Blue Shield of California negotiates with network providers to protect access to care while keeping coverage affordable

A health plan network is a group of doctors, hospitals and other providers that are contracted with a health insurance company to provide services to you at predetermined prices. Blue Shield offers a broad network of quality, affordable healthcare facilities and providers throughout California.

There are multiple reasons why a contract may not be renewed. As a nonprofit organization, our goal is to help ensure that you have access to quality health care at an affordable price. Sometimes, priorities for healthcare providers differ from those of the health plan. Healthcare system administrators may request rate increases that exceed Blue Shield’s budget — rate increases that do not support member premiums and affordability standards, and often go beyond the targets set by California’s Office of Health Care Affordability (OHCA).

Our priority is to keep costs low for our members. If a new agreement cannot be reached, the hospital, medical group or healthcare provider may leave the network. In the healthcare industry, this is known as a “Provider Termination.” While this outcome is rare, we make sure our members have access to other quality in-network providers. We also continue to negotiate with the provider after the contract ends, with the goal of bringing them back into the network.

Yes, you can choose a different PCP at any time using the Blue Shield Find a Doctor tool located within your online account. There, you can search for in-network PCPs and other providers in your community.

Hard copy and digital cards will be updated, and if your communication preference is mail, an updated ID card will be sent no later than five days before a provider or medical group contract ends. Digital cards will also be automatically updated within your Blue Shield online account.

Yes, emergency services are always covered at in-network benefit levels. This applies even if the hospital is no longer in-network. You should go to the nearest Emergency Room (ER) or call 911 if you are experiencing a medical emergency.

If you have an illness or injury that is serious, but does not require an emergency visit, you may want to consider visiting an in-network urgent care center. Urgent care is typically faster and costs less than an ER visit. Use Blue Shield's Find a Doctor tool located within your online account to search for in-network urgent care centers near you.

Our Continuity of Care Program is designed to make sure your care is not interrupted when a provider leaves our network. If you are receiving services for a course of treatment from a provider that is no longer in Blue Shield’s network, you may be eligible to continue receiving treatment from that provider under the same terms and conditions that applied before the contract termination date. The program applies if you have a qualifying medical condition such as:

• An acute medical or behavioral health condition, including a maternal mental health condition

• A serious chronic or complex condition

• A pregnancy, regardless of trimester, including postpartum care

• Care of a newborn (0 to 36 months)

• A terminal illness

• Undergoing a course of institutional or inpatient care

• Performance of a surgery or procedure that has been authorized by Blue Shield as part of a documented course of treatment and has been recommended to occur within 180 days after the provider contract termination date

Once the Continuity of Care application is complete, Blue Shield will work directly with your provider to process the application.

Submission instructions are provided on the last page of the form. We accept applications beginning 30 days prior to the contract end date and until 90 days after the provider leaves the network. You can contact Blue Shield Customer Service for assistance, using the phone number on your Blue Shield ID card.

Applications are reviewed once all required documents are submitted. Written notification of the decision will be mailed within five business days unless additional medical records are needed.

If your request is not approved, your provider will be considered out-of-network after the contract ends. If you have an HMO plan, this means services will not be covered by your plan. If you have a PPO plan, services may be covered, but your out-of-network benefits will apply. For more information, check your plan documents or contact Blue Shield Customer Service. If you feel your request should have been approved, you can appeal the decision. Learn more here.