Blue shield of california

Enrollment Kit - blue shield of ca (medical)

This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.

​Our goal is to process your new group enrollment easily and efficiently in order to provide you and your client with a quick approval.  The following list outlines Blue Shield of California’s case submission requirements.​​​

1. Every new group is required to submit the following:

Master Group Application (either paper, Blue Shield MGA spreadsheet when used in conjunction with the Employee Enrollment spreadsheet, or online portal*)

Applications from all enrolling employees and dependents (either paper, Blue Shield Employee Enrollment spreadsheet, or online portal*)

Refusal of Coverage form​s for all eligible employees and any eligible dependents who refuse or waive coverage at the time of open enrollment (either paper, Blue Shield Employee Enrollment spreadsheet, or online portal*)

Applications for COBRA or Cal-COBRA enrollees, if available (may be submitted later as maintenance)

First month’s payment on company check stock or the completed Small Group Initial Payment Form
  •     Blue Shield will refund the full deposit to the group if the group application is declined
  •    When the Small Group Initial Payment Form is used, documentation from the bank that includes the bank name, the group name, and account and routing numbers may be submitted in lieu of a copy of a voided business check.

*Employer/broker retains these forms when applying through the online portal or using the MGA and/or Employee Enrollment spreadsheet.
†Employer/Broker retains the Small Group Initial Payment form when applying through the online portal.


2. New groups with 1-2 eligible employees or less than 3 Full-time and Full-time Equivalent (FT/FTE) employees or more than 95 FT/FTE employees are required to submit the following additional documentation to verify eligibility. Blue Shield reserves the right to require this documentation for new groups with 3 or more eligible employees or 3 or more FT/FTE employees.

  •     The group’s most recent DE9C Quarterly State Tax Withholding Statement
  •     Payroll register for employees hired after the DE9C filing or if any employees are out of state


3. New groups with 1-2 eligible employees or less than 3 Full-time and Full-time Equivalent (FT/FTE) employees are required to submit the following additional documentation based on the type of entity to verify group and owner eligibility. Blue Shield reserves the right to require this documentation for new groups with 3 or more eligible employees.

Sole Proprietorship       
  • If group uses a DBA: DBA printed on the group’s business check or current California business license or Fictitious Business Name (FBN) filing
  • If owner is enrolling or refusing coverage and is not listed on the DE9C: Complete and sign Blue Shield of California Small Group Owner Eligibility Statement
Partnership, Limited Partnership (LP), Limited Liability Partnership (LLP)
  • Partnership Agreement
  • If owners are enrolling or refusing coverage and are not listed on the DE9C: Complete and sign Blue Shield of California Small Group Owner Eligibility Statement for each owner not listed on the DE9C.

Corporations
  • Statement of Information or Articles of Incorporation
  • If owner are enrolling or refusing coverage and are not listed on the DE9C: Complete and sign Blue Shield of California Small Group Owner Eligibility Statement for each owner not listed on the DE9C.

Limited Liability Company (LLC)
  • Statement of Information or Operating Agreement
  • If owners are enrolling or refusing coverage and are not listed on the DE9C: Complete and sign Blue Shield of California Small Group Owner Eligibility Statement for each owner not listed on the DE9C

Nonprofit
  • Statement of Information
  • Additional documentation that may be required: Nonprofit 990 EZ tax form, Nonprofit Corporation By-Laws, Board of Directors or shareholders meeting minutes.
  • If officers, directors and/or trustees are enrolling or refusing coverage and are not listed on the DE9C: W-2

4. Groups in the following categories have unique documentation requirements that must be submitted when one or more employees are enrolling:

Employers of union and nonunion employees
For small employer groups with union and nonunion employees, when the union members receive health coverage through a trust fund established by a collective bargaining agreement, Blue Shield will cover only the nonunion employees.
When the total number of both union and nonunion employees does not exceed 100, the employer can apply for small group coverage to cover only the nonunion employees. Only the eligible nonunion employees will be counted for purposes of minimum enrollment and participation requirements. To qualify for this coverage, the employer must provide Blue Shield with the following additional documentation:
• Most recently filed DE9C and/or payroll register (payroll register required if any employees are out of state) with union and
nonunion employees identified
• A copy of the collective bargaining agreement showing that the employer pays contributions to the trust fund
• The Statement of ERISA Rights from the union trust fund Summary Plan Description

