word & brown—broker's health plan reference guide for … · 2010-02-16 · the health...
TRANSCRIPT
C a l i f o r n i a
HEalTH Plan rEfErEnCE GUiDEfor Brokers
Group Health, Dental & Vision
Employer Services:
Employee Services:
Broker Services:
Carrier Online Services
1 All features are available to members who enroll on Aetna Navigator. There is no cost for Aetna Navigator.2 Service currently available with RelayHealth.com3 Employer must sign up with Kaiser Permanente’s Customer Account Services in order to access on-line services.4 Employers must register at employereservices.com.
Employees must register at myuhc.com®.Brokers must register at unitedeservices.com.
* Must be registered with Aflac Account Services in order to access online services† An employer can order ID cards for an employee.
View Employee Add-Ons
View EmployeeTerminations
Rates ForEEs/Dependents
Online Billing
Online Addition of Employee
Online Terminationof Employee
View Directory
Download Forms
E-Mail CustomerService
Premium Payment
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Aflacafl
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Blue Sh
ield
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Califor
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Health
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Health
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Cost S
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HSA Cali
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Kaiser
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Sharp
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United
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uhc.c
om
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View Claims Status
Order ID Cards
View Benefits
View Current PCP Or Doctor
Change Doctor
View Directory
Download Forms
Book DoctorAppointments
Manage GroupAccount
CommissionInformation
Group Information(e.g. Add-Ons)
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Helpful Plan Transition Tips for Your Clients ....3 Carrier Billing Cycles ........................................5Health Plan Comparison Chart ..........................6 Medicare Part D Prescription Coverage ..........12Broker of Record Change Requirements..........14HPV Vaccine Coverage Summary....................15Carrier RAF Summaries ..................................16
WORKSITE VOLUNTARY PRODUCTS ..............29Aflac ..........................................................31Allstate Workplace Division........................37
MEDICAL ........................................................41Aetna ........................................................43Blue Shield of California ............................49CaliforniaChoice® ......................................55California CPA............................................65Health Net..................................................71HealthEdge Cost Saver ..............................77HSA California® ..........................................83Kaiser Permanente ....................................91Kaiser Permanente Choice Solution ..........97Sharp Health Plan ....................................103UnitedHealthcare/PacifiCare ....................109UnitedHealthcare......................................115
CONSUMER DIRECTED PLANS......................121
DENTAL ........................................................129Dental Plan Comparison Chart..................130Aetna ......................................................135Allied National Companies ......................137BEST Life & Health Insurance ..................139Blue Shield of California ..........................141CaliforniaChoice®......................................143Delta Dental ............................................145Delta Dental/Morgan White Group............147Freedom Dental BEN-E-LECT....................149Golden West Dental ................................151 Health Net................................................153HSA California® ........................................155Kaiser Permanente Choice Solution..........157MetLife/SafeGuard....................................159Principal Financial Group ........................161Reliance Standard ....................................163SelectDent ..............................................165SmileSaver ..............................................167UnitedHealthcare/PacifiCare ....................169UnitedHealthcare......................................171
VISION..........................................................173BEST Life & Health Insurance ..................175Blue Shield of California ..........................177Camden Insurance – Affiliateof Vision Plan of America ........................179Principal Financial Group ........................181SafeGuard ................................................183SelectVision ............................................185Vision Plan of America ............................187
C O N T E N T S
TO OUR BROKERS:The information in this book was collected from carriers marketed throughWord & Brown and is accurate to the best of our knowledge at the time ofprinting. However, since this publication is intended strictly as a guide – andplan specifications may change – we recommend that you verify any datawith your Word & B rown sales representative and the carrier before basingany decisions on the information provided. Word & Brown disclaims any andall liability regarding the errors or omissions of the carriers.
INLAND EMPIREEmpire Towers
3633 Inland Empire Blvd., Suite 525Ontario, CA 91764
877-225-0988909-945-2224 • Fax 909-945-3339
LOS ANGELES801 N. Brand Blvd., Suite 900
Glendale, CA 91203 800-560-5614
818-247-2861 • Fax 800-355-9711
NORTHERN CALIFORNIA1737 N. First Street, Suite 680
San Jose, CA 95112800-255-9673
408-437-5929 • Fax 408-437-5925
ORANGE721 South Parker, Suite 300
Orange, CA 92868800-869-6989
714-835-6752 • Fax 714-953-9404
SAN DIEGO3131 Camino Del Rio North, Suite 820
San Diego, CA 92108800-397-3381
619-299-5001• Fax 619-299-2070
The Health Plan Reference Guide (HPRG) is a compilation of Carrier Plans and Services offered to youthrough Word & Brown. The HPRG provides brokers withinformation on plan commissions, benefits, enrollment andeligibility requirements and coverage areas. This information isprinted on a quarterly basis and the most up to date guidelinesare posted on our website.
www.wordandbrown.com
Helpful transition tips for your clients
www.wordandbrown.com
Northern California 800.255.9673 ■ Los Angeles 800.560.5614 ■ Inland Empire 877.225.0988 ■ Orange 800.869.6989 ■ San Diego 800.397.3381
3
Please share these tips with all of your clients changing insurance plans
Until the new insurance plan has been approved, please make sure your clients are aware of the following:
Emergency Care –In case of an emergency situation, your client should call 911 or go to the nearest in-network hospital* for their new plan and pay cashor use a credit card for any incurred fees. Once their group is approved by the carrier, they can request reimbursement (less their plan’semergency room co-payment). Also remind clients to keep a record of their payment for submission to the carrier. Some plans waive theemergency room co-payment if the patient is admitted to the hospital directly from the emergency room. Important: The diagnosis by theemergency room physician must meet the carrier’s definition of a true emergency in order to receive any reimbursement.
* If your client is taken by car or ambulance to a non-network hospital because it’s within closer proximity than an in-network hospital, the new carrier must be notified within24-48 hours. Please have them call their company’s insurance contact person or you, the broker, if they need assistance with this notification process.
Continuity of Care/Completion of Covered Services – If your client or their enrolling spouse/domestic partner is pregnant and receiving care by a non-network doctor, your client is undergoingtreatment for an acute condition, a serious chronic condition or terminal illness by a non-network doctor or your client’s newborn child isreceiving care from a non-network doctor between birth and age 36 months, they may come under the provisions of the California lawrequiring carriers to provide continuity of care (completion of covered services) with the non-network doctor in specific circumstances. Itis important that they notify their company’s designated insurance contact person or you as soon as possible so you can assist them withsubmitting the continuity of care form to the carrier if their situation meets this law’s criteria and the carrier’s program guidelines.
Doctor Office Visit –Some offices will allow the patient to sign a waiver and pay for the visit up front. Remind your client to keep record of their payment forsubmission to the carrier along with their reimbursement form once they have their new ID number. If your client is a current patient, somedoctors will agree to bill the new insurance carrier once the patient gets their new insurance ID number and will have them pay only theoffice visit co-payment for their new plan. It is best to call the office before their appointment and explain their situation so they know whatthe payment procedures are in advance. If this visit can be postponed without adverse consequences to their health, they may want toconsider rescheduling their appointment for a later date when they have their new ID number.
Prescriptions –Clients should refill maintenance prescriptions prior to the effective date for their new coverage. For example, they should refill amaintenance high blood pressure medication no later than 12/31 for new coverage that will be effective 1/1. If they need to fill aprescription on or after the effective date for their new coverage, but they do not have their new ID number yet, they can pay for theprescription at the pharmacy and then request reimbursement from the carrier once they receive their new ID number. For reimbursement,they must submit the pharmacy receipt that includes the name of the drug & dosage rather than only the cash register receipt. If theypaid for the prescription by credit or debit card, and return to the pharmacy with their ID number within 7-10 business days, somepharmacies will credit any overpayment back to their account. This is the fastest way for them to get their money back. When amedication is expensive, some pharmacies will work with the client by allowing them to buy a smaller amount (Ex: 10-day supply). Whenthe client returns to pick up the remaining balance of their 30-day supply, the appropriate payment adjustment will be made once theyshow the pharmacy their new ID number. Some brand name drugs have generic equivalents that are much more cost effective. You oryour client can find out if their prescription medication is name brand or generic (and the co-payment amount) by using the carrier’sWeb site Rx search. For your clients’ convenience, Web site addresses are included on the other side of this sheet.
Once the plan is approved and your clients’ employees have received their new membership cards:
• They should carry their membership card at all times. It is important for them to show their new ID card to their doctor during theirfirst visit after their new insurance plan becomes effective.
• Your clients should always make sure they use an in-network doctor or an in-network hospital in order to maximize their coverageand prevent significant gaps in coverage and/or higher out of pocket expenses.
• You should encourage your clients to review all of the benefit descriptions they received during enrollment including their Explanationof Benefits booklet (which the carrier mails to their home address) so they are familiar with their co-payments and covered procedures.
• Ensure they are aware of which procedures will require prior authorization in their plan documents. Remember that proceduresauthorized with their previous carrier may require pre-authorization with their new carrier. Each carrier has their own criteria, so anauthorization by one carrier does not guarantee authorization by another carrier in all circumstances.
• For any additional questions, your client should call Member Services (see other side of this sheet or their ID card for the phone number).
4
Contact Member Services for anyquestions or assistance
Northern California 800.255.9673 ■ Los Angeles 800.560.5614 ■ Inland Empire 877.225.0988 ■ Orange 800.869.6989 ■ San Diego 800.397.3381
* There are two categories of Blue Shield PPO plans: Blue Shield of California Shield Spectrum PPO plans (Shield Spectrum PPO) and Blue Shield of California Life & HealthPPO plans (Blue Shield Life PPO). They are filed differently with the state of California and there are differences in the networks. If you need to call PPO Member Servicesprior to receiving your new ID card and do not know which category of PPO you selected, please check with the person conducting your Enrollment Meeting, the companyinsurance contact person or your employer’s insurance agent.
** Third Party Administrator (TPA)
CARRIER or PLAN MEMBER SUPPORTBILINGUALSUPPORT
PROVIDERELIGIBILITY
VERIFICATION
INTERNET SUPPORT
Aetna® 888-702-3862 (HMO)888-802-3862,(PPO)
888-702-3862 (HMO)888-802-3862 (PPO)
888-632-3862 www.aetna.comwww.aetnanavigator.com
CaliforniaChoice® ** 800-558-8003 800-558-8003 Press #9 for Spanish
800-558-8003 www.calchoice.com
Kaiser Permanente® 800-464-4000 800-788-0616 800-464-4000 www.kaiserpermanente.org
Health Net® 800-361-3366 800-331-1777 800-361-3366 www.healthnet.com
Sharp 800-359-2002 800-359-2002 619-228-2490 www.sharphealthplan.com
HSA California® 866-251-4718 866-251-4718 Press #9 for Spanish
866-251-4718 Press #1
www.hsacalifornia.com
Kaiser PermanenteChoice Solution
800-580-9626 800-580-9626Press #9 for Spanish
800-580-9626 www.kpchoicesolution.com
Blue Shield of California 800-424-6521 (HMO)800-200-3242 (ShieldSpectrum PPO*)800-431-2809 (BlueShield Life PPO*)
800-248-5451 800-424-6521 (HMO)800-200-3242 (ShieldSpectrum PPO*)800-431-2809 (BlueShield Life PPO*)
www.mylifepath.com
California CPA ProtectPlus
Bunyan Consulting,LLC877-480-7923
Anthem Blue Cross –California Society ofCPAs 888-209-7847Select prompt # 2-5based on languagepreference
Anthem Blue Cross –California Society ofCPAs888-209-7847
www.cpaprotectplus.comwww.anthem.com/ca
HealthEdge Inc.Administrators **
Cost Saver Plan
Allied National ** 800-825-7531
Foundation for MedicalCare 800-334-7341Ask for Spanishspeaking Rep
Allied National ** 800-825-7531
www.alliednational.com(Note: HealthEdge Inc & theCost Saver Plan are notreferenced until you log in tothe secure member section)
PacifiCare®
A UnitedHealthcare®
Company
800-624-8822 (HMO)800-913-9133 (POS)866-316-9776 (PPO)
866-863-9776 www.pacificare.com800-624-8822 (HMO)800-913-9133 (POS)866-316-9776 (PPO)Follow prompts orask for interpreter800-730-7270 forSpanish only (PPO)
UnitedHealthcare® Call number on ID cardor Temporary ID cardprinted after registrationon www.myuhc.com
Call number on ID cardor Temporary ID cardprinted after registrationon www.myuhc.com
877-842-3210 www.myuhc.com
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w w w. w o r d a n d b r o w n . c o m
Carrier Date of Billing Due Date Termination Date
Aetna 15th of the prior month 1st of the month End of the month
Aetna 15th Effective Date* 1st of the month 15th of the month 15th of the following month
Aflac 1st or 15th of the month 30 days after date of billing 30 days after due date
Anthem Blue Cross 7-8th of the prior month 1st of the month 30 days after due date
Blue Shield of California 15th of the prior month 1st of the month End of the month
Blue Shield of CA 15th eff. date* 1st of the month 15th of the month 15th of the following month
CaliforniaChoice® 1st week of the month prior20th of the month prior, 10%late fee assessed after the 12thof the month
Last business day of the month
California CPA 15th of the prior month 1st of the month 30 days after due date
HealthEdge Cost Saver 15th of the prior month 1st of the month End of the month
Health NetAssigned date by account rep(usually within the first 3 weeksof the prior month)
1st of the month End of the month
Health Net 15th effective date* Determined by Account rep Determined by Account rep Determined by Account rep
HSA California® 1st week of the month prior20th of the month prior, 10%late fee assessed after the 12thof the month
Last business day of the month
Kaiser Permanente 10th of the month prior 1st of the month 30 days after due date
Kaiser Permanente ChoiceSolution 1st week of the month prior
20th of the month prior, 10%late fee assessed after the 12thof the month
Last business day of the month
Sharp Health Plan 5th of the prior month 1st of the month End of the month
UnitedHealthcare/PacifiCare 2nd week of the prior month 1st of the month End of the month
UnitedHealthcare Call your Word & Brown representative 1st of the month End of the month
*These carriers will only offer 15th of the month effective dates if they are coming off a group plan that ends on the 15th
Carrier Billing Cycles
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HEALTH PLAN COMPARISON CHART
CompositeRates
Domestic Partner
Coverage
Full-time Student
Max. Age/Min. Units
MedicarePrimary/
Secondary*
Available on all plansfor small group with
25+ enrolling CAemployees.
Maximum of 4 plansmay be offered whentaking composite rates
Yes—CA residentsonly. Aetna treatsdomestic partners
the same as spousesin accordance with
AB 2208
Maximum age: 24 (in CA)
Minimum units:12
2-50: Not available
Yes—domesticpartners are treated
as spouses inaccordance
with AB 2208
Maximum age: 24
Minimum units:12
Not available
Yes—domesticpartners are treated
as spouses in accordance
with AB 2208
Maximum age: 25
Minimum units:12
New in Business
Do your age 65+rates vary based onwhether Medicare is
Primary or Secondary?
If yes, do you requireproof of Medicare PartsA and B before givingthe 65+ employee the
lower Medicare primary rate?
If a 65+ employee ina Medicare primarygroup is not eligiblefor Medicare will yoube the Primary payor
on their claims?
Please see pages 12-13for information regarding
Creditable and Non-Creditable Overview
Minimum length oftime in business?
Payroll recordsrequired?
If yes, how long?
Copy of businesslicense?
Other documentsrequired?
Yes
Yes
Yes
2 life group: 60 days3+ group: on or priorto requested effective
date
A minimum of 1 runor from start date tocurrent, whichever is
greater
Call representative
Call representative
Yes
Yes
Yes
Call representative
Call representative
Call representative
Call representative
No
No
Six weeks prior to the effective date
with a minimum of 2 eligible employees
At least 2 weeks worth of payroll,
or a letter from anattorney or certifiedpublic accountant(CPA) listing the
names of allemployees and
number of hoursworked each week
Refer to other documents required
Call representative
51+
Yes—CA residentsonly. California CPA
treats domesticpartners the same
as spouses inaccordance with
AB 2208
Maximum age: Through age 24
Minimum units:9
Yes
No
No
Call representative
No—except when spouse is enrolled as an employee
No
Subscription Agreementwith CalCPA membership
number, or if not,currently a photocopy of
Society membershipapplication
Yes
Yes—domesticpartners are treated
the same as spousesin accordance with
AB 2208
Health NetAvailable on HMO, ELECT Open Access & POS with a
minimum of 10 enrolledemployees on a given plan. Not available for EnhancedChoice, Silver Choice, PPO,FlexNet, Hn Options and HnOptions Silver Subscribers
Maximum age:24
Minimum units:9
No
N/A
Yes
6 weeks prior to effective
date with minimum 2 eligible employees
DE-6 required unless notin business long enough
to have one. Then 6weeks of payroll prior tothe effective date for at least 2 employees and 2 weeks for all other employees. 2 weeks
of payroll for new hiresnot on DE-6 and to verify
wage discrepancies on DE-6
Acceptable ownershipdocumentation varies by
business structure—call Word & Brown
representative
Acceptable ownershipdocumentation varies
by business structure—call your Word & Brown
representative
AetnaBlue Shieldof California CaliforniaChoice® California CPA
HealthEdge Cost Saver
15+ enrolled
Dependents eligible to age 25
Full-time student not required
Yes
No minimum required
No
Call representative
No
No
First full payroll and first filed SQUTR
when available
Yes—CA residentsonly. Domestic
partners are treated the same as
spouses in accordance
with AB 2208
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w w w. w o r d a n d b r o w n . c o m
HEALTH PLAN COMPARISON CHART
CompositeRates
Domestic Partner
Coverage
Full-time Student
Max. Age/Min. Units
New in Business
Not available
Yes—domesticpartners are
treated the same as spouses in accordance
with AB 2208
Maximum age:24
Minimum units:12
Not available
Yes—employers whooffer coverage for
spouses must offer equalbenefits for domesticpartners. Employer is
responsible for keepingevidence of
interdependence on file.Domestic partners and
their dependents are noteligible for
COBRA coverage
N/A
Sharp Health Plan treats domestic
partners the same as spouses in accordance
with AB 2208
Maximum age: 24
Minimum units:Use the definition offull-time student of
institution child is attending
Minimum length oftime in business?
Payroll recordsrequired?
If yes, how long?
Copy of businesslicense?
Other documentsrequired?
MedicarePrimary/
Secondary*Do your age 65+
rates vary based onwhether Medicare is
Primary or Secondary?
If yes, do you requireproof of Medicare PartsA and B before givingthe 65+ employee the
lower Medicare primary rate?
If a 65+ employee ina Medicare primarygroup is not eligiblefor Medicare will yoube the Primary payor
on their claims?
Please see pages 12-13for information regarding
Creditable and Non-Creditable Overview
No
N/A
Yes
45 days
Yes—6 weeks
Yes
Yes—refer to SHP website for details
N/A
Yes—when usingKaiser Permanente
network
On or prior to requested effective date
Yes—payroll records fromstart date to current with a
minimum of one week.Payroll records must includerun date, employee names,wages, withholdings, Social
Security numbers andsummary totals.
If Social Security numbersare missing, a copy of eachemployee’s W-4 is required
Depends on business entity—call yourWord & Brown representative
Depends on business entity—
call yourWord & Brown representative
No No
N/A
Yes
45 days
Depends on business entity—
call yourWord & Brown representative
Depends on business entity—
call yourWord & Brown representative
Not available
Yes—employers who offer coveragefor spouses must
offer equal benefits for
domestic partners
Maximum age:24
Minimum units:Determined by
Group/Employer
N/A
Yes—when usingKaiser Permanente
network
50% of previous calendar quarter.
If proves less, Kaiser Permanente
will recertify the groupupon the first renewal
Varies depending onwhen the business
was established but 1 month
may be acceptable
Yes
New group application, employee applications,
declination of coverage, andproprietor/partner/
corporate officer form
No
Not available
Yes—domesticpartners are
treated the same as spouses in accordance
with AB 2208
Maximum age: 25
Minimum units:12
No
N/A
Yes
2 life group: 60 days
3+ group:on or prior to
requested effective date
A minimum of 1 runor from start date tocurrent, whichever is
greater
Call representative
Call representative
Depends on business entity—call yourWord & Brown representative
Maximum age:25
Minimum units:12
Not available
Call yourWord & Brown representative
No
Although rates do notvary for Medicare
Primary/Secondary,members with Medicare
Primary must submitcopy of Medicare card to
verify parts A & B
Yes
Call yourWord & Brown representative
Yes—call yourWord & Brown representative
Depends on business entity—
call yourWord & Brown representative
Depends on business entity—call yourWord & Brown representative
Maximum age:through age 25
Minimum units:12
Kaiser PermanenteChoice Solution
UnitedHealthcare/PacifiCare
SharpHealth Plan
Kaiser Permanente
HSA California® UnitedHealthcare
8
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On plans which includeout-of-network
benefits,are these paid
based on aLimited FeeSchedule
(LFS) or Usual,Customary &Reasonable
(UCR)?
LFS:MC $500 80/60
MC $1,000 70/50MC $750 80/50/50
MC $1,000 80/50/50MC $2,000 80/50/50
MC $2,500 75/50MC Basic
MC $10,000 100/50MC HDHP HSA $2,300
80/50MC HDHP HSA $3,000
100/50MC HDHP HSA $3,300
80/50MC HDHP HRA $3,000
80/50UCR:
MC $250 90/70MC $250 80/60PPO $500 90/70PPO $750 80/60OOS PPO $250OOS PPO $500
OOS PPO $1,000Indemnity
Blue Shield pays out-of-networkproviders at the same contracted
dollar amount that a PPO provider
would be paid for the same service. The member is
responsible for anybilled charges abovethis PPO contracted
dollar amount
HMO:N/A
PPO:Negotiated Fee
Wrap with Kaiser
Permanente
Aetna will accept the greater of 50%
eligible and aminimum of 8 enrolled
All plans are available
2-50 lives:Blue Shield
Single Option, Dual Option and
Suite Deal package: Yes*— a minimum of 5 or 50% of the total
active enrolledemployees (whicheveris greater) must enroll
with Blue Shield
When Active Choice or Shield Savings Plan4800 is offered as theonly Blue Shield plan
alongside anothercarrier’s HMO plan:
Minimum Blue Shieldenrollment is five
active employees or20% of overall enrolledemployees (whichever
is greater).
Blue Shield PlanSelect:
Yes*— a minimum of 5 or 75% of the
total active enrolledemployees (whicheveris greater) must enroll
with Blue Shield.
*SIGNED REFUSALREQUIRED FOR ALL
KAISER PERMANENTEENROLLEES
2-50 lives:
Not allowed
HEALTH PLAN COMPARISON CHART
2+ lives:
HMOYes—do allow HMOwrap. Employees
covered by anotherHMO are not
counted as eligible
PPODo not allow
PPO wrap
LFS
Is the Deductible part of the
out-of-pocketMaximum?
No The deductible applies to the
out-of-pocket in all plans
HSA 1500* & HSA 2400*:
Yes
PPO 750, PPO 1000,& PPO 2400:
No
*HSA-Qualified HighDeductible Health Plan
HSA plans only
Maximum AllowableAmount 75th Percentile:
PPO 10 - Standard & ValuePOS 10,POS 20,
Value HSA 1500
LFS:PPO 20 - Standard & ValuePPO 30 - Standard & ValuePPO 40 - Standard & Value
Salud PPOValue HSA 2500Value HSA 3500Value HSA 4500
Standard HSA 2000Standard HSA 3000Standard HSA 4000
Options PPO 250, 500,1500, 1750,
Options PPO 3000/4000HSA Comp.
2-4 active enrolled: Not allowed
5 active enrolled:Hn Options packageonly. See below for
details.
6-50 active enrolled:
HMO & EOA*: Yes—on a single plan
choice basis. 50%with a minimum of 6
must enroll withHealth Net.
*Silver Network HMO plans areincluded in this
offering
POS & PPO: Yes—on a single plan choice basis.
75% with a minimum of 6 must
enroll with Health Net. Call
your Word & Brown representative for
details.
Enhanced Choice& Silver Choice: Yes—75% with a
minimum of 6 must enroll with Health Net
Hn Options & HnOptions Silver Choice
Min of 5 active enrolled with 75%
participation on somegroup health plan.
HSA plans only
AetnaBlue Shieldof California CaliforniaChoice® California CPA
UCR
2+ lives: If offered on a class
carve-out basis. Participation of 75%
of eligible in the classoffered Cost Saver
must be met
No
HealthEdge Cost SaverHealth Net
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HEALTH PLAN COMPARISON CHART
UCR—refer to Evidence of
Coverage for further details
Not applicable
All PPOs & POS:LFS (based on
National Medicare)
Sharp Health Companion PPO Plans
use a UCR schedule
POS or Dual Option:2-50 lives:
Not allowed
HMO, PPO or Multi Option:
2-9 lives: Not allowed
10-15 lives: Yes—a minimum of
10 (excludingCOBRA) must enroll
with PacifiCare.
16-50 lives: Yes—minimum 60% of eligible employees
must enroll withPacifiCare.
(For Multi ChoiceOption only Kaiser
Permanente HMO allowed)
2-9 enrolled: Not available
10-15 enrolled:Minimum 10 enrolled
16+: 50% or 10 enrolled
whichever is greater
On plans which includeout-of-network
benefits,are these paid
based on aLimited FeeSchedule
(LFS) or Usual,Customary &Reasonable
(UCR)?
Wrap with Kaiser
Permanente
HMO:N/A
POS:UCR
Not applicable
Is the Deductible part of the
out-of-pocketMaximum?
Limits apply. Call your
Word & Brown representative
HMO 20/$1,000, HDHP 1400, & HDHP 2400:
Yes
PPO 30/$500,PPO HSA 2200, POS 20/$1,000, POS 30/$1,500& Indemnity:
No
No for all products except forHMO plans with anannual deductible
HMO Plans:N/A
Sharp Health Companion PPO
Plans:No
HMO:N/A
PPO:Limited FeeSchedule
2-50 lives:
Not allowed
Yes—all plans
Call your Word & Brownrepresentative
Call your Word & Brownrepresentative
Call your Word & Brownrepresentative
Kaiser PermanenteChoice Solution
UnitedHealthcare/PacifiCare
SharpHealth Plan
Kaiser Permanente
HSA California® UnitedHealthcare
10
w w w. w o r d a n d b r o w n . c o m
N/A
N/A
Do any of your HSA-Compatible High Deductible
Health Plans(HDHP) have an
embedded*deductible withina family plan in
which anindividual family
member does not have to meetthe higher family
deductible ifhe/she has met
the lowerindividual
deductible?
Yes
*When HSA plans were first introduced in 2004, IRS publications used the term “embedded deductible” to refer to the individual deductiblewithin a family plan in which an individual family member does not have to meet the higher family deductible if he/she has met the lowerindividual deductible. Current IRS publications do not use the term “embedded deductible”.
IRS Publication 969 (2007) “Health Savings Accounts and Other Tax-Favored Health Plans” provides the following HDHP eligibility clarificationon page 4:
“Family plans that do not meet the high deductible rules. There are some family plans that have deductibles for both the family as a wholeand for individual family members. Under these plans, if you meet the individual deductible for one family member, you do not have to meetthe higher annual deductible amount for the family. If either the deductible for the family as a whole or the deductible for an individual familymember is below the minimum annual deductible for family coverage, the plan does not qualify as an HDHP.”
No
List each of your HSA-Compatible High Deductible
Health Plans(HDHP) with
an embedded*individualdeductible
CA MC $2300 80/50
CA MC $3000 100/50
CA MC $3300 80/50
Shield Savings Plan2500
Shield Savings Plan4800
N/A
HEALTH PLAN COMPARISON CHART
N/A
NoYes No
N/A
HealthEdge Cost SaverHealth NetAetna
Blue Shieldof California CaliforniaChoice® California CPA
11
w w w. w o r d a n d b r o w n . c o m
*When HSA plans were first introduced in 2004, IRS publications used the term “embedded deductible” to refer to the individual deductiblewithin a family plan in which an individual family member does not have to meet the higher family deductible if he/she has met the lowerindividual deductible. Current IRS publications do not use the term “embedded deductible”.
IRS Publication 969 (2007) “Health Savings Accounts and Other Tax-Favored Health Plans” provides the following HDHP eligibility clarificationon page 4:
“Family plans that do not meet the high deductible rules. There are some family plans that have deductibles for both the family as a whole andfor individual family members. Under these plans, if you meet the individual deductible for one family member, you do not have to meet thehigher annual deductible amount for the family. If either the deductible for the family as a whole or the deductible for an individual familymember is below the minimum annual deductible for family coverage, the plan does not qualify as an HDHP.”
Do any of your HSA-Compatible High Deductible
Health Plans(HDHP) have an
embedded*deductible withina family plan in
which anindividual family
member does not have to meetthe higher family
deductible ifhe/she has met
the lowerindividual
deductible?
List each of your HSA-Compatible High Deductible
Health Plans(HDHP) with
an embedded*individualdeductible
Yes
HMO 2600,HMO 2800B
Yes YesNoYes
HEALTH PLAN COMPARISON CHART
PPO HSA 2200 UnitedHealthcare HSA Choice
Plus Plan D6-1
UnitedHealthcare HSA Choice
Plus Plan C3-X
N/A$0/$2,700 Deductible
Plan with HSA
$30/$2,700 Deductible
Plan with HSA
Kaiser PermanenteChoice Solution
UnitedHealthcare/PacifiCare
SharpHealth Plan
Kaiser Permanente
HSA California® UnitedHealthcare
Call your Word & Brownrepresentative
Call your Word & Brownrepresentative
12*Applies to both Silver Network and Full Network plans.
Medicare Part D Prescription CoverageCreditable & Non-Creditable Overview by Health Plan
Creditable Coverage Prescription drug benefit with current plan from employer is at least as good as the pharmacy benefits offered through the new Medicare Part D standard planNon-creditable Coverage Prescription drug benefit with current plan from employer is not as good as the pharmacy benefits offered through the new Medicare Part D standard plan
CreditableCreditableNon
CreditableNon
Creditable
AetnaHMO
HMO $10 ■HMO $15 ■HMO $20 ■HMO $30 ■HMO $40 ■HMO Deductible $1,000 ■Health HMO HRA $750 $15/$30 ■Health HMO HRA $1,500 $25/$50 ■Aetna Value Network HMO $10 ■Aetna Value Network HMO $20 ■Aetna Value Network HMO $30 ■Aetna Value Network HMO $40 ■
PPO/EPOMC $250 90/70 ■MC $250 80/60 ■MC $500 80/60 ■MC $750 80/50/50 ■MC $1,000 80/50/50 ■MC $1,000 70/50 ■MC $2,000 80/50/50 ■MC $2,500 75/50 ■MC Basic ■MC $10,000 100/50 ■PPO $500 90/70 ■PPO $750 80/60 ■Aetna EPO 80 ■MC HDHP HSA $2,300 80/50 ■MC HDHP HSA $3,300 80/50 ■MC HDHP HSA $3,000 100/50 ■MC HDHP HRA $3,000 80/50 ■
IndemnityIndemnity ■
Blue ShieldHMO
Access+ HMO Plan 5 ■Access+ HMO Plan 10 ■Access+ HMO Plan 15 ■Access+ HMO Plan 20 ■Access+ HMO Value 20 ■Local Access+ HMO Plan 20 Value ■Access+ HMO Plan 25 ■Access+ HMO Plan 30 ■Local Access+ HMO Plan 30 ■Access+ HMO Plan 40 ■Access Baja HMO Plan 5 ■Access Baja HMO Plan 10 ■
PPOActive Choice Plan 500 SG ■Active Choice Plan 750 SG ■Shield Savings, Zero Deductible ■Shield Spectrum PPO Plan 250 Premier ■Shield Spectrum PPO Plan 250 Standard ■Shield Spectrum PPO Plan 500 Premier ■Shield Spectrum PPO Plan 500 Standard ■Shield Spectrum PPO Plan 500 Value ■Shield Spectrum PPO Plan 750 Value ■Shield Spectrum PPO Plan 1000 Value ■Shield Spectrum PPO Plan 1500 Value ■Shield Spectrum PPO Plan 2000 Value ■Shield Spectrum PPO Plan 1000 ■Shield Spectrum PPO Plan 3000 ■Shield Savings Plan 1800/3600 ■Shield Savings Plan 2000/4000 ■Shield Savings Plan 2250/4500 ■ Shield Savings Plan 2500 ■Shield Savings Plan 3000/6000 ■Shield Savings Plan 4800 ■
POSAdded Advantage POS ■
CaliforniaChoice®
HMOCalChoice® HMO 15 ■CalChoice® HMO 25 ■CalChoice® HMO 25 Value ■CalChoice® HMO 30 ■
CaliforniaChoice® (cont.)CalChoice® HMO 30 Value ■CalChoice® HMO 40 ■CalChoice® HMO 40 Value ■Elect Open Access 25 ■Salud HMO y mas ■
PPO CalChoice® PPO 750 ■CalChoice® PPO 1000 ■CalChoice® PPO 2400 ■
Consumer Directed Plans Active ChoiceSM 500 ■
HSA-Compatible CalChoice® HSA 1500 ■CalChoice® HSA 2400 ■
California CPAHMO
HMO Advantage 100 ■HMO Value 80 ■
PPO ProtectPlus 10 ■ProtectPlus 15 ■ProtectPlus 15 Enhanced ■ProtectPlus 25 ■ProtectPlus 25 Enhanced ■ProtectPlus 35 ■ProtectPlus 35 Enhanced ■ProtectPlus 45 ■
HSA-CompatibleProtect HSA ■
Health NetHMO/EPO
HMO 10 Standard & Value* ■HMO 20 Standard & Value* ■HMO 30 Standard & Value* ■HMO 40 Standard* ■HMO 40 Value* ■EOA 10 Standard & Value ■EOA 20 Standard & Value ■EOA 30 Standard & Value ■EOA 40 Standard ■EOA 40 Value ■EOA Silver HMO 10* ■EOA Silver HMO 20* ■EOA Silver HMO 30* ■EOA Silver HMO 40* ■Options HMO 25 ■Options HMO 35 ■Options EOA 25 ■Options EOA 35
POS POS 10 ■POS 20 ■
PPOPPO 10 Standard & Value ■PPO 20 Standard & Value ■PPO 30 Standard & Value ■PPO 40 Standard ■PPO 40 Value ■Flex Net ■HMO Conversion ■Value HSA 1500 ■Value HSA 2500 ■Value HSA 3500 (if Medicare secondary) ■Value HSA 4500 (if Medicare secondary) ■Standard HSA 2000 (if Medicare secondary) ■Standard HSA 3000 (if Medicare secondary) ■Standard HSA 4000 (if Medicare secondary) ■Options PPO 250 ■Options PPO 500 ■Options PPO 1500 ■Options PPO 1750 ■Options PPO HSA 3000 (if Medicare secondary) ■Options PPO HSA 4000 (if Medicare secondary) ■HRA 3000 (if Medicare secondary) ■HRA 5000 (if Medicare secondary) ■
Medicare Part D Prescription CoverageCreditable & Non-Creditable Overview by Health Plan
Creditable Coverage Prescription drug benefit with current plan from employer is at least as good as the pharmacy benefits offered through the new Medicare Part D standard planNon-creditable Coverage Prescription drug benefit with current plan from employer is not as good as the pharmacy benefits offered through the new Medicare Part D standard plan
CreditableNon
CreditableCreditableNon
Creditable
HSA California®
HMO/EPOHMO 1800 ■HMO 2200 ■HMO 2600 ■HMO 2800B ■
PPOPPO 2500 (if Medicare secondary) ■PPO 3500 (if Medicare secondary) ■PPO 4500 (if Medicare secondary) ■
Kaiser PermanenteHMO/EPO
$5 Copayment Plan ■$15 Copayment Plan ■$20 Copayment Plan ■$30 Copayment Plan ■$50 Copayment Plan ■$30/$1000 Deductible Plan ■$30/$1500 Deductible Plan ■
PPO$40/$1000 PPO Plan ■
POS$35 POS Plan ■
HSA-Compatible$40/$2,500 Deductible Plan with HSA ■$30/$2,700 Deductible Plan with HSA ■$0/$2,700 Deductible Plan with HSA ■$0/$1,500 Deductible Plan with HSA ■$0/$2,200 HSA Comp plan ■
Kaiser Permanente Choice SolutionHMO
HMO 10 ■HMO 30 ■HMO 20/$1,000 ■
PPOPPO 30/$500 ■PPO HSA 2200 ■
POSPOS 20/$1,000 ■POS 30/$1,500 ■
Indemnity Indemnity ■
HSA-CompatibleHDHP 1400 ■HDHP 2400 ■
Sharp Health PlanHMO
Blue Plan 10/10/0 ■Blue Plan 15/15/250 ■Blue Plan 20/30/500 ■Blue Plan 20/40/1000 ■Blue Plan 30/40/1000 ■Blue Plan 30/40/750/day ■Blue Plan 40/40/750/day ■Gold Plan 10/10/0 ■Gold Plan 15/15/250 ■Gold Plan 20/30/500 ■Gold Plan 20/40/1000 ■Gold Plan 30/40/1000 ■Gold Plan 30/40/750/day ■Gold Plan 40/40/750/day ■
PPO Companion PlansCompanion Plan 1 20/500/80/50 ■Companion Plan 2 30/1000/80/50 ■
UnitedHealthcare/PacifiCareHMO/EPO
SignatureValue 10-30/100 ■SignatureValue 15-30/250a ■SignatureValue 20-40/500d ■SignatureValue 35/600d ■SignatureValue 10/500d ■SignatureValue 20/1500ded ■SignatureValue Advantage 10/500d ■SignatureValue Advantage 20/1500ded ■SignatureValue Advantage 35/600d ■SignatureValue™ Advantage 40-60/2000ded ■SignatureValue™ 10-30/500d ■SignatureValue™ 15-30/300a ■SignatureValue™ 20-40/1500d ■SignatureValue™ 10-30/100 Advantage ■SignatureValue™ 10-30/500d Advantage ■SignatureValue™ 15-30/300a Advantage ■SignatureValue™ 20-40/1500d Advantage ■SignatureValue™ 20-40/500d Advantage ■SignatureValue™ 35-45/600d Advantage ■HCP Network HMO 25-50/500 ded. ■HCP Network HMO 25-75/1500 ded. ■HCP Network HMO 25-75/500 ded. ■
PPOSignatureOptions™ 15/80-60 ■SignatureOptions™ 20/90-50/250 ■SignatureOptions™ 30/80-60/250 ■SignatureOptions™ 30/80-60/500 ■SignatureOptions™ 40/50-50/1000 ■SignatureOptions™ 40/70-50/1000 ■SignatureOptions™ 40/70-50/250 ■SignatureOptions™ 70-50/2000 ■SignatureOptions™ 70-50/3500 ■
POSSignaturePOS 15/80-60 ■
UnitedHealthcarePPO
Choice Plus PPO 20/250/90% (C3-J) ■Choice Plus PPO 30/500/80% (C3-M) ■Choice Plus PPO 40/500/70% (C3-R) ■Choice Plus Balanced PPO 20/3000/90% (C3-I) ■Choice Plus Balanced PPO 30/1000/80% (C3-K) ■Choice Plus Balanced PPO 30/2500/80% (C3-L) ■Choice Plus Balanced PPO 40/1000/70% (C3-P) ■Choice Plus Balanced PPO 40/1500/70% (C3-Q) ■Choice Plus Balanced PPO 40/1000/50% (C3-N) ■Choice Plus Balanced PPO 40/2000/50% (C3-0) ■Choice Plus Bal. Value PPO 20/3000/90% (D6-L) ■Choice Plus Bal. Value PPO 30/1000/80% (D6-M) ■Choice Plus Bal. Value PPO 30/2500/80% (D6-N) ■Choice Plus Bal. Value PPO 40/1000/70% (D6-Q) ■Choice Plus Bal. Value PPO 40/1500/70% (D6-R) ■Choice Plus Bal. Value PPO 40/1000/50% (D6-0) ■Choice Plus Bal. Value PPO 40/2000/50% (D6-P) ■Non-Differential PPO 2000/80% (6H-F) ■
HSA-CompatibleChoice Plus Definity HSA 2000/100% (D6-K) ■Choice Plus Definity HSA 1500/80% (C3-Z) ■Choice Plus Definity HSA (embedded) 2850/80% (D6-I) ■Choice Plus Definity HSA 2850/80% (D6-J) ■Choice Plus Definity HSA (embedded) 3000/70% (C3-X) ■Choice Plus Definity HSA 3500/70% (C3-Y) ■
HRA-CompatibleChoice Plus Definity HRA 2000/90% (C3-W) ■Choice Plus Definity HRA 1500/80% (C3-U) ■Choice Plus Definity HRA 2500/80% (C3-V) ■Choice Plus Definity HRA 2000/70% (C3-S) ■Choice Plus Definity HRA 3000/70% (C3-T) ■
13
14
w w w. w o r d a n d b r o w n . c o m
Broker of Record Change Requirements—California Medical Carriers
CARRIERNAME
NEED ORIGINALBOR CHANGELETTER ONCOMPANY
LETTERHEAD ORCOPY OK?
