California Assembly Bill (AB) 72 Out-Of-Network Coverage and Member Cost-Sharing

This applies to all health insurers in the state of California, this happens to be Blue Shield of California’s notice:

New California law 
Effective July 1, 2017, this new state law protects individuals from receiving unexpected “surprise or balance” medical bills from an out-of-network (OON) doctor when receiving inpatient and outpatient non-emergency care and services at an in-network healthcare facility such as a hospital, clinic, lab, imaging center or other healthcare facility.

Changes to out-of-network coverage and cost-sharing 
When individuals go to an in-network facility for care but receive services from an out-of-network doctor or healthcare provider, they only have to pay their in-network cost-sharing amount that counts toward the annual deductible and annual out-of-pocket maximum limits according to their health plan.

An out-of-network doctor should only bill individuals after both parties have received a copy of the Explanation of Benefits (EOB) that reflects the correct in-network cost-sharing amount owed for the care received. If for any reason the out-of-network doctor or healthcare provider receives payment that is more than the cost share allowed, the out-of-network doctor must refund the overpayment within 30 days.

Below is a list of affected Blue Shield health plans.

HMO Plans PPO Integrated Deductible Plans PPO Separate Deductible Plans
– Blue Shield $0 Cost-Share HMO AI-AN
– Blue Shield Gold 80 HMO AI-AN
– Blue Shield Gold 80 HMO
– Blue Shield Platinum 90 HMO AI-AN
– Blue Shield Platinum 90 HMO
– Blue Shield Silver 70 HMO AI-AN
– Blue Shield Silver 70 HMO
– Blue Shield Silver 73 HMO
– Blue Shield Silver 87 HMO
– Blue Shield Silver 94 HMO
– Blue Shield Bronze 60 HDHP PPO AI-AN
– Blue Shield Bronze 60 HDHP PPO
– Blue Shield Minimum Coverage PPO
– Blue Shield Bronze 5550 PPO
– Blue Shield $0 Cost Share PPO AI-AN
– Blue Shield Bronze 60 PPO AI-AN
– Blue Shield Bronze 60 PPO
– Blue Shield Gold 80 PPO AI-AN
– Blue Shield Gold 80 PPO
– Blue Shield Platinum 90 PPO AI-AN
– Blue Shield Platinum 90 PPO
– Blue Shield Silver 70 PPO AI-AN
– Blue Shield Silver 70 PPO
– Blue Shield Silver 73 PPO
– Blue Shield Silver 87 PPO
– Blue Shield Silver 94 PPO
– Blue Shield Silver 1850 PPO
– Blue Shield Silver Seven 3750 PPO