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Small Business Group Plans – California

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2019 Plan Overviews / Summary of Benefits

Plan Overviews
Plans for new and renewing groups effective 1/1/19.

EnhancedCare PPO

Platinum 90 250/15 + Child Dental Alt (ENG) 2.3MB   11/06/18

Gold 80 1000/30 + Child Dental Alt (ENG) 2.3MB   11/02/18

Gold Value (ENG) 2.3MB   11/02/18

Silver 70 2000/55 + Child Dental Alt (ENG) 2.3MB   11/02/18

Silver Value (ENG) 2.3MB   11/02/18

Silver 70 HDHP 1350/40 + Child Dental Alt (ENG) 2.3MB   11/02/18

Bronze 60 HDHP 5600/15 + Child Dental Alt (ENG) 2.3MB   11/02/18


PPO

Platinum 90 0/15 + Child Dental (ENG) 2.3MB   11/02/18

Platinum 90 0/15 + Child Dental (SPN) 2.3MB   01/14/19

Gold 80 0/30 + Child Dental (ENG) 2.3MB   11/02/18

Gold 80 0/30 + Child Dental (SPN) 2.3MB   01/14/19

Gold 80 Value 750/10 + Child Dental Alt (ENG) 2.3MB   11/02/18

Gold 80 Value 750/10 + Child Dental Alt (SPN) 2.3MB   01/14/19

Silver 70 2000/45 + Child Dental (ENG) 2.3MB   11/02/18

Silver 70 2000/45 + Child Dental (SPN) 2.3MB   01/14/19

Silver 70 HDHP 1350/40 + Child Dental Alt (ENG) 2.3MB   11/02/18

Silver 70 HDHP 1350/40 + Child Dental Alt (SPN) 2.3MB   01/14/19

Bronze 60 6300/75 + Child Dental (ENG) 2.3MB   11/02/18

Bronze 60 6300/75 + Child Dental (SPN) 2.3MB   01/14/19

Bronze 60 HDHP 5600/15 + Child Dental Alt (ENG) 2.3MB   11/02/18

Bronze 60 HDHP 5600/15 + Child Dental Alt (SPN) 2.3MB   01/14/19


PureCare HSP

Platinum 90 0/15 + Child Dental (ENG) 539kB   11/06/18

Gold 80 0/30 + Child Dental (ENG) 537kB   11/06/18

Silver 70 2000/45 + Child Dental (ENG) 540kB   11/06/18

Bronze 60 6300/75 + Child Dental (ENG) 541kB   11/06/18


HMO

Platinum 10 (ENG) 521kB   11/09/18

Platinum 20 (ENG) 522kB   11/09/18

Platinum 30 (ENG) 469kB   11/09/18

Gold 30 (ENG) 522kB   11/09/18

Gold 35 (ENG) 466kB   11/09/18

Gold 40 (ENG) 522kB   11/09/18

Silver 50 (ENG) 522kB   11/09/18


WholeCare HMO

Platinum 10 (ENG) 543kB   10/31/18

Platinum 10 (CHI) 809kB   01/23/19

