – Preventive Care
Your Blue Cross HMO plan gives you comprehensive health care coverage that includes physical exams by your Primary Care Physician, and routine cancer screenings, such as mammograms, Pap smears and testing for prostate cancer.
Well Woman Preventive Care
Self Referral for OB/GYN Care
For well woman exams, including mammography and Pap testing, all women enrolled in a Blue Cross HMO plan have the option to use their Primary Care Physicians or select an obstetrician and/or gynecologist (OB/GYN) directly from a participating specialist, without referral from their Primary Care Physicians. Your medical group can provide you with a list of participating OB/GYN referral physicians
Self Referral for OB/GYN is not only for well woman exams. It extends to other health care services offered by obstetricians and gynecologists including pregnancy, birth control, and other women’s health concerns, such as menopause.
HealthyExtensions
HMO Plan members can also take advantage of discounts for healthy lifestyles resources. HealthyExtensions* lets members know about independent vendors and professional who offer 10%-50% discounts on a variety of alternative health care and wellness products and services, including programs to lose weight and quit smoking, eyecare, hearing impairment, nutritional supplements, fitness and sports equipment and more.
Additionally, HealthyExtensions informs members about health and wellness practitioners who offer 10%-25% discounts on massage therapy, hypnotherapy, yoga and nutrition.
When You Need Care
When you need care, simply call your Primary Care Physician for an appointment. He or she can help you when you are ill, either by treating you directly, or referring you to a specialist.
Programs for Quick Access to Specialists
Blue Cross provides you with additional options for accessing health care through the following special programs for our HMO members:
Blue Cross DirectAccessSM
Blue Cross DirectAccess allows HMO plan members to select specialists for some services without authorization from their Primary Care Physicians. The speciality services include allergy, dermatology, and ear, nose and throat.
The program is available to HMO members who choose a medical group or IPA that participates in DirectAccess. Participation of a medical group or IPA is indicated in the provider directory. It is important that you check participation before utilizing DirectAccess.
Blue Cross SpeedyReferralSM
With SpeedyReferral, HMO members can be referred by their Primary Care Physicians for specialist visits without prior authorization from the medical group or IPA. Specialty services include, cardiology, dermatology, ear, nose, and throat, endocrinology, gastroenterology, general surgery, hematology, neurology, oncology, ophthalmology, orthopedic surgery, podiatry, routine laboratory, routine x-ray and urology.
This program is available to HMO members who choose a medical group or IPA that participates in SpeedyReferral. Participation of a medical group or IPA is indicated in the provider directory. It is important that you check participation before utilizing SpeedyReferral.
Emergency Care
Blue Cross covers emergency services necessary to screen and stabilize your condition. No authorization or precertification is required if you reasonably believe an emergency medical condition exists. A medical emergency is an unexpected acute illness, injury or condition that could endanger your health if not treated immediately. Examples of medical emergencies include:
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Severe Pain |
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Chest Pains |
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Heavy Bleeding |
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Difficulty breathing or shortness of breath |
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Sudden loss of consciousness |
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Active natal labor (childbirth) |
Sudden weakness or numbness of the face, arm or leg on one side of the body
When you consider a medical condition to be an emergency, immediately call 911 or go to the nearest hospital emergency room. If as a result of the medical emergency you are admitted into the hospital through the emergency room, you or a member of your family must notify your Primary Care Physician or medical group as soon as possible, but not later than 48 hours after the initial care has been provided.
Mental Health Coverage
Blue Cross provides the same level of coverage as other medical diagnoses for the medically necessary treatment of severe mental illnesses in persons of any age. Severe mental illness, as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM), includes the following diagnoses:
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Schizophrenia |
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Schizoaffective disorder |
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Bipolar disorder (manic-depressive illness) |
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Major depressive disorders |
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Panic disorder |
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Obsessive-compulsive disorder |
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Pervasive developmental disorder or autism |
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Anorexia nervosa |
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Bulimia nervosa |
Blue Cross also provides the same level of coverage as other medical diagnoses for serious emotional disturbances in children that result in behavior inappropriate to the child’s age, according to expected development norms. More limited benefits are provided for other mental disorders such as primary substance use disorder and developmental disorder. For more details regarding these benefits, refer to the Evidence of Coverage (EOC).
Member and Blue Cross Rights and Obligations
No-Obligation Review Period
After you enroll in a Blue Cross health plan, you will receive an Evidence of Coverage policy booklet that explains the exact terms and conditions of coverage, including the plan’s exclusions and limitations. You have 10 full days to examine your plan’s features. During that time, if you are not fully satisfied, you may decline by returning your Evidence of Coverage booklet along with a letter notifying us that you wish to discontinue coverage. Evidence of Coverage booklets are available for you to examine prior to enrolling. Ask your agent or Blue Cross.
Your Right to Privacy
We do not release information that identifies your diagnosis or medical condition without your consent, except as permitted by law. Your treating physician also has rules about your medical information. Physicians customarily ask their patients to sign a release form before they give their patients medical information to anyone, even Blue Cross. You may request to see a copy of your physicians confidentiality policy, and you should talk to your physician about how your privacy is protected.
Requirement for Binding Arbitration
If you are applying for coverage, please note that Blue Cross requires binding arbitration to settle all disputes, including claims of medical malpractice. California Health and Safety Code Section 1363.1 and Insurance Code Section 10123.19 require specified disclosures in this regard, including the following notice: “It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will by California law, and not by lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Both parties also agree to give up any right to pursue on a class basis any claim or controversy against the other.
Grievances
All complaints and disputes relating to your coverage must be resolved in accordance with Blue Cross’ grievance procedure. Grievances may be made by telephone or in writing; the phone number and address are located on your Blue Cross ID card. All grievances received by Blue Cross will be answered in writing, together with a description of how Blue Cross proposes to resolve the grievance.
Department of Managed Health Care
The California Department of Managed Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at (800) 333-0912 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s Internet Web site (http://www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions on-line.
Third-Party Liability
Blue Cross of California is entitled to reimbursement of benefits paid if you recover damages from a legally liable third party. Examples of third-party liability include car accidents and work-related injuries. For complete information about third-party liability, refer to the plan Evidence of Coverage booklet.
Loss Ratio
As required by law, we are advising you that Blue Cross of California’s incurred loss ratio for 2001 was 80.28 percent. This loss ratio was calculated after provider discounts were applied.
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