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
01/01/2018 Download
Employer Application
01/01/2018 Download
Employee Roster
01/01/2018 Download
New Business Late Submission Acknowledgement Form
03/01/2018 Download
In Force Group Forms
Employer Change Form
01/01/2018 Download
Employer Change Form - Spanish
01/01/2018 Download
Administration
Employer Guide
01/01/2018 Download
Navigating Your Bill
01/01/2018 Download
Form Name Effective Date Download Form
Enrollment and Change Forms
Employee Application
01/01/2018 Download
Employee Change Form
01/01/2018 Download
Employee Change Form - Spanish
01/01/2018 Download
COBRA Forms
COBRA Election Form
01/01/2018 Download
COBRA Cancellation Form
01/01/2018 Download
Claim Forms
Request for Appeal Form
01/01/2018 Download
Complaint Form
01/01/2018 Download
Form Name Effective Date Download Form
2018 Medical Plan Summary Brochures
All Tiers Plan Summary Brochure
03/01/2018 Summary
Platinum Plan Summary Brochure
03/01/2018 Summary
Gold Plan Summary Brochure
03/01/2018 Summary
Silver Plan Summary Brochure
03/01/2018 Summary
Bronze Plan Summary Brochure
03/01/2018 Summary
2018 Medical HMO SBCs
Blue Shield HMO
Blue Shield Platinum 90 HMO 0/15 Trio + Child Dental
01/01/2018 SBC
Blue Shield Platinum 90 HMO 0/15 Trio + Child Dental INF (with Infertility)
01/01/2018 SBC
Blue Shield Gold 80 HMO 0/25 Trio + Child Dental
01/01/2018 SBC
Blue Shield Gold 80 HMO 0/25 Trio + Child Dental INF (with Infertility)
01/01/2018 SBC
Blue Shield Silver 70 HMO 2000/45 Trio + Child Dental
01/01/2018 SBC
Blue Shield Silver 70 HMO 2000/45 Trio + Child Dental INF (with Infertility)
01/01/2018 SBC
CCHP HMO
CCHP Platinum 90 HMO 0/15 + Child Dental
01/01/2018 SBC
CCHP Platinum 90 HMO 0/15 + Child Dental INF (with Infertility)
01/01/2018 SBC
CCHP Gold 80 HMO 0/25 + Child Dental
01/01/2018 SBC
CCHP Gold 80 HMO 0/25 + Child Dental INF (with Infertility)
01/01/2018 SBC
CCHP Silver 70 HMO 2000/45 + Child Dental
01/01/2018 SBC
CCHP Silver 70 HMO 2000/45 + Child Dental INF (with Infertility)
01/01/2018 SBC
CCHP Bronze 60 HMO 6300/75 + Child Dental
01/01/2018 SBC
CCHP Bronze 60 HMO 6300/75 + Child Dental INF (with Infertility)
01/01/2018 SBC
CCHP Bronze 60 HDHP 4800/40% HMO + Child Dental
01/01/2018 SBC
CCHP Bronze 60 HDHP 4800/40% HMO + Child Dental INF (with Infertility)
01/01/2018 SBC
Kaiser Permanente HMO
Kaiser Platinum 90 HMO 0/10 Alt
01/01/2018 SBC
Kaiser Platinum 90 HMO 0/10 Alt INF (with Infertility)
01/01/2018 SBC
Kaiser Platinum 90 HMO 0/15
01/01/2018 SBC
Kaiser Platinum 90 HMO 0/15 INF (with Infertility)
01/01/2018 SBC
Kaiser Gold 80 HMO 0/25
01/01/2018 SBC
Kaiser Gold 80 HMO 0/25 INF (with Infertility)
01/01/2018 SBC
Kaiser Gold 80 HMO 500/30 Alt
01/01/2018 SBC
Kaiser Gold 80 HMO 500/30 Alt INF (with Infertility)
