If you live in the counties of San Luis Obispo, Ventura or Santa Barbara (Covered California Rating Region 12) you have four choices for health insurance coverage under the Affordable Care Act. Really you have two choices unless you live in Ventura or want to travel to Ventura where you can be covered by the Kaiser Permanente Health Maintenance Organization (HMO-where you go to their facility and see their doctors) or the Ventura County Health Care Plan HMO. For the rest of us living in San Luis Obispo or Santa Barbara Counties our choices comes down to Anthem Blue Cross or Blue Shield (description and history of the two plans) Preferred Provider Organizations (PPO – where you can see all the doctors in the network or pay higher fees for “Out of Network.”)
There is one critical difference between the Anthem Blue Cross PPO and Blue Shield PPO.
Sansum Clinic is not presently part of the Blue Shield network.
The Sansum website says, “Sansum Clinic is considered Out of Network for Blue Shield Individual Plans and Small Group Plans through Covered California (Exchange) and off-Exchange (plans sold directly by the health plan for Individual and Small Group plans)…which will likely necessitate you to pay higher Out of Network Coinsurance, Out of Network Deductibles, and Out of Network benefits at a higher out of pocket cost than In Network providers. ”
What this means is that if you want to see or continue to see a Sansum Clinic doctor your only option under Covered California is to enroll in the Anthem Blue Cross PPO or pay the higher Out of Network fees.
Greg Friedrich, Director Santa Barbara Cottage Hospital, told me that if the proposed merger between Cottage and Sansum Clinic is approved by the Federal Trade Commission, Sansum may or may not join the Blue Shield network. He also said when looking up Cottage on the list of providers on the Anthem Blue Cross website you should put in Santa Barbara Cottage Hospital.