• Who/What is CaliforniaChoice?
• Who is the Group Plan Administrator?
• Who is my Health Plan?
  • Can I change my Health Plan?
• Can each family member select a different Health Plan?
  • What is my benefit design/plan?
  • Can each family member select a different benefit plan?
• Can I change my benefit design/plan?
• When is my company's annual Renewal?
• When can dependents obtain coverage?
• How many health plans can I offer my employees?
• What benefits does CaliforniaChoice offer?
• Will CaliforniaChoice help me save money?
• Do the plans cover prescription drugs?
• What are the employer group eligibility requirements for CaliforniaChoice?
• What if an employee just does not want health care coverage?
• Can any employee or dependent be denied health coverage?
• Are there any waiting periods imposed before coverage begins?
• Is the cost of coverage guaranteed?
• Are my employees covered if they have pre-existing conditions?
• How long are pre-existing conditions not covered by CaliforniaChoice?
• What about my employees' dependents? Do they have to be covered, and, if so, does the employer have to pay for them?
• How does CaliforniaChoice define a dependent?
• When are children no longer considered dependents?
• Can my employer group be canceled because of too many claims?
• When should my employees choose dependent coverage?
• Will my employees and I be able to keep our current doctors?
• How are rates determined?
• Is there a monthly billing fee?
• How is CaliforniaChoice remunerated for the services it provides?
• Is out-of-state coverage available?
• What materials will I receive once I am enrolled?
• Additional Questions?

Who/What is CaliforniaChoice?
CaliforniaChoice is the TPA (Third Party Administrator) that has brought several insurance companies together to allow you and your employees the ability to select different plans of health coverage.

Who is the Group Plan Administrator?
The Group Plan Administrator is the employee selected by your company to be the main contact to CaliforniaChoice.

Who is my Health Plan?
Your Health Plan is the participating insurance company you selected under the CaliforniaChoice program to provide your health care. (i.e. Anthem Blue Cross, Health Net, Kaiser, Sharp, Western Health Advantage)

Can I change my Health Plan? (i.e. Anthem Blue Cross, Health Net, Kaiser, Sharp, Western Health Advantage)
Yes, but only during your group's annual renewal period or if you move your residence to a location where there are no medical providers under your current Health Plan and you notify CaliforniaChoice within 30 days of your move.

Can each family member select a different Health Plan? (i.e. Anthem Blue Cross, Health Net, Kaiser, Sharp, Western Health Advantage)
No, all family members must select the same Health Plan, but each member may choose a different PCP.

What is my benefit design/plan? (i.e. HMO 15, HMO 25, HMO 25 Value, HMO 30, HMO 30 Value, HMO 40, HMO 40 Value, PPO 750, PPO 750 GenRx, PPO 1000, PPO 1000 GenRx, PPO 3000, PPO 4000, HSA 1800, HSA 2500)
The level of coverage/benefits that you selected related to co-payments or coverage for doctor visits, hospitalizations, etc. (i.e. HMO 15, HMO 25, HMO 25 Value, HMO 30, HMO 30 Value, HMO 40, HMO 40 Value, PPO 750, PPO 750 GenRx, PPO 1000, PPO 1000 GenRx, PPO 3000, PPO 4000, HSA 1800, HSA 2500)

Can each family member select a different benefit plan? (i.e. HMO 15, HMO 25, HMO 25 Value, HMO 30, HMO 30 Value, HMO 40, HMO 40 Value, PPO 750, PPO 750 GenRx, PPO 1000, PPO 1000 GenRx, PPO 3000, PPO 4000, HSA 1800, HSA 2500)
No, all family members must select the same benefit plan.

Can I change my benefit design/plan? (i.e. HMO 15, HMO 25, HMO 25 Value, HMO 30, HMO 30 Value, HMO 40, HMO 40 Value, PPO 750, PPO 750 GenRx, PPO 1000, PPO 1000 GenRx, PPO 3000, PPO 4000, HSA 1800, HSA 2500)
Yes, but only during the annual renewal period for your company.

When is my company's annual renewal?
Your company's annual renewal period is usually two months prior to the anniversary date (your company's initial effective date). All changes made during annual renewal are effective on the company anniversary date. Check with the Group Plan Administrator for the exact date.

How many health plans can I offer my employees? (i.e. Anthem Blue Cross, Health Net, Kaiser, Sharp, Western Health Advantage)
Up to 4 based on the employee's resident zip code and it's still easy for you! Only through CaliforniaChoice can each employee choose a different health plan using one universal enrollment form, while you get one bill and write only one check a month, regardless of the number of health plans chosen by employees.

What benefits does CaliforniaChoice offer?
With CaliforniaChoice each employee can choose from up to 5 health plans and HMO, PPO and HSA benefit designs. The plans offer a variety of co-payments and network options. Benefits are standardized for easy comparison. Please see the benefit overview for details.

