Covered California for Small Business

Form Name	Effective Date	Download Form
New Group Submission
Enrollment Checklist	01/01/2020	Download
Employer Application 1.23	01/01/2023	Download
New Business Late Submission Acknowledgement Form	05/01/2023	Download
New Business Documentation Guide	07/01/2022	Download
In Force Group Forms
Employer Change Request Form 1.23	01/01/2023	Download
Employer Change Request Form 1.22	01/01/2022	Download
COBRA Participant Cancellation Form	07/01/2022	Download
Administration
Small Business Employer Guide	01/01/2023	Download
CCSB Carrier Contacts	03/01/2022	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 7.23	07/01/2023	Download
Employee Enrollment Form 1.23	01/01/2023	Download
Employee Change Request Form 7.23	07/01/2023	Download
Employee Change Request Form 1.23	01/01/2023	Download
Employee Change Request Form 1.22	01/01/2022	Download
COBRA Forms
COBRA Election Form	07/01/2022	Download

Form Name	Effective Date	Download Form
2023 Medical HMO
Blue Shield Access+ HMO Network
Blue Shield Access+ Platinum 90 HMO 0/20 + Child Dental [New 7/1/2023]	07/01/2023	Summary	SBC
Blue Shield Access+ Platinum 90 HMO 0/20 + Child Dental INF [New 7/1/2023]	07/01/2023		SBC
Blue Shield Access+ Gold 80 HMO 250/35 + Child Dental [New 7/1/2023]	07/01/2023	Summary	SBC
Blue Shield Access+ Gold 80 HMO 250/35 + Child Dental INF [New 7/1/2023]	07/01/2023		SBC
Blue Shield Access+ Silver 70 HMO 2500/55 + Child Dental [New 7/1/2023]	07/01/2023	Summary	SBC
Blue Shield Access+ Silver 70 HMO 2500/55 + Child Dental INF [New 7/1/2023]	07/01/2023		SBC
Blue Shield Trio HMO Network
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental	01/01/2023	Summary	SBC
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental INF	01/01/2023		SBC
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental	01/01/2023	Summary	SBC
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental INF	01/01/2023		SBC
Blue Shield Trio Silver 70 HMO 2500/55 + Child Dental	01/01/2023	Summary	SBC
Blue Shield Trio Silver 70 HMO 2500/55 + Child Dental INF	01/01/2023		SBC
Blue Shield Bronze Trio HMO 7000/70 + Child Dental [New 7/1/2023]	07/01/2023	Summary	SBC
Blue Shield Bronze Trio HMO 7000/70 + Child Dental INF [New 7/1/2023]	07/01/2023		SBC
Kaiser Permanente HMO
Kaiser Platinum 90 HMO 0/10 + Child Dental Alt	01/01/2023	Summary	SBC
Kaiser Platinum 90 HMO 0/10 + Child Dental Alt INF	01/01/2023		SBC
Kaiser Platinum 90 HMO 0/20 + Child Dental	01/01/2023	Summary	SBC
Kaiser Platinum 90 HMO 0/20 + Child Dental INF	01/01/2023		SBC
Kaiser Gold 80 HMO 0/30 + Child Dental Alt	01/01/2023	Summary	SBC
Kaiser Gold 80 HMO 0/30 + Child Dental Alt INF	01/01/2023		SBC
Kaiser Gold 80 HMO 25/35 + Child Dental	01/01/2023	Summary	SBC
Kaiser Gold 80 HMO 250/35 + Child Dental INF	01/01/2023		SBC
Kaiser Gold 80 HMO 1000/40 + Child Dental Alt	01/01/2023	Summary	SBC
Kaiser Gold 80 HMO 1000/40 + Child Dental Alt INF	01/01/2023		SBC
Kaiser Gold 80 HDHP HMO 1600/15% + Child Dental Alt	01/01/2023	Summary	SBC
Kaiser Gold 80 HDHP HMO 1600/15% + Child Dental Alt INF	01/01/2023		SBC
Kaiser Silver 70 HMO 1900/65 + Child Dental Alt	01/01/2023	Summary	SBC
Kaiser Silver 70 HMO 1900/65 + Child Dental Alt INF	01/01/2023		SBC
Kaiser Silver 70 HMO 2300/65 + Child Dental Alt	01/01/2023	Summary	SBC
Kaiser Silver 70 HMO 2300/65 + Child Dental Alt INF	01/01/2023		SBC
