Mandates
Consolidated Appropriations Act / Transparency in Coverage Final Rule
The Consolidated Appropriations Act was signed into law in 2021, as part of a $2.3 trillion funding package. The Act provides a number of healthcare-related provisions including surprise medical bill protections, treatment cost transparency, and an expansion of the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008.
The Transparency in Coverage Final Rule was a joint effort enacted in 2020 by the Department of Health and Human Services (HHS), the Department of Labor, and the Department of Treasury. The rule improves transparency in price and quality to aid consumers in making informed health care decisions.
Please see Consolidated Appropriations Act and Transparency in Coverage Final Rule for additional information.
2025 Effective mandates
SB 729 Infertility coverage
On September 29th, 2024, Governor Newsom signed SB 729 which expands access to fertility and infertility coverage for fully insured employer groups.
In the Large Group Market, plans are required to provide coverage for the diagnosis and treatment of infertility and fertility services, including a maximum of 3 completed oocyte retrievals (egg retrievals) with unlimited embryo transfers.
In the Small Business Market, health plans are required to offer the diagnosis and treatment of infertility and fertility services.
Blue Shield is working in good faith to implement the requirements of SB 729 and intends to comply with the requirements due by July 1, 2025.
For additional details, please view the SB 729 FAQs.
Medical Loss Ratio (MLR)
The Affordable Care Act (ACA) requires health plans to spend a minimum percentage of plan members’ premium on medical expenses, known as the “Medical Loss Ratio” standard or the “80/20 rule.” The 80/20 rule in the Affordable Care Act is intended to ensure that consumers get value for their healthcare dollars.
The Medical Loss Ratio reporting and rebate requirements apply to all fully insured group and individual plans, including grandfathered plans. They do not apply to self-funded (ASO) business, Shared Advantage, or Medicare Supplemental plans.
COVID-19 High Deductible Health Plan Updates
Testing and therapeutics
During the COVID-19 public health emergency (PHE), Health Savings Account (HSA) compatible High Deductible Health Plans (HDHPs) were allowed to cover COVID-19 testing and treatment without being subject to a deductible, which is otherwise required for a HDHP status (IRS Notice 2020-15).
Following the end of the PHE on May 11, 2023, The Treasury Department and the IRS determined that this relief is no longer needed and is only available to HSA compatible HDHPs until December 31, 2024 (IRS Notice 23-037).
Coverage for COVID-19 testing (including at-home test kits) and therapeutics are subject to the member’s deductible in accordance with the updated IRS requirements for HSA compatible HDHPs effective January 1, 2025.
Telehealth waiver
Similar to testing and therapeutics, the telehealth waiver for HSA compatible HDHP plans established under the CARES Act expired on December 31, 2024, making telehealth services subject to the member’s deductible effective January 1, 2025.
AB 904 Health care coverage – Doulas
AB 904 requires health plans to develop a maternal and infant health equity program that addresses racial health disparities in maternal and infant health outcomes through the use of doulas.
Blue Shield’s Maven program provides all fully insured commercial members access to unlimited virtual doulas to meet the requirements of this bill.
2024 Effective mandates
SB 923 Gender affirming care
SB 923 requires plans to identify which in-network providers offer gender-affirming services in provider directories.
Blue Shield’s Provider Directories have been updated to meet the requirements of this bill.
2023 Effective mandates
SB 1473 Continued coverage for COVID-19 and future public health emergencies
IFP and fully insured Group plans
Member cost-share will continue to be waived for in-network diagnostic testing, vaccines, and therapeutics. However, cost-share for out-of-network COVID-19 services will no longer be waived for most plans and member cost-share may be applied based on a member’s out-of-network plan benefits. Members can continue to submit a request for reimbursement for up to 8 at-home COVID-19 tests per month. As a reminder, coverage for treatments other than therapeutics is based on an individual’s standard in- or out-of-network benefits.
Self-funded Group plans
Following the end of the PHE on May 11, 2023, self-funded group plan sponsors were no longer required to waive the member cost-share for diagnostic testing. Coverage and member cost-shares for both in- and out-of-network COVID-19 testing and testing services apply based on a member’s plan benefits, unless a group elected to offer COVID-19 coverage in alignment with that of fully insured plans, outlined above. Coverage and cost-share waivers of the COVID-19 vaccines continue to be required under the Advisory Committee on Immunization Practices (ACIP) preventive services recommendations, when services are provided in network. There were no changes for treatments as this is based on standard in- or out-of-network benefits.
2022 Effective mandates
SB 368 Deductible and out-of-pocket maximum disclosure statements
SB 368 requires health plans to send members information on their deductible and out-of-pocket maximum accrual amounts when benefits are used on a monthly basis. Blue Shield has been sending subscriber accrual notices since October 2022 meeting the requirements of this bill as it applies to our fully insured group plans.
By default, the subscriber will receive the monthly accrual notice in the same method as they selected for their explanation of benefits (EOB), whether paper or electronic. To opt in to electronic statements rather than paper mail, subscribers can sign into their member portal online or call Member Services. Subscribers can opt back into paper notifications at any time.
2021 Effective mandates
California Senate Bill (SB) 260 Automatic health care coverage enrollment
California Senate Bill (SB) 260 requires Blue Shield of California to annually notify enrollees with individual or group health care coverage that if the enrollee ceases to be enrolled in coverage, Blue Shield will provide information, including the enrollee’s name, address, and other contact information to Covered California so that the enrollee may obtain other coverage. Enrollees may opt out of this transfer of information to Covered California.
Blue Shield sends members this annual notification for existing members in Q1 annually and upon new member enrollment.
Please see the notices attached for additional information:
Blue Shield of California Notice
Blue Shield of California Life & Health Notice
California Senate Bill (SB) 1008 Dental Plan Transparency Effect
The Dental Plan Transparency Effect, also known as Senate Bill No. 1008, was passed to ensure standardized health insurance reporting and disclosures for dental services. Similar to how the Affordable Care Act mandated medical plan Summary of Benefits Coverage (SBCs) to allow members to easily shop for and compare health insurance plans, SB 1008 requires a similar benefits and coverage disclosure matrix for dental plan benefits. This bill was signed into law in 2018 and goes into effect for plan or policy years on and after January 1, 2021.
Updates to plans due to changes in federal and state laws require endorsements which contain amended pages to the Evidence of Coverage (EOC), Summary of Benefits (SOB), and/or Certificate of Insurance (COI). For complete endorsements, please visit our Endorsement updates page.
