Covered California for Small Business

Covered California for Small Business offers four levels of coverage — Bronze, Silver, Gold and Platinum — each with multiple plan options. We make it easy for you to choose not one level, but two adjoining levels of coverage.

 

Form Name Effective Date Download Form
New Group Submission
Enrollment Checklist
01/01/2020 Download
Employer Application (fillable) 10.21
10/01/2021 Download
Employee Roster
01/01/2020 Download
New Business Late Submission Acknowledgement Form
01/01/2020 Download
New Business Documentation Guide
04/01/2021 Download
In Force Group Forms
Employer Change Request Form 1.21
01/01/2021 Download
COBRA Participant Cancellation Form
01/01/2020 Download
Administration
Small Business Employer Guide
02/01/2021 Download
CCSB Carrier Contacts
01/01/2020 Download
ASKCCSB Employer Portal Registration Guide
01/01/2020 Download
Employer Portal - Renewal Guide
01/01/2020 Download
Invoice Tutorial
01/01/2020 Download
Open Enrollment Checklist
04/01/2020 Download
Form Name Effective Date Download Form
Enrollment and Change Forms
Employee Enrollment Form 3.21
03/01/2021 Download
Employee Change Request Form 2021
03/01/2021 Download
COBRA Forms
COBRA Election Form
01/01/2020 Download
Form Name Effective Date Download Form
2021 Medical HMO
Blue Shield HMO
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental
01/01/2021 Summary SBC
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental INF (with Infertility)
01/01/2021 SBC
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental
01/01/2021 Summary SBC
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental INF (with Infertility)
01/01/2021 SBC
Blue Shield Trio Silver 70 HMO 2250/55 + Child Dental
01/01/2021 Summary SBC
Blue Shield Trio Silver 70 HMO 2250/55 + Child Dental INF (with Infertility)
01/01/2021 SBC
Kaiser Permanente HMO
Kaiser Platinum 90 HMO 0/10 Alt
01/01/2021 Summary SBC
Kaiser Platinum 90 HMO 0/10 Alt INF (with Infertility)
01/01/2021 SBC
Kaiser Platinum 90 HMO 0/20
01/01/2021 Summary SBC
Kaiser Platinum 90 HMO 0/20 INF (with Infertility)
01/01/2021 SBC
Kaiser Gold 80 HMO 0/30 Alt
01/01/2021 Summary SBC
Kaiser Gold 80 HMO 0/30 Alt INF (with Infertility)
01/01/2021 SBC
Kaiser Gold 80 HMO 250/35
01/01/2021 Summary SBC
Kaiser Gold 80 HMO 250/35 INF (with Infertility)
01/01/2021 SBC
Kaiser Gold 80 HMO 1000/40 Alt
01/01/2021 Summary SBC
Kaiser Gold 80 HMO 1000/40 Alt INF (with Infertility)
01/01/2021 SBC
Kaiser Silver 70 HMO 1650/55 Alt
01/01/2021 Summary SBC
Kaiser Silver 70 HMO 1650/55 Alt INF (with Infertility)
01/01/2021 SBC
Kaiser Silver 70 HMO 2100/55 Alt
01/01/2021 Summary SBC
Kaiser Silver 70 HMO 2100/55 Alt INF (with Infertility)
01/01/2021 SBC
Kaiser Silver 70 HMO 2250/55
01/01/2021 Summary SBC
Kaiser Silver 70 HMO 2250/55 INF (with Infertility)
01/01/2021 SBC
Kaiser Silver 70 HMO 2600/55 Alt
01/01/2021 Summary SBC
Kaiser Silver 70 HMO 2600/55 Alt INF (with Infertility)
01/01/2021 SBC
Kaiser Silver 70 HDHP HMO 2500/20%
01/01/2021 Summary SBC
Kaiser Silver 70 HDHP HMO 2500/20% INF (with Infertility)
01/01/2021 SBC
Kaiser Bronze 60 HMO 5400/60 Alt
01/01/2021 Summary SBC
Kaiser Bronze 60 HMO 5400/60 Alt INF (with Infertility)
01/01/2021 SBC
Kaiser Bronze 60 HMO 6300/65
01/01/2021 Summary SBC
Kaiser Bronze 60 HMO 6300/65 INF (with Infertility)
01/01/2021 SBC
Kaiser Bronze 60 HDHP HMO 7000/0%
01/01/2021 Summary SBC
Kaiser Bronze 60 HDHP HMO 7000/0% INF (with Infertility)
01/01/2021 SBC
Sharp HMO
Sharp Performance Platinum 90 HMO 0/15 + Child Dental
01/01/2021 Summary SBC
Sharp Performance Platinum 90 HMO 0/15 + Child Dental INF (with Infertility)
01/01/2021 SBC
Sharp Premier Platinum 90 HMO 0/20 + Child Dental
01/01/2021 Summary SBC
Sharp Premier Platinum 90 HMO 0/20 + Child Dental INF (with Infertility)
01/01/2021 SBC
Sharp Premier Gold 80 HMO 250/35 + Child Dental
01/01/2021 Summary SBC
Sharp Premier Gold 80 HMO 250/35 + Child Dental INF (with Infertility)
01/01/2021 SBC
Sharp Performance Gold 80 HMO 350/25 + Child Dental
01/01/2021 Summary SBC
Sharp Performance Gold 80 HMO 350/25 + Child Dental INF (with Infertility)
01/01/2021 SBC
Sharp Performance Silver 70 HMO 2250/50 + Child Dental
01/01/2021 Summary SBC
Sharp Performance Silver 70 HMO 2250/50 + Child Dental INF (with Infertility)
01/01/2021 SBC
Sharp Premier Silver 70 HMO 2250/55 + Child Dental
01/01/2021 Summary SBC
Sharp Premier Silver 70 HMO 2250/55 + Child Dental INF (with Infertility)
01/01/2021 SBC
Sharp Premier Silver 70 HDHP HMO 2500/20% + Child Dental
01/01/2021 Summary SBC
Sharp Premier Silver 70 HDHP HMO 2500/20% + Child Dental INF (with Infertility)
01/01/2021 SBC
Sharp Performance Bronze 60 HMO 6300/65 + Child Dental
01/01/2021 Summary SBC
Sharp Performance Bronze 60 HMO 6300/65 + Child Dental INF (with Infertility)
01/01/2021 SBC
Sharp Premier Bronze 60 HDHP HMO 7000/0% + Child Dental
01/01/2021 Summary SBC
Sharp Premier Bronze 60 HDHP HMO 7000/0% + Child Dental INF (with Infertility)
01/01/2021 SBC
2021 Medical EPO
Oscar EPO
Oscar Circle Platinum 90 EPO 0/20 + Child Dental
01/01/2021 Summary SBC
Oscar Circle Platinum 90 EPO 0/20 + Child Dental INF (with Infertility)
01/01/2021 SBC
Oscar Circle Gold 80 EPO 0/30 + Child Dental Alt
01/01/2021 Summary SBC
Oscar Circle Gold 80 EPO 0/30 + Child Dental Alt INF (with Infertility)
01/01/2021 SBC
Oscar Circle Gold 80 EPO 250/35 + Child Dental
01/01/2021 Summary SBC
Oscar Circle Gold 80 EPO 250/35 + Child Dental INF (with Infertility)
01/01/2021 SBC
Oscar Circle Silver 70 EPO 1500/50 + Child Dental Alt
01/01/2021 Summary SBC
Oscar Circle Silver 70 EPO 1500/50 + Child Dental Alt INF (with Infertility)
01/01/2021 SBC
Oscar Circle Silver 70 EPO 2250/55 + Child Dental
01/01/2021 Summary SBC
Oscar Circle Silver 70 EPO 2250/55 + Child Dental INF (with Infertility)
01/01/2021 SBC
Oscar Circle Bronze 60 HDHP EPO 7000/0% + Child Dental
01/01/2021 Summary SBC
Oscar Circle Bronze 60 HDHP EPO 7000/0% + Child Dental INF (with Infertility)
01/01/2021 SBC
2021 Medical PPO
Blue Shield PPO
Blue Shield Platinum 90 PPO 0/15 + Child Dental
01/01/2021 Summary SBC
Blue Shield Platinum 90 PPO 0/15 + Child Dental INF (with Infertility)
01/01/2021 SBC
Blue Shield Gold 80 PPO 350/25 + Child Dental
01/01/2021 Summary SBC
Blue Shield Gold 80 PPO 350/25 + Child Dental INF (with Infertility)
01/01/2021 SBC
Blue Shield Silver 70 PPO 2250/50 + Child Dental
01/01/2021 Summary SBC
Blue Shield Silver 70 PPO 2250/50 + Child Dental INF (with Infertility)
01/01/2021 SBC
Blue Shield Bronze 60 PPO 6300/65 + Child Dental
01/01/2021 Summary SBC
Blue Shield Bronze 60 PPO 6300/65 + Child Dental INF (with Infertility)
01/01/2021 SBC
Health Net PPO
Health Net Platinum 90 PPO 0/15 + Child Dental
01/01/2021 Summary SBC
Health Net Platinum 90 PPO 0/15 + Child Dental INF (with Infertility)
01/01/2021 SBC
Health Net EnhancedCare Platinum 90 PPO 250/15 + Child Dental Alt
01/01/2021 Summary SBC
Health Net EnhancedCare Platinum 90 PPO 250/15 + Child Dental Alt INF (with Infertility)
01/01/2021 SBC
Health Net Gold 80 PPO 0/30 + Child Dental Alt
01/01/2021 Summary SBC
Health Net Gold 80 PPO 0/30 + Child Dental Alt INF (with Infertility)
01/01/2021 SBC
Health Net Gold 80 PPO 350/25 + Child Dental
01/01/2021 Summary SBC
Health Net Gold 80 PPO 350/25 + Child Dental INF (with Infertility)
01/01/2021 SBC
Health Net Gold 80 PPO Value 750/15 + Child Dental
01/01/2021 Summary SBC
Health Net Gold 80 PPO Value 750/15 + Child Dental INF (with Infertility)
01/01/2021 SBC
Health Net EnhancedCare Gold 80 PPO 1000/30 + Child Dental Alt
01/01/2021 Summary SBC
Health Net EnhancedCare Gold 80 PPO 1000/30 + Child Dental Alt INF (with Infertility)
01/01/2021 SBC
Health Net Silver 70 Value PPO 1700/50 + Child Dental Alt
01/01/2021 Summary SBC
Health Net Silver 70 Value PPO 1700/50 + Child Dental Alt INF (with Infertility)
01/01/2021 SBC
Health Net Silver 70 PPO 2250/50 + Child Dental
01/01/2021 Summary SBC
Health Net Silver 70 PPO 2250/50 + Child Dental INF (with Infertility)
01/01/2021 SBC
Health Net Silver 70 HDHP PPO 1400/40% + Child Dental Alt
01/01/2021 Summary SBC
Health Net Silver 70 HDHP PPO 1400/40% + Child Dental Alt INF (with Infertility)
01/01/2021 SBC
Health Net EnhancedCare Silver 70 HDHP PPO 1400/40% + Child Dental Alt
01/01/2021 Summary SBC
Health Net EnhancedCare Silver 70 HDHP PPO 1400/40% + Child Dental Alt INF (with Infertility)
01/01/2021 SBC
Health Net EnhancedCare Silver 70 PPO 2250/55 + Child Dental Alt
01/01/2021 Summary SBC
Health Net EnhancedCare Silver 70 PPO 2250/55 + Child Dental Alt INF (with Infertility)
01/01/2021 SBC
Health Net Bronze 60 PPO 6300/65 + Child Dental
01/01/2021 Summary SBC
Health Net Bronze 60 PPO 6300/65 + Child Dental INF (with Infertility)
01/01/2021 SBC
Health Net Bronze 60 HDHP PPO 7000/0% + Child Dental
01/01/2021 Summary SBC
Health Net Bronze 60 HDHP PPO 7000/0% + Child Dental INF (with Infertility)
01/01/2021 SBC
2020 Medical HMO
Blue Shield HMO
Blue Shield Trio Platinum 90 HMO 0/15 + Child Dental
01/01/2020 Summary SBC
Blue Shield Trio Platinum 90 HMO 0/15 + Child Dental INF (with Infertility)
01/01/2020 SBC
Blue Shield Trio Gold 80 HMO 250/25 + Child Dental
01/01/2020 Summary SBC
Blue Shield Trio Gold 80 HMO 250/25 + Child Dental INF (with Infertility)
01/01/2020 SBC
Blue Shield Trio Silver 70 HMO 2250/50 + Child Dental
01/01/2020 Summary SBC
Blue Shield Trio Silver 70 HMO 2250/50 + Child Dental INF (with Infertility)
01/01/2020 SBC
Kaiser Permanente HMO
Kaiser Platinum 90 HMO 0/10 Alt
01/01/2020 Summary SBC
Kaiser Platinum 90 HMO 0/10 Alt INF (with Infertility)
01/01/2020 Summary SBC
Kaiser Platinum 90 HMO 0/15
01/01/2020 Summary SBC
Kaiser Platinum 90 HMO 0/15 INF (with Infertility)
01/01/2020 Summary SBC
Kaiser Gold 80 HMO 250/25
01/01/2020 Summary SBC
Kaiser Gold 80 HMO 250/25 INF (with Infertility)
01/01/2020 Summary SBC
Kaiser Gold 80 HMO 500/30 Alt
01/01/2020 Summary SBC
Kaiser Gold 80 HMO 500/30 Alt INF (with Infertility)
01/01/2020 Summary SBC
Kaiser Silver 70 HMO 1650/55 Alt
01/01/2020 Summary SBC
Kaiser Silver 70 HMO 1650/55 Alt INF (with Infertility)
01/01/2020 Summary SBC
Kaiser Silver 70 HMO 1800/55 Alt
01/01/2020 Summary SBC
Kaiser Silver 70 HMO 1800/55 Alt INF (with Infertility)
01/01/2020 Summary SBC
Kaiser Silver 70 HMO 2250/50
01/01/2020 Summary SBC
Kaiser Silver 70 HMO 2250/50 INF (with Infertility)
01/01/2020 Summary SBC
Kaiser Silver 70 HDHP HMO 2500/20%
01/01/2020 Summary SBC
Kaiser Silver 70 HDHP HMO 2500/20% INF (with Infertility)
01/01/2020 Summary SBC
Kaiser Bronze 60 HMO 6300/65
01/01/2020 Summary SBC
Kaiser Bronze 60 HMO 6300/65 INF (with Infertility)
01/01/2020 Summary SBC
Kaiser Bronze 60 HDHP HMO 6900/0%
01/01/2020 Summary SBC
Kaiser Bronze 60 HDHP HMO 6900/0% INF (with Infertility)
01/01/2020 Summary SBC
Sharp HMO
Sharp Performance Platinum 90 HMO 0/15 + Child Dental
01/01/2020 Summary SBC
Sharp Performance Platinum 90 HMO 0/15 + Child Dental INF (with Infertility)
01/01/2020 SBC
Sharp Premier Platinum 90 HMO 0/15 + Child Dental
01/01/2020 Summary SBC
Sharp Premier Platinum 90 HMO 0/15 + Child Dental INF (with Infertility)
01/01/2020 SBC
Sharp Performance Gold 80 HMO 250/25 + Child Dental
01/01/2020 Summary SBC
Sharp Performance Gold 80 HMO 250/25 + Child Dental INF (with Infertility)
01/01/2020 SBC
Sharp Premier Gold 80 HMO 250/25 + Child Dental
01/01/2020 Summary SBC
Sharp Premier Gold 80 HMO 250/25 + Child Dental INF (with Infertility)
01/01/2020 SBC
Sharp Performance Silver 70 HMO 2250/50 + Child Dental
01/01/2020 Summary SBC
Sharp Performance Silver 70 HMO 2250/50 + Child Dental INF (with Infertility)
01/01/2020 SBC
Sharp Premier Silver 70 HMO 2250/50 + Child Dental
01/01/2020 Summary SBC
Sharp Premier Silver 70 HMO 2250/50 + Child Dental INF (with Infertility)
01/01/2020 SBC
Sharp Premier Silver 70 HDHP HMO 2500/20% + Child Dental
01/01/2020 Summary SBC
Sharp Premier Silver 70 HDHP HMO 2500/20% + Child Dental INF (with Infertility)
01/01/2020 SBC
Sharp Performance Bronze 60 HMO 6300/65 + Child Dental
01/01/2020 Summary SBC
Sharp Performance Bronze 60 HMO 6300/65 + Child Dental INF (with Infertility)
01/01/2020 SBC
Sharp Premier Bronze 60 HDHP HMO 6900/0% + Child Dental
01/01/2020 Summary SBC
Sharp Premier Bronze 60 HDHP HMO 6900/0% + Child Dental INF (with Infertility)
01/01/2020 SBC
2020 Medical EPO
Oscar EPO
Oscar Platinum 90 EPO 0/15 + Child Dental
01/01/2020 Summary SBC
Oscar Platinum 90 EPO 0/15 + Child Dental INF (with Infertility)
01/01/2020 Summary SBC
Oscar Gold 80 EPO 0/30 + Child Dental Alt
01/01/2020 Summary SBC
Oscar Gold 80 EPO 0/30 + Child Dental Alt INF (with Infertility)
01/01/2020 Summary SBC
Oscar Gold 80 EPO 250/25 + Child Dental
01/01/2020 Summary SBC
Oscar Gold 80 EPO 250/25 + Child Dental INF (with Infertility)
01/01/2020 Summary SBC
Oscar Silver 70 EPO 1500/50 + Child Dental Alt
01/01/2020 Summary SBC
Oscar Silver 70 EPO 1500/50 + Child Dental Alt INF (with Infertility)
01/01/2020 Summary SBC
Oscar Silver 70 EPO 2250/50 + Child Dental
01/01/2020 Summary SBC
Oscar Silver 70 EPO 2250/50 + Child Dental INF (with Infertility)
01/01/2020 Summary SBC
Oscar Bronze 60 HDHP EPO 6900/0% + Child Dental
01/01/2020 Summary SBC
Oscar Bronze 60 HDHP EPO 6900/0% + Child Dental INF (with Infertility)
01/01/2020 Summary SBC
2020 Medical PPO
Blue Shield PPO
Blue Shield Platinum 90 PPO 0/15 + Child Dental
01/01/2020 Summary SBC
Blue Shield Platinum 90 PPO 0/15 + Child Dental INF (with Infertility)
01/01/2020 SBC
Blue Shield Gold 80 PPO 250/25 + Child Dental
01/01/2020 Summary SBC
Blue Shield Gold 80 PPO 250/25 + Child Dental INF (with Infertility)
01/01/2020 SBC
Blue Shield Silver 70 PPO 2250/50 + Child Dental
01/01/2020 Summary SBC
Blue Shield Silver 70 PPO 2250/50 + Child Dental INF (with Infertility)
01/01/2020 SBC
Blue Shield Bronze 60 PPO 6300/65 + Child Dental
01/01/2020 Summary SBC
Blue Shield Bronze 60 PPO 6300/65 + Child Dental INF (with Infertility)
01/01/2020 SBC
Health Net PPO
Health Net Platinum 90 PPO 0/15 + Child Dental
01/01/2020 Summary SBC
Health Net Platinum 90 PPO 0/15 + Child Dental INF (with Infertility)
01/01/2020 SBC
Health Net EnhancedCare Platinum 90 PPO 250/15 + Child Dental Alt
01/01/2020 Summary SBC
Health Net EnhancedCare Platinum 90 PPO 250/15 + Child Dental Alt INF (with Infertility)
01/01/2020 SBC
Health Net Gold 80 PPO 0/30 + Child Dental Alt
01/01/2020 Summary SBC
Health Net Gold 80 PPO 0/30 + Child Dental Alt INF (with Infertility)
01/01/2020 SBC
