Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers Effective April 1, 2018 Grups f 1 t 100 emplyees This bklet cntains guidelines that represent Blue Shield s general apprach t underwriting new and existing small grup business fr health plans and specialty benefits plans. These guidelines apply t cverage written by either Blue Shield f Califrnia r Blue Shield f Califrnia Life & Health Insurance Cmpany. We will make every effrt t keep yu infrmed and up-t-date n changes t these guidelines. Only Blue Shield may make the final decisin t accept r decline cverage fr a case r assign an effective date fr cverage. Prducers are nt authrized t bind r guarantee cverage r assign a specific rate r effective date fr cverage. Please advise all prspective grups t maintain their current cverage until Blue Shield ntifies them in writing f any acceptance int a Blue Shield plan. Please nte: Blue Shield f Califrnia is a licensed health care service plan under prvisins f the Califrnia Health & Safety Cde Sec.1340 et seq. (the "Knx-Keene Act"). Blue Shield f Califrnia Life & Health Insurance Cmpany is a licensed life and disability insurer under the prvisins f the Califrnia Insurance Cde. Blue Shield f Califrnia is an independent member f the Blue Shield Assciatin A16060-REV (1/11/18) (1/09)
Table f Cntents Sectin I: Health Plan General Requirements... 5 Small emplyer defined... 5 Small emplyer eligibility requirements... 5 Grups nt cnsidered small emplyers...5 Other emplyer requirements... 6 Emplyer dues/premium cntributin requirements... 6 New grup eligibility/effective date...6 Orientatin and waiting perids... 7 Additinal enrllment and plan criteria... 7 Special enrllment perid fr small grups... 7 Plicy n HRAs fr small emplyers purchasing a Blue Shield health plan... 7 HMO service area... 7 HMO prvider netwrks and pairing ptins... 8 Access+ HMO Prvider Netwrk (Off-Exchange Package nly)... 8 Lcal Access+ Prvider Netwrk (Off-Exchange Package nly)... 8 Tri ACO HMO Prvider Netwrk (Off-Exchange and Mirrr Packages)... 8 PPO prvider netwrks and pairing ptins... 9 Tandem PPO Prvider Netwrk (Off-Exchange Package nly)... 9 Additinal benefits available... 9 Blue Shield f Califrnia Off-Exchange Package fr Small Business... 9 Accunt-based health plans... 10 Off-Exchange Package fr Small Business participatin requirements... 10 Off-Exchange Package fr Small Business ntes... 11 Blue Shield f Califrnia Mirrr Package fr Small Business... 11 Mirrr Package fr Small Business participatin requirements... 11 Mirrr Package fr Small Business ntes... 11 Sectin II: Health Plan Other Requirements... 12 Emplyers f unin and nnunin emplyees... 12 Prfessinal Emplyer Organizatin ( leased ) emplyees... 12 Cmbining multiple emplyer grups... 12 Spin-ff grups... 12 Sectin III: Wh can enrll?... 13 Emplyee eligibility fr cverage... 13 Part-time emplyee eligibility fr cverage... 13 Dependent eligibility fr cverage... 13 Dmestic partners... 14 Dmestic partner dcumentatin requirements t enrll a dmestic partner... 14 Spuses r dmestic partners wrking fr the same emplyer... 14 Sectin IV: Health Plan Rating Criteria... 14 Quting a grup... 14 Field rating... 14 Rating plicies... 15 Medicare primary and secndary rules... 15 Blue Shield Medicare Supplement plans... 15 Rate changes... 15 Sectin V: New Business Submissin Requirements... 15 Guidelines fr cmpleting frms... 15 Prcessing time specificatins... 15 Start-up grups... 16 Exceptin fr small emplyer start-ups when five r mre are enrlling... 16 Evaluatin criteria... 16 2 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
Blue Shield may decline grups if... 16 Waivers/declinatins... 16 Grup enrllment checklist... 17 Dcumentatin t submit based n nature f business... 18 Sectin VI: Existing Business Guidelines... 20 Enrlling new hires... 20 Enrlling late enrllees... 20 Special enrllment perid... 20 Regular effective dates fr special enrllment perids... 20 Qualifying/Triggering events... 21 Open enrllment... 24 Guaranteed renewal... 24 Small-t-large grup renewal cnversins... 24 Cntract benefit mdificatins... 24 Grup level... 24 Subscriber level... 24 Re-enrllees... 24 Benefit Mdificatin Optins Chart... 25 Sectin VII: Health Plan Benefit Cntinuity... 26 Prir deductible credit...26 Takever prvisins... 26 Sectin VIII: Definitins... 26 Guaranteed assciatins defined... 26 Declinatins... 26 Late enrllee... 27 Sectin IX: State and Federal Regulatins... 28 Federal regulatins... 28 Cal-COBRA/COBRA cntinuatin cverage... 29 Federal COBRA cverage... 30 Disabled COBRA extensin... 30 Extensin f COBRA under Califrnia Health and Safety Cde 1373.621... 30 HIPAA requirements after COBRA and Cal-COBRA terminatin... 30 Emplyer ptin t include part-time emplyees... 31 Takever prvisins (Califrnia Insurance Cde)... 31 Cnfidentiality f persnal and health infrmatin... 31 Meeting yur bligatins... 32 Sectin X: Specialty Benefit Plan Guidelines... 33 General requirements... 33 Eligible emplyees... 33 Emplyer ptin t include part-time emplyees... 33 Small business dental plans general requirements... 34 Emplyer dues/premium cntributin requirements... 34 New grup eligibility/effective date...34 DHMO service area... 34 Small business dental plan participatin requirements... 34 Small business dental plan ntes... 35 Rating plicies... 35 Rate changes... 36 Cverage guarantee... 36 Small business visin plans general requirements... 36 Emplyer dues/premium cntributin requirements... 36 New grup eligibility/effective date...36 Small business visin plan participatin requirements... 36 Small business visin plan ntes... 37 3 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
Rating plicies... 37 Rate changes... 37 Cverage guarantee... 37 Small business life insurance general requirements...37 SIC limitatins... 37 Emplyer dues/premium cntributin requirements... 37 New grup eligibility/effective date...38 Additinal enrllment and plan criteria... 38 Special enrllment perid fr grups f 2-50 emplyees purchasing life insurance... 38 Small business life insurance participatin requirements... 38 Small business life insurance ntes... 38 Rating plicies... 39 Rate changes... 39 Cverage guarantee... 39 Appendix... 40 Frm names and frm numbers... 40 4 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
