We offer Blue Cross of California's HIPAA plans that can keep you covered when coverage through an employer-sponsored plan ends. Coverage is guaranteed under one of our HIPAA plans for anyone who qualifies.
Are you eligible?
To qualify for a HIPAA plan, you must:
- Have completed a minimum 18 months of continuous health coverage, most recently under an employer-sponsored group health plan;
- Have elected and exhausted continuation of coverage under COBRA or Cal-COBRA, if available;
- Have lost coverage within the last 63 days; and
- Not be eligible for Medi-Cal or Medicare, or have any other medical coverage.
Do you meet enrollment requirements?
To enroll, you must be:
- A permanent legal resident of California;
- The applicant's spouse and not Medicare eligible;
- The applicant's child, or the child of the applicant's enrolling spouse, under 19 years of age; or
- The applicant's unmarried dependent child between the ages of 19 and 23 ("dependent" as defined by the Internal Revenue Service).
What are your HIPAA plan choices from Blue Cross?
HIPAA Plans: Overview of Coverage...
...and your share of costs (after deductible)
HIPAA Share 2500 (SMG2)
| Your Plan Features |
Participating Provider |
Non-participating Provider |
| Lifetime Maximum |
$5,000,000 |
Annual Out-of-Pocket Maximum
(includes deductible) |
Once you pay $5,000 for covered expenses incurred in a year, you pay nothing for covered expenses the rest of the year[1] |
| Annual Deductible |
$2,500 |
| Office Visits |
25% of negotiated fee
deductible waived |
50% of negotiated fee
deductible waived |
Professional Services
(x-ray, lab, anesthesia, surgeon, etc.) |
25% of negotiated fee |
50% of negotiated fee plus excess |
| Hospital Inpatient/Outpatient |
25% of negotiated fee[2,3] |
All charges except:
$650/day inpatient,
$380/day outpatient |
| Emergency Services |
25% of negotiated fee[4] |
25% of customary & reasonable for the first 48 hours plus excess; after 48 hours, you pay all charges except $650/day for covered services[4] |
Maternity
after deductible |
$1,000 copay[5]
plus 25% of negotiated fee |
$1,000 copay[5]
plus 50% of negotiated fee plus excess |
| Preventive Care |
HealthyCheackSM Centers:
$25 or $75 copay for basic screenins; routine mammogram, Pap and PSA ordered by physician: 25% of negotiated fee |
Routine mammogram, Pap and PSA ordered by physician: 50% of negotiated fee plus excess |
Drug Benefits
(Retail or Mail Order: 30-day supply) |
10% generic[6], $25 brand copay after $500 brand deductible[7]; 30% of negotiated fee for self-administered injectables except insulin |
to% of generic[6] or 50% of brand drug limited-fee schedule within California; $500 brand deductible[7] |
1 Non-participating charges in excess of the negotiated fee will not be paid and do not apply to the out-of-pocket maximum.
2 Additional $500 admission charge at Participating Hospital (no additional for Preferred Participating Hospitals) is for surgery or infusion therapy. This charge is not required for Ambulatory Surgical Centers or medical emergencies
3 Organ tissue transplants require prior authorization: $250 penalty applies if not obtained ($250 penalty does not apply to out-of-pocket maximum).
4 Additional $30 copay for PPO Plans applies for each emergency room visit (waived if admitted as inpatient).
5 Maternity copay is per pregnancy and does not apply to out-of-pocket maximum.
6 Generic drugs are based upon the Blue Cross drug formulary.
7 Brand drug deductible does not apply to out-of-pocket maximum.
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HIPAA Share 1500 (SMG3)
| Your Plan Features |
Participating Provider |
Non-participating Provider |
| Lifetime Maximum |
$5,000,000 |
Annual Out-of-Pocket Maximum
(includes deductible) |
Once you pay $4,000 for covered expenses incurred in a year, you pay nothing for covered expenses the rest of the year[1] |
| Annual Deductible |
$2,500 |
| Office Visits |
25% of negotiated fee
deductible waived |
50% of negotiated fee
deductible waived |
Professional Services
(x-ray, lab, anesthesia, surgeon, etc.) |
25% of negotiated fee |
50% of negotiated fee plus excess |
| Hospital Inpatient/Outpatient |
25% of negotiated fee[2,3] |
All charges except:
$650/day inpatient,
$380/day outpatient |
| Emergency Services |
25% of negotiated fee[4] |
25% of customary & reasonable for the first 48 hours plus excess; after 48 hours, you pay all charges except $650/day for covered services[4] |
Maternity
after deductible |
$1,000 copay[5]
plus 25% of negotiated fee |
$1,000 copay[5]
plus 50% of negotiated fee plus excess |
| Preventive Care |
HealthyCheackSM Centers:
$25 or $75 copay for basic screenins; routine mammogram, Pap and PSA ordered by physician: 25% of negotiated fee |
Routine mammogram, Pap and PSA ordered by physician: 50% of negotiated fee plus excess |
Drug Benefits
(Retail or Mail Order: 30-day supply) |
10% generic[6], $25 brand copay after $250 brand deductible[7]; 30% of negotiated fee for self-administered injectables except insulin |
to% of generic[6] or 50% of brand drug limited-fee schedule within California; $250 brand deductible[7] |
1 Non-participating charges in excess of the negotiated fee will not be paid and do not apply to the out-of-pocket maximum.
2 Additional $500 admission charge at Participating Hospital (no additional for Preferred Participating Hospitals) is for surgery or infusion therapy. This charge is not required for Ambulatory Surgical Centers or medical emergencies
3 Organ tissue transplants require prior authorization: $250 penalty applies if not obtained ($250 penalty does not apply to out-of-pocket maximum).
4 Additional $30 copay for PPO Plans applies for each emergency room visit (waived if admitted as inpatient).
5 Maternity copay is per pregnancy and does not apply to out-of-pocket maximum.
6 Generic drugs are based upon the Blue Cross drug formulary.
7 Brand drug deductible does not apply to out-of-pocket maximum.
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