01/01/2018 SBC
Kaiser Silver 70 HMO 1000/50 Alt
01/01/2018 SBC
Kaiser Silver 70 HMO 1000/50 Alt INF (with Infertility)
01/01/2018 SBC
Kaiser Silver 70 HMO 2000/45
01/01/2018 SBC
Kaiser Silver 70 HMO 2000/45 INF (with Infertility)
01/01/2018 SBC
Kaiser Silver 70 HDHP HMO 2000/20%
01/01/2018 SBC
Kaiser Silver 70 HDHP HMO 2000/20% INF (with Infertility)
01/01/2018 SBC
Kaiser Bronze 60 HMO 6300/75
01/01/2018 SBC
Kaiser Bronze 60 HMO 6300/75 INF (with Infertility)
01/01/2018 SBC
Kaiser Bronze 60 HDHP HMO 4800/40%
01/01/2018 SBC
Kaiser Bronze 60 HDHP HMO 4800/40% INF (with Infertility)
01/01/2018 SBC
Sharp HMO
Sharp Platinum 90 HMO 0/15 + Child Dental Performance
01/01/2018 SBC
Sharp Platinum 90 HMO 0/15 + Child Dental Performance INF (with Infertility)
01/01/2018 SBC
Sharp Platinum 90 HMO 0/15 + Child Dental Premier
01/01/2018 SBC
Sharp Platinum 90 HMO 0/15 + Child Dental Premier INF (with Infertility)
01/01/2018 SBC
Sharp Gold 80 HMO 0/25 + Child Dental Performance
01/01/2018 SBC
Sharp Gold 80 HMO 0/25 + Child Dental Performance INF (with Infertility)
01/01/2018 SBC
Sharp Gold 80 HMO 0/25 + Child Dental Premier
01/01/2018 SBC
Sharp Gold 80 HMO 0/25 + Child Dental Premier INF (with Infertility)
01/01/2018 SBC
Sharp Silver 70 HMO 2000/45 + Child Dental Performance
01/01/2018 SBC
Sharp Silver 70 HMO 2000/45 + Child Dental Performance INF (with Infertility)
01/01/2018 SBC
Sharp Silver 70 HMO 2000/45 + Child Dental Premier
01/01/2018 SBC
Sharp Silver 70 HMO 2000/45 + Child Dental Premier INF (with Infertility)
01/01/2018 SBC
Sharp Silver 70 HDHP HMO 2000/20% + Child Dental Premier
01/01/2018 SBC
Sharp Silver 70 HDHP HMO 2000/20% + Child Dental Premier INF (with Infertility)
01/01/2018 SBC
Sharp Bronze 60 HMO 6300/75 + Child Dental Performance
01/01/2018 SBC
Sharp Bronze 60 HMO 6300/75 + Child Dental Performance INF (with Infertility)
01/01/2018 SBC
Sharp Bronze 60 HDHP HMO 4800/40% + Child Dental Premier
01/01/2018 SBC
Sharp Bronze 60 HDHP HMO 4800/40% + Child Dental Premier INF (with Infertility)
01/01/2018 SBC
2018 Medical PPO
Blue Shield PPO SBCs
Blue Shield Platinum 90 PPO 0/15 + Child Dental
01/01/2018 SBC
Blue Shield Platinum 90 PPO 0/15 + Child Dental INF (with Infertility)
01/01/2018 SBC
Blue Shield Gold 80 PPO 0/25 + Child Dental
01/01/2018 SBC
Blue Shield Gold 80 PPO 0/25 + Child Dental INF (with Infertility)
01/01/2018 SBC
Blue Shield Silver 70 PPO 2000/45 + Child Dental
01/01/2018 SBC
Blue Shield Silver 70 PPO 2000/45 + Child Dental INF (with Infertility)
01/01/2018 SBC
Blue Shield Bronze 60 PPO 6300/75 + Child Dental
01/01/2018 SBC
Blue Shield Bronze 60 PPO 6300/75 + Child Dental INF (with Infertility)
01/01/2018 SBC
Health Net PPO
Health Net Platinum 90 PPO 0/15 + Child Dental
01/01/2018 SBC
