Enrollment Kit - health net (medical)
Current As Of
PLEASE NOTE: 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.
- Groups applying for a 1st-of-the-month effective date must be submitted to Health Net by the 5th of the month. Paperwork must be completed by the 20th of the month; otherwise, the group will be rolled to the following month.
- A signed original application for Group Service Agreement (GSA)/Group Policy
- A complete employee application for each eligible employee enrolling/waiving coverage
- An Electronic Check form and a copy of the group's voided business check for the first month’s premium
- The latest quarter DE-9C, reconciled:
- If the group has not been in business long enough to have a DE-9C, six weeks of payroll, including withholdings, may be submitted.
- 2-week payroll is required for all employees that don’t appear on the current DE-9C.
- For wages exceeding part-time and wages below full-time status, payroll will be required.
- To reconcile the DE-9C, please indicate next to each employee’s name one of the following:
W – Eligible and waiving coverage S – Seasonal
WP – Waiting period (include date of hire for those in waiting period) TEMP – Temporary employees
PT – Part-time Covered by another carrier – add carrier name.
- Ownership paperwork (required if owner/partners’ names do not appear on the DE-9C or payroll records). Must list each person’s first and last name. Paperwork must be filed with the state or county. Documentation may include:
- For sole proprietor:
- Fictitious Business Name Statement
- Schedule C Tax Form
- For partnership:
- Fictitious Business Name Statement (showing both names)
- Schedule K Tax Form (for all eligible owners)
- Tax certificate (showing both names)
- For corporation:
- Statement of Information
- Tax Form 1120
Note: Please consult your sales representative for acceptable ownership documentation for other business structures.
For PPO and EnhancedCare PPO plans:
- Copies of EOBs for employees requesting Deductible Credit from prior carrier
After approval, prior carrier termination letter must be submitted by the employer or broker.
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 Health Net’s SBCs, contact your Word & Brown representative.
Health Net’s SBCs, please go to the SBC Page or contact your Word & Brown Representative.