| Form Name | Effective Date | Download Form |
|---|---|---|
|
New Group Submission |
||
|
New Group Submission Checklist |
01/01/2024 | Download |
|
Employer Application - Small Group |
01/01/2024 | Download |
|
Employer Application - Large Group |
01/01/2024 | Download |
|
ACH Initial Payment Form |
01/01/2024 | Download |
|
Employer Attestation for Out of Area Employee Mailing Address |
01/01/2020 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Enrollment and Change Forms |
||
|
Employee Enrollment Form-Bilingual |
01/01/2024 | Download |
|
Employee Waiver Form-Bilingual |
01/01/2024 | Download |
|
Affidavit for Enrollment of Domestic Partners |
01/01/2024 | Download |
|
Continuity of Care Brochure and Form |
01/01/2020 | Download |
|
Claim Forms |
||
|
Health Care Services Reimbursement Form |
08/01/2021 | Download |
|
SENTRI Pass Reimbursement Form |
01/01/2020 | Download |
| Form Name | Effective Date | Download Form | |
|---|---|---|---|
|
2024 Medical HMO Small Group |
|||
|
P5 Platinum HMO Plan (P5) |
01/01/2024 | Summary | SBC |
|
P10 Platinum HMO Plan (P10) |
01/01/2024 | Summary | SBC |
|
Platinum 90 HMO 0/20 INF Plan (PM90) |
01/01/2024 | Summary | SBC |
|
Gold 80 HMO 250/35 INF Plan (GM80) |
01/01/2024 | Summary | SBC |
|
2024 Medical HMO Large Group |
|||
|
VP5 HMO |
01/01/2024 | Summary | SBC |
|
VP10 HMO |
01/01/2024 | Summary | SBC |
|
VP20 HMO |
01/01/2024 | Summary | SBC |
|
MEP HMO |
01/01/2024 | Summary | SBC |
|
QEP HMO |
01/01/2024 | Summary | SBC |
|
2023 Medical HMO Small Group |
|||
|
P5 Platinum HMO Plan (P5) |
01/01/2023 | Summary | SBC |
|
P10 Platinum HMO Plan (P10) |
01/01/2023 | Summary | SBC |
|
Platinum 90 HMO 0/20 INF Plan (PM90) |
01/01/2023 | Summary | SBC |
|
Gold 80 HMO 250/35 INF Plan (GM80) |
01/01/2023 | Summary | SBC |
|
2023 Medical HMO Large Group |
|||
|
VP5 HMO |
01/01/2023 | Summary | SBC |
|
VP10 HMO |
01/01/2023 | Summary | SBC |
|
VP20 HMO |
01/01/2023 | Summary | SBC |
|
MEP HMO |
01/01/2023 | Summary | SBC |
|
QEP HMO |
01/01/2023 | Summary | SBC |
|
2022 Medical HMO Small Group |
|||
|
P5 Platinum HMO Plan (P5) |
01/01/2022 | Summary | SBC |
|
P10 Platinum HMO Plan (P10) |
01/01/2022 | Summary | SBC |
|
Platinum 90 HMO 0/20 INF Plan (PM90) |
01/01/2022 | Summary | SBC |
|
Gold 80 HMO 250/35 INF Plan (GM80) |
01/01/2022 | Summary | SBC |
|
2022 Medical HMO Large Group |
|||
|
VP5 HMO |
01/01/2022 | Summary | SBC |
|
VP10 HMO |
01/01/2022 | Summary | SBC |
|
VP20 HMO |
01/01/2022 | Summary | SBC |
|
MEP HMO |
01/01/2022 | Summary | SBC |
|
QEP HMO |
01/01/2022 | Summary | SBC |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
General Information |
||
|
Health Plans for Small Businesses 1.24 |
01/01/2024 | Download |
|
Health Plans for Small Businesses (Spanish) 1.24 |
01/01/2024 | Download |
|
Underwriting Guidelines 4.23 |
01/01/2024 | Download |
|
Small Group Carrier Update Q2 2024 |
04/01/2024 | Download |
|
MediExcel Contact Sheet |
04/01/2024 | Download |
|
Dependent Only Coverage Kit (includes FAQ, Employer Instructions and Employee Dependent Only Coverage Application) |
07/01/2023 | Download |
|
CA Department of Managed Health Care Infographic |
04/01/2024 | Download |
|
Imperial County Flyer |
04/01/2024 | Download |
|
Independent Medical Review |
01/01/2020 | Download |
|
Health Plans for Large Group 1.23 |
01/01/2023 | Download |
|
MediExcel Advantage Value Flyer |
04/01/2024 | Download |
|
Large Group MEP Rates 2024 |
04/01/2024 | Download |
|
Large Group QEP Rates 2024 |
04/01/2024 | Download |
|
Medical Authorization Process Brochure |
04/01/2024 | Download |
|
MediExcel Health Plan Accepted at AFC Urgent Care Flyer |
04/01/2024 | Download |
|
Minute Clinic Flyer |
01/01/2020 | Download |
|
MediExcel Mobile App Flyer |
04/01/2024 | Download |
|
Patient Portal Flyer |
04/01/2024 | Download |
|
Prescription Drug Formulary - In Mexico |
02/01/2020 | Download |
|
Prescription Drug Formulary - Urgent Care in the US |
02/01/2020 | Download |
|
SENTRI Pass Flyer |
04/01/2024 | Download |
|
San Ysidro Port of Entry Facility Flyer |
04/01/2024 | Download |
|
Urgent Care Network Flyer |
04/01/2024 | Download |
|
Virtual Care Services Flyer |
04/01/2024 | Download |
|
Where You Go for Care Flyer |
04/01/2024 | Download |
|
Ancillary |
||
|
Dental D100 Sell Sheet - Voluntary & Employer Paid |
04/01/2024 | Download |
|
Dental D200 Sell Sheet - Voluntary & Employer Paid |
04/01/2024 | Download |
|
Vision V100 Sell Sheet - Voluntary & Employer Paid |
04/01/2024 | Download |
| Video Name | Watch Video |
|---|---|
| Introduction to MediExcel |
Watch Video
|
| Form Name | Effective Date | Download Form |
|---|---|---|
|
MediExcel Small Group Rates [effective 1/1/2024] |
01/01/2024 | Download |