Health Net Platinum 90 PPO 0/15 + Child Dental INF (with Infertility)
01/01/2018 SBC
Health Net Platinum 90 EnhancedCare PPO 250/15 + Child Dental Alt (10.1.18 and Later Effective Dates)
10/01/2018 SBC
Health Net Platinum 90 EnhancedCare PPO 250/15 + Child Dental Alt INF (with Infertility) (10.1.18 and Later Effective Dates)
10/01/2018 SBC
Health Net Gold 80 PPO 0/25 + Child Dental
01/01/2018 SBC
Health Net Gold 80 PPO 0/25 + Child Dental INF (with Infertility)
01/01/2018 SBC
Health Net Gold 80 PPO Value 750/10 + Child Dental
01/01/2018 SBC
Health Net Gold 80 PPO Value 750/10 + Child Dental INF (with Infertility)
01/01/2018 SBC
Health Net Gold 80 EnhancedCare PPO 1000/30 + Child Dental Alt (10.1.18 and Later Effective Dates)
10/01/2018 SBC
Health Net Gold 80 EnhancedCare PPO 1000/30 + Child Dental Alt INF (with Infertility) (10.1.18 and Later Effective Dates)
10/01/2018 SBC
Health Net Silver 70 PPO 2000/45 + Child Dental
01/01/2018 SBC
Health Net Silver 70 PPO 2000/45 + Child Dental INF (with Infertility)
01/01/2018 SBC
Health Net Silver 70 EnhancedCare PPO 2000/55 + Child Dental Alt (10.1.18 and Later Effective Dates)
10/01/2018 SBC
Health Net Silver 70 EnhancedCare PPO 2000/55 + Child Dental Alt INF (with Infertility) (10.1.18 and Later Effective Dates)
10/01/2018 SBC
Health Net Silver 70 PPO Value 1700/30 + Child Dental Alt
01/01/2018 SBC
Health Net Silver 70 PPO Value 1700/30 + Child Dental Alt INF (with Infertility)
01/01/2018 SBC
Health Net Silver 70 HDHP 1350/40 PPO + Child Dental Alt
01/01/2018 SBC
Health Net Silver 70 HDHP 1350/40 PPO + Child Dental Alt INF (with Infertility)
01/01/2018 SBC
Health Net Silver 70 HDHP 1350/40 EnhancedCare PPO + Child Dental Alt
01/01/2018 SBC
Health Net Silver 70 HDHP 1350/40 EnhancedCare PPO + Child Dental Alt INF (with Infertility)
01/01/2018 SBC
Health Net Bronze 60 PPO 6300/75 + Child Dental
01/01/2018 SBC
Health Net Bronze 60 PPO 6300/75 + Child Dental INF (with Infertility)
01/01/2018 SBC
Health Net Bronze 60 HDHP 5600/15 PPO + Child Dental Alt
01/01/2018 SBC
Health Net Bronze 60 HDHP 5600/15 PPO + Child Dental Alt INF (with Infertility)
01/01/2018 SBC
Health Net Bronze 60 HDHP 5600/15 EnhancedCare PPO + Child Dental Alt
01/01/2018 SBC
Health Net Bronze 60 HDHP 5600/15 EnhancedCare PPO + Child Dental Alt INF (with Infertility)
01/01/2018 SBC
2017 Medical HMO
Blue Shield HMO
Blue Shield Platinum 90 HMO 0/15 + Child Dental INF (with Infertility)
01/01/2017 SBC
Blue Shield Gold 80 HMO 0/30 + Child Dental INF (with Infertility)
01/01/2017 SBC
Blue Shield Silver 70 HMO 2000/45 + Child Dental INF (with Infertility)
01/01/2017 SBC
CCHP HMO
CCHP Platinum 90 HMO 0/15 + Child Dental
01/01/2017 SBC
CCHP Platinum 90 HMO 0/15 + Child Dental INF (with Infertility)
01/01/2017 SBC
CCHP Gold 80 HMO 0/30 + Child Dental
