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.
 

2023 Effective mandates

California Privacy Rights Act (CPRA)

Beginning January 1, 2023, the California Privacy Rights Act (CPRA) will take the place of the California Consumer Protection Act of 2018 (CCPA). The 2018 CCPA created new member privacy rights and data protection requirements for businesses. While the new CPRA will strengthen certain parts of the CCPA, non-profit entities like Blue Shield will continue to remain exempt from the new CPRA as it was from the 2018 CCPA.
 

Medical Loss Ratio (MLR)

The Affordable Care Act (ACA) requires Blue Shield of California and other health insurance carriers 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 commercial plans, including grandfathered plans. They do not apply to self-funded (ASO) business, Shared Advantage, or Medicare Supplemental plans.
 

2023 MLR

We are now collecting information from employer groups with <150 employees to calculate the 2023 MLR rebates through this short survey until March 31, 2024. To access the survey, please use the group ID and web key provided via email. As a reminder, when calculating 2023 MLR rebates owed, 2022 information is used for statistical sampling purposes. If any rebates are owed, these will be issued by September 30, 2024.

AB 2352 – Real Time Pharmacy Drug Cost

AB 2352 requires health plans to provide information about prescription drugs and associated cost-shares to members and providers. Blue Shield has launched a digital tool known as “Price Check My Rx” which allows members to view real time information on drugs, such as the actual cost to the member, cost-effective drug alternatives, and the price the member would pay for these drugs at varying pharmacies. This tool is available to members enrolled in any fully-insured or self-funded plan with Blue Shield pharmacy benefits upon logging into the member portal at www.blueshieldca.com. 
 

2022 Effective mandates

AB 1184 – Combined Medical Information

AB 1184 allows greater consumer protection of health plan communications that disclose personal health information (PHI). Members can submit a Confidential Communication Request (CCR) form (PDF, 67 KB) to prevent Blue Shield from

• Requiring anyone besides the protected individual to obtain authorization to receive sensitive services or submit a claim for sensitive services if the protected individual has the right to consent to care; and
• Disclosing medical information to the primary Subscriber, relating to sensitive health services provided to a protected individual or any plan enrollees other than the protected individual receiving care.

AB 1184 builds on previously passed California state law requiring privacy protections for minors 12 and older. Under these laws, a minor’s family member will not have access to a minor’s PHI, unless the minor releases this information to a given family member. The requirements of AB 1184 apply to fully-insured and flex-funded groups, but not to self-funded groups. The bill also applies to IFP on- and off-exchange plans, including grandfathered plans.
 

SB 368 – Deductible and Out-of-Pocket Maximum Disclosure Statements

SB 368 mandates that health plans provide members with deductible and out-of-pocket maximum accrual notices for any month when benefits are used. Subscribers receive these statements, showing progress toward their deductible or maximum out-of-pocket limits, if any, until they hit their full deductible or out-of-pocket maximum.

Blue Shield is addressing the compliance obligation of this mandate as it applies to our fully-insured group plans and has been sending subscriber accrual notices since October 2022. 

By default, the subscriber will receive the monthly accrual notice in the same method as they selected for their 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. 

SB 368 applies to fully-insured and flex-funded groups, but not to self-funded groups. The bill also applies to Medicare Supplement and IFP, including grandfathered plans.
 

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 must also provide to Covered California the name, address and other contact information of enrollees who cease to be enrolled in coverage and who have not opted out of this information transfer.

Blue Shield emailed and/or sent enrollees the Annual Notification with opt-out instructions between February 22, 2021 and March 4, 2021.

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. 

California Senate Bill (SB) 855 – California Mental Health Parity Act (Revised)

California Senate Bill (SB) 855 updates and expands the California Mental Health Parity Act of 1999 and requires health plans and insurers to provide treatment for all mental health and substance use disorder conditions under the same terms and conditions that are applied when treating medical conditions that are medically necessary.

SB 855 applies to health plans and policies, including grandfathered plans, issued, delivered, amended, or renewed on or after January 1, 2021. SB 855 does not apply to Medicare Advantage, Med-Supp, Medi-Cal, Cal Medi-Connect (CMC), Stand-Alone Dental or Vision, and Self-funded, ASO and Shared Advantage.

The bill defines “medically necessary treatment of a mental health or substance use disorder” as “a service or product addressing the specific needs of that patient, for the purpose of preventing, diagnosing, or treating an illness, injury, condition, or its symptoms, including minimizing the progression of that illness, injury, condition, or its symptoms,” and defines “mental health and substance use disorders” as those conditions listed in the most recent edition of the World Health Organization’s International Classification of Diseases or in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders. 

SB 855 further requires that plans utilize utilization management guidelines and criteria developed by nonprofit professional associations, when available, and that clinical staff is trained in the application of these guidelines and criteria. Training will also be available to providers and enrollees.

While SB 855 addresses the utilization review criteria for Mental Health/Substance Use Disorder (MH/SUD), the Consolidated Appropriations Act (CAA) Sec 203 Mental Health Parity and Addiction Equity Act (MHPAEA), mandates that plans and insurers conduct data analysis to ensure that MH/SUD treatment limitations are comparable and not more stringent than those applied to medical/surgical benefits. More information on CAA Sec 203 can be found on the Consolidated Appropriations Act and Transparency in Coverage Final Rule page.