Covered California for Small Business

Form Name	Effective Date	Download Form
New Group Submission
Enrollment Checklist	01/01/2020	Download
Employer Application 3.23	01/01/2024	Download
New Business Late Submission Acknowledgement Form	01/01/2024	Download
New Business Documentation Guide	07/01/2022	Download
In Force Group Forms
Employer Change Request Form 1.23	01/01/2023	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 Combined Enrollment & Change Form 7.24	07/01/2024	Download
COBRA Forms
COBRA Election Form	07/01/2022	Download

Form Name	Effective Date	Download Form
2024 Medical HMO
Blue Shield Access+ HMO Network
Blue Shield Access+ Platinum 90 HMO 0/20 + Child Dental	01/01/2024	Summary	SBC
Blue Shield Access+ Platinum 90 HMO 0/20 + Child Dental INF	01/01/2024		SBC
Blue Shield Access+ Gold 80 HMO 250/35 + Child Dental	01/01/2024	Summary	SBC
Blue Shield Access+ Gold 80 HMO 250/35 + Child Dental INF	01/01/2024		SBC
Blue Shield Access+ Silver 70 HMO 2500/55 + Child Dental	01/01/2024	Summary	SBC
Blue Shield Access+ Silver 70 HMO 2500/55 + Child Dental INF	01/01/2024		SBC
Blue Shield Trio HMO Network
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental	01/01/2024	Summary	SBC
Blue Shield Trio Platinum 90 HMO 0/20 + Child Dental INF	01/01/2024		SBC
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental	01/01/2024	Summary	SBC
Blue Shield Trio Gold 80 HMO 250/35 + Child Dental INF	01/01/2024		SBC
Blue Shield Trio Silver 70 HMO 2500/55 + Child Dental	01/01/2024	Summary	SBC
Blue Shield Trio Silver 70 HMO 2500/55 + Child Dental INF	01/01/2024		SBC
Blue Shield Trio Bronze 60 HMO 7000/70 + Child Dental Alt	01/01/2024	Summary	SBC
Blue Shield Trio Bronze 60 HMO 7000/70 + Child Dental Alt INF	01/01/2024		SBC
Kaiser Permanente HMO
Kaiser Platinum 90 HMO 0/10 + Child Dental Alt	01/01/2024	Summary	SBC
Kaiser Platinum 90 HMO 0/10 + Child Dental Alt INF	01/01/2024		SBC
Kaiser Platinum 90 HMO 0/20 + Child Dental	01/01/2024	Summary	SBC
Kaiser Platinum 90 HMO 0/20 + Child Dental INF	01/01/2024		SBC
Kaiser Platinum 90 HMO 250/30 + Child Dental Alt	01/01/2024	Summary	SBC
Kaiser Platinum 90 HMO 250/30 + Child Dental Alt INF	01/01/2024		SBC
Kaiser Gold 80 HMO 0/35 + Child Dental Alt	01/01/2024	Summary	SBC
Kaiser Gold 80 HMO 0/35 + Child Dental Alt INF	01/01/2024		SBC
Kaiser Gold 80 HMO 250/35 + Child Dental	01/01/2024	Summary	SBC
Kaiser Gold 80 HMO 250/35 + Child Dental INF	01/01/2024		SBC
Kaiser Gold 80 HMO 1000/40 + Child Dental Alt	01/01/2024	Summary	SBC
Kaiser Gold 80 HMO 1000/40 + Child Dental Alt INF	01/01/2024		SBC
Kaiser Gold 80 HDHP HMO 1750/15% + Child Dental Alt	01/01/2024	Summary	SBC
Kaiser Gold 80 HDHP HMO 1750/15% + Child Dental Alt INF	01/01/2024		SBC
Kaiser Silver 70 HMO 1900/65 + Child Dental Alt	01/01/2024	Summary	SBC
Kaiser Silver 70 HMO 1900/65 + Child Dental Alt INF	01/01/2024		SBC
Kaiser Silver 70 HMO 2300/65 + Child Dental Alt	01/01/2024	Summary	SBC
Kaiser Silver 70 HMO 2300/65 + Child Dental Alt INF	01/01/2024		SBC
Kaiser Silver 70 HMO 2500/55 + Child Dental	01/01/2024	Summary	SBC
Kaiser Silver 70 HMO 2500/55 + Child Dental INF	01/01/2024		SBC
Kaiser Silver 70 HMO 2950/65 + Child Dental Alt	01/01/2024	Summary	SBC
Kaiser Silver 70 HMO 2950/65 + Child Dental Alt INF	01/01/2024		SBC
Kaiser Silver 70 HDHP HMO 2850/25% + Child Dental	01/01/2024	Summary	SBC
Kaiser Silver 70 HDHP HMO 2850/25% + Child Dental INF	01/01/2024		SBC
Kaiser Bronze 60 HMO 5400/60 + Child Dental Alt	01/01/2024	Summary	SBC
Kaiser Bronze 60 HMO 5400/60 + Child Dental Alt INF	01/01/2024		SBC