Platinum 20 (ENG) 546kB   10/31/18

Platinum 20 (CHI) 809kB   01/23/19

Platinum 30 (ENG) 498kB   10/31/18

Platinum 30 (CHI) 788kB   01/23/19

Gold 30 (ENG) 548kB   10/31/18

Gold 30 (CHI) 808kB   01/23/19

Gold 35 (ENG) 448kB   11/16/18

Gold 35 (CHI) 756kB   01/23/19

Gold 40 (ENG) 546kB   10/31/18

Gold 40 (CHI) 809kB   01/23/19

Silver 50 (ENG) 544kB   10/31/18

Silver 50 (CHI) 810kB   01/23/19


SmartCare HMO

Platinum 10 (ENG) 546kB   10/31/18

Platinum 10 (CHI) 808kB   01/23/19

Platinum 20 (ENG) 546kB   10/31/18

Platinum 20 (CHI) 808kB   01/23/19

Platinum 30 (ENG) 500kB   10/31/18

Platinum 30 (CHI) 786kB   01/23/19

Gold 30 (ENG) 546kB   10/31/18

Gold 30 (CHI) 809kB   01/23/19

Gold 35 (ENG) 448kB   11/16/18

Gold 35 (CHI) 758kB   01/23/19

Gold 40 (ENG) 546kB   10/31/18

Gold 40 (CHI) 811kB   01/23/19

Silver 50 (ENG) 544kB   10/31/18

Silver 50 (CHI) 810kB   01/23/19


Salud HMO y Más

Platinum 10 (ENG) 523kB   12/03/18

Platinum 20 (ENG) 523kB   12/03/18

Platinum 30 (ENG) 2.3MB   12/03/18

Gold 30 (ENG) 523kB   12/03/18

Gold 35 (ENG) 2.3MB   12/03/18

Gold 40 (ENG) 523kB   12/03/18

Silver 50 (ENG) 523kB   12/03/18


CommunityCare HMO

Gold 5 (ENG) 581kB   10/31/18

Gold 5 (CHI) 895kB   01/23/19

Silver 20 (ENG) 579kB   10/31/18

Silver 20 (CHI) 795kB   01/23/19

Bronze 45 (ENG) 579kB   10/31/18

Bronze 45 (CHI) 795kB   01/23/19


Summary of Benefits

Enhanced Care PPO

Platinum 90 250/15 3.2MB   01/07/19

Platinum 90 250/15 w/inf 3.2MB   01/07/19

Gold 80 1000/30 3.1MB   01/07/19

Gold 80 1000/30 w/inf 3.1MB   01/07/19

Gold Value 3.2MB   01/07/19

Gold Value w/inf 3.2MB   01/07/19

Silver 70 2000/55 3.2MB   01/08/19

Silver 70 2000/55 w/inf 3.2MB   01/07/19

Silver Value 3.2MB   01/08/19

Silver Value w/inf 3.2MB   01/08/19

Silver 70 HDHP 1350/40 3.2MB   01/08/19

Silver 70 HDHP 1350/40 w/inf 3.2MB   01/08/19

Bronze 60 HDHP 5600/15 3.1MB   01/07/19

Bronze 60 HDHP 5600/15 w/inf 3.1MB   01/07/19


PPO

Platinum 90 0/15 3.1MB   01/08/19

Platinum 90 0/15 w/inf 3.1MB   01/08/19

Platinum 90 250/15 3.1MB   01/08/19

Platinum 90 250/15 w/inf 3.1MB   01/08/19

Gold 80 0/30 3.1MB   01/08/19

Gold 80 0/30 w/inf 3.1MB   01/08/19

Gold 80 1000/30 3.1MB   01/08/19

Gold 80 1000/30 w/inf 3.1MB   01/08/19

Gold 80 Value 750/10 3.1MB   01/08/19

Gold 80 Value 750/10 w/inf 3.1MB   01/08/19

Silver 70 2000/45 3.1MB   01/08/19

Silver 70 2000/45 w/inf 3.1MB   01/08/19

Silver 70 2000/55 3.2MB   01/08/19

Silver 70 2000/55 w/inf 3.2MB   01/08/19

Silver 70 Value 1700/30 3.1MB   01/08/19

Silver 70 Value 1700/30 w/inf 3.1MB   01/08/19

Silver 70 HDHP 1350/40 3.1MB   01/08/19

Silver 70 HDHP 1350/40 w/inf 3.1MB   01/08/19

Bronze 60 6300/75 3.1MB   01/08/19

Bronze 60 6300/75 w/inf 3.1MB   01/08/19

Bronze 60 HDHP 5600/15 3.1MB   01/08/19

Bronze 60 HDHP 5600/15 w/inf 3.1MB   01/08/19


PureCare HSP

Platinum 90 0/15 3.5MB   01/08/19

Platinum 90 0/15 w/inf 3.5MB   01/08/19

Gold 80 0/30 2.9MB   01/08/19

Gold 80 0/30 w/inf 2.9MB   01/08/19

Silver 70 2000/45 3.5MB   01/08/19

Silver 70 2000/45 w/inf 3.5MB   01/08/19

Bronze 60 6300/75 2.9MB   01/08/19

Bronze 60 6300/75 w/inf 2.9MB   01/08/19


HMO

Platinum 10 2.1MB   01/07/19

Platinum 10 w/inf 2.1MB   01/07/19

Platinum 20 2MB   01/07/19

Platinum 20 w/inf 2.1MB   01/07/19

Platinum 30 2MB   01/07/19

Platinum 30 w/inf 2.1MB   01/07/19

Gold 30 2MB   01/07/19

Gold 30 w/inf 2.1MB   01/07/19

Gold 35 2MB   01/07/19

Gold 35 w/inf 2.1MB   01/07/19

Gold 40 2MB   01/07/19

Gold 40 w/inf 2.1MB   01/07/19

Silver 50 2MB   01/07/19

Silver 50 w/inf 2MB   01/07/19


WholeCare HMO

Platinum 10 2.1MB   01/07/19

Platinum 10 w/inf 2.1MB   01/07/19

Platinum 20 2.1MB   01/07/19

Platinum 20 w/inf 2.1MB   01/07/19

Platinum 30 2.1MB   01/07/19

Platinum 30 w/inf 2.1MB   01/07/19

Gold 30 2.1MB   01/07/19

Gold 30 w/inf 2.1MB   01/07/19

Gold 35 2.1MB   01/07/19

Gold 35 w/inf 2.1MB   01/07/19

Gold 40 2.1MB   01/07/19

Gold 40 w/inf 2.1MB   01/07/19

Silver 50 2.1MB   01/07/19

Silver 50 w/inf 3.5MB   01/07/19


SmartCare HMO

Platinum 10 2.1MB   01/07/19

Platinum 10 w/inf 2.1MB   01/07/19

Platinum 20 2.1MB   01/07/19

Platinum 20 w/inf 2.1MB   01/07/19

Platinum 30 2.1MB   01/07/19

Platinum 30 w/inf 2.1MB   01/07/19

Gold 30 2.1MB   01/07/19

Gold 30 w/inf 2.1MB   01/07/19

Gold 35 2.1MB   01/07/19

Gold 35 w/inf 2.1MB   01/07/19

Gold 40 2.1MB   01/07/19

Gold 40 w/inf 2.1MB   01/07/19

Silver 50 2.4MB   01/07/19

Silver 50 w/inf 2.4MB   01/07/19


Salud HMO y Más

Platinum 10 3.5MB   01/08/19

Platinum 10 w/inf 3.5MB   01/08/19

Platinum 20 3.5MB   01/08/19

Platinum 20 w/inf 3.5MB   01/08/19

Platinum 30 3.5MB   01/08/19

Platinum 30 w/inf 3.5MB   01/08/19

Gold 30 3.5MB   01/08/19

Gold 30 w/inf 3.6MB   01/08/19

Gold 35 2.1MB   01/08/19

Gold 35 w/inf 2.1MB   01/08/19

Gold 40 2.1MB   01/08/19

Gold 40 w/inf 2.1MB   01/08/19

Silver 50 3.5MB   01/08/19

Silver 50 w/inf 3.5MB   01/08/19


CommunityCare HMO

Gold 5 3.5MB   01/07/19

Gold 5 w/inf 3.5MB   01/07/19

Silver 20 2.1MB   01/07/19

Silver 20 w/inf 2.1MB   01/07/19

Bronze 45 3.5MB   01/07/19

Bronze 45 w/inf 3.5MB   01/07/19


Certificate of Insurance

EnhancedCare PPO

Platinum 90 250/15 + Child Dental 4.2MB   10/31/18

Platinum 90 250/15 + Child Dental w/inf 4.2MB   10/31/18

Gold 80 1000/30 + Child Dental Alt 2.9MB   10/31/18

Gold 80 1000/30 + Child Dental Alt w/inf 2.9MB   10/31/18

Gold Value 4.2MB   10/31/18

Gold Value w/inf 4.2MB   10/31/18

Silver Value 2.9MB   10/31/18

Silver Value w/inf 2.9MB   10/31/18

Silver 70 2000/55 + Child Dental Alt 2.9MB   10/31/18

Silver 70 2000/55 + Child Dental Alt w/inf 3.2MB   11/02/18

Silver 70 HDHP 1350/40 + Child Dental Alt 2.9MB   10/31/18

Silver 70 HDHP 1350/40 + Child Dental Alt w/inf 2.9MB   10/31/18

Bronze 60 HDHP 5600/15 + Child Dental Alt 4.2MB   10/31/18

Bronze 60 HDHP 5600/15 + Child Dental Alt w/inf 4.2MB   10/31/18


2018 Plan Overviews / Summary of Benefits

Plan Overviews
Platinum $30 plan and Gold $35 plan for new and renewing groups effective 7/1/18. PPO and EnhancedCare PPO Platinum 250/15, Gold 1000/30 and Silver 2000/55 for new and renewing groups effective 10/1/18. All other plans for new and renewing groups effective 1/1/18.

EnhancedCare PPO

Platinum 90 250/15 2.8MB   08/17/18

Gold 80 1000/30 2.8MB   08/17/18

Gold Value 515kB   08/22/17

Silver 70 2000/55 2.8MB   08/17/18

Silver Value 519kB   08/22/17

Silver HDHP 500kB   11/16/17

Bronze HDHP 500kB   11/16/17


PPO

Platinum 90 (ENG) 496kB   11/16/17

Platinum 90 250/15 (ENG) 2.8MB   08/17/18

Gold 80 (ENG) 496kB   11/16/17

Gold 80 (SPN) 502kB   10/15/18

Gold 80 1000/30 (ENG) 2.8MB   08/17/18

Gold 80 1000/30 (SPN) 504kB   10/12/18

Gold Value (ENG) 496kB   11/16/17

Gold Value (SPN) 500kB   10/12/18

Silver 70 (ENG) 521kB   02/14/18

Silver 70 (SPN) 521kB   10/12/18

Silver 70 2000/55 (ENG) 2.8MB   08/17/18

Silver 70 2000/55 (SPN) 504kB   10/15/18

Silver Value (ENG) 500kB   11/16/17

Silver Value (SPN) 3.3MB   10/12/18

Silver HDHP (ENG) 499kB   11/16/17

Silver HDHP (SPN) 524kB   10/12/18

Bronze 60 (ENG) 498kB   11/16/17

Bronze HDHP (ENG) 499kB   11/16/17


PureCare HSP

Platinum 90 496kB   11/16/17

Gold 80 499kB   11/16/17

Silver 70 499kB   11/16/17

Bronze 60 500kB   11/16/17


HMO

Platinum 10 498kB   11/16/17

Platinum 20 499kB   11/16/17

Platinum 30 509kB   05/02/18

Gold 30 498kB   11/17/17

Gold 35 509kB   05/02/18

Gold 40 498kB   11/16/17

Silver 40 495kB   11/16/17


WholeCare HMO

Platinum 10 (ENG) 497kB   11/16/17

Platinum 10 (SPN) 522kB   10/12/18

Platinum 20 (ENG) 498kB   11/16/17

Platinum 20 (SPN) 522kB   10/12/18

Platinum 30 (ENG) 518kB   05/02/18

Platinum 30 (SPN) 2.3MB   10/12/18

Gold 30 (ENG) 498kB   11/16/17

Gold 30 (SPN) 522kB   10/12/18

Gold 35 (ENG) 537kB   05/02/18

Gold 35 (SPN) 481kB   10/12/18

Gold 40 (ENG) 498kB   11/16/17

Gold 40 (SPN) 3.3MB   10/12/18

Silver 40 (ENG) 497kB   11/16/17

Silver 40 (SPN) 3.3MB   10/12/18


SmartCare HMO

Platinum 10 (ENG) 498kB   11/16/17

Platinum 10 (SPN) 522kB   10/12/18

Platinum 20 (ENG) 498kB   11/16/17

Platinum 20 (SPN) 522kB   10/12/18

Platinum 30 (ENG) 517kB   05/02/18

Platinum 30 (SPN) 2.3MB   10/12/18

Gold 30 (ENG) 499kB   11/16/17

Gold 30 (SPN) 522kB   10/12/18

Gold 35 (ENG) 2.3MB   05/02/18

Gold 35 (SPN) 482kB   10/12/18

Gold 40 (ENG) 498kB   11/16/17

Gold 40 (SPN) 522kB   10/12/18

Silver 40 (ENG) 499kB   11/16/17

Silver 40 (SPN) 3.3MB   10/12/18


Salud HMO y Más

Platinum 10 (ENG) 498kB   11/16/17

Platinum 10 (SPN) 3.3MB   10/12/18

Platinum 20 (ENG) 498kB   11/16/17

Platinum 20 (SPN) 3.3MB   10/12/18

Platinum 30 (ENG) 2.3MB   05/02/18

Platinum 30 (SPN) 466kB   10/15/18

Gold 30 (ENG) 498kB   11/16/17

Gold 30 (SPN) 522kB   10/12/18

Gold 35 (ENG) 2.3MB   05/02/18

Gold 35 (SPN) 482kB   10/12/18

Gold 40 (ENG) 498kB   11/16/17

Gold 40 (SPN) 522kB   10/15/18

Silver 40 (ENG) 498kB   11/16/17

Silver 40 (SPN) 3.3MB   10/12/18


CommunityCare HMO

Gold 5 495kB   11/16/17

Silver 20 495kB   11/16/17

Bronze 45 495kB   11/16/17


Summary of Benefits

EnhancedCare PPO

Platinum 90 250/15 4.2MB   10/25/18

Platinum 90 250/15 w/inf 4.2MB   10/25/18

Gold 80 1000/30 4.2MB   10/25/18

Gold 80 1000/30 w/inf 4.2MB   10/25/18

Gold Value 1.6MB   01/25/18

Gold Value w/inf 1.6MB   01/25/18

Silver Value 1.6MB   01/25/18

Silver Value w/inf 1.6MB   01/25/18

Silver 70 2000/55 1.7MB   10/25/18

Silver 70 2000/55 w/inf 1.7MB   10/25/18

Silver HDHP 1.6MB   01/25/18

Silver HDHP w/inf 1.6MB   01/25/18

Bronze HDHP 1.6MB   01/25/18

Bronze HDHP w/inf 1.6MB   01/25/18


PPO

Platinum 90 1.6MB   01/25/18

Platinum 90 w/inf 1.6MB   01/25/18

Platinum 90 250/15 4.2MB   10/25/18

Platinum 90 250/15 w/inf 4.2MB   10/25/18

Gold 80 1.6MB   01/25/18

Gold 80 w/inf 1.6MB   01/25/18

Gold 80 1000/30 1.8MB   10/25/18

Gold 80 1000/30 w/inf 1.8MB   10/25/18

Gold Value 1.6MB   01/25/18

Gold Value w/inf 1.6MB   01/25/18

Silver 70 1.6MB   02/05/18

Silver 70 w/inf 1.6MB   02/05/18

Silver Value 1.6MB   01/25/18

Silver Value w/inf 1.6MB   01/25/18

Silver 70 2000/55 4.2MB   10/25/18

Silver 70 2000/55 w/inf 4.2MB   10/25/18

Silver HDHP 1.6MB   01/25/18

Silver HDHP w/inf 1.6MB   01/25/18

Bronze 60 1.6MB   02/05/18

Bronze 60 w/inf 1.6MB   02/05/18

Bronze HDHP 1.6MB   01/25/18

Bronze HDHP w/inf 1.6MB   01/25/18


PureCare HSP

Platinum 90 1.7MB   07/13/18

Platinum 90 w/inf 1.7MB   07/13/18

Gold 80 1.7MB   07/13/18

Gold 80 w/inf 1.7MB   07/13/18

Silver 70 1.7MB   07/13/18

Silver 70 w/inf 1.7MB   07/13/18

Bronze 60 1.7MB   07/13/18

Bronze 60 w/inf 1.7MB   07/13/18


HMO

Platinum 10 1.6MB   01/25/18

Platinum 10 w/inf 1.6MB   01/25/18

Platinum 20 1.6MB   01/25/18

Platinum 20 w/inf 1.6MB   01/25/18

Platinum 30 1.3MB   08/09/18

Platinum 30 w/inf 1.3MB   08/09/18

Gold 30 1.6MB   01/25/18

Gold 30 w/inf 1.6MB   01/25/18

Gold 35 1.3MB   08/09/18

Gold 35 w/inf 1.3MB   08/09/18

Gold 40 1.6MB   01/25/18

Gold 40 w/inf 1.6MB   01/25/18

Silver 40 1.7MB   02/05/18

Silver 40 w/inf 1.7MB   02/05/18


WholeCare HMO

Platinum 10 1.6MB   01/25/18

Platinum 10 w/inf 1.7MB   01/25/18

Platinum 20 1.6MB   01/25/18

Platinum 20 w/inf 1.7MB   01/25/18

Platinum 30 2.9MB   08/09/18

Platinum 30 w/inf 2.9MB   08/09/18

Gold 30 1.7MB   01/25/18

Gold 30 w/inf 1.7MB   01/25/18

Gold 35 2.9MB   08/09/18

Gold 35 w/inf 2.9MB   08/09/18

Gold 40 1.6MB   01/25/18

Gold 40 w/inf 1.7MB   01/25/18

Silver 40 1.7MB   06/13/18

Silver 40 w/inf 1.7MB   06/13/18


SmartCare HMO

Platinum 10 1.6MB   01/25/18

Platinum 10 w/inf 1.6MB   01/25/18

Platinum 20 1.6MB   01/25/18

Platinum 20 w/inf 1.6MB   01/25/18

Platinum 30 2.9MB   08/09/18

Platinum 30 w/inf 2.9MB   08/09/18

Gold 30 1.6MB   01/25/18

Gold 30 w/inf 1.6MB   01/25/18

Gold 35 2.9MB   08/09/18

Gold 35 w/inf 2.9MB   08/09/18

Gold 40 1.6MB   01/25/18

Gold 40 w/inf 1.6MB   01/25/18

Silver 40 1.7MB   06/13/18

Silver 40 w/inf 1.7MB   06/13/18


Salud HMO y Más

Platinum 10 1.7MB   01/25/18

Platinum 10 w/inf 1.7MB   01/25/18

Platinum 20 1.7MB   01/25/18

Platinum 20 w/inf 1.7MB   01/25/18

Platinum 30 2.4MB   10/25/18

Platinum 30 w/inf 2.4MB   10/25/18

Gold 30 1.7MB   01/25/18

Gold 30 w/inf 1.7MB   01/25/18

Gold 35 3.1MB   10/25/18

Gold 35 w/inf 3.2MB   10/25/18

Gold 40 1.7MB   01/25/18

Gold 40 w/inf 1.7MB   01/25/18

Silver 40 1.8MB   06/13/18

Silver 40 w/inf 1.8MB   06/13/18


CommunityCare HMO

Gold 5 1.6MB   01/25/18

Gold 5 w/inf 1.6MB   01/25/18

Silver 20 1.6MB   01/25/18

Silver 20 w/inf 1.6MB   01/25/18

Bronze 45 1.7MB   02/05/18

Bronze 45 w/inf 1.7MB   02/05/18


Plan Brochures / Product Overviews


Portfolio Plan Desktopper

January 2019 108kB   10/25/18

October 2018 163kB   07/30/18


Portfolio Guide

January 2019 1.2MB   11/09/18

October 2018 1.2MB   08/31/18


Renewal Guide

April 2019 1.9MB   02/06/19

January 2019 1.9MB   10/18/18


Broker PPO Fast Facts

English 152kB   02/05/19


Member Open Enrollment PPO Brochure

English 2.5MB   08/23/18



Standard Product Overview Folders

English 5.5MB   08/29/18

En Español (Spanish) 7.2MB   08/29/18



Presentation Folder, with pocket

English 529kB   11/25/15


Applications and Forms

Enrollment and Change Applications

Top Reasons for Employee Enrollment Delays

English 656kB   05/24/18


Employee Enrollment and Change Form (January 2019)

English 715kB   10/25/18

En Español (Spanish) 692kB   12/21/18

Chinese (Chinese) 1MB   01/23/19

Korean (Korean) 878kB   12/21/18

Must be completed & submitted at time of enrollment in order to enroll new employees & existing dependents. Also used for employees/dependents waiving coverage.


Employee Enrollment and Change Form (October 2018)

English 2.5MB   08/31/18

Must be completed & submitted at time of enrollment in order to enroll new employees & existing dependents. Also used for employees/dependents waiving coverage.


Renewal Election and Open Enrollment Medical Plan Change Request Form

January 2019 809kB   01/14/19

October 2018 794kB   07/26/18


Open Enrollment Meeting Request Form

English 107kB   08/25/16


Group Service Agreement/Policy Applications

Small Group 10+ Participation Attestation Form

English 52kB   05/11/18


Group Size Attestation Form

English 109kB   01/08/19

Must be completed & signed by the Employer Group.


Application for Group Service Agreement/Policy

January 2019 643kB   10/09/18

October 2018 666kB   08/31/18

Must be completed & signed by the Employer Group and Broker at time of enrollment and submitted along with check for first month's premium and enrollment forms. For renewals, this form must be completed and signed by the Employer Group and submitted to SBG Account Management for processing.


Renewal Date Change Request Form

English 68kB   11/02/17


Religious Exemption Employer Form

English 892kB   12/12/17


Transition of Care

Continuity of Care Assistance Request Form

English 524kB   01/17/18

En Español (Spanish) 572kB   01/17/18


Prescription Transition form

English 464kB   05/15/18

En Español (Spanish) 463kB   05/15/18


Claims

Commercial Medical Claim Form

English 542kB   12/19/17

En Español (Spanish) 502kB   12/19/17


Prescription Drug Claim Form

English 499kB   09/14/18

En Español (Spanish) 523kB   10/04/18


Dental Claim Form

English 2.8MB   04/12/10


Vision Claim Form

English 84kB   04/14/10


HIPAA Disclosures

Group Health Plan HIPAA Disclosure Forms

Disclosure Directive 95kB   06/13/16


Authorization For Disclosure of PHI

English 0kB   12/31/69

En Español (Spanish) 0kB   12/31/69

Chinese (Chinese) 0kB   12/31/69

Korean (Korean) 0kB   12/31/69


Health Net Life Insurance Forms

Employee Enrollment and Change Form

English 938kB   07/25/17

En Español (Spanish) 549kB   07/25/17


Group Life Insurance Conversion Form

English 61kB   02/20/15


Evidence of Insurability Life Form

English 618kB   02/22/18


Additional Forms

Employer Group Size Verification Form

English 64kB   08/01/17


Electronic Check Form

English 69kB   06/07/17


Proof of Eligibility Statement For Sole Proprietor, Partner or Corporate Officer

English 51kB   01/06/16


Rate Guides

Standard

January 2019

English 2MB   11/06/18

Rates effective January 1, 2019, through March 15, 2019


October 2018

English 1.7MB   08/24/18

Rates effective October 1, 2018, through December 15, 2018


July 2018

English 1.6MB   11/06/18

Rates effective July 1, 2018, through September 15, 2018


April 2018

English 1.3MB   04/03/18

Rates effective April 1, 2018, through June 15, 2018


Covered California

January 2019

English 1.3MB   10/18/18

Rates effective January 1, 2019, through March 15, 2019


October 2018

English 1.5MB   08/24/18

Rates effective October 1, 2018, through December 15, 2018


Cal-Choice

January 2019

English 1.1MB   10/25/18

Rates effective January 1, 2019, through March 15, 2019


October 2018

English 1MB   08/31/18

Rates effective October 1, 2018, through December 15, 2018


Underwriting Guidelines


Underwriting Promotions

English 93kB   02/05/19


January 2019

Enhanced Choice A

English 282kB   12/17/18


Enhanced Choice B

English 284kB   12/17/18


Dental and Vision

English 286kB   12/17/18


Health Net Life

English 283kB   12/17/18


October 2018

Enhanced Choice A

English 284kB   08/09/18


Enhanced Choice B

English 286kB   08/09/18


Dental and Vision

English 290kB   08/09/18


Health Net Life

English 285kB   08/09/18


Support Tools


Broker Portal Overview

English 3.8MB   07/15/16

Broker Portal Overview (Flip Book)


Health Care Reform Materials

Summary of Benefits and Coverage (SBC) Search Flyer

English 385kB   03/13/15

Download only


Ensure Your Employees Understand Their Health Care

English 58kB   05/24/18


Preventive Care Services Overview (ACA Non-Grandfathered Plans)

English 611kB   03/07/18

En Español (Spanish) 613kB   03/07/18


Support Tools

Heal flyer (PPO, POS and EOA plans only)

English 0kB   12/31/69

En Español (Spanish) 0kB   12/31/69

Available through your PPO insurance plan and the SELECT/ELECT 2 (PPO) tier of your SELECT (POS) or Elect Open Access health plan.


Teladoc (Telehealth) Introductory Flyer

English/Spanish 247kB   11/16/18


Teladoc (Telehealth) FAQs

English 661kB   01/14/19

En Español (Spanish) 627kB   01/14/19


Active&Fit Direct Member Flyer

English 1.7MB   11/16/18

En Español (Spanish) 1.7MB   11/16/18


CommunityCare HMO Sell Sheet

English 216kB   12/11/18


Chiropractic Care flyer

English 159kB   09/28/18


Understanding the Continuity of Care Assistance Policy

English 1MB   07/02/18

Download only


How To Read Your Commission Statement

English 477kB   02/11/16

Download only


Top Reasons to Sell Health Net

English 785kB   09/11/18


Protect Your Wallet. Always Use the PureCare HSP Network flyer

English 249kB   01/21/16


Cadillac Tax Fact Sheet

English 141kB   01/19/16


Health Net Beginnings

English 193kB   02/22/18

En Español (Spanish) 171kB   02/22/18


MinuteClinics Brochure

English 701kB   06/15/18


Prior-Carrier Deductible Credit Flyer

English 635kB   04/18/18


Commercial Sales Guidelines

English 738kB   05/24/18


Information for Small Business Groups

English 107kB   08/24/18


ER vs. Urgent Care

English/Spanish 150kB   08/14/17


Employer Welcome Guide

English 3.1MB   11/14/18


HealthNet.com Flyer

English 314kB   01/14/19

En Español (Spanish) 1.3MB   01/14/19


Uniform Glossary of Health Coverage and Medical Terms