Professional Employer Organization (“leased”) employees
Professional Employer Organization (PEO or “leased”) employees are considered employees of the PEO company. Small employer groups that have canceled their PEO arrangement and hired the former PEO employees will be considered for coverage as a qualified small employer pursuant to small group rules.
For small employer groups that have recently canceled their contract with a PEO, the following additional documentation is required:
• A copy of the letter sent from the PEO to the client business verifying the cancellation of the leasing arrangement.
• A copy of a payroll register from the PEO company that separates the formerly leased employees by business location

Combining multiple employer groups
If an owner believes that the structure of his/her holdings produces a single employer/employee relationship, Blue Shield will require filed ownership documentation for eligible subsidiaries/ affiliated companies.

Spin-off groups
A “spin-off group” is a newly formed business that is not yet eligible for qualified small group coverage, and in which a majority of the employees of the new business have left an established business (“former business”) currently offering Blue Shield coverage to its employees. A spin-off group must meet all small group requirements except for the length of time that the group has employed at least one eligible common-law employee who was covered under the former business’s Blue Shield small group health plan.
The requirements for issuance of coverage are:
• At least 50% of the employees in the spin-off group must have been enrolled in Blue Shield through the former business
• The new group does not have shared ownership with the business it has separated from
• W-4 forms for all W-2 employees
• Blue Shield of California Start-up Companies/Spin-off Group Eligibility Statement completed and signed by one of the group’s owners
• Blue Shield of California Small Group Owner Eligibility Statement completed and signed by any additional owners who are enrolling or refusing coverage
• Filed owner documentation linking owner to business
• All enrollment documents (employer and employee applications, refusals, business check/Small Group Initial Payment Form)

Start-up groups
A start-up group must meet all small group requirements except for the length of time that the group has employed at least one eligible common-law employee. Blue Shield will consider start-up groups that have been in business and have employed at least one eligible common-law employee for less than six weeks.
A start-up group must submit the following documentation:
• W-4 forms for all W-2 employees
• Blue Shield of California Start-up Companies/Spin-off Group Eligibility Statement completed and signed by one of the group’s owners
• Blue Shield of California Small Group Owner Eligibility Statement completed and signed by any additional owners who are enrolling or refusing coverage
• Filed owner documentation linking owner to business
• All enrollment documents (employer and employee applications, refusals, business check/Small Group Initial Payment Form)

 

Broker LicensingProducer Agreement - Effective 3/1/2021

Direct Deposit Authorization Form - for Broker

NOTE: Anytime dental and/or vision coverage is added to a new or existing small business client’s medical coverage, a 5% rate discount applies. A 10% rate discount will be effective 1/1/2019.

 
After approval, prior carrier termination letter must be submitted by the employer or broker.

 

​​​For other useful or older documents, please refer to the Forms database.

 

Important Reminder:  To help your client comply with ACA requirements, provide a copy of the appropriate Summary of Benefits and Coverage (SBC) to each employee at the Enrollment Meeting, via email or by posting on an internal company website.  For the most recent information regarding Blue Shield’s SBCs, please go to the SBC Page or contact your Word & Brown Representative.​​

  • Small Group Initial Payment Form
    • Blue Shield of California

    • form # N/A

    • Effective date: 10.01.2019

  • Small Group Owner Eligibility Statement
    • Blue Shield of California

    • form # N/A

    • Effective date: 03.01.2020

  • Start-up Companies/ Spin-off Group Eligibilty Statement
    • Blue Shield of California

    • form # N/A

    • Effective date: 03.01.2020

  • Master Group Application
    • Blue Shield of California

    • form # N/A

    • Effective date: 04.01.2021

  • Medical / Dental / Vision / Life Enrollment Application And Refusal Of Personal Coverage Form
    • Blue Shield of California

    • form # N/A

    • Effective date: 04.01.2021

  • Enrollment Spreadsheet With Master Application
    • Blue Shield of California

    • form # N/A

    • Effective date: 04.01.2021

  • New Group Submission Checklist
    • Blue Shield of California

    • form # N/A

    • Effective date: 04.01.2021

  • 2021 Producer Agreement
    • Blue Shield of California

    • form # N/A

    • Effective date: 03.01.2021