Kaiser Silver 70 HMO 2500/55 + Child Dental	01/01/2023	Summary	SBC
Kaiser Silver 70 HMO 2500/55 + Child Dental INF	01/01/2023		SBC
Kaiser Silver 70 HMO 2800/65 + Child Dental Alt	01/01/2023	Summary	SBC
Kaiser Silver 70 HMO 2800/65 + Child Dental Alt INF	01/01/2023		SBC
Kaiser Silver 70 HDHP HMO 2700/25% + Child Dental	01/01/2023	Summary	SBC
Kaiser Silver 70 HDHP HMO 2700/25% + Child Dental INF	01/01/2023		SBC
Kaiser Bronze 60 HMO 5400/60 + Child Dental Alt	01/01/2023	Summary	SBC
Kaiser Bronze 60 HMO 5400/60 + Child Dental Alt INF	01/01/2023		SBC
Kaiser Bronze 60 HMO 6300/65 + Child Dental	01/01/2023	Summary	SBC
Kaiser Bronze 60 HMO 6300/65 + Child Dental INF	01/01/2023		SBC
Kaiser Bronze 60 HDHP HMO 7000/0% + Child Dental	01/01/2023	Summary	SBC
Kaiser Bronze 60 HDHP HMO 7000/0% + Child Dental INF	01/01/2023		SBC
Sharp HMO
Sharp Performance Platinum 90 HMO 0/15 + Child Dental	01/01/2023	Summary	SBC
Sharp Performance Platinum 90 HMO 0/15 + Child Dental INF	01/01/2023		SBC
Sharp Premier Platinum 90 HMO 0/20 + Child Dental	01/01/2023	Summary	SBC
Sharp Premier Platinum 90 HMO 0/20 + Child Dental INF	01/01/2023		SBC
Sharp Performance Gold 80 HMO 350/25 + Child Dental	01/01/2023	Summary	SBC
Sharp Performance Gold 80 HMO 350/25 + Child Dental INF	01/01/2023		SBC
Sharp Premier Gold 80 HMO 250/35 + Child Dental	01/01/2023	Summary	SBC
Sharp Premier Gold 80 HMO 250/35 + Child Dental INF	01/01/2023		SBC
Sharp Performance Silver 70 HMO 2500/55 + Child Dental	01/01/2023	Summary	SBC
Sharp Performance Silver 70 HMO 2500/55 + Child Dental INF	01/01/2023		SBC
Sharp Premier Silver 70 HMO 2500/55 + Child Dental	01/01/2023	Summary	SBC
Sharp Premier Silver 70 HMO 2500/55 + Child Dental INF	01/01/2023		SBC
Sharp Premier Silver 70 HDHP HMO 2700/25% + Child Dental	01/01/2023	Summary	SBC
Sharp Premier Silver 70 HDHP HMO 2700/25% + Child Dental INF	01/01/2023		SBC
Sharp Performance Bronze 60 HMO 6300/65 + Child Dental	01/01/2023	Summary	SBC
Sharp Performance Bronze 60 HMO 6300/65 + Child Dental INF	01/01/2023		SBC
Sharp Premier Bronze 60 HDHP HMO 7000/0% + Child Dental	01/01/2023	Summary	SBC
Sharp Premier Bronze 60 HDHP HMO 7000/0% + Child Dental INF	01/01/2023		SBC
2023 Medical PPO
Blue Shield PPO
Blue Shield Platinum 90 PPO 0/15 + Child Dental	01/01/2023	Summary	SBC
Blue Shield Platinum 90 PPO 0/15 + Child Dental INF	01/01/2023		SBC
Blue Shield Gold 80 PPO 350/25 + Child Dental	01/01/2023	Summary	SBC
Blue Shield Gold 80 PPO 350/25 + Child Dental INF	01/01/2023		SBC
Blue Shield Silver 70 PPO 2500/55 + Child Dental	01/01/2023	Summary	SBC
Blue Shield Silver 70 PPO 2500/55 + Child Dental INF	01/01/2023		SBC
Blue Shield Silver Full PPO Savings 2300/25% + Child Dental [New 7/1/2023]	07/01/2023	Summary	SBC
Blue Shield Silver Full PPO Savings 2300/25% + Child Dental INF [New 7/1/2023]	07/01/2023		SBC
Blue Shield Bronze 60 PPO 6300/65 + Child Dental	01/01/2023	Summary	SBC
Blue Shield Bronze 60 PPO 6300/65 + Child Dental INF	01/01/2023		SBC
Blue Shield Bronze Full PPO Savings 7000 + Child Dental [New 7/1/2023]	07/01/2023	Summary	SBC
Blue Shield Bronze Full PPO Savings 7000 + Child Dental INF [New 7/1/2023]	07/01/2023		SBC
2022 Medical HMO
Blue Shield HMO
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental	01/01/2022	Summary	SBC
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental INF	01/01/2022		SBC
