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General

HMO Plans 
PPO Plans
For New and Renewing Business Effective 1/1/14
Dental Prepaid 1000 and 3000
Dental EPO 3000, EPO 3500, PPO 4000 and PPO 5000

HMO Plans

PPO Plans



For New and Renewing Business Effective 1/1/14


Dental Prepaid 1000 and 3000



 

Dental EPO 3000, EPO 3500, PPO 4000 and PPO 5000



 
General

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. Aetna, Anthem Blue Cross, Health Net, Kaiser Permanente, Sharp, UnitedHealthcare, Western Health Advantage)
Can each family member select a different Health Plan? (i.e. Aetna, Anthem Blue Cross, Health Net, Kaiser Permanente, Sharp, UnitedHealthcare, Western Health Advantage)
No, all family members must select the same Health Plan, but each member may choose a different Primary Care Physician (PCP).
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's anniversary date. Check with the Group Plan Administrator for the exact date.
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 plan and health plan they want.
Do the plans cover prescription drugs?
Yes, all benefit plans include a variety of copayments for generic and brand name prescriptions.
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, your company will still be required to meet all participation requirements to qualify for CaliforniaChoice coverage.

Waiving Coverage: It is extremely important that employees wishing to waive coverage complete the CaliforniaChoice Medical/Dental Waiver portion of the Enrollment Application advising them of their 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.
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, a domestic partner, and/or child (must be born to, a stepchild or legal ward of, adopted by, or have an established parent-child relationship with the eligible employee, employee spouse or domestic partner) under the age of 26 (unless disabled, disability diagnosed prior to age 26).
When are children no longer considered eligible 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 plan:
  • For Medical, Chiro, Vision and Smilesaver Dental, at the end of the month following 26th birthday
  • For Ameritas Dental, at the end of the month following marriage or 26th 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 in-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.
Is there a monthly billing fee?
Yes. A billing fee based on number of covered employees as such:
  • Up to 8 = $20
  • 9 - 20 = $25
  • 21+ = $30

In addition to the monthly billing fee which is added to your invoice, the premium amount includes commissions and other fees. 

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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 Anthem PPO benefit plans available to them (if any).
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 plan selected and an identification card.

HMO Plans

What is a copayment?
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 may have selected (or been assigned) 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 who is 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, contact your Health Plan's Member Services Department using the phone number on your medical I.D. card. Some plans may allow you to change your PCP through their website. (some restrictions may apply)
What if I need to see a specialist?
Under the HMO plans, your Primary Care Physician, in consultation with a contracted 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 treatment with a specialist.
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. 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 obtain authorization. If you are unable to get in touch with your Primary Care Physician, contact the Health Plan's Member Services Department on your I.D. 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's Member Services Department on your I.D. card.
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. In that event, contact your Health Plan's Member Services Department on your I.D. card 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 he/she 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 the Health Plan's Member Services Department on your I.D. Card.
PPO Plans

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 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.

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's 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.

For New and Renewing Business Effective 1/1/14

What is my benefit plan?

The level of coverage/benefits that you selected related to co-payments or coverage for doctor visits, hospitalizations, etc. (i.e. Bronze HMO A, B or C, Bronze EPO A, Bronze PPO A, Silver HMO A, B or C, Silver EPO A, Silver PPO A or B, Gold HMO A,B or C, Gold PPO A, B, C or D, Platinum HMO A, B or C)
Can each family member select a different benefit plan?
No, all family members must select the same benefit plan. (i.e. Bronze HMO A, B or C, Bronze EPO A, Bronze PPO A, Silver HMO A, B or C, Silver EPO A, Silver PPO A or B, Gold HMO A, B or C, Gold PPO A, B, C or D, Platinum HMO A, B or C)
Can I change my benefit plan?
Yes, but only during the annual renewal period for your company.
When can dependents obtain coverage?
Eligible dependents may be added at the employee's initial enrollment, when acquired (newborn/adoption/marriage/domestic partner), or during annual renewal. Other than during annual renewal, *dependents may only be added when first eligible. (i.e. newborns and newly acquired dependents may be enrolled within 60 days of the qualifying event: date of birth, adoption, marriage/domestic partner.)
Can I change my Health Plan? (i.e. Aetna, Anthem Blue Cross, Health Net, Kaiser Permanente, Sharp, UnitedHealthcare, 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 60 days of your move.
How many health plans can I offer my employees? (i.e. Aetna, Anthem Blue Cross, Health Net, Kaiser Permanente, Sharp, UnitedHealthcare, Western Health Advantage)
Up to 7 based on the employee's residential zip code and metal tier(s) that you have selected. 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 7 health plans from HMO's (some of which are HSA Qualified High Deductible Plans), EPO's and PPO's. The plans offer a variety of copayments and network options. Benefits are standardized for easy comparison. Please see the benefit overview for details.
What are the employer group eligibility requirements for CaliforniaChoice?
CaliforniaChoice benefits are offered exclusively to small businesses with up 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 its working days during the preceding calendar quarter or preceding calendar year.
  • 1 - 2 Employees: 100% of all employees.  All groups must include at least one medical enrolled employee who is not a business owner or spouse of business owner
  • 3 - 50 Employees: 70% of eligible employees, with a minimum of 2 employees enrolling in CaliforniaChoice
  • Employees with other group coverage are not counted towards participation unless employer contribution is 100%
  • Home Office must be in California (principal executive office)
  • A group must have been actively engaged in business for a minimum of 6 weeks prior to the requested effective date
  • If a business was established after the preceding quarter, payroll may be accepted in lieu of a Quarterly Wage Report, at the discretion of the Underwriter
  • 51% of your eligible employees must reside in California
  • You must have a valid Federal Tax ID Number (Not a Social Security Number)
  • You must have active Worker's Compensation Coverage
  • Employees must be permanent and actively working an average of 30+ hours per week over the course of a month, at the small employer's regular place of business or 20+ hours per normal work week for at least 50% of the weeks in the previous calendar quarter. Applicable documentation will be requested to verify employee eligibility (such as a Quarterly Wage Report).
Are there any waiting periods imposed before coverage begins?
Yes, first day of the month following: Date of Hire or 30 days. You may choose to waive the waiting period for your new employees during initial enrollment, but this must be consistent for all employees. Newly hired employees added after initial enrollment will be covered under CaliforniaChoice on the 1st day of the month following completion of the waiting period, provided the application is received no later than 60 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 address or dependent status may affect individual costs of coverage.
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 plan 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.
Are my employees covered if they have pre-existing conditions?
Under the Affordable Care Act, there will no longer be pre-existing exclusion limitations.


What is a copayment?
The copayment is 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? (PRIOR TO 1/1/14)
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?
Yes, each family member can go to a different dental office/dentist. If you and/or your dependents would like to change your dental office/dentist, contact Smilesaver Member Services Department at (800) 333-9561.
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.

Dental EPO 3000, EPO 3500, PPO 4000 and PPO 5000

May I or my dependents obtain EPO 3000, EPO 3500, PPO 4000 or PPO 5000 coverage but not be enrolled in the medical program? (PRIOR TO 1/1/14)
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. However, the benefits will be covered at a lower amount for major services provided by a non-contracting dentist. (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 dental 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.

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 businesses. We look forward to serving you with quality, affordable health care choices.
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