SEND BROKER OFRECORD CHANGE
LETTER TO(DEPT NAME + FAX
# OR MAILINGADDRESS)
TURN AROUNDTIME FOR
PROCESSING THIS CHANGE
DOES CARRIERNOTIFY EXISTINGBROKER OF THIS
REQUESTEDCHANGE?
EFFECTIVE DATEFOR NEW BROKERIF GROUP DOES
NOT RESCIND THISCHANGE REQUEST
IS PRIOR AGENTVESTED? IF YES,
HOW LONG
IS GA VESTED? IF YES, HOW
LONG?
Aetna Copy Sales Support888-258-4530
7-10business days No Date of
processing No Life of plan
AnthemBlue Cross Copy
Sales Support Attn: Mia/Vanessa
805-713-71913-4 Weeks Yes 1st of following
month No Life of plan
Blue Shield ofCalifornia Copy Producer Services
209-367-64897-14
Business Days Yes 1st of followingmonth No Life of plan
CaliforniaChoice®
Copy Finance714-972-7368
7-14 Business Days
(15 day rescission period)
Yes 1st of followingmonth
Yes—for the first 6
monthsLife of plan
California CPA*
*Broker of Recordchanges apply to
Word & Brown agentsbusiness ONLY
Copy or fax of letter isrequired
Effective 11/1/09:Banyan Consulting, LLCAttn: Tom Zimmerman
1215 Manor Drive, Suite 200
Mechanicsburg, PA17055
FAX 877-237-4519Phone 877-480-7923
Banyan Consulting,LLC will recognize the BOR change the first of the
following month upon receipt
from Word & Brown
prior to the 15th of the current month
Yes
1st of followingmonth upon receipt from
Word & Brownprior to the 15th of the current
month
No
Yes—as long asCPA firm continues
participation in the Group
Insurance Trust
HealthEdge Original onletterhead
Sales & Marketing661-616-4889 1 week Yes 1st of following
month 1st year Life of plan
Health Net Copy
AccountManagement:
So. Cal Fax 818-676-6297No. Cal Fax
800-303-3110
7-10 Business Days Yes 1st of following
month No Life of plan
HSA California® Copy Finance714-972-7368
7-14 Business Days
(15 day rescission period)
Yes 1st of followingmonth
Yes—for the first 6
monthsLife of plan
Kaiser Permanente Copy
BrokerAdministration 800-440-2323
Fax626-405-5947
14 Business Days Yes 1st of following
month No Life of plan
Kaiser Permanente
Choice Solution
Copy Finance714-972-7368
14 Business Days Yes 1st of following
month
Yes—for the first 6
monthsLife of plan
Sharp Copy Sales and Marketing619-228-2446
7-10 Business Days Yes
1st of followingmonth unless
requested during the 1st week of
month to be effective that month
No Life of plan
UnitedHealthcare/PacifiCare Copy
AccountManagement800-926-2951
10 Business Days Yes 1st of following
month No Life of plan
UnitedHealthcare CopyCall your
Word & Brownrepresentative
Call your Word & Brownrepresentative
Yes 1st of followingmonth No Life of plan
15
w w w. w o r d a n d b r o w n . c o m
HPV Vaccine Summary by Carrier
Quadrivalent HPV VaccineBrand Name: Gardasil
GARDASIL is a vaccine against the HPV or Human Papillomavirus. The GARDASIL vaccine protects recipients against 4 typesof HPV, including the two types that cause most cervical cancers and the two types that cause the most genital warts.
GARDASIL is for girls and women ages 9 to 26. GARDASIL works when given before you have any contact with HPV Types 6,11, 16, and 18.
GARDASIL will be given as a three dose series completed over 6 months.
The retail price of the vaccine is $120 per dose ($360 for full series).
Federal health programs such as Vaccines for Children (VFC) will cover the HPV vaccine. The VFC program provides freevaccines to children and teens under 19 years of age, who are either uninsured, Medicaid-eligible, American Indian, or AlaskaNative. There are over 45,000 sites that provide VFC vaccines, including hospitals, private clinics, and public clinics. The VFCProgram also allows children and teens to get VFC vaccines through Federally Qualified Health Centers or Rural HealthCenters, if their private health insurance does not cover the vaccine.
Answers to frequently asked questions about the vaccine:
X - Approved under Medical Benefit rather than Prescription Drug because it is a vaccine series administered by a physician.PA - Prior authorization required
Carrier Status
Aetna X
Blue Shield of California X
CaliforniaChoice® X
California CPA X
HealthEdge Cost Saver X
Health Net X
HSA California® X
Kaiser Permanente X
Kaiser Permanente Choice Solution X
Sharp Health Plan X
UnitedHealthcare/PacifiCare X
UnitedHealthcare X
16
Health PlanUpdate
www.wordandbrown.com
Each carrier’s Underwriting Department assigns the final Risk Adjustment Factor (RAF) for each group based upon their own RAF assignmentguidelines and current special RAF reduction program (if any). This information is intended for use as a guide to help you know what to expect whenyou submit a group that meets the carrier’s eligibility criteria. RAF assignment procedures and special RAF reduction programs are subject to changeat the carriers’ discretion. Word & Brown cannot guarantee what RAF a carrier will give a particular group. According to California law, no smallgroup (2-50) can receive an RAF lower than 0.90, or higher than 1.10, based on the carrier’s standard risk rates (1.00).
RAF ASSIGNMENT BY GROUP SIZE
& SPECIAL RAF REDUCTION PROGRAMS
2-4 Automatic 1.10 RAF7/1/09 – 12/31/09
5-9 Enrolling employeeswill be medicallyunderwritten to
determine their RAF
7/1/09 – 12/31/09
EffectiveDates
Group Size (based on number ofenrolling employees)
RAF ReductionOffer
Program Rules & Eligibility Criteria Checklist
★★★ Special RAF Reduction Program ★★★
RAF Assignment by Group Size*(based on number of enrolling employees)
2-4 ➢ Automatic 1.105-9 ➢ Minimum .90 - Maximum 1.10
10-50 ➢ Minimum .90 - Maximum 1.10
AETNA
Maximum .90 RAFif group meets
program rules &eligibility criteria
7/1/09 – 12/31/09
*These are the RAF assignment guidelines for groups that do not qualify for the Special RAF Reduction Program outlined below.
10-50
• Groups coming from a large group contract that are AB1672 eligibleare eligible if they can provide a large group renewal of less than a20% increase within 90 days of their requested effective date
• Carve out groups (management/non-management, union/non-union)are not eligible for RAF promotion
• Groups must submit a copy of both their current and last year’srenewal or their issued RAF at new business
• Groups that received a 10-point increase in their RAF are ineligible forthis promotion
• Groups applying for the guaranteed RAF must be AB 1672 eligible andhave a current RAF of 1.06 or less with their current carrier
• This underwriting offer does not apply to groups enrolled withCaliforniaChoice®, Contractor’s Choice, HSA California® or KaiserPermanente Choice Solution, or groups that have withdrawn fromAetna within 12 months of the requested effective date
• COBRA/CalCOBRA enrollees do not count toward the enrolledemployee counts
• Groups with no prior coverage do not qualify• If a group meets the RAF promotion guidelines, no health statements
required• To qualify for RAF reduction specials, the prior carrier renewal must
be the original renewal—not a revised renewal
Maximum .90 RAF if group meets
program rules &eligibility criteria
7/1/09 – 12/31/09 Downsized large group nowunder 50 eligible employees
Health PlanUpdate
17
www.wordandbrown.com
Each carrier’s Underwriting Department assigns the final Risk Adjustment Factor (RAF) for each group based upon their own RAF assignmentguidelines and current special RAF reduction program (if any). This information is intended for use as a guide to help you know what to expect whenyou submit a group that meets the carrier’s eligibility criteria. RAF assignment procedures and special RAF reduction programs are subject to changeat the carriers’ discretion. Word & Brown cannot guarantee what RAF a carrier will give a particular group. According to California law, no smallgroup (2-50) can receive an RAF lower than 0.90, or higher than 1.10, based on the carrier’s standard risk rates (1.00).
RAF ASSIGNMENT BY GROUP SIZE
& SPECIAL RAF REDUCTION PROGRAMS
EffectiveDates
Group Size (based on number ofenrolling employees)
RAF ReductionOffer
Program Rules & Eligibility Criteria ChecklistRAF Program for Groups Not Selecting the
“Suite Deal” Package
★★★ Special RAF Reduction Program ★★★
*These are the RAF assignment guidelines for groups that do not qualify for the Special RAF Reduction Program outlined below or on the following pages.
RAF Assignment by Group Size*(based on number of enrolling employees)2-5 ➢ Minimum 1.00 - Maximum 1.106-9 ➢ Minimum .95 - Maximum 1.10
10-50 ➢ Minimum .90 - Maximum 1.10
BLUE SHIELD OF CALIFORNIA
6-9 10-pointRAF reductionif group meets
program rules &eligibility criteria
• Group must have a renewal RAF of 1.05 or lower to qualify for thisRAF program
• Must provide original copy of current health carrier renewal letterwith initial group enrollment
• No health statements or employer questionnaires• If Blue Shield cannot validate employee eligibility based on
documents provided then standard underwriting guidelines apply• Program applies to guaranteed-issue small groups only • Groups must meet standard underwriting guidelines (i.e. contribution
and participation) and submit the most recent quarter DE-6 and/orother required documentation to verify employee eligibility
• Sole proprietor, partner or corporate officer statement (C15293) isrequired on officers/owners who are not listed on the DE-6
• Standard underwriting guidelines apply to non-guaranteed issue groups or groups that do not qualify
• This program does not apply to groups that do not currently have coverage, groups that are not eligible for guaranteed acceptance, groups coming off of a “special deal” or association plan, or groups currently enrolled with CaliforniaChoice®
• Groups are eligible for the RAF reduction two months (60 days) beforetheir renewal date to two months (60 days) after their renewal date
• Risk Adjustment Factors are adjusted to the nearest .025 increment• The lowest RAF available is .90. For example: if a group has a
renewing RAF of .95, it will receive only a .90 RAF from Blue Shield• Groups may apply for a lower RAF via standard underwriting
guidelines and the submission of health questionnaires• The RAF reduction is a first-year reduction to the RAF for new small
group medical plans only• To qualify for RAF reduction specials, the prior carrier renewal must
be the original renewal - not a revised renewal
7/1/09 – 12/31/09
10+ Guaranteed .90 RAF ifgroup meets program
rules & eligibilitycriteria
7/1/09 – 12/31/09
See the following pages for additional Blue Shield RAF Reduction Programs
Note: Groups with employees enrolling in plans that are permissible to pair with a wrap product are not eligible for the RAFprogram. This exclusion applies whether the plans are offered as standalone or as part of any package. These plans areShield Savings Plan 1800/3600, Shield Savings Plan 2250/4500 and Shield Spectrum PPO Plan 3000.
18
Health PlanUpdate
www.wordandbrown.com
Each carrier’s Underwriting Department assigns the final Risk Adjustment Factor (RAF) for each group based upon their own RAF assignmentguidelines and current special RAF reduction program (if any). This information is intended for use as a guide to help you know what to expect whenyou submit a group that meets the carrier’s eligibility criteria. RAF assignment procedures and special RAF reduction programs are subject to changeat the carriers’ discretion. Word & Brown cannot guarantee what RAF a carrier will give a particular group. According to California law, no smallgroup (2-50) can receive an RAF lower than 0.90, or higher than 1.10, based on the carrier’s standard risk rates (1.00).
RAF ASSIGNMENT BY GROUP SIZE
& SPECIAL RAF REDUCTION PROGRAMS
EffectiveDates
Group Size (based on number ofenrolling employees)
RAF ReductionOffer
Program Rules & Eligibility Criteria Checklist“Suite Deal” RAF Program for Groups
With Current Coverage
★★★ Special RAF Reduction Program ★★★
*These are the RAF assignment guidelines for groups that do not qualify for the Special RAF Reduction Program outlined below or on the previous or following pages.
RAF Assignment by Group Size*(based on number of enrolling employees)2-5 ➢ Minimum 1.00 - Maximum 1.106-9 ➢ Minimum .95 - Maximum 1.10
10-50 ➢ Minimum .90 - Maximum 1.10
BLUE SHIELD OF CALIFORNIA
6-9 10-pointRAF reductionif group meets
program rules &eligibility criteria
• This RAF promotion is only available to new groups with current coverage thatselect the “Suite Deal” package
• Group must have a renewal RAF of 1.05 or lower to qualify for this RAF program• Must provide original copy of current health carrier renewal letter• No health statements or employer questionnaires• If Blue Shield cannot validate employee eligibility based on documents
provided then standard underwriting guidelines apply• Program applies to guaranteed-issue small groups only • Groups must meet standard underwriting guidelines (i.e. contribution
and participation) and submit the most recent quarter DE-6 and/or otherrequired documentation to verify employee eligibility
• Sole proprietor, partner or corporate officer statement (C15293) is required onofficers/owners who are not listed on the DE-6
• Standard underwriting guidelines apply to non-guaranteed issue groups orgroups that do not qualify
• This program does not apply to groups that do not currently have coverage,groups that are not eligible for guaranteed acceptance, groups coming off of a “special deal” or association plan, or groups currently enrolled withCaliforniaChoice®
• Applies to groups within 9 months of their most recent renewal. This programextends the eligibility of the renewal RAF letter from the prior carrier from 60days to nine months. This RAF promotion extension is only available for newgroups that select the “Suite Deal” package
• Groups must have 6 to 50 enrolling employees to qualify for the RAF program• Risk Adjustment Factors are adjusted to the nearest .025 increment• The lowest RAF available is .90. For example: if a group has a renewing RAF of
.95, it will receive only a .90 RAF from Blue Shield• Groups may apply for a lower RAF via standard underwriting guidelines and
the submission of health questionnaires• The RAF reduction is a first-year reduction to the RAF for new small group
medical plans only• Group must maintain at least 75% of renewal enrollment in order to qualify for
RAF reduction. (Applies to the “Suite Deal” RAF program only—not thestandard RAF program.)
• To qualify for RAF reduction specials, the prior carrier renewal must be theoriginal renewal - not a revised renewal
7/1/09 – 12/31/09
10+ Guaranteed .90 RAF ifgroup meets program
rules & eligibilitycriteria
7/1/09 – 12/31/09
See previous and following pages for additional Blue Shield RAF Reduction Programs
Note: Groups with employees enrolling in plans that are permissible to pair with a wrap product are not eligible for the RAF program. This exclusion applieswhether the plans are offered as standalone or as part of any package. These plans are Shield Savings Plan 1800/3600, Shield Savings Plan 2250/4500 and ShieldSpectrum PPO Plan 3000.
Health PlanUpdate
19
www.wordandbrown.com
Each carrier’s Underwriting Department assigns the final Risk Adjustment Factor (RAF) for each group based upon their own RAF assignmentguidelines and current special RAF reduction program (if any). This information is intended for use as a guide to help you know what to expect whenyou submit a group that meets the carrier’s eligibility criteria. RAF assignment procedures and special RAF reduction programs are subject to changeat the carriers’ discretion. Word & Brown cannot guarantee what RAF a carrier will give a particular group. According to California law, no smallgroup (2-50) can receive an RAF lower than 0.90, or higher than 1.10, based on the carrier’s standard risk rates (1.00).
RAF ASSIGNMENT BY GROUP SIZE
& SPECIAL RAF REDUCTION PROGRAMS
EffectiveDates
Group Size (based on number ofenrolling employees)
RAF ReductionOffer
Program Rules & Eligibility Criteria Checklist“Suite Deal” RAF Program for Groups
With No Prior Coverage
★★★ Special RAF Reduction Program ★★★
*These are the RAF assignment guidelines for groups that do not qualify for the Special RAF Reduction Program outlined below or on the previous pages.
RAF Assignment by Group Size*(based on number of enrolling employees)2-5 ➢ Minimum 1.00 - Maximum 1.106-9 ➢ Minimum .95 - Maximum 1.10
10-50 ➢ Minimum .90 - Maximum 1.10
BLUE SHIELD OF CALIFORNIA
6-9 Guaranteed 1.00 RAFif group meets
program rules &eligibility criteria
• This RAF promotion is only available to new groups with no prior coveragethat select the “Suite Deal” package
• “Groups with no prior coverage” is defined as a group in business for oneyear or more with no prior coverage for at least 12 months, or a group inbusiness for less than a year that meets the Blue Shield interpretation ofAB1672 and has no prior group coverage
• No health statements or employer questionnaires• If Blue Shield cannot validate employee eligibility based on
documents provided then standard underwriting guidelines apply• Program applies to guaranteed-issue small groups only • Groups must meet standard underwriting guidelines (i.e. contribution
and participation) and submit the most recent quarter DE-6 and/or otherrequired documentation to verify employee eligibility
• Sole proprietor, partner or corporate officer statement (C15293) is required onofficers/owners who are not listed on the DE-6
• Standard underwriting guidelines apply to non-guaranteed issue groups orgroups that do not qualify
• Groups must have 6 to 50 enrolling employees to qualify for the RAF program• Risk Adjustment Factors are adjusted to the nearest .025 increment• The lowest RAF available is .90 • Groups may apply for a lower RAF via standard underwriting guidelines and
the submission of health questionnaires• The RAF reduction is a first-year reduction to the RAF for new small group
medical plans only
7/1/09 – 12/31/09
10+ Guaranteed .90 RAF ifgroup meets program
rules & eligibilitycriteria
7/1/09 – 12/31/09
See previous pages for additional Blue Shield RAF Reduction Programs
20
Health PlanUpdate
www.wordandbrown.com
Each carrier’s Underwriting Department assigns the final Risk Adjustment Factor (RAF) for each group based upon their own RAF assignmentguidelines and current special RAF reduction program (if any). This information is intended for use as a guide to help you know what to expect whenyou submit a group that meets the carrier’s eligibility criteria. RAF assignment procedures and special RAF reduction programs are subject to changeat the carriers’ discretion. Word & Brown cannot guarantee what RAF a carrier will give a particular group. According to California law, no smallgroup (2-50) can receive an RAF lower than 0.90, or higher than 1.10, based on the carrier’s standard risk rates (1.00).
★★★ Special RAF Reduction Program ★★★
RAF Assignment by Group Size(based on number of medically enrolling employees)
2-4 ➢ Automatic 1.105-14 ➢ Automatic 1.0015-50 ➢ 0.90* or 1.00
CALIFORNIACHOICE®
* To qualify for 0.90 RAF group must meet the following criteria:• Must submit a copy of their current renewal RAF statement from their current carrier showing a renewal RAF of 1.00 or less• Renewal statement must be within 3 effective dates of their CaliforniaChoice® requested effective date determined by underwriting
RAF ASSIGNMENT BY GROUP SIZE
& SPECIAL RAF REDUCTION PROGRAMS
None Currently in Progress
21
Health PlanUpdate
www.wordandbrown.com
Each carrier’s Underwriting Department assigns the final Risk Adjustment Factor (RAF) for each group based upon their own RAF assignmentguidelines and current special RAF reduction program (if any). This information is intended for use as a guide to help you know what to expect whenyou submit a group that meets the carrier’s eligibility criteria. RAF assignment procedures and special RAF reduction programs are subject to changeat the carriers’ discretion. Word & Brown cannot guarantee what RAF a carrier will give a particular group. According to California law, no smallgroup (2-50) can receive an RAF lower than 0.90, or higher than 1.10, based on the carrier’s standard risk rates (1.00).
RAF ASSIGNMENT BY GROUP SIZE
& SPECIAL RAF REDUCTION PROGRAMS
HEALTH NET
EffectiveDates
Group Size (based on number ofenrolling employees)
RAF ReductionOffer
Program Rules & Eligibility Criteria Checklist
★★★ Special RAF Reduction Program ★★★
Guaranteed .95 RAFif group meets
program rules &eligibility criteria
• To qualify must be new AB1672 group of 6-50 enrolling employees with a current competitor renewal RAF of 1.06 or lower
• Effective date with Health Net of 1/1/09 – 12/31/09• Group’s renewal must be within 3 effective dates of their original
effective date with Health Net (i.e. January 1 Health Net group whoseother carrier renewal day falls between October 1 and April 1)
• Must submit copy of their current carrier renewal at the time of casesubmission
• Must have minimum of 6 qualifying new subscribers (excludingCalCOBRA and COBRA enrollees) who are effective with the groupon the date the group becomes effective
• Current CaliforniaChoice®, Contractor’s Choice, HSA California®,Kaiser Permanente Choice Solution, existing Health Net groups, andgroups under an association affiliation are not eligible
• Non-guaranteed issue groups are not eligible• New groups of 6-9 enrolling employees can submit Health
Statements to try for a lower rate – standard underwriting guidelineswill apply
• RAF guarantee is for the full 12-month contract period• All other standard paperwork and Underwriting rules apply• If group with SIC code on the Health Net industry load or discount
list is eligible for this RAF program then the normal industry load ordiscount does not apply
• For groups applying for a lower RAF, standard underwritingguidelines apply
1/1/09 – 12/31/09 6-9
Guaranteed .90 RAFIf group meets
program rules &eligibility criteria
1/1/09 – 12/31/09 10-50
*These are the RAF assignment guidelines for groups that do not qualify for the 2009 RAF Reduction Program outlined below.
RAF Assignment by Group Size*(based on number of enrolling employees)
2-5 ➢ Automatic 1.10 (could qualify for a 1.00 RAF if in a discounted industry and have clean health questionnaires)6-9 ➢ Minimum .90 with Individual Health Statements - Maximum 1.10
10-50 ➢ Minimum .90 - Maximum 1.10
Health PlanUpdate
www.wordandbrown.com
Each carrier’s Underwriting Department assigns the final Risk Adjustment Factor (RAF) for each group based upon their own RAF assignmentguidelines and current special RAF reduction program (if any). This information is intended for use as a guide to help you know what to expect whenyou submit a group that meets the carrier’s eligibility criteria. RAF assignment procedures and special RAF reduction programs are subject to changeat the carriers’ discretion. Word & Brown cannot guarantee what RAF a carrier will give a particular group. According to California law, no smallgroup (2-50) can receive an RAF lower than 0.90, or higher than 1.10, based on the carrier’s standard risk rates (1.00).
★★★ Special RAF Reduction Program ★★★
RAF Assignment by Group Size
N/A
HEALTHEDGE
RAF ASSIGNMENT BY GROUP SIZE
& SPECIAL RAF REDUCTION PROGRAMS
None Currently in Progress
22
Health PlanUpdate
www.wordandbrown.com
Each carrier’s Underwriting Department assigns the final Risk Adjustment Factor (RAF) for each group based upon their own RAF assignment guide-lines and current special RAF reduction program (if any). This information is intended for use as a guide to help you know what to expect when yousubmit a group that meets the carrier’s eligibility criteria. RAF assignment procedures and special RAF reduction programs are subject to change atthe carriers’ discretion. Word & Brown cannot guarantee what RAF a carrier will give a particular group. According to California law, no small group(2-50) can receive an RAF lower than .90, or higher than 1.10, based on the carrier’s standard risk rates (1.00).
RAF ASSIGNMENT BY GROUP SIZE
& SPECIAL RAF REDUCTION PROGRAMS
★★★ Special RAF Reduction Program ★★★
RAF Assignment by Group Size(based on number of medically enrolling employees)
2-4 ➢ Automatic 1.105-14 ➢ Automatic 1.0015-50 ➢ 0.90* or 1.00
HSA CALIFORNIA®
* To qualify for 0.90 RAF group must meet the following criteria:• Must submit a copy of their current renewal RAF statement from their current carrier showing a renewal RAF of 1.00 or less• Renewal statement must be within 3 effective dates of their HSA California requested effective date determined by underwriting
None Currently in Progress
23
Health PlanUpdate
www.wordandbrown.com
Each carrier’s Underwriting Department assigns the final Risk Adjustment Factor (RAF) for each group based upon their own RAF assignmentguidelines and current special RAF reduction program (if any). This information is intended for use as a guide to help you know what to expect whenyou submit a group that meets the carrier’s eligibility criteria. RAF assignment procedures and special RAF reduction programs are subject to changeat the carriers’ discretion. Word & Brown cannot guarantee what RAF a carrier will give a particular group. According to California law, no smallgroup (2-50) can receive an RAF lower than 0.90, or higher than 1.10, based on the carrier’s standard risk rates (1.00).
RAF ASSIGNMENT BY GROUP SIZE
& SPECIAL RAF REDUCTION PROGRAMS
★★★ Special RAF Reduction Program ★★★
RAF Assignment by Group Size (based on number of enrolling employees)
2-5 ➢ Automatic 1.106-15 ➢ Automatic 1.00
16-50 ➢ Automatic .90**
KAISER PERMANENTE
Existing Kaiser Permanente & CaliforniaChoice® groups are considered a spin-off(formerly known as breakaway) and should be issued the same RAF as the purchaser they spin-off of.
** Groups of 16-50 receive a .90 RAF if 75% are new members to Kaiser Permanente
None Currently in Progress
24
Health PlanUpdate
www.wordandbrown.com
Each carrier’s Underwriting Department assigns the final Risk Adjustment Factor (RAF) for each group based upon their own RAF assignmentguidelines and current special RAF reduction program (if any). This information is intended for use as a guide to help you know what to expect whenyou submit a group that meets the carrier’s eligibility criteria. RAF assignment procedures and special RAF reduction programs are subject to changeat the carriers’ discretion. Word & Brown cannot guarantee what RAF a carrier will give a particular group. According to California law, no smallgroup (2-50) can receive an RAF lower than 0.90, or higher than 1.10, based on the carrier’s standard risk rates (1.00).
RAF ASSIGNMENT BY GROUP SIZE & SPECIAL RAF REDUCTION PROGRAMS
1-5Less than 10 NA
KAISER PERMANENTE CHOICE SOLUTION
The following information defines what Risk Adjusted Factor (RAF) is applied to the rates quoted:• Groups with 2-5 employees are always quoted 1.10.• Groups with 6-50 employees are quoted with the 1.00 RAF before the final RAF is applied in underwriting.
Note: Life only employees and COBRA members are not included in the overall employee count.
1.10
1-40
6-40
10 or more
10 or more
Less than 10
11-15
16+
NA
1.00
0.90
Most recently assigned KaiserPermanente RAF (0.95 and 1.05
will be rounded to 1.00)
Note: Life only employees and COBRA members are not included in the overall employee count.
# of employees currently enrolledin Kaiser Permanente
# of employees ADDED throughKaiser Permanente Choice Solution
TOTAL number of employeesenrolled in Kaiser Permanente
Choice Solution
Final RAF appliedduring Underwriting
Total number of employees enrolled in Kaiser Permanente Choice Solution Final RAF applied during underwriting
2 - 5
6 - 15
16 - 50
1.10
1.00
0.90
Note: Life only employees and COBRA members are not included in the overall employee count.
The following table defines how the RAF is applied during underwriting for groups who do not currently have existing coverage withKaiser Permanente or CaliforniaChoice® within 12 months of the effective date:
The following table defines how the RAF is applied during underwriting for groups who currently have existing coverage withKaiser Permanente or CaliforniaChoice® within 12 months of the effective date:
25
Health PlanUpdate
www.wordandbrown.com
Each carrier’s Underwriting Department assigns the final Risk Adjustment Factor (RAF) for each group based upon their own RAF assignmentguidelines and current special RAF reduction program (if any). This information is intended for use as a guide to help you know what to expect whenyou submit a group that meets the carrier’s eligibility criteria. RAF assignment procedures and special RAF reduction programs are subject to changeat the carriers’ discretion. Word & Brown cannot guarantee what RAF a carrier will give a particular group. According to California law, no smallgroup (2-50) can receive an RAF lower than 0.90, or higher than 1.10, based on the carrier’s standard risk rates (1.00).
RAF ASSIGNMENT BY GROUP SIZE & SPECIAL RAF REDUCTION PROGRAMS
★★★ Special RAF Reduction Program ★★★
RAF Assignment by Group Size*(based on number of enrolled employees)
2-5 ➢ Automatic 1.106-50 ➢ Minimum .90 – Maximum 1.10
SHARP HEALTH PLAN
Individual health statements are required for groups of 2-24 enrolled subscribers. Group questionnaire is required for groups of 25-50 enrolled subscribers.
*These are the RAF assignment guidelines for groups that do not qualify for the Special RAF Reduction Program outlined below.
2-5 enrolling employees Automatic 1.10 RAF • No health questionnaires or employer questionnaire required if allprogram criteria is met
• All groups applying for the RAF discount must be AB1672 eligible;standard underwriting guidelines apply to non-guaranteed issuegroups, to include the submission of health questionnaires.
• Groups must have a current RAF of 1.06 or less with their currentcarrier
• Group must submit a copy of their current carrier renewal reflectingthe renewal date and renewal RAF upon submission to Sharp HealthPlan. The renewal date reflected must be within 2 months of therequested Sharp Health Plan effective date
• Groups that received a 10 point increase in their RAF at renewal areineligible for this promotion
• COBRA enrollees do not count toward the enrolled employee counts• Groups with no prior group coverage are ineligible for this promotion• This offer does not apply to groups enrolled with CaliforniaChoice® ,
Contractor’s Choice, HSA California®, Kaiser Permanente ChoiceSolution, or who have withdrawn/terminated from Sharp Health Planwithin 12 months of the requested effective date
• Groups must meet all standard underwriting guidelines• The RAF promotion is a first-year reduction only for new small group
business• Groups of 6-9 may apply for a lower RAF via standard underwriting
guidelines, to include the submission of health questionnaires• PPO questionnaires required but RAF reduction automatically
applies as long as program criteria and participation requirementsare met.
• Out of service area or out of state employees enrolling in the PPOwill always be at a 1.0 RAF, and do not count towards in service areaparticipation requirements for the RAF reduction program. Pleaserefer to standard underwriting guidelines.
1/1/09 – 12/1/09
6-9 enrolling employees Guaranteed .95 RAFif group meets program
rules & eligibility criteria
1/1/09 – 12/1/09
EffectiveDates
Group Size (based on number ofenrolling employees)
RAF ReductionOffer
Program Rules & Eligibility Criteria Checklist
10-50 enrolling employees Guaranteed .90 RAF if group meets program
rules & eligibility criteria
1/1/09 – 12/1/09
26
★★★ Special RAF Reduction Program ★★★
www.wordandbrown.com
Each carrier’s Underwriting Department assigns the final Risk Adjustment Factor (RAF) for each group based upon their own RAF assignmentguidelines and current special RAF reduction program (if any). This information is intended for use as a guide to help you know what to expect whenyou submit a group that meets the carrier’s eligibility criteria. RAF assignment procedures and special RAF reduction programs are subject to changeat the carriers’ discretion. Word & Brown cannot guarantee what RAF a carrier will give a particular group. According to California law, no smallgroup (2-50) can receive an RAF lower than 0.90, or higher than 1.10, based on the carrier’s standard risk rates (1.00).
RAF ASSIGNMENT BY GROUP SIZE & SPECIAL RAF REDUCTION PROGRAMS
Health PlanUpdate
UNITEDHEALTHCARE/PACIFICARE
6-50 Guaranteed .90 RAF without medical
questions if groupmeets program rules & eligibility criteria
• Groups coming from a large group contract that are now AB1672-eligible canqualify for the RAF promotion if they can provide a large group renewal ofless than 20% increase within three months of their requested effective date.New group must submit a copy of its current carrier renewal reflecting theRAF/renewal census and documentation from its current carrier disclosingthe amount of the RAF change with the group's initial submission
• Groups must meet Small Group eligibility requirements (AB1672)• Guaranteed .90 RAF for groups with prior carrier RAF of 1.06 or better• CalCOBRA/COBRA enrollees do not count toward group size• Groups must be enrolling with PacifiCare and/or UnitedHealthcare for
October 1, 2009 - December 31, 2009 effective dates• New groups must present a prior carrier small group renewal that reflects a
renewal date within 3 months of the new business effective date withPacifiCare or UnitedHealthcare Plans
• New group must submit a copy of its current carrier small group renewalreflecting the RAF with the group’s initial submission
• When the current carrier small group renewal does not reflect the enrolledcensus, include copy of the current carrier’s most recentbilling statement
• All other paperwork and underwriting guidelines apply (i.e. participation,employer contribution, wage and tax information, etc.)
• New groups of 2-5 active enrolling employees are not eligible for this RAFProgram
• Groups that receive a 10-point increase on their renewal with another carrierdo not qualify
• Group’s current carrier renewal census must match the enrolling employeesin PC/UHC
• CaliforniaChoice®, Contractor’s Choice, HSA California®, Kaiser PermanenteChoice Solution, existing PC/UHC groups, Non-GI and Association cases arenot eligible
• Groups with enrollment in more than one medical carrier must meet all of theabove requirements
10/1/09 – 12/31/09
EffectiveDates
Group Size (based on number ofenrolling employees)
RAF ReductionOffer
Program Rules & Eligibility Criteria Checklist
*These are the RAF assignment guidelines for groups that do not qualify for the Special RAF Reduction Program outlined below.
27
RAF Assignment by Group Size*(based on number of enrolling employees)
1) Less than 3 enrolled employees: 1.102) Groups of 3 enrolled employees: 1.00-1.103) Groups of 4 enrolled employees: .95-1.104) 5+ enrolled employees: .90-1.10
WORKSITEVOLUNTARYPRODUCTS
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29
31
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Colusa
Calaveras Marin
Monterey
Sacra- mento
Alameda
Alpine Amador
Butte
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Mariposa
Mendocino
Merced
Modoc
Mono
Napa
Nevada
Orange
Placer
Plumas
Riverside
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis
Obispo
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sut- ter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
NY
VAWVA
MD
DE
NJ
MA
ME
NH
VT
CT RI
Customer Service, Bilingual Support,& Broker Services800-99-AFLAC800-SI-AFLAC (Spanish)Commissions Please contact your Aflac representativeClaimsAmerican Family Life Assurance Companyof Columbus (Aflac)Worldwide Headquarters1932 Wynnton RoadColumbus, GA 31999-7251800-99-AFLACFax (Add-ons/Deletes)877-44-AFLAC
California Coverage Area:All of California is covered. Plans areindemnity policies and pay all benefitsto policy holder unless assigned
U.S. Coverage Area:The entire U.S. is covered. Plans areindemnity policies and pay all benefitsto policy holder unless assigned
32
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OUT-OF-STATE COVERAGE
PRODUCTS OFFERED
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
Yes
N/A; 3 or more policy holders.
All States are allowedCall your Word & Brown representative
The rates are based on SIC of Company
All plan types
Policy: AccidentFeatures:
• Emergency Treatment Benefit• Specific-Sum Injuries Benefit• Accidental-Death Benefit• Initial Hospitalization Benefit
Policy: Short-Term DisabilityFeatures:
• Selection of:■ Monthly benefit amount■ Elimination Period■ Benefit Period
• Guaranteed-renewable to age 70• Benefits paid directly to policy holder unless chosen otherwise• Benefits paid regardless of any other insurance
Policy: Cancer/Specified-DiseaseFeatures:
• First-Occurrence Benefit• Hospital Confinement Benefit• Radiation and Chemotherapy Benefit• Cancer Screening Wellness Benefit• Ambulance transportation and lodging benefits• Surgical/Anesthesia Benefit
Policy: Hospital Confinement IndemnityFeatures:
• Hospital Confinement Benefit• Rehabilitation Unit Benefit• Surgical Benefit
Policy: Specified Health BenefitFeatures:
• Pays a First-Occurrence Benefit as well as Hospital Confinement and Continuing Care Benefits for:■ Heart attack & coronary artery bypass surgery■ Stroke■ End-stage renal failure■ Major human organ transplant■ Major third-degree burns■ Coma■ Paralysis
Policy: Hospital Intensive CareFeatures:
• Daily ICU Confinement Benefit• Daily Subacute Unit Confinement Benefit
Policy: DentalFeatures:
• Freedom of choice (Pick any dentist)• Portable• Guaranteed-renewable at the same payroll rate• Pays regardless of any other insurance you may have• No deductible• Easy to understand
Policy: LifeFeatures:
• Provides up to $200,000 of term life, whole life, or a combination of both on a very competitive basis
• Waiver of Premium Benefit• Optional Spouse & Child Riders• Optional Accidental-Death Benefit Rider
Policy: Hospital Confinement Sickness IndemnityFeatures:
• Physician Visits Benefit• Initial Hospitalization Benefit• Major Diagnostic Exams Benefit• Surgical Benefit
Policy: VisionFeatures:
• Eye Examination Benefit• Vision Correction Benefit• Specific Eye Disease/Disorder Benefit• No network restrictions
33
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ENROLLMENT INFORMATION & REQUIREMENTS
Are Commission-Only employees allowed?Yes—but limited products
Are 1099 employees allowed?Yes—but limited products
Any ineligible industries?Possibly for Disability. Please contact your Word & Brown representative
RATING INFORMATION
MINIMUM EMPLOYER CONTRIBUTION
EXCLUSIONS ALLOWED BY CARRIER:Must earn $21,000 per year for Disability in CA
Minimum group size3+ for Disability
IMPORTANT: Aflac products are individual, NOTgroup; therefore, they are NOT guaranteed issue.They are “simplified” issue, meaning, employeeswill/may have to pass underwriting.
*Claims paid to policy holder, NOT to the provider.
CARVE OUTS*
PLAN ELIGIBILITY REQUIREMENTS
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
Minimum 3 Participating Employees
N/A, Individual Products
Yes
None—100% Employee Paid
Carrier's Effective Date1st or 15th of the month
Premium Amount Required for 15th?N/A
Employee Waiting Periods AvailableVaries by Product
Applications must be dated within:Prior to effective date
Spouse/Domestic Partner Employees - 1 application or 2?1 application – if covered by Group Health Plan
Employee Waiver Cards Required at enrollment?Preferred
Is Over Age Dependent Verification Required?No
Are Telephone Interviews done by Underwriting?Yes—life only (large face values)
Must Brokers Carry Errors & Omissions Insurance?No—only the Aflac field force assisting the broker isrequired to have E&O
Does Carrier Offer Open Enrollment?Yes
DOCUMENTATION & PAYMENT INFORMATIONDE-6 statement required?
Payroll Records OK if no DE6?
Is a Prior Booklet required?
Is Prior Billing required?
Must submit check with initial application?
Check Made payable to:
FEESEnrollment Fee Amount
Type of Enrollment Fee
Monthly Administration Fee
BILLING OPTIONS
•Paper
•Online/Web Based
•Express Reconciliation
N/A
N/A
N/A
N/A
No—billed in arrears
Aflac
None
None
None
34
w w w. w o r d a n d b r o w n . c o m
VALUE ADDED SERVICES
Aflac’s payroll deduction and Section 125 capabilities offer powerful ways to:
• Eliminate or reduce the pressure for future company-paid plans.
• Strengthen benefits packages in a tight labor market.
• Introduce choice and portability at the employee level.
• Let employees access the power of pre-tax dollars.
• Save FICA contributions.
• Communicate the value of total company benefits in real-dollar terms.
Aflac is a premier provider of insurance policies, insuring:
• Over 11,937 state governments (and government agencies) and municipalities (company statistics, December 30, 2006).
• More than 1,108 colleges (company statistics, December 30, 2006).
• Over 1,764 hospitals (December 30, 2006).
• Over 12,083 school districts (December 30, 2006).
• More than 372,000 U.S. payroll accounts (December 30, 2006).
Aflac offers superior enrollment, communications, and claims efficiencies, such as:
• Leading-Edge Technology. Our SmartApp® point-of-sale laptop enrollment system (recognized by the Smithsonian Institution)
provides instant submission of applications via electronic signature capture.
