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Participation and Alongside Guidelines

Posted: August 21, 2019 by Staff Writer

Aetna

Standalone

60% participation for all group sizes excluding valid waivers (rounded down)

Alongside Another Carrier

25% participation and a minimum of 5 employees enrolling required for groups offering another carrier’s HMO plan

Anthem BlueCross

Standalone

1-4 enrolled employees: 65% participation through 12/15/19 effective dates

5+ enrolled employees: 25% participation through 12/15/19 effective dates

Applies to Medical, Dental and Vision Products

Alongside Another Carrier

Employees covered by the same employer on another group policy are not considered a valid waiver

Another carrier’s HMO or PPO plans can be sold alongside Anthem as long as Anthem receives the required participation

Employees who enroll with Kaiser will be considered invalid waivers

Blue Shield of California

Standalone

70% participation for mirror plans

65% participation for off exchange plans

25% participation for off exchange plans available to group of 5+ enrolling through 12/31/19

0% participation for groups selecting Trio only plans with no end date

Applies to Specialty Products

Alongside Another Carrier

Only one major medical carrier is allowed to be written alongside Blue Shield. Health exchanges are not eligible. MediExcel or SIMNSA can be written alongside as a third carrier

The Mirror Package for Small Business cannot be offered alongside another carrier. At least 25% of the total number of eligible employees must enroll with no fewer than 5 enrolled. Blue Shield must be the sole carrier for dental, vision and life plans

Employees who enroll with Kaiser will be considered invalid waivers.

CaliforniaChoice

Standalone

1-2 eligible employees: 100% participation

3+ eligible employees: 70% participation

Alongside Another Carrier

Cannot be written alongside another carrier

CalCPA Health

Standalone

If the employer is paying 100% contribution, all eligible employees must enroll

If less than 100% contribution, a minimum of 75% of eligible employees must enroll

Alongside Another Carrier

A firm is eligible to enroll in CalCPA Health if 1 employee is joining the program. The rest of the eligible employees may wrap with Kaiser or waive

Health Net

Standalone

Enhanced Choice A package: 66% for 1-5 and 50% for 6+ eligible employees

Enhanced Choice B package: 66% for 1-5 and 35% for 6+ eligible employees

No participation requirement for Salud Package with minimum of 2 enrolled through 12/31/19

HMO Package: No participation or Participation Attestation Form required with 6+ active enrolling employees through 12/31/19

Alongside Another Carrier

Another carrier’s HMO or PPO plans can be sold alongside Health Net as long as Health Net receives the required participation

Employees who enroll with Kaiser will be considered invalid waivers on the Enhanced Choice A & Enhanced Choice B Plans

Kaiser Permanente

Standalone

50% of eligible employees must be covered by a group plan through 1/1/20 effective dates

Alongside Another Carrier

A minimum of 1 W2 must enroll with Kaiser Permanente (cannot be an owner or spouse of an owner)

MediExcel

Standalone

Minimum participation: 3 enrolled required for PM, P5 and P20 except for Gold Mirror (GM)

Alongside Another Carrier

Group must have at least one non-owner W2 employee enrolling

Oscar

Standalone

100% employer contribution requires 100% participation excluding any valid waivers.

99%-50% employer contribution requires 60% participation excluding any valid waivers

Alongside Another Carrier

As long as 60% of the eligible employees enroll in a plan offered by the employer, Oscar will only require three eligible employees to enroll with Oscar through 12/15/19

Aetna, Blue Shield, CalChoice, CalCPA and UHC will not write alongside Oscar

Sharp Health Plan

Standalone

70% participation is required for all group sizes.

HMO: Minimum of 60% participation, excluding any valid waivers

Alongside Another Carrier

Group must have at least 5+ enrolled subscribers or 50% of the enrollment with Sharp Health Plan (whichever is greater). Multiple HMO plans allowed: 1-5 enrolled – 2 plans on 1 Network; 6+ enrolled – 6 plans on each of 2 Networks maximum

Wrap with CaliforniaChoice® is not allowed and PPO product is not available alongside another carrier

SIMNSA

Standalone

At least 5 employees enrolling

Alongside Another Carrier

Multiple carriers may be offered alongside as long as SIMNSA is the only option across the border

UnitedHealthcare

Standalone

60% participation for all group sizes excluding valid waivers

If the employer is paying 100% contribution, all eligible employees must enroll

Uniform dependent enrollment is required. All enrolling dependents Product Selection must match for each line of coverage

Alongside Another Carrier

Choice Simplified Package alongside to staff model carrier: 60% participation between the two carriers with 5 CA employees enrolling with UHC is required

Multi-Choice® State Package alongside to staff model carrier: 60% participation with UHC is required

Eligible staff-models include: CCHP, KP, MediExcel, Sharp, SIMNSA, Sutter and WHA




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