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.
2026 Effective mandates
AB 144 Coverage of Preventive Care Services - Vaccines
AB 144 ensures Californians maintain access to recommended vaccines even if federal standards change. It requires health plans to cover all ACIP-recommended vaccines as of January 1, 2025, without cost-sharing, and empowers the state health department to add or update vaccine requirements based on guidance from trusted medical organizations.
Blue Shield is compliant with this bill.
Effective Date: October 8, 2025
Applicability: Fully Insured employer groups
AB 260 Sexual and Reproductive Health Care - Mifepristone
AB 260 protects access to medication abortion and safeguards providers and patients from out-of-state legal actions. It requires health plans to cover mifepristone, brand and generic, even if its use differs from FDA labeling or federal risk mitigation strategies. The law also prohibits insurers from penalizing providers for lawful abortion-related care, allows pharmacists to dispense mifepristone without prescriber or pharmacy details on labels for privacy, and repeals outdated criminal abortion provisions. Overall, AB 260 reinforces California’s constitutional right to abortion care and ensures continued coverage and confidentiality for medication abortion services.
Blue Shield covers this service as part of previous abortion mandates.
Effective Date: September 26, 2025
Applicability: Fully Insured employer groups
SB 40 Healthcare Coverage - Insulin
SB 40 caps member cost-sharing for insulin at $35 for a 30-day supply and prohibits the use of step therapy as a prerequisite for coverage. The law requires large group plans to include at least one insulin option for each drug type in all forms and concentrations on their formulary. High-deductible health plans cannot impose cost-sharing above $35 unless doing so would conflict with federal HDHP rules. These changes aim to improve affordability and access for Californians managing diabetes.
There are no changes to benefits to meet the requirements of this bill, however the Summary of Benefits (SOB) will include a minor language update to reflect this requirement.
Effective Date: Large Group - Upon new issuance or renewal starting January 1, 2026; Small Group - Upon new issuance or renewal starting January 1, 2027
Applicability: Fully Insured employer groups
SB 41 Prescription Drug Cost Reform
SB 41 prescription drug cost reform intends to increase transparency and affordability for members and requires the following:
- All PBM and vendor contracts meet state standards
- Member’s cost sharing never exceeds the actual amount paid for medications
- Manufacturer rebates are applied to help lower out‑of‑pocket costs
- No spread pricing occurs within our pharmacy programs
Beyond meeting regulatory requirements, Blue Shield has been a statewide leader in driving PBM reform through our Pharmacy Care Reimagined initiative, an effort designed to bring greater clarity, accountability, and value to the pharmacy ecosystem. You can read more about our policy leadership and approach here.
Effective Date: January 1, 2026
Applicability: Fully Insured employer groups
SB 729 Infertility coverage
On June 30, 2025, Governor Newsom officially signed AB 116 which delayed the effective date for SB 729 from July 1, 2025, to January 1, 2026.
Fully-insured Large groups can expect changes to fertility coverage as outlined in SB 729 to take effect on or after January 1, 2026, upon new issuance or renewal.
The change in effective date does not impact Small groups as coverage remains optional. Small groups that select to offer coverage under SB 729 will see coverage changes take effect upon new issuance or renewal.
For additional details, please view the SB 729 FAQs.
Effective Date: Upon new issuance or renewal starting January 1, 2026
Applicability: Fully Insured employer groups
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.
To accurately calculate 2025 MLR rebates, Blue Shield will be collecting group size information from groups with 150 and fewer employees between January 28, 2026 and March 31, 2026. This includes all Small Groups and some Mid Market Groups.
Effective Date: Any rebates owed are due by September 30 annually, Blue Shield's survey is due March 31 annually
Applicability: Fully Insured employer groups with 150 and fewer employees
One Big Beautiful Bill - High Deductible Health Plan Telehealth Waiver
The One Big Beautiful Bill (OBBB) signed into law on July 4, 2025, includes a provision that permanently allows, but does not require, health savings account (HSA) compatible High Deductible Health Plans (HDHP) to cover telehealth services before a deductible is met, without compromising HSA eligibility.
Blue Shield’s implementation approach was to make changes to all portfolio fully-insured groups prospectively upon renewal starting January 1, 2026, and upon custom group renewal, as requested, in 2025.
Applicability: Fully Insured and Self-funded employer groups
Effective Date: July 2, 2025 (Please note that the provision does not require this change, rather allows health plans to make this change)
2025 Effective mandates
AB 2843 Health Care Coverage: Rape and Sexual Assault
This bill requires a health plans to provide coverage without cost sharing for emergency room medical care and follow up health care treatment for an enrollee or insured who is treated following a rape or sexual assault.
Effective date: Upon new issuance or renewal starting July 1, 2025
Applicability: Fully Insured groups
COVID-19 high deductible health plan 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.
Effective Date: January 1, 2025
Applicability: Fully Insured groups
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.
Effective Date: January 1, 2025
Applicability: Fully Insured groups
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.
Applicability: Fully Insured groups
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.
Effective Date: Upon new issuance or renewal starting July 1, 2022
Applicability: Fully Insured groups
2021 Effective mandates
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, for any reason, 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. Opt out is only required once and can be changed at any time.
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
Effective Date: January 1, 2021
Applicability: Fully Insured groups