Sectin I: Health Plan General Requirements T qualify fr any Blue Shield health plan cverage, a grup must meet the criteria utlined belw in the qualified small emplyer, small emplyer eligibility requirements and ther emplyer requirements sectins. Small emplyer defined (applies t medical plans nly) The grup must qualify as a small emplyer as defined by the Small Grup Act in Califrnia and the federal Patient Prtectin and Affrdable Care Act (ACA) as fllws: The grup must be a persn, firm, prprietary r nnprfit crpratin, partnership, public agency, assciatin r guaranteed assciatin. The grup must emply at least ne cmmn-law emplyee. A cmmn-law emplyee is defined by the Internal Revenue Service (IRS) as anyne wh perfrms services fr an emplyer if the emplyer can cntrl what will be dne and hw it will be dne. A cmmn-law emplyee must als meet the definitin f an eligible emplyee (see page 13). The grup emplyed ne t 100 emplyees n at least 50% f its wrking days during the preceding calendar quarter r calendar year. In determining whether t apply the preceding calendar quarter r year test, Blue Shield will use the test that ensures eligibility. Fr plan years cmmencing n r after January 1, 2016, fr nngrandfathered plans, a small emplyer is determined using the definitin f emplyee. An emplyee is defined as a full-time emplyee r full-time equivalent emplyee as thse terms are defined in Internal Revenue Cde Sectin 4980H(c)(2): A full-time emplyee is an emplyee wh has n average at least 30 hurs f service per week, r at least 130 hurs f service ttal during a calendar mnth. The number f full-time equivalent emplyees is determined as fllws: 1. Cmbine the number f hurs f service f all nn-full-time emplyees fr the mnth, but d nt include mre than 120 hurs f service per emplyee. 2. Divide the ttal by 120. 3. If the result is a fractin, rund dwn t the next whle number. In determining the number f emplyees fr small emplyer eligibility, grups that are affiliated cmpanies and that are eligible t file a cmbined state tax return shall be cnsidered ne emplyer, even if they are nt presently filing tgether. The affiliated cmpanies are treated as a single emplyer and are written under the same cntract. The grup is nt frmed primarily fr the purpse f btaining health cverage. The grup ffers health plan cverage t 100% f its eligible emplyees. At least 51% f the grup s emplyees must be emplyed in Califrnia. Small emplyer eligibility requirements A small emplyer meeting the fllwing eligibility requirements is eligible fr Blue Shield s small grup health plans n a guaranteed issue and guaranteed renewable basis: Must qualify as a small emplyer. Must be actively engaged in business r service. Must have and maintain applicable business licensure, permits, etc. allwing the cmpany t cnduct business in Califrnia. All emplyees must be cvered by wrkers cmpensatin when required by law. The fllwing grups are nt cnsidered small emplyers: A grup nt meeting the definitin f small emplyer. Grups with nly a sle prprietr and/r a sle prprietr s spuse-emplyee. Carve-ut grups (see Sectin II, Health Plan Other Requirements n page 12). Assciatins, multiplayer trusts, unin trust plans, Taft-Hartley grups, retirees and hur bank grups. Blue Shield defines these grups as fllws: 5 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
Assciatin A grup f emplyer units that are banded tgether fr any reasn, unless the grup meets the definitin f a guaranteed assciatin. Multiple Emplyer Trust Emplyers, usually in the same r related industries, that are brught tgether by an insurer, agent, brker r administratr fr the purpse f prviding insurance fr their emplyees under a master cntract issued t a trustee under a trust agreement. Unin trust plans When a small grup emplyer is cntributing t a labr fund in cmpliance with a cllective bargaining agreement fr the purchase f healthcare benefits, that emplyer s unin emplyees are cnsidered ineligible fr Blue Shield purpses. Retirees Retirees are individuals wh are frmer emplyees, typically ver age 65, wh may be eligible fr retiree benefits if ffered by the emplyer. Taft-Hartley A grup in a trust established under the authrity f the Labr Management Relatins Act f 1948. It is cmprised f ne r mre unins and ne r mre emplyers wh prvide cverage fr unin members. A grup cntract is issued t the trustees named under the trust agreement, which usually results frm cllective bargaining. Hur bank grup A Taft-Hartley Welfare Fund in which eligibility under the fund is determined by a specific number f hurs wrked. If an emplyee wrks mre hurs than is needed t maintain eligibility, the emplyee can put all r a prtin f these excess hurs in the bank. If an emplyee wrks insufficient hurs t maintain eligibility, the emplyee can draw n banked hurs. Other classificatins that d nt qualify as a small emplyer include: private husehlds, emplyees prviding cntracted services (i.e., receiving 1099 frms fr incme tax purpses), leased emplyees r emplyees part f a cemplyment r PEO relatinship, dmestic help and members f rganizatins (such as credit unins r fraternal rder member rganizatins). Please see Prfessinal Emplyer Organizatin (PEO) sectin n page 12 fr eligibility infrmatin cncerning leased emplyees r emplyees that are part f a c-emplyer relatinship. Other emplyer requirements The grup agrees t infrm its emplyees f the availability f cverage. The grup must infrm its emplyees wh refuse cverage that, unless they qualify fr late r special enrllment, as described belw, they must wait until their grup s next anniversary date t btain cverage (see late enrllee and special enrllment perid ). There can be nly ne emplyer grup per grup agreement/plicy. Multiple emplyer grups that meet the definitin f a single emplyer under the Small Grup Act in Califrnia are cunted as a single grup. This means that wners f multiple crpratins may nt cmbine thse crpratins under a single Blue Shield agreement, unless they are eligible t file a cmbined tax return fr the purpses f state taxatin, meeting the definitin f ne emplyer as defined in the Small Grup Act in Califrnia. Emplyer dues/premium cntributin requirements Medical benefits: The emplyer must cntribute either (1) a defined cntributin f a minimum $100 per emplyee (r the cst f the ttal emplyee rates, whichever is less), r (2) a minimum f 50% f the ttal emplyee rates. The emplyer must agree t make the required premium payments. There is n minimum cntributin requirement fr dependents. Payrll deductin is required if cntributry. New grup eligibility/effective date The eligibility date fr existing emplyees and dependents is the grup s effective date, unless new hires have nt yet satisfied their grup s impsed waiting perid. Grup effective dates ther than the first f the mnth will be cnsidered if requested t bridge cverage frm the previus carrier; hwever, health maintenance rganizatin (HMO) plans can be effective nly n the first day f the mnth. Once rates are quted t the emplyer grup, the emplyer then has 30 days in which t accept cverage at the quted rates. Once accepted, the emplyer can pt t change Blue Shield plan cntracts t a different plan f benefits during the 6 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