• Employee Benefits Communication System. This people-friendly program is designed to show employees the value of the
benefits their employers provide. It can communicate all benefits, including core benefits and policies sold on a voluntary
basis.
• Info One® Personalized Benefits Statements. Generally free of charge, this service illustrates the “hidden paycheck” by
calculating the total cost of employee benefits by including the employer’s share.
• Flexible Spending Accounts, including Medical Reimbursement (Section 125) and Dependent Day-Care Accounts (Section 129).
• Transit One (Section 132) transportation expense program.
• Internet Billing and Payment Capabilities. Designed for smaller accounts, this system facilitates real-time statement changes
and updates on an easy-to-use basis.
• Single-Point Billing Services. These services are for accounts with 50 or more employees.
• Corporate Alliance Programs. These include COBRA/HIPAA administration and PEO services.
• Comprehensive Call Center. This specially dedicated customer service resource handled over 9.9 million calls in 2006
(December 31, 2006).
• Outstanding Performance in Claims Service. In 2006, Aflac processed more than six million claims in the United States. Aflac
processes most claims within four days (December 31, 2006).
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FEATURES AND BENEFITS
Benefits to Business Owners:
• Wellness Benefits that help provide an incentive for early detection, helping to mitigate claims costs; having a potentially positive
impact on medical plan experience and employee “return to work” times.
• Eliminate or reduce the pressure for future company-paid plans through “Voluntary, employee funded programs”.
• Revenue generation through FICA and Workers Compensation savings from the pre-taxing of Aflac Benefits.
• Expansion of your benefit program, at “No Cost,” increasing your retention and attraction power of quality employees.
• Ability to reduce “exposure” to Workers Compensation claims through additional programs that pay “Cash Benefits” and provide
“Disability Income” from the 1st day an employee misses work.
Benefits to Employees:
• The power to "choose" the quality of care they desire; while using added benefits to "buffer" the added costs of going outside a
managed care network in order to see a specialist or have a second opinion in time of need.
• Provides insurance products that generate cash to employees to help with out-of-pocket costs associated with illness or injury
that are not covered by traditional medical insurance plans. Allowing them the "choice" of protecting themselves, their families or
their paycheck.
• Access to affordable "Consumer Driven Health Plans" that are "owned" by the consumer, completely portable and guaranteed
renewable
Benefits to Broker:
• A client solution by providing some relief to increasing health insurance premiums by offering products that can help the
employer make decisions to increase deductibles and co-pays, position the company to pass premium expense to the
employee, and reduce an employer’s FICA taxes and potentially, Worker’s Compensation premiums.
• Relief to employees by offering products that reduce out-of-pocket expenses related to higher co-pays, deductibles and other
costs.
• Health Savings Account compatible products.
• The ability to attract and retain employer clients by offering additional products to their employees at no direct premium cost
before a competitive broker does.
• Additional credibility by working with Aflac, a rate-stable, Fortune 500 company with tremendous brand awareness and a 92%
claims satisfaction rate.
• Increased commissions and vesting opportunities with little time commitment.
• Provides the broker with an opportunity to maintain his/her competitive position with his/her employer client.
• Positions the broker to assist the employer with developing a more comprehensive benefit portfolio with no additional premium
cost to the employer.
37
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Colusa
Calaveras Marin
Monterey
Sacra- mento
Alameda
Alpine Amador
Butte
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Mariposa
Mendocino
Merced
Modoc
Mono
Napa
Nevada
Orange
Placer
Plumas
Riverside
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis
Obispo
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sut- ter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
NY
VAWVA
MD
DE
NJ
MA
ME
NH
VT
CT RI
Customer ServicePolicyholder ServicesPhone: 800-521-3535Fax: 972-510-1795
Broker ServicesRegional Support Center 888-655-5725
Commissions Please contact your Allstate representative
ClaimsAllstate Workplace Division Workplace Claim Department P.O. Box 43967 Jacksonville, FL 32203-3067 Phone: 800-348-4489 Fax: 972-510-1773
Add-ons/DeletesFax: 972-510-1786
California Coverage Area:All of California is covered.Plans are indemnity policiesand pay all benefits to theinsured unless assigned
U.S. Coverage Area:Coverage is available in shaded states. Plansare indemnity policies and pay all benefits tothe insured unless assigned
TC plan only available
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These products are designed to cover some of the things a healthinsurance policy may not and to supplement any coveragereceived through an employer. The products are guaranteed issueat initial enrollment – meaning no medical questions are required.
Group Voluntary Term LifeThis program offers Group Voluntary Term Life for the enrollee,their spouse and dependent children. It is meant to supplementany coverage one may already have through their employer byproviding valuable life insurance coverage at an affordable cost.This coverage is ideal for those who want to protect their families,but may not need a permanent Life Policy. For convenience,premiums are payroll deducted.
Group Voluntary Term Life Insurance is designed to providecoverage for a specified time and provides the ability for anenrollee to choose a plan for themselves or the entire family. Thelump sum benefit can help offset final burial expenses or costsincurred as life events happen.
An insured or their family members may use term life insurance to:
Pay off a mortgage or other outstanding debtsProvide for childcare or educational expensesReplace income to continue the same standard of living
Additional Benefit CoverageThe Waiver of Premium and Accelerated Death Benefit are includedwith the Group Voluntary Term Life coverage. Each benefitenhances the basic coverage and can help with expensesassociated with disability or terminal illness.
Waiver of PremiumIf an insured becomes disabled prior to age 60 and the disabilitylasts for 6 months or longer, they will not be required to paypremiums for as long as the disability lasts or until they reach age65, whichever occurs first, provided the group policy remains inforce.
Accelerated Death BenefitIf an insured or spouse are diagnosed with terminal illness (definedas less than 12 months to live), this benefit pays a portion of thetotal face amount up to 50%. The remaining life insurance benefitis paid upon death of the insured.
Benefit Reduction ScheduleReduction in group insurance amounts will apply at older ages,according to the following schedule:
Insured’s Attained Age Reduction to x% of OriginalCoverage
70 65%75 50%80 35%
If the insured does not enroll during their open enrollment period,they may enroll later during the annual re-enrollment period.However, they must submit evidence of insurability with theirenrollment form.
Continuation of CoverageThe insured has the option, when no longer eligible for coverage,to continue coverage at group rates up to age 70, so long as thegroup policy remains in force.
Group Voluntary Critical IllnessGroup Voluntary Critical Illness insurance pays a lump-sum benefitupon diagnosis of a covered critical illness or condition. Havingsupplemental Critical Illness insurance can help lessen financialimpact to the wallet. It allows the insured to concentrate ongetting better, rather than spending time and energy worryingabout how to pay the bills.
The lump-sum benefit for each category of coverage helps to:
Pay for treatments not covered under medical insuranceSpend precious time with family and friendsPay for mortgage and other expenses
Traditional health insurance is valuable, but often has limits.Because medical treatments and technology are advancing daily,people are living longer with major illnesses or disease. This canbe very costly. Financial hardship can happen, due to indirectmedical expenses that health and disability insurance doesn’tcover. Group Voluntary Critical Illness insurance is a strongsupplement to current health and disability insurance coverage.
The insured may choose either a $5,000 or $10,000 basic benefitamount. Depending on the basic benefit amount selected, up to100% of the basic benefit amount will be payable in each of threebenefit categories; Coronary Artery By-Pass Surgery, Alzheimer’sDisease and Carcinoma in Situ pay 25% of the benefit amount.
Group Voluntary AccidentGroup Voluntary Accident Insurance offers the insured and theirfamily coverage against sudden accidental injuries that can occurwithout warning. It protects the insured and their family 24-hours aday, seven days a week, both on- or off-the-job.
Each pre-packaged plan doesn’t just cover the insured; if theychoose, it also covers their dependents (which can include spouseand dependent children). This valuable coverage can helpsupplement traditional medical insurance. Traditional medicalinsurance is valuable, but may limit coverage during anunexpected accidental injury.
The insured and each covered family member can be sure they willreceive:
· A lump sum benefit, in case the accident leads to death or dismemberment
· 24-7 protection for accidental injuries**· Benefit coverage that goes where you go**
Unexpected accidents can also mean unexpected out-of-pocketexpenses. Hospital stays, medical or surgical treatments,dislocations or fractures, and transportation by air or groundambulance can add up quickly and be very costly. This GroupVoluntary Accident Insurance helps offset some of these expensesso that the insured’s finances remain healthy.
**Treatment must be obtained in the U.S. or its territories.
If a covered person sustains an injury which results in a coveredloss within 90 days from the date of an accident, while coverage isin force, Allstate Workplace Division will pay the benefits as statedin the benefits provisions.
· Accidental Death· Common Carrier Accidental Death· Dismemberment· Dislocation and Fracture· Initial Hospital Confinement· Hospital Confinement· Intensive Care· Ambulance (ground and air)· Medical Expenses· Outpatient Physician’s Treatment
NOTE: This Product Overview is an agent recruitment and trainingdocument and is not intended for consumer use. The insuranceproducts discussed in this document may vary based on state ofissue and may not be available for sale in all states.
PRODUCTS OFFERED (High and Low Options)
39
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DOCUMENTATION & PAYMENT INFORMATIONWage & Tax Statements required?
Payroll Records OK if no Wage & Tax Statements?
Is a Prior Booklet required?
Is Prior Billing required?
Must submit check with initial application?
Check Made payable to:
ENROLLMENT INFORMATION & REQUIREMENTS
Are Commission-Only employees allowed?Yes
Are 1099 employees allowed?Yes
Any ineligible industries?Please contact your Word & Brown representative
RATING INFORMATION
MINIMUM EMPLOYER CONTRIBUTION
EXCLUSIONS ALLOWED BY CARRIER:
Minimum group size5-200 eligible
CARVE OUTS*
PLAN ELIGIBILITY REQUIREMENTS
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
5-200 eligible
Minimum 1 Year
No
A minimum of 5 participants are required to initiate the SBSprogram. If the total number of participants fall below 5, theemployer has 3 billing cycles (months) to bring the levels up tominimum before the plan will be terminated. Groups with over200 eligible employees will not qualify for participation
Carrier's Effective Date1st of the month
Premium Amount Required for 15th?N/A
Employee Waiting Periods AvailableEmployer Determines Eligibility
Applications must be dated within:Prior to effective date
Spouse/Domestic Partner Employees - 1 application or 2?1 application
Employee Waiver Cards Required at enrollment?Yes
Is Over Age Dependent Verification Required?No
Are Telephone Interviews done by Underwriting?Initial contact to Region, then Broker, then Employer ifnecessary.
Must Brokers Carry Errors & Omissions Insurance?Yes
Does Carrier Offer Open Enrollment?Yes
FEESEnrollment Fee Amount
Type of Enrollment Fee
Monthly Administration Fee
BILLING OPTIONS
Paper only
N/A
N/A
N/A
N/A
None
None
None
No—billed in arrears
Allstate Workplace Division
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VALUE ADDED SERVICES
• 15% broker commission (1st year and renewal)
• Products are Guarantee Issue
• No participation requirements
• Products are portable as an individual component (not as a package)
• Monthly billing
OUT-OF-STATE COVERAGE
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in NV?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
Yes
N/A; 5 or more insureds
Contact your Word & Brown representativeContact your Word & Brown representative
The rates are based on SIC of company
All plan types
FEATURES AND BENEFITS
Additional Wellness Screening BenefitAllstate has enhanced the coverage by providing a Wellness Screening Benefit. A $100 benefit will be paid for one of thefollowing screening tests performed while not hospital confined:
· Bone Marrow Testing· CA15-3 (blood test for breast cancer)· CA125 (blood test for ovarian cancer)· CEA (blood test for colon cancer)· Chest X-ray· Colonoscopy· Flexible sigmoidoscopy· Hemocult stool analysis· Mammography, including breast ultrasound· Pap Smear, including Thin Prep Pap Test· PSA (blood test for prostate cancer)· Serum Protein Electrophoresis (test for myeloma)· Biopsy for skin Cancer· Stress test on bike or treadmill· Electrocardiogram· Carotid Doppler· Echocardiogram· Lipid panel (total cholesterol count)· Blood test for triglycerides
There is no limit to the number of years screening tests can be received, and the benefit is paid regardless of the result ofthe test(s). Limited to one test each calendar year for each covered person.
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MEDICAL
Colusa
CalaverasMarin
Monterey
Sacra-mento†
Alameda
AlpineAmador
Butte
ContraCosta
Del Norte
El Dorado
Fresno†
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Mariposa
Mendocino
Merced
Modoc
Mono
Napa
Nevada
Orange
Placer†
Plumas
Riverside†
SanBenito
San Bernardino†
San Diego
San Francisco
SanJoaquin†
SanLuis
Obispo
SanMate
SantaBarbara
Santa Clara
SantaCruz
Shasta
Sierra
Siskiyou
Solano†
Sonoma†
Stanislaus
Sut-ter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo†
Yuba
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EPO/MC PPO Only Counties
All Plan Types
HMOHMO Claim Dept. Aetna P.O. Box 24019Fresno, CA 93779-4019888-702-3862
PPOPPO Claim Dept. Aetna P.O. Box 981204El Paso, TX 79998-1204888-802-3862
Claims
HMO/POS
† The HMO network is availablein select areas of Fresno,Placer, Riverside, Sacramento,San Bernardino, San Joaquin,Solano, Sonoma and YoloCounties. Contact your Word & Brown representativefor details
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Plan may not be available in all zip codes within county. Check withyour Word & Brown representativeto confirm if coverage is availablefor your group location.
�
Broker SupportBOR changes, renewals and group terminations 877-249-2472, Option 6Broker licensing and appointment information 866-511-2863
Email: [email protected]: 888-539-7601
Commissions 800-622-3435
Employer Support 877-249-7235Adds/Terms Fax 888-258-4528
Enrollment Department 866-910-9895(Mon-Fri., 8:00 AM – 5:00 PM EST)Fax: 866-651-3120For Group online access Eligibility you will need the Group Account number.
Payments AetnaBox #894920c/o Citibank Lock Box Operations5860 Uplander WayCulver City, CA 90230866-910-9895, Option 5
Provider Services 888-632-3862Prior Carrier Deductible Credit Fax: 859-455-8650
(include new Aetna ID number and a copy of ID card and/or SSN and date of b irth)
Member Support 888-702-3862 (HMO)888-802-3862 (PPO/Indemnity)
Bilingual Support See member support numbers aboveCal COBRA Department 888-595-1542
Fax: 866-651-3120
HMOAetna HMOAetna HMO Value NetworkAetna HMO HRA and HMO DeductibleNetwork
EPOMC Plans: Managed Choice®
PPOPPO Plans: Open Choice®
LIFE
DENTAL
VISION
INFERTILITY
CHIROPRACTIC
ACUPUNCTURE
MASSAGE THERAPY
PRODUCTS OFFERED
OPTIONAL BENEFITS
GROUP SIZE
PROVIDER INFORMATION
HMO/EPO PPO POS
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CONSUMER DIRECTED HEALTHCARE
HSA-CompatiblePPO
HRA-CompatiblePPO
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Is Workers' Comp required oncorporate officers, partnersand sole proprietors?No
Is on-the-job covered for corporate officers, partnersand sole proprietors?Yes
Is there a premium adjustmentfor 24 hour coverage?No
How often can members change their Primary Care Physician (PCP)?
Can family members eachchoose a PCP from a differentIPA/Medical Group?
Does carrier allow an OB/GYNto be Primary Care Physician?
Self-referral available?
Express referral available?
●
Available
Available
Included
Please refer to Infertility Section on page 47
Discount Included
Discount Included
2-50
Standalone life available 26+.
Aetna
Aetna
AetnaHMOPlans
Aetna HMO Plans
HMO PPO/EPOAetna Indemnity
Indemnity
●Aetna EPO 1
●Aetna MC Plans
●Aetna PPO Plans
●Aetna MC HDHP
●Aetna Indemnity***
●
AetnaEPO
●
●
●
●
●
AetnaMC
Plans
●
●
●
●
●
●
AetnaPPOPlans
●
●
●
●
●Aetna Value Network $10/$20**Aetna Value Network $30/$40**
● ● ●
● ● ●
●
MCHDHP
●
●
●
●
●
AetnaIndem.
●
●
●
●
N/A
HMO $10HMO $15HMO $20HMO $30HMO $40
HMO Deductible $1,000Aetna HMO HRA $750 $15/$30Aetna HMO HRA $1500 $25/$50Aetna Value Network HMO $10Aetna Value Network HMO $20Aetna Value Network HMO $30Aetna Value Network HMO $40
MC HDHP HSA $2,300 80/50MC HDHP HSA $3,000 100/50MC HDHP HSA $3,300 80/50
DUAL OPTION (MIX AND MATCH)
Boxes containing a “●” indicate that these coordinate plans offered by thiscarrier can be written together to create a dual option package. Blankboxes indicate which plans cannot be written together.
Aetna
Aetna
No—see self-referral information above
HMO: Yes—OB/GYN well woman exams (including PAP smear),gynecological-related problems, follow-up care & obstetrical carePPO: YesEPO: Yes
SELECTION
SPECIALIST REFERRALS
NETWORKS
HMO: Anytime. Change must berequested by the 15th of the month tobe effective the 1st of the following monthEPO, PPO & Indemnity: No PCP selection is required
Yes
Yes—if OB/GYN is listed as a PCP
For 2+ groups when sold withmedical. No excluded industrieson dental
●
ALTERNATIVE DISCIPLINES
●
We offer chiro with some of our medical plans andalongside our discount program, this benefit isunlimited with the discount program.
MC HDHP HRA $3,000 80/50
MC $250 90/70MC $250 80/60MC $500 80/60
MC $750 80/50/50MC $1,000 80/50/50
MC $1,000 70/50 MC $2,000 80/50/50
MC $2,500 75/50MC Basic
MC $10,000 100/50PPO $500 90/70PPO $750 80/60
Out of State PPO $250Out of State PPO $500Out of State PPO $1000
MC HDHPAetna EPO 80
Aetna's multi option program is called Pick-A-Plan. Employers of groups with 2+ enrolling employees (excludingCal-COBRA/COBRA) can select up to 32 different plans at the time of initial enrollment. All plans selected at initialenrollment will be available to future new hires even if no one enrolled at the initial effective date.
**Aetna’s Value Network may be included in a Pick-A-Plan package alongside all HMO plans.
***Aetna’s Indemnity plan is only available if MC and PPO networks do not exist in areas within California.
●
●
●
●
●
●
24 HOUR COVERAGE
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AFTERINITIAL ISSUE
ENROLLMENT GROUP SIZE
Employees
Dependents
Employees
Dependents
EXCLUSIONS ALLOWED BY CARRI-ER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
Does carrier underwrite and rate
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Employees
For Dependents
% of Total Cost:
PLAN ELIGIBILITY REQUIREMENTS
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE CARVE OUTS*
WRAP* REQUIREMENTS
*Indicates flexibility in being offered with products of another carrier.
GROUP Can be written with another SIZE carrier's PPO or indemnity plan?
GROUP Can be written with another SIZE carrier's HMO, POS or EPO?
SPECIAL CONSIDERATIONS
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EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?Yes—subject to Aetna Underwriting approval †
Management/Non-management?Yes—subject to Aetna Underwriting approval †
Union/Non-union?Yes—will be considered guarantee-issue when proof ofcoverage is provided on the union employees. Aetna musthave a minimum of 8 subscribers enroll. Eligibility forunion/non-union carve-outs is based on the number of non-union employees.
Minimum group size8 enrolled with Aetna who reside within Aetna’s California Network Service Area.
Does carrier underwrite and rate carve out groups accordingto AB1672 guidelines?No—carve-outs are not subject to AB 1672 guarantee issue requirements and may be denied by Aetna.
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
2-50
50%
N/A
N/A
1* 1*50 N/A
2-50 Yes—standard participation of 75% must be met in order for a group to qualify for coverage.Employees waiving due to coverage throughspouse will NOT be considered eligible incalculating participation for a group sold alongside another carrier
Aetna
Aetna
Aetna
Aetna
GROUP Can be written with another SIZE carrier's HMO, POS or EPO?
◆◆ 100% 100%
N/A N/A
2-3 4-50
◆◆ 100% 75%
N/A N/A
Pick-A-Plan 2-50
Two Options:1) 50% of the employee rate
for plan employee selects;2) Defined contribution of at
least $80 or the actual costof the plans picked,whichever is less
† Employer must provide all employee class definitions in writingon company letterhead prior to approval.
Groups of 25-50 enrolling employees are no longer required to submitany business structure paperwork (Articles of Incorporation, Statementof Information, Statement by Domestic Stock Corporation, Schedule K-1’s, etc.) with the initial new group submissions. In addition to theEmployer and Employee applications, we will simply require the DE-6and an Aetna Proof of Employer Eligibility Form if the officers are notlisted on the DE-6.
Groups will go through the Aetna re-verification annually. Aetna sendsout the documentation 6 months prior to the effective date.
Dependents who reside separately from the employee and are not in anapproved Aetna service area will be enrolled on the subscriber's HMOplan and will need to access care via the selected Primary Care Physicianin the subscriber's/family's HMO service area (except for urgent andemergency care). Any dependent that is currently enrolled in the out-of-area dependent Aetna PPO plan will not be impacted by this change solong as they remain eligible for coverage.
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan, Medicare or Medicaid
Min. # of employeesMax. # of employees
*AB 1672 group of 2 with one valid waiver due to other groupcoverage, Medicare or Medicaid
2-50 Yes—Aetna will accept the greater of 50% eligibleand a minimum of eight enrolled when writingalongside another carrier's HMO plan. Employeeswaiving due to coverage through spouse will NOTbe considered eligible in calculating participationfor a group sold alongside another carrier.(Standard participation applies alongside another carrier's POS, EPO or PPO plans.)
COVERAGE RESTRICTIONSAre Commission-Only employees allowed?Yes—must be full-time employee, have an employer/employeerelationship and have workers' comp coverage. Need to submitDE-6 for proof
Are 1099 employees allowed?Yes—if employer submits Aetna’s 1099 Contractor VerificationForm along with the individual’s last year’s 1099-Misc. tax formsand tax returns. 1099 employees must have been covered underprior small group health plan in order to be eligible for coveragewith Aetna. No more than 25% of the group may be 1099employees.
Are employees covered if traveling out of USA?Emergency services. Other services are paid at the non-networkbenefit level.
Is coverage available for out-of-state employees?Yes—employees who reside out-of-state will be offeredCalifornia plans and rates. Product availability is based onnetwork availability: • Out-of-state employees who reside in an area with an MC
network must enroll in an MC plan; • Out-of-state employees who reside in an area with a PPO
network must enroll in a California PPO plan;• Out-of-state employees who reside in an Indemnity-only
network must enroll in a California Indemnity plan;• HMO & EPO plans are not available outside California
Max. % of employees residing out-of-state allowedAetna does not have a maximum out-of-state percentage.However, if more than 49% of employees reside outside of CA,group will not be guarantee issue
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MEDICAL UNDERWRITING REQUIREMENTS
Current Employees
TimelyAdd-ons
RAF Increments (2-50 lives) 5-50: Determined byunderwriting
Composite Rates Available on all plans for smallgroup with enrolling CA employees.Maximum of 4 plans may be offeredwhen taking composite rates, andmust have 1 member enrolled in theplan for it to be offered to new hires
Rate Guarantee†† 12 Months
Apply Trend Factor? No
Use Employee Zips? No—groups rated based onemployer zip code. (Employee zipcodes must also be provided.)
ENROLLMENT INFORMATION & REQUIREMENTS
Carrier's Effective Date
Premium Amount Required for 15th?
Employee Waiting Periods Available
Applications must be dated within:
Spouse/Domestic Partner Employees - 1 application or 2?
Employee Waiver Cards Required at enrollment?
Is Over Age Dependent Verification Required?
Are Telephone Interviews done by Underwriting?
Must Brokers Carry Errors & Omissions Insurance?
Does Carrier Offer Open Enrollment?
DOCUMENTATION & PAYMENT INFORMATIONDE-6 statement required?
Payroll Records OK if no DE6?
Is a Prior Booklet required?
Is Prior Billing required?
Must submit check with initial application?
Check Made payable to:
FEESEnrollment Fee Amount
Type of Enrollment Fee
Monthly Administration Fee
DEDUCTIBLE CREDITPrior carrier deductible credit given?
4th quarter deductiblecarry-over credit given?
GROUP SIZE
RATING INFORMATION
46
Instant quotes online: www.wordandbrown.comQuotes in 24 hours: (800) 869-6989†† According to the California Insurance Code “The standard
employee risk rates applied to a small employer for new business shall be in effect for no less than six months.”
ITEMS REVIEWED IN RAF CALCULATION
Medical Conditions
Years in Business
# of Pregnancies
Virgin Group
Type of Industry
Percent of Owners
Group Size
% of COBRA Insureds
% of Family Related
Participation
Plan(s) Requested
24 HR Coverage Req'd
Employer Contribution
Bankruptcy
Gender Mix
Current Employees
TimelyAdd-ons
Yes†
Yes—minimum 2 weeks*
No
Yes
Yes
Aetna, Inc.
N/A
N/A
N/A
Yes
No
Yes
No
No
No
Yes
No
No
No
No
No
No
No
No
17 Medical 5 MedicalQuestions on Questions on
Employee App Employee App
Non NonMedical Medical
1st or 15th of the month
N/A
Min: 1st of the month following date of hireMax: 6 months/180 days
60 days & prior to requested effective date
Either 1 or 2 applications
Yes—plus copy of current carrier ID card
Yes
No
Yes
Yes—30 days before renewal anniversary
Aetna
Aetna
GROUP SIZE
HMO, HMO HRA, M/C, PPO & Indemnity
* Payroll records must include the number of hours worked for each employee. If no DE-6, group must also submit copy of their business license and tax ID number. Groupmust be in business a minimum of 50% of prior quarter in order to be guaranteed issue.
No
2-10 11-50
† See Special Considerations on page 45 for important details regarding 5+groups with owners, partners or corporate officers not on DE-6.
Infertility
Adult Physical Child Physical Annual OB/GYNPLAN TYPE Exam Exam/Immunizations Visit/Pap Smear Mammography
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SPECIAL CONCERNS*
Hearing treatment
Are Hearing Aids Covered?
Speech therapy
PREVENTIVE BENEFITS*
PRESCRIPTIONS
* Information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?
Are non-formulary drugs available?
MAIL ORDER - 90 DAY SUPPLY
Are oral contraceptives covered?
* Unless otherwise noted, information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
BENEFIT INFORMATION SHOWN ON THIS PAGE IS A BRIEF SUMMARY. LIMITATIONS AND EXCLUSIONS APPLY. PLEASE REFER TO CERTIFICATE BOOK, EVIDENCE OF COVERAGE OR CALL REPRESENTATIVE FOR DETAILS.
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FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?
Are non-formulary drugs available?
MAIL ORDER
Are oral contraceptives covered?
Contact your Word & Brown representative
No—we will honor ‘dispense as written’
Yes
Yes
Yes—higher non-formulary copay applies
HMO & PPO plans: 2X retail copay - 31 day up to 90 day
supply available
Yes
* Information shown in this section reflects in-network benefits.
Aetna
Aetna
Aetna
HMO, EPO & all PPOsexcept MC Basic
100% after copay 1 100% after copay 1 100% after copay 2 100% after copay 2
M/C, PPO & Indemnity
Limited to every 12 months
MC Basic & Indemnity Coinsurance applies 1 Coinsurance applies 1 Coinsurance applies 2 Coinsurance applies 2
GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive ageneric equivalent rather than a brand name drug?
If doctor writes “dispense as written” on prescription, is brand name available at the brandcopay amount?
No prescription deductibles on any plan
1Age & frequency schedules apply2Frequency schedules apply
All plans: Coverage only for the diagnosis andtreatment of the underlying medicalcondition. Member cost sharing isbased on the type of service performedand place where it is rendered. (SeeCertificate Book for details). Nocoverage for artificial insemination, IVF,ZIFT, ICSI & other related services
HMO $30, HMO $40MC $750 80/50/50, MC $1000 80/50/50,MC $2000 80/50/50:
GIFT is covered on these plans onlywith a lifetime maximum of $2000 permember. IVF and injectable medications areexcluded
Contact your Word & Brown representative
Call your Word & Brown representative
See plan benefits todetermine coverage
See plan benefits todetermine coverage
See plan benefits todetermine coverage
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DIABETIC BENEFITS
These services may change at any time without notice. Please contact your Word & Brown representative for specific inquiries on listed services
48
Are the following items covered under the Prescription Drug Benefit or the Durable MedicalEquipment Benefit of the member’s selected plan design?
Insulin
Needles & Syringes
Glucose Monitor
Chem-Strips and/or Testing Agents
Insulin Pump
Insulin Pump Supplies
SELF-INJECTABLE DRUG BENEFITS
Are self-injectable drugs(other than insulin)covered under the
Prescription Drug Benefitor Medical Benefit?
Is pre-authorizationrequired?
Must self-injectables(other than insulin)
be purchased via thecarrier-contracted
mail order Rx vendor?
Aetna
Aetna
Aetna
Prescription Drug Benefit
Prescription Drug Benefit
Medical/Durable Medical Equipment Benefit
Prescription Drug Benefit
Medical/Durable Medical Equipment Benefit
Medical/Durable Medical Equipment Benefit
MedicalBenefit
Generally under the 4th tierPrescription Drug Benefit
Generally under the 4th tierPrescription Drug Benefit
Depends on drug*
Depends on drug*
Depends on drug*
Typically through AetnaSpecialty Pharmacy
Typically through AetnaSpecialty Pharmacy
Typically through AetnaSpecialty Pharmacy
* Check Aetna's Rx formulary at www.aetna.com/formulary
HMO plans:
EPO & MC plans:
PPO & Indemnity plans:
Access Baja HMO plans can meet the needs of Californiaemployers whose workers seek coverage in BajaCalifornia, Mexico.
Members must live or work in the municipality of Tijuanaor Mexicali, or the area in California, U.S., generallywithin a 50-mile radius from the border crossing points atSan Ysidro and Calexico. For small groups, the AccessBaja HMO plans must be offered alongside another BlueShield plan(s).
Colusa
CalaverasMarin
Monterey
Sacra-mento
Alameda
AlpineAmador
Butte
ContraCosta
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Mariposa
Mendocino
Merced
Modoc
Mono
Napa
Nevada
Orange
Placer
Plumas
Riverside
SanBenito
San Bernardino
San Diego
San Francisco
SanJoaquin
SanLuis
Obispo
SanMateo
SantaBarbara
Santa Clara
SantaCruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sut-ter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
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Member Support 800-424-6521 (HMO)Customer Service 800-535-8000 (PPO) Bilingual Support 800-248-5451Claims Fax 209-367-2880Pre-Authorization Dept. 800-821-1315Cal-COBRA Dept. 800-228-9476
Fax 916-350-7480Sm. Group Cancellations/Reinstatements Fax 209-367-6369Group Service 800-325-5166
Broker Licensing Dept. Fax (209) 371-5830Email: [email protected]
Commissions 800-559-5905Adds/Terms Fax 209-367-6475
Pharmacy Services Dept. 800-535-9481
Blue ShieldP.O. Box 272540Chico, CA 95927-2540800-200-3242
PPO Only Counties
HMO & PPO Counties�
AdministratorBlue Shield New Business3021 Reynolds Ranch Pkwy.Lodi, CA 95240
proud participant in:
HMO/POS
Small GroupPremium PaymentsBlue Shield of California File 55331 Los Angeles, CA 90074-5331
Billing800-325-5166, Option 3
Claims
Plan may not be available in all zip codes within county. Check with your Word & Brown representative to confirm if coverage is available for your group location.
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How often can members change their Primary Care Physician (PCP)?
Can family members eachchoose a PCP from a differentIPA/Medical Group?
Does carrier allow an OB/GYNto be Primary Care Physician?
Available
Available
Available
Rider Available*
Available
Available
Discount †
2-50
HMO/EPOBlue Shield HMOLocal Access+ HMO Network* (*Available toemployers in portions of Los Angeles, SanDiego, Orange, San Bernardino and Riverside)
PPOBlue Shield PPOBlue Shield Life Network (Active Choice Plans, Shield Spectrum PPO Plan500 Value, Plan 500 Standard, Shield SpectrumPPO Plan 750 Value, Shield Spectrum PPO Plan1000 Value, Shield Spectrum PPO Plan 1500Value, Shield Spectrum PPO Plan 2000 Value,Shield Spectrum PPO 3000, Shield Savings Plan1800/3600, Shield Savings Plan 2000/4000,Shield Savings Plan 2500/4500, Shield SavingsPlan 3000/6000 & Shield Savings Plan 4800)
POSBlue Shield PPO & Blue Shield HMO
†Discount provided throughMylifepathSM program
PRODUCTS OFFERED
MIX AND MATCH
OPTIONAL BENEFITS
GROUP SIZE
PROVIDER INFORMATIONHMO/EPO
Blue Shield of CA
Blue Shield of CA
Blue Shieldof CA
LIFE
DENTAL
VISION
INFERTILITY
CHIROPRACTIC
ACUPUNCTURE
MASSAGE THERAPY
Active Choice Plan 500 SG Active Choice Plan 750 SG
Shield Spectrum PPO Plan ZeroDeductible
Shield Spectrum PPO Plan 500 ValueShield Spectrum PPO Plan 750 Value
Shield Spectrum PPO Plan 250 Premier Shield Spectrum PPO Plan 250 Standard Shield Spectrum PPO Plan 500 Premier
Shield Spectrum PPO Plan 500 StandardShield Spectrum PPO Plan 1000
Shield Spectrum PPO Plan 1000 ValueShield Spectrum PPO Plan 1500 ValueShield Spectrum PPO Plan 2000 Value
Shield Spectrum PPO Plan 3000 †
Added AdvantagePOS
Shield Savings Plan 1800/3600†
Shield Savings Plan 2250/4500†
Shield Savings Plan 2000/4000Shield Savings Plan 2500
Shield Savings Plan 3000/6000Shield Savings Plan 4800
Shield Savings Plan 1800/3600Shield Savings Plan 2250/4500
Shield Spectrum PPO Plan 3000
Access+ HMO Plan 5Access+ HMO Plan 10Access+ HMO Plan 15Access+ HMO Plan 20
Access+ HMO Plan 20 ValueLocal Access+ HMO Plan 20 Value
Access+ HMO Plan 25Access+ HMO Plan 30
Local Access+ HMO Plan 30Access+ HMO Plan 40
Access Baja HMO Plan 5Access Baja HMO Plan 10
Dual Option (HMO & PPO or HMO & POS) available 2-50 lives. PlanSelect: Groups of 2-50 enrolled employees can pick ANY combination of plans or all 28 small group plans: 8 HMO, 12 PPO, 1 POS, 2 Active Choice, and 5 HSA-eligible plans.
PlanSelect is available to groups 2-50 with any combination from 2-28 different health plan choices.
Suite Deal program: Employers with 2-50 enrolled employees can choose any of the following:
Access+ HMO® Plan 20 Value Shield Spectrum PPO Plan 1500 ValueAccess+ HMO Plan 30 Shield Spectrum PPO Plan 2000 ValueShield Spectrum PPO Plan 500 Standard Shield Savings Plan 2000/4000Shield Spectrum PPOSM Plan 500 Value Shield Savings Plan 3000/6000Shield Spectrum PPO Plan 1000 Value
Employer may offer the Suite Deal program with the Local Access HMO plans or the Standard HMOplans - but not both. All plans in the Suite Deal must be offered—however, enrollment in all plans is notrequired. Employer must contribute either 1) a defined contribution consisting of a minimum $100 peremployee (or the cost of the total employee rate, whichever is less), or 2) a minimum of 50% of the totalemployee rates.
Employees may choose from the plans selected by their employer. Employer must contribute aminimum of $100 per enrolled employee or 50% of total employee rates.
Access Baja can be offered in addition to PlanSelect and is not included in a PlanSelect package as oneof the choices.
Local Access+ is not available with PlanSelect.
CONSUMER DIRECTED HEALTHCARE
HSA-Compatible PPO HRA-Compatible PPO
SPECIALIST REFERRALS
Self-referral available?
Express referral available?
HMO & POS: YesPPO: N/A
Yes—if listed as a PCP in the directory
HMO: OB/GYN visits—yes; Other services: if Access + provider—yes All services: specialist must be in same med.group/IPA as PCPPOS: Yes—PPO and non-PPO portions onlyPPO: Yes
No—see self-referral information above
Blue Shield of CA
Participants may change anytime bycontacting Member Services. Changewill be effective on the 1st day of month following notice of approval
SELECTION
NETWORKS
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† Only these two HSA-compatible plans plus the non-HSA compatible Shield Spectrum PPO 3000 plan can be used in conjunction with a self-funding arrangement
ALTERNATIVE DISCIPLINES
Is Workers' Comp required oncorporate officers, partnersand sole proprietors?No
Is on-the-job covered for corporate officers, partnersand sole proprietors?YesIs there a premium adjustmentfor 24 hour coverage?Yes—if group does not have Workers’Comp
24 HOUR COVERAGE
POSPPO
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Employees
Dependents
Employees
Dependents
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Employees
For Dependents
% of Total Cost:
PLAN ELIGIBILITY REQUIREMENTS
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE CARVE OUTS*
WRAP* REQUIREMENTS
*Indicates flexibility in being offered with products of another carrier.
GROUP Can be written with another SIZE carrier's PPO or indemnity plan?
SPECIAL CONSIDERATIONS
51
COVERAGE RESTRICTIONS
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Are employees covered if traveling out of USA?
Is coverage available for out-of-state employees?
Max. % of employees residing out-of-state allowed
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2-50
2-50
50%
N/A
N/A
1* 1*
50 N/A
2-50 No
GROUP Can be written with another SIZE carrier's HMO, POS or EPO?
1) These plans have an Annual Brand Rx Deductible:$150 Annual Brand Rx Deductible*
Access+ HMO 20, Access+ HMO 20 Value, Local Access+ HMO Plan 20 Value,
Access+ HMO Plan 30, Local Access+ HMO Plan 30,
PPO Plan 500 Premier and Added Advantage POS $250 Annual Brand Rx Deductible*
Access+ HMO Plan 25,Access+ HMO Plan 40,
PPO Plan 500 Standard, PPO Plan 1000, PPO Plan 500 Value and Active Choice 750
PPO Plan 750 Value$500 Annual Brand Rx Deductible*
PPO Plan 3000 and Active Choice 500 —2) Blue Shield no longer requires the following paperwork for guaranteed
issue groups of 25 to 50 enrolled employees: Articles of Incorporation,Schedule K-1, Statement by Domestic Stock Corporation, and/or Statementof Information. The group’s DE6 is required and, if the company offi-cers/owners are not listed on the form, the group must also submit a SoleProprietor, Partner or Corporation Officer Statement (form C-15293) foreach officer/owner.
3) Upon enrollment in Suite Deal or Dual Choice, the employer must chooseto either offer Local Access+ HMO or Access+ HMO plan(s). They cannotbe offered together.
Blue Shield of CA
Blue Shield of CA
Blue Shield
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
Does carrier underwrite and rate carve out groups according to AB1672 guidelines?
Yes—if total group size is 50 or less. Health statements are requiredregardless of group size. Participation: 75% of all eligible employeeswith a minimum of 8. Blue Shield must be the only carrier
Yes—see requirements above
Yes—if total group size is 50 or less.UNION EMPLOYEES: When a small group employer, in compliancewith a collective bargaining agreement, is purchasing healthcarebenefits for his union employees, those union employees will beconsidered eligible by Blue ShieldUNION TRUST PLANS: When a small group employer is contributingto a labor fund, in compliance with a collective bargaining agreement,for the purchase of healthcare benefits, that employer's unionemployees will be considered ineligible by Blue Shield. Copies of theunion’s statement of ERISA rights will be required.FOR BOTH: If total employees (union plus non-union) is 50 or less,group will be guarantee issue.Legal documentation verifying employer's method of compliance withthe collective bargaining agreement is required.
8 (except for the union situation outlined above witha minimum group of 2)
No—therefore a carve out group could get a final RAF higher than1.10 or be declined (only exceptions are the union situations outlinedabove)
◆◆ 75%
◆◆ N/A
◆◆ 100%
◆◆ N/A
*AB 1672 group of 2 with one valid waiver due to other group coverage
*This separate per member Rx deductiblealso applies to home self-administeredinjectable drugs
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
AFTERINITIAL ISSUE
ENROLLMENT GROUP SIZE
Min. # of employees
Max. # of employees2-50 Blue Shield Single, Option, Dual Option or
Suite Deal: Yes—a minimum of 5 or 50% ofthe total active enrolled employees(whichever is greater) must enroll with BlueShield.
Blue Shield PlanSelect Package: Yes—aminimum of 5 or 75% of the total activeenrolled employees (whichever is greater)must enroll with Blue Shield
†Signed refusal required for all Kaiser enrollees.
Yes—commission-only employees are eligible if they are on the DE-6
No
Yes
Yes*—Blue Card program available. Access+ HMO and POS plans are not designed to provide coverage for employees who reside outside of California. Employers with employees who reside or work for over six months outside of California should consider a PPO plan*Except employees living in Hawaii
For guaranteed issue, a maximum of 49% out-of-state employees allowed. When there are not at least 51% of the employees in CA, the out-of-state employees are not eligible for coverage and the CA employees can only be written on a non-guaranteed issue basis
2-50 Suite Deal(See Mix & Match Section - page 50)
◆◆ 100%
◆◆ N/A
◆◆ 65%
◆◆ N/A
A minimum of $100 peremployee or a minimum of 50%
of the total employee rates
N/A
N/A
2-50 Defined Contribution
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MEDICAL UNDERWRITING REQUIREMENTS
Current Employees
TimelyAdd-ons
Group Size
Composite Rates
Rate Guarantee*
Apply Trend Factor?
Use Employee Zips?
ENROLLMENT INFORMATION & REQUIREMENTS
Carrier's Effective Date
Premium Amount Required for 15th?
Employee Waiting Periods Available
Applications must be dated within:
Spouse/Domestic Partner Employees - 1 application or 2?
Employee Waiver Cards Required at enrollment?
Is Over Age Dependent Verification Required?
Are Telephone Interviews done by Underwriting?
Must Brokers Carry Errors & Omissions Insurance?
Does Carrier Offer Open Enrollment?
DOCUMENTATION & PAYMENT INFORMATION
DE-6 statement required?
Payroll Records OK if no DE6?
Is a Prior Booklet required?
Is Prior Billing required?
Must submit check with
initial application?
Check Made payable to:
FEES
Enrollment Fee Amount
Type of Enrollment Fee
Monthly Administration Fee
DEDUCTIBLE CREDITPrior carrier deductible credit give
GROUP SIZE
RATING INFORMATION
52
Instant quotes online: www.wordandbrown.comQuotes in 24 hours: (800) 869-6989
†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”
ITEMS REVIEWED IN RAF CALCULATION
Medical ConditionsYears in Business# of PregnanciesVirgin GroupType of IndustryPercent of OwnersGroup Size% of COBRA Insureds% of Family RelatedParticipationPlan(s) Requested24 HR Coverage Req'dEmployer ContributionBankruptcy Gender Mix
Current Employees
TimelyAdd-ons
GROUP SIZE
RATING INFORMATION
.025
2-50 Not Available
12 Months
No
No
1st of the month unless replacing
Submit one month's premium
Min: 1 Max: 180 (1st of month following)*
45 days
Yes
Yes
No
Yes
Yes—30 days prior to renewal date
Yes*
Call your Word & Brown representative
No
Yes
Yes
Blue Shield
None
N/A
None
2-14 15-50
Full Employer Medical Questionnaire
Non NonMedical Medical
Blue Shield of CA
Blue Shield of CA
HMO & Active Choice PPO: N/APPO & POS: Yes †
Prior carrier deductible credit given?
4th quarter deductiblecarry-over credit given? No
†This does NOT include credit for the Rx Deductible
*Employer may elect 2 different waiting periodsbased on class of employees
RAF Increments (2-50 lives)
Composite Rates
Rate Guarantee††
Apply Trend Factor?
Use Employee Zips?
YesNo*YesNoYes †
NoYesYesNoYesYesYesYes NoNo
* If group meets guarantee issue criteria, then years in business is not takeninto consideration. However, for a new group that does not meet guaranteeissue criteria, years in business is a determining factor for group eligibility.
† 15+ groups without individual health statements in these industries willreceive a 10 point load: medical services (doctors, hospitals, urgent centers),convalescent hospitals, lawyers, insurance agents, municipalities, schooldistricts, car dealers, religious organizations and construction.
Either 1 or 2 applications. Refusal required if electing to enroll as dependentbut does not count against participation. When husband and wife areenrolling separately under the same group a waiver form is required
* DE-6 must be unaltered. If any alterations special requirements apply. Call your Word & Brown representative for details.
Access+ HMO 20 Value, 25, 30 & 40,Local Access+ HMO 20 Value and 30: No—unless prior authorization is obtained from Blue
ShieldPPO Plan Zero Deductible, PPO Plan 250 Premier, PPO Plan 250 Standard, PPO Plan 500 Premier, PPO Plan 500 Standard, and PPO Plan 1000: Yes - $50 non-formulary copay appliesHMO Plan 5, HMO Plan 10, HMO Plan 15, & HMO Plan 20: Yes - $45 non-formulary copay appliesPPO 500 Value, Active Choice 500, Active Choice 750, & PP0 3000: Yes - $50 non-formulary copay applies (or 50% of
contracted rate, whichever is greater)Shield Savings Plans 2250/4500, Yes, $50 non-formulary copay applies (or 50% of & 2500: contracted rate, whichever is greater). Medical
deductible appliesShield Savings Plans 1800/3600,2000/4000, 3000/6000 & 4800 (HSA): Yes - $0 copay Medical deductible applies
HMO Plan 5 & HMO Plan 10: $20 generic/$50 form. brand/$90 non-form. brandHMO Plan 15 & HMO Plan 20: $30 generic/$60 form brand/$90 non-form. brand PPO Plan 500 Value, PPO Plan 3000,Active Choice 500 & 750*: $30 generic/$60 Brand-name drug or 30% of Blue
Shield Life contracted rate, whichever is greater/$100non-form. brand or 50% of Blue Shield Lifecontracted rate whichever is greater
PPO Plan 750 Value, Plan 1000 Value & PPO Plan 1500 Value: $30 Generic drug, $60 Brand-name drug or (30% of
Blue Shield Life contracted rate, whichever isgreater.) (see special considerations on page 51)
PPO Plan 2000 Value: Generic $30, Brand is not covered HMO 20 Value, HMO Plan 25, Local Access+ HMO 20 Value and 30,HMO Plan 30 & HMO Plan 40: $30 generic/$60 formulary brand
Added Advantage POS Plan: $30 generic/$60 formulary brandPPO Plan Zero Deductible & PPO Plan 250 Premier: $20 generic/$50 form. brand/$100 non form. brand.PPO Plan 250 Standard, PPO Plan 500 Premier, PPO Plan 500 Standard & PPO Plan 1000: $20 generic/$60 form. brand/$100 non form. brand.Shield Savings Plans (HSA): Savings Plans 2250/4500, & 2500: Medical deduct. applies first then, $20
generic/$60 Brand-name drug or 30% of Blue Shield contracted ratewhichever is greater/$100 non-form. Brand or 50% of Blue Shieldcontracted rate whichever is greater.
Shield Savings Plans 1800/3600, 2000/4000, 3000/6000 & 4800: $0 copay after medical deductible.
Adult Physical Child Physical Annual OB/GYNPLAN TYPE Exam Exam/Immunizations Visit/Pap Smear Mammography
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GENERIC VS. BRAND NAMEIf generic available, and doctor has notindicated “dispense as written,” willmember receive a generic equivalent ratherthan a brand name drug?
If doctor writes “dispense as written” on prescription, is brand name available at the brand copay amount?
Yes—or member must pay generic copay plus differencebetween cost of generic and brand name drug
SPECIAL CONCERNS*
PRESCRIPTIONS
* Information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
BENEFIT INFORMATION SHOWN ON THIS PAGE IS A BRIEF SUMMARY. LIMITATIONS AND EXCLUSIONS APPLY. PLEASE REFER TO CERTIFICATE BOOK, EVIDENCE OF COVERAGE OR CALL REPRESENTATIVE FOR DETAILS.
53
Hearing treatment
Are Hearing Aids covered?
Speech therapy
Are non-formulary drugs available?
Access + HMO Covered at 100% Covered at 100% Covered at 100% Covered at 100%PPO-Active Choice Covered under Category 1, Covered under Category 1, Covered under Category 1, Covered under Category 1,
First Dollar Services coverage† First Dollar Services coverage† First Dollar Services coverage† First Dollar Services coverage†
PPO (except Active Choice) 100% after 100% after 100% after 100% afteroffice visit copay office visit copay office visit copay office visit copay(in-network only) (in-network only) (in-network only) (in-network only)
POS Covered at 100% (level 1 only) Covered at 100% (level 1 only) Covered at 100% (level 1 only) Covered at 100% (level 1 only)
HMO & POS: Hearing screening exams by PCP covered at 100% up to age 18
PPO: Covers ear screenings to determine the need for audiograms for dependent children through age 18 only
* Information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
Blue Shield of CA
Blue Shield of CA
† Member is responsible for all charges above the individual or family First Dollar Services amount until member's Maximum Calendar Year Copayment has been reached
Are oral contraceptives covered?Yes—for all plans
Yes
InfertilityHMO & POS: 50% for diagnosis & treatment of cause of
infertility. Rider available covering limited ZIFT, GIFT, IVF, etc.—call representative for details
PPO: Not covered unless rider is added - contact representative or see brochure for more information
Covered as outlined in the Schedule of Benefits and Evidenceof Coverage.
* Unless otherwise noted, information shown in this sectionreflects in-network benefits. For Triple Option plans, themost managed plans are shown.
PREVENTIVE BENEFITS*
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All Blue Shield plans have a waiver of deductible for preventive care
No
An annual prescription drug limitation applies to the followingplans:PPO Plan 1000 Value: Subject to $1,000 maximum on brandname drugs, per person, per calendar year. PPO Plan 1500 Value: Subject to $500 maximum on brandname drugs, per person, per calendar year.
*See Special Consideration #1 on page 51 for important information on Annual Brand Rx Deductible
FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?Yes—for all plans
MAIL ORDER - 90 DAY SUPPLY
DIABETIC BENEFITS
These services may change at any time without notice. Please contact your Word & Brown representative for specific inquiries on listed services
54
DISCOUNTS, AWARDS & OTHER VALUE-ADDED BENEFITS
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SELF-INJECTABLE DRUG BENEFITS
Are self-injectable drugs(other than insulin)covered under the
Prescription Drug Benefitor Medical Benefit?
Is pre-authorizationrequired?
Must self-injectables(other than insulin)
be purchased via thecarrier-contracted
mail order Rx vendor?
Blue Shield of CA
Blue Shield of CA
Prescription Drug Benefit †—if plan has an annual brand Rx
deductible, this deductible also applies to home self-administered injectables
Prescription Drug Benefit †—(in-network only) If plan has an
annual brand Rx deductible, thisdeductible also applies to home
self-administered injectables
Some medications and/ordosages may require
prior authorization
Some medications and/ordosages may require
prior authorization
Yes*—Caremark 800-237-2767& Curascript
888-773-7376, option 3
Yes*—Caremark 800-237-2767& Curascript
888-773-7376, option 3
HMO plans:**
PPO plans:
Covered under the medical benefit -
Medical Deductible applies
Some medications and/ordosages may require
prior authorization
Yes*—Caremark 800-237-2767& Curascript
888-773-7376, option 3
HSA plans:
† Home self-administered Injectables require prior authorization and are listed in the Blue Shield of California Prescription DrugFormulary. Please note that self-administered injectable copays vary from those for other prescription drugs.
* Imitrex and Lovenox will continue to be available from any Blue Shield participating pharmacy with prior authorization.
Blue Shield of CA
Prescription Drug Benefit
Prescription Drug Benefit
Diabetes Care Benefit*
Prescription Drug Benefit
Diabetes Care Benefit*
Diabetes Care Benefit*
Are the following items covered under the Prescription Drug Benefit, Durable Medical EquipmentBenefit or Diabetes Care Benefit of the member’s selected plan design?
Insulin
Needles & Syringes
Glucose Monitor
Chem-Strips and/or Testing Agents
Insulin Pump
Insulin Pump Supplies
*Subject to medical deductible if plan has one, and coinsurance. Does not have $2000 annual maximum of Durable Medical Equipment
55
Colusa
CalaverasMarin
Monterey
Sacra-mento
Alameda
AlpineAmador
Butte
ContraCosta
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Mariposa
Mendocino
Merced
Modoc
Mono
Napa
Nevada
Orange
Placer
Plumas
Riverside
SanBenito
San Bernardino
San Diego
San Francisco
SanJoaquin
SanLuis
Obispo
SanMateo
SantaBarbara
Santa Clara
SantaCruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sut-ter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba �PPO Only Counties
HMO & PPO Counties
Plan may not be available in all zip codes within county. Check with your Word & Brown representative to confirm if coverage is available for your group location.
CaliforniaChoice®
Customer Service Center 800-558-8003Blue Shield of California
HMO (English) 800-424-6521HMO (Spanish) 800-248-5451PPO 800-535-8000
Health Net 800-361-3366Kaiser Permanente
English 800-464-4000Spanish 800-788-0616
Sharp Health Plan 800-359-2002Western Health Advantage 888-563-2250
To contact by mail, or for payment submission:CaliforniaChoice® Benefit Administrators721 South Parker, Suite 200Orange, CA 92868
Broker Services & Commissions 714-542-6992 - Ext. 4390
Broker of Record Changes Fax 714-972-7368
Adds/Terms Fax 714-558-8000
Billing Questions 800-558-8003
Member Support
The following HMOs have an “Excellent” rating from the NCQA
for their commercial products:
Blue Shield of CA (HMO/POS)Health Net (HMO/POS)
Kaiser Permanente (HMO)Western Health Advantage
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How often can members change their Primary Care Physician (PCP)?
Can family members eachchoose a PCP from a differentIPA/Medical Group?
Does carrier allow an OB/GYNto be Primary Care Physician?
Refer to summary on pages 60-61
Refer to summary on pages 60-61
Refer to summary on pages 60-61
Maximum Choice For EmployeesEach employee's health care needs are different. The CaliforniaChoice®
program provides employees the maximum choice in meeting thoseneeds with these health plans—all within one program:
HMO
Available
Discount or Buy-up
Discount or Buy-up
Not Available
Chiro only or Chiro & Acupuncture Riders Available
Combined Chiro & Acupuncture Rider Available
Varies by HCSP
2-50
Networks vary according toHealth Care Service Plan (HCSP)
No
No
Yes
PLEASE NOTE: Not all healthplans are available in all areas
PRODUCTS OFFERED
MULTI OPTION (MIX AND MATCH)
OPTIONAL BENEFITS
GROUP SIZE
PROVIDER INFORMATION
Group Size Plans Available
5-9 medically enrolledemployees
All HMO and HMO Value Plans and CalChoice® PPO 1000,CalChoice® PPO 2400, CalChoice® HSA 1500, CalChoice® HSA
2400 & Active Choice 500
COBRA enrollees are not counted toward total group size.“Life Only” enrollees are not counted toward total group size.
“Dental Only” enrollees are not counted toward total group size.
10+ medically enrolledemployees
All HMO and HMO Value Plans and CalChoice® PPO 750,CalChoice® PPO 1000, CalChoice® PPO 2400, CalChoice® HSA
1500, CalChoice® HSA 2400 & Active Choice 500
CaliforniaChoice® PPO Guidelines
For Salud HMO ymas, only Saludnetwork optional
benefits are shownhere. SIMNSA
network benefitsvary—call your Word & Brown representative
for details
CaliforniaChoice®
CaliforniaChoice®
CaliforniaChoice®
LIFE
DENTAL
VISION
INFERTILITY
CHIROPRACTIC
ACUPUNCTURE
MASSAGE THERAPY
Blue Shield of California PPOBlue Shield of California HMOHealth Net HMO
Elect Open Access (from Health Net)Salud HMO y mas
Kaiser Permanente HMOSharp Health Plan HMOWestern Health Advantage HMO
24 HOUR COVERAGE
SPECIALIST REFERRALS
Self-referral available?
Express referral available?Varies by Health Care Service Plan (See summary on pages 60-61)
Varies by Health Care Service Plan (See summary on pages 60-61)
CONSUMER DIRECTED HEALTHCARE
HSA-Compatible PPO
HRA-CompatiblePPO
MRP-CompatiblePPO
CalChoice® HSA 1500 †*CalChoice® HSA 2400 †*
N/A N/A
CalChoice® HMO 15CalChoice® HMO 25
CalChoice® HMO 25 ValueCalChoice® HMO 30
CalChoice® HMO 30 ValueCalChoice® HMO 40
CalChoice® HMO 40 ValueElect Open Access 25
Salud HMO y mas
PPOCalChoice® PPO 750 †
CalChoice® PPO 1000 †
CalChoice® PPO 2400 †
CaliforniaChoice®
Is Workers' Comp required oncorporate officers, partners and sole proprietors?
Is on-the-job covered for corporate officers, partners and sole proprietors?
Is there a premium adjustmentfor 24 hour coverage?
SELECTION
NETWORKS
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ALTERNATIVE DISCIPLINES
Active ChoiceSM 500 †
* HSA-Qualified High Deductible Health Plan† PPO plan availability based on group eligibility and may be subject to change
2-4 medically enrolledemployees
All HMO and HMO Value Plans and CalChoice® PPO 1000, CalChoice® PPO 2400, CalChoice® HSA 1500
& CalChoice® HSA 2400
† PPO plan availability based on groupeligibility and may be subject to change
Employees
Dependents
Employees
Dependents
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COVERAGE RESTRICTIONS
Are Commission employees allowed?
Are 1099 employees allowed?
Are employees covered if traveling out of USA?
Is coverage available for out-of-state employees?
Max. % of employees residing out-of-state allowed
*100%
N/A N/A
2-2 3-50
Yes—if on DE-6 and showing at least minimum wages and withholdings
No
Only for emergency benefits
Yes*— CalChoice ® PPO 750, CalChoice ®1000, CalChoice ® 2400, Active Choice SM 500, CalChoice ® HSA 1500** and CalChoice ® HSA 2400**
* Except for employees in Hawaii** HSA-Qualified High Deductible Health Plan
49% (Main office must be located in California)
2-50
50% of lowest cost plan
N/A
N/A
2 250* N/A
2-50 No
2-50 No
*100% ◆70%
N/A N/A
◆ Those covered by another plan are NOT considered eligible in calculating participation. In order to NOT be considered eligible, the other coverage must be a group plan, Champus, Medicare or Medi-Cal
* No 1 Life groups allowed† Employer contribution is 100% of employee lowest cost HMO plan
or more
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Employees
For Dependents
% of Total Cost:
PLAN ELIGIBILITY REQUIREMENTS
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE CARVE OUTS*
WRAP* REQUIREMENTS
*Indicates flexibility in being offered with products of another carrier.
GROUP Can be written with another SIZE carrier's HMO, POS or EPO?
GROUP Can be written with another SIZE carrier's HMO, POS or EPO?
SPECIAL CONSIDERATIONS
100% of employees not coveredby group insurance and 70% ofall employees regardless ofother coverage
†
CaliforniaChoice®
CaliforniaChoice®
CaliforniaChoice®
CaliforniaChoice®
AFTERINITIAL ISSUE
ENROLLMENT GROUP SIZE
Min. # of employeesMax. # of employees
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No
No
Yes—coverage available for non-union only. Group must submit union billing to underwriting for verification that all other employees have union coverage
2
Yes
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
Does carrier underwrite and ratecarve out groups according to AB1672 guidelines?
* Over 50 only if group is SB 578 qualified. (If group has less than 50 employees, for 50% of the preceding calendar quarter or preceding calendar year) M
ED
IC
AL
MEDICAL UNDERWRITING REQUIREMENTS
Current Employees
TimelyAdd-ons
ENROLLMENT INFORMATION & REQUIREMENTS
Carrier's Effective Date
Premium Amount Required for 15th?
Employee Waiting Periods Available
Applications must be dated within:
Spouse/Domestic Partner Employees - 1 application or 2?
Employee Waiver Cards Required at enrollment?
Is Over Age Dependent Verification Required?
Are Telephone Interviews done by Underwriting?
Must Brokers Carry Errors & Omissions Insurance?
Does Carrier Offer Open Enrollment?
DOCUMENTATION & PAYMENT INFORMATION
DE-6 statement required?
Payroll Records OK if no DE6?
Is a Prior Booklet required?
Is Prior Billing required?
Must submit check with
initial application?
Check Made payable to:
FEES
Enrollment Fee Amount
Type of Enrollment Fee
Monthly Billing Fee
DEDUCTIBLE CREDITPrior carrier deductible credit given?
4th quarter deductiblecarry-over credit given?
GROUP SIZE
ITEMS REVIEWED IN RAF CALCULATION
RATING INFORMATION
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Instant quotes online: www.wordandbrown.comQuotes in 24 hours: (800) 869-6989
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†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”
ITEMS REVIEWED IN RAF CALCULATION
Medical Conditions
Years in Business
# of Pregnancies
Virgin Group
Type of Industry
Percent of Owners
Group Size
% of COBRA Insureds
% of Family Related
Participation
Plan(s) Requested
24 HR Coverage Req'd
Employer Contribution
Bankruptcy
Gender Mix
1st of the month only
N/A
Min: 30 Max: 365
60 days
Use either 1 or 2 applications
Yes
Yes
Yes
Yes—60 days prior to anniversary
Yes
Call representative
Yes*
Yes*
Yes
C.C.B.A. (California ChoiceBenefit Admin.)
None
N/A
1-8 9-20 21+
$20 $25 $30
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
*Only if any employees take PPO Dental
2-4: 1.105-50: 1.0015-50: 1.00**Groups may qualify for a .90. See quote for details.
N/A
12 Months
No
HMO: YesPPO: Yes
2-14 15-50
Employee Master AppMedical (Employer
Questionnaire Questions)
Non Non Medical Medical
CaliforniaChoice®
CaliforniaChoice®
(if enrolling separately, 2 applications required)
HMO: N/APPO: Yes*
No
RAF Increments (2-50 lives)
Composite Rates
Rate Guarantee††
Apply Trend Factor?
Use Employee Zips?
Yes—full time student or disabled dependent information requested if child over age.
*This does NOT include credit for the RX deductible
Refer to summary on pages 60-61
Refer to summary on pages 60-61
HMO
CalChoice® PPO 750 & CalChoice® PPO 1000
Active ChoiceSM 500†
CalChoice® PPO 2400, CalChoice® HSA 1500**
& CalChoice® HSA 2400 **
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GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive ageneric equivalent rather than a brand namedrug?
If doctor writes “dispense as written” on prescription, is brand name available at the brandcopay amount?
SPECIAL CONCERNS*
Hearing treatment
PREVENTIVE BENEFITS*
PRESCRIPTIONS
Adult Physical Child Physical Annual OB/GYNPLAN TYPE Exam Exam/Immunizations Visit/Pap Smear Mammography
FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?
Are non-formulary drugs available?
MAIL ORDER - 90 DAY SUPPLY
Are oral contraceptives covered?
HMO: Routine hearing screening in PCP's office only—office visit copay applies
PPO: Covers ear screenings to determine the needfor audiograms for dependent children throughage 18 only
Refer to summary on pages 60-61
Refer to summary on pages 60-61
Refer to summary on pages 60-61
Yes—subject to the Drug Formulary for the HealthCare Service Plan selected by member
* Unless otherwise noted, information shown in this section reflects in-networkbenefits.
* Information shown in this section reflects in-network benefits.** HSA-Qualified High Deductible Health Plan
Salud HMO y mas plan design varies depending onwhether the Salud provider network or the SIMNSAprovider network is utilized by the employee anddependents. The information outlined on this page only reflects the Salud provider network. Call your Word & Brown representative for Mexico benefit details.
CaliforniaChoice®
CaliforniaChoice®
CaliforniaChoice®
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100% after copay
Office visit copay(ded. waived)
100% up to $500/ind.& $1000/family for allcategory 1 services
Office visit copay(ded. waived)
100% after copay
Office visit copay(ded. waived)
100% up to $500/ind.& $1000/family for allcategory 1 services
Office visit copay+80% immun. (ded. waived)
100% after copay
Office visit copay(ded. waived)
100% up to $500/ind.& $1000/family for allcategory 1 services
Office visit copay(ded. waived)
100% after copay
Office visit copay(ded. waived)
100% up to $500/ind.& $1000/family for allcategory 1 services
Office visit copay(ded. waived)
† After Active ChoiceSM 500 first dollar preventive care category 1 limit has been reached,member is responsible for all allowed charges until calendar year max. is reached. Once calendar year max. is reached, Blue Shield pays 100% of allowable amount
Note: CalChoice® HSA 2400 does not have an Rx card. Prescription drugs are covered - subject to calendaryear deductible and coinsurance. Member pays fullprice then submits prescription drug claims to BlueShield of California.
InfertilityHMO: $1500 lifetime maximum on infertility drugs.
Evaluation & treatment using coveredprocedures (no in-vitro fertilization)—50% ofallowed charges. Note: Covered procedures& allowed charges will vary by HCSP (HealthCare Service Plan).
See Evidence of Coverage or Benefit Booklet
PPO: Not Covered
Speech therapy
HMO: Outpatient covered if HCSP determines there will be significant improvement in 60 days—officevisit copay applies
PPO: Covered for certain conditions (see Evidence ofCoverage or call representative)—subject todeductible and coinsurance
Are Hearing Aids covered?No
CaliforniaChoice® now offers EPIC Hearing Service Plan(HSP) to all CaliforniaChoice® members at no additionalcost
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PROVIDER INFORMATION
PRESCRIPTIONS
Can member self-referto an OB/GYN?
Allows OB/GYN to bePrimary Care Physician?
If generic available, anddoctor has not indicated“dispense as written,”will member receive ageneric equivalent ratherthan a name brand drug?
If doctor writes “dispense as written” onprescription, is brand name available at the brand copay?
Does health plan use Rx formulary?
If medically necessary,are non-formulary drugs covered?
Mail order
BENEFIT SUMMARY
*generic copay/brand namecopay/non-formulary copay if applicable
NOTE: Each HCSP HMO has their own PCP change approval process
FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR WORD & BROWN REPRESENTATIVE
BlueShield HMO
Anytime
Yes
No
Yes—if OB/GYN in samemedIcal group/IPAas PCP
Yes—if OB/GYN islisted as PCP
Yes—or must paygeneric copay + difference in costbetween brand name & genericequivalent
Yes
Yes
Yes—if pre-approved
90 day supply—double the retail copayNo mail order benefit for non-formulary
Self: Yes—if usingAccess+ providerExpress: Yes—ifAccess+
No
Yes
Health Net HMO, Elect Open Access,& Salud HMO y mas*(*only Salud network benefits shown)
Once amonth
HMO: Self: Yes— if Rapid Access provider
HMO: Yes— OB/GYN must be in same med grp/IPA as PCP
Yes—if OB/GYN is listed as PCP
Yes—or must pay brandcopay + difference in costbetween brand name &generic equivalent
Yes* — $50 non-formularycopay applies*Prior authorization may be required for certain medications
90 day supply—double retail copay
Yes
Yes
What is copay for covered non-formulary drugs?
CalChoice® HMO15:CalChoice® HMO 25:CalChoice® HMO 30:CalChoice® HMO 40:
CalChoice® HMO 25 Value:CalChoice® HMO 40 Value:
$10$15$15$20$15$15
$20 $100 Ded. - $25$150 Ded. - $30$200 Ded. - $35$200 Ded. - $30$250 Ded. - $30
A $50 non-formulary copay applies for:CalChoice® HMO 15, CalChoice® HMO
25, CalChoice® HMO 25 Value, CalChoice® HMO 30, CalChoice® HMO
30 Value, CalChoice® HMO 40,CalChoice® HMO 40 Value,
Elect Open Access and Salud HMO y mas
Generic Brand Generic Brand
Elect Open Access:Yes—member may selfrefer to any doctor in PPOnetwork for a $40 copay
Elect Open Access: Yes
CaliforniaChoice®
CaliforniaChoice®
CaliforniaChoice®
Kaiser Permanente HMO
Generic Brand
Anytime—change is effective immediately
Yes—from KaiserPermanentePhysicians
Self: Yes—to OB/GYN andcertain other specialties(list varies by region)Express: Yes—referraldirect from physician
Yes—to a KaiserPermanente OB/GYN
Yes
Yes
Yes
Yes —if deemed medicallynecessary by KaiserPermanente Physician
100 day supply—double the retail copay
No
Yes
$10$15$15$15
$20 $25 $30$30
How often can familymembers change theirPrimary Care Physician?(PCP)
Can family memberseach choose a PCPfrom a differentIPA/Medical Group?
Do plans have these types of programs to speed the specialist referral process in network: Self referral?Express referral?
Is there an Out-of-Network benefit?
HMO
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WELL WOMAN BENEFITS
PPO 750, PPO 1000 & PPO 2400:$50 non-formulary copay*Active ChoiceSM 500:$50 non-formulary copay (or 50% of Blue Shield contracted rate)*HSA 1500* & HSA 2400*: $50 copay after plan deductible
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What is copay for covered non-formulary drugs?
CalChoice® HMO15:CalChoice® HMO 25:CalChoice® HMO 30:CalChoice® HMO 40:
CalChoice® HMO 25 Value:CalChoice® HMO 40 Value:
SharpHealth Plan
Once a month
Yes
Self: Yes—availablethrough medical group(some medical groupsoffer direct access tocertain specialists)
Yes—on anunlimited basis in same IPA orPMG as PCP
Yes—if OB/GYN islisted asPCP
Yes—or must pay non-formularycopay
Yes
Yes* — non-formularycopay applies *Prior authorization may be required for certain medications
90 day supply—double the30-day retail copay
non-formulary:Call your
Word & Brown representative
No
Yes
Generic Brand
Double theformulary brand
copay
Can member self-referto an OB/GYN?
Allows OB/GYN to bePrimary Care Physician?
If generic available, anddoctor has not indicated“dispense as written,”will member receive ageneric equivalent ratherthan a name brand drug?
If doctor writes “dispense as written” onprescription, is brand name available at the brand copay?
Does health plan use Rx formulary?
If medically necessary,are non-formulary drugs covered?
Mail order*generic copay/brand namecopay/non-formulary copay if applicable
How often can familymembers change theirPrimary Care Physician?(PCP)
Can family memberseach choose a PCPfrom a differentIPA/Medical Group?
Do plans have these types of programs to speed the specialist referral process in network: Self referral?Express referral?
Is there an Out-of-Network benefit?
WELL WOMAN BENEFITS*
PRESCRIPTIONS
NOTE: Each HCSP HMO has their own PCP change approval process
BENEFIT SUMMARYBENEFIT
SUMMARYPROVIDER INFORMATION
FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR WORD & BROWN REPRESENTATIVE
Anytime—in a PPO, you do nothave to choose a PCP
Yes—each family member canmake their own physician choice
Yes—in a PPO, you don't have togo through a specialist referralprocess
Yes—Negotiated Fee Reimbursement(NFR).
Yes—In a PPO, you can choose any OB/GYN anytime
Yes— In a PPO, there is no PCP. You can choose any OB/GYN anytime
Active ChoiceSM 500, PPO 750, PPO 1000 & PPO 2400Yes—or member pays the generic copay plus thedifference between the cost of the brand name &generic*
HSA 1500* & HSA 2400*:Yes—20% copay applies to brand name andgeneric after paying deductible
Blue Shield PPO
Active ChoiceSM 500, PPO 750, PPO 1000 & PPO 2400:Yes – non-formulary available at higher copay*HSA 1500* & HSA 2400*: Formulary does not apply
PPO 750, PPO 1000 & PPO 2400:Yes—$50 non-formulary copay*Active ChoiceSM 500:Yes—$50 non-formulary copay (or 50% of Blue Shield contracted rate)*HSA 1500* & HSA 2400*:Yes—Formulary does not apply
No
WesternHealth Advantage
Yes
Yes—Advantage Referral Program allowsPCP referral to most specialists in the WHAnetwork
Yes—anytime toan OB/GYNin the WHANetwork
Yes—in somecases
Yes—or must pay thebrand copay plus thedifference in costbetween the brandname and genericequivalent
Yes
Yes
90 day supply—double the retail copay
Yes
Once a month
CaliforniaChoice®
CaliforniaChoice®
CaliforniaChoice®
Active ChoiceSM 500, PPO 750, PPO 1000 & PPO 2400Yes*
HSA 1500* & HSA 2400*:20% copay applies to brand name and generic afterpaying deductible
*PPO 750- $150PPO 1000 - $200PPO 2400 - $250Active ChoiceSM 500 -$500 separate per individual Rxdeductible applies toformulary & non-formulary BRAND NAME drugs
BENEFIT SUMMARY
PPO
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PPO 750, PPO 1000 & PPO 2400:90 day supply - $30/$60/$100*Active ChoiceSM 50090 day supply - $20/$60 or 30% whichever is greater /$100 or50% whichever is greater - Non FormularyHSA 1500* & HSA 2400*: 90 day supply-$30/$60/$100
$35 $50$50$50
CalChoice® HMO 40 Value $50
*HSA-Qualified High Deductible Health Plan
non-formulary:CalChoice® HMO 15: $70CalChoice® HMO 25: $100CalChoice® HMO 30: $100CalChoice® HMO 40: $100CalChoice® HMO 40 Value: $100
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DIABETIC BENEFITS
Are self-injectabledrugs (other thaninsulin) covered underthe Prescription Drugbenefit or MedicalBenefit?
BENEFIT SUMMARY
BlueShield HMO
Health Net HMO, Elect Open Access,& Salud HMO y mas*(*only Salud network benefits shown)
SELF-INJECTABLE DRUG BENEFITS
CaliforniaChoice®
CaliforniaChoice®
Kaiser Permanente HMO
Insulin
Is pre-authorizationrequired?
Must self-injectables(other than insulin) bepurchased via the carrier-contracted mailorder RX vendor?
Needles & Syringes
Glucose Monitor
Chem-Strips and/orTesting Agents
Insulin Pump
Insulin Pump Supplies
PrescriptionDrug Benefit
Some medicationsand/or dosagesmay requireprior authorization
No—not availablemail order
PrescriptionDrug Benefit
PrescriptionDrug Benefit
Covered under the Prescription DrugBenefit (Preferred monitors only) All other monitors covered at: CalChoice® HMO 15 - 90%CalChoice® HMO 25 - 80%CalChoice® HMO 25 Value - 80%CalChoice® HMO 30 - 80%CalChoice® HMO 30 Value - 80%CalChoice® HMO 40 - 80%CalChoice® HMO 40 Value - 80%Elect Open Access 25 - 80%Salud HMO y mas - 80%
PrescriptionDrug Benefit
Covered at:CalChoice® HMO 15 - 90%CalChoice® HMO 25 - 80%CalChoice® HMO 25 Value - 80%CalChoice® HMO 30 - 80%CalChoice® HMO 30 Value - 80%CalChoice® HMO 40 - 80%CalChoice® HMO 40 Value - 80%Elect Open Access 25 - 80%Salud HMO y mas - 80%
Covered at:CalChoice® HMO 15 - 90%CalChoice® HMO 25 - 80%CalChoice® HMO 25 Value - 80%CalChoice® HMO 30 - 80%CalChoice® HMO 30 Value - 80%CalChoice® HMO 40 - 80%Cal Choice® HMO 40 Value - 80%Elect Open Access 25 - 80%Salud HMO y mas - 80%
Medical Benefit
Yes
No—use doctor'scontracted vendor
PrescriptionDrug Benefit
PrescriptionDrug Benefit
Durable MedicalEquipment Benefit
PrescriptionDrug Benefit
Durable MedicalEquipment Benefit
Durable MedicalEquipment Benefit
PrescriptionDrug Benefit
Must be prescribedby a planphysician
Must use planpharmacies(including affiliatedpharmacies)
62
HMO
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Are the following items covered under the Prescription DrugBenefit, Durable MedicalEquipment Benefit orDiabetes Care Benefitof the member’s selected plan design?
PrescriptionDrug Benefit
PrescriptionDrug Benefit
Diabetes Care Benefit*
PrescriptionDrug Benefit
Diabetes Care Benefit*
Diabetes Care Benefit*
* Subject to medical deductible if plan has one, and coinsurance. Does not have $2000 annual maximum of Durable Medical Equipment
63
SharpHealth Plan
Are self-injectabledrugs (other thaninsulin) covered underthe Prescription Drugbenefit or MedicalBenefit?
Insulin
Is pre-authorizationrequired?
Must self-injectables(other than insulin) bepurchased via the carrier-contracted mailorder RX vendor?
Needles & Syringes
Glucose Monitor
Chem-Strips and/orTesting Agents
Insulin Pump
Insulin Pump Supplies
PrescriptionDrug Benefit
Durable MedicalEquipment Benefit
Durable MedicalEquipment Benefit
Durable MedicalEquipment Benefit
Durable MedicalEquipment Benefit
Durable MedicalEquipment Benefit
PrescriptionDrug Benefit
Some medicationsand/or dosagesmay requireprior authorization
No—mail ordernot required
DIABETIC BENEFITS
BENEFIT SUMMARY
Blue Shield PPOWesternHealth Advantage
CaliforniaChoice®
CaliforniaChoice
SELF-INJECTABLE DRUG BENEFITS CaliforniaChoice®
PrescriptionDrug Benefit
PrescriptionDrug Benefit
Durable MedicalEquipment Benefit
PrescriptionDrug Benefit
Durable MedicalEquipment Benefit
Durable MedicalEquipment Benefit
PrescriptionDrug Benefit(in-network)
Some medicationsand/or dosagesmay requireprior authorization
No—not availablemail order
PrescriptionDrug Benefit
PrescriptionDrug Benefit
Durable MedicalEquipment Benefit
PrescriptionDrug Benefit
Durable MedicalEquipment Benefit
Durable MedicalEquipment Benefit
Medical Benefit
Yes
Depends onmedical group
PPO
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Are the following items covered under the Prescription DrugBenefit, Durable MedicalEquipment Benefit orDiabetes Care Benefitof the member’s selected plan design?
KEY TO HEALTH CARE SERVICE PLANSOFFERING LISTED PROGRAM
BS Blue Shield
HN Health Net
KP Kaiser Permanente
SH Sharp Health Plan
WH Western Health Advantage
* All CaliforniaChoice® medical members are eligible for discounts on eye exams, lenses, frames, andcontacts through the Vision One Eye Care Program administered by Cole Managed Vision/EyeMedVision Care.
1Discounts of frames and lenses available through Kaiser Permanente facilities.
2 Discounts on vitamins and herbal supplements available through the “Affinity Program” which linksKaiser Permanente members to Healthy Roads
3Member must use a Kaiser Permanente weight loss program.
Which health care plans offer these discounts, awards and other value-added benefits?
Eyewear & lenses discount ..............................................................................................................................BS, HN, KP 1
Health Club Membership or fitness equipment/sporting goods discount…….......................................BS, HN, KP, WH
Health Literature, telephone tapes and/or videos (no charge)..................................................................BS, HN, KP, SH
available in the following languages: Spanish
Home childproofing products discount ..........................................................................................................................HN
Infant car seat:
discount ............................................................................................................................................................HN
awarded upon prenatal class completion ........................................................................................................HN
Nurses 24 Hour Hotline ..............................................................................................................................BS, HN, KP, SH
Vitamins and/or herbal supplements discount ..............................................................................................HN, KP 2, SH
Weight control program discount ..................................................................................................................HN, KP 3, SH
DISCOUNTS, AWARDS & OTHER VALUE-ADDED BENEFITS (cont.)
BENEFIT SUMMARY
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HMO & PPO Counties�
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Plan may not be available in all zip codes within county. Check with your Word & Brown representative to confirm if coverage is available for your group location.
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Colusa
CalaverasMarin
Monterey
Sacra-mento
Alameda
AlpineAmador
Butte
ContraCosta
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Mariposa
Mendocino
Merced
Modoc
Mono
Napa
Nevada
Orange
Placer
Plumas
Riverside
SanBenito
San Bernardino
San Diego
San Francisco
SanJoaquin
SanLuis
Obispo
SanMateo
SantaBarbara
Santa Clara
SantaCruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sut-ter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
Member Support 877-480-7923
Commissions 714-567-4390
Adds/Terms Fax 877 237-4519
Administrator Claims888-209-7847(Effective 11/1/09)
Banyan Consulting, LLC Attn: Tom Zimmerman 1215 Manor Drive, Suite 200Mechanicsburg, PA 17055 Phone 877-480-7923Fax 877-237-4519
Protect HSA 1500/3000Protect HSA 2500/2500Protect HSA 2850/5650
LIFE
DENTAL
VISION
INFERTILITY
CHIROPRACTIC
ACUPUNCTURE
MASSAGE THERAPY
PRODUCTS OFFERED
OPTIONAL BENEFITS
GROUP SIZE
PROVIDER INFORMATION
HMO
66
CONSUMER-DIRECTED HEALTHCARE
HSA-CompatiblePPO
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ALTERNATIVE DISCIPLINES
Is Workers' Comp required oncorporate officers, partners andsole proprietors?:
Is on-the-job covered for corporate officers, partners and sole proprietors?:
Is there a premiumadjustment for 24 hour coverage?:
HMOAnthem Blue Cross
PPOAnthem Blue Cross
No
Yes
How often can members change their Primary Care Physician (PCP)?
Can family members each choose a PCP from a differentIPA/Medical Group?
Does carrier allow an OB/GYN to be Primary Care Physician?
Self-referral available?
Express referral available?
24 HOUR COVERAGE
SPECIALIST REFERRALS
A member may change as frequently asdesired with a first of the month followingeffective date. However if a member is inthe middle of a treatment plan, say physicaltherapy with a Medical Group, they maynot switch to a different Primary CarePhysician (PCP) until the treatment plan has ended.
Yes
Yes
No
Only Well-Woman exams withinthe PCP Medical Group
SELECTION
NETWORKS
N/A
N/A
N/A
Yes
Yes
Yes
No
HMO Advantage 100HMO Value 80
2+
PPO
ProtectPlus 10ProtectPlus 15
ProtectPlus 15 EnhancedProtectPlus 25
ProtectPlus 25 EnhancedProtectPlus 35
ProtectPlus 35 EnhancedProtectPlus 45
No
California CPA
California CPA
California CPA
GROUP Can be written with another SIZE carrier's PPO or indemnity plan?
Employees
Dependents
Employees
Dependents
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
Does carrier underwrite and ratecarve out groups according to AB1672 guidelines?
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
ENROLLMENT GROUP SIZE
Employees
For Dependents
% of Total Cost:
PLAN ELIGIBILITY REQUIREMENTS
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Min. # of employees
Max. # of employees
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
AFTERINITIAL ISSUE
CARVE OUTS*
WRAP* REQUIREMENTS
*Indicates flexibility in being offered with products of another carrier.
GROUP Can be written with another SIZE carrier's HMO, POS or EPO?
SPECIAL CONSIDERATIONS
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COVERAGE RESTRICTIONS
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Are employees covered if traveling out of USA?
Is coverage available for out-of-state employees?
Max. % of employees residing out-of-state allowed
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No
No
Yes—out of network or BlueCard (for emergencies only)
Yes
51% of the group’s employees must reside in California.Use the employer’s zip code for the out-of-stateemployees on the census
100%
100%
2+
2+ Yes (with Kaiser Permanente only)
2+ No—do not allow PPO wrap
50%
N/A
N/A
75%
N/A
2+
2 2
No max. No max.
Not allowed
Not allowed
Not allowed
2
No
Participation is available to the CA-based owners and employeesof accounting firms in public practice or offering generalfinancial services (SIC 8721). To be eligible and retain sucheligibility, more than 50% of all of the firms' owners (principals,partners, shareholders or other owners) must be CPA's or non-CPA members of CaICPA, and all CPA owners must be membersof CaICPA in good standing.
Non-student dependent children ages 19 through age 24 can becovered at employee rates. Call your Word and Brownrepresentative.
Groups can turn in apps for CalCPA membership withEnrollment. Membership ID# must be included on the MasterApp.
All employees who work at least 20 or 30 hours per week areeligible to enroll.
California CPA
California CPA
California CPA
MEDICAL UNDERWRITING REQUIREMENTS
Current Employees
TimelyAdd-ons
Group Size
Composite Rates
Rate Guarantee*
Apply Trend Factor?
Use Employee Zips?
ENROLLMENT INFORMATION & REQUIREMENTS
Carrier's Effective Date
Premium Amount Required for 15th?
Employee Waiting Periods Available
Applications must be dated within:
Spouse/Domestic Partner Employees - 1 application or 2?
Employee Waiver Cards Required at enrollment?
Is Over Age Dependent Verification Required?
Are Telephone Interviews done by Underwriting?
Must Brokers Carry Errors & Omissions Insurance?
Does Carrier Offer Open Enrollment?
DOCUMENTATION & PAYMENT INFORMATION
DE-6 statement required?
Payroll Records OK if no DE6?
Is a Prior Booklet required?
Is Prior Billing required?
Must submit check with
initial application?
Check Made payable to:
FEES
Enrollment Fee Amount
Type of Enrollment Fee
Monthly Administration Fee
DEDUCTIBLE CREDITPrior carrier deductible credit given?
4th quarter deductiblecarry-over credit given?
GROUP SIZE2+
RATING INFORMATION
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Instant quotes online: www.wordandbrown.comQuotes in 24 hours: (800) 869-6989
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†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”
ITEMS REVIEWED IN RAF CALCULATION
Medical Conditions
Years in Business
# of Pregnancies
Virgin Group
Type of Industry
Percent of Owners
Group Size
% of COBRA Insureds
% of Family Related
Participation
Plan(s) Requested
24 HR Coverage Req'd
Employer Contribution
Bankruptcy
Gender Mix
1st of the month only
N/A
Yes—1st of the month after date of hire—6 months max.
30 days
Yes
Yes—must submit copy of college transcript with initial enrollment
No
Yes
Yes—each November for a January 1 effective date
None
N/A
N/A
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
Yes
No
Non-Medical
No
N/A
No
No
No
Check not requiredwith submission
If husband and wife are both employees and they enroll separately,they need a W-2 to prove the spouse works there. If they are writtenas one, the CPA must be the primary insured
Non-Medical
HMO Automatic 1.10PPO Rate tables vary by
group size (2-14, 15-50)
Yes—51+
12 months
No
Yes
California CPA
California CPA
SPECIAL CONCERNS*
InfertilityCovered—Diagnosis and treatment of infertility, asmedically necessary, provided you are under treatmentof a physician. Artificial insemination and in vitrofertilization are covered; any drugs prescribed forinfertility and any laboratory procedures related to invitro are not covered
Not Covered—Any services or supplies furnished inconnection with the diagnosis and treatment of infertility,including, but not limited to, diagnostic tests, medication,surgery, artificial insemination, in vitro fertilization,sterilization reversal, and gamete intrafallopian transfer,except as specifically stated under “Infertility Treatment”provision of medical care that is covered
PREVENTIVE BENEFITS*
PRESCRIPTIONS
Adult Physical Child Physical Annual OB/GYNPLAN TYPE Exam Exam/Immunizations Visit/Pap Smear Mammography
GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive ageneric equivalent rather than a brand namedrug?
If doctor writes “dispense as written” on prescription, is brand name available at thebrand copay amount?
* Information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?
Are non-formulary drugs available?
MAIL ORDER - 60 DAY SUPPLY
Are oral contraceptives covered?
* Unless otherwise noted, information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
BENEFIT INFORMATION SHOWN ON THIS PAGE IS A BRIEF SUMMARY. LIMITATIONS AND EXCLUSIONS APPLY. PLEASE REFER TO CERTIFICATE BOOK, EVIDENCE OF COVERAGE OR CALL REPRESENTATIVE FOR DETAILS.
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Hearing treatment
Are Hearing Aids covered?
Speech therapy
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All Plans 100% after copayoffice visit copay
(deductible waived)up to $250 max.
Exempt from thedeductible, then
insured pays officevisit copay and
coinsurance, no limit
Exempt from thedeductible, then
insured pays officevisit copay and
coinsurance, no limit
Exempt from thedeductible, then
insured pays officevisit copay and
coinsurance, no limit
Not covered—routine hearing tests, except asspecifically provided under “Preventive Care” benefitsof medical care that is covered (Beneficiaries age 7 and older)
Yes—outpatient speech therapy following injury ororganic disease
No
No
No “dispense as written” override to get brand copaywhen generic available
N/A
Yes
Yes—using Prescription Drug Program
Yes
California CPA
California CPA
California CPA
DIABETIC BENEFITS
These services may change at any time without notice. Please contact your Word & Brown representative for specific inquiries on listed services
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Are the following items covered under the Prescription Drug Benefit or the Durable MedicalEquipment Benefit of the member’s selected plan design?
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Insulin
Needles & Syringes
Glucose Monitor
Chem-Strips and/or Testing Agents
Insulin Pump
Insulin Pump Supplies
SELF-INJECTABLE DRUG BENEFITS
Are self-injectable drugs(other than insulin)covered under the
Prescription Drug Benefitor Medical Benefit?
Is pre-authorizationrequired?
*Must self-injectables(other than insulin)
be purchased via thecarrier-contracted
mail order Rx vendor?
Prescription Drug Benefit
Prescription Drug Benefit
Durable Medical Equipment Benefit
Prescription Drug Benefit
Durable Medical Equipment Benefit
Durable Medical Equipment Benefit
Prescription Drug Benefit
Yes NoHMO
Prescription Drug Benefit
No NoPPO
California CPA
California CPA
*Some injectables may be required to go through the Anthem Specialty Rx Program—call your Word & Brown representative
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PPO Counties
All Plan Types
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Plan may not be available in all zip codes within county. Check withyour Word & Brown representative toconfirm if coverage is available foryour group location.
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Colusa
Calaveras Marin
Monterey
Sacra- mento
Alameda
Alpine Amador
Butte
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Mariposa
Mendocino
Merced
Modoc
Mono
Napa
Nevada
Orange
Placer
Plumas
Riverside
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis
Obispo
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sut- ter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
Member Support 800-361-3366Bilingual Support 800-331-1777Account Service & Membership Accounting Dept. 800-447-8812 Option 2 Benefits & Eligibility Dept. 800-224-8808 Option 3
(Mon.-Fri. 8:00 AM-4:30 PM PST)Enrollment Dept. 800-224-8808 Option 3
(Mon.-Fri. 8:00 AM-4:30 PM PST)For Group online access Eligibility you will need the Group Account number.
Federal COBRA Enrollments Fax 916-935-4420 (ATTN: COBRA)Release Authorization (for HIPAA Release Auth. Forms) Fax 916-935-4420 Precertification Department 800-977-7282 Broker of Record Changes/Group Termination Requests Fax - So Cal. 818-676-6297
Fax - No. Cal. 800-303-3110Caremark Pharmacy Services 800-600-0180, Option 1Client Management Dept.(for rates and service issues) 800-447-8812Adds/Terms Fax 916-935-4420Account Services 800-547-2967 (8 a.m.-5 p.m.)
or via email: [email protected]
Commissions 800-448-4411, Option 4�
Health Net Corp. Office21281 Burbank Blvd.Woodland Hills, CA 91367
ClaimsP.O. Box 14702Lexington, KY 40512
ADMINISTRATOR
Salud Mexico is available to groups located within 50 miles of the border
Salud EPO and Salud PPO plans areavailable to employer groups ormembers located in Los Angeles,Orange and Ventura Counties.
CLAIMS
proud participant in:
Health NetFile 52617Los Angeles, CA 90074-2617800-224-8808, Option 3
BILLING
HMO/POS
The Silver Network isavailable in all or parts ofKern, Los Angeles, Orange,Riverside, San Bernardino,San Diego, San Franciscoand Ventura counties
Salud HMO y Mas is available toemployer groups or members located inOrange County and parts of Los Angeles,Riverside, San Bernardino and San DiegoCounties.
SIMNSA (for all plans)Mexico Service Area: Tijuana, Mexicali, Rosarito or Tecate
Self-referral available?
Express referral available?
AvailableAvailable**Available**
Not Available
AvailableAvailable
Included if optional Chiropractic elected byemployer
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LIFEDENTALVISION
INFERTILITY
CHIROPRACTICACUPUNCTURE
MASSAGE THERAPY
PRODUCTS OFFERED
OPTIONAL BENEFITS
GROUP SIZE
PROVIDER INFORMATION
HMO/EPO PPO POS
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CONSUMER DIRECTED HEALTHCARE
HSA-Compatible PPO HRA-Compatible PPO
ALTERNATIVE DISCIPLINESIs on-the-job covered for corporate officers, partnersand sole proprietors?
Is there a premium adjustmentfor 24 hour coverage?
How often can members change their Primary Care Physician (PCP)?
Can family members eachchoose a PCP from a differentIPA/Medical Group?
Does carrier allow an OB/GYNto be Primary Care Physician?
2-50
Once a month within PMG/IPAPMG/IPA may be changed once a month
**Optional Health Net Dental & Vision plans available—call representative for details
Health Net
Health Net
HMO/EPO
HMO 10*†HMO 20*†HMO 30*†HMO 40*†EOA 10*†EOA 20*†EOA 30*†EOA 40*†Salud HMO Y Mas 15 1
Salud HMO Y Mas 25 1
Salud Mexico 3
Salud EPO 4
Options HMO 25Options HMO 35Options EOA 25Options EOA 35Hn Options Silver HMO 25Hn Options Silver HMO 35
PPO
PPO 10*PPO 20*PPO 30*PPO 40*Salud PPO 5
Options PPO 250Options PPO 500Options PPO 1500Options PPO 1750
POSPOS 10POS 20
INDEMNITYFlexNet 2
(Out of Area)
Value HSA 1500Value HSA 2500Value HSA 3500Value HSA 4500
Standard HSA 2000
Standard HSA 3000Standard HSA 4000
Options PPO 3000 HSAOptions PPO 4000 HSA
HRA 3000 HRA 5000
Hn Options (MIX AND MATCH) Health Net
Health Net
Is Workers' Comp required oncorporate officers, partnersand sole proprietors?
24 HOUR COVERAGE
SPECIALIST REFERRALS
Yes
HMO/POS: Yes—if medical groupoffers OB/GYN as PCP choice
PPO: N/A
HMO: Yes—OB/GYN visits only (OB/GYNmust be in same medical group as PCP)POS & ELECT Open Access: HMO (Tier 1)Yes—same as HMO above; PPO (Tier 2) YesPPO: Yes—no PCP selection required
Yes—if a Rapid Access Provider
Yes
No
No—all employees must haveWorkers' Comp except those notlegally required to be covered.Workers' Comp that is "pending” atthe time of sale is not acceptable
SELECTION
NETWORKS
For Salud Y Mas, only Los Angeles, Orange,Riverside, San Bernardino,San Diego and VenturaCounty network optionalbenefits are shown here.Mexico network benefits vary—call your Word & Brownrepresentative for details
HMOHealth NetSilver Network (all HMO and EOA Standard, andValue plans in Southern CA & San Francisco only)EOAHealth Net HMO/PPOPPOHealth Net PPOPOSHealth Net HMO/PPOSALUD Y MASLos Angeles, Orange, Riverside, San Bernardino and San Diego Counties: Call your Word & Brown
representativeVentura County: Salud Primero EPOMexico: Sistemas Medicas (Tijuana,
Mexicali, Nacionales, S.A de C.V., Rosarito & Tecate (SIMNSA)
1 Currently available to groups or members in Los Angelesand Orange Counties, and select zip codes of Riverside andSan Bernardino Counties
2 Not available on a standalone basis3 Available to groups who are within 50 miles of the border in
San Diego or Imperial Counties4 Currently available to groups or members in Los Angeles,
Orange and Ventura Counties only5 Available Los Angeles, Orange and Ventura counties
Groups of 5-9 enrolled employeesEach employee selects from the following plans:
Options HMO 35Options PPO 500, 1750, 3000 & 4000Salud HMO y Mas, PPO and EPO★
Salud Mexico ★
Flex Net ★
Groups of 10-50 enrolled employeesEach employee selects from the following plans:
Options HMO 25 and 35Options PPO 250, 500, 1500, 1750, 3000 & 4000Options EOA 25 & Options EOA 35Salud HMO y Mas, PPO and EPO★
Salud Mexico ★
Flex Net ★
★ Service area restrictions apply. Call your Word & Brown representative for more details
†Each of these plans are available Silver.*Each of these plans are available either Standard or Value. Call your Word & Brown representativefor more details
Hn Options Silver (MIX AND MATCH) Health Net
Groups of 5-9 enrolled employeesEach employee selects from the following plans:
Options HMO Silver 35Options PPO 500, 1750, 3000 & 4000Salud HMO y Mas, PPO and EPO★
Salud Mexico ★
Flex Net ★
Groups of 10-50 enrolled employeesEach employee selects from the following plans:
Options HMO Silver 25 and 35Options PPO 250, 500, 1500, 1750, 3000 & 4000Salud HMO y Mas, PPO and EPO★
Salud Mexico ★
Flex Net ★
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AFTERINITIAL ISSUE
Employees
ENROLLMENT GROUP SIZE
Min. # of employeesMax. # of employees
Employees
For Dependents
% of Total Cost:
PLAN ELIGIBILITY REQUIREMENTS
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
GROUP SIZE
GROUP SIZE
WRAP* REQUIREMENTS
*Indicates flexibility in being offered with products of another carrier.
GROUP Can be written with another SIZE carrier's PPO or indemnity plan?
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COVERAGE RESTRICTIONS
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Are employees covered if traveling out of USA?
Is coverage available for out-of-state employees?
Max. % of employees residing out-of-state allowed
Yes—if employed on a full-time basis for a minimum of 3 months andmeeting the hour per week requirement & probationary periodindicated on the Group Service Agreement. DE-6 earnings must bereported & employee must have workers' comp. If employee is newand does not appear on last quarter's DE-6, submit payroll records.
Yes—if the group first meets AB1672 and 1099 employee is affiliatedwith group long enough to be tied to company through a federal taxreturn & can meet the definition of a full-time employee. This can bedemonstrated in the form of one Schedule C and Form 1099-Miscfrom the most recent year.
Emergency coverage only
Yes—groups of 2-50 eligible employees with over 50% of the totalgroup located in CA are subject to the out-of-area requirementsoutlined below. Coverage not available in Hawaii.
Up to 49% (including and/or excluding COBRA) of total eligiblepopulation may be written on an out-of-state PPO plan. Of the 49%,only those employees who are out of the out-of-state PPO servicearea may be written on a Flex plan. Coverage not available in Hawaii.
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
PLAN ELIGIBILITY REQUIREMENTS
Non-Contributory
STANDARD WRAP* REQUIREMENTS
◆◆75%
Single/Enhanced/
Silver Choice
◆◆ Those covered by another employer group plan are NOTconsidered eligible in calculating participation. In order to NOT be considered eligible, the other coverage must be an employer group plan or MediCal/Medicare
* AB1672 group of 2 with one valid waiver due to other coverage† 51-59 available. Group must have less than 50 employees for more than
50% of last quarter or last year.
In order to be considered guaranteed issue, the group must meet all 3 of these criteria:1) Must have had between 2 and 50 employees for at least 6 weeks
prior to the effective date.2) More than 50% of the group must be located in California;3) Both the carve-out and non-carve-out populations must be offered
group coverage
CARVE OUTS* Health Net
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
Does carrier underwrite and rate carve outgroups according to AB1672 guidelines?
†Group size is based on number of active enrolling employees*Indicates flexibility in being offered with products of another carrier.
GROUP Can be written with another SIZE carrier's HMO, EOA, POS, EPO,
PPO or indemnity plan?
Single Option 2-50
N/A
Yes—Health Net must be the only carrier offered to the carve out population. TheDE-6 and/or payroll must clearly define the class of employees which may beselected from (i.e. carved out) the entire group. Carve out may or may not beguaranteed issue based on criteria shown below. Individual Health statements arerequired on all carve outs
Yes—see requirements above
Employer does not pay directly toward union health plan: Yes—if Health Net is sole carrier for carve out and submits letter from group or broker oncompany letterhead that includes: 1) Describes basis for carve out; 2) Includesname and SSNs of those eligible; 3) Indicates if non-carve out population is offeredcoverage elsewhere; 4) Indicates employer does not contribute directly to unionhealth plan, but only pays toward union dues. No health statements required.Employer pays directly toward union health plan: Yes—if Health Net is solecarrier for carve out and group/broker submits a letter with all items outlined aboveexcept #4. This letter must indicate that employer contributes directly to unionhealth plan. Health statements are required.
2 eligibles, 1 enrolling, 1 valid waiver
1* 150 † 50 †
Hn Options 5-50Hn Options Silver 5-50Enhanced Choice 2-50
Silver Choice 2-50
$100 or 50% of lowest cost plan EE
rate (excluding Salud)
N/A
N/A
H n Options
2-5† Not eligible6-50 † HMO/HMO Silver/EOA: Yes—on a single plan choice
basis. 50% with a minimum of 6 must enroll with HealthNet. POS & PPO: Yes—on a single plan choice basis. 75%with a minimum of 6 must enroll with Health Net.Enhanced Choice/Silver Choice: Yes—75% with aminimum of 6 must enroll with Health Net
Minimum 5 enrollingemployees for 10 planpackage, and minimum10 enrolling employeesfor 15 plan package.75% of eligibleemployees must becovered by employerwith H n Options oranother carrier plan
Dependents N/A
N/A
Same requirement as contributory (see above)Employees
Dependents
◆◆75%
N/A
50% of lowest costplan EE rate
(excluding Salud)
N/A
N/A
Hn OPTIONS:
2-4† Not eligible5-9† Yes—10-plan package: 75% of eligible employees must be
covered by employer with Hn Options, Hn Options Silver oranother carrier's group plan.
10-50 † Yes—15-plan package: 75% of eligible employees must becovered by employer with Hn Options, Hn Options Silver oranother carrier's group plan.
Hn OPTIONS/Hn OPTIONS SILVER* WRAP REQUIREMENTS
†Group size is based on number of active enrolling employees*Indicates flexibility in being offered with products of another carrier.
Hn Options Silver
Minimum 5 enrollingemployees for 10 planpackage, and minimum10 enrolling employeesfor 13 plan package.75% of eligibleemployees must becovered by employerwith H n Options oranother carrier plan
N/A
N/A
Can be written with another carrier's HMO,EOA, POS, EPO, PPO or indemnity plan?
GROUPSIZE
Hn OPTIONS SILVER:
2-4† Not eligible5-9† Yes—10-plan package: 75% of eligible employees must be
covered by employer with Hn Options, Hn Options Silver oranother carrier's group plan.
10-50 † Yes—13-plan package: 75% of eligible employees must becovered by employer with Hn Options, Hn Options Silver oranother carrier's group plan.
Can be written with another carrier's HMO,EOA, POS, EPO, PPO or indemnity plan?
GROUPSIZE
RAF Increments (2-50 lives)
Composite Rates
Rate Guarantee††
Apply Trend Factor?
Use Employee Zips?
MEDICAL UNDERWRITING REQUIREMENTS
Current Employees
TimelyAdd-ons
ENROLLMENT INFORMATION & REQUIREMENTS
Carrier's Effective Date
Premium Amount Required for 15th?
Employee Waiting Periods Available
Applications must be dated within:
Spouse/Domestic Partner Employees - 1 application or 2?
Employee Waiver Cards Required at enrollment?
Is Over Age Dependent Verification Required?
Are Telephone Interviews done by Underwriting?
Must Brokers Carry Errors & Omissions Insurance?
Does Carrier Offer Open Enrollment?
DOCUMENTATION & PAYMENT INFORMATION
DE-6 statement required?
Payroll Records OK if no DE6?
Is a Prior Booklet required?
Is Prior Billing required?
Must submit check with
initial application?
Check Made payable to:
FEES
Enrollment Fee Amount
Type of Enrollment Fee
Monthly Administration Fee
DEDUCTIBLE CREDITPrior carrier deductible credit given?
4th quarter deductiblecarry-over credit given?
GROUP SIZE
RATING INFORMATION
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Instant quotes online: www.wordandbrown.comQuotes in 24 hours: (800) 869-6989
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†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”
ITEMS REVIEWED IN RAF CALCULATION
Medical Conditions/# of Pregnancies
Years in Business/Virgin Group
Plan(s) Requested
Employer Contribution
Participation/Gender Mix
Type of Industry
% Percent of Owners or Family Related
Group Size
% of COBRA Insureds
24 HR Coverage Req'd/Bankruptcy
1st of the month—15th OK if prior group coverage ends on 15th
1 1/2 months premium
Min: 1st of month following hire Max.: 6 months
60 days
Yes—if valid waivers is more than 50% of eligibles
Yes
No
Yes
Yes—open enrollment allowed at renewal
Yes
No—unless new company †
No
No
Yes
Health Net
None
N/A
None
† Minimum 6 weeks of payroll records required
2-5 6-9 10-50
Non Full Master AppMedical Medical (Employer
Questions)*
Non Non NonMedical Medical Medical
Yes
No
No
No
No
Yes
No
Yes
No
Health Net
Health Net
If both domestic partners and spouses are eligible as employees they canopt to enroll on one application together or separately with Health Net
HMO: N/AIndemnity, PPO & POS: Yes
HMO: N/AIndemnity, PPO & POS: Yes
2-5: Automatic 1.106-9 : Guaranteed .90 if group meets
RAF Special Program criteria. If not,RAF assigned in .01 increments.
10-50: Guaranteed .90 if group meets RAFSpecial Program Criteria. If not,RAF assigned in .01 increments.
Available on HMO, ELECT Open Access, POS and Salud HMO Y Mas plans with aminimum of 10 enrolled employees on agiven plan
12 Months
No
Yes
Not available for Enhanced Choice or SilverChoice groups (H n Options, H n OptionsSilver or PPO & FlexNet subscribers)
Yes—20% or more gets automatic 1.10
(Unless group eligiblefor an industry discount)
* If employer gives name of an employee in response to one of these questions, an Individual Health Statement must be submitted by that employee
HMO, ELECT OpenAccess & POS
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GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive ageneric equivalent rather than a brand name drug?
If doctor writes “dispense as written” on prescription, is brand name available at the brand copay amount?
FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?Yes—Health Net refers to this as their RecommendedDrug List
Are non-formulary drugs available?Yes—$50 non-formulary copay
MAIL ORDER - 90 DAY SUPPLYMail order is covered at twice the retail copay
Are oral contraceptives covered?Yes
Hearing Treatment
Yes—member will receive generic unless brand is requested. If brand is requested by member, the memberwill pay the brand copay plus the difference in costbetween the brand and generic
Yes
* Information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
SPECIAL CONCERNS*
PREVENTIVE BENEFITS*
PRESCRIPTIONS
Adult Physical Child Physical Annual OB/GYNPLAN TYPE Exam Exam/Immunizations Visit/Pap Smear Mammography
* Unless otherwise noted, information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
BENEFIT INFORMATION SHOWN ON THIS PAGE IS A BRIEF SUMMARY. LIMITATIONS AND EXCLUSIONS APPLY. PLEASE REFER TO CERTIFICATE BOOK, EVIDENCE OF COVERAGE OR CALL REPRESENTATIVE FOR DETAILS.
Health Net
Health Net
Health Net
Prescriptions filled at a non-participating pharmacy will have aseparate $100 deductible per member and 50% coinsurance.
PPO, EOA, & HMO Value plans: Brand Name deductible
Options Plans (all): $200 brand deductible per member percalendar year
100% after officevisit copay—periodichealth evaluation only
100% birth throughage 2. 100% after office
visit copay age 3-17
100% after office visit copay on Tier 1 only; Tier 2 covered
with coinsurance
HMO: Covered in fullPOS: Coinsurance
PPO (All)
100% after officevisit copay—Max. $250/year for
routine physical exam
100% after office visit copay
100% after office visit copay
PPO 10, 20, 30, 40 & Options PPO:Applicable plan deductible &
coinsurance appliesCovered as part of annual exam
Salud Mexico's plan design cannot be clearly outlined on this page. Please call your Word & Brown sales representativefor details.
HMO: Routine hearing screening in PCP's office—office visit copay
EOA: Tier 1: Covered as outlined above for HMO. Plan 10—$10; Plan 20—$20; Plan 30—$30; Plan 40—$40 office visit copayTier 2: Plan 10—$35; Plan 20—$35; Plan 30—$45; Plan 40—$55 office visit copay
POS: Covered on Tier 1 only (See HMO entry above)PPO: (All) Routine preventive exams only through
age 16;
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InfertilityStandard & ValueHMO and EOA, Options HMO & Options EOA: 50% copay - includes professional services,
inpatient/outpatient care, treatment by injection/prescriptiondrugs & artificial insemination. GIFT, ZIFT, IVF, IFT notincluded
POS: Covered as outlined above on Tier 1 only. GIFT, ZIFT, IVF &IFT not included on either Open Access or POS. Artificialinsemination not covered on POS
PPO Standard & Value, Value HSA 1500, 2500, 3500 & 4500, Standard HSA 2000, 3000 & 4000: Applicable coinsurance applies. Calendar year deductible—
$500; Lifetime max: $2000
Options PPO 250500, 1500, 1750,3000 HSA & 4000 HSA: Applicable coinsurance applies. Calendar year deductible—
$500; Lifetime max: $2000
Speech TherapyHMO: Office visit copay—provided as long as
significant improvement is expected
Options EOA: Office visit copay—maximum 12 visits per year (Tier 1 & Tier 2 combined)
Open Access& POS: 100%—as long as significant improvement
expected (Tier 1)
PPO: Applicable coinsurance applies/max. 12 visits per year (combined for PPO & out-of-network)— outpatient only
Are Hearing Aids covered?No
All PPO Plans: GIFT, ZIFT, artificial insemination, IVF & IFT not covered
Options HMO 100% after officevisit copay—periodichealth evaluation only
100% birth throughage 2. 100% after office
visit copay age 3-17
100% after office visit copay
HMO:100% (no copay)
Salud con Health Net plan design varies depending onwhether the Los Angeles, Orange and Ventura Countyprovider network or the Mexico provider network is utilizedby the employee and dependents. Therefore, the benefitinformation cannot be outlined on this page. Please call yourWord & Brown sales representative for details.
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DIABETIC BENEFITS
These services may change at any time without notice. Please contact your Word & Brown representative for specific inquiries on listed services
76
Are the following items covered under the Prescription Drug Benefit or the Durable MedicalEquipment Benefit of the member’s selected plan design?
SELF-INJECTABLE DRUG BENEFITS
DISCOUNTS, AWARDS & OTHER VALUE-ADDED BENEFITS
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Insulin
Needles & Syringes
Glucose Monitor
Chem-Strips and/or Testing Agents
Insulin Pump
Insulin Pump Supplies
SELF-INJECTABLE DRUG BENEFITS
Are self-injectable drugs(other than insulin)covered under the
Prescription Drug Benefitor Medical Benefit?
Is pre-authorizationrequired?
Must self-injectables(other than insulin)
be purchased via thecarrier-contracted
mail order Rx vendor?
For the most up-to-date information onHealth Net's programs, go to
www.healthnet.com
Health Net
Health Net
Prescription Drug Benefit
Prescription Drug Benefit
Prescription Drug or Durable Medical Equipment Benefit depending on brand
Prescription Drug Benefit
Durable Medical Equipment Benefit
Durable Medical Equipment Benefit
Medical Benefit
Medical Benefit
Medical Benefit
Yes
Yes
Yes
No—doctor'scontracted vendor
HMO tier: doctor’scontracted vendor;
PPO tier: pre-cert. applies,carrier-contracted vendor
is optional
Pre-cert. applies, carrier-contracted vendor
is optional
HMO plans:
POS plans:
PPO plans:
Health Net
Health Net
Copayments for self-injectables go towards OOP max. on all plans
77
PPO Counties
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Plan may not be available in all zip codes within county. Check with your Word & Brown rep to confirm if coverage is available for your group location.
Colusa
Calaveras Marin
Monterey
Sacra- mento
Alameda
Alpine Amador
Butte
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Mariposa
Mendocino
Merced
Modoc
Mono
Napa
Nevada
Orange
Placer
Plumas
Riverside
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis
Obispo
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sut- ter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
Member Support,Customer Service,Commissions
Adds/Terms
Claims
Allied National800-825-7531
Fax 816-221-4638
Allied National-Global CareEDI# 07689PO Box 247Alpharetta, GA 30009-0247
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How often can members change their Primary Care Physician (PCP)?
Can family members each choose a PCP from a differentIPA/Medical Group?
Does carrier allow an OB/GYN to be Primary Care Physician?
Self-referral available?
Express referral available?
Is Workers' Comp required oncorporate officers, partners andsole proprietors?:
Is on-the-job covered for corporate officers, partners and sole proprietors?:
Is there a premiumadjustment for 24 hour coverage?:
LIFE
DENTAL
VISION
INFERTILITY
CHIROPRACTIC
ACUPUNCTURE
MASSAGE THERAPY
PRODUCTS OFFERED
OPTIONAL BENEFITS
GROUP SIZE
PROVIDER INFORMATION
PPO
78
CONSUMER-DIRECTED HEALTHCARE
HSA-CompatiblePPO
HRA-CompatiblePPO
MRP-CompatiblePPO
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ALTERNATIVE DISCIPLINES
Kern & Santa Barbara Counties:Foundation for Medical Carewww.cfmcnet.org
All other counties: Interplanwww.interplanhealth.com
Mexico: SIMNSAHospital Santa Margarita San Luis Rio
No
No
Referrals not required
Referrals not required
Available
N/A
N/A
N/A
Covered with limits
Covered with limits
Covered with limits
HealthEdge Cost Saver
N/A
No
Yes Yes
24 HOUR COVERAGE
SPECIALIST REFERRALS
PCP not required
SELECTION
NETWORKS
PCP not required
PCP not required
Plans administered by Allied National, underwritten by American Alternative Insurance Corporation (A+ Rated)
and reinsured by Munich-RE America Corporation.
HealthEdge
HealthEdge
HealthEdge
GROUP Can be written with another SIZE carrier's PPO or indemnity plan?
Employees
Dependents
Employees
Dependents
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
Does carrier underwrite and ratecarve out groups according to AB1672 guidelines?
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
ENROLLMENT GROUP SIZE
Employees
For Dependents
% of Total Cost:
PLAN ELIGIBILITY REQUIREMENTS
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Min. # of employees
Max. # of employees
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
AFTERINITIAL ISSUE
CARVE OUTS*
WRAP* REQUIREMENTS
*Indicates flexibility in being offered with products of another carrier.
GROUP Can be written with another SIZE carrier's HMO, POS or EPO?
SPECIAL CONSIDERATIONS
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COVERAGE RESTRICTIONS
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Are employees covered if traveling out of USA?
Is coverage available for out-of-state employees?
Max. % of employees residing out-of-stateallowed
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Yes—must work exclusively for employer
Yes—must work exclusively for employer
Yes—limited to 30 days
Yes
50% when employees are in: CO, GA, IA, IL, IN, KS, MO, NE, NV, OH, OK, PA, TN & TX. 25% in all other states
100%
N/A
2+
2+ Cost Saver only
2+ Cost Saver only
25%
N/A
N/A
75%
N/A
2+
2 2
N/A N/A
Yes—participation based on included classes only
Yes
Yes
2
Yes
1. No medical underwriting is required
2. No well baby benefit coverage is included
3. Multiple locations need home office approval—contact yourWord & Brown representative
HealthEdge
HealthEdge
HealthEdge
MEDICAL UNDERWRITING REQUIREMENTS
Current Employees
TimelyAdd-ons
Group Size
Composite Rates
Rate Guarantee*
Apply Trend Factor?
Use Employee Zips?
ENROLLMENT INFORMATION & REQUIREMENTS
Carrier's Effective Date
Premium Amount Required for 15th?
Employee Waiting Periods Available
Applications must be dated within:
Spouse/Domestic Partner Employees - 1 application or 2?
Employee Waiver Cards Required at enrollment?
Is Over Age Dependent Verification Required?
Are Telephone Interviews done by Underwriting?
Must Brokers Carry Errors & Omissions Insurance?
Does Carrier Offer Open Enrollment?
DOCUMENTATION & PAYMENT INFORMATION
DE-6 statement required?
Payroll Records OK if no DE6?
Is a Prior Booklet required?
Is Prior Billing required?
Must submit check with
initial application?
Check Made payable to:
FEES
Enrollment Fee Amount
Type of Enrollment Fee
Monthly Administration Fee
DEDUCTIBLE CREDITPrior carrier deductible credit given?
4th quarter deductiblecarry-over credit given?
GROUP SIZE
RATING INFORMATION
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Instant quotes online: www.wordandbrown.comQuotes in 24 hours: (800) 869-6989
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†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”
ITEMS REVIEWED IN RAF CALCULATION
Medical Conditions
Years in Business
# of Pregnancies
Virgin Group
Type of Industry
Percent of Owners
Group Size
% of COBRA Insureds
% of Family Related
Participation
Plan(s) Requested
24 HR Coverage Req'd
Employer Contribution
Bankruptcy
Gender Mix
Any day of the month
Yes—submit one month’s premium
Minimum: 0 days; Max: 180 days
On or before requested effective date
2 apps—husband & wife groups—not guaranteed issue
Yes
No—coverage ends at age 24 regardless of student status
Yes
No
Yes—at anniversary
N/A
N/A
Call rep
No
No
No
No
Yes
No
Yes
No
No
Yes
No
No
Yes
No
No
Yes—in same calendar year
No
Non-Medical
Yes
Yes
No
Yes
Yes
Allied National
Non-Medical
2-100; over 100 livesrequires approval
For groups of 15+
12 Months
Yes
No
2+
HealthEdge
HealthEdge
SPECIAL CONCERNS*
Infertility
PREVENTIVE BENEFITS*
PRESCRIPTIONS
Adult Physical Child Physical Annual OB/GYNPLAN TYPE Exam Exam/Immunizations Visit/Pap Smear Mammography
GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive ageneric equivalent rather than a brand namedrug?
If doctor writes “dispense as written” on prescription, is brand name available at thebrand copay amount?
* Information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?
Are non-formulary drugs available?
MAIL ORDER - 90 DAY SUPPLY
Are oral contraceptives covered?
* Unless otherwise noted, information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
BENEFIT INFORMATION SHOWN ON THIS PAGE IS A BRIEF SUMMARY. LIMITATIONS AND EXCLUSIONS APPLY. PLEASE REFER TO CERTIFICATE BOOK, EVIDENCE OF COVERAGE OR CALL REP FOR DETAILS.
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Hearing treatment
Are Hearing Aids covered?
Speech therapy
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Infertility
Physicians diagnosis or treatment of infertility:$500 lifetime benefit
Cost Saver N/A Subject to office visit benefit
10 visits per calendar year
10 visits per calendar year
No
Generic offered. If member chooses brand they pay thecost difference between generic and brand
Formulary only
Yes
Same
2X copay
Yes
HealthEdge
HealthEdge
HealthEdge
DIABETIC BENEFITS
These services may change at any time without notice. Please contact your Word & Brown rep for specific inquiries on listed services
82
Are the following items covered under the Prescription Drug Benefit or the Durable MedicalEquipment Benefit of the member’s selected plan design?
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Insulin
Needles & Syringes
Glucose Monitor
Chem-Strips and/or Testing Agents
Insulin Pump
Insulin Pump Supplies
SELF-INJECTABLE DRUG BENEFITS
Are self-injectable drugs(other than insulin)covered under the
Prescription Drug Benefitor Medical Benefit?
Is pre-authorizationrequired?
Must self-injectables(other than insulin)
be purchased via thecarrier-contracted
mail order Rx vendor?
Prescription Drug Benefit
Prescription Drug Benefit
Durable Medical Equipment Benefit
Prescription Drug Benefit
Durable Medical Equipment Benefit
Durable Medical Equipment Benefit
If available through pharmacy, covered
under Rx Benefit
Yes NoFormulary Plans Only
HealthEdge
HealthEdge
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Colusa
CalaverasMarin
Monterey
Sacra-mento
Alameda
AlpineAmador
Butte
ContraCosta
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Mariposa
Mendocino
Merced
Modoc
Mono
Napa
Nevada
Orange
Placer
Plumas
Riverside
SanBenito
San Bernardino
San Diego
San Francisco
SanJoaquin
SanLuis
Obispo
SanMateo
SantaBarbara
Santa Clara
SantaCruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sut-ter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba �PPO Only Counties
HMO & PPO CountiesPlan may not be available in all zip codes within county. Check with your Word & Brown representative to confirm if coverage is available for your group location.
Billing
Health Net 800-361-3366Western Health Advantage 888-563-2250Kaiser Permanente
English 800-464-4000Spanish 800-788-0616
HSA California ® Customer Service 866-251-4718
HSA CaliforniaBenefit Administrators721 South Parker, Ste. 200Orange, CA 92868
Broker Services &Commissions
Member Support
714-542-6992 - Ext. 4390
The following HMOs have an “Excellent” rating from the NCQA
for their commercial products:
Kaiser Permanente (HMO)Western Health Advantage (HMO)
Adds/Terms Fax 866-251-4724
Administrator
HSA CaliforniaBenefit Administrators721 South Parker, Ste. 200Orange, CA 92868
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Is Workers' Comp required oncorporate officers, partners and sole proprietors?
Is on-the-job covered for corporate officers, partners and sole proprietors?
Is there a premium adjustmentfor 24 hour coverage?
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How often can members change their Primary Care Physician (PCP)?
Can family members eachchoose a PCP from a differentIPA/Medical Group?
Does carrier allow an OB/GYNto be Primary Care Physician?
Refer to summary on pages 88-89
Refer to summary on pages 88-89
Refer to summary on pages 88-89
Maximum Choice For EmployeesEach employee's health care needs are different. The HSA Californiaprogram provides employees the maximum choice in meeting thoseneeds with these health plans—all within one program:
HMO
Available
Buy-up
Discount or Buy-up
Not Available
Varies by HCSP
2-50
Networks vary according toHealth Care Service Plan (HCSP)
No
No
Yes
PLEASE NOTE: Not all health plans are available in all areas
PRODUCTS OFFERED
MULTI OPTION (MIX AND MATCH)
OPTIONAL BENEFITS
GROUP SIZE
PROVIDER INFORMATION
HSA California
HSA California®
HSACalifornia
LIFE
DENTAL
VISION
INFERTILITY
MASSAGE THERAPY
Health Net PPOKaiser Permanente HMOWestern Health Advantage HMO
24 HOUR COVERAGE
SPECIALIST REFERRALS
Self-referral available?
Express referral available?Varies by Health Care Service Plan (See summary on pages 88-89)
Varies by Health Care Service Plan (See summary on pages 88-89)
HMO 1800HMO 2200HMO 2600
HMO 2800B
PPOPPO 2500PPO 3500PPO 4500
SELECTION
NETWORKS
ALTERNATIVE DISCIPLINES
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Employees
Dependents
Employees
Dependents
COVERAGE RESTRICTIONS
Are Commission employees allowed?
Are 1099 employees allowed?
Are employees covered if traveling out of USA?
Is coverage available for out-of-state employees?
Max. % of employees residing out-of-state allowed
*100%
N/A N/A
2-2 3-50
Yes—if on DE-6 and showing at least minimum wages and withholdings
No
Only for emergency benefits
Yes*— PPO 2500, PPO 3500, PPO 4500
* Except for employees in Hawaii
49% (Main office must be located in California)
2-50
50% of lowest cost plan
N/A
N/A
2 250* N/A
2-50 No
2-50 No
*100% ◆70%
N/A N/A
◆ Those covered by another plan are NOT considered eligible in calculating participation. In order to NOT be considered eligible, the other coverage must be a group plan, Champus, Medicare or Medi-Cal
* No 1 Life groups allowed† Employer contribution is 100% of employee lowest cost HMO plan
or more
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Employees
For Dependents
% of Total Cost:
PLAN ELIGIBILITY REQUIREMENTS
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE CARVE OUTS*
WRAP* REQUIREMENTS
*Indicates flexibility in being offered with products of another carrier.
GROUP Can be written with another SIZE carrier's HMO, POS or EPO?
GROUP Can be written with another SIZE carrier's HMO, POS or EPO?
SPECIAL CONSIDERATIONS
100% of employees not coveredby group insurance and 70% ofall employees regardless ofother coverage
†
HSA California®
HSA California
HSA California
HSA California
AFTERINITIAL ISSUE
ENROLLMENT GROUP SIZE
Min. # of employeesMax. # of employees
No
No
Yes—coverage available for non-union only. Group must submit union billing to underwriting for verification that all other employees have union coverage
2
Yes
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
Does carrier underwrite and ratecarve out groups according to AB1672 guidelines?
* Over 50 only if group is SB 578 qualified. (If group has less than 50 employees, for 50% of the preceding calendar quarter or preceding calendar year) M
ED
IC
AL
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MEDICAL UNDERWRITING REQUIREMENTS
Current Employees
TimelyAdd-ons
ENROLLMENT INFORMATION & REQUIREMENTS
Carrier's Effective Date
Premium Amount Required for 15th?
Employee Waiting Periods Available
Applications must be dated within:
Spouse/Domestic Partner Employees - 1 application or 2?
Employee Waiver Cards Required at enrollment?
Is Over Age Dependent Verification Required?
Are Telephone Interviews done by Underwriting?
Must Brokers Carry Errors & Omissions Insurance?
Does Carrier Offer Open Enrollment?
DOCUMENTATION & PAYMENT INFORMATION
DE-6 statement required?
Payroll Records OK if no DE6?
Is a Prior Booklet required?
Is Prior Billing required?
Must submit check with
initial application?
Check Made payable to:
FEES
Enrollment Fee Amount
Type of Enrollment Fee
Monthly Billing Fee
DEDUCTIBLE CREDITPrior carrier deductible credit given?
4th quarter deductiblecarry-over credit given?
GROUP SIZE
ITEMS REVIEWED IN RAF CALCULATION
RATING INFORMATION
Instant quotes online: www.wordandbrown.comQuotes in 24 hours: (800) 869-6989
†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”
ITEMS REVIEWED IN RAF CALCULATION
Medical Conditions
Years in Business
# of Pregnancies
Virgin Group
Type of Industry
Percent of Owners
Group Size
% of COBRA Insureds
% of Family Related
Participation
Plan(s) Requested
24 HR Coverage Req'd
Employer Contribution
Bankruptcy
Gender Mix
1st of the month only
N/A
Min: 30 Max: 365
60 days
Use either 1 or 2 applications
Yes
Yes
Yes
Yes—60 days prior to anniversary
Yes
Call representative
Yes*
Yes*
Yes
HSA California
None
N/A
1-8 9-20 21+$20 $25 $30
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
*Only if any employees take PPO Dental
2-4: 1.105-50: 1.0015-50: 1.00**Groups may qualify for a .90. See quote for details.
N/A
12 Months
No
HMO: YesPPO: Yes
2-14 15-50
Employee Master AppMedical (Employer
Questionnaire Questions)
Non Non Medical Medical
HSA California®
HSA California
(if enrolling separately, 2 applications required)
HMO: N/APPO: Yes*
No
RAF Increments (2-50 lives)
Composite Rates
Rate Guarantee††
Apply Trend Factor?
Use Employee Zips?
Yes—full time student or disabled dependent information requested if child over age.
*This does NOT include credit for the RX deductible
GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive ageneric equivalent rather than a brand namedrug?
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Refer to summary on page 88
HMO 1800
SPECIAL CONCERNS*
Hearing treatment
PREVENTIVE BENEFITS1,2
PRESCRIPTIONS
Adult Physical Child Physical Annual OB/GYNPLAN TYPE Exam Exam/Immunizations Visit/Pap Smear Mammography
FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?
HMO: Routine hearing screening in PCP's office only—office visit copay applies
PPO: Covers ear screenings to determine the needfor audiograms for dependent children throughage 18 only
* Unless otherwise noted, information shown in this section reflects in-networkbenefits.
1 Information shown in this section reflects in-network benefits.2 Not subject to deductible
HSA California®
HSA California
HSA California
No Charge No Charge No Charge No Charge
HMO 2200 $20 copay $10 copay $20 copay $10 copay
HMO 2600 $30 copay $10 copay $30 copay $10 copay
HMO 2800B $40 copay No Charge No Charge No Charge
PPO 2500 $25 copay $25 copay $25 copay $25 copay
PPO 3500 $35 copay $35 copay $35 copay $35 copay
PPO 4500 $45 copay $45 copay $45 copay $45 copay
InfertilityNot Covered
Speech therapyHMO: Outpatient covered if HCSP determines there
will be significant improvement in 60 days—office visit copay applies
PPO: Covered for certain conditions (see Evidence ofCoverage or call representative)—subject todeductible and coinsurance
Are Hearing Aids covered?No
HSA California now offers EPIC Hearing Service Plan(HSP) to all HSA California members at no additionalcost
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If doctor writes “dispense as written” on prescription, is brand name available at the brandcopay amount?
Refer to summary on page 88
Refer to summary on page 88
Refer to summary on page 88
$20 generic/$40 brand
Refer to summary on page 88
Are non-formulary drugs available?
MAIL ORDER - 90 DAY SUPPLY
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PROVIDER INFORMATION
PRESCRIPTIONS
Can member self-referto an OB/GYN?
Allows OB/GYN to bePrimary Care Physician?
If generic available, anddoctor has not indicated“dispense as written,”will member receive ageneric equivalent ratherthan a name brand drug?
If doctor writes “dispense as written” on prescription, is brand name available at the brand copay?
Does health plan use Rx formulary?
If medically necessary,are non-formulary drugs covered?
Mail order
BENEFIT SUMMARY
*generic copay/brand namecopay/non-formulary copay if applicable
NOTE: Each HCSP HMO has their own PCP change approval process
FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR WORD & BROWN REPRESENTATIVE
What is copay for covered non-formulary drugs?
HSA California®
HSA California
HSA California
Kaiser Permanente HMO
HMO 2200$10 Generic$20 BrandHMO 2600
$10 Generic$30 Brand
Anytime
Yes—but only PlanPhysicians
Yes—referrals comedirectly from PCP; no other approval is needed
Anytime
Yes
Yes
Yes
Yes
No
Yes
How often can familymembers change theirPrimary Care Physician?(PCP)
Can family memberseach choose a PCPfrom a differentIPA/Medical Group?
Do plans have these types of programs to speed the specialist referral process in network: Self referral?Express referral?
Is there an Out-of-Network benefit?
WELL WOMAN BENEFITS
HMO 2200$20 Generic$40 BrandHMO 2600
$20 Generic$60 Brand
Western HealthAdvantage HMO
Once a month,effective for the following month
Yes
Yes—Advantage ReferralProgram allows PCP to refera member to a specialist who participates in WHA’sAdvantage Referral program
Yes
No In a PPO, you do not have tochoose a PCP
Yes—or you mustpay the brand copayplus the differencein cost between brand name &generic equivalent
Yes
No
Yes
HMO 1800No Charge
HMO 2800B$20 Generic$60 Brand
$100 Non-Formulary
HMO 1800No Charge
HMO 2800B$50 Copay
Yes
Health NetPPO
Anytime—in a PPO,you do not have tochoose a PCP
Yes—each familymember can maketheir own physicianchoice
Yes—in a PPO, youdon't have to gothrough a specialistreferral process
In a PPO, youchoose anyOB/GYNanytime
Yes—or you mustpay the brand copayplus the differencebetween the cost of the brand name & generic
Yes
Yes
Yes
Participating Pharmacy$30 Generic$60 Brand
$100 Non-Formulary
Non-ParticipatingPharmacy
Not Covered
Participating Pharmacy$50 Non-Formulary
Non-Participating Pharmacy50%
Prior authorization may berequired for certain medications
Yes
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FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR WORD & BROWN REPRESENTATIVE
Kaiser Permanente HMO
Are self-injectabledrugs (other thaninsulin) covered underthe Prescription Drugbenefit or MedicalBenefit?
Are the following items covered under the Prescription Drug Benefit or the Durable MedicalEquipment Benefit of themember’s selected plan design?
Insulin
Is pre-authorizationrequired?
Must self-injectables(other than insulin) bepurchased via the carrier-contracted mailorder RX vendor?
Needles & Syringes
Glucose Monitor
Chem-Strips and/orTesting Agents
Insulin Pump
Insulin Pump Supplies
DIABETIC BENEFITS HSA California®
SELF-INJECTABLE DRUG BENEFITS
PrescriptionDrug Benefit
PrescriptionDrug Benefit
Durable MedicalEquipment ratherthan PrescriptionDrug BenefitHMO 2200 : 75%HMO 2600: 70%
PrescriptionDrug Benefit
Durable MedicalEquipment Benefit
Durable MedicalEquipment Benefit
PrescriptionDrug Benefit
Must be prescribedby Plan physician, inaccord with our drugformulary guidelines
Must use planpharmacies(including affiliated pharmacies)
PrescriptionDrug Benefit
PrescriptionDrug Benefit
Prescription Drug Benefit (preferredmonitors only) All other monitors covered as Durable Medical Equipment PPO 2500 & 3500:In-Network: 70% Out-of-Network: 50% Up to max $2,000PPO 4500:In-Network: 60% Out-of-Network: 40% Up to max $1,000
PrescriptionDrug Benefit
Durable Medical Equipment PPO 2500 & 3500:In-Network: 70% Out-of-Network: 50% Up to max $2,000PPO 4500:In-Network: 60% Out-of-Network: 40% Up to max $1,000
Durable Medical Equipment PPO 2500 & 3500:In-Network: 70% Out-of-Network: 50% Up to max $2,000PPO 4500:In-Network: 60% Out-of-Network: 40% Up to max $1,000
Medical Benefit
Yes—required through Pharmacy
May use mail order vendor or contractedpharmacy vendor
Health NetPPO
Western HealthAdvantage HMO
PrescriptionDrug Benefit
PrescriptionDrug Benefit
Durable MedicalEquipment ratherthan PrescriptionDrug BenefitHMO 1800: 100%HMO 2800B: 80%
Durable MedicalEquipment Benefit
Durable MedicalEquipment Benefit:HMO 1800: 100%HMO 2800B: 80%
Durable MedicalEquipment Benefit:HMO 1800: 100%HMO 2800B: 80%
Medical Benefit
Yes
Depends on Medical Group
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KEY TO HEALTH CARE SERVICE PLANSOFFERING LISTED PROGRAM
HN Health Net
KP Kaiser Permanente
WH Western Health Advantage
* All HSA California ® medical members are eligible for discounts on eye exams, lenses, frames, andcontacts through the Vision One Eye Care Program administered by Cole Managed Vision/EyeMedVision Care.
1Discounts of frames and lenses available through Kaiser Permanente facilities.
2 Discounts on vitamins and herbal supplements available through the “Affinity Program” which linksKaiser Permanente members to Healthy Roads
3Member must use a Kaiser Permanente weight loss program.
Which health care plans offer these discounts, awards and other value-added benefits?
Eyewear & lenses discount......................................................................................................................................BS, KP 1
Health Club Membership or fitness equipment/sporting goods discount……. ............................................HN, KP, WH
Health Literature, telephone tapes and/or videos (no charge) ..............................................................................HN, KP
available in the following languages: Spanish
Home childproofing products discount ..........................................................................................................................HN
Infant car seat:
discount ............................................................................................................................................................HN
awarded upon prenatal class completion ........................................................................................................HN
Nurses 24 Hour Hotline ............................................................................................................................................HN, KP
Vitamins and/or herbal supplements discount ......................................................................................................HN, KP 2
Weight control program discount ..........................................................................................................................HN, KP 3
DISCOUNTS, AWARDS & OTHER VALUE-ADDED BENEFITS (cont.)
BENEFIT SUMMARY
HSA California®
Colusa
Calaveras Marin
Monterey
Sacra- mento
Alameda
Alpine Amador
Butte
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Mariposa
Mendocino
Merced
Modoc
Mono
Napa
Nevada
Orange
Placer
Plumas
Riverside
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis
Obispo
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sut- ter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
91
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Plan may not be available in all zip codes within county. Check with your Word & Brown representative to confirm if coverage is available for your group location.
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AdministratorSee address under map
Emergency Claims Addresses
Southern CaliforniaKaiser Foundation Health Plan, Inc.Claims DepartmentP.O. Box 7004Downey, CA 90242-7004
Northern CaliforniaKaiser Foundation Health Plan, Inc.Claims DepartmentP.O. Box 12923Oakland, CA 94604-2923
proud participant in:
Member Support 800-464-4000
Member Claims 800-390-3510
Release Authorization(for HIPAA Release Forms) Fax 858-614-3345
Customer Service 800-790-4661
Spanish Member Support 800-788-0616
Commissions 800-440-2323
Adds/Terms No. Cal. Fax 858-614-3344So. Cal. Fax 858-614-3345
Kaiser PermanenteHealth Plan393 E. Walnut St.LSRS-4Pasadena, CA 91103
NOTE: The Kaiser Permanente material is included in this reference guide for your convenience. Word & Brown does not have a contract. Please submit your Kaiser Permanente business direct.
All Plan Types
Claims
ALTERNATIVE DISCIPLINES
PRODUCTS OFFERED
OPTIONAL BENEFITS
GROUP SIZE
PROVIDER INFORMATION
92
CONSUMER DIRECTED HEALTHCARE
HSA-Compatible PPO HRA-CompatiblePPO
MRP-CompatiblePPO
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ALTERNATIVE DISCIPLINES
How often can members changetheir Primary Care Physician (PCP)?
Can family members eachchoose a PCP from a differentIPA/Medical Group?
Does carrier allow an OB/GYNto be Primary Care Physician?
DUAL OR MULTI OPTION Boxes containing a “●” indicate that these coordinate plans offered by this carrier canbe written together to create a dual or multi option package. Blank boxes indicatewhich plans cannot be written together.
Kaiser Permanente
Is Workers' Comp required oncorporate officers, partnersand sole proprietors?
Is on-the-job covered for corporate officers, partnersand sole proprietors?
OB/GYN: Yes
Other Specialties: Yes—to certain specialties. Self-refer specialties listvaries by geographical region
Not Available
Available
HMO: Benefits vary by planPOS: Exam included on Tier 1 (HMO) only
HMO: Benefits vary by plan*POS: Optional rider*
Optional Rider
Not Available
Not Available
2-50
Kaiser Permanente—HMO &POS (Tier 1 only)
Private Healthcare Systems (PHCS)
No
No
Yes
PRODUCTS OFFERED
OPTIONAL BENEFITS
GROUP SIZE
PROVIDER INFORMATION
CaliforniaChoice
Kaiser Permanente
KaiserPermanente
HMO/EPO
LIFE
DENTAL
VISION
INFERTILITY
CHIROPRACTIC
ACUPUNCTURE
MASSAGE THERAPY
*See “Special Concerns” Section on page 95 for details.
1 Southern California/Northern California2 Available only through the multiple plan offering. A prospect that chooses this plan must pair it
with a copayment plan (see chart below).3 See Special Considerations on page 93 for important requirements for PPO.4 If employer elects the POS plan, employees must enroll in either the HMO Plan or 3-tier POS
$5 Copayment Plan S/N 1
$15 Copayment Plan S/N 1
$20 Copayment Plan S/N 1
$30 Copayment Plan S/N 1
$50 Copayment Plan S/N 1
$30/$1000 Deductible Plan S/N 1
$30/$1500 Deductible Plan 2
Self-referral available?
24 HOUR COVERAGE
SPECIALIST REFERRALS
Plan 5*
Plan 15*
Plan 20*
Plan 30*
Plan 5 Plan 15 Plan 20 Plan 30
$35 POS Plan
$30/$1000
★
$30/$1500
Express referral available?Yes—referral direct from physician
Kaiser Permanente
Is there a premium adjustmentfor 24 hour coverage?
Anytime—change is effectiveimmediately
Yes:HMO: From Kaiser PermanentePhysiciansPOS: From Private HealthcareSystems (PHCS)
Yes
★
* These HMO plans cannot be written together as a dual option package unless group creates a management carve-out. Then, one HMO plan may be selected by employer for all management and another HMO plan for all non-management.If employer elects the POS plan, employees must enroll in either the HMO Plan or 3-tier POS.
● Enhanced Choice multi-plan offering with 8 HMO plan designs available to groups of 3+ enrolling employees. Minimum employer contribution is 50% of the employee-only rate for the under-30 age band based on the lowest premium plan selected.
2 Available only through the multiple plan offering. Must pair it with a copayment plan.† PPO must be offered with one or more copayment plans. If offered with two or more plans, standard MPO rules apply.
70% must be enrolled under 2 HMO/DHMO plans and no more than 30% of eligibles can be on the PPO.
SELECTION
NETWORKSPOS
$35 POS Plan4
$30/$2700 Deductible Plan with HSA$0/$2700 Deductible Plan with HSA$0/$1500 Deductible Plan with HSA
$40/$2,500 Deductible Plan with HSA$0/$2,200 HSA Comp plan
$30/$2,500 Plan with HRA3
$30/$1,500 Plan with HRA3 N/A
$30/1500 Deduct. Plan2
Plan 50*
Plan 50
●
●
●
●
●
●
●
●●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
● ● ● ● ●●
ALTERNATIVE DISCIPLINES
PPO$40/$1000 PPO Plan3
PPO:$40/$1000$30/$2500$30/$1500
●†
●†
●†
●†
●†
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Employees
Dependents
Employees
Dependents
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
Does carrier underwrite and ratecarve out groups according to AB1672 guidelines?
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
COVERAGE RESTRICTIONS
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Are employees covered if traveling out of USA?
Is coverage available for out-of-state employees?
Max. % of employees residing out-of-state allowed
Employees
For Dependents
% of Total Cost:
PLAN ELIGIBILITY REQUIREMENTS
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
AFTERINITIAL ISSUE
CARVE OUTS*
WRAP* REQUIREMENTS
*Indicates flexibility in being offered with products of another carrier.
GROUP Can be written with another SIZE carrier's PPO or indemnity plan?
GROUP Can be written with another SIZE carrier's HMO, POS or EPO?
SPECIAL CONSIDERATIONS
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1* 1*
50 50
50%
N/A
N/A
◆◆ 70% on any group plan
N/A
2-50
2-50HMO & POS
*In California, a minimum of 1 must enroll. At least 70% ofgroup's eligible employee population should be covered byeither a group health plan or Medicare.
Employees are eligible for coverage if they live or work withinthe Kaiser Permanente service area zip codes.
3 PPO cannot be sold as a standalone plan. PPO must beoffered with one or more copayment plans. PPO may not besold along with Chiropractic rider with any DeltaCare HMOplans.
For PPO+2 or more copay plans standard MPO rules apply.
*See special considerations below
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan (i.e. through their employer or their spouse's employer) or Medicare
Yes—must be a full time employee, have an employer/employee relationship and have workers' comp coverage. Need to submit DE-6 for proof
No
Yes—for emergencies only
Yes
51% of eligible employees need to reside in CA
Yes
Yes
Non-union only
2
Yes
2-50 Yes—for HMO and POS plans only. 70% of group’s eligible employee populationshould be covered by a group health careplan. If a group chooses a PPO, they cannothave another carrier written alongside.
2-50 Yes—for HMO and POS plans only. 70% of group’s eligible employee populationshould be covered by a group health careplan. If a group chooses a PPO, they cannothave another carrier written alongside.
Kaiser Permanente
Kaiser Permanente
Kaiser Permanente
ENROLLMENT GROUP SIZE
Min. # of employees
Max. # of employees
2-50PPO+1 or PPO+2copayment plans
At least 70% of members must beenrolled under HMO/DHMO & up to 30%of members can be enrolled in the PPO
plan (combined PPO and POS members)
N/A
◆◆ 70% on any group plan
N/A
At least 70% of members must beenrolled under HMO/DHMO & up to 30%of members can be enrolled in the PPO
plan (combined PPO and POS members)
N/A
NonMedical
Non Medical
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MEDICAL UNDERWRITING REQUIREMENTS
Current Employees
TimelyAdd-ons
ENROLLMENT INFORMATION & REQUIREMENTS
DOCUMENTATION & PAYMENT INFORMATION
DE-6 statement required?
Payroll Records OK if no DE6?
Is a Prior Booklet required?
Is Prior Billing required?
Must submit check with
initial application?
Check Made payable to:
FEES
Enrollment Fee Amount
Type of Enrollment Fee
Monthly Administration Fee
DEDUCTIBLE CREDITPrior carrier deductible credit given?
4th quarter deductiblecarry-over credit given?
GROUP SIZE
ITEMS REVIEWED IN RAF CALCULATION
RATING INFORMATION
94
Instant quotes online: www.wordandbrown.comQuotes in 24 hours: (800) 869-6989
ITEMS REVIEWED IN RAF CALCULATION
Medical Conditions
Years in Business
# of Pregnancies
Virgin Group
Type of Industry
Percent of Owners
Group Size
% of COBRA Insureds
% of Family Related
Participation
Plan(s) Requested
24 HR Coverage Req'd
Employer Contribution
Bankruptcy
Gender Mix
N/A
N/A
N/A
1st of each month
N/A
Min: 1st of the month following date of hire
Max: 1st of the month following 2 years of employment
30 days
2 separate applications
Yes
Yes
No
Yes
Yes—30 days prior to renewal date
2-5
NonMedical
Non Medical
Kaiser Permanente
Kaiser Permanente
N/A
N/A
Carrier's Effective Date
Premium Amount Required for 15th?
Employee Waiting Periods Available
Applications must be dated within:
Spouse/Domestic Partner Employees - 1 application or 2?
Employee Waiver Cards Required at enrollment?
Is Over Age Dependent Verification Required?
Are Telephone Interviews done by Underwriting?
Must Brokers Carry Errors & Omissions Insurance?
Does Carrier Offer Open Enrollment?
6-15Yes
No
Yes
No
No
No
Yes
No
No
No
No
No
No
No
No
DOCUMENTATION & PAYMENT INFORMATION
DE-6 statement required?
Payroll Records OK if no DE6?
Is a Prior Booklet required?
Is Prior Billing required?
Must submit check with
initial application?
Check Made payable to:
Yes*
Yes†
No
No
No—but they do need a copy of checkKaiser Permanente
16-50
NonMedical
Non Medical
*Must also submit payroll records for employees hired after DE-6 filing†If company has not been in business for at least 50% of the previous calendar quarter/calendar year, Kaiser Permanente will recertify these groups at their one year anniversary
†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”
2-5 Automatic 1.106-15 Automatic 1.0016-50 Automatic .90
Not Available
12 Months
No
No—except when employer isout of service area butemployees reside within it.Call Kaiser Permanente formore details
RAF Increments (2-50 lives)
Composite Rates
Rate Guarantee††
Apply Trend Factor?
Use Employee Zips?
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SPECIAL CONCERNS*
Infertility
PREVENTIVE BENEFITS*
PRESCRIPTIONS
Adult Physical Child Physical Annual OB/GYNPLAN TYPE Exam Exam/Immunizations Visit/Pap Smear Mammography
GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive ageneric equivalent rather than a brand name drug?
* Information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?
Are non-formulary drugs available?
MAIL ORDER - 90 DAY SUPPLY
Are oral contraceptives covered?
* Unless otherwise noted, information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
BENEFIT INFORMATION SHOWN ON THIS PAGE IS A BRIEF SUMMARY. LIMITATIONS AND EXCLUSIONS APPLY. PLEASE REFER TO CERTIFICATE BOOK, EVIDENCE OF COVERAGE OR CALL REPRESENTATIVE FOR DETAILS.
95
Hearing treatment
Are Hearing Aids covered? ME
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HMO: Coverage includes medical examinations of theear and audiometric examination to measurehearing acuity.
POS: Exams covered on Tier 1 (HMO) only
HMO: Covered if deemed medically necessary byHealth Plan physician
POS: Limited coverage; please see Certificate Book or contact Health Plan representative
Copayment HMOs
POS
FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?
Are non-formulary drugs available?
MAIL ORDER - 100 DAY SUPPLY
Are oral contraceptives covered?
HMO: YesPOS: Yes
HMO: Yes—if deemed medically necessary by PlanPhysician
POS: Yes—$40 non-formulary copay applies. Select prescription medications are excluded from out-of-network coverage
HMO & POS: Yes—for 100 pills or 100 day supply;whichever comes first
Kaiser Permanente
Kaiser Permanente
Kaiser Permanente
100% after copay 100% after copayimmunizations: no charge
100% after copay 100% after copay
Deductible HMOs Copay-Ded. waived Copay-Ded. waived/immunizations: no charge
Copay-Ded. waived Copay-Ded. waived
* Information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
Covered on Tier 1(HMO) only:
100% after copay atHealth Plan facilities
Covered on Tier 1(HMO) only:
100% after copay at HealthPlan facilities
20% copay 20% copay
HMO: YesPOS: Yes
If doctor writes “dispense as written” on prescription, is brand name available at thebrand copay amount?
HMO: YesPOS: Yes—if brand name is on Health Plan
Formulary
$30 Copay Plan, $10/$1000 Ded. Plan, $20/$1000 Ded. Plan &the $30/$1000 Ded. Plan have a separate $250 brand namecalendar year deductible per member
HMO: YesPOS: Yes
HMO Plan 5 & 15: 50% for diagnosis and treatment of cause
of infertility. Please see EOC forexclusions and limitations.
HMO Plan 20 & 30: Not covered
POS: Limited coverage on HMO tier only;please see Certificate Booklet or callHealth Plan representative. No coverageon PPO or out-of-network tiers.
Speech therapy
No
DIABETIC BENEFITS
These services may change at any time without notice. Please contact your Word & Brown representative for specific inquiries on listed services
96
Are the following items covered under the Prescription Drug Benefit or the Durable MedicalEquipment Benefit of the member’s selected plan design?
SELF-INJECTABLE DRUG BENEFITS
DISCOUNTS, AWARDS & OTHER VALUE-ADDED BENEFITS
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Insulin
Needles & Syringes
Glucose Monitor
Chem-Strips and/or Testing Agents
Insulin Pump
Insulin Pump Supplies
SELF-INJECTABLE DRUG BENEFITS
Are self-injectable drugs(other than insulin)covered under the
Prescription Drug Benefitor Medical Benefit?
Is pre-authorizationrequired?
Must self-injectables(other than insulin)
be purchased via thecarrier-contracted
mail order Rx vendor?
Kaiser Permanente
Kaiser Permanente
Kaiser Permanente
Prescription Drug Benefit
Prescription Drug Benefit
Durable Medical Equipment Benefit
Prescription Drug Benefit
Durable Medical Equipment Benefit
Durable Medical Equipment Benefit
Prescription Drug Benefit
Prescription Drug Benefit
No—must be prescribedby a plan physician
No
Must use planpharmacies (includingaffiliated pharmacies)
No—levels of coveragemay differ
HMO plans:
POS plans:
Colusa
CalaverasMarin
Monterey
Sacra-mento
Alameda
AlpineAmador
Butte
ContraCosta
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Mariposa
Mendocino
Merced
Modoc
Mono
Napa
Nevada
Orange
Placer
Plumas
Riverside
SanBenito
San Bernardino
San Diego
San Francisco
SanJoaquin
SanLuis
Obispo
SanMateo
SantaBarbara
Santa Clara
SantaCruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sut-ter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
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Member SupportKaiser Permanente Choice SolutionCustomer Service Center 800-580-9626
Kaiser PermanenteEnglish 800-464-4000Spanish 800-788-0616
Renewal Changes Employer Fax 800-566-7803Employee Fax 800-566-8514
Commissions 800-542-4218, Ext. 4390
Adds/Terms Fax 800-566-8514
AdministratorCHOICE Administrators®
721 South ParkerSuite 200Orange, CA 92868
ClaimsKaiser PermanenteClaims800-464-4000
Plan may not be available in all zip codes within county. Check with your Word & Brown representative to confirm if coverage is available for your group location.�All Plan Types Available
HMO, POS, PPO & Indemnity
PPO & Indemnity Only
LIFE
DENTAL
VISION
INFERTILITY
CHIROPRACTIC
ACUPUNCTURE
MASSAGE THERAPY
PRODUCTS OFFERED
OPTIONAL BENEFITS
GROUP SIZE
PROVIDER INFORMATION
HMO/EPO PPO POS
98
CONSUMER-DIRECTED HEALTHCARE
HSA-CompatiblePPO
HRA-CompatiblePPO
MRP-CompatiblePPO
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ALTERNATIVE DISCIPLINES
Available
Available
Not Available
HMO: Benefits vary by planPOS/PPO/Indemnity: Benefits vary by plan
Not Available
Not Available
Not Available
HMO 10HMO 30
HMO 20/$1,000
N/A
30/$500PPO HSA 2200*
20/$1,00030/$1,500
INDEMNITYIndemnity
HDHP 1400*HDHP 2400*
N/A
Kaiser Permanente Choice Solution
Kaiser Permanente Choice Solution
2-50Is Workers' Comp required oncorporate officers, partners and sole proprietors?
Is on-the-job covered for corporate officers, partners and sole proprietors? Yes
Is there a premium adjustmentfor 24 hour coverage? No
Self-referral available?
How often can members change their Primary Care Physician (PCP)?
Can family members eachchoose a PCP from a differentIPA/Medical Group?Yes—HMO: From Kaiser Permanentephysicians
POS/PPO: From PHCS Network
Does carrier allow an OB/GYNto be Primary Care Physician?Yes
HMO/EPO
Kaiser Permanente
POS/PPOPrivate Healthcare Systems (PHCS)
Anytime—change is effectiveimmediately
No
24 HOUR COVERAGE
SPECIALIST REFERRALS
OB/GYN: YesOther specialists: Yes—to certainspecialties. Self-refer specialtieslist varies by geographical region
Yes—referral direct from physician
Express referral available?
SELECTION
NETWORKS
*HSA-Qualified High Deductible Health Plan
* Over 50 only if group is SB 578 qualified. (If group has less than 50 employees, for 50% of the preceding calendar quarter or preceding calendar year)
GROUP Can be written with another SIZE carrier's PPO or indemnity plan?
Employees
Dependents
Employees
Dependents
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
Does carrier underwrite and ratecarve out groups according to AB1672 guidelines?
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Employees
For Dependents
% of Total Cost:
PLAN ELIGIBILITY REQUIREMENTS
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE CARVE OUTS*
WRAP* REQUIREMENTS
*Indicates flexibility in being offered with products of another carrier.
GROUP Can be written with another SIZE carrier's HMO, POS or EPO?
SPECIAL CONSIDERATIONS
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COVERAGE RESTRICTIONS
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Are employees covered if traveling out of USA?
Is coverage available for out-of-state employees?
Max. % of employees residing out-of-stateallowed
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*100%
N/A N/A
Yes—if on DE-6 and showing at least minimum wages and withholdings
No
Only for emergency benefits
Yes
49% (At least 51% of eligible employees must live or work in California)
2-50
50% of lowest cost plan
N/A
N/A
2 250* N/A
2-50 Yes—contact your Word & Brown representative regarding guidelines
2-50 Yes—contact your Word & Brown representative regarding guidelines
*100% ◆70%
N/A N/A
◆ Those covered by another plan are NOT considered eligible in calculating participation. In order to NOT be considered eligible, the other coverage must be a group plan, Champus, Medicare or Medi-Cal
* No 1 Life groups allowed† Employer contribution is 100% of employee lowest cost HMO plan
or more
No
No
Yes—coverage available for non-union only. Group must submit union billing to underwriting for verification that all other employees have union coverage
2
Yes
2 250* N/A
AFTERINITIAL ISSUE
Min. # of employeesMax. # of employees
ENROLLMENT GROUP SIZE
2-2 3-50
100% of employees not coveredby group insurance and 70% ofall employees regardless ofother coverage
Kaiser Permanente Choice Solution
Kaiser Permanente Choice Solution
Kaiser Permanente Choice Solution
MEDICAL UNDERWRITING REQUIREMENTS
Current Employees
TimelyAdd-ons
Group Size
Composite Rates
Rate Guarantee††
Apply Trend Factor?
Use Employee Zips?
ENROLLMENT INFORMATION & REQUIREMENTS
Carrier's Effective Date
Premium Amount Required for 15th?
Employee Waiting Periods Available
Applications must be dated within:
Spouse/Domestic Partner Employees - 1 application or 2?
Employee Waiver Cards Required at enrollment?
Is Over Age Dependent Verification Required?
Are Telephone Interviews done by Underwriting?
Must Brokers Carry Errors & Omissions Insurance?
Does Carrier Offer Open Enrollment?
DOCUMENTATION & PAYMENT INFORMATION
DE-6 statement required?
Payroll Records OK if no DE6?
Is a Prior Booklet required?
Is Prior Billing required?
Must submit check with
initial application?
Check Made payable to:
FEES
Enrollment Fee Amount
Type of Enrollment Fee
Monthly Billing Fee
DEDUCTIBLE CREDITPrior carrier deductible credit given?
4th quarter deductiblecarry-over credit given?
GROUP SIZE
RATING INFORMATION
100
Instant quotes online: www.wordandbrown.comQuotes in 24 hours: (800) 869-6989
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†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”
ITEMS REVIEWED IN RAF CALCULATION
Medical Conditions
Years in Business
# of Pregnancies
Virgin Group
Type of Industry
Percent of Owners
Group Size
% of COBRA Insureds
% of Family Related
Participation
Plan(s) Requested
24 HR Coverage Req'd
Employer Contribution
Bankruptcy
Gender Mix
Kaiser Permanente Choice Solution
Kaiser Permanente Choice Solution
1st of the month
N/A
Min: 1st of the month following date of hire Max: 365 days
60 days
Use either 1 or 2 applications
Yes
Yes
Yes
Yes—60 days prior to anniversary
Yes
Call representative
Yes*
Yes*
Yes
Choice Administrators
None
N/A
2-8 9-20 21+$20 $25 $30
No
No
No
No
No
No
Yes
No
No
No
No
No
No
No
No
*Only if any employees take PPO Dental
2-5: 1.106-15: 1.0016-50 0.90
N/A
12 Months
No
Yes
2-14 15-50
Employee Master AppMedical (Employer
Questionnaire Questions)
Non Non Medical Medical
HMO: N/APPO: Yes*
No*This does NOT include credit for the RX deductible
(if enrolling separately, 2 applications required)
Yes—full-time student or disabled dependent information requested if child over age.
SPECIAL CONCERNS*
Infertility
PREVENTIVE BENEFITS*
PRESCRIPTIONS
Adult Physical Child Physical Annual OB/GYNPLAN TYPE Exam Exam/Immunizations Visit/Pap Smear Mammography
GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive ageneric equivalent rather than a brand namedrug?
If doctor writes “dispense as written” on prescription, is brand name available at thebrand copay amount?
* Information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?
Are non-formulary drugs available?
MAIL ORDER - 90 DAY SUPPLY
Are oral contraceptives covered?
* Unless otherwise noted, information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
BENEFIT INFORMATION SHOWN ON THIS PAGE IS A BRIEF SUMMARY. LIMITATIONS AND EXCLUSIONS APPLY. PLEASE REFER TO CERTIFICATE BOOK, EVIDENCE OF COVERAGE OR CALL REPRESENTATIVE FOR DETAILS.
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Hearing treatment
Are Hearing Aids covered?Call your Word & Brown representative
Kaiser Permanente Choice Solution
Kaiser Permanente Choice Solution
Kaiser Permanente Choice Solution
HMO/POS/PPO: Yes
HMO/POS/PPO: Yes
HMO
PPO
POS
Indemnity
HMO: Medical exams of the ear and audiometric exam to measure hearing
POS/PPO/Indemnity: Call your Word & Brown representative
Yes
Yes
Yes
Yes
100% after copay
Office visit copay
Office visit copay
$25 deductible then Maximum Allowable Charge
100% after copay
Office visit copay
Office visit copay
$10 deductible per visit then Maximum Allowable Charge
100% after copay
Office visit copay
Office visit copay
$25 deductible then Maximum Allowable Charge
100% after copay
Office visit copay
Office visit copay
$25 deductible then Maximum Allowable Charge
HMO: 50% for diagnosis and treatment of cause ofinfertility.
POS/PPO/Indemnity: Benefits vary by plan
Speech therapy HMO: Covered if medically necessary
PPO: Covered if medically necessary
POS: Covered if medically necessary
Indemnity: Covered if medically necessary
DIABETIC BENEFITS
These services may change at any time without notice. Please contact your Word & Brown representative for specific inquiries on listed services
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Are the following items covered under the Prescription Drug Benefit or the Durable MedicalEquipment Benefit of the member’s selected plan design?
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Insulin
Needles & Syringes
Glucose Monitor
Chem-Strips and/or Testing Agents
Insulin Pump
Insulin Pump Supplies
SELF-INJECTABLE DRUG BENEFITS
Are self-injectable drugs(other than insulin)covered under the
Prescription Drug Benefitor Medical Benefit?
Is pre-authorizationrequired?
Must self-injectables(other than insulin)
be purchased via thecarrier-contracted
mail order Rx vendor?
Kaiser Permanente Choice Solution
Kaiser Permanente Choice Solution
Prescription Drug Benefit
Prescription Drug Benefit
Durable Medical Equipment Benefit
Prescription Drug Benefit
Durable Medical Equipment Benefit
Durable Medical Equipment Benefit
Prescription Drug Benefit
No Use plan pharmacies(including affiliated)
HMO
Prescription Drug Benefit
No Use plan pharmacies(including affiliated)
POS
Prescription Drug Benefit
No Use plan pharmacies(including affiliated)
PPO
Prescription Drug Benefit
No Use plan pharmacies(including affiliated)
Indemnity
Colusa
Calaveras Marin
Monterey
Sacra- mento
Alameda
Alpine Amador
Butte
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Mariposa
Mendocino
Merced
Modoc
Mono
Napa
Nevada
Orange
Placer
Plumas
Riverside
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis
Obispo
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sut- ter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
103
Administration
HMOSharp Health Plan4305 University AvenueSuite 200San Diego, CA 92105800-359-2002
proud participant in:
Member Support 800-359-2002
Customer Service 800-359-2002
Bilingual Support 800-359-2002
Commissions 619-228-2404
Broker Licensing Paperwork Fax 619-228-2444
Adds/Terms Fax 619-228-2399
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HMOSharp Health PlanP.O. Box 939036San Diego, CA 92193
Claims
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�PPO Counties
HMO & PPO Counties
Plan may not be available in all zip codes within county. Check with your Word & Brown representative to confirm if coverage is available for your group location.
PRODUCTS OFFERED PROVIDER INFORMATION
HMO/EPO PPO POS
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Is Workers' Comp required oncorporate officers, partners and sole proprietors?
Is on-the-job covered for corporate officers, partners and sole proprietors?
Is there a premium adjustmentfor 24 hour coverage?
Self-referral available?
How often can members change their Primary Care Physician (PCP)?
Can family members eachchoose a PCP from a differentIPA/Medical Group?
Does carrier allow an OB/GYNto be Primary Care Physician?
Anytime—change is effective 1st of the following month
No
No
Yes
*See page 107 for details.
Sharp Health Plan
24 HOUR COVERAGE
SPECIALIST REFERRALS
Yes
Yes—if OB/GYN is listed as a PCP
Yes—for OB/GYN visits if OB/GYN is in same IPA as PCP.Sharp Rees-Sealy enrollees can self-refer to allergists, ENTS,OB/GYNs, ophthalmologists &podiatrists.
Yes—if available through medical group
Express referral available?
SELECTION
NETWORKS
LIFE†
DENTAL
VISION
INFERTILITY
CHIROPRACTIC
ACUPUNCTURE
MASSAGE THERAPY
OPTIONAL BENEFITS†
GROUP SIZE
CONSUMER DIRECTED HEALTHCARE
HSA-CompatiblePPO
HRA-CompatiblePPO
MRP-CompatiblePPO
ALTERNATIVE DISCIPLINES
Blue Plan 10/10/0Blue Plan 15/15/250Blue Plan 20/30/500Blue Plan 20/40/1000Blue Plan 30/40/1000
Blue Plan 30/40/750/dayBlue Plan 40/40/750/day
Gold Plan 10/10/0Gold Plan 15/15/250Gold Plan 20/30/500Gold Plan 20/40/1000Gold Plan 30/40/1000
Gold Plan 30/40/750/dayGold Plan 40/40/750/day
2-19
Not Available
Discount dental throughFirst Dental Health is free to all small group HMO
members
Available
Not Available
Available
Discounts Available
Discounts Available
Sharp Health Plan
SharpHealth
Plan 20-50
Not Available
Discount dental throughFirst Dental Health is free to all small group HMO
members
Available
Rider Available*
Available
Discounts Available
Discounts Available
HMO
DUAL OPTION (MIX AND MATCH)Boxes containing a “●” indicate that these coordinate plans offered by this carrier can be writtentogether to create a dual option package. Blank boxes indicate which plans cannot be writtentogether.
HSA Companion Plan40/2500/5000
N/A N/A
Sharp Health Plan
Companion Plan 120/500/80/50
Companion Plan 230/1000/80/50
PPO
*Sharp Gold Network is all Sharp Medical Groups excluding the independently contracted physicians
HMOSharp Health Plan
PPOFirst Health and Interplan
Blue Plan
10/10/0
Blue Plan
15/15/250
Blue Plan
20/30/500
Blue Plan
20/40/1000
Blue Plan
30/40/1000
Blue Plan
30/40/750
Blue Plan
40/40/750
Gold Plan
10/10/0
Gold Plan
15/15/250
Gold Plan
20/30/500
Gold Plan
20/40/1000
Gold Plan
30/40/1000
Gold Plan
30/40/750
Gold Plan
40/40/750
CompanionPlan 1
$20/80%/50%
CompanionPlan 2
$40/80%/50%
* Any groups with 6+ employees can choose a combination of one PPO and/or 1 HSA plan and any HMO plans.
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
†Assist America (worldwide emergency services coverage) free with all Sharp HMO plans
Blue Plan 10/10/0Blue Plan 15/15/250Blue Plan 20/30/500Blue Plan 20/40/1000Blue Plan 30/40/1000Blue Plan 30/40/750Blue Plan 40/40/750Gold Plan 10/10/0Gold Plan 15/15/250 Gold Plan 20/30/500Gold Plan 20/40/1000Gold Plan 30/40/1000Gold Plan 30/40/750 Gold Plan 40/40/750Companion Plan 1$20/80%/50%
Companion Plan 2$40/80%/50%
2-9 No10-15 Yes—minimum of 10 must enroll with
Sharp16-50 Yes–minimum of 10 or 50% (whichever
is greater) must enroll with Sharp
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
Does carrier underwrite and rate carve outgroups according to AB1672 guidelines?
105
GROUP Can be written with Kaiser?†
SIZE
COVERAGE RESTRICTIONS
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Are employees covered if traveling out of USA?
Is coverage available for out-of-state employees?
Max. % of employees residing out-of-state allowed
Yes—if listed on employer's DE-6
Yes—1099 Employees are not defined as an eligibleemployee and therefore not protected by AB1672; however, Sharp Health Plan will allow 1099 employeesto enroll, subject to the guidelines listed in SpecialConsiderations section at right.
Yes—emergency services covered worldwide
HMO: No PPO: Yes
Not applicable
Employees must reside or work within the service area.
Guidelines for 1099 employee coverage:
• 1099 employees must appear on the prior carrier billing statement.
• An Employer may only add 1099 employees to their plan either at the initialenrollment or at renewaL
• 1099 employees must work full-time (minimum of 30 hours per week) on ayear-round basis or 20 hours per week if the group covers part-timeemployees.
• There must be an affiliation between the employer and the employee longenough for a Federal Tax return to be filed.
• The employer must agree to contribute the same amount towards thepremium as they would for an employee reported on a W-2.
• The employer must agree to offer coverage to all future 1099 employees.
• No more than 25% of the group may be 1099 employees.
• The 1099 employee verification form must be completed and submittedalong with the following documentation:
-- Letter from the employer requesting to cover 1099 employees. -- Copies of the Form 1040 Schedule C and Form 1099 Miscellaneous
for the prior year.
Yes—if approved by Sharp underwriting. A minimum of 5 must enroll. 100% participation andan Individual Health Questionnaire is mandatory. Call representative
Pre-approval required from Sharp. Call representative
Pre-approval required from Sharp. Call representative
5 enrolledPPO - Carve-outs down to 2 lives with minimum of 3HMO subscribers
No
2-9 No10-15 Yes—minimum of 10 must enroll with
Sharp16-50 Yes–minimum of 10 or 50% (whichever
is greater) must enroll with Sharp
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Employees
For Dependents
% of Total Cost:
PLAN ELIGIBILITY REQUIREMENTS
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE CARVE OUTS*
WRAP* REQUIREMENTS
* Indicates flexibility in being offered with products of another carrier.
◆◆ Those covered by another plan are NOT considered eligible in calculating participation. In order to NOT be considered eligible, the other coverage must be a group plan
GROUP Can be written with another SIZE carrier's HMO, POS or EPO?†
SPECIAL CONSIDERATIONS
N/A
N/A
Sharp Health Plan
Sharp Health Plan
Sharp Health Plan
Sharp HealthPlan
2-50
50
ENROLLMENT GROUP SIZE
Min. # of employees
Max. # of employees
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† SHARP WILL NOT PERMIT WRAP WITH CALIFORNIACHOICE®
Employees
Dependents
Employees
Dependents
◆◆ 100%
N/A
2-50
◆◆ 70% HMO Only◆◆ 75% HMO and PPO
N/ A
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Employer can choose between adefined amount ($100 minimum) or a percentage (50% minimum).
minimum of 2 eligible employees*
*AB1672 group of 2 with one waiver due to other group coverage
AFTERISSUEINITIAL
N/A
minimum of 2 eligible employees*
106
Carrier's Effective Date
Premium Amount Required for 15th?
Employee Waiting Periods Available
Applications must be dated within:
Spouse/Domestic Partner Employees - 1 application or 2?
Employee Waiver Cards Required at enrollment?
Is Over Age Dependent Verification Required?
Are Telephone Interviews done by Underwriting?
Must Brokers Carry Errors & Omissions Insurance?
Does Carrier Offer Open Enrollment?
MEDICAL UNDERWRITING REQUIREMENTS
Medical Conditions
Years in Business
# of Pregnancies
Virgin Group
Type of Industry
Percent of Owners
Group Size
% of COBRA Insureds
% of Family Related
Participation
Plan(s) Requested
24 HR Coverage Req'd
Employer Contribution
Bankruptcy
Gender Mix
ENROLLMENT INFORMATION & REQUIREMENTS
DOCUMENTATION & PAYMENT INFORMATION
DE-6 statement required?
Payroll Records OK if no DE-6?
Is a Prior Booklet required?
Is Prior Billing required?
Must submit check with
initial application?
Check Made payable to:
GROUP SIZE
ITEMS REVIEWED IN RAF CALCULATION
RATING INFORMATION
2-50
Yes
No
Yes
No
No
No
Yes
No
No
No
No
No
No
No
Yes
1st of the month
N/A
1st of the month following date of hire; Max: 365 days
60 days of effective date
Use either 1 or 2 (Group must have a minimum of 2 subscribers)
Yes
Yes
No
Yes
Yes—annually at employer's election
Current Employees
TimelyAdd-ons*
6-24
Individual HealthQuestionnaire
Individual HealthQuestionnaire
Sharp Health Plan
Sharp Health Plan
FEES
Enrollment Fee Amount
Type of Enrollment Fee
Monthly Administration Fee
DEDUCTIBLE CREDITPrior carrier deductible credit given?
4th quarter deductiblecarry-over credit given?
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2-5: Automatic 1.106+: .90 - 1.1
No
12 Months
No
No
RAF Increments (2-50 Lives)
Composite Rates
Rate Guarantee††
Apply Trend Factor?
Use Employee Zips?
†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”
Instant quotes online: www.wordandbrown.comQuotes in 24 hours: (800) 869-6989
25-50
GroupQuestionnaire
GroupQuestionnaire
N/A
N/A
N/A
Yes
Yes
Yes
Yes
Yes
HMO: Sharp Health PlanPPO: American AlternativeInsurance Corporation (AAIC)
Yes
No
* Groups of 2-5 receive an automatic 1.10 RAF — Individual Health Questionnaires not required
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SPECIAL CONCERNS*
Hearing treatment Hearing exams by PCP covered as any illness to determine need for hearing correction
PREVENTIVE BENEFITS*
PRESCRIPTIONS
Adult Physical Child Physical Annual OB/GYNPLAN TYPE Exam Exam/Immunizations Visit/Pap Smear Mammography
GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive ageneric equivalent rather than a brand namedrug?
If doctor writes “dispense as written” on prescription, is brand name available at the brand copay amount?
* Information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?
Are non-formulary drugs available?
MAIL ORDER - 90 DAY SUPPLY
Are oral contraceptives covered?
* Unless otherwise noted, information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
BENEFIT INFORMATION SHOWN ON THIS PAGE IS A BRIEF SUMMARY. LIMITATIONS AND EXCLUSIONS APPLY. PLEASE REFER TO CERTIFICATE BOOK, EVIDENCE OF COVERAGE OR CALL REPRESENTATIVE FOR DETAILS.
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Are Hearing Aids covered?Not covered
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YesCovered at double the retail copay
Yes
Yes
Yes—non-formulary copay applies
Sharp Health Plan
Sharp Health Plan
Sharp Health Plan
InfertilityCovered at 50%; see Member Handbook for details of covered expenses. If a 20+ group, optional riders available for ART (Assisted Reproductive Technologies)—call your representative for details
Speech therapyTreatment of acute conditions covered as any illness - (See Member Handbook for details)
HMO 100% after office 100% after office 100% after office 100% after officevisit copay visit copay visit copay visit copay
PPO $250 annual benefit in and out of network
after copay
100% after officevisit copay
100% after officevisit copay
100% after officevisit copay
DIABETIC BENEFITS
These services may change at any time without notice. Please contact your Word & Brown representative for specific inquiries on listed services
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Are the following items covered under the Prescription Drug Benefit or the Durable MedicalEquipment Benefit of the member’s selected plan design?
SELF-INJECTABLE DRUG BENEFITS
DISCOUNTS, AWARDS & OTHER VALUE-ADDED BENEFITS
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Insulin
Needles & Syringes
Glucose Monitor
Chem-Strips and/or Testing Agents
Insulin Pump
Insulin Pump Supplies
SELF-INJECTABLE DRUG BENEFITS
Are self-injectable drugs(other than insulin)covered under the
Prescription Drug Benefitor Medical Benefit?
Is pre-authorizationrequired?
Must self-injectables(other than insulin)
be purchased via thecarrier-contracted
mail order Rx vendor?
Sharp Health Plan
Sharp Health Plan
Sharp Health Plan
Prescription Drug Benefit
Prescription Drug Benefit
Diabetic Supply Benefit
Diabetic Supply Benefit
Diabetic Supply Benefit
Diabetic Supply Benefit
Prescription Drug Benefit
Some medicationsand/or dosages may require
prior authorization
No—mail ordernot required
HMO plans:
Prescription Drug Benefit
Some medicationsand/or dosages may require
prior authorization
No—mail ordernot required
PPO plans:
Plan may not be available in all zip codes within county. Check with your Word & Brown representative to confirm if coverage is available for your group location.
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109
HMO/EPO Counties
PPO Counties
Both Plan Types��PPO Counties
HMO, POS & PPO Counties
CLAIMS ADDRESS INFO:
HMO ClaimsPacifiCare of CaliforniaP.O. Box 6006Cypress, CA 90630800-624-8822
PPO ClaimsPacifiCare of CaliforniaP.O. Box 6099Cypress, CA 90630866-316-9776
POS Out-of-Area ClaimsPacifiCare of CaliforniaP.O. Box 6019Cypress, CA 90630
★ Signature Value Advantage plans are only available in these eight counties:
Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego,San Francisco and Santa Clara.
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Colusa
CalaverasMarin
Monterey
Sacra-mento
Alameda
AlpineAmador
Butte
ContraCosta
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Mariposa
Mendocino
Merced
Modoc
Mono
Napa
Nevada
Orange
Placer
Plumas
Riverside
SanBenito
San Bernardino
San Diego
San Francisco
SanJoaquin
SanLuis
Obispo
SanMateo
SantaBarbara
Santa Clara
SantaCruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sut-ter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
Member Support
Customer Service
Bilingual SupportGroup ServiceCall Center
Broker Service/Commissions(Small Group)
Adds/Terms
PacifiCare of California5701 Katella AvenueCypress, CA 90630-5028
800-624-8822 (HMO)800-913-9133 (POS)866-316-9776 (PPO)
Call Member Support(See above)
Call Member Support(See above)
(See addresses under map)
Administrator Claims
Fax 866-372-1316
800-591-9911
800-947-1672
HMO
IMPORTANT NOTICE: UnitedHealthcare will be eliminating the PacifiCare PPO and POS portfoliofrom the marketplace effective January 1, 2010. Affected customers will be offered comparableUnitedHealthcare options at their renewal on or after January 1, 2010.
LIFE
DENTAL
VISION
INFERTILITY
CHIROPRACTIC
ACUPUNCTURE
MASSAGE THERAPY
PRODUCTS OFFERED
OPTIONAL BENEFITS
GROUP SIZE
PROVIDER INFORMATION
HMO/EPO PPO POS
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CONSUMER DIRECTED HEALTHCARE
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Is Workers' Comp required oncorporate officers, partners and sole proprietors?
Is on-the-job covered for corporate officers, partners and sole proprietors?
Is there a premium adjustmentfor 24 hour coverage?
How often can members change their Primary Care Physician (PCP)?
Can family members eachchoose a PCP from a differentIPA/Medical Group?
Does carrier allow an OB/GYNto be Primary Care Physician?DUAL OPTION (MIX AND MATCH)
PacifiCare Choice Series: Groups enrolling 5–50 active employees may select up to four HMO, HMOAdvantage and/or PPO plans. HMO plans may not be offered alongside HMOAdvantage plans. Minimum participation requirement is 75%. Refer tounderwriting guidelines for product options available. If you need assistance,please contact your Word & Brown representative.
Available
Available
Not Available
PPO: Included; HMO/POS: Rider Available
PPO: Included; HMO/POS: Rider Available
Not Available
2-50
HMOPacifiCare HMOPacifiCare Signature Value Advantage(Limited network)
PPO
PacifiCare Life and Health PPO
Out of California PPONational network consisting of PL&Hproprietary network and PHCS
No, if legally exempt
No
Yes, if legally exempt
* Only available to out-of-state employees of a PacifiCare group.No Hawaii employees. Maximum percentages apply. Seebottom of page 111 for details.
** Only available on a standalone basis† Only available in eight counties: Kern, Los Angeles, Orange,
Riverside, San Bernardino, San Diego, San Francisco and SantaClara.
SignatureValue™ 10-30/100SignatureValue™ 15-30/250aSignatureValue™ 20-40/500d
SignatureValue™ 35/600dSignatureValue™ 10/500d
SignatureValue™ 20/1500dedSignatureValue™ Advantage 10/500d †
SignatureValue™ Advantage 20/1500ded†
SignatureValue™ Advantage 35/600d †
SignatureValue™ Advantage 40-60/2000dedSignatureValue™ 10-30/500dSignatureValue™ 15-30/300a
SignatureValue™ 20-40/1500dSignatureValue™ 10-30/100 Advantage
SignatureValue™ 10-30/500d AdvantageSignatureValue™ 15-30/300a Advantage
SignatureValue™ 20-40/1500d AdvantageSignatureValue™ 20-40/500d AdvantageSignatureValue™ 35-45/600d Advantage
HCP Network HMO 25-50/500 ded.HCP Network HMO 25-75/1500 ded.HCP Network HMO 25-75/500 ded.
HMO PPO
POS
▲= Triple Option Plan
Self-referral available?
24 HOUR COVERAGE
SPECIALIST REFERRALS
As often as necessary (submit changerequest on or before the 15th in orderto be effective the 1st of the followingmonth)
Yes
Yes—if listed as a PCP in the directory
HMO: Yes—for OB/GYN visits (OB/GYN must be in the same medical group/IPA asyour PCP)
POS: HMO (Tier 1): Yes—same as HMO above; PPO (Tier 2): No PCP selection required
PPO: Yes—no PCP selection required
Yes—if an Express Referrals™participating medical group. SeePacifiCare Provider Directory orwww.pacificare.com for list ofparticipating medical groups.
SignaturePOS™15/80-60 **
Express referral available?
HRA-Compatible PPO
SELECTION
NETWORKS
SignatureOptionsTM 70-50/2000
MRP-Compatible PPOSignatureOptionsTM 10/90-70/250SignatureOptionsTM 15/90-50/250SignatureOptionsTM 20/80-60/250SignatureOptionsTM 30/70-50/250SignatureOptionsTM 35/80-60/500SignatureOptionsTM 35/50-50/1000SignatureOptionsTM 35/70-50/1000
SignatureOptionsTM 70-50/2000SignatureOptionsTM 70-50/3500
ALTERNATIVE DISCIPLINES
PacifiCare PPO and Indemnity products are available through UnitedHealthcare. For details, contact your UnitedHealthcare representative.
UnitedHealthcare/PacifiCare
UnitedHealthcare/PacifiCare
UnitedHealthcare/PacifiCare
UnitedHealthcare/PacifiCare
SignatureOptions™ 15/80-60SignatureOptions™ 20/90-50/250SignatureOptions™ 30/80-60/250SignatureOptions™ 30/80-60/500SignatureOptions™ 40/50-50/1000SignatureOptions™ 40/70-50/1000SignatureOptions™ 40/70-50/250SignatureOptions™ 70-50/2000SignatureOptions™ 70-50/3500
Employees
Dependents
Employees
Dependents
PARTICIPATION
EXCLUSIONS ALLOWED BY CARRIER:
Hourly/Salary?1) Groups excluding classes are subject to underwriting approval
and may be declined if they do not meet PacifiCare underwritingcriteria. Call your Word & Brown representative
2) Employer must provide a letter indicating why they want to offerone class of employees and not the other
3) No other carrier offered alongside4) The case is non-guarantee issue
Management/Non-management?1) Groups excluding classes are subject to underwriting approval
and may be declined if they do not meet PacifiCare underwritingcriteria. Call your Word & Brown representative
2) Employer must provide a letter indicating why they want to offerone class of employees and not the other
3) No other carrier offered alongside4) The case is non-guarantee issue
Union/Non-union?1) Groups excluding classes are subject to underwriting approval
and may be declined if they do not meet PacifiCare underwritingcriteria. Call your Word & Brown representative
2) Employer must provide a letter indicating why they want to offerone class of employees and not the other
3) No other carrier offered alongside4) The case is non-guarantee issue
Minimum group size2
Does carrier underwrite and rate carve out groups according to AB1672 guidelines?No
AFTERINITIAL ISSUE
1*
50
1*
50*AB1672 group of 2 with one waiver due to other group coverage
Min. # of employees
Max. # of employees
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* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
COVERAGE RESTRICTIONS
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Are employees covered if traveling out of USA?
Is coverage available for out-of-state employees?
Max. % of employees residing out-of-state allowed
Employees
For Dependents
% of Total Cost:
PLAN ELIGIBILITY REQUIREMENTS
MINIMUM EMPLOYER CONTRIBUTION
Non-Contributory
GROUP SIZE
GROUP SIZE CARVE OUTS*
WRAP* REQUIREMENTS
*Indicates flexibility in being offered with products of another carrier.
SPECIAL CONSIDERATIONS
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Contributory
50%
- 0 -
- 0 -
of average employee-only premium
◆◆75%
N/A
Standalone or Choice Option2-15
◆◆100%
N/A
◆◆60%
N/A
16-50
◆◆100%
N/A
◆◆75%
N/A
10-15
◆◆100%
N/A
Choice Series (Multi Choice)
◆◆ Those covered by another plan are NOT considered eligible in calculatingparticipation. In order to NOT be considered eligible, the other coveragemust be a group plan through their spouse or parent's employer,Champus, MediCal or Medicare (if no share-of-cost to individual). COBRAparticipants and employees in waiting period are not considered eligibleemployees. Therefore, they are not included when determining the totalgroup size.
1) Health statements are required for all employees 2-50. 2) Group must have Workers' Comp policy in force.3) Employee must work or reside within PacifiCare of California's
service area in order to enroll in a PacifiCare HMO or POS plan.4) A 2-life husband and wife group cannot be a sole proprietor
with both names on the business license. One must be a W-2 employee. Call your Word & Brown representative forsubmission requirements on husband and wife partnerships orcorporations.
5) Any group coming out of a current PacifiCare PEO will not be re-written as a new PacifiCare small group. Contact your Word & Brown representative for details regarding transferprocedures and rates.
2-50 No
GROUP Can be written with another SIZE carrier's PPO or indemnity plan?
GROUP Can be written with another SIZE carrier's HMO, POS or EPO?
◆◆60%
N/A
16-50
◆◆100%
N/A
Yes—if they receive a W-2 or are an owner/partner/officer
May be allowed on an exception. Prior approval fromPacifiCare underwriting required prior to submission. Call your Word & Brown representative
Emergency coverage only
Yes—on PPO, utilizing both PacifiCare's proprietary and PHCS'national networks.
No more than 25% outside a PacifiCare state.
POS or Choice Option:2-50 No
HMO, PPO or Multi Choice Option:2-9 No
10-15 Yes—with a staff model HMO only (i.e. Kaiser). Minimumof 10 (excluding COBRA) must enroll with PacifiCare
16-50 Yes—with one other HMO allowed & 60% of eligible employees must enroll with PacifiCare. For Multi Choice Option, 75% participation required and it must be a staff model HMO
Groups must have at least 10 enrolled employees with PacifiCare to be eligible tooffer another carrier (excluding allowable waivers).
ENROLLMENT GROUP SIZE
2-50
UnitedHealthcare/PacifiCare
UnitedHealthcare/PacifiCare
UnitedHealthcare/PacifiCare
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MEDICAL UNDERWRITING REQUIREMENTS
Current Employees
TimelyAdd-ons
ENROLLMENT INFORMATION & REQUIREMENTS
Carrier's Effective Date
Premium Amount Required for 15th?
Employee Waiting Periods Available
Applications must be dated within:
Spouse/Domestic Partner Employees - 1 application or 2?
Employee Waiver Cards Required at enrollment?
Is Over Age Dependent Verification Required?
Are Telephone Interviews done by Underwriting?
Must Brokers Carry Errors & Omissions Insurance?
Does Carrier Offer Open Enrollment?
GROUP SIZE
ITEMS REVIEWED IN RAF CALCULATION
RATING INFORMATION
112
Instant quotes online: www.wordandbrown.comQuotes in 24 hours: (800) 869-6989
1st of month only
N/A
0-6 months*
60 days prior to the requested effective date †
2-life group: separate apps**/3+: either 1 or 2
Yes
Yes
Not currently
Yes
Annually only
Health statements are required for all employees 2-50
*2-9 enrolling employees:only 1 waiting period allowed for all new hires
10-50 enrolling employees: may have 2 waiting periods based upon specific job classifications (e.g. management/non-management, salaried/hourly, etc.)
1 Group must submit letter on company letterhead that contains: 1) start date of business(minimum 45 days in business); 2) Tax ID number; 3) list of all current employees with hiredate and Social Security Number for each. Must also submit a summary page, a copy ofcurrent Business License, Business Tax Certificate or receipt of payment for CaliforniaBusiness License. If group comprised of all owner/partners with no DE-6, call yourrepresentative for submission details. Payroll records must meet requirements listed inPacifiCare Quick Reference Guide—call representative for details.
*If DE-6 from EDD, no cover page required but may be requested by PCUV if math does not balance. If DE-6 from ADP (payroll service) mustsubmit cover page or quarterly Tax Summary to confirm total employeecount.
** See Special Considerations sectionon page 111 for important information regarding 2-life husband and wifegroups
† Applications must be dated priorto or on the 1st day of the monthin which coverage becomeseffective or PacifiCare will roll thegroup
HMO: N/APPO & POS: Yes
HMO: N/APPO & POS: No
Yes—except as noted below*
Yes—if DE-6 not filed yet 1
No For PPO or Dental only
YesPacifiCare
DEDUCTIBLE CREDITPrior carrier deductible credit given?
4th quarter deductiblecarry-over credit given?
†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”
ITEMS REVIEWED IN RAF CALCULATION
Medical Conditions
Years in Business
# of Pregnancies
Virgin Group
Type of Industry
Percent of Owners
Group Size
% of COBRA Insureds
% of Family Related
Participation
Plan(s) Requested
24 HR Coverage Req'd
Employer Contribution
Bankruptcy
Gender Mix
Yes
No
Yes
No
No
No
Yes
No
No
No
No
No
No
No
No
DOCUMENTATION & PAYMENT INFORMATION
DE-6 statement required?Payroll Records OK if no DE6?Is a Prior Booklet required?Is Prior Billing required?Must submit check with initial application?Check Made payable to:
RAF by Group Size
Composite Rates
Rate Guarantee††
Apply Trend Factor?
Use Employee Zips?
Full Medical 2-50
* Employees with health conditions that are named by the employer in theresponses must submit an Individual Health Statement
N/A
Contract states 6-month re-rating(in accordance with CA insurance code).However, in practice PacifiCare has lengthened this to 12-months
No
No
UnitedHealthcare/PacifiCare
UnitedHealthcare/PacifiCare
1) Less than 3 enrolled employees is 1.102) Groups of 3 enrolled employees 1.00-1.103) Groups of 4 enrolled employees .95-1.104) 5+ enrolled employees is .90-1.10
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FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?Yes
Are non-formulary drugs available?Yes—higher non-formulary copay applies. ForSignaturePOS™, both formulary and non-formulary are covered on in-network level only
MAIL ORDER - 90 DAY SUPPLY
Yes—2 retail copays
Are oral contraceptives covered?Yes
GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive ageneric equivalent rather than a brand name drug?
If doctor writes “dispense as written” on prescription, is brand name available at thebrand copay amount?
SPECIAL CONCERNS*
PREVENTIVE BENEFITS*
PRESCRIPTIONS
Adult Physical Child Physical Annual OB/GYNPLAN TYPE Exam Exam/Immunizations Visit/Pap Smear Mammography
* Unless otherwise noted, information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
BENEFIT INFORMATION SHOWN ON THIS PAGE IS A BRIEF SUMMARY. LIMITATIONS AND EXCLUSIONS APPLY. PLEASE REFER TO CERTIFICATE BOOK, EVIDENCE OF COVERAGE OR CALL REPRESENTATIVE FOR DETAILS.
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PRESCRIPTIONS
HMO & POS
PPO
Periodic Health Evaluations covered—100% after office visit copay (POS covered
in-network level 1 only)
Periodic Health Evaluations(age 19 & over) covered to
max. $400 per calendar year
100% after officevisit copay
(POS: level 1 only)
Covered throughage 18
100% after officevisit copay
(POS: level 1 only)
Covered
100% after officevisit copay
(POS: level 1 only)
Covered
Hearing treatmentHMO: Hearing screening exam by PCP or PCP
referred specialist covered at office visit copay for a specialist
POS: Covered in-network only as outlined above for HMO
PPO: Routine hearing screening to determine hearing loss covered under Periodic Health Evaluations
Note: If a company offers UnitedHealthcare’s PPOportfolio and the PacifiCare HMO portfolio, they willhave two different Rx systems.
Managed or Closed Formulary Plans: Yes—or member must pay the brand
formulary or brand non-formulary copayplus the difference between the genericprice and the brand price
Open Formulary Plans: Yes—or member must pay non-formulary copay
Yes—only for members with a three tier or buy-up Rxbenefit.
SignatureOptions™ 70-50/2000 and 70-50/3500 have a $250 separate annual Rx deductible combined for formulary and non-formulary drugs
SignatureOptions™ 70-50/2000 &SignatureOptions™ 70-50/3500
Deductible & Coinsuranceapplies
Deductible & Coinsuranceapplies
Deductible & Coinsuranceapplies
Deductible & Coinsuranceapplies
All other SignatureOptions™PPO plans:
100% after office visit copay.Deductible & coinsurance
applies to lab & x-ray
100% after office visit copay.Deductible & coinsurance
applies to lab & x-ray
100% after office visit copay.Deductible & coinsurance
applies to lab & x-ray
100% after office visit copay.Deductible & coinsurance
applies to lab & x-ray
Are Hearing Aids covered?No
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Speech therapyHMO: Included in Outpatient Rehabilitation
Therapy. Benefit: 100% after office visit copay. (Limitations apply— see Evidence of Coverage)
POS: Covered in-network only as outlined above for HMO
PPO: Combined $2000 max. per calendar year for speech, physical and occupational rehabilitation services (Limitations apply—see Evidence of Coverage)
InfertilityHMO 20-40/500d: Not covered
HMO Value 40-60/2000ded: Not covered
HMO 35/600d: Not covered
Advtg 10/500d &Advtg 35/600d: Not covered
HMO 10-30/100& HMO 15-30/250a: 50% of cost copay for
covered benefits
POS: In-network level only - 50% of covered benefits
PPO: Max. $2000 while insured by PacifiCare
UnitedHealthcare/PacifiCare
UnitedHealthcare/PacifiCare
UnitedHealthcare/PacifiCare
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DIABETIC BENEFITS
These services may change at any time without notice. Please contact your Word & Brown representative for specific inquiries on listed services
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Are the following items covered under the Prescription Drug Benefit or the Durable MedicalEquipment Benefit of the member’s selected plan design?
SELF-INJECTABLE DRUG BENEFITS
DISCOUNTS, AWARDS & OTHER VALUE-ADDED BENEFITS
Insulin
Needles & Syringes
Glucose Monitor
Chem-Strips and/or Testing Agents
Insulin Pump
Insulin Pump Supplies
SELF-INJECTABLE DRUG BENEFITS
Are self-injectable drugs(other than insulin)covered under the
Prescription Drug Benefitor Medical Benefit?
Is pre-authorizationrequired?
Must self-injectables(other than insulin)
be purchased via thecarrier-contracted
mail order Rx vendor?
PacifiCare
HMO plans:*
POS plans:
PPO plans:
Prescription Drug Benefit
Prescription Drug Benefit
Durable Medical Equipment Benefit
Prescription Drug Benefit
Durable Medical Equipment Benefit
Usually Durable Medical Equipment Benefit—supplies containing insulinare covered under Prescription Drug Benefit
Medical Benefit Yes—pre-authorizationmay be required
Yes
Medical Benefit Yes—pre-authorizationmay be required
Yes
Medical Benefit Yes Yes
* With the SignatureValueTM, SignatureValueTM Advantage, and SignaturePOS plans, a separate copayment applies forinjectable drugs except when the negotiated rate is less than the copayment amount—then you will pay the negoti-ated rate. The copayment for SignatureValueTM Advantage 10/500d is $150 and the copayment for 35/600d is $100
UnitedHealthcare/PacifiCare
UnitedHealthcare/PacifiCare
Colusa
Calaveras Marin
Monterey
Sacra- mento
Alameda
Alpine Amador
Butte
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Mariposa
Mendocino
Merced
Modoc
Mono
Napa
Nevada
Orange
Placer
Plumas
Riverside
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis
Obispo
San Mateo
Santa Barbara
Santa Clara
Santa Cruz
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sut- ter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
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PPO Counties�
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Plan may not be available in all zip codes within county. Check with your Word & Brown rep to confirm if coverage is available for your group location.
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Member Support Call number on ID card (or temporary ID printed after registration on myuhc.com)
Group ServiceCall Center 888-842-4571, press 2
Broker Service/Commissions 888-842-4571, press 1(Small Group) [email protected]
Adds/Terms Call your Word & Brownrepresentative
Account Executive Department 866-288-4993, prompt 1, 1
Fax 800-926-2951
5701 Katella AvenueCypress, CA 90630-5028800-858-9168Fax 800-926-2951
Administrator Claims
UnitedHealthcareP.O. Box 659426San Antonio, TX
78265-9426
How often can members change their Primary Care Physician (PCP)?
Can family members eachchoose a PCP from a differentIPA/Medical Group?
Does carrier allow an OB/GYNto be Primary Care Physician?
LIFE
DENTAL
VISION
INFERTILITY
CHIROPRACTIC
ACUPUNCTURE
MASSAGE THERAPY
PRODUCTS OFFERED
OPTIONAL BENEFITS
GROUP SIZE
PROVIDER INFORMATION
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CONSUMER-DIRECTED HEALTHCARE
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ALTERNATIVE DISCIPLINES
Is Workers' Comp required oncorporate officers, partners and sole proprietors?
Is on-the-job covered for corporate officers, partners and sole proprietors?
Is there a premium adjustmentfor 24 hour coverage?
Call your Word & Brownrepresentative
No, if legally exempt
No
Yes, if legally exempt
UnitedHealthcare Choice Plus Traditional w/ Deductible PPO 20/250/90% (C3-J)UnitedHealthcare Choice Plus Traditional w/ Deductible PPO 30/500/80% (C3-M)UnitedHealthcare Choice Plus Traditional w/ Deductible PPO 40/500/70% (C3-R)
UnitedHealthcare Choice Plus Balanced PPO 20/3000/90% (C3-I)UnitedHealthcare Choice Plus Balanced PPO 30/1000/80% (C3-K)UnitedHealthcare Choice Plus Balanced PPO 30/2500/80% (C3-L)UnitedHealthcare Choice Plus Balanced PPO 40/1000/70% (C3-P)UnitedHealthcare Choice Plus Balanced PPO 40/1500/70% (C3-Q)UnitedHealthcare Choice Plus Balanced PPO 40/1000/50% (C3-N)UnitedHealthcare Choice Plus Balanced PPO 40/2000/50% (C3-0)
UnitedHealthcare Choice Plus Balanced Value PPO 20/3000/90% (D6-L)UnitedHealthcare Choice Plus Balanced Value PPO 30/1000/80% (D6-M)UnitedHealthcare Choice Plus Balanced Value PPO 30/2500/80% (D6-N)UnitedHealthcare Choice Plus Balanced Value PPO 40/1000/70% (D6-Q)UnitedHealthcare Choice Plus Balanced Value PPO 40/1500/70% (D6-R)UnitedHealthcare Choice Plus Balanced Value PPO 40/1000/50% (D6-0)UnitedHealthcare Choice Plus Balanced Value PPO 40/2000/50% (D6-P)
UnitedHealthcare Non-Differential PPO 2000/80% (6H-F)
PPO
Self-referral available?
24 HOUR COVERAGE
SPECIALIST REFERRALS
Call your Word & Brownrepresentative
Call your Word & Brownrepresentative
Call your Word & Brownrepresentative
Call your Word & Brownrepresentative
Call your Word & Brownrepresentative
Express referral available?
SELECTION
NETWORKS
UnitedHealthcare Choice Plus Definity HSA 2000/100% (D6-K) UnitedHealthcare Choice Plus Definity HSA 1500/80% (C3-Z)
UnitedHealthcare Choice Plus Definity HSA (embedded) 2850/80% (D6-I)UnitedHealthcare Choice Plus Definity HSA 2850/80% (D6-J)
UnitedHealthcare Choice Plus Definity HSA (embedded) 3000/70% (C3-X)UnitedHealthcare Choice Plus Definity HSA 3500/70% (C3-Y)
HSA
UnitedHealthcare Choice Plus Definity HRA 2000/90% (C3-W)UnitedHealthcare Choice Plus Definity HRA 1500/80% (C3-U)UnitedHealthcare Choice Plus Definity HRA 2500/80% (C3-V)UnitedHealthcare Choice Plus Definity HRA 2000/70% (C3-S)UnitedHealthcare Choice Plus Definity HRA 3000/70% (C3-T)
HRA
Available
Available
Available
Available
Available
Available
Not Available
2-50
DUAL OPTION (MIX AND MATCH) UnitedHealthcare
UnitedHealthcare Multi-Choice package: Groups enrolling 5-50 active employeesmay select up to a total of 35 PacifiCare HMO and UnitedHealthcare PPO plans.HMO plans may not be offered alongside HMO Advantage plans. Minimumparticipation requirement is 75%. Refer to underwriting guidelines for productoptions available.
UnitedHealthcare
UnitedHealthcare
UnitedHealthcare/PacifiCare
UnitedHealthcare
GROUPSIZE PPO or Indemnity
Employees
Dependents
Employees
Dependents
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?Available for groups with 2-50 eligible employees. All included classesmust meet participation guidelines for the class. The employer mustsubmit a signed, dated letter on company letterhead confirming the classdescription and verifying that no other group medical coverage is beingoffered to the otherwise eligible employees excluded by the classdescription
Management/Non-management?Available for groups with 2-50 eligible employees. All included classesmust meet participation guidelines for the class. The employer mustsubmit a signed, dated letter on company letterhead confirming the classdescription and verifying that no other group medical coverage is beingoffered to the otherwise eligible employees excluded by the classdescription
Union/Non-union?Available for groups with 2-50 eligible employees. All included classesmust meet participation guidelines for the class. The employer mustsubmit a signed, dated letter on company letterhead confirming the classdescription and verifying that no other group medical coverage is beingoffered to the otherwise eligible employees excluded by the classdescription. Note: Union/Non-union requires a copy of the union bill.
Minimum group size2
Does carrier underwrite and rate carve out groups according to AB1672 guidelines?No—These groups are non GI
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
ENROLLMENT GROUP SIZE
Employees
For Dependents
% of Total Cost:
PLAN ELIGIBILITY REQUIREMENTS
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Min. # of employees
Max. # of employees
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
AFTERINITIAL ISSUE
CARVE OUTS*
WRAP* REQUIREMENTS
SPECIAL CONSIDERATIONS
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COVERAGE RESTRICTIONS
Are Commission-Only employees allowed?Call your Word & Brown representative
Are 1099 employees allowed?Yes—maximum of 25% of the enrolled may be 1099contractors, and the independent contractors paid by1099 form is required
Are employees covered if traveling out of USA?Emergency coverage only
Is coverage available for out-of-state employees?No more than 25% of the group may be located inVermont or Washington.
Max. % of employees residing out-of-stateallowedThe group will be rated in the state with 51% of theeligible employees. If there is not 51% of the eligibleemployees in any state, special guidelines apply todetermine base location. Contact your Word & Brownrepresentative
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2-50
2-50 UnitedHealthcare PremierSource™: No
10-15 Standalone (one UnitedHealthcare plan): Yes—minimum 75% of eligible employees must enroll with UnitedHealthcare*
16-50 Standalone (one UnitedHealthcare plan): Yes—minimum 60% of eligible employees must enroll with UnitedHealthcare*
10-50 UnitedHealthcare Multi-Choice package: Yes—minimum 75% of eligible employees must enroll with UnitedHealthcare*
1) Health statements are required for all employees 2-50, includingCOBRA or Cal-COBRA continuees
2) Group must have Workers' Comp policy in force.3) A 2-life husband and wife group cannot be a sole proprietor with both
names on the business license or Schedule C. Husband/wife groupsmust provide separate tax or QWR documentation showing they arean owner or full-time employee. Call your Word & Brownrepresentative for submission requirements on husband and wifepartnerships or corporations.
4) Business must be located in UnitedHealthcare’s licensed service areato be eligible for the products licensed in that area.
5) Proof of ownership documentation is required for all groups applyingfor medical coverage with fewer than 6 enrolling employees or anysize “owner only” groups.
2 2
50 50
50%
- 0 -
- 0 -
◆◆75%
N/A
2-15
◆◆100%
N/A
◆◆60%
N/A
16-50
◆◆100%
N/A
◆◆ Those covered by another plan are NOT considered eligible in calculatingparticipation. In order to NOT be considered eligible, the other coveragemust be a group plan through their spouse or parent's employer,Champus, MediCal or Medicare (if no share-of-cost to individual). COBRAparticipants and employees in waiting period are not considered eligibleemployees. Therefore, they are not included when determining the totalgroup size.
UnitedHealthcare
UnitedHealthcare
UnitedHealthcare
GROUPSIZE HMO, POS or EPO10-50 UnitedHealthcare PremierSource™: Yes—staff model
HMO only. 75% of eligible employees must enroll in UnitedHealthcare and the staff model HMO with a minimum of 5 active employees enrolling in the PremierSource portfolio (those waiving for a staff model HMO do not count toward participation.)
10-15 Standalone (one UnitedHealthcare plan): Yes—minimum 75% of eligible employees must enroll with UnitedHealthcare*
16-50 Standalone (one UnitedHealthcare plan): Yes—minimum 60% of eligible employees must enroll with UnitedHealthcare*
10-50 UnitedHealthcare Multi-Choice package: Yes—minimum 75% of eligible employees must enroll with UnitedHealthcare*
* The Standalone (one UnitedHealthcare plan) and UnitedHealthcare Multi-Choice package entries that appear in the PPO/Indemnity wraprequirement section above also apply to HMO, POS or EPO plans.
MEDICAL UNDERWRITING REQUIREMENTS
Current Employees
TimelyAdd-ons
RAF by Group Size
Composite Rates
Rate Guarantee*
Apply Trend Factor?
Use Employee Zips?
ENROLLMENT INFORMATION & REQUIREMENTS
Carrier's Effective Date
Premium Amount Required for 15th?
Employee Waiting Periods Available
Applications must be dated within:
Spouse/Domestic Partner Employees - 1 application or 2?
Employee Waiver Cards Required at enrollment?
Is Over Age Dependent Verification Required?
Are Telephone Interviews done by Underwriting?
Must Brokers Carry Errors & Omissions Insurance?
Does Carrier Offer Open Enrollment?
DOCUMENTATION & PAYMENT INFORMATION
DE-6 statement required?
Payroll Records OK if no DE6?
Is a Prior Booklet required?
Is Prior Billing required?
Must submit check with
initial application?
Check Made payable to:
FEES
Enrollment Fee Amount
Type of Enrollment Fee
Monthly Administration Fee
DEDUCTIBLE CREDITPrior carrier deductible credit given?
4th quarter deductiblecarry-over credit given?
GROUP SIZE
RATING INFORMATION
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Instant quotes online: www.wordandbrown.comQuotes in 24 hours: (800) 869-6989
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†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”
ITEMS REVIEWED IN RAF CALCULATION
Medical Conditions
Years in Business
# of Pregnancies
Virgin Group
Type of Industry
Percent of Owners
Group Size
% of COBRA Insureds
% of Family Related
Participation
Plan(s) Requested
24 HR Coverage Req'd
Employer Contribution
Bankruptcy
Gender Mix
Yes*
No
Yes (including all pages)
Yes
UnitedHealthcare
N/A
Call your Word & Brownrepresentative
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Health Statements are required forall employees 2-50
Call your Word & Brownrepresentative
Call your Word & Brownrepresentative
No
12 Months
No
No
1st (or 15th of the month for UnitedHealthcare standalone only)
Call your Word & Brown representative
minimum: 0 maximum: 180 (1st of the month following)
90 days prior to effective date; however for backdating, alldocuments must be received, signed and dated by the 5th ofthe month in order to backdate coverage to the 1st of the month
2 life group: separate apps / 3+ group: either 1 or 2 but no double coverage allowed
Yes
Periodically
Yes
1) Less than 3 enrolled employees is 1.102) Groups of 3 enrolled employees 1.00-1.103) Groups of 4 enrolled employees .95-1.104) 5+ enrolled employees is .90-1.10
UnitedHealthcare
UnitedHealthcare
Yes—only if the company has notbeen in business long enough tohave filed a DE-6.†
Yes, month prior to renewal—plan changes (Benefit Modifications) aresubject to Underwriting review and approval at open enrollment
* If DE-6 reflects more than a 50% change in census, a current payroll will also be required† Husband/wife groups or groups comprised of family members must always provide a Quarterly Wage Report (DE-6)
Health Statements are required forall employees 2-50
Yes—if UnitedHealthcare PremierSource™ is written with a staff model HMO,the staff model HMO applications must be submitted in lieu of waivers
SPECIAL CONCERNS*
PREVENTIVE BENEFITS*
PRESCRIPTIONS
Adult Physical Child Physical Annual OB/GYNPLAN TYPE Exam Exam/Immunizations Visit/Pap Smear Mammography
GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive ageneric equivalent rather than a brand namedrug?
If doctor writes “dispense as written” on prescription, is brand name available at thebrand copay amount?
* Information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?No
Are non-formulary drugs available?UnitedHealthcare’s Rx portfolio does not base tiers on generic, brand, formulary and non-formulary.UnitedHealthcare products have a three tier system in small group that is drug specific. The member would need to refer to drug list to determine which tier the drug falls into.
If a company offers UnitedHealthcare’s PPO portfolio andthe PacifiCare HMO portfolio, they will have two differentRx systems.
MAIL ORDER - 90 DAY SUPPLYYes—2.5 X copay
Are oral contraceptives covered?Yes
* Unless otherwise noted, information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.
BENEFIT INFORMATION SHOWN ON THIS PAGE IS A BRIEF SUMMARY. LIMITATIONS AND EXCLUSIONS APPLY. PLEASE REFER TO CERTIFICATE BOOK, EVIDENCE OF COVERAGE OR CALL REP FOR DETAILS.
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CA
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All Traditionaland BalancedChoice Plans
Covered at 100% afteroffice visit copay.Deductible and
coinsurance applies to lab and x-ray
Covered at 100% afteroffice visit copay.Deductible and
coinsurance applies to lab and x-ray
Covered at 100% afteroffice visit copay.Deductible and
coinsurance applies to lab and x-ray
Covered at 100% afteroffice visit copay.Deductible and
coinsurance applies to lab and x-ray
Yes
Yes
UnitedHealthcare
UnitedHealthcare
UnitedHealthcare
Hearing treatmentMaximum 30 visits of post-cochlear implant auraltherapy. Pre-service notification is required. Copaymentvaries by plan—see Certificate of Coverage for details
Are Hearing Aids covered?No
Speech therapySpeech therapy is not covered except as required fortreatment of a speech impediment or speechdysfunction that results from injury, stroke, cancer,congenital anomaly or autism spectrum disorders.Maximum 20 visits of speech therapy. Pre-servicenotification is required. Copayment varies by plan—see Certificate of Coverage for details
InfertilityAvailable
Services to treat or correct underlying causes ofinfertility are covered. Benefits are limited to $2,000 percovered person during the entire period of time he orshe is enrolled for coverage under the policy. Pre-service notification is required. See Certificate ofCoverage for details.
Health services and associated expenses for infertilitytreatments, including assisted reproductive technology,regardless of the reason for the treatment, are notcovered.
DIABETIC BENEFITS
These services may change at any time without notice. Please contact your Word & Brown rep for specific inquiries on listed services
120
Are the following items covered under the Prescription Drug Benefit or the Durable MedicalEquipment Benefit of the member’s selected plan design?
w w w. w o r d a n d b r o w n . c o m
Insulin
Needles & Syringes
Glucose Monitor
Chem-Strips and/or Testing Agents
Insulin Pump
Insulin Pump Supplies
SELF-INJECTABLE DRUG BENEFITS
Are self-injectable drugs(other than insulin)covered under the
Prescription Drug Benefitor Medical Benefit?
Is pre-authorizationrequired?
Must self-injectables(other than insulin)
be purchased via thecarrier-contracted
mail order Rx vendor?
UnitedHealthcare
UnitedHealthcare
Prescription Drug Benefit
Prescription Drug Benefit
Durable Medical Equipment Benefit*
Prescription Drug Benefit
Durable Medical Equipment Benefit*
Usually Durable Medical Equipment Benefit*—supplies containing insulinare covered under Prescription Drug Benefit
*Pre-service notification is required for Durable Medical Equipment and diabetes equipment in excess of $1,000
All Plans Call your Word & Brown representative
Call your Word & Brown representative
Call your Word & Brown representative
121
w w w. w o r d a n d b r o w n . c o m
CONSUMERDIRECTED
PLANS
$4,000
$4,500
Health Plan Plan Name Co-pay/Co-insurance
Deductible Rx Coverage*
Small Group Plans
Anthem BlueCross
Blue Shield
Shield Savings 2250/4500
Shield Savings 2500
✓✓✓
✓
✓✓
Ded / 80%
Ded / 80%
Ded / $10, $30, $50
Ded / $10, $30, $50
Ded / 80%
Ded / 80%
Lumenos HSA 2500 80/50 Ded / 80% Ded / $10, $30, $50 Ded / 80%$2,500
$2,250
$2,000 Shield Savings 2000/4000 ✓Ded / 100% Ded / 100% Ded / 100%$2,000
$2,500
$5,000
High Deductible EPO ✓✓✓Ded / 80% Ded / $10, $25, 30% Ded / 80%$2,000
Lumenos HSA 1500 80/50 Ded / 80% Ded / $10, $30, $50 Ded / 80%$1,500
$3,100
$3,000
✓Lumenos HSA 2000 100/70 Ded / 100% Ded / 100% Ded / 100%$2,000 $2,000
✓Lumenos HSA 3500 80/50 Ded / 80% Ded / $10, $30, $50 Ded / 80%$3,500 $5,000
✓Lumenos HSA 3000 100/70 Ded / 100% Ded / 100% Ded / 100%$3,000 $3,000
PPO 2400 Ded / $35 Ded / $10, $25, 20% Ded / 80%$2,400
PPO 3500 Ded / $35 Ded / $10, $25, 30% Ded / 100%$3,500
$3,600
✓Lumenos HSA 5000 100/70 Ded / 100% Ded / $10, $30, $50 Ded / 100%$5,000 $5,800
$4,000
Shield Savings 1800/3600 ✓Ded / 100% Ded / 100% Ded / 100%$1,800 $1,800
Shield Savings 3000/6000 ✓Ded / 100% Ded / 100% Ded / 100%$3,000 $3,000
Shield Savings 4800 ✓Ded / 100% Ded / 100% Ded / 100%$4,800 $4,800
$5,600
$4,500
HSA California
HMO HSA 2200
HMO HSA 2600
✓✓
Ded / $20
Ded / $30
Ded / $10, $20
Ded / $10, $30
Ded / 75%
Ded / 70%
$2,200
$2,600
HMO HSA 1800
✓
Ded / 100% Ded / 100% Ded / 100%$1,800 $1,800
HMO HSA 2800B
✓
Ded / $40 Ded / $10, $30, $50 Ded / $500 per day$2,800 $4,000
HSA 2500
✓
Ded / $25 Ded / $15, $30, $50 $250 / Ded / 70%$2,500 $5,000
HSA 3500
✓
Ded / $35 Ded / $15, $30, $50 $250 / Ded / 70%$3,500 $5,000
HSA 4500
✓
Ded / $45 Ded / $15, $30, $50 $250 / Ded / 60%$4,500 $5,600
✓
MC HDHP $3,000 80/50 ✓Ded / 80% Ded / $20, $40, $70 Ded / 80%$3,000 $4,500
Aetna
Hospital withHRA
Max Out Of Pocket
withHSA
Carrier-approved for sale
MC HDHP $2,300 80/50 ✓Ded / 80% Ded / $20, $40, $70 Ded / 80%$2,300 $4,000
MC HDHP $3,000 100/50
✓Ded / 100% Ded / $20, $40, $70 Ded / 100%$3,000 $4,000
MC HDHP $3,300 80/50
✓
HMO Ded $1,000 ✓$40 Ded / $20, $40, $60 Ded / 70%$1,000 $3,500
Ded / 80% Ded / $20, $40, $70 Ded / 80%$3,300 $5,000
✓
✓
Protect HSA 2850
CaliforniaChoice HSA 1500***
Ded / 70%
Ded / 80%
Ded / 70% Ded / 70%
Ded / 80%Ded / $15
$2,850
$1,500
✓✓✓✓
✓
$5,500
✓CalCPA Protect HSA 1500 Ded / 70% Ded / 70% Ded / 70%$1,500 $4,500
✓
Health Net
Value HSA 1500 Ded / $10 Ded / $10, $25, $50 Ded / 80%$1,500 $2,500
✓Value HSA 2500 Ded / $20 Ded / $15, $30, $50 $250 / Ded / 80%$2,500 $3,500
✓HRA 3000 Ded / 80% Ded / $10, $25, $50 Ded / 80%$3,000 $4,000
✓HRA 5000 Ded / 80% Ded / $10, $25, $50 Ded / 80%$5,000 $6,000
✓✓
Value HSA 3500
Value HSA 4500
Ded / $30
Ded / $40
Ded / $15, $30, $50
Ded / $15, $30, $50
$250 / Ded / 70%
$500 / Ded / 50%
$3,500
$4,500
$4,500
$5,000
Options PPO 3000 HSA
Options PPO 4000 HSA
Ded / $25
Ded / $35
Ded / $15, $30, $50
Ded / $15, $30, $50
$250 / Ded / 70%
$250 / Ded / 60%
$3,000
$4,000
$4,000
$5,000
Standard HSA 2000 Ded / 100% Ded / 100% Ded / 100%$2,000 $2,000
Standard HSA 3000 Ded / 100% Ded / 100% Ded / 100%$3,000 $3,000
Standard HSA 4000 Ded / 100% Ded / 100% Ded / 100%$4,000 $4,000
$2,800
✓HSA 2400*** Ded / 80% Ded / $15 Ded / 80%$2,400 $3,200
KaiserPermanente
✓✓
$30 / $1,500 Ded Plan w/HRA
$30 / $2,500 Ded Plan w/HRA
Ded / $30
Ded / $30
$10, $250 Rx BrandDed / $35, NA
$10, $250 Rx BrandDed / $35, NA
Ded / 80%
Ded / 80%
$1,500
$2,500
$3,000
$5,000
✓
HSA $0 / $1,500 Ded / 100% Ded / 100% Ded / 100%$1,500 $1,500
✓
HSA $0 / $2,200 Ded / 100% Ded / 100% Ded / 100%$2,200 $2,200
✓
HSA $0 / $2,700 Ded / 100% Ded / 100% Ded / 100%$2,700 $2,700
HSA $30 / $2,700 Ded / $30 Ded / $10, $35, NA Ded / 70%$2,700 $5,250
HSA 2400*** Ded / $30 Ded / $10, $30, NA Ded / 80%$2,400 $3,200
KaiserPermanenteChoice Solution
HSA 1400*** Ded / 100% Ded / 100% Ded / 100%$1,400 $1,400
HSA 2200*** Ded / $40 Ded / $15, $35, NA Ded / 70%$2,200 $4,000
✓✓
✓
✓Protect HSA 2500 Ded / 100% Ded / 100% Ded / 100%$2,500 $2,500
✓Lumenos HSA 1500 100/70 Ded / 100% Ded / $10, $30, $50 Ded / 100%$1,500 $3,000
✓HSA PPO $40 / $2,500 Ded / $40 Ded / $15, $35, NA Ded / 70%$2,500 $5,000
✓Spectrum PPO Plan 3000 HRA Ded / 80% Ded / 80%Ded / $15, $30, $15$3,000 $6,000
✓
Consumer Directed Health Plans (CDHP)(November 2009)
123
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wordandbrown.com(Continued on following page)
124
Consumer Directed Health Plans (CDHP)
Word & Brown offers more to California’s brokerthan any other General Agency.
With Consumer Directed Health Plans, employers reduce monthlypremium and employees increase control over how their healthcaredollars are spent. Word & Brown can provide you with qualityinformation to help make decisions that are right for your client’sbudgets and needs.
Word & Brown Consumer Directed Health Plan Reference Tool – Answers your questions about HRAs, HSAs,FSAs and lists many of the expenses that typically qualify under these plans.
Tools you should be using today –
What Expenses Typically Qualify* Under An HRA, HSA, or FSA?HRAs and Health FSAs are subject to Code Section 105 generally; therefore, only expenses that qualify as medical care
under Code Section 213(d) are eligible for reimbursement, subject to some additional restrictions:• In accordance with Code Section 106, HRAs cannot reimburse expenses for qualified long term care services• In accordance with Code Section 106 and 125, Health FSAs cannot reimburse expenses for qualified long term
care services and/or insurance premiumsHSAs are subject to Code Section 223; therefore, only expenses that qualify as “medical care” under Code Section 213(d)
are eligible for tax free reimbursement except as otherwise limited by Code Section 223:• No insurance premiums except for long term care premiums, COBRA premiums, health coverage received whilereceiving unemployment compensation, and any deductible health insurance coverage for individuals who areage 65 or older, other than Medicare Supplemental Policies.
Medical Expenses:
Fees paid to the following providers for treatment of a specific disease:
• Acupuncture• Ambulance hire• Artificial limbs and teeth• Automobile modifications (handcontrols, special equipment, mechanicallifts if for handicapped persons)• Braille books & magazines• Contact lenses & solutions• Crutches/slings
• Doctor copays• Examination, physical• Eye examination
• Eyeglasses• Hearing devices• Hospital bills for medical care• Iron lungs, operating cost• Laetrile, when prescribed by doctor• Laser eye surgery• Lip reading lessons for the hearing impaired• Eligible over-the-counter
(OTC) medications*• Nursing care• Obstetrical expenses
• Operation• Oxygen equipment• Prescription drugs for medical care• Rental of medical or healing equipment(requires doctor’s note)• Seeing-eye dogs• Telephones for the hearing impaired• Transportation expense relative to illness(including doctor’s office)• X-Rays
• Chiropodist (expense)• Chiropractor• Clinic• Dentist• Doctor• Gynecologist• Hospital• Laboratory• Midwife• Nurse
• Obstetrician• Oculist• Ophthalmologist• Optician• Optometrist• Oral Surgeon• Osteopath• Pediatrician• Physician• Physiotherapist
• Podiatrist• Practical nurse• Psychiatrist• Psychoanalyst• Psychologist• Psychopathologist• Sanitarium• Specialist• Surgeon
Common expenses that are not eligible for reimbursement include: Cosmetic surgery for non-medical reasons (including liposuction, hair transplants
and electrolysis), weight loss programs (unless physician prescribed for treatment of a specific illness including obesity) and orthodontia services not
received during the plan year.FSA expenses must be incurred (i.e. services rendered) during the plan year.Funds can be withdrawn from an HSA Account for other purposes; however, the withdrawal amount will be subject to taxes and penalties. Please
consult your tax advisor.*The information in this document represents a summary of information only and does not constitute a guarantee of any benefit nor limit CONEXIS’
ability to require additional substantiation of a claim. Please refer to the plan summary that your Health Plan will provide for complete details on
the plan’s benefits, limitations and exclusions for your selected plan. For details concerning your rights and responsibilities with respect to your HSA
(including information concerning the terms of eligibility, qualifying High Deductible Health Plan, contributions to the HSA, and distributions from the
HSA), please refer to your HSA Custodial Agreement. OTC list available on request.
Qualified expenses must be for out-of-pocket medical care for the diagnosis, cure, mitigation, treatment or prevention of
disease, or for the purpose of affecting any structure or function of the body.
Northern California 800.255.9673 ■ Inland Empire 877.225.0988 ■ Los Angeles 800.560.5614 ■ Orange 800.869.6989 ■ San Diego 800.397.3381
www.wordandbrown.comWB7108B.7.09
Employer funded medical expense
reimbursement plan for qualifying
medical expenses
Employer and/or Employee funded
account in the Employee’s name
(eligible individual) for current and
future medical expenses – requires a
High-deductible Health Plan and a
qualified trustee or custodian
Definition
Employee and/or employer
funded account for qualifying
medical expenses
Any Size Group
(Only common-law employees can
participate on a tax free basis.)
Any Size Employer
(Only eligible individuals can
establish an HSA).
Qualifications
Any Size Group
(Only common-law employees
can participate.)
Contributions are Tax Deductible when paid to
the participant to reimburse an expense
Contributions are Tax Deductible in the
year the contribution is made
Employer Tax Savings
Contributions are Tax Deductible when
paid to the participant to reimburse an
expense. As a result of salary reductions,
lower adjusted Employee income
reduces Employer matching FICA
& Federal Unemployment
An HRA is not subject to a minimum
deductible. An HRA may be offered in
conjunction with high deductible health
plan; however, deductible amount
established by employer.
$1,200 min (single)
$2,400 min (family)
Deductibles(2010)
A health FSA is not subject to a minimum
deductible. A health FSA may be offered in
conjunction with a high deductible health
plan; however, the deductible amount is
established by Employer.
Employer Sets Funding Levels
Maximum Out-of-Pocket
(2010)
Employer Sets Funding Levels
Employer
Employer, Employee, and for any
other Individuals
Source of Funding
Employer & Employee
Employer (unless benefits paid
from a trust)
Employee (eligible individual name on
the established trust account)
Who Owns
Unused Funds?
If funds attributable to employee
pre-tax salary reductions, the plan owns
(if an ERISA plan)
Can be offered alone or in conjunction
with a major medical plan.
Allows otherwise unreimbursed Code
213(d) medical expenses including health
insurance premiums. May not reimburse
expenses for qualified long term care
services. Employer may restrict scope of
reimbursements by plan design
(many plans limit reimbursement to
deductibles, co-payments, coinsurance).
If participant also has an HSA, the HRA
must be limited to the following: qualified
dental expenses, vision expenses, expenses
constituting preventive care, Premiums,
“suspended HRA”, and retiree only HRA.
Can only be established by those who
have qualifying high deductible health
plan coverage (deductible must meet
statutory limit) and no disqualifying non-
high deductible health plan coverage.
Employees who are entitled to Medicare
cannot establish or contribute to an HSA.
Allows otherwise unreimbursed medical
Code Section 213(d) expenses excluding
most premiums. An employer cannot
restrict the scope of HSA distributions
except for expenses paid with an
electronic payment card so long as account
beneficiary has other means to obtain
funds from HSA. Qualified expenses must
be incurred after the HSA is established.Allowable Expenses
& Plan Restrictions
Can be offered alone or in conjunction
with a major medical plan.
Allows otherwise unreimbursed Code
213(d) medical expense excluding
premiums and qualified long term
care services.
Employer may restrict scope of
reimbursements by plan design.
If participant also has an HSA, the FSA
must be limited to the following:
qualified dental expenses, vision
expenses, and expenses constituting
preventive care.
No (however, it may have a
post-termination spend-down feature.)
Yes – funds belong to the Employee
(eligible individual)
Is Fund Portable?
No
Yes
Yes
Prescription Co-pay
Yes
CONEXIS
Insurance Co, Bank, TPA
Administration
CONEXIS
Yes, if Employer specifies
Yes
Do Funds Rollover?
No* – however, an employer may establish a grace
period that follows the end of the plan year during
which unused amounts allocated to the FSA may
be used to reimburse eligible expenses incurred
during the grace period. The grace period may
not exceed two months and fifteen days.
Not required to prefund – uniform
coverage rule does not apply
Funds must be present before withdrawal
is made. Employer may contribute to
HSA periodically or all at once.
Funding Requirement
Uniform coverage rule applies – claims
must be paid without regard to
amount contributed
No
Taxable and Subject to 10% Penalty
(no penalty if age 65 or older or
disabled as defined by Code Section 72)
Non-medical Expense
Withdrawals
No
Reimbursements for
eligible expenses are excluded
from income
Contributions can be Pre-Tax or are Tax
Deductible on the Employee’s personal
tax return. Funds earn interest tax-free.
Reimbursements for qualified medical
expenses are excluded from income.
Employee may withdraw funds for
non-medical expenses subject to
income and excise tax.
Employee Tax Savings
Contributions are made Pre-Tax.
Reimbursements for eligible expenses
are excluded from income.
The information in this document represents a summary of the information only as of the date referenced below and does not constitute a guarantee of any benefit nor limit CONEXIS’ ability to require
additional substantiation of a claim. Refer to the published IRS documents for specifics. Health FSAs and HRAs are covered under IRS Section 105 and 106. Health FSAs are subject to additional rules set
forth in the regulations under IRS Code Section 125. HRAs are subject to additional rules set forth in Notice 2002-45 and Rev. Rul. 2002-41. HSAs were established under the Medicare Reform Package,
covered under IRS Code Section 223.
* As part of the Tax Relief and Health Care Act of 2006, HSAs can now be funded with a one-time tax free rollover from an existing FSA or HRA (a "Qualified HSA Distribution") provided certain conditions are satisfied
(this provision is effective upon enactment but expires January 1, 2012).
**Maximum contribution requires either full year eligibility or initial eligibility as of 12/01 and continuation of eligibility throughout the following year.
No – however, an employer may
establish annual plan limits.
Maximum Statutory
Contribution**
(2010)
No – however, an employer may
establish annual plan limits.
Northern California 800.255.9673 ■ Inland Empire 877.225.0988 ■ Los Angeles 800.560.5614 ■ Orange 800.869.6989 ■ San Diego 800.397.3381www.wordandbrown.com
WB7108B.7.09
$5,950 min (single)
$11,900 min (family)
$3,050 max (single)
$6,150 max (family)
$1,000 max (catch up contribution
for individuals age 55 or over)
HRA
Health Reimbursement Arrangement
HSAHealth Savings Account
FSAFlexible Spending Account
Health Plan Plan Name Deductible Rx Coverage*
Anthem Blue Cross PPO 3500 (HSA)
Blue Shield Shield Spectrum PPOSavings Plan 1800
✓
✓
✓✓
✓
Ded / $35
Ded / 100%
Ded / $10, $30, 50%
Ded / $10, $30, 50%
Ded / 70%
Ded / 100%
$1,800
$3,500
Hospital Max Out Of Pocket
Individual and Family Plans
Health NetFarm Bureau
CFB Saver ll 1800 HSA Ded / 100% Ded / 100% Ded / 100%$1,800
CFB Saver ll 2800 HSA Ded / 100% Ded / 100% Ded / 100%$2,800
CFB Saver ll 4800 HSA Ded / 100% Ded / 100% Ded / 100%$4,800
$5,600
Shield Spectrum PPOSavings Plan 5200
✓Ded / 100% Ded / 100% Ded / 100%$5,200 $5,200
Shield Spectrum PPOSavings Plan 4000
✓Ded / 100% Ded / 100% Ded / 100%$4,000 $4,000
$5,000
Health Net Optimum AdvantageHSA 2500
✓Ded / 100% Ded / 100% Ded / 100%$2,500 $2,500
Optimum AdvantageHSA 4500 ✓Ded / 100% Ded / 100% Ded / 100%$4,500 $4,500
N/A
N/A
N/A
Co-pay /Co-insurance
✓✓
HSA 1500 Ded / 100% Ded / 100% Ded / 100%$1,500
HSA 2700 Ded / 100% Ded / 100% Ded / 100%$2,700
$1,500
$2,700
✓HSA 5000 Ded / 100% Ded / 100% Ded / 100%$5,000 $5,000
PacifiCare
Carrier-approved for sale
✓CFB Saver ll 3800 HSA Ded / 100% Ded / 100% Ded / 100%$3,800 N/A
Aetna HSA 3000 ✓Ded / 100% Ded / 100% Ded / 100%$3,000 $3,000
HSA 5000 ✓Ded / 100% Ded / 100% Ded / 100%$5,000 $5,000
✓Shield Spectrum PPOSavings Plan 2400 Ded / $35 Ded / $10, $30, 50% Ded / 70%$2,400 $4,000
✓Shield Spectrum PPOSavings Plan 3500 Ded / 100% Ded / $10, $35, $50 Ded / 100%$3,500 $5,000
✓✓✓
✓✓
UHC/PacifiCare
Definity HRA 2000/90%
Definity HSA 1500/80%
Ded / 90%
Ded / 80%
$10/$35, $60 after$250 Rx Ded
Ded / $10, $30, $50
Ded / 90%
Ded / 80%
$2,000
$1,500
$5,000
$3,000
Definity HSA 2000/100%
Definity HSA 2850/80% –Embedded
Ded / 100%
Ded / 80%
Ded / $10, $30, $50
Ded / $10, $30, $50
Ded / 100%
Ded / 80%
$2,000
$2,850
$4,000
$3,500
Definity HSA 3000/70%
Ded / 80%
Ded / 70%
Ded / $10, $30, $50
Ded / $10, $30, $50
Ded / 80%
Ded / 70%
$2,850
$3,000
$3,500
$5,000
withHRA
withHSA
Health Plan Plan Name Co-pay/Co-insurance
Deductible Rx Coverage*
Small Group Plans
Hospital withHRA
Max Out Of Pocket
withHSA
Carrier-approved for sale
✓Definity HSA 3500/70% Ded / 70% Ded / $10, $30, $50 Ded / 70%$3,500 $5,000
Definity HSA 2850/80% –Non-Embedded
✓
Definity HRA 2000/70% Ded / 70%$10/$35, $60 after
$250 Rx Ded Ded / 70%$2,000 $5,000 ✓
Definity HRA 1500/80% Ded / 80% $10/$35, $60 after$250 Rx Ded Ded / 80%$1,500 $6,000 ✓
Definity HRA 2500/80% Ded / 80%$10/$35, $60 after
$250 Rx Ded Ded / 80%$2,500 $6,000 ✓
Definity HRA 3000/70% Ded / 70% $10/$35, $60 after$250 Rx Ded Ded / 70%$3,000 $6,000 ✓
* Generic Formulary, Brand Formulary, Brand Non-Formulary.** Group may receive a self funding factor load.
*** HSA - Qualified High Deductible Health Plan.† Maximum 3 doctor visits per member per year.
This summary is for general comparison purposes only. Please refer to the Evidence of Coverage orCertificate of Insurance for a detailed description of coverage benefits and limitations.
125
w w w. w o r d a n d b r o w n . c o m
Northern California 800.255.9673 ■ Inland Empire 877.225.0988 ■ Los Angeles 800.560.5614 ■ Orange 800.869.6989 ■ San Diego 800.397.3381
wordandbrown.com
Employer funded medical expensereimbursement plan for qualifying
medical expenses
Employer and/or Employee fundedaccount in the Employee’s name
(eligible individual) for current and future medical expenses – requires aHigh-deductible Health Plan and a
qualified trustee or custodian
DefinitionEmployee and/or employer
funded account for qualifying medical expenses
Any Size Group (Only common-law employees can
participate on a tax free basis.)
Any Size Employer(Only eligible individuals can
establish an HSA).Qualifications
Any Size Group(Only common-law employees
can participate.)
Contributions are Tax Deductible when paid tothe participant to reimburse an expense
Contributions are Tax Deductible in theyear the contribution is madeEmployer Tax Savings
Contributions are Tax Deductible whenpaid to the participant to reimburse anexpense. As a result of salary reductions,
lower adjusted Employee income reduces Employer matching FICA
& Federal Unemployment
An HRA is not subject to a minimum deductible. An HRA may be offered in
conjunction with high deductible healthplan; however, deductible amount
established by employer.
$1,200 min (single)$2,400 min (family)
Deductibles(2010)
A health FSA is not subject to a minimumdeductible. A health FSA may be offered inconjunction with a high deductible healthplan; however, the deductible amount is
established by Employer.
Employer Sets Funding LevelsMaximum Out-of-Pocket
(2010) Employer Sets Funding Levels
Employer Employer, Employee, and for any
other IndividualsSource of Funding Employer & Employee
Employer (unless benefits paid from a trust)
Employee (eligible individual name onthe established trust account)
Who Owns Unused Funds?
If funds attributable to employee pre-tax salary reductions, the plan owns
(if an ERISA plan)
Can be offered alone or in conjunctionwith a major medical plan.
Allows otherwise unreimbursed Code213(d) medical expenses including healthinsurance premiums. May not reimburse
expenses for qualified long term careservices. Employer may restrict scope of
reimbursements by plan design (many plans limit reimbursement to
deductibles, co-payments, coinsurance).
If participant also has an HSA, the HRAmust be limited to the following: qualifieddental expenses, vision expenses, expenses
constituting preventive care, Premiums,“suspended HRA”, and retiree only HRA.
Can only be established by those whohave qualifying high deductible healthplan coverage (deductible must meet
statutory limit) and no disqualifying non-high deductible health plan coverage.
Employees who are entitled to Medicarecannot establish or contribute to an HSA.
Allows otherwise unreimbursed medicalCode Section 213(d) expenses excluding
most premiums. An employer cannotrestrict the scope of HSA distributions
except for expenses paid with anelectronic payment card so long as account
beneficiary has other means to obtainfunds from HSA. Qualified expenses mustbe incurred after the HSA is established.
Allowable Expenses & Plan Restrictions
Can be offered alone or in conjunctionwith a major medical plan.
Allows otherwise unreimbursed Code213(d) medical expense excludingpremiums and qualified long term
care services.
Employer may restrict scope ofreimbursements by plan design.
If participant also has an HSA, the FSA must be limited to the following:qualified dental expenses, vision
expenses, and expenses constitutingpreventive care.
No (however, it may have a post-termination spend-down feature.)
Yes – funds belong to the Employee(eligible individual)Is Fund Portable? No
Yes YesPrescription Co-pay Yes
CONEXIS Insurance Co, Bank, TPAAdministration CONEXIS
Yes, if Employer specifies YesDo Funds Rollover?
No* – however, an employer may establish a graceperiod that follows the end of the plan year duringwhich unused amounts allocated to the FSA maybe used to reimburse eligible expenses incurredduring the grace period. The grace period may
not exceed two months and fifteen days.
Not required to prefund – uniformcoverage rule does not apply
Funds must be present before withdrawal is made. Employer may contribute to
HSA periodically or all at once.Funding Requirement
Uniform coverage rule applies – claims must be paid without regard to
amount contributed
NoTaxable and Subject to 10% Penalty
(no penalty if age 65 or older or disabled as defined by Code Section 72)
Non-medical ExpenseWithdrawals
No
Reimbursements for eligible expenses are excluded
from income
Contributions can be Pre-Tax or are TaxDeductible on the Employee’s personaltax return. Funds earn interest tax-free.Reimbursements for qualified medicalexpenses are excluded from income.Employee may withdraw funds for non-medical expenses subject to
income and excise tax.
Employee Tax SavingsContributions are made Pre-Tax.
Reimbursements for eligible expenses are excluded from income.
The information in this document represents a summary of the information only as of the date referenced below and does not constitute a guarantee of any benefit nor limit CONEXIS’ ability to requireadditional substantiation of a claim. Refer to the published IRS documents for specifics. Health FSAs and HRAs are covered under IRS Section 105 and 106. Health FSAs are subject to additional rules setforth in the regulations under IRS Code Section 125. HRAs are subject to additional rules set forth in Notice 2002-45 and Rev. Rul. 2002-41. HSAs were established under the Medicare Reform Package,covered under IRS Code Section 223.
* As part of the Tax Relief and Health Care Act of 2006, HSAs can now be funded with a one-time tax free rollover from an existing FSA or HRA (a "Qualified HSA Distribution") provided certain conditions are satisfied(this provision is effective upon enactment but expires January 1, 2012).
**Maximum contribution requires either full year eligibility or initial eligibility as of 12/01 and continuation of eligibility throughout the following year.
No – however, an employer may establish annual plan limits.
Maximum StatutoryContribution**
(2010)No – however, an employer may
establish annual plan limits.
$5,950 min (single)$11,900 min (family)
$3,050 max (single)$6,150 max (family)
$1,000 max (catch up contribution for individuals age 55 or over)
HRAHealth Reimbursement Arrangement
HSAHealth Savings Account
FSAFlexible Spending Account
Northern California 800.255.9673 ■ Inland Empire 877.225.0988 ■ Los Angeles 800.560.5614 ■ Orange 800.869.6989 ■ San Diego 800.397.3381
wordandbrown.com
What Expenses Typically Qualify* Under An HRA, HSA, or FSA?
HRAs and Health FSAs are subject to Code Section 105 generally; therefore, only expenses that qualify as medical careunder Code Section 213(d) are eligible for reimbursement, subject to some additional restrictions:
• In accordance with Code Section 106, HRAs cannot reimburse expenses for qualified long term care services• In accordance with Code Section 106 and 125, Health FSAs cannot reimburse expenses for qualified long term
care services and/or insurance premiums
HSAs are subject to Code Section 223; therefore, only expenses that qualify as “medical care” under Code Section 213(d)are eligible for tax free reimbursement except as otherwise limited by Code Section 223:
• No insurance premiums except for long term care premiums, COBRA premiums, health coverage received whilereceiving unemployment compensation, and any deductible health insurance coverage for individuals who areage 65 or older, other than Medicare Supplemental Policies.
Medical Expenses:
Fees paid to the following providers for treatment of a specific disease:
• Acupuncture• Ambulance hire• Artificial limbs and teeth• Automobile modifications (hand
controls, special equipment, mechanicallifts if for handicapped persons)
• Braille books & magazines• Contact lenses & solutions• Crutches/slings• Doctor copays• Examination, physical• Eye examination
• Eyeglasses• Hearing devices• Hospital bills for medical care• Iron lungs, operating cost• Laetrile, when prescribed by doctor• Laser eye surgery• Lip reading lessons for the
hearing impaired• Eligible over-the-counter
(OTC) medications*• Nursing care• Obstetrical expenses
• Operation• Oxygen equipment• Prescription drugs for medical care• Rental of medical or healing equipment
(requires doctor’s note)• Seeing-eye dogs• Telephones for the hearing impaired• Transportation expense relative to illness
(including doctor’s office)• X-Rays
• Chiropodist (expense)• Chiropractor• Clinic• Dentist• Doctor• Gynecologist• Hospital• