Health Plans

California Health Insurance Exchange - 2018

Small Group
Sansum Clinic is pleased to be included in the small group exchange/non-exchange network. Please visit  plan websites or CoveredCA for more information.

Individual
BlueShield is the only individual health plan offered by Covered CA in 2018 in Santa Barbara County. We are an out-of-network provider in the individual marketplace, for Blue Shield at this time. We are working diligently with Blue Shield to become a network provider by January 1st, 2018.

All other plan types:

 

Health Maintenance Organization (HMO/POS)

IMPORTANT: To obtain HMO coverage for services provided by Sansum Clinic:

  • Your HMO must be contracted with Sansum Clinic; and
  • You must be assigned to either Sansum Clinic or an affiliated independent physician association (i.e. Jackson Medical Group or Santa Barbara Internal Medicine Group); and
  • Your treatment must meet any other requirements set out by the HMO. (For example, medically necessary, provided by your primary care physician or someone he/she refers you to, non-elective, not subject to carve outs, etc.

  
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Preferred Provider Organization (PPO)

We contract with these preferred provider organization (PPO) plans. The following list includes most though not all of the PPO plans we can accept. Check directly with your benefit office or the insurer to determine whether your plan allows access to Sansum Clinic, since many plans may have different networks that Sansum Clinic may not be included in per product plan/design.

IMPORTANT: Prior to using our services, always verify with your employer benefits manager or with health plan that Sansum Clinic is considered an in-network provider; otherwise, your out-of-pocket costs may be higher or not covered at all if your health plans product/plan design excludes Sansum Clinic as a participating provider.
  
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Exchange/Off-Exchange (narrow) Provider Organization (EPPO) - Individual Plans

  • To be determined, due to Anthem Blue Cross and their decision to exit California Regions, including Region 12 which includes Santa Barbara County.

Off-Exchange - Provider Organizations - Small Group Plans

Exclusive Provider Organizations (EPO)

  • BlueShield EPO (i.e. County of Santa Barbara)
  • Blue Cross EPO (i.e. UC Select Care, tier 1)

Medicare Advantage Plans (HMO, PPO, Pharmacy)

Medicare Advantage Plans - HMO for Individuals - 2018

Medicare Advantage Plans - HMO for Employer Groups/Retirees - 2018

Medicare Advantage Plans - PPO - 2018

  • United Healthcare Medicare Advantage PPO - Employer Groups Only (i.e. PERS)
  • There are not any Medicare Advantage PPO products sold to individuals in Santa Barbara/Lompoc for 2018, but an individual or retiree may access care at Sansum Clinic if their plan is on our PPO list, and we will courtesy bill the MA PPO plan (i.e. Anthem Medicare Preferred standard PPO)

  
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Pharmacy

Medicare Part D (Prescription Drug Coverage) - 2018

The following are some of the many plans offered in Santa Barbara County and Sansum Prescription Pharmacy may honor. We encourage you to ask one of our pharmacists whether your plan is among the Medicare Part D plans we can accept. Generally, you can change enrollment between October 15th and December 7th of each year, to take effect on January 1st of the following year (low-income seniors may be eligible to change enrollment at any time).

  
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Other Government Plans

We are providers and accept Medicare assignment for:

  • Original Medicare
  • Tricare by United Healthcare until 12/31/2017; Tricare Standard and Prime HMO plans. Tricare Prime HMO by United Healthcare provides coverage at Sansum Clinic for specialty care upon referral from Tricare Military Treament Center, and/or a United Healthcare Tricare authorization from Tricare Military Treatment Center (Vandenberg AFB). We can accept primary care patients for Tricare Prime HMO familes and retirees that live outside a 30-mile radius from Vandenberg AFB.

We are non participating with the government programs below, however we will bill insurance as a courtesy:

We Do Not Accept or Bill For

  • Veterans Affairs (VA)
  • Triwest Healthcare Alliance
  • Triwest Choice Plan

  
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Medi-Cal HMO Plans

Currently, we are closed to all new CenCal adults for assignment to any Sansum Clinic primary care provider. We are open to all New CenCal pediatric patients at our four pediatric sites that can take CenCal Pediatrics as we must have vaccines for children (VFC) program approved and available at site.  Only Hitchcock Pediatrics, Lompoc Pediatrics, Country Clinic, and Carpinteria sites have this VFC approval which CenCal requires for their pediatric patient immunizations. 

Exceptions due to our Closed Adult practices for CenCal, can be made only by well-established Sansum Clinic primary patient calling CenCal Member Services directly. Our providers or site staff can not make exceptions to accept a CenCal adult into their practice. Rather, exceptions lists are sent/reviewed weekly to Sansum Clinic and we follow strict exception criteria in our communication back to CenCal Health. NO exceptions to the exception criteria are made. 

Other Publicly-Funded Health Plans

CenCal Health also administers the following plans that Sansum Clinic provides coverage for as described under Medi-Cal HMO Plans:

  
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Ambulatory Surgery Centers

Sansum Clinic offers two locations:

Foothill Surgery Center at Sansum Clinic

We are a full service facility provider for the following health plans:

  • Aetna HMO, PPO
  • Anthem Blue Cross HMO, PPO, EPPO
  • Blue Shield HMO, PPO, EPO
  • Cigna HMO, PPO
  • Coventry/First Health, an Aetna Healthcare Company
  • Health Net HMO, PPO
  • Seniority Plus HMO
  • Tricare by United Healthcare - Tricare Standard and Prime HMO Plans until 12/31/2017
  • United Healthcare HMO, PPO
  • United Healthcare Medicare Complete HMO

Sansum Clinic Ambulatory Surgery at 317 W. Pueblo Street

We are a GastroIntestinal procedure (i.e. colonoscopy) facility provider for the following health plans:

  • Aetna HMO, PPO
  • Anthem Blue Cross HMO, PPO, EPPO
  • Blue Shield HMO, PPO, EPO
  • Cigna HMO, PPO
  • Coventry/First Health, an Aetna Healthcare Company
  • Health Net HMO, PPO
  • Medical Care Foundation of Santa Barbara and Kern Company
  • Seniority Plus HMO
  • Tricare by United Healthcare - Tricare Standard and Prime HMO Plans until 12/31/2017
  • United Healthcare HMO, PPO
  • United Healthcare Medicare Complete HMO

  
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Mental (Behavioral) Health Carveout Plans

See the Billing Information for Insurance Plans pages for more information about carveouts.

  
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Workers Compensation Plans

  
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Eyewear and Refraction Plans

NOTE: Sansum Clinic is not responsible for information in third party websites. All plan/network names on this page are the trademarks of the respective companies and are not the property of Sansum Clinic.
  
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