Members report access problems after Blue Shield Medicare Advantage PPO rollout; board hears update

Blue Shield of California and San Francisco Health Service System officials told the Health Service Board on Jan. 8 that the enrollment transition of roughly 19,100 Medicare members completed in mid‑December, but several members and advocates reported continued access problems and communication gaps.

The board heard a presentation from Olga Stavinska Velasquez, SFHSS operations manager, and Charles Lee, Blue Shield senior manager for group retiree plans. Stavinska Velasquez said SFHSS began sending enrollment files early to speed ID‑card delivery and that “a very small portion, about 7% of the records sent to Blue Shield” required manual processing; most were resolved by Dec. 20. She also described a feature that allows callers to SFHSS to be routed directly to a Blue Shield concierge line and reported first‑contact resolution above 90 percent for SFHSS call center work in December.

But public commenters said those numbers did not reflect their experience. Sarah Coe, who identified herself as a resident, said she and her husband were told that Blue Shield’s contracting with American Specialty Health meant their longtime acupuncture clinic no longer accepted their coverage: “We were told we cannot use that clinic anymore,” Coe said. Maureen O’Shea, a retiree, said she received no card for weeks and had to involve the mayor’s office to get attention: “I think that I should have received a card no later than December 1 and probably November 1,” she said.

Blue Shield acknowledged a small number of implementation errors and notification mistakes. Charles Lee told the board that Blue Shield sent a templated CMS confirmation letter that mistakenly included language implying prior authorization was required for out‑of‑network services. “That was an issue on Blue Shield’s side that it was sent out by mistake,” Lee said; he added that Blue Shield quickly sent a correction and has put a review step in place for future member materials.

Lee also said some providers initially questioned whether Blue Shield prior authorizations would be accepted during the transition and that Blue Shield had issued written confirmations to providers to avoid care interruptions. On pharmacy changes, Lee said the pharmacy transition was completed at the Jan. 1 effective date and that Blue Shield’s “pharmacy reimagine” partners — including a home‑delivery option — are available to members; he said Blue Shield increased concierge staffing after December call volumes spiked.

Board members asked for more details and for copies of materials handed to the board. President Howe said staff would arrange for the pamphlet Blue Shield handed to the board to be posted with meeting materials. Several commissioners pressed for follow‑up on SilverSneakers gym access after retirees reported no in‑network options in parts of Marin County; Lee said Blue Shield is working with Tivity (the SilverSneakers vendor) and local facilities to fill gaps.

The board did not take action on the update. Members of the public urged SFHSS and Blue Shield to speed resolutions for callers who need time‑sensitive care; one commenter who had chemotherapy concerns said delays in authorization could be life‑threatening. Several callers credited individual SFHSS or Blue Shield staff for helping resolve cases after extended calls.

SFHSS said it will post Blue Shield materials used at the meeting and continue to report call‑center metrics and specific corrective actions at future meetings.

Looking ahead, Stavinska Velasquez told the board that PeopleSoft and regulatory feeds remain on schedule for later in 2025 and that SFHSS will track a small backlog of manually corrected records until all members have final enrollment kits.