01/01/2017 SBC
CCHP Gold 80 HMO 0/30 + Child Dental INF (with Infertility)
01/01/2017 SBC
CCHP Silver 70 HMO 2000/45 + Child Dental
01/01/2017 SBC
CCHP Silver 70 HMO 2000/45 + Child Dental INF (with Infertility)
01/01/2017 SBC
CCHP Bronze 60 HMO 6300/75 + Child Dental
01/01/2017 SBC
CCHP Bronze 60 HMO 6300/75 + Child Dental INF (with Infertility)
01/01/2017 SBC
Kaiser Permanente HMO
Kaiser Platinum 90 HMO 0/10 Alt
01/01/2017 SBC
Kaiser Platinum 90 HMO 0/10 Alt INF (with Infertility)
01/01/2017 SBC
Kaiser Platinum 90 HMO 0/15
01/01/2017 SBC
Kaiser Platinum 90 HMO 0/15 INF (with Infertility)
01/01/2017 SBC
Kaiser Gold 80 HMO 0/30
01/01/2017 SBC
Kaiser Gold 80 HMO 0/30 INF (with Infertility)
01/01/2017 SBC
Kaiser Gold 80 HMO 500/35 Alt
01/01/2017 SBC
Kaiser Gold 80 HMO 500/35 Alt INF (with Infertility)
01/01/2017 SBC
Kaiser Silver 70 HMO 1000/50 Alt
01/01/2017 SBC
Kaiser Silver 70 HMO 1000/50 Alt INF (with Infertility)
01/01/2017 SBC
Kaiser Silver 70 HMO 2000/45
01/01/2017 SBC
Kaiser Silver 70 HMO 2000/45 INF (with Infertility)
01/01/2017 SBC
Kaiser Silver 70 HDHP HMO 2000/20%
01/01/2017 SBC
Kaiser Silver 70 HDHP HMO 2000/20% INF (with Infertility)
01/01/2017 SBC
Kaiser Bronze 60 HMO 6300/75
01/01/2017 SBC
Kaiser Bronze 60 HMO 6300/75 INF (with Infertility)
01/01/2017 SBC
Kaiser Bronze 60 HDHP HMO 4800/40%
01/01/2017 SBC
Kaiser Bronze 60 HDHP HMO 4800/40% INF (with Infertility)
01/01/2017 SBC
Sharp HMO
Sharp Platinum 90 HMO 0/15 + Child Dental Network 1
01/01/2017 SBC
Sharp Platinum 90 HMO 0/15 + Child Dental Network 1 INF (with Infertility)
01/01/2017 SBC
Sharp Platinum 90 HMO 0/15 + Child Dental Network 2
01/01/2017 SBC
Sharp Platinum 90 HMO 0/15 + Child Dental Network 2 INF (with Infertility)
01/01/2017 SBC
Sharp Gold 80 HMO 0/30 + Child Dental Network 1
01/01/2017 SBC
Sharp Gold 80 HMO 0/30 + Child Dental Network 1 INF (with Infertility)
01/01/2017 SBC
Sharp Gold 80 HMO 0/30 + Child Dental Network 2
01/01/2017 SBC
Sharp Gold 80 HMO 0/30 + Child Dental Network 2 INF (with Infertility)
01/01/2017 SBC
Sharp Silver 70 HMO 2000/45 + Child Dental Network 1
01/01/2017 SBC
Sharp Silver 70 HMO 2000/45 + Child Dental Network 1 INF (with Infertility)
01/01/2017 SBC
Sharp Silver 70 HMO 2000/45 + Child Dental Network 2
01/01/2017 SBC
Sharp Silver 70 HMO 2000/45 + Child Dental Network 2 INF (with Infertility)
01/01/2017 SBC
Sharp Silver 70 HDHP HMO 2000/20% + Child Dental Network 1
01/01/2017 SBC
Sharp Silver 70 HDHP HMO 2000/20% + Child Dental Network 1 INF (with Infertility)
01/01/2017 SBC
Sharp Bronze 60 HDHP HMO 4800/40% + Child Dental Network 1
01/01/2017 SBC
Sharp Bronze 60 HDHP HMO 4800/40% + Child Dental Network 1 INF (with Infertility)
01/01/2017 SBC
Sharp Bronze 60 HMO 6300/75 + Child Dental Network 2
01/01/2017 SBC
