Health Maintenance Organizations (HMOs or Managed Care)
Membership in a Health Maintenance Organization (HMO) requires plan members to obtain their medical care services from doctors and hospitals affiliated with the HMO. It is common practice in HMOs for the plan member to choose a primary care physician who treats and directs medical care decisions and who coordinates referrals to specialties within the HMO network. The doctors and hospital personnel may be employees of the HMO or contracted providers. Since HMOs operate in restricted geographic regions, this may limit coverage for plan members if medical treatment is obtained outside the HMO network or coverage area. California HMOs are required to cover medically necessary emergency services even when outside of their coverage area. The intent of managed care products is to create less costly delivery of medical care services while maintaining quality medical care by specifying provider choice. HMOs offer access to a comprehensive package of covered medical care services in return for a prepaid monthly amount (premium). Most HMOs charge a small copayment depending upon the type of service provided.

All HMOs in California are regulated by the Department of Managed Medical Care (DMHC). If you have a complaint with an HMO, contact the member services department of your HMO. HMOs are required to have an internal complaint/grievance process in place. If you file a grievance and it has not been resolved within 30 days or there is some question as to the HMOs decision, then you may contact the DMHC for assistance. Please see contact information listed for the DMHC in the "Resources" section of this brochure.

Important Points to Remember About Health Maintenance Organizations:

• You must obtain medical care services from HMO providers, except in certain emergency situations.
• Your choice of primary care physician is important because he/she directs your care. Also, your primary care physician often coordinates referrals to specialties within the HMO.
• Your options may be limited by the geographic restrictions of the HMO network.
• You may be charged a small copayment each time you utilize an HMO covered service.
• You can seek assistance from the DMHC on all HMO and managed care questions.

Fast Facts

Year founded: 1939   Service area: California   Annual revenue: $7.5 billion   Total employees: 4,500   Chairman, President and Chief Executive Officer: Bruce G. Bodaken   Blue Shield is a California not-for-profit mutual benefit corporation.   National affiliation: Independent Member of the BlueCross BlueShield Association   Parent company: California Physicians' Service, Inc. Accreditation The National Committee for Quality Assurance (NCQA) recently awarded Blue Shield an "Excellent" rating for service and clinical quality for its HMO and Point of Service (POS) lines of business.   "Excellent" accreditation status is reserved for the best health plans in the nation and is only awarded to those plans that meet or exceed NCQA's rigorous requirements for consumer protection and quality improvement and deliver excellent clinical care. Review Blue Shield's NCQA Health Plan Report Card at www.ncqa.org. Financial Ratings (as of February 2006)   A (stable) rating from Standard and Poors   A (excellent) rating from AM Best   A (excellent) rating by Weiss Ratings, Inc. Membership (as of January 2006) HMO: 1,300,000 PPO: 1,200,000 TRICARE: 500,000 Other: 300,000*   Total: 3,300,000   *= Includes non-underwritten ASO and National Accounts   Provider Network (as of August 2006) Type of Provider  HMO  PPO   Primary Care Physicians 11,027 18,516  Specialists 16,917  29,372  Total 27,944 47,888 Hospital Network (as of August 2006) HMO: 304 PPO: 351   Blue Shield also has offices in Chico, Folsom, Fresno, Gold River, Irvine, Hemet, Lodi, Monterey Park, Orange, Petaluma, Redding, Riverside, Sacramento, San Diego, San Jose, Santa Barbara, Walnut Creek and Woodland