PARTICIPATION AND ALONGSIDE GUIDELINES

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*100% employee participation required with 100% employer contribution

Always refer to carrier underwriting guidelines for all pertinent details.

Carrier

Standalone

Alongside Another Carrier

*Relaxed Participation Promotion through 12/31/20

  • 1-4 enrolling: 65% participation
  • 5+ enrolling: 25% participation

Groups offering another carrier’s HMO must have a minimum of 5 employees and 25% participation in an Aetna plan.

Relaxed Participation Promotion through 12/31/20

Aetna will allow one other Carrier HMO and/or PPO alongside (excludes EPO plans). Participation with another carrier is not considered a valid waiver.

*Relaxed Participation Promotion through 12/15/20 

1-4 enrolling: 65% participation
5+ enrolling: 25% participation

Same participation rules for Dental and Vision with a minimum of 2 enrollees.

An owner of multiple entities will not be considered a valid waiver if the owner is declining due to coverage under another entity in which he/she holds ownership. Dual coverage by the same employer would not be considered a valid waiver.
Another carrier’s HMO or PPO plans can be sold alongside Anthem so long as Anthem receives the required participation. 

Promotion Through 12/15/20

Groups have two dual HMO Network options and can select Full HMO and Select HMO networks alongside each other. Groups may also select Select HMO and Priority Select networks together.

*Mirror plans: 70% participation

Off-exchange plan promotion through 12/31/20:

1-4 enrolling: 65% participation
5+ enrolling: 25% participation

Includes Medical, Dental, Vision, and Life.

Promotion also waives participation requirements for Trio-only groups (minimum 1 enrolling).

Cannot offer Mirror plans alongside other carriers.

Can write only 1 HMO carrier alongside Off-exchange plans, except for either MediExcel or SIMNSA as a third carrier (not both). Minimum 65% participation between all carriers required. In the combination of Blue Shield plans, the participation must be equal to the greater of five enrolled employees or 50% of the total number of enrolled employees.

Cannot write EPO benefit-designed plans alongside Blue Shield. Blue Shield must also be sole carrier when offering Dental, Vision, and Life products.

*1-2 enrolling: 100% participation

3+ enrolling: 70% participation. 70% participation requirement must be exactly 70% or more (not rounded up or down)..

When employer contribution is less than 100%, employees waiving for other groups are not counted.

Cannot write alongside other carriers.

*If the employer contribution is less than 100%, 75% participation is required.

May offer CalCPA Health plans alongside Kaiser. Firms may enroll in CalCPA with one eligible employee if all other employees enroll with Kaiser or have another valid waiver.

If the employer contribution is less than 100%, 75% participation is required

May sell another carrier alongside CoveredCalifornia so long as 70% of eligible employees enroll with CoveredCalifornia.

Promotion through 12/31/20

Enhanced Choice A:
1-5 enrolling: 66% participation
6+ enrolling: 50% participation 

Enhanced Choice B:
1-5 enrolling: 66% participation
6+ enrolling: 35% participation

Salud:
2+ enrolling: No minimum participation. No waivers need to be submitted for Salud.

HMO:
6+ enrolling: No minimum participation

May sell HMO with 6+ lives with no DE9C, attestation, prior carrier bill, nor waivers required. Small business groups can mix and match any plans that come with the Salud HMO y Más Network.

May sell another carrier alongside Health Net so long as Health Net participation requirements are met.

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At least 1 eligible employee must enroll.

1-100 enrolling: 50% participation

With PPO offering, Kaiser must be the sole carrier for medical coverage. May write alongside another carrier so long as Kaiser’s participation requirement is met.

GM plan: 1 eligible employee

PM, P5, and P20 plans: 3 eligible employees

May sell alongside any CA HMO, PPO, and/or cross-border carrier so long as MediExcel’s participation requirement is met.

*Promotion through 12/15/20

Relaxed Participation Rules

As long as the number of employees in all locations is under 100, only the employees within Oscar’s service area (Los Angeles and Orange Counties: rating regions 15, 16, 18) will be counted towards participation.

Relaxed Split Carrier Participation Rules

If 60% of the eligible employees enroll in a plan offered by the employer, Oscar will only require three eligible employees to enroll with Oscar. If the employer pays less than 100% of contribution, 60% participation required after subtracting valid waivers.

Promotion through 12/15/20

IFP coverage is a valid waiver. An individual does not need to be receiving a subsidy (APTC) to be considered a valid waiver.

Oscar can be written alongside any other carrier, and any plan type including HMOs, PPOs and EPOs so long as a minimum of 3 employees enroll with Oscar.

Groups with CaliforniaChoice and Covered California for Small Business are not eligible for this promotion.

1-100 eligible HMO: 60% participation
10+ enrolling HMO/PPO: 60% participation with no more than 15% enrollment on PPO.

Multiple carriers may be offered alongside with SIMNSA as the only option across the border.

At least 5 employees enrolling

Multiple carriers may be offered alongside with SIMNSA as the only option across the border.

*At least 60% participation required.

May write alongside 2 other carriers which must be staff-model carriers. This includes Chinese Community Health Plan, Kaiser, MediExcel, Sharp, SIMSA, Sutter and Western Health Advantage. May not write alongside California Choice or Covered California.

UHC Choice Simplified Package with a staff model: 60% participation between carriers with 5 CA employees enrolling with UHC.

UHC Multi-Choice® State Package with a staff model: 60% participation with UHC