first 30 days after the grup s effective date. Hwever, nce quted rates are accepted by a grup, the grup cannt cancel cverage withut being cnsidered a cancelled r terminated grup. The emplyer has the ptin, at the initial grup enrllment nly, t waive the waiting perid fr all new hires. Grups will nt be guaranteed an effective date unless cmplete and crrect grup enrllment materials are received and apprved by the underwriter. Orientatin and waiting perids An emplyer may impse a bna fide emplyment-based rientatin (affiliatin) perid fr new emplyees. The rientatin perid cannt exceed 30 days. A waiting perid may als be impsed befre cverage becmes effective. The waiting perid begins the first day after any rientatin perid and cannt exceed 90 days. A grup may impse its wn waiting perid. This waiting perid must be the same fr each emplyee classificatin. The waiting perid may be waived fr all emplyees fr the initial grup enrllment. The emplyer must ntify Blue Shield f the waiting perid it has in place, and which is cnsistent with ne f the fllwing fur ptins: Effective the first day f the mnth fllwing the date f hire Effective the first day f the mnth fllwing 30 days frm the date f hire Effective the first f the mnth fllwing 60 days frm the date f hire Effective n the 91 st day fllwing the date f hire. When the 91 st day effective date results in a partial mnth f cverage, that partial mnth f cverage will be reflected n the emplyer s next mnthly bill Additinal enrllment and plan criteria Special enrllment perid fr small grups New grup applicatins received between Nvember 15 and December 15 requesting a January 1 effective date are eligible fr cverage withut meeting the minimum participatin and cntributin requirements. The grup must meet all ther small grup eligibility requirements, and The grup must meet the minimum participatin requirements upn renewal t cntinue cverage. Plicy n HRAs fr Small Emplyers purchasing a Blue Shield health plan Small business health plans ffered by Blue Shield f Califrnia cannt be paired r integrated with an emplyer-spnsred health reimbursement arrangement (HRA). An emplyer-spnsred HRA, als knwn as a health reimbursement accunt, is a type f accunt-based grup health plan funded slely by an emplyer t reimburse an emplyee fr qualified medical care expenses incurred by the emplyee and dependents, up t a maximum dllar amunt fr a cverage perid. It must be integrated with a high-deductible health plan t cmply with market refrm. This des nt include the fllwing types f HRAs: 1. A retiree HRA (cvering nly retirees) 2. An excepted benefits HRA (an HRA that has a limited purpse and reimburses nly certain benefits recgnized as HIPAAexcepted benefits such as limited scpe visin benefits r dental benefits) This plicy replaces Blue Shield s plicy n pairing wrap plans with small business health plans effective July 1, 2015. HMO service area T ffer HMO plans, the emplyer s place f business must be lcated in that Blue Shield HMO plan s service area. HMO plans are nt designed t prvide cverage fr emplyees wh reside utside Califrnia. Emplyees must live r wrk within the HMO plan s service area. Therefre, emplyers with emplyees wh reside r wrk mre than six mnths utside Califrnia shuld cnsider a PPO plan. With an HMO plan, eligible emplyees and family members must live r wrk in an area served by the Blue Shield HMO plan t enrll and maintain enrllment, except students, lng-term travelers and 7 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
wrkers n extended ut-f-state assignments enrlled in the Away Frm Hme Care prgram. The Blue Shield HMO service area is identified in the HMO Physician and Hspital Directry. Each enrlled emplyee and dependent must have a designated primary care physician (PCP). Each member may select a different PCP, as lng as each prvider is lcated adequately clse t the member s hme r wrk address t ensure access t care, as determined by Blue Shield. HMO prvider netwrks and pairing ptins Off-Exchange Package In the Off-Exchange Package, three HMO prvider netwrks are ffered. Every HMO plan is available as an Access+ HMO plan, a Lcal Access+ HMO plan r a Tri HMO plan. In the Off-Exchange Package, Access+ HMO and Tri HMO plans may be ffered tgether. Lcal Access+ HMO plans cannt be ffered with Access+ HMO r Tri HMO plans. Mirrr Package In the Mirrr Package, every HMO plan is a Tri ACO HMO Prvider Netwrk plan. Access+ HMO Prvider Netwrk (Off- Exchange Package nly) The Access+ HMO Prvider Netwrk, available with the Access+ HMO plans, is the largest HMO prvider netwrk ffered by Blue Shield. HMO plans with the Access+ HMO Prvider Netwrk are available in the Blue Shield f Califrnia Off-Exchange Package fr Small Business. The Access+ HMO plans are: Platinum Access+ HMO 0/20 OffEx Platinum Access+ HMO 0/25 OffEx Platinum Access+ HMO 0/30 OffEx Gld Access+ HMO 500/35 OffEx Gld Access+ HMO 1700/35 OffEx Silver Access+ HMO 1750/55 OffEx When selecting the Off-Exchange Package, a grup may ffer multiple Access+ HMO and Tri HMO plans tgether, but Access+ HMO plans may nt be ffered alngside Lcal Access+ HMO plans. Lcal Access+ HMO Prvider Netwrk (Off-Exchange Package nly) The Lcal Access+ HMO Prvider Netwrk is a smaller subset f the Access+ HMO Prvider Netwrk, featuring a netwrk f physicians available in prtins f Cntra Csta, Kern, Ls Angeles, Riverside, Sacrament, San Bernardin, San Dieg, San Mate and Ventura cunties, as well as in all f Marin, Orange, San Francisc, San Luis Obisp, Santa Clara, Santa Cruz, Snma, Stanislaus and Yl cunties. A grup must be lcated in the Lcal Access+ HMO plan service area t select an HMO plan with the Lcal Access+ HMO Prvider Netwrk. HMO plans with the Lcal Access+ HMO Prvider Netwrk are available in the Blue Shield f Califrnia Off-Exchange Package fr Small Business. The Lcal Access+ HMO plans are: Platinum Lcal Access+ HMO 0/20 OffEx Platinum Lcal Access+ HMO 0/25 OffEx Platinum Lcal Access+ HMO 0/30 OffEx Gld Lcal Access+ HMO 500/35 OffEx Gld Lcal Access+ HMO 1700/35 OffEx Silver Lcal Access+ HMO 1750/55 OffEx When selecting the Off-Exchange Package, a grup may ffer multiple Lcal Access+ HMO plans, but cannt ffer them alngside Access+ HMO plans r Tri HMO plans. Tri ACO HMO Prvider Netwrk (Off- Exchange and Mirrr Packages) The Tri ACO HMO Prvider Netwrk is a cllabratin amng physicians, hspitals and Blue Shield t help imprve the patient experience and lwer cst. ACO stands fr accuntable care rganizatin. The Tri HMO plans are available in prtins f El Drad, Kern, Ls Angeles, Marin, Nevada, Placer, Riverside, Sacrament, San Bernardin, San Dieg, San Luis Obisp, Slan, Stanislaus, Tulare, Ventura and Yl cunties, as well as all f Alameda, Cntra Csta, Orange, San Francisc, San Jaquin, San Mate, Santa Clara and Santa Cruz cunties. The Tri ACO Prvider Netwrk is the smallest HMO prvider netwrk available. 8 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