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental	01/01/2022	Summary	SBC
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental INF	01/01/2022		SBC
Blue Shield Trio Silver 70 HMO 2250/55 + Child Dental	01/01/2022	Summary	SBC
Blue Shield Trio Silver 70 HMO 2250/55 + Child Dental INF	01/01/2022		SBC
Kaiser Permanente HMO
Kaiser Platinum 90 HMO 0/10 + Child Dental Alt	01/01/2022	Summary	SBC
Kaiser Platinum 90 HMO 0/10 + Child Dental Alt INF	01/01/2022		SBC
Kaiser Platinum 90 HMO 0/20 + Child Dental	01/01/2022	Summary	SBC
Kaiser Platinum 90 HMO 0/20 + Child Dental INF	01/01/2022		SBC
Kaiser Gold 80 HMO 0/30 + Child Dental Alt	01/01/2022	Summary	SBC
Kaiser Gold 80 HMO 0/30 + Child Dental Alt INF	01/01/2022		SBC
Kaiser Gold 80 HMO 250/35 + Child Dental	01/01/2022	Summary	SBC
Kaiser Gold 80 HMO 250/35 + Child Dental INF	01/01/2022		SBC
Kaiser Gold 80 HMO 1000/40 + Child Dental Alt	01/01/2022	Summary	SBC
Kaiser Gold 80 HMO 1000/40 + Child Dental Alt INF	01/01/2022		SBC
Kaiser Gold 80 HDHP HMO 1600/15% + Child Dental Alt	01/01/2022	Summary	SBC
Kaiser Gold 80 HDHP HMO 1600/15% + Child Dental Alt INF	01/01/2022		SBC
Kaiser Silver 70 HMO 1650/55 + Child Dental Alt	01/01/2022	Summary	SBC
Kaiser Silver 70 HMO 1650/55 + Child Dental Alt INF	01/01/2022		SBC
Kaiser Silver 70 HMO 2100/55 + Child Dental Alt	01/01/2022	Summary	SBC
Kaiser Silver 70 HMO 2100/55 + Child Dental Alt INF	01/01/2022		SBC
Kaiser Silver 70 HMO 2250/55 + Child Dental	01/01/2022	Summary	SBC
Kaiser Silver 70 HMO 2250/55 + Child Dental INF	01/01/2022		SBC
Kaiser Silver 70 HMO 2600/55 + Child Dental Alt	01/01/2022	Summary	SBC
Kaiser Silver 70 HMO 2600/55 + Child Dental Alt INF	01/01/2022		SBC
Kaiser Silver 70 HDHP HMO 2500/20% + Child Dental	01/01/2022	Summary	SBC
Kaiser Silver 70 HDHP HMO 2500/20% + Child Dental INF	01/01/2022		SBC
Kaiser Bronze 60 HMO 5400/60 + Child Dental Alt	01/01/2022	Summary	SBC
Kaiser Bronze 60 HMO 5400/60 + Child Dental Alt INF	01/01/2022		SBC
Kaiser Bronze 60 HMO 6300/65 + Child Dental	01/01/2022	Summary	SBC
Kaiser Bronze 60 HMO 6300/65 + Child Dental INF	01/01/2022		SBC
Kaiser Bronze 60 HDHP HMO 7000/0% + Child Dental	01/01/2022	Summary	SBC
Kaiser Bronze 60 HDHP HMO 7000/0% + Child Dental INF	01/01/2022		SBC
Sharp HMO
Sharp Performance Platinum 90 HMO 0/15 + Child Dental	01/01/2022	Summary	SBC
Sharp Performance Platinum 90 HMO 0/15 + Child Dental INF	01/01/2022		SBC
Sharp Premier Platinum 90 HMO 0/20 + Child Dental	01/01/2022	Summary	SBC
Sharp Premier Platinum 90 HMO 0/20 + Child Dental INF	01/01/2022		SBC
Sharp Performance Gold 80 HMO 350/25 + Child Dental	01/01/2022	Summary	SBC
Sharp Performance Gold 80 HMO 350/25 + Child Dental INF	01/01/2022		SBC
Sharp Premier Gold 80 HMO 250/35 + Child Dental	01/01/2022	Summary	SBC
Sharp Premier Gold 80 HMO 250/35 + Child Dental INF	01/01/2022		SBC
Sharp Performance Silver 70 HMO 2250/50 + Child Dental	01/01/2022	Summary	SBC
Sharp Performance Silver 70 HMO 2250/50 + Child Dental INF	01/01/2022		SBC
Sharp Premier Silver 70 HMO 2250/55 + Child Dental	01/01/2022	Summary	SBC
Sharp Premier Silver 70 HMO 2250/55 + Child Dental INF	01/01/2022		SBC
Sharp Premier Silver 70 HDHP HMO 2500/20% + Child Dental	01/01/2022	Summary	SBC
Sharp Premier Silver 70 HDHP HMO 2500/20% + Child Dental INF	01/01/2022		SBC
Sharp Performance Bronze 60 HMO 6300/65 + Child Dental	01/01/2022	Summary	SBC
