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CaliforniaChoice Eligibility

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Underwriting Requirements

  • 1-2 Employees: 100% of all employees. All groups must include at least one medical enrolled employee who is not a business owner or spouse of business owner.
  • 3-50 Employees: 70% of eligible employees, with a minimum of 2 employees enrolling in CaliforniaChoice.
  • Employees with other group coverage are not counted towards participation unless employer contribution is 100%.
  • Group’s home office must be located in California (Principal Executive Office).
  • 51+% of eligible employees must reside in California.

Employer Application (Includes medical and optional benefits information)

  • Workers’ Compensation coverage must be in force prior to or on the requested CaliforniaChoice effective date.
  • Group must have a 9-digit Federal Tax ID Number (cannot be SS#).
  • Quarterly/Annual Wage Report – Must list employee names, social security numbers, wages, and withholdings (no alterations are permitted). Indicate employee status directly on the quarterly/annual wage report (All employees must be accounted for): E=Enrolling W=Waiving P=Part-time TP=Temporary S=Seasonal WP=Waiting Period T=Terminated U=Union
  • W-4 form is required for new hires not shown on the quarterly/annual wage report.
  • Payroll records required for entire group if more than 50% are not on the quarterly/annual wage report. Payroll may be requested for new hires.
  • Owner/Partner Statement – Required if owner(s) not shown on the quarterly/annual wage report with a full-time salary (current state minimum wage multiplied by number of hours to be considered eligible (20 or 30) then multiplied by 13 weeks)
  • Current Dental Carrier Billing (for groups with 10+ eligible who are electing EPO 3000, EPO 3500, PPO 4000 or PPO 5000 Dental)
  • Submit copy of current billing statement and statement from 12 months prior in order to waive the waiting period for major services (statement from 24 months prior required for Ortho—must show Ortho coverage).
  • Minimum Premium Deposit Check – Employer may submit a copy of the group’s premium deposit check, payable to CaliforniaChoice at case submission. Original check(s) for at least 90% of total premium due must be received by the underwriter prior to case approval.
  • Section 125 (POP)—Add an additional $100 one-time fee to the premium deposit.
  • COBRA premium is not required, but if submitted, include a separate check from employer or COBRA enrollee. CONEXIS will bill directly.

Employee Forms

  • Employee Enrollment Application/Waivers (and dependent waivers, if dependents not enrolling). Employee waivers require reason for waiving and must be completed in full.
  • Disabled Dependent Certification Form — Must be completed for dependent child(ren) over the age of 26.

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