A grup must be lcated in the Tri HMO plan service area t select a Tri HMO plan. HMO plans with the Tri ACO HMO Prvider Netwrk are available in the Blue Shield f Califrnia Off-Exchange Package fr Small Business and the Blue Shield f Califrnia Mirrr Package. The Tri HMO plans are: Platinum Tri HMO 0/20 OffEx Platinum Tri HMO 0/25 OffEx Platinum Tri HMO 0/30 OffEx Gld Tri HMO 500/35 OffEx Gld Tri HMO 1700/35 OffEx Silver Tri HMO 1750/55 OffEx Blue Shield Platinum 90 HMO 0/15 Tri + Child Dental Blue Shield Gld 80 HMO 0/25 Tri + Child Dental Blue Shield Silver 70 HMO 2000/45 Tri + Child Dental When selecting the Off-Exchange Package, a grup may ffer multiple Tri HMO plans and Access+ HMO plans tgether but Tri HMO plans may nt be ffered alngside Lcal Access+ HMO plans. In the Mirrr Package, Tri HMO plans are the nly HMO plans ffered. PPO prvider netwrks and pairing ptins Off-Exchange Package In the Off-Exchange Package, tw PPO prvider netwrks are ffered: the Full PPO Prvider Netwrk and the Tandem PPO Prvider Netwrk. Full PPO and Tandem PPO plans may be ffered tgether. Full PPO and Tandem PPO plans may be ffered with HMO prvider netwrk plans; hwever, Lcal Access+ HMO plans cannt be ffered with Access+ HMO r Tri HMO plans. Mirrr Package In the Mirrr Package, all PPO plans are Full PPO Prvider Netwrk plans. Tandem PPO Prvider Netwrk (Off- Exchange Package nly) Blue Shield s Tandem PPO plans feature a select statewide netwrk f prviders frm ur Full PPO netwrk and ffer the same benefits as the Full PPO plan at a lwer cst. Like ther PPO plans, Tandem ffers members the flexibility t see any dctr r specialist in the Tandem netwrk withut a referral. The Tandem PPO plan als features care crdinatin thrugh a primary care physician. A list f prviders in the Tandem PPO Prvider Netwrk is available n the Blue Shield f Califrnia member website. PPO plans with the Tandem PPO Prvider Netwrk are available in the Blue Shield f Califrnia Off-Exchange Package fr Small Business. The Tandem PPO plans are: Platinum Tandem PPO 0/10 OffEx Platinum Tandem PPO 250/15 OffEx Gld Tandem PPO 750/30 OffEx Silver Tandem PPO 1700/55 OffEx Silver Tandem PPO 2000/45 OffEx Brnze Tandem PPO 3750/65 OffEx Additinal benefits available An ptinal infertility benefit rider is available fr PPO and HMO plans in the Blue Shield f Califrnia Off-Exchange Package fr Small Business and the Blue Shield f Califrnia Mirrr Package fr Small Business. When a grup selects the ptinal infertility rider, it will be included in all PPO and HMO plans ffered by the grup. A dental cntract/plicy is available with r withut a health plan. A Blue Shield f Califrnia Life & Health Insurance Cmpany visin plicy is available with r withut a health plan. A Blue Shield f Califrnia Life & Health Insurance Cmpany Basic Life and AD&D insurance plicy is available with r withut a health plan. Blue Shield f Califrnia Off-Exchange Package fr Small Business The Blue Shield f Califrnia Off-Exchange Package fr Small Business is available fr grups with ne r mre enrlling emplyees. Grups may select ne r mre plans frm the package that includes: Platinum Access+ HMO 0/20 OffEx Platinum Lcal Access+ HMO 0/20 OffEx Platinum Tri HMO 0/20 OffEx Platinum Access+ HMO 0/25 OffEx Platinum Lcal Access+ HMO 0/25 OffEx Platinum Tri HMO 0/25 OffEx Platinum Access+ HMO 0/30 OffEx Platinum Lcal Access+ HMO 0/30 OffEx Platinum Tri HMO 0/30 OffEx Platinum Full PPO 0/10 OffEx Platinum Tandem PPO 0/10 OffEx 9 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
Platinum Full PPO 250/15 OffEx Platinum Tandem PPO 250/15 OffEx Gld Access+ HMO 500/35 OffEx Gld Lcal Access+ HMO 500/35 OffEx Gld Tri HMO 500/35 OffEx Gld Access+ HMO 1700/35 OffEx Gld Lcal Access+ HMO 1700/35 OffEx Gld Tri HMO 1700/35 OffEx Gld Full PPO 0/20 OffEx Gld Full PPO 450/30 OffEx Gld Full PPO 750/30 OffEx Gld Tandem PPO 750/30 OffEx Gld Full PPO 1200/35 OffEx Silver Full PPO 1700/55 OffEx Silver Tandem PPO 1700/55 OffEx Silver Access+ HMO 1750/55 OffEx Silver Lcal Access+ HMO 1750/55 OffEx Silver Tri HMO 1750/55 OffEx Silver Full PPO 2000/45 OffEx Silver Tandem PPO 2000/45 OffEx Silver Full PPO Savings 2000/20% OffEx Brnze Full PPO 3750/65 OffEx Brnze Tandem PPO 3750/65 OffEx Brnze Full PPO 5700/60 OffEx Brnze Full PPO Savings 4300/40% OffEx Brnze Full PPO Savings 6550 OffEx Accunt-based health plans An accunt-based health plan (ABHP) pairs a grup health insurance plan with a taxadvantaged medical spending accunt. Blue Shield f Califrnia ffers three HSAcmpatible high deductible health plans (HDHP) that may be bundled with a health savings accunt (HSA) frm HealthEquity, a health accunt administratr. When a grup ffers HealthEquity as the HSA administratr by indicating this selectin n the Master Grup Applicatin, Blue Shield f Califrnia shares eligibility and claims data with HealthEquity fr a seamless experience. HSA-cmpatible high deductible health plans that may be bundled with an HSA frm HealthEquity are: Silver Full PPO Savings 2000/20% OffEx Brnze Full PPO Savings 4300/40% OffEx Brnze Full PPO Savings 6550 OffEx A grup may ffer ne r mre f the Full PPO Savings plans but cannt ffer a mix f a standalne Full PPO Savings plans and Full PPO Savings plans bundled with a HealthEquity HSA. When a grup selects the bundled ptin, emplyees cannt enrll in a standalne Full PPO Savings plan. The grup must maintain the required minimum participatin requirements set frth belw t remain eligible (r 100% participatin, if nn-cntributry). Grups are subject t nn-renewal if participatin falls belw the required minimum. Under the Off-Exchange Package fr Small Business, when Blue Shield is the nly carrier ffered, a minimum f ne eligible emplyee and at least 65% f all eligible emplyees must enrll in the Blue Shield plan(s). If Blue Shield is ffered alngside anther carrier s HMO, r MediExcel and anther carrier s HMO, a minimum participatin f 65% between all carriers is required and, in the cmbinatin f Blue Shield plans, the participatin must be equal t the greater f five enrlled emplyees r 50% f the ttal number f enrlled emplyees. 100% cntributin/participatin requirements: If the grup cntributes 100% f dues/premium, then 100% f eligible emplyees must enrll (except thse waiving due t grup cverage thrugh anther emplyer). Declining r waiving cverage: A Refusal f Cverage frm (C19927) is required if refusing cverage with Blue Shield due t cverage with anther carrier thrugh a different emplyer. Refusals f cverage in this instance are nt cunted twards the participatin requirement. A Refusal f Cverage frm (C19927) is required if refusing cverage with Blue Shield due t cverage with anther carrier thrugh the same emplyer. Refusals f cverage in this instance are cunted twards the participatin requirement. Off-Exchange Package fr Small Business participatin requirements 10 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
If an eligible emplyee and spuse r dmestic partner bth wrk fr the same emplyer, they may enrll separately as emplyees, r ne may enrll as a dependent n the ther s cverage. Any child(ren) f such persns may be enrlled as the dependent(s) f either emplyee, but nt bth. Off-Exchange Package fr Small Business ntes: Emplyers whse place f business is lcated utside f ne f Blue Shield f Califrnia s HMO service areas will nt have the ptin f ffering an HMO plan within the Off-Exchange Package fr Small Business. If a grup selects the Blue Shield f Califrnia Off-Exchange Package fr Small Business, it may make ne r mre plan ptins available t eligible emplyees by indicating its selected plans n the Master Grup Applicatin. There is n requirement fr an emplyee t be enrlled in each f the plans selected and made available as ptins fr emplyees. Califrnia emplyers in certain cunties and cities whse eligible emplyees live and/r wrk in the Lcal Access+ HMO plan service area r the Tri HMO plan service area have the ptin f selecting an Off-Exchange Package fr Small Business t ffer multiple HMO plan ptins t emplyees. A grup can ffer multiple Access+ HMO and Tri HMO plans tgether. A grup may ffer multiple Lcal Access+ HMO plans, but cannt ffer them alngside Access+ HMO plans r Tri HMO plans. An enrlling emplyee, and any dependents, must live r wrk in the service area f the HMO plan they are enrlling in. A plan in the Off-Exchange Package fr Small Business may be ffered as a single ptin plan. Blue Shield f Califrnia Mirrr Package fr Small Business Grups with ne r mre enrllees may select any number f plans in the Blue Shield f Califrnia Mirrr Package fr Small Business. The package includes: Blue Shield Platinum 90 PPO 0/15 + Child Dental Blue Shield Gld 80 PPO 0/25 + Child Dental Blue Shield Silver 70 PPO 2000/45 + Child Dental Blue Shield Brnze 60 PPO 6300/75 + Child Dental Blue Shield Platinum 90 HMO 0/15 Tri + Child Dental Blue Shield Gld 80 HMO 0/25 Tri + Child Dental Blue Shield Silver 70 HMO 2000/45 Tri + Child Dental Mirrr Package fr Small Business participatin requirements The grup must maintain the required minimum participatin requirements set frth belw t remain eligible (r 100% participatin, if nn-cntributry). Grups are subject t nn-renewal if participatin falls belw the required minimum. Under the mirrr package, a minimum f ne eligible emplyee and at least 70% f all eligible emplyees must enrll in the Blue Shield plan(s). 100% cntributin/participatin requirements: If the grup cntributes 100% f dues/premium, then 100% f eligible emplyees must enrll (except thse waiving due t grup cverage thrugh anther emplyer). Declining r waiving cverage: A Refusal f Cverage frm (C19927) is required if refusing cverage with Blue Shield due t cverage with anther carrier thrugh a different emplyer. Refusals f cverage in this instance are nt cunted twards the participatin requirement. If an eligible emplyee and spuse r dmestic partner bth wrk fr the same emplyer, they may enrll separately as emplyees, r ne may enrll as a dependent n the ther s cverage. Any child(ren) f such persns may be enrlled as the dependent(s) f either emplyee, but nt bth. Mirrr Package fr Small Business ntes: The emplyer s place f business must be lcated in the Tri HMO plan service area in rder t ffer Tri HMO plans frm the Mirrr Package fr Small Business. 11 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
An enrlling emplyee, and any dependents, must live r wrk in the service area f the HMO plan they are enrlling in. The Mirrr Package fr Small Business cannt be ffered alngside anther carrier. Plans in the Mirrr Package fr Small Business cannt be ffered with plans frm any ther package. A plan in the Mirrr Package fr Small Business may be ffered as a single ptin plan. Sectin II: Health Plan Other Requirements Emplyers f unin and nnunin emplyees Fr small emplyer grups with unin and nnunin emplyees, when the unin members receive health cverage thrugh a trust fund established by a cllective bargaining agreement, Blue Shield will cver nly the nnunin emplyees. When the ttal number f bth unin and nnunin emplyees des nt exceed 100, the emplyer can apply fr small grup cverage t cver nly the nnunin emplyees. Only the eligible nnunin emplyees will be cunted fr purpses f minimum enrllment and participatin requirements. T qualify fr this cverage, the emplyer must prvide Blue Shield with: A cpy f the cllective bargaining agreement shwing that the emplyer pays cntributins t the trust fund. The Statement f ERISA Rights frm the unin trust fund Summary Plan Descriptin. Prfessinal Emplyer Organizatin ( leased ) emplyees Prfessinal Emplyer Organizatin (PEO r leased ) emplyees are cnsidered emplyees f the PEO cmpany. Small emplyer grups that have canceled their PEO arrangement and hired the frmer PEO emplyees will be cnsidered fr cverage as a qualified small emplyer pursuant t small grup rules. Qualified small emplyer cverage - Fr small emplyer grups that have recently canceled their cntract with a PEO: A cpy f the letter sent frm the PEO t the client business verifying the cancellatin f the leasing arrangement will be required. If