Will CaliforniaChoice help me save money?
Yes. We all know health insurance is expensive, but CaliforniaChoice helps ease the uncertainty of rising health care costs by allowing you to base your contribution on a specific plan. Each employee can still pick whatever plan best fits his/her individual needs. If there's a difference between the employer contribution and the cost of the coverage the employee selected, it's paid through payroll deduction. The result is, you set a fixed benefit budget, while employees have the flexibility to individually select the benefit design and health plan they want.

Do the plans cover prescription drugs?
Yes, all benefit designs include a variety of co-payments for generic and brand name prescriptions.

What are the employer group eligibility requirements for CaliforniaChoice?
CaliforniaChoice benefits are offered exclusively to small businesses with 2 to 50 full-time, eligible employees. However, businesses with more than 50 employees may be eligible if they had less than 50 full-time, eligible employees for 50% of the preceding calendar year or 50% of the preceding calendar quarter.

• You must be actively in business with a street address in California.
• Your home office must be in California.
• 51% of your employees must reside in California.
• You must have a California Federal Tax ID number.
• You must have Worker's Compensation Coverage effective on the requested CaliforniaChoice effective date.
• 70% of your eligible employees must enroll with CaliforniaChoice or have group spousal or governmental coverage (i.e. Medicare, Tricare - formerly Champus).
• An eligible employee must work a minimum of 20 or 30 hours per week. You may set the minimum number of hours (20 or 30) for eligibility, but those hours must be consistent for all employees. We'll need applicable tax documentation to verify your eligible employees (such as an annual/quarterly wage report).

What if an employee just does not want health care coverage?
An individual employee may decline coverage if he/she wishes; however, his/her dependents will not be able to enroll. In addition, the employee will not be able to enroll with CaliforniaChoice until the employer's next annual renewal period, unless the employee has a qualifying event. (i.e. loss of other group coverage; proof must be provided) Remember, for your employer group to qualify for CaliforniaChoice coverage, 70% of your eligible employees must enroll with CaliforniaChoice.

Waiving Coverage: It is extremely important that employess wishing to waive coverage complete the CaliforniaChoice Medical/Dental Waiver portion of the Enrollment Application advising them of thier legal rights. Pursuant to the Knox Keene Act, Section 1357(d)(4)(A), employees wishing to waive coverage must execute a written waiver and Employers are required to maintain that waiver on file. Waivers may also be submitted to CaliforniaChoice at (714) 558-8000 for retention in our files.

Can any employee or dependent be denied health coverage due to health conditions?
No. In CaliforniaChoice, as with all small group health insurance, coverage is "guaranteed acceptance". This means your employees and their dependents cannot be turned down or their coverage dropped due to prior medical history or current health status. However, an employee or dependent may be denied only for failure to meet the eligibility requirements.

Are there any waiting periods imposed before coverage begins?
You, the employer, may establish a waiting period for new employees. This waiting period may be 30, 60, 90, 180 or 365 days from the employee's date of hire. This waiting period must be consistent for all employees since multiple waiting periods are not allowed. You may choose to waive the waiting period for your new employees during initial enrollment, but this also must be consistent for all employees. Newly hired employees added after initial enrollment will be covered under CaliforniaChoice on the 1^st day of the month following completion of the waiting period, provided the application is received no later than 30 days after the eligible effective date.

Is the cost of coverage guaranteed?
Yes. Once your business is enrolled, costs for the health plans chosen by your employees are guaranteed for 12 months. Once a year the case will go through a renewal process, during which time rates may increase. Employees will be allowed to switch plans for a lower or higher cost premium. The new rates at renewal will also be guaranteed for 12 months. Changes to an employee's age (i.e. changing to age 30, 40, 50, 55, 60, or 65) address, and dependent status may affect individual costs of coverage.

Are my employees covered if they have pre-existing conditions?
It depends on their previous coverage and the plan the employee selects. A pre-existing condition is any medical condition that has been treated during the previous 6 months. If an employee selects an HMO, he or she will be covered regardless of any pre-existing conditions. If a PPO plan is chosen, the employee or covered dependent may have to wait for a period of time (exclusionary period) before getting coverage for the pre-existing condition. Please note that all other contractually covered medical conditions will be covered during that period. If the employee or covered dependent had health insurance coverage continuously for at least 6 months prior to buying coverage through CaliforniaChoice, he/she would not have a required exclusionary period. Those that did not have previous coverage, are subject to the exclusionary period.

How long are pre-existing conditions not covered by CaliforniaChoice?
For those employees or covered dependents, electing a PPO plan, and who did not have previous coverage prior to the effective date of the new CaliforniaChoice plan, a one-time exclusionary period of up to 6 months must be observed. An important item to note, however, is that all other contractually covered medical conditions other than the pre-existing condition will be covered. Employees electing an HMO plan are never subject to an exclusionary period even when previous qualifying coverage did not exist.

