| Form Name | Effective Date | Download Form |
|---|---|---|
|
New Group Submission |
||
|
Small Group Submission Checklist 1.19 |
01/01/2020 | Download |
|
Large Group Submission Checklist 1.19 |
01/01/2020 | Download |
|
Employer Application - Small Group 1.21 |
01/01/2021 | Download |
|
Employer Application - Large Group 5.20 |
05/01/2020 | 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 |
05/01/2022 | Download |
|
Employee Waiver Form-Bilingual 1.19 |
01/01/2020 | Download |
|
Affidavit for Enrollment of Domestic Partners 1.19 |
01/01/2020 | Download |
|
Continuity of Care Brochure and Form |
01/01/2020 | Download |
|
Dependent Only Coverage Kit (includes Dependent Only Enrollment Application) |
01/01/2020 | |
|
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 | |
|---|---|---|---|
|
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 |
|
2021 Medical HMO Small Group |
|||
|
P5 Platinum HMO Plan (P5) |
01/01/2021 | Summary | SBC |
|
P10 Platinum HMO Plan (P10) |
01/01/2021 | Summary | SBC |
|
Platinum 90 HMO 0/20 INF Plan (PM90) |
01/01/2021 | Summary | SBC |
|
Gold 80 HMO 250/35 INF Plan (GM80) |
01/01/2021 | Summary | SBC |
|
2021 Medical HMO Large Group |
|||
|
VP5 HMO |
01/01/2021 | Summary | SBC |
|
VP10 HMO |
01/01/2021 | Summary | SBC |
|
VP20 HMO |
01/01/2021 | Summary | SBC |
|
MEP HMO |
01/01/2021 | Summary | SBC |
|
QEP HMO |
01/01/2021 | Summary | SBC |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
General Information |
||
|
Health Plans for Small Businesses 1.23 |
01/01/2023 | Download |
|
Health Plans for Small Businesses (Spanish) 1.22 |
01/01/2022 | Download |
|
Small Group Benefit Matrix 1.22 |
01/01/2022 | Download |
|
Underwriting Guidelines 4.23 |
04/01/2023 | Download |
|
Small Group Carrier Update Q4 2023 |
10/01/2023 | Download |
|
Small Group Carrier Update Q2 2023 |
04/01/2023 | Download |
|
Binational Healthcare Flyer |
01/01/2020 | Download |
|
Commission Schedule |
01/01/2023 | Download |
|
MediExcel Contact Sheet |
01/01/2021 | Download |
|
COVID-19 and Antibody Testing Flyer |
10/01/2020 | Download |
|
Dependent Only Coverage Kit (includes FAQ, Employer Instructions and Employee Dependent Only Coverage Application) |
07/01/2023 | Download |
|
DMHC Infographic |
08/01/2020 | Download |
|
DMHC Infographic & 2019 Annual Report |
06/01/2020 | Download |
|
Imperial County Flyer |
01/01/2020 | Download |
|
Independent Medical Review |
01/01/2020 | Download |
|
Health Plans for Large Group 1.23 |
01/01/2023 | Download |
|
Large Group Value Flyer |
01/01/2020 | Download |
|
Large Group 2020 MEP QEP Plans [effective 10/1/2020] |
10/01/2020 | Download |
|
Large Group 2020 MEP Rates [effective 10/1/2020] |
10/01/2020 | Download |
|
Large Group 2020 QEP Rates [effective 10/1/2020] |
10/01/2020 | Download |
|
Medical Authorization Process Brochure |
01/01/2020 | Download |
|
MediExcel Health Plan Accepted at AFC Urgent Care Flyer |
06/01/2020 | Download |
|
Minute Clinic Flyer |
01/01/2020 | Download |
|
Patient Portal Flyer |
02/01/2022 | Download |
|
Prescription Drug Formulary - In Mexico |
02/01/2020 | Download |
|
Prescription Drug Formulary - Urgent Care in the US |
02/01/2020 | Download |
|
Provider Directory |
01/01/2020 | Download |
|
SENTRI Pass Flyer |
01/01/2020 | Download |
|
Urgent Care Network Flyer |
10/01/2020 | Download |
|
Virtual Care Services Flyer |
07/01/2020 | Download |
|
Where You Go for Care Flyer |
01/01/2022 | Download |
|
Ancillary |
||
|
Dental Sell Sheet |
01/01/2020 | Download |
|
Vision Sell Sheet |
01/01/2020 | Download |
|
Dental D100 Sell Sheet - Voluntary & Employer Paid [Effective 10/1/2021] |
10/01/2021 | Download |
|
Dental D200 Sell Sheet - Voluntary & Employer Paid [Effective 10/1/2021] |
10/01/2021 | Download |
|
Vision V100 Sell Sheet - Voluntary & Employer Paid [Effective 10/1/2021] |
10/01/2021 | Download |
| Video Name | Watch Video |
|---|---|
| Introduction to MediExcel |
Watch Video
|
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Small Group Rates 1.23 |
01/01/2023 | Download |
