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

Participation for medical contributory plans

Promotions through March 31, 2022

1-4 enrolled: 60% participation

5-100 enrolled: 25% participation

Participation Promotion (Q3 ’21 through Q1 ’22 promotion)

Aetna relaxed its participation guidelines through March 2022.

  • Small groups enrolling 5-100 employees can now meet 25% participation.
  • Standard 60% participation applies to groups enrolling less than 5.

Note: Information is subject to change and carriers can request additional documents as needed.

Alongside other carriers

1-4 enrolling: 60% participation for 4 or less CA enrolled employees

5+ enrolling: 25% participation and a minimum of 5 or more CA employees enrolling in Aetna plan

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

Employees covered by the same employer on another group policy are not considered a valid waiver.

Participation for medical contributory plans

1-14 enrolling: 70% participation

15+ enrolling: 50% participation

Anthem may conduct periodic audits to confirm participation levels.

Participation Promotion Through 03/31/22

25% participation for groups with 5 or more enrolled subscribers. 65% participation for groups with 4 or less enrolled subscribers.

Note: Information is subject to change and carriers can request additional documents as needed.

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.

Relaxed Participation Promotion Though 03/15/21

subscribers. 65% participation for groups with 4 or less enrolled subscribers

Mirror plans

70% participation

Participation Promotion through 12/31/21:

1-4 enrolling: 65% participation

5+ enrolling: 25% participation

Includes Medical, Dental, Vision, and Life

The promotion also waives participation requirements for Trio and Tandem PPO plans (minimum 1 enrolling).

Note: Information is subject to change and carriers can request additional documents as needed.

Mirror plans

Cannot offer Mirror plans alongside other carriers.

Off-exchange plans

If Blue Shield is offered alongside another carrier (Promotion through December 31, 2021) 

Relaxed Participation Guidelines:

1-4 enrolled: 60% participation

5+ enrolled: 25% participation

Blue Shield must also be sole carrier when offering Dental, Vision, and Life products.

Note: Information is subject to change and carriers can request additional documents as needed.

1-2 enrolling: 100% participation

3-100 enrolling: 70% participation

51% of eligible employees must reside in California

Cannot write alongside other carriers.

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

Employees who waive coverage on the grounds that they have other medical coverage, including Kaiser, are not counted as eligible employees.

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.

70% participation for all group sizes

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

Promotion through 3/31/22

Enhanced Choice A & B (available through 3/31/22):

1-4 enrolled: 70% participation

5+enrolled: 25% participation

Sell HMP with 6 (available through 3/31/22):

6+ enrolled: No minimum participation

For Enhanced Choice A and Enhanced Choice B promo, all eligible employees declining coverage must provide a waiver including those enrolling with another carrier.

Note: Information is subject to change and carriers can request additional documents as needed.

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

Promotion through 3/31/22

Enhanced Choice A & B (available through 3/31/22):

1-4 enrolled: 70% participation

5+enrolled: 25% participation

Sell HMP with 6 (available through 3/31/22):

6+ enrolled: No minimum participation

Salud (2 active subscribers)

Mix and match any plans with the Salud HMO y Más network

HMO (6+ active subscribers)

No DE9C, attestation, prior carrier bill, nor waivers required.

Mix and match any plans from the HMO networks + Full Network PPO Bronze

Note: Information is subject to change and carriers can request additional documents as needed.

At least 1 eligible employee must enroll.

1-100 enrolling: 50% participation

With PPO offering, Kaiser must be the sole carrier for medical coverage.

Only one PPO plan may be offered in Multiple Plan Options (when offering other KaiserPermanente Plans)

May write alongside another carrier so long as 50% of eligible employees are enrolled in a valid health plan

As sole carrier

GM plan: 1 eligible employee

PM, P5, and P20 plans: 3 eligible employees minimum

Alongside other carriers

GM plan: 1 eligible employee

PM, P5, and P20 plans: 3 eligible employees minimum

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

Participation Requirements

Groups must ensure employee participation requirements are met at the time the group initially enrolls and each year upon renewal. 

Noncontributory (employer pays all): 100% participation

Contributory (employer pays less than all): 60% participation

Note: Information is subject to change and carriers can request additional documents as needed.

Split Carrier Participation Rules

3+ enrolled: 60% overall participation

Oscar can be written alongside any other carrier, and any plan type – HMO, PPO, or EPO.

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

HMO

1-100 eligible HMO: 60% participation

HMO/PPO

10/15% rule: At least 10 active enrolled subscribers with 15% maximum participation on the Sharp Health Plan PPO partnership product (in & out of service area), rounded up.

60% participation with no more than 15% enrollment on PPO.

60% of eligible W-2 employees are covered by a group health plan offered by the employer AND a minimum of 5 enrolled with Sharp.

Will not wrap alongside private or public exchanges.

Sharp Health Plan partnership PPO product is not available alongside another carrier.

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, excluding COBRA participants.

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

*100% employee participation required with 100% employer contribution

Always refer to carrier underwriting guidelines for all pertinent details.