Sharp Bronze 60 HMO 6300/75 + Child Dental Network 2 INF (with Infertility)
01/01/2017 SBC
Western Health Advantage HMO
WHA Platinum 90 HMO 0/15 + Child Dental
01/01/2017 SBC
WHA Gold 80 HMO 0/30 + Child Dental
01/01/2017 SBC
WHA Silver 70 HMO 2000/45 + Child Dental
01/01/2017 SBC
WHA Silver 70 HDHP HMO 2000/20 + Child Dental
01/01/2017 SBC
WHA Bronze 60 HMO 6300/75 + Child Dental
01/01/2017 SBC
WHA Bronze 60 HDHP HMO 4800/40 + Child Dental
01/01/2017 SBC
WHA Bronze 60 HDHP HMO 6500/0 + Child Dental Alt
01/01/2017 SBC
2017 Medical PPO & EPO
Blue Shield PPO
Blue Shield Platinum 90 PPO 0/15 + Child Dental
01/01/2017 SBC
Blue Shield Platinum 90 PPO 0/15 + Child Dental INF (with Infertility)
01/01/2017 SBC
Blue Shield Gold 80 PPO 0/30 + Child Dental
01/01/2017 SBC
Blue Shield Gold 80 PPO 0/30 + Child Dental INF (with Infertility)
01/01/2017 SBC
Blue Shield Silver 70 PPO 2000/45 + Child Dental
01/01/2017 SBC
Blue Shield Silver 70 PPO 2000/45 + Child Dental INF (with Infertility)
01/01/2017 SBC
Blue Shield Bronze 60 PPO 6300/75 + Child Dental
01/01/2017 SBC
Blue Shield Bronze 60 PPO 6300/75 + Child Dental INF (with Infertility)
01/01/2017 SBC
Health Net PPO and EPO
Health Net Platinum 90 PPO 0/15 + Child Dental
01/01/2017 SBC
Health Net Platinum 90 PPO 0/15 + Child Dental INF (with Infertility)
01/01/2017 SBC
Health Net Gold 80 PPO 0/30 + Child Dental
01/01/2017 SBC
Health Net Gold 80 PPO 0/30 + Child Dental INF (with Infertility)
01/01/2017 SBC
Health Net PPO Gold Value
10/01/2017 SBC
Health Net PPO Gold Value + INF (with Infertility)
10/01/2017 SBC
Health Net Silver 70 PPO 2000/45 + Child Dental
01/01/2017 SBC
Health Net Silver 70 PPO 2000/45 + Child Dental INF (with Infertility)
01/01/2017 SBC
Health Net PPO Silver Value
10/01/2017 SBC
Health Net PPO Silver Value + INF (with Infertility)
10/01/2017 SBC
Health Net Bronze 60 PPO 6300/75 + Child Dental
01/01/2017 SBC
Health Net Bronze 60 PPO 6300/75 + Child Dental INF (with Infertility)
01/01/2017 SBC
Health Net PPO Bronze HSA
10/01/2017 SBC
Health Net PPO Bronze HSA + INF (with Infertility)
10/01/2017 SBC
Health Net Gold 80 EPO 1300/20 + Child Dental Alt
01/01/2017 SBC
Health Net Gold 80 EPO 1300/20 + Child Dental Alt INF (with Infertility)
01/01/2017 SBC
Health Net Silver 70 EPO 2000/20 + Child Dental Alt
01/01/2017 SBC
Health Net Silver 70 EPO 2000/20 + Child Dental Alt INF (with Infertility)
01/01/2017 SBC
Form Name Effective Date Download Form
2018 Schedule Of Commissions
01/01/2018 Download
Agent Guide for Enrollment and Eligibility
01/01/2018 Download
CCSB Health Insurance Made Easy Employer Brochure
01/01/2018 Download
CCSB Small Business Trifold
01/01/2018 Download
Small Business Tax Credit Fact Sheet
01/01/2018 Download
Form Name Effective Date Download Form
Contact Sheet
Download