Group Medical Participation Guidelines
Aetna
Standalone
1-4 enrolled employees: 60% participation rounded down
5+ enrolled employees: 25% participation
Alongside Another Carrier
1-4 California enrolled employees: 60% participation
5+ California enrolled employees: 25% participation and a minimum of 5 enrolling in California
Anthem BlueCross
Standalone
1-4 enrolled employees: 65% participation through Quarter 2 2021 effective dates
5+ enrolled employees: 25% participation through Quarter 2 2021 effective dates
Alongside Another Carrier
Employees covered by the same employer on another group policy are not considered a valid waiver
Another carrier’s HMO or PPO plans can be sold alongside Anthem as long as Anthem receives the required participation
Blue Shield of California
Standalone
70% participation for mirror plans
65% participation for off exchange plans
25% participation for off exchange plans available to groups of 5+ enrolling through December 31, 2021
0% participation for groups selecting Trio HMO only or Tandem PPO only plans with no end date
Applies to Specialty Products
Alongside Another Carrier
Only one major medical carrier is allowed to be written alongside Blue Shield. Health exchanges are not eligible. MediExcel or SIMNSA can be written alongside as a third carrier
The Mirror Package for Small Business cannot be offered alongside another carrier. At least 25% of the total number of eligible employees must enroll with no fewer than 5 enrolled. Blue Shield must be the sole
carrier for dental, vision and life plans
Employees covered by the same employer on another group policy are ot considered a valid waiver
CaliforniaChoice
Standalone
1-2 eligible employees:100% participation
3+ eligible employees: 70% participation
Alongside Another Carrier
Cannot be written alongside another carrier
Health Net
Enhanced Choice A and Enhanced Choice B package: 70% with 1-5 eligible, 25% for 6+ eligible with a minimum of 5 enrolling
Promotion will end 3/31/2021:
No participation requirement for Salud Package with minimum of 2 enrolled. Waivers are not required for Salud Package
Promotion through 6/15/2021:
HMO Package: No participation or Participation Attestation Form required with 6+ active enrolling employees
Waivers are not required
Mix and Match any plans from the HMO networks for HMO Package promotion
HSP, EnhancedCare PPO and Full Network PPO plans do not qualify for the HMO Package promotion
Alongside Another Carrier
Another carrier’s HMO or PPO plans can be sold alongside Health Net as long as Health Net receives the required participation
Employees covered by the same employer on another group policy will not be considered a valid waiver on the Enhanced Choice A & Enhanced Choice B plans
Kaiser Permanente
Standalone
50% of eligible employees must be covered by a group plan
Alongside Another Carrier
A minimum of 1 must enroll with Kaiser Permanente
UnitedHealthcare
Standalone
60% participation for all group sizes excluding valid waivers
Uniform child enrollment is required. All enrolling children’s Product Selection must match for each line of coverage
Employees who are waiving due to enrolling as dependents under another employee at the same group are not considered valid waivers
Alongside Another Carrier
Choice Simplified Package alongside to staff model carrier: 60% participation between the carriers with 5 CA employees enrolling with UHC is required
Multi-Choice® State Package alongside to staff model carrier: 60% participation with UHC is required
Eligible staff-models include: CCHP, KP, MediExcel, Sharp, SIMNSA, Sutter and WHA
Participation and Alongside Guidelines
This guide has been created as a quick reference and does not replace the full underwriting guidelines published by each carrier
Please refer to the carrier guidelines for additional information