Credit will be given for having qualifying coverage for part of the previous 6 months. The employee and/or dependent will be given partial or full credit for that period fulfilled under the previous qualifying coverage. For example, if the employee had fulfilled 4 months of a pre-existing condition limitation period, through the previous qualifying coverage, he/she would receive credit for those 4 months, thus leaving only a 2 month pre-existing condition exclusion period under the new CaliforniaChoice plan.

What about my employees' dependents? Do they have to be covered, and, if so, does the employer have to pay for them?
Dependents do not have to be covered and there is no participation requirement for dependents. The employer is not required to pay for the coverage of any dependent. All CaliforniaChoice plans are available to dependents if elected by the employee. If you, the Employer chooses to contribute towards dependent coverage, the cost for dependent coverage can be payroll deducted from the employee's paycheck. The contribution level must be consistent for all employees since multiple contribution levels are not allowed.

How does CaliforniaChoice define a dependent?
A dependent is a spouse, domestic partner or child including legal ward, adopted child or stepchild, if under the age of 26.

When are children no longer considered dependents?
A child is no longer eligible at the end of the month when he/she reaches an ineligible age based on their current benefit design:

• For Medical, Chiro, Vision and Smilesaver Dental, at the end of the month following 26^th birthday
• For Ameritas Dental, at the end of the month following marraige or 26^th birthday.

Can my employer group be canceled because of too many claims?
No. An employer group can be canceled only for non-payment or non-compliance with policy rules.

When should my employees choose dependent coverage?
It is very important to make the decision about who will be covered at the time the employee enrolls. After initial enrollment, an employee cannot add dependent coverage until the next renewal period, unless the employee has a qualifying "Life Event" (adoption, birth, marriage, domestic partner).

Will my employees and I be able to keep our current doctors?
Yes, if you select an HMO that your doctor is contracted with or if you elect a PPO Plan. If an HMO plan is chosen, benefits are payable only if HMO providers are used. A PPO plan gives employees incentives to use network doctors, but you may still choose to use out-of-network providers. Before you and your employees make a selection you will want to know the health plans in which your physician is a participant. For a listing of physicians and networks, go to the online provider directory or ask your broker for a printed physician directory.

How are rates determined?
CaliforniaChoice has a standardized set of benefits for the consumer. Prices will vary based on the health plan and the benefit design the employee chooses, as well as his/her family status. All rates are filed with and approved by the State of California. Once you purchase CaliforniaChoice your rates are guaranteed for 12 months.

Is there a monthly billing fee?
Yes. An billing fee based on number of covered employees as such:

• 1 - 8 = $20
• 9 - 20 = $25
• 21+ = $30

How is CaliforniaChoice remunerated for the services it provides?
CaliforniaChoice is remunerated by the monthly billing fee and by the insurance company from the premium.

Is out-of-state coverage available?
Yes. The employee must enroll in one of the PPO benefit designs available to them based on their group's eligibility.

What materials will I receive once I am enrolled?
Upon enrollment, the employer group will receive a welcome kit from CaliforniaChoice confirming your effective date and containing administrative instructions, providing you complete information on how to administer your health insurance throughout the year. Also, the health plans you and your employees select will send information to your office or your employees' homes. This information explains benefits and exclusions, information on the network of providers (if applicable); instructions on how to use the health plan and benefit design selected and an identification card.

Additional Questions?
For additional questions about eligibility, enrollment, COBRA plans, administrative or customer services issues, please call our Customer Service Center at 800-558-8003 Monday through Friday 8:00 am. – 5:00 pm or e-mail us at CustomerService@Calchoice.com, and a CaliforniaChoice specialist will be glad to assist you.

For referral to a broker in your area call CaliforniaChoice at 888-542-4218.

CaliforniaChoice is dedicated to helping insure California small business. We look forward to serving you with quality, affordable health care choices.

What is a co-payment?
The amount the insured/member must pay for medical services (doctor visits, drug prescriptions, hospitalizations, etc.).

Who/What is my Primary Care Physician?
A Primary Care Physician can be a family practitioner, internist, or pediatrician. At the time of enrollment, you were asked to select a Primary Care Physician for yourself and each dependent. The Primary Care Physician coordinates all health care and medical needs including basic care, preventive services, referrals to specialists, and hospitalization arrangements.

Can each family member select a different Primary Care Physician?
Yes, each family member may choose a different Primary Care Physician, best suited to their needs (i.e. the employee and spouse may want to select a general practitioner, while selecting a pediatrician for their dependent children.).

Can I change my Primary Care Physician?
Yes, (some restrictions may apply) contact your Health Plan Member Services Department using the phone number on your medical ID card. Some plans may allow you to change your PCP through their website.

What if I need to see a specialist?
Your Primary Care Physician, in consultation with the IPA or medical group, will determine the proper treatment and make referrals to specialists when necessary. A change in Primary Care Physician or Health Plan could cause a problem if you are in the middle of specialist treatment.

If hospitalization is necessary, what hospital will I use?
Primary Care Physicians work with specific hospitals; check your I.D. card, the provider directory or ask your Primary Care Physician. This was listed in the CaliforniaChoice directory at the time you chose your Primary Care Physician (In an emergency situation, always go to the nearest available hospital.).

What if I need to see a doctor while away from home?
If you are away from home and cannot see your Primary Care Physician, you will only be covered for emergency treatment that is medically necessary. Contact your Primary Care Physician first to confirm coverage. If you are unable to get in touch with your Primary Care Physician, contact the Health Plan Member Services Department on your ID card.

What if I have an emergency situation?
In the event of any emergency, contact your Primary Care Physician first. Depending on the nature of the emergency, your physician will either: help over the phone; make an appointment for you to come in as soon as possible; or make a referral to an emergency room or urgent care facility. If the emergency is life threatening, such as a heart attack, or is critically serious, such as a broken leg, go directly to the nearest medical facility. However, you (or a family member) must contact your Primary Care Physician within 24 hours. If you are unable to get in touch with your Primary Care Physician, contact the Health Plan Member Services Department.

What if I receive a bill?
Although you should not receive bills for medical care provided or approved by your Primary Care Physician, you may receive a bill in error. Contact the CaliforniaChoice Customer Service Center at 800-558-8003 for assistance.

What if medical services are needed before permanent I.D. cards are received?
The member should present his/her temporary I.D. card to the Primary Care Physician they selected for services. The physician's office may then contact CaliforniaChoice who will assist with verifying coverage.

What if a prescription is needed before permanent I.D. cards are received?
The member should make sure the pharmacy they wish to use works with their Health Plan. The member will need to pay the full amount of the prescription up front, but may request reimbursement by retaining the paid receipt and contacting CaliforniaChoice Customer Service Center at 800-558-8003 for assistance.

What if a prescription is needed before permanent I.D. cards are received?
PPO 750, PPO 750 GenRx, PPO 1000, PPO 1000 GenRx, PPO 3000 & 4000:
The member should make sure the pharmacy they wish to use works with their Health Plan and Rx provider. The member will need to pay the full amount of the prescription up front, but may request reimbursement by retaining the paid receipt and submitting a claim after their permanent I.D. card has been received.

PPO 1800 & 2500:
The member will need to pay the full amount of the prescription up front and then submit (as any other claim) to Anthem Blue Cross for reimbursement. Just like your other medical expenses, benefits will not be paid until your deductible has been met.

If hospitalization is necessary, what hospital will I use?
The accredited hospital you choose to use is up to you, but remember medical services will be covered at a greater percentage at those hospitals listed in the network. Check with your Health Plan Member Services Department if you are unsure if the hospital you are considering is a provider in the network for your Health Plan. (In an emergency situation, always go to the nearest available hospital.)

What is a co-payment?
The amount the insured/member must pay for dental services.

May I or my dependents obtain Prepaid 1000 or plan 3000 coverage but not be enrolled in the medical program?
Yes, but when dependents are covered by both the medical and dental programs, the dependents must be the exact same individuals enrolled in the medical program as enrolled in the dental program.

Can each family member go to a different dental office?
No, each family member must use the same dental office each time they seek service.

What if I receive a bill?
Although you should not receive bills for dental care provided or approved by your dental office, you may receive a bill in error. Contact the SmileSaver Member Services department at (800) 333-9561 for assistance.

May I or my dependents obtain EPO 3000, EPO 3500, PPO 4000 or PPO 5000 coverage but not be enrolled in the medical program?
Yes, but when dependents are covered by both the medical and dental programs, the dependents must be the exact same individuals.

Can each family member go to a different dental office?
Yes, each family member can go to a different dentist each time they seek service.

What if I need to see a dentist while away from home?
You are not restricted to see any specific dentist. Please note: EPO 3000 & 3500 - In Network providers available in California only.

What if I receive a bill?
If you take your dental claim form with you to your dentist visit, the dentist will generally complete all the paperwork and send you a bill only for the amount you are responsible to pay.

My Employer chose the Prepaid  3000 and FDH 100 for our company. Can I enroll in the PPO 5000?
No, you only have the option to select from the plans designated by your Employer.

My Employer chose the PPO 5000 (without the orthodontia option). Can I enroll in the PPO 5000 and add the orthodontia option?
No, the orthodontia option must be elected by your Employer.