Health Net Gold 80 PPO 250/25 + Child Dental
01/01/2020 Summary SBC
Health Net Gold 80 PPO 250/25 + Child Dental INF (with Infertility)
01/01/2020 SBC
Health Net Gold 80 PPO Value 750/15 + Child Dental
01/01/2020 Summary SBC
Health Net Gold 80 PPO Value 750/15 + Child Dental INF (with Infertility)
01/01/2020 SBC
Health Net EnhancedCare Gold 80 PPO 1000/30 + Child Dental Alt
01/01/2020 Summary SBC
Health Net EnhancedCare Gold 80 PPO 1000/30 + Child Dental Alt INF (with Infertility)
01/01/2020 SBC
Health Net Silver 70 PPO 2250/50 + Child Dental
01/01/2020 Summary SBC
Health Net Silver 70 PPO 2250/50 + Child Dental INF (with Infertility)
01/01/2020 SBC
Health Net Silver 70 Value PPO 1700/50 + Child Dental Alt
01/01/2020 Summary SBC
Health Net Silver 70 Value PPO 1700/50 + Child Dental Alt INF (with Infertility)
01/01/2020 SBC
Health Net Silver 70 HDHP PPO 1400/40% + Child Dental Alt
01/01/2020 Summary SBC
Health Net Silver 70 HDHP PPO 1400/40% + Child Dental Alt INF (with Infertility)
01/01/2020 SBC
Health Net EnhancedCare Silver 70 PPO 2250/55 + Child Dental Alt
01/01/2020 Summary SBC
Health Net EnhancedCare Silver 70 PPO 2250/55 + Child Dental Alt INF (with Infertility)
01/01/2020 SBC
Health Net EnhancedCare Silver 70 HDHP PPO 1400/40% + Child Dental Alt
01/01/2020 Summary SBC
Health Net EnhancedCare Silver 70 HDHP PPO 1400/40% + Child Dental Alt INF (with Infertility)
01/01/2020 SBC
Health Net Bronze 60 PPO 6300/65 + Child Dental
01/01/2020 Summary SBC
Health Net Bronze 60 PPO 6300/65 + Child Dental INF (with Infertility)
01/01/2020 SBC
Health Net Bronze 60 HDHP PPO 5600/20% + Child Dental Alt
01/01/2020 Summary SBC
Health Net Bronze 60 HDHP PPO 5600/20% + Child Dental Alt INF (with Infertility)
01/01/2020 SBC
Health Net EnhancedCare Bronze 60 HDHP PPO 5600/20% + Child Dental Alt
01/01/2020 Summary SBC
Health Net EnhancedCare Bronze 60 HDHP PPO 5600/20% + Child Dental Alt INF (with Infertility)
01/01/2020 SBC
Form Name Effective Date Download Form
General Information
2021 Plan Summary
01/01/2021 Download
Underwriting Guidelines
01/01/2020 Download
Agent Commission Structure
08/01/2021 Download
Flexible Plan Options with More Metal Tiers Flyer
10/01/2021 Download
Health Insurance Made Simple Employer Brochure
01/01/2020 Download
Health & Dental Plan Offerings and Network Summary
01/01/2020 Download
How to Access or Order A Member ID Card
09/01/2020 Download
MyCCSB Broker Portal Registration Flyer
01/01/2020 Download
MyCCSB FAQ - Processing Additions
04/01/2020 Download
MyCCSB FAQ - Processing Terminations
01/01/2020 Download
Small Business Tax Credit Fact Sheet
02/01/2021 Download
Small Business Tax Credit Instructions Flyer
02/01/2021 Download
Small Business Trifold
01/01/2020 Download
Value Added Benefit Grid
09/01/2020 Download
Why Sell CCSB - Think Differently
01/01/2020 Download
Form Name Effective Date Download Form
Contact Sheet
Download