a cpy f a payrll register frm the PEO cmpany is submitted with the new grup applicatin that separates the frmerly leased emplyees by business lcatin, the grup will be cnsidered a qualified grup. Cmbining multiple emplyer grups If an wner believes that the structure f his/her hldings prduces a single emplyer/emplyee relatinship, Blue Shield will require cpies f all assciated Articles f Incrpratin, Partnership Agreements and a letter frm the emplyer s CPA stating that all business entities are eligible t file a cmbined state tax return. Blue Shield s determinatin f whether r nt there is ne respnsible emplyer will be final. Spin-ff grups A spin-ff grup is a newly frmed business that is nt yet eligible fr qualified small grup cverage, and in which a majrity f the emplyees f the new business have left an established business ( frmer business ) currently ffering Blue Shield cverage t its emplyees. Spin-ff grups will be issued cverage thrugh underwriting. The requirements fr issuance f cverage are: At least 50% f the emplyees in the spinff grup must have been enrlled in Blue Shield thrugh the frmer business. The new grup des nt have shared wnership with the business it has separated frm. All enrllment dcuments are required (master applicatin, subscriber applicatins, refusals, business check, etc.) Ownership paperwrk and eligibility verificatin fr the wner is required. A cpy f the mst recent payrll register is required. If n payrll register is available, a W-4 frm fr all emplyees will be initially required, with subsequent submissin f the first cmplete payrll register within 30 days f the grup s effective date. 12 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
Sectin III: Wh can Enrll? Emplyee eligibility fr cverage ( eligible emplyee ) The fllwing criteria determine if an individual is an eligible emplyee and is eligible fr enrllment in the grup health plan: He/she wrks n a full-time basis in the cnduct f the business f the emplyer, whse nrmal wrk week is an average f 30 hurs, and whse duties in such emplyment are perfrmed at the emplyer s regular places f business (subject t withhlding n a W-2 frm), r He/she is a sle prprietr, crprate fficer r partner f a partnership engaged n a full-time basis, an average f 30 hurs per week, in the emplyer s regular places f business. He/she wrks at least 20 hurs, but n mre than 29 hurs, per week, in the emplyer s business n a permanent, year-rund basis and meets the individual emplyee criteria, as defined within the Califrnia Small Grup Act fr an eligible part-time emplyee. He/she receives mnetary cmpensatin (W2 emplyee) fr that wrk by the emplyer. He/she is a bna fide emplyee f the emplyer (a bna fide emplyee/emplyer relatinship must exist). He/she has met any applicable emplyerimpsed eligibility waiting perid. The fllwing individuals are nt cnsidered eligible emplyees and are nt eligible fr cverage: Residents f Hawaii Retirees Part-time (unless ffered by the emplyer and meet the requirements f an eligible part-time emplyee), temprary, substitute, r seasnal emplyees (seasnal r substitute emplyees are defined as emplyees hired with a planned future terminatin date) 1099 independent cntractrs Dmestic help Emplyees participating in a multiple emplyer grup Leased emplyees r emplyees part f a c-emplyment r PEO relatinship (see PEO sectin fr leased emplyees r emplyees that are part f a c-emplyer relatinship) Emplyees living utside f the United States Part-time emplyee eligibility fr cverage All guidelines that apply t full-time emplyees als apply t part-time emplyees (PTEs) with these additinal guidelines: The PTE must wrk a minimum f 20 hurs per week t be eligible. The emplyee must have wrked at least 20 hurs, but nt mre than 29 hurs, per nrmal wrk week, fr at least 50% f the wrking days in the previus calendar quarter. It is the emplyer s ptin t ffer health cverage t PTEs. If that ptin is exercised, all similarly situated individuals must be ffered cverage under the emplyer s benefit plan. The emplyer cntributin, waiting perid and benefit chice (which may include dental and/r visin plans) must match the cverage given t full-time emplyees. Participatin requirements are based n the ttal number f PTEs and full-time emplyees. T add PTE eligibility t an existing accunt, we require a cver letter, a new emplyer applicatin, a DE9C and applicatins/declinatins n all eligible PTEs. Existing grups may add this ptin nly n their renewal date. Blue Shield may require infrmatin necessary t dcument the hurs and time perids f PTEs, including, but nt limited t, payrll recrds and emplyee wage and tax filings. NOTE: If the abve criteria are met fr health cverage, then life insurance cverage can be written fr eligible PTEs. Dependent eligibility fr cverage Dependent cverage is available t the fllwing individuals: An emplyee s legally married spuse wh is nt cvered fr benefits as an emplyee and is nt legally separated frm the emplyee An emplyee s dmestic partner wh is nt cvered fr benefits as an emplyee An emplyee s, spuse s r dmestic partner s child (including any stepchild r child placed fr adptin r any ther child fr whm the emplyee r dmestic partner has been appinted as a nntemprary legal guardian by a curt f apprpriate legal jurisdictin) wh is nt 13 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
cvered fr benefits as a subscriber and wh is less than 26 years f age Enrllment requests fr an adpted child r a child placed fr adptin must be accmpanied by cnfirming fficial adptin dcuments, such as curt dcuments, r evidence f the subscriber s r spuse s right t cntrl the health care f the child placed fr adptin. An emplyee s, spuse s r dmestic partner s newbrn child, if added t an existing plicy within 60 days fllwing the date f birth Over-age disabled dependents Enrlled dependent children wh wuld nrmally lse their eligibility under the Blue Shield f Califrnia small business plan slely because f age, but wh are disabled by reasn f a physically r mentally disabling injury, illness r cnditin may have their eligibility extended by written applicatin within 31 days f the date the dependent child reaches the age eligibility wuld therwise cease. T qualify fr this extensin, the disabled dependent child must be incapable f self-sustaining emplyment and be chiefly dependent upn the subscriber fr supprt and maintenance. A cmpleted medical certificatin f disability, the Declaratin f Disability fr Over Age Dependent Child, must be submitted. A