Health Reform Timeline

Health Reform Flag

Understand what's changing when with Blue Shield's Health Reform Timeline.

2012 Medical Loss Ratio

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Individuals and Families

Federal health reform, officially titled the Affordable Care Act (ACA), is a strategic approach to improving the quality of health care and increasing access to care for you and your family.

A majority of the law's mandates have already been implemented, with many of the remaining mandates to be in place by 2014.

Learn more about health reform and find out what Blue Shield is doing to implement the new requirements.

Don't forget to check out our Health Reform Timeline to see what changes are taking place and when.

Covered California – California’s Health Insurance Marketplace

One of the important parts of the Affordable Care Act are new, state-run competitive health insurance ‘marketplaces’ (also known as ‘exchanges’) where individuals and small businesses (defined by Blue Shield as generally companies with less than 50 employees) will be able to purchase affordable private health insurance for 2014. California’s health insurance marketplace is known as Covered California.
In addition to buying coverage through Covered California, individuals and small businesses will also be able to purchase health insurance the way they do today from brokers and directly through health insurance carriers.

Covered California for Individuals and Families

Covered California is a new marketplace where individuals may get financial assistance to help make coverage more affordable and be able to compare and choose health coverage that best fits their needs and budget. By law, coverage can't be dropped or denied even if an individual has a pre-existing medical condition or gets sick.

Subsidies will be available through Covered California to applicants with annual incomes between 134% and 400% of the Federal Poverty Level (FPL) and other applicable guidelines. Those with an FPL under 134% FPL may be eligible for Medi-Cal. Consumers can purchase health care from Covered California even if they do not qualify to receive subsidies.

Open Enrollment for Individuals and Families for 2014

Enrollment in health plans effective in 2014 will begin on October1, 2013 and end on March 31, 2014. This open enrollment period is generally the only time individuals will be able to obtain coverage for 2014 - either through Covered California or in the private market. If a consumer has a life-changing event, such as the loss of a job, death of a spouse or birth of a child, they may be eligible for special enrollment within 60 days of the event.

Open Enrollment for Individuals and Families for 2015 and Beyond

Annual open enrollment periods will be held October 15—December 7 of each year with an initial effective date of January 1st of the following year.

Go to Covered California's site to learn more.

Learn more about Health Insurance Marketplaces on Healthcare.gov.

How will Blue Shield participate?

Blue Shield intends to offer plans for individuals and families inside of Covered California. Once we have received qualification from the state later this year, you will be able to purchase new plans from Blue Shield through Covered California, as well as through traditional methods, starting on October 1st.

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Benefit Changes

Learn more about health reform plan rule changes.

Extension of Dependent Coverage Up To Age 26

The provision - Dependents have the option of staying on their parents’ group or family medical plan up to age 26 or re-enrolling on the plan.  Dependents are eligible regardless of student, residency, employment or marital status.

For Blue Shield plans - Blue Shield is applying this same extension of coverage to dental, vision, and life insurance* plans as well.

For more information, please see our Frequently Asked Questions (PDF, 51KB). 

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No Pre-existing Condition Exclusion for Enrollees Under Age 19

The provision - Health insurance can’t be denied to a child under the age of 19 due to a pre-existing health condition. This means that health insurers must enroll any child until their 19th birthday, no matter what their health status is—as long as that child meets other eligibility criteria.

For Blue Shield plans - All Blue Shield group and Individual and Family plans that have pre-existing condition exclusions have been modified to remove pre-existing exclusions for enrollees under age 19.

For more information, please see our Frequently Asked Questions (PDF, 51KB).

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Removal of Lifetime and Annual Dollar Limits

The Provision - Lifetime dollar limits on “essential health benefits” for medical plans must be removed.  Although not specifically defined by the Department of Health and Human Services (HHS), the general list of essential health benefits includes:

  • Emergency services

  • Maternity and newborn care

  • Mental health, substance abuse disorder services, and behavioral health treatment

  • Prescription drugs

  • Preventive, wellness, and chronic disease management

  • Pediatric services, including dental and vision care

For Blue Shield plans - Blue Shield has removed the limit on the dollar amount for which a member can be covered for medical expenses for essential benefits during the coverage year and well as the lifetime of the coverage

For more information, please see our Frequently Asked Questions (PDF, 50KB).

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Removal of Member Cost-sharing on Preventive Health Benefits

The provision - An expanded number of preventive health services will now be provided at no cost-sharing to the member for all individual and family plans which are not grandfathered. Preventive services include:

  • Preventive care for children up to age 16

  • All generally accepted cancer screenings, including breast, cervical, and prostate

  • Preventive services and immunizations for children and adults

This means that a member will not be charged a deductible, copayment or coinsurance for these services.

For Blue Shield plans - Most of these services were already covered by Blue Shield of California and Blue Shield Life. Those that were previously covered as medical benefits will now be covered as preventive services and members will no longer pay a copayment.

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Preventive Health Services for Women at No Additional Charge 

The provision - Additional preventive heath services for women have been added to the preventive services that must be offered without a co-payment, co-insurance or a deductible.  These services include: well-woman visits, gestational diabetes screening, HPV DNA testing, STI counseling, and HIV screening and counseling, contraception and contraceptive counseling, breastfeeding support, supplies, and counseling, and domestic violence screening

For Blue Shield plans – Beginning with plans new or renewing August 1, 2012, members will no longer pay a copayment for these preventive services for women.

For more information, please see our Frequently Asked Questions  (PDF, 50KB). 

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Patient Protections

The provision - This provision broadens federally-required options for members in obtaining care, including:

  • A patient's right to select any participating physician as their primary care provider. This applies to primary pediatric care providers as well

  • No referral needed for OB/GYN services

  • Improved access to out-of-network emergency care

  • No higher copays/coinsurance for out-of-network emergency services

  • No prior authorizations for emergency services

For Blue Shield Plans - Blue Shield is already compliant with these provisions as they were already required by California law.

For more information, please see our Frequently Asked Questions  (PDF, 50KB).

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Plan Rule Changes

 

Member Appeals

The provision – Health insurance carriers must change their appeals procedures so that members can continue to receive coverage, pending the outcome of the appeals process.

For Blue Shield plans - If you appeal a Blue Shield coverage decision, there will be no interruption in coverage while the appeal is in progress.  You will be covered until the appeals process is complete.

For more information, please see our Frequently Asked Questions  (PDF, 50KB)

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New Rescission Rules

The provision - Once an enrollee is covered under an Individual and Family plan, a carrier may only rescind coverage in cases in which the individual "performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage."

For Blue Shield plans - Under this mandate, Blue Shield can only rescind (cancel) your Individual and Family coverage if you commit deliberate fraud, or for non-payment of your premiums.

For more information, please see our Frequently Asked Questions  (PDF, 50KB)

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Medical Loss Ratio (MLR)

The provision - Health reform requires health carriers to spend a certain percentage of premium revenue on medical expenses. This percentage is determined from a calculation called the Medical Loss Ratio (MLR) where medical expenses must be a certain percentage of premiums.  For individuals and small group health plans – carriers must spend no less than 80% of premium revenue on medical expenses. For large groups – carriers must spend no less than 85% of premium revenue on medical expenses. If carriers do not meet the required MLR, they will be required to pay rebates to employers and individuals.

For Blue Shield plans - Blue Shield reported our 2011 MLR on June 1, 2012.  For more information on MLR and rebate eligibility, please see MLR: Why It Matters to You.

For more information, please see our Frequently Asked Questions  (PDF, 69KB)

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Summary of Benefits and Coverage

The provision - Health Reform requires that all health carriers make available uniform coverage documentation, intended to enable consumers to more easily understand the coverage they already have and/or help them make “apples-to-apples” comparisons of available options when purchasing new coverage. Requirements include:

  • Summary of Benefits and Coverage (SBC) – benefit summary describing plan benefits, cost sharing and limitations.

  • Coverage Examples - included along side the SBC, illustrating customer costs based on a specific plan’s benefits for common medical scenarios.

  • Glossary – a standard document with definitions for common medical and insurance terms.

  • Carriers are also required to notify members whenever there is a material modification to a benefit, known as a Notice of Modification (NM).

For Blue Shield plans - A distinct SBC form has been developed for every plan offered by Blue Shield. Blue Shield of California will be creating the SBC documentation, including coverage examples.

For more information, please see our Frequently Asked Questions  (PDF, 69KB)

* Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life).

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