Aetna Anthem Blue Cross Health Net Yes, 2-50 required Yes, 2-50 required Yes, 25 +

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Ann Welch
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1 No owner docs if enrollment is: GI 2-50 Eligible Aetna Anthem Blue Cross Health Net Yes, 2-50 required Yes, 2-50 required Yes, AND prior carrier bill (AB1672) 15 + (AB1672) 25 + (AB1672) weeks. 2 owners: 50% of the prior calendar quarter or year weeks. 2 owners: 50% of the prior calendar quarter or year 1 W/C Needed? No No Yes (unless owners only) Sole Proprietor 1040C OR 1040F OR 1040 SE OR 1040ES (est. tax) OR FBN/DBA filing 1065/ OR 1040 SE OR 1040 ES (est. tax) Agreement OR FBN/DBA filing OR OR FBN/DBA filing Husband & Wife Sole Prop. (as above &) If owner name listed on the DE6 above or where the group name would be indicated, owner doc not needed. Agreement AND Fed Tax ID letter OR Statement of Authority Contact your Warner Pacific Case Advocate for samples of these documents or to discuss other potential options if your group does not have one of the documents listed EE s and/or owners: 6 weeks or 50% of the prior calendar quarter or year OR FBN/DBA filing OR WITH 1040 (both names) OR FBN/DBA filing OR (both names) 1065/ OR Business license OR FBN/DBA filing OR Tax Certificate OR Statement of Authority (gen) 1120 OR 1120A OR 1120W OR OR (if Single Member ) FBN/DBA filing OR Articles of Organization with Operating Agreement OR Stamped/Filed SOI AND Stamped/Filed Cert. of Qualif. (if inc. out of state) NOTE: For LP s, Limited Partners must appear on DE6/payroll to be eligible. OR (if Single Member ) Stamped/Filed SOI OR Articles of Organization w/ Operating Agreement 1065/ OR 1120 (w/ all owners & %'s) OR Articles of Organization w/ Agreement OR FBN/DBA filing OR OR Stamped/ Filed SOI OR Schedule C (if Single Member ) 1120 OR 1120A OR 1120W OR 1120 S OR Schedule K-1 or Form 8832 (entity Classification, s treated as a corp) FBN/DBA filing OR Stamped/Filed/ SOI AND Stamped/ Filed Cert. of Qualif. (if inc. out of state) 1120 OR 1120S OR Stamped/Filed SOI OR Stamped/Filed Statement of Foreign Corp 1120 OR FBN/DBA filing OR Stamped/Filed SOI OR 1120S OR OR OR Form 2553 AND IRS approval letter 1 If the enrolling group consists of only 2, broken down as 1 owner (on legal doc s) and 1 on payroll OR 2 owners not on payroll, the 50% of the prior calendar quarter will apply. Kimberly Gomez, Page 1, Last Revised 8/9/2010

2 No owner docs if enrollment is: CIGNA CaliforniaChoice Kaiser Permanente N/A Yes, 2-50 required. Yes, 2-50 required. N/A 5 + (AB1672) N/A GI 2-50 Eligible 2-50 EE s and/or owners: 50% of the prior calendar (BASED ON ENROLLING) 2 60 days, 3-50 on or 2-50 EE s and/or owners: On or before the effective date quarter or year before effective date. W/C Needed? No Yes (unless owners only) Yes (unless owners only) Sole Proprietor AND 1 OF THE FOLLOWING: Business License OR FBN/DBA filing (w/both names) AND 1 OF THE FOLLOWING: FBN/DBA filing (with both names) OR OR WITH most recent cancelled draw check, front & back (most recent) OR FBN/DBA filing WITH most recent cancelled draw check, front & back (most recent) Sub. 1 of the following showing owner(s) name), FBN/DBA filing, Sellers Permit,, Professional License (except Realtors) AND See footnote ** 1040 & OR Marriage License & (if recently married) AND See footnote ** Agreement AND Federal Tax ID Appointment letter AND (showing all partners) AND K-1 (if available) Legal Notarized Agreement OR 1065/ OR Stamped/Filed LLP Registration WITH most recent cancelled draw check Sub. 1 of the following showing owner(s) name: General Agreement, (or K),, FBN/DBA filing, Sellers Permit, AND See Footnote ** Organization w/ Operating Agreement AND Stamped/Filed SOI AND (if available) Stamped/Filed SOI OR Articles of Organization WITH most recent draw check (front & back) OR 1065/Schedule K-1 CA Business Portal & 1 of the following: Stamped/Filed SOI by (mbrs listed),, FBN/DBA filing, Sellers Permit, Stamped & Filed / SOI OR Statement by Domestic Stock Stamped/Filed SOI OR 1120E (showing owner names) OR Articles of Inc WITH most recent cancelled draw checks front & back (most recent) CA Business Portal & submit 1 of the following showing owner(s) name: Stamped/Filed SOI, Shareholder or Stock Certificate, 1120, Election by Small Business Corp (Form 2553), (or K), Bylaws, Minutes, Operating Agreement, Written Consent,, FBN/DBA filing, Sellers Permit, ** One of the following is required in addition to the above to verify the company is active in business:, FBN/DBA Filing, Contractors License, Sellers Permit, Motor Carrier Permit (See additional links and helpful websites for Kaiser Permanente) Kimberly Gomez, Page 2, Last Revised 8/9/2010