Sharp Performance Bronze 60 HMO 6300/65 + Child Dental INF	01/01/2022		SBC
Sharp Premier Bronze 60 HDHP HMO 7000/0% + Child Dental	01/01/2022	Summary	SBC
Sharp Premier Bronze 60 HDHP HMO 7000/0% + Child Dental INF	01/01/2022		SBC
2022 Medical PPO
Blue Shield PPO
Blue Shield Platinum 90 PPO 0/15 + Child Dental	01/01/2022	Summary	SBC
Blue Shield Platinum 90 PPO 0/15 + Child Dental INF	01/01/2022		SBC
Blue Shield Gold 80 PPO 350/25 + Child Dental	01/01/2022	Summary	SBC
Blue Shield Gold 80 PPO 350/25 + Child Dental INF	01/01/2022		SBC
Blue Shield Silver 70 PPO 2250/50 + Child Dental	01/01/2022	Summary	SBC
Blue Shield Silver 70 PPO 2250/50 + Child Dental INF	01/01/2022		SBC
Blue Shield Bronze 60 PPO 6300/65 + Child Dental	01/01/2022	Summary	SBC
Blue Shield Bronze 60 PPO 6300/65 + Child Dental INF	01/01/2022		SBC
Health Net PPO
Health Net Platinum 90 PPO 0/15 + Child Dental	01/01/2022	Summary	SBC
Health Net Platinum 90 PPO 0/15 + Child Dental INF	01/01/2022		SBC
Health Net Gold 80 PPO 0/30 + Child Dental Alt	01/01/2022	Summary	SBC
Health Net Gold 80 PPO 0/30 + Child Dental Alt INF	01/01/2022		SBC
Health Net Gold 80 PPO 350/25 + Child Dental	01/01/2022	Summary	SBC
Health Net Gold 80 PPO 350/25 + Child Dental INF	01/01/2022		SBC
Health Net Gold 80 PPO 1000/30 + Child Dental Alt	01/01/2022	Summary	SBC
Health Net Gold 80 PPO 1000/30 + Child Dental Alt INF	01/01/2022		SBC
Health Net Silver 70 PPO 2250/50 + Child Dental	01/01/2022	Summary	SBC
Health Net Silver 70 PPO 2250/50 + Child Dental INF	01/01/2022		SBC
Health Net Silver 70 PPO 2250/55 + Child Dental Alt	01/01/2022	Summary	SBC
Health Net Silver 70 PPO 2250/55 + Child Dental Alt INF	01/01/2022		SBC
Health Net Silver 70 HDHP PPO 1400/40% + Child Dental Alt	01/01/2022	Summary	SBC
Health Net Silver 70 HDHP PPO 1400/40% + Child Dental Alt INF	01/01/2022		SBC
Health Net Bronze 60 PPO 6300/65 + Child Dental	01/01/2022	Summary	SBC
Health Net Bronze 60 PPO 6300/65 + Child Dental INF	01/01/2022		SBC
Health Net Bronze 60 HDHP PPO 7000/0% + Child Dental	01/01/2022	Summary	SBC
Health Net Bronze 60 HDHP PPO 7000/0% + Child Dental INF	01/01/2022		SBC
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

Form Name	Effective Date	Download Form
General Information
2022 Plan Summary	01/01/2022	Download
Underwriting Guidelines 1.23	01/01/2023	Download
Flexible Plan Options with More Metal Tiers Flyer	10/01/2021	Download
Health Insurance Made Simple Employer Brochure	07/01/2022	Download
Health & Dental Plan Offerings and Network Summary	07/01/2022	Download
How to Access or Order A Member ID Card	01/01/2022	Download
Employer Guide - How to Make a Payment	07/01/2022	Download
Broker How to Get Certified to Sell Flyer	08/01/2022	Download
MyCCSB Broker Portal Registration Flyer	01/01/2020	Download
MyCCSB Enrollment Online Portal Agent Guide	01/01/2023	Download
MyCCSB Enrollment Online Portal Employer Guide	07/01/2022	Download
Small Business Tax Credit Fact Sheet	08/01/2022	Download
Small Business Tax Credit Instructions Flyer	02/01/2021	Download
Small Business Trifold Brochure	07/01/2022	Download
Value Added Benefit Grid	01/01/2022	Download
Why Sell CCSB - Think Differently	07/01/2022	Download

Form Name	Effective Date	Download Form
Contact Sheet		Download

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 just one level, but two, three or four adjoining or contiguous levels of coverage.