Health Plans
Health Plan Negotiations
Sutter Health has reached an agreement with Blue Shield of California (Blue Shield) covering commercial HMO, EPO and PPO plans for Sansum Clinic in 2025.
However, Blue Shield informed Sansum Clinic that it no longer wants our provider network in its Medicare Advantage (MA) HMO network for 2025. We understand that Blue Shield will send notices to their Sansum Clinic MA HMO members beginning November 15. In order to continue accessing Sansum Clinic, Blue Shield MA HMO members must select a new health plan during Medicare’s Annual Enrollment Period, which ends on December 7.
To continue seeing their Sansum Clinic doctors in 2025, existing patients can select one of the following health plan options:
- AARP Medicare Advantage from UHC CA-0024 PPO
- Aetna Medicare Core (PPO)
- Aetna Medicare Eagle Plus (PPO)
- Original Medicare
Patients can also visit sansumclinic.org/medicare-events for information about in-person events and webinars with local licensed insurance agents to help them better understand their Medicare health plan options in Santa Barbara County.
California Health Insurance Exchange
Individual
Sansum Clinic is contracted with Blue Shield for all individual health insurance plans offered through Covered California and directly through Blue Shield the health plan. This means that Sansum Clinic is an in-network
provider for plans sold by Blue Shield and through Covered California. It is always a good idea to confirm with your plan administrator that the plan you choose will include Sansum Clinic.
Small Group
Sansum Clinic is pleased to be included in the small group exchange/non-exchange network for Health Net and off-exchange (direct with plan) for Anthem Blue Cross PPO. Please visit plan websites or CoveredCA for more information.
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
- Blue Shield EPPO for Individual Plans On and Off Exchange
- Anthem Blue Cross for Individual On and Off Exchange Plans
Off-Exchange - Provider Organizations - Small Group Plans
Exclusive Provider Organizations (EPO)
- Blue Cross EPO (i.e. UC Select Care, tier 1)
- Blue Shield EPO (i.e. County of Santa Barbara)
- Blue Shield HMO
Medicare Advantage Plans (HMO, PPO, Pharmacy)
Medicare Advantage Plans - HMO for Individuals
- Blue Shield 65 Plus (HMO) – Terminates Dec. 31, 2024
Medicare Advantage Plans - HMO/PPO for Employer Groups/Retirees
Medicare Advantage Plans - PPO
- Aetna Medicare Core (PPO)
- Aetna Medicare Eagle Plus (PPO)
- United Healthcare AARP Medicare Advantage from UHC CA-0024 (PPO)
- United Healthcare Medicare Advantage PPO - Employer Groups Only (i.e. PERS)
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Pharmacy
Medicare Part D (Prescription Drug Coverage)
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 - 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 Treatment 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 families 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
- Triwest Choice Plan
- Triwest Healthcare Alliance
- Veterans Affairs (VA) - Accepted with VA authorization
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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, EPPO
- 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
- United Healthcare HMO, PPO
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, EPPO
- 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
- United Healthcare HMO, PPO
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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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