Kaiser Bronze 60 HMO 6300/60 + Child Dental	01/01/2024	Summary	SBC
Kaiser Bronze 60 HMO 6300/60 + Child Dental INF	01/01/2024		SBC
Kaiser Bronze 60 HDHP HMO 7050/0% + Child Dental	01/01/2024	Summary	SBC
Kaiser Bronze 60 HDHP HMO 7050/0% + Child Dental INF	01/01/2024		SBC
Sharp HMO
Sharp Performance Platinum 90 HMO 0/15 + Child Dental	01/01/2024	Summary	SBC
Sharp Performance Platinum 90 HMO 0/15 + Child Dental INF	01/01/2024		SBC
Sharp Premier Platinum 90 HMO 0/20 + Child Dental	01/01/2024	Summary	SBC
Sharp Premier Platinum 90 HMO 0/20 + Child Dental INF	01/01/2024		SBC
Sharp Performance Gold 80 HMO 350/25 + Child Dental	01/01/2024	Summary	SBC
Sharp Performance Gold 80 HMO 350/25 + Child Dental INF	01/01/2024		SBC
Sharp Premier Gold 80 HMO 250/35 + Child Dental	01/01/2024	Summary	SBC
Sharp Premier Gold 80 HMO 250/35 + Child Dental INF	01/01/2024		SBC
Sharp Performance Silver 70 HMO 2500/55 + Child Dental	01/01/2024	Summary	SBC
Sharp Performance Silver 70 HMO 2500/55 + Child Dental INF	01/01/2024		SBC
Sharp Premier Silver 70 HMO 2500/55 + Child Dental	01/01/2024	Summary	SBC
Sharp Premier Silver 70 HMO 2500/55 + Child Dental INF	01/01/2024		SBC
Sharp Premier Silver 70 HDHP HMO 2850/25% + Child Dental	01/01/2024	Summary	SBC
Sharp Premier Silver 70 HDHP HMO 2850/25% + Child Dental INF	01/01/2024		SBC
Sharp Performance Bronze 60 HMO 6300/60 + Child Dental	01/01/2024	Summary	SBC
Sharp Performance Bronze 60 HMO 6300/60 + Child Dental INF	01/01/2024		SBC
Sharp Premier Bronze 60 HDHP HMO 7050/0% + Child Dental	01/01/2024	Summary	SBC
Sharp Premier Bronze 60 HDHP HMO 7050/0% + Child Dental INF	01/01/2024		SBC
2024 Medical PPO
Blue Shield PPO
Blue Shield Platinum 90 PPO 0/15 + Child Dental	01/01/2024	Summary	SBC
Blue Shield Platinum 90 PPO 0/15 + Child Dental INF	01/01/2024		SBC
Blue Shield Gold 80 PPO 350/25 + Child Dental	01/01/2024	Summary	SBC
Blue Shield Gold 80 PPO 350/25 + Child Dental INF	01/01/2024		SBC
Blue Shield Silver 70 PPO 2500/55 + Child Dental	01/01/2024	Summary	SBC
Blue Shield Silver 70 PPO 2500/55 + Child Dental INF	01/01/2024		SBC
Blue Shield Silver 70 HDHP PPO 2300/30% + Child Dental Alt	01/01/2024	Summary	SBC
Blue Shield Silver 70 HDHP PPO 2300/30% + Child Dental Alt INF	01/01/2024		SBC
Blue Shield Bronze 60 PPO 6300/60 + Child Dental	01/01/2024	Summary	SBC
Blue Shield Bronze 60 PPO 6300/60 + Child Dental INF	01/01/2024		SBC
Blue Shield Bronze 60 HDHP PPO 7500/0% + Child Dental Alt	01/01/2024	Summary	SBC
Blue Shield Bronze 60 HDHP PPO 7500/0% + Child Dental Alt INF	01/01/2024		SBC
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

Form Name	Effective Date	Download Form
General Information
Standard Plan Summary Platinum 2024	01/01/2024	Download
Standard Plan Summary Gold 2024	01/01/2024	Download
Standard Plan Summary Silver 2024	01/01/2024	Download
Standard Plan Summary Bronze 2024	01/01/2024	Download
Standard Plan Summary Platinum 2023	01/01/2023	Download
Standard Plan Summary Gold 2023	01/01/2023	Download
Standard Plan Summary Silver 2023	01/01/2023	Download
Standard Plan Summary Bronze 2023	01/01/2023	Download
Underwriting Guidelines 1.24	01/01/2024	Download
Employer Guide 2024	01/01/2024	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
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
Network Summary Health Plan Offerings	10/01/2023	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
Top 10 Reasons to Consider Covered California	10/01/2023	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.