Enrollment Kit - cCHP (medical)
0
Forms Selected
Clear Selection
Form Name
Effective Date
Current As Of
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 Chinese Community Health Plan's case submission requirements.
To ensure prompt processing, please make sure to include the following documents:
All documents below must be submitted at the time of application.
A signed original Employer Group Application - Effective 1/1/2021
A copy (all pages) of the most recent state Quarterly Wage and Tax Report (DE-9C).
If the group has not been in business long enough to have a DE-9C, six weeks of payroll, including withholdings, may be submitted.
For all employees that don’t appear on the current DE-9C, a copy of the most recent payroll is required.
Copy of Worker’s Compensation.
To reconcile the DE-9C, please indicate next to each employee’s name one of the following:
T- Terminated (including termination date)
E- Eligible and enrolling
W- Eligible and waving coverage
A copy of the current carrier’s most recent billing statement (including all pages). Employees appearing on the current bill with a reported termination date of 90 days or greater will be required to complete a COBRA application or waiver form as verification of their eligibility to continue or decline coverage.
Employee Enrollment Form - Effective 1/1/2021
Completed and signed by all eligible employee(s) enrolling/waiving coverage.
If Medicare is primary, a copy of each employee’s Medicare card is required to verify enrollment in parts A and B. A copy of the Medicare card is also required to confirm participation requirements.
First month premium check made payable to CCHP.
If Broker is involved, a Broker of Record letter is required.
Proof of Ownership documentation:
Required for all groups enrolling and owner-only groups of any size when the owners do not appear on the DE-9C or payroll records.
Must list each person’s first and last name. Paperwork must be filled out with the state or country documentation may include:
Sole Proprietorship:
California Business License, or
Fictitious Business Name Statement, if any, or
Most recent IRS Schedule C (Form 1040)
Partnership / LLP:
Partnership Agreement signed by each partner plus a federal EIN assignment letter, or
IRS Schedule K-1 (Form 1065) for all enrolling partners or Partnership Agreement signed by each partner.
Corporation:
Statement of Information
S-Corps: IRS Schedule K-1 (Form1120S) for all enrolling owners/officers.
C-Corps: IRS Form 1120 (pages 1 & 2) which includes “Schedule E”
LLC:
LLC Agreement signed by all managers/members/parties or copies of appropriate tax returns (follow the guidelines for an S-Corp, Partnership or Sole Proprietorship based on how the LLC was formed)
Statement of Information (From LLC-12)
New/Start-up Businesses:
Payroll records or applicable filing indicating the length of time the group has been in business. These documents must span the twelve (12) weeks preceding the effective date and demonstrate one or more eligible employees for the entire period. Payroll records must include all pages for all pay periods and list the following:
Company name
Date of pay periods
Employee names, wages paid, withholdings and grand totals
Individual payroll / pay stubs, estimated payroll, payroll summarries or handwritten journals are not deemed acceptable.
Broker Licensing: Agent Agreement
| 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.