The Consolidated Appropriations Act was signed into law as part of a $2.3 trillion funding package. The Act provides a number of healthcare-related provisions including surprise medical bill protections, cost transparency, and an expansion of the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 and total to 5,593 pages of legislation.
The Transparency in Coverage Final Rule was a joint effort enacted by the Department of Health and Human Services (HHS), the Department of Labor, and the Department of Treasury on October 29, 2020. 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.
SB 368 mandates that health plans provide members with deductible and out-of-pocket maximum accrual notices for any month when benefits are used. Members receive these statements, showing progress toward their deductible or maximum out-of-pocket limits, until the member hits 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 will be sending member accrual notices to keep members informed.
SB 368 applies to fully-insured and flex-funded groups, but not to self-funded groups. The bill also applies to IFP, including grandfathered plans.
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.
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.
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.
Please see California Mental Health Parity for additional information.
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.
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 is emailing and/or sending enrollees the Annual Notification with opt-out instructions between February 22,2021 through March 4, 2021.
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.
Blue Shield of California (Blue Shield) does not owe Medical Loss Ratio rebates for 2020. For more information, please review this Producer Alert.
Blue Shield is mailing the MLR employer survey to Small Business Groups requesting the following information from groups to help calculate the MLR for 2020, as required by the ACA.
Groups should fax this form back to (855) 895-3497 by March 31, 2021. Groups can still submit their information via our online survey at blueshieldca.com/groupsize .
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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.