The Affordable Care Act requires Blue Shield of California to refund part of the premiums it receives if it does not spend at least 80% of the premiums on healthcare services, such as doctors and hospital bills, and activities to improve healthcare quality, such as efforts to improve patient safety. This is referred to as the Medical Loss Ratio (MLR) requirement.
The Affordable Care Act requires that health carriers spend at least:
80% of premiums received for Individual and Family Plan and small group business plans on medical care or quality improvement programs.
85% of premiums received for large group plans on medical care or quality improvement programs. A group is considered large if it had over 100 eligible employees in the year prior to the MLR reporting year (101+ employees in 2017) and appropriately communicated this information to Blue Shield when asked to provide the information.
Subscribers and employer groups who are eligible for 2018 rebates are listed below and will be notified by letter by September 30, 2019.
Blue Shield of California Small Business Plans (DMHC regulated)
Eligible employers enrolled in health plans from Blue Shield of California (DMHC regulated plans), with 100 or fewer employees, will receive rebates by September 30, 2019. Sole proprietorships with only the business owner and/or the owner’s spouse covered on the policy are categorized as having an individual policy for MLR purposes and are excluded from the 2018 rebates if identified as ineligible. Blue Shield of California missed the 80% target by 0.3% of premiums for its Small Business Plans in 2018.
The following subscribers and employer groups will not receive 2018 plan year rebates, since Blue Shield met or exceeded the MLR targets for those health plans.
Individual and Family members with Blue Shield of California Life & Health Insurance Company (Blue Shield Life) and Blue Shield of California plans
Small businesses with Blue Shield Life
Large groups with Blue Shield Life and Blue Shield of California plans
If you have any questions, please call Producer Services at (800) 559-5905 or contact your Blue Shield representative.
SB 1021 extends the sunset date for AB 339 (Healthcare Coverage for Outpatient Prescription Drugs), which included provisions related to pharmacy cost-share maximums and formulary standards.
SB 1021 also includes a provision to limit member cost-share to the contracted retail price if it is lower than the member’s copayment or coinsurance. This means when a member purchases an outpatient prescription drug from a participating pharmacy and the pharmacy’s contracted rate for the prescription drug is less than the member’s copayment or coinsurance, the member pays only the contracted retail price. This cost-share amount is also applied to the member’s deductible and out-of-pocket maximum (OOPM), if applicable.
SB 1021 extends this specific provision until January 1, 2023.
Click here for more information about California Senate Bill (SB) 1021.
The California Gender Recognition Act of 2017 is a new state law that allows Californians to obtain and or change their official state issued identity documents that legally recognize their gender identity as female, male, and nonbinary.
Effective January 1, 2018, the nonbinary option under Senate Bill (SB)179 became available on official state documents. Starting September 1, 2018, Californians could start changing their gender on their birth certificate. And as of January 1, 2019, Californians could start changing their gender identity to nonbinary gender on their driver’s licenses and state ID cards.
• Allows individuals to identify as female, male, or nonbinary.
•A physician’s declaration to petition for a gender change court order is no longer required.
• Individuals 18 years and older need to attest, under penalty or perjury, that changing their legal gender to their gender identity is not for any fraudulent purposes.
•A minor under the age of 18 can obtain new state documents when their legal guardian files a petition to the California state courts.
Blue Shield of California has added a gender identity category to align with the new state law even though health insurance companies are not required to do so. As an organization, Blue Shield recognizes our members whose gender identity is female, male or nonbinary.
Members who would like to update their gender identity in their profile should call the Member Services number on the back of their Blue Shield member ID card to speak with a Customer Care Representative. They will have the option to self-identify as female, male or non-binary.
California Senate Bill (SB)1375 stops Californians from purchasing health plans that offer fewer benefits and protections than those that comply with the Affordable Care Act.
This new state law changes the definition of “eligibility” for small employer health plans and employees and prevents small businesses and self-employed individuals with no employees from enrolling in a group health plan. The law prohibits employer group plans from being issued, marketed, or sold to a sole proprietorship or partnership (and their spouses), without eligible “common law” employees, directly or indirectly through any arrangement including an association.
This means that only individual health plans can be sold to any entity without employees, and individuals must purchase health coverage in the individual market if they wish to obtain health insurance.
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Health insurance products are offered by Blue Shield of California Life & Health Insurance Company. Health plans are offered by Blue Shield of California.