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Blue Shield of California and Stanford Health (Stanford) are engaged in discussions to renegotiate the terms of Stanford’s hospital agreement (HMO/PPO) for Stanford Medical Center/Stanford Healthcare-University Healthcare Alliance PPO professional services, ValleyCare Medical Center, and Valley Memorial Hospital (LTC) serving Alameda and Santa Clara counties. Since they have not reached a new agreement, their contract for Stanford Medical Center/Stanford Healthcare-University Healthcare Alliance PPO professional services has expired, effective April 30, 2018, at 11:59 p.m.

The contracts for ValleyCare Medical Center, and Valley Memorial Hospital (LTC) remain in effect through May 31, 2018. Lucile Salter Packard Children’s Hospital is not part of this contract termination. Members who have used Stanford Medical Center/Stanford Healthcare-University Healthcare Alliance PPO professional services in the last 12-month period received notification of this termination on May 4, 2018, providing them with alternate network facilities and advising of their continuation of covered services options.

Affinity Medical Group (now part of Stanford Health) is also part of the contract negotiation. Though the current contract for Affinity Medical Group remains in effect until June 30, 2018, the Department of Managed Health Care (DMHC) regulations require Blue Shield to notify HMO members of a change to their medical group and if applicable, primary care physician (PCP), 60 days in advance of a potential termination. Therefore, because they have not reached an agreement with Stanford Health, letters were mailed to HMO members assigned to Affinity Medical Group on May 1, 2018. If they reach an agreement later, members will be notified and may request to be assigned back to the Affinity Medical Group and their Affinity PCP.

Who is affected?

The Stanford Medical Center/Stanford Healthcare-University Healthcare Alliance PPO professional services and Affinity Medical Group contract affects Small Business, Core, Premier, and CalPERS market segments. Medicare members are not affected.

How does a contract termination with Stanford Medical Center/Stanford Healthcare-University Healthcare Alliance PPO professional services affect their members?

Commercial HMO/POS members

Since their commercial HMO agreements with Affinity Medical Group are scheduled to expire on June 30, 2017, and they have not reached a new agreement, Blue Shield commercial HMO members accessing Stanford Health will need to know the following:

  • Blue Shield sent notifications to commercial HMO/POS members assigned to PCPs with Affinity on May 1, 2018 to advise them that they will be reassigned to an alternate medical group for a July 1, 2018 effective date. Members can call the Member Services number on the back of their Blue Shield member ID card to select a different PCP other than the one assigned to them.
  • Blue Shield members assigned to an Affinity PCP who are receiving care from an Affinity physician on July 1, 2018, or who have a procedure scheduled to be performed by Stanford within 180 days of July 1, 2018, can request continuity of care through Blue Shield for ongoing treatment with their provider. These members can call the Blue Shield Member Services number on their Blue Shield ID card. Stanford is generally used as a high-level, tertiary, and quaternary care facility.

Palo Alto Medical Foundation (PAMF) is not affected

PAMF uses Stanford as a primary admitting facility. PAMF (all pods) enrollees are not affected by this contract termination because their PAMF enrollment will continue accessing Stanford hospitals as a network facility. A contract termination will not affect Blue Shield members assigned to PAMF.  Please use this link to see the affected facilities and medical group as well as their complete listing of alternate providers.

Continuity of Care

HMO members

HMO members who are currently in a course of treatment or who have a procedure scheduled at a Stanford Medical Center/Stanford Healthcare-University Healthcare Alliance PPO professional services within 180 days of May 1, 2018, can request continuity of care by calling the Member Services number on the back of their Blue Shield ID card. They will work closely with the IPAs to facilitate these requests. If eligible for continuity of care, applicable network copays will apply.

PPO members

PPO members who are currently receiving or who have a procedure scheduled at a Stanford Medical Center/Stanford Healthcare-University Healthcare Alliance PPO professional services within 180 days of May 1, 2018, can request continuity of care for an ongoing cource of treatment, and if eligible, receive the higher, preferred benefit level. These members can call the Blue Shield customer service telephone number on their Blue Shield ID card. They may also access Blue Shield’s Continuity of Care online.

  • PPO members may continue to seek professional and/or hospital services from Stanford Medical Center and professional providers after the contract termination date. However, reimbursement for any such services, other than emergency services, will be reimbursed at the lower “Non-Preferred Provider” benefit level. Members will be responsible for all additional charges, up to the professionals’ and hospitals’ usual billed charges.
  • PPO members who wish to have their provider care and visits covered at the higher, preferred benefit level must receive care from a Blue Shield contracted provider. These members can call the Blue Shield customer service telephone number on their Blue Shield ID card or go online to Blue Shield’s Find a Doctor page.

POS members

Blue Shield’s Point of Service (POS) plans combine both HMO and PPO service delivery features. A POS member’s network determination or eligibility for continuity of care would be governed according to either the HMO or PPO definitions above, depending on which network the member is accessing.

Medicare members

Medicare members are not affected by this contract termination.

Emergency services

Blue Shield members who need emergency services should call 911 or seek care at the nearest emergency room, including Stanford. Blue Shield will provide the full emergency care level of benefits for these services.

Blue Shield encourages members to make informed decisions about when to use urgent care as opposed to emergency room care. Urgent care is appropriate when a member needs a physician’s attention for a condition that is non-life threatening. Any member needing urgent care but whose physician or network provider is unavailable should go to the nearest immediate or urgent care facility. Members can access a list of nearby urgent care facilities online at Find a DoctorRead here for more.

Contact your LISI Regional Sales Manager to find out more.