recertificatin f disability may be required within tw years after the initial medical certificatin and annually thereafter, except in cases f lng-term disability. If the parent r guardian and dependent have nt been cvered by a Blue Shield f Califrnia health plan prir t the age that dependent eligibility ceases, evidence/prf f prir dependent cverage will be required in additin t the medical certificatin f disability and applicatin. Dmestic partners Dmestic partner eligibility is a mandated benefit fr all Blue Shield grup health plans. T qualify as a dependent, a dmestic partner must have filed a Declaratin f Dmestic Partnership with the state. Blue Shield s standard r prtfli small grup plans include dmestic partner cverage nly fr thse dmestic partners registered with the state. Sme f Blue Shield s internal dcuments refer t this cverage as narrw cverage, because state registratin is limited t same-sex dmestic partners and nly thse ppsite-sex cuples where ne partner is at least age 62 and eligible fr Scial Security. Hwever, Blue Shield will ffer small grups the ptin t select brad cverage. The brad cverage defines dmestic partners as either the same r ppsite sex (ver the age f 18). If a grup selects this cverage, Blue Shield will issue an Evidence f Cverage/Certificate f Insurance supplement t amend prtfli cverage. Dmestic partner dcumentatin requirements t enrll a dmestic partner Althugh narrw cverage requires the dmestic partner cuple t be registered, Blue Shield will nt require a cpy f the Califrnia State Declaratin f Dmestic Partnership registratin r a cpy f any ther municipality r cunty registratin frm r affidavit fr enrllment purpses. Enrllment frms and prcedures fr dmestic partners during initial and pen enrllment perids, and during the year when a partnership is established, are exactly the same as thse used by spuses. Emplyers have the ptin t request these dcuments, but they d nt need t be submitted t Blue Shield. Spuses r dmestic partners wrking fr the same emplyer If spuses r dmestic partners bth wrk fr the same emplyer, they may enrll separately as emplyees r ne may enrll as a dependent n the ther s cverage. Any children f such persns may be enrlled as the dependents f either emplyee, but nt bth. Sectin IV: Health Plan Rating Criteria Quting a grup Field rating A field-rating tl is available t prducers, t allw quick and easy nline rating fr small emplyer grups. The rating tl is available at blueshieldca.cm/prducer. Grup mnthly premiums are calculated based n the subscribers ages and the emplyer s principal business address as f the first day f the mnth. Cmpsite rating is nt available. Befre submitting an applicatin fr a grup, please review the requirements 14 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
under Submitting an applicatin and Certifying yur cmpliance n page 32. Rating plicies All rates will be based upn actual enrllment. Final rates, effective date and acceptability f the grup will be determined by the small grup underwriter. Apprved ut-f-state emplyees will be charged an area rate based n the lcatin f the emplyer s principal business address in Califrnia. Medicare primary and secndary rules Fr emplyers wh are subject t federal Medicare secndary payer laws, Medicare entitlement is currently based n three basic situatins and depends n grup size. The three situatins are: 1. Medicare entitlement based n age (65 r lder) Fr grups with an average f 20 r mre fulland/r part-time ttal emplyees fr each wrking day in each f 20 r mre calendar weeks in the current r preceding calendar year, Blue Shield cmmercial cverage will be the primary payer t Medicare fr active emplyees ages 65 r lder and the spuses (ages 65 r lder) f active emplyees. 2. Medicare entitlement based n disability Fr grups (nt part f a multi-emplyer plan) with an average f fewer than 100 emplyees in the prir calendar year, Medicare is the primary payer t the emplyer grup s cmmercial plan fr active emplyees and dependents f active emplyees wh are entitled t Medicare based n disability. Fr grups that emply 100 r mre full, part-time, r temprary emplyees 50% r mre business days f the previus calendar year, Blue Shield cmmercial cverage is the primary payer. 3. Medicare entitlement based slely n end-stage renal disease (ESRD) Regardless f grup size r current wrking requirement, if a grup ffers emplyees, r frmer emplyees under age 65, an emplyee grup plan, Blue Shield cmmercial cverage will be the primary payer t Medicare during the 36-mnth crdinatin perid that begins with the mnth f Medicare entitlement. The crdinatin perid is 30 mnths with a threemnth waiting perid (fr a pssible ttal crdinatin perid f 36 mnths). The threemnth waiting perid is waived if the member has a transplant r hme dialysis. Then the crdinatin perid is nly 30 mnths. Mre cmplex situatins (such as Medicare dual entitlement) d arise. If yu have any questins cncerning Medicare entitlement fr grups ffering Blue Shield cmmercial plans, please cntact Blue Shield fr further guidance. Blue Shield Medicare Supplement plans Blue Shield als prvides a variety f standardized Medicare Supplement plans n an individual basis. Medicare-eligible emplyees have the freedm t chse any Medicare-participating dctr r hspital, althugh benefits and dues vary. Fr mre infrmatin n Blue Shield Medicare Supplement plans, please cntact yur Blue Shield representative r call (800) 963-8008. Rate changes The grup s rate will nt change mre ften than every 12 mnths. Sectin V: New Business Submissin Requirements Guidelines fr cmpleting frms T ensure fast and accurate applicatin prcessing, fllw these enrllment applicatin guidelines: All questins must be answered and all signatures and dates btained befre we can begin prcessing the grup applicatins. If the apprpriate applicatins and related dcuments are incmplete and the underwriter cannt begin prcessing, Blue Shield retains the ptin f returning all paperwrk the applicatins and the supprting dcuments t the prducer. Fr new grup submissins, the emplyee s signature cannt be dated mre than 90 days prir t the requested effective date. All answers n the enrllment applicatins must be in the emplyee s wn handwriting. On the riginal emplyee applicatin, n alteratins r changes may be made by anyne ther than the emplyee. Language assistance: Whenever an individual cmpleting the applicatin has a language barrier and requires assistance t prperly cmplete the frm, a signed Blue Shield Exceptin t Standard Enrllment Frm frm the grup r the prducer explaining the situatin must accmpany the submitted applicatin. Prcessing time specificatins 15 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