3 No owner docs if enrollment is: GI 2-50 Eligible Kaiser Permanente Choice Solution PacifiCare / UHC Yes, 2-50 required. N/A Yes, 2-50 required. 5 + (AB1672) 6 + (AB1672) N/A 2-50 EE s and/or owners: On or before effective date 2-50 EE s and/or owners: 50% of the prior calendar quarter or year *NOTE: Husband/Wife groups or groups comprised of family members must provide separate tax or QWR documentation showing they are an owner or FT ee 2-50 EE s or owners: 45 days W/C Needed? Yes (unless owners only) Yes (unless owners only) Yes (unless owners only) Sole Proprietor OR WITH 2 cancelled draw checks, front & back (most recent) OR FBN/DBA filing WITH 2 cancelled draw checks, front & back (most recent) Sharp OR FBN/DBA filing Articles of LLP OR Legally Notarized Agreement OR 1065 Stamped/Filed SOI OR Articles of Agreement OR (if single member ) (w/ both names) OR Agreement (notarized) OR FBN/DBA filing (w/ both names) OR Not Defined If members not listed: Bylaws OR Minutes OR Operating Agreement OR Written Consent Operating Agreement Shareholder / Stock Certicificates OR Stamped/Filed SOI OR 1120 (showing owner names) OR Form 2553 Election by Small Business Corp OR OR Bylaws OR Minutes OR Operating Agreement OR Written Consent S Corp: 1120 C Corp: 1120 (pages 1 & 2, incl. Schedule E) Stamped/Filed SOI OR Stmt of Foreign Corp Stamped/Filed SOI OR Statement by Domestic Stock Kimberly Gomez, Page 3, Last Revised 8/9/2010

4 Additional Links and Helpful Websites-Primarily for Kaiser CA Secretary of State, Business Portal - Better Business Bureau CA Contractors State License Board sp CA Dept. of Consumer Affairs CA Community Care Licensing Division California Fictitious Business Names - o County FBN s not listed on the above website: Plumas County Can call (530) & request a fax. San Joaquin County FBN Search - Sutter County - Enter text in box and click submit Tehama County - Click on Search Now Trinity County - Enter fbn in user ID and no password. No Online Service available for the following counties: Alpine, Colusa, Glenn, Humboldt, Inyo, Kings, Madera, Mariposa, Mendocino, Modoc, Mono, San Benito, Sierra, Sonoma, Yuba NOTE: If you are searching for a medical professional s (Dr. or DDS) FBN try: CA dept of Consumer Affairs. They are sometimes listed here instead of on the county website Kimberly Gomez, Page 4, Last Revised 8/9/2010

5 Confirmation of eligibility for employees (Assuming GI is already established) New Hire FT w/ Low wages PT w/ High Wages Anthem Blue Cross 30 days, or 4 weeks. If payroll not avail, new hire letter* 30 days or 4 weeks payroll Hours worked per week/ wages per hour (may ask for payroll) Aetna 2 weeks payroll. If payroll not avail., new hire 2 weeks payroll 2 weeks payroll letter* Cigna 2 weeks payroll 2 weeks payroll 2 weeks payroll CaliforniaChoice Current run of payroll and W-4 if SSNs not shown. If payroll not avail., W-4 Current run of payroll If a trend, Verification of Eligibility Form. Otherwise current** payroll Health Net 2 weeks payroll or new hire letter* 2 weeks payroll 2 weeks payroll Kaiser Permanente 1 week payroll or W-4 (must provide tax ID) n/a (may require payroll or W-4 if under May require 2 weeks payroll $500) KP Choice Solution Current run of payroll. If payroll not avail., W-4 Current run of payroll Confirmation of Eligibility Form PHS/UHC 30 days or 4 weeks payroll 30 days or 4 weeks payroll 30 days or 4 weeks payroll NOTE: Payroll must include hours, wages, withholdings, and pay period dates. Carriers prefer a Payroll Register or Journal from a professional payroll service. *New Hire Letter must include Name, DOH, # hours worked per week, and hourly wage/salary. **Current run of payroll is defined by the group. If the group pays weekly, that is sufficient. If bi-weekly, etc. Kimberly Gomez, Page 5, Last Revised 8/9/2010

Enrollment Statistics Northern Counties Region 1

Enrollment Statistics Northern Counties Region 1 Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter,