| Form Name | Effective Date | Download Form |
|---|---|---|
|
New Group Submission |
||
|
New Business Submission Checklist |
04/01/2024 | Download |
|
Employer Application - HMO Small Group 3.23 |
10/01/2023 | Download |
|
Employer Application - HMO Large Group 2.23 |
04/01/2024 | Download |
|
Employee Declination Spreadsheet |
04/01/2024 | Download |
|
Employer Group Size Attestation Form |
11/01/2023 | Download |
|
Small Group Initial Payment ACH Form |
04/01/2024 | Download |
|
In Force Group Forms |
||
|
Administration |
||
|
Group Administration Manual |
04/01/2024 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Enrollment and Change Forms |
||
|
Employee Enrollment and Change Form 9.23 |
11/01/2023 | Download |
|
Declaration of Domestic Partnership |
04/01/2024 | Download |
|
Request for Continuity of Care |
04/01/2024 | Download |
|
Claim Forms |
||
|
Authorization for Use of Disclosure of Health Information |
04/01/2024 | Download |
|
Medical Claim Form |
04/01/2024 | Download |
|
Pharmacy Claim Form |
04/01/2024 | Download |
| Form Name | Effective Date | Download Form | |
|---|---|---|---|
|
2024 Medical HMO |
|||
|
Non-Mirrored Plans - These benefits are not available on the Exchange and are available with any Sharp network; Choice, Value, Performance and Premier |
|||
|
Platinum HMO NG 1 |
01/01/2024 | Summary | SBC |
|
Platinum HMO NG WOW 1 |
01/01/2024 | Summary | SBC |
|
Platinum HMO NG 2 |
01/01/2024 | Summary | SBC |
|
Platinum HMO NG 3 |
01/01/2024 | Summary | SBC |
|
Platinum HMO NG 4 |
01/01/2024 | Summary | SBC |
|
Platinum HMO NG 7 |
01/01/2024 | Summary | SBC |
|
Platinum HMO NG 8 |
01/01/2024 | Summary | SBC |
|
Gold HMO NG 1 |
01/01/2024 | Summary | SBC |
|
Gold HMO NG WOW 1 |
01/01/2024 | Summary | SBC |
|
Gold HMO NG 2 |
01/01/2024 | Summary | SBC |
|
Gold HMO NG 3 |
01/01/2024 | Summary | SBC |
|
Gold HMO NG 4 |
01/01/2024 | Summary | SBC |
|
Gold HMO NG 5 |
01/01/2024 | Summary | SBC |
|
Gold HMO NG 6 |
01/01/2024 | Summary | SBC |
|
Gold HMO NG 7 |
01/01/2024 | Summary | SBC |
|
Silver HMO NG 1 |
01/01/2024 | Summary | SBC |
|
Silver HMO NG WOW 1 |
01/01/2024 | Summary | SBC |
|
Silver HMO NG 2 |
01/01/2024 | Summary | SBC |
|
Bronze NG WOW 1 |
01/01/2024 | Summary | SBC |
|
Bronze HDHP NG 1 |
01/01/2024 | Summary | SBC |
|
Mirrored Plans - These are the same plan benefits and HMO networks as available on Covered California for Small Business |
|||
|
Performance Platinum 90 HMO 0/15 + Child Dental |
01/01/2024 | Summary | SBC |
|
Premier Platinum 90 HMO 0/20 + Child Dental |
01/01/2024 | Summary | SBC |
|
Performance Gold 80 HMO 350/25 + Child Dental |
01/01/2024 | Summary | SBC |
|
Premier Gold 80 HMO 250/35 + Child Dental |
01/01/2024 | Summary | SBC |
|
Performance Silver 70 HMO 2500/55 + Child Dental |
01/01/2024 | Summary | SBC |
|
Premier Silver 70 HMO 2500/55 + Child Dental |
01/01/2024 | Summary | SBC |
|
Premier Silver 70 HDHP HMO 2700/25% + Child Dental |
01/01/2024 | Summary | SBC |
|
Performance Bronze 60 HMO 6300/65 + Child Dental |
01/01/2024 | Summary | SBC |
|
Premier Bronze 60 HDHP HMO 7000/0% + Child Dental |