Because prcessing applicatins within specific time frames is imprtant, all frms and ther dcuments fr evaluatin shuld be accurately cmpleted and included with the applicatin when the case is first submitted t Blue Shield. The underwriting department can usually make a timely decisin if all prper dcumentatin is received with the initial submissin. Please refer t the Grup enrllment checklist n page 17 fr a list f required dcumentatin. Any missing dcumentatin and/r dues will cause a delay in the underwriting prcess. Underwriting will request additinal infrmatin nly when it is needed t accurately assess r verify the eligibility f the grup and/r emplyee(s). Blue Shield must receive all cmpleted paperwrk by the fifth wrking day f the mnth when the requested effective date is fr the first day f that mnth. Any additinal required infrmatin must be submitted t Blue Shield within 48 hurs f the request t cmplete the prcessing within that mnth. Start-up grups A start-up grup must meet all small grup requirements except fr the length f time that the grup has had at least ne eligible cmmn-law emplyee. Blue Shield will cnsider start-up grups that have been in business and have emplyed at least ne cmmn-law emplyee fr a minimum f at least fur weeks. Evidence f time in business and eligibility must be supprted by payrll recrds. The payrll recrds must cver the fur weeks preceding the requested effective date fr at least ne eligible emplyee. Acceptable payrll must include: Cmpany name Dates f pay perids All pages submitted Emplyee names, wages paid, withhldings and grand ttals The payrll submitted must be cpies f each payrll register fr each pay perid cvered Individual payrll/pay stubs, estimated payrll, payrll summaries r handwritten jurnals are nt acceptable. Exceptin fr small emplyer start-ups when five r mre emplyees are enrlling Blue Shield will cnsider start-up grups that have had at least ne eligible cmmn-law emplyee fr less than fur weeks if at least five emplyees are enrlling and the business has emplyed an eligible cmmn-law emplyee fr at least ne pay perid. Evidence f time in business and eligibility must be supprted by payrll recrds. The payrll recrds fr the mst recent pay perid fr the eligible emplyees are required. If less than five emplyees are enrlling, the start-up grup must have emplyed an eligible cmmn-law emplyee fr a minimum f at least fur weeks, and payrll recrds must cver the fur weeks preceding the requested effective date fr at least ne eligible emplyee as nted in Start-up grups in Sectin V. Evaluatin criteria Underwriting is based n the fllwing criteria: Cntributin Emplyee and dependent eligibility Participatin Please nte that any emplyee/dependent accepted fr a Blue Shield small grup health plan cannt cncurrently be cvered under a Blue Shield individual cntract. The applicant must elect, in writing, ne r the ther cverage t avid duplicate Blue Shield cverage. Blue Shield may decline grups if: N bna fide emplyer/emplyee relatinship exists (i.e., independent cntractrs, leased emplyees, dmestic help) Grup has mre than 49% f emplyees lcated utside Califrnia Emplyer is nt authrized t cnduct business in Califrnia Grup emplyed less than ne cmmnlaw emplyee (W2) r mre than 100 emplyees n 50% f the wrkdays in the previus calendar quarter r the previus calendar year Grup is a carve-ut (see Sectin II, Health Plan Other Requirements ) Grup is therwise nt subject t the Small Grup Act in Califrnia and the Affrdable Care Act guidelines Waivers/declinatins If an emplyee is waiving cverage due t grup cverage (either as a subscriber r a dependent), the emplyee may be cnsidered ineligible fr the purpses f calculating participatin. The emplyer grup must submit a declinatin frm fr these emplyees. 16 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers
Any eligible emplyee and/r dependent waiving cverage fr any reasn at the time f enrllment, r canceling cverage fr themselves r dependents fr any reasn, must cmplete the Refusal f Persnal Cverage sectin n the back page f the Emplyee Enrllment Frm, and the emplyer must frward this infrmatin t Blue Shield. Fr emplyers ffering mre than ne carrier, waivers are required fr emplyees that are enrlling in anther carrier s plan. Grup enrllment checklist The fllwing dcumentatin is required when submitting new business: Master Grup Applicatin Applicatins frm all enrlling emplyees and dependents Refusal f Persnal Cverage frms fr all eligible emplyees and any eligible dependents wh refuse r waive cverage at the time f pen enrllment First mnth s payment n cmpany check stck r the cmpleted check by fax frm Additinal dcumentatin may be required under certain circumstances: Fr eligibility verificatin, the fllwing wage infrmatin is required fr each enrlling emplyee: Cpy f the grup s mst recent DE9C Quarterly State Tax Withhlding Statement cntaining current emplyment status f all emplyees Payrll recrds fr emplyees hired after the DE9C filing Prf f wner s/emplyer s eligibility if the wner/emplyer is nt listed n the DE9C The Blue Shield f Califrnia Sle Prprietr, Partner r Crprate Officer Statement (wner affidavit) fr grups enrlling 25 r mre emplyees If applying fr small grup replacement cverage, a cpy f the last mnth s grup premium statement If applying fr cntinuus replacement cverage, dcumentatin f the previus cverage with the last premium statement. COBRA/FMLA/Cal-COBRA Electin Frm, if applicable A business check r cmpleted check by fax frm fr the first mnth s dues as a depsit, payable t Blue Shield f Califrnia r Blue Shield Life, as applicable (Blue Shield will refund the full depsit t the grup if the grup applicatin is declined) Owner eligibility requirements: Sle prprietrship: 1040 Schedule C fr the preceding calendar year and a cmpleted Blue Shield f Califrnia Sle Prprietr, Partner r Crprate Officer Statement Partnership: K-1 fr the preceding year fr each partner and a cmpleted Blue Shield f Califrnia Sle Prprietr, Partner r Crprate Officer Statement Crpratin: Articles f Incrpratin (state seal affixed) t include the field list f fficers K-1 and a cmpleted Blue Shield f Califrnia Sle Prprietr, Partner r Crprate Officer Statement Signed enrllment frm r refusal fr each fficer eligible fr cverage 17 Blue Shield f Califrnia Small Grup Underwriting Guidelines fr Prducers