01/01/2024 | Summary | SBC |
|
Pseudo-Mirrored Plans - These are the same plan benefits available on the Exchange but available with other networks. PeVC = Performance, Value, Choice and PrVC = Premier, Value, Choice |
|||
|
Platinum 90 HMO 0/20/250 + Child Dental (PeVC) |
01/01/2024 | Summary | SBC |
|
Platinum 90 HMO 0/15/10% + Child Dental (PrVC) |
01/01/2024 | Summary | SBC |
|
Gold 80 HMO 250/35/600 + Child Dental (PeVC) |
01/01/2024 | Summary | SBC |
|
Gold 80 HMO 350/25/20% + Child Dental (PrVC) |
01/01/2024 | Summary | SBC |
|
Silver 70 HMO 2500/55/40% + Child Dental (PeVC-300) |
01/01/2024 | Summary | SBC |
|
Silver 70 HMO 2500/55/35% + Child Dental (PrVC-35%) |
01/01/2024 | Summary | SBC |
|
Silver 70 HDHP HMO 2700/25%/25% + Child Dental (PeVC) |
01/01/2024 | Summary | SBC |
|
Bronze 60 HMO 6300/65/40% + Child Dental (PrVC) |
01/01/2024 | Summary | SBC |
|
Bronze 60 HDHP HMO 7000/0%/0% + Child Dental (PeVC) |
01/01/2024 | Summary | SBC |
|
2024 Medical POS |
|||
|
Platinum POS NG 1 |
01/01/2024 | Summary | SBC |
|
Gold POS NG 1 |
01/01/2024 | Summary | SBC |
|
Silver POS NG 1 |
01/01/2024 | Summary | SBC |
|
2023 Medical HMO |
|||
|
Non-Mirrored Plans - These benefits are not available on the Exchange and are available with any Sharp network; Choice, Value, Performance and Premier |
|||
|
Platinum HMO NG 1 |
01/01/2023 | Summary | SBC |
|
Platinum HMO NG WOW 1 [New 10/1/2023] |
10/01/2023 | Summary | SBC |
|
Platinum HMO NG 2 |
01/01/2023 | Summary | SBC |
|
Platinum HMO NG 3 |
01/01/2023 | Summary | SBC |
|
Platinum HMO NG 4 |
01/01/2023 | Summary | SBC |
|
Platinum HMO NG 7 |
01/01/2023 | Summary | SBC |
|
Platinum HMO NG 8 |
01/01/2023 | Summary | SBC |
|
Gold HMO NG 1 |
01/01/2023 | Summary | SBC |
|
Gold HMO NG WOW 1 [New 10/1/2023] |
10/01/2023 | Summary | SBC |
|
Gold HMO NG 2 |
01/01/2023 | Summary | SBC |
|
Gold HMO NG 3 |
01/01/2023 | Summary | SBC |
|
Gold HMO NG 4 |
01/01/2023 | Summary | SBC |
|
Gold HMO NG 5 |
01/01/2023 | Summary | SBC |
|
Gold HMO NG 6 |
01/01/2023 | Summary | SBC |
|
Gold HMO NG 7 |
01/01/2023 | Summary | SBC |
|
Silver HMO NG 1 |
01/01/2023 | Summary | SBC |
|
Silver HMO NG WOW 1 [New 10/1/2023] |
10/01/2023 | Summary | SBC |
|
Silver HMO NG 2 |
01/01/2023 | Summary | SBC |
|
Bronze HDHP NG 1 |
01/01/2023 | Summary | SBC |
|
Bronze NG WOW 1 [New 10/1/2023] |
10/01/2023 | Summary | SBC |
|
Mirrored Plans - These are the same plan benefits and HMO networks as available on Covered California for Small Business |
|||
|
Performance Platinum 90 HMO 0/15 + Child Dental |
01/01/2023 | Summary | SBC |
|
Premier Platinum 90 HMO 0/20 + Child Dental |
01/01/2023 | Summary | SBC |
|
Performance Gold 80 HMO 350/25 + Child Dental |
01/01/2023 | Summary | SBC |
|
Premier Gold 80 HMO 250/35 + Child Dental |
01/01/2023 | Summary | SBC |
|
Performance Silver 70 HMO 2500/55 + Child Dental |
01/01/2023 | Summary | SBC |
|
Premier Silver 70 HMO 2500/55 + Child Dental |
01/01/2023 | Summary | SBC |
|
Premier Silver 70 HDHP HMO 2700/25% + Child Dental |
01/01/2023 | Summary | SBC |
|
Performance Bronze 60 HMO 6300/65 + Child Dental |
01/01/2023 | Summary | SBC |
|
Premier Bronze 60 HDHP HMO 7000/0% + Child Dental |
01/01/2023 | Summary | SBC |
|
Pseudo-Mirrored Plans - These are the same plan benefits available on the Exchange but available with other networks. PeVC = Performance, Value, Choice and PrVC = Premier, Value, Choice |
|||
|
Platinum 90 HMO 0/20/250 + Child Dental (PeVC) |
01/01/2023 | Summary | SBC |
|
Platinum 90 HMO 0/15/10% + Child Dental (PrVC) |
01/01/2023 | Summary | SBC |
|
Gold 80 HMO 250/35/600 + Child Dental (PeVC) |
01/01/2023 | Summary | SBC |
|
Gold 80 HMO 350/25/20% + Child Dental (PrVC) |
01/01/2023 | Summary | SBC |
|
Silver 70 HMO 2500/55/40% + Child Dental (PeVC-300) |
01/01/2023 | Summary | SBC |
|
Silver 70 HMO 2500/55/35% + Child Dental (PrVC-35%) |
01/01/2023 | Summary | SBC |
|
Silver 70 HDHP HMO 2700/25%/25% + Child Dental (PeVC) |
01/01/2023 | Summary | SBC |
|
Bronze 60 HMO 6300/65/40% + Child Dental (PrVC) |
01/01/2023 | Summary | SBC |
|
Bronze 60 HDHP HMO 7000/0%/0% + Child Dental (PeVC) |
01/01/2023 | Summary | SBC |
|
2023 Medical POS |
|||
|
Platinum POS NG 1 |
01/01/2023 | Summary | SBC |
|
Gold POS NG 1 |
01/01/2023 | Summary | SBC |
|
Silver POS NG 1 |
01/01/2023 | Summary | SBC |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
General Information |
||
|
Small Group Benefit Brochure 2023 |
11/01/2023 | Download |
|
Member Resource Guide 2024 |
04/01/2024 | Download |
|
Member Resource Kit 2023 |
11/01/2023 | Download |
|
HMO Underwriting Guidelines |
01/01/2024 | Download |
|
POS Underwriting Guidelines |
01/01/2024 | Download |
|
POS Plan Brochure for Small Group |
04/01/2024 | Download |
|
POS Plan Brochure for Large Group |
04/01/2024 | Download |
|
Active & Fit Flyer |
04/01/2024 | Download |
|
BestHealth Coaching Program Flyer |
04/01/2024 | Download |
|
Emergency Travel Assistance |
10/01/2023 | Download |
|
Mail Order Pharmacy Flyer |
04/01/2024 | Download |
|
Minute Clinic Flyer |
10/01/2023 | Download |
|
Mobile App Flyer |
10/01/2023 | Download |
|
HMO Network Comparison Guide |
01/01/2023 | Download |
|
HMO Licensed Service Areas |
04/01/2024 | Download |
|
Choice Network Overview |
11/01/2023 | Download |
|
Value Network Overview |
11/01/2023 | Download |
|
Performance Network Overview |
11/01/2023 | Download |
|
Premier Network Overview |
11/01/2023 | Download |
|
Choice Network Provider & Pharmacy Directory |
04/01/2024 | Download |
|
Value Network Provider & Pharmacy Directory |
04/01/2024 | Download |
|
Performance Network Provider & Pharmacy Directory |
04/01/2024 | Download |
|
Premier Network Provider & Pharmacy Directory |
04/01/2024 | Download |
|
Pediatric Vision Flyer |
04/01/2024 | Download |
|
Wellness Assessment 1-2-3 Flyer |
10/01/2023 | Download |
|
Winning with an HSA Employee Flyer |
04/01/2024 | Download |
| Form Name | Effective Date | Download Form |
|---|---|---|
|
Small Group Rate Sheet [effective 4/1/2024] |
04/01/2024 | Download |
|
Small Group POS Rate Sheet [effective 4/1/2024] |
04/01/2024 | Download |
|
Small Group Rate Sheet [effective 1/1/2024] |
01/01/2024 | Download |
|
Small Group POS Rate Sheet [effective 1/1/2024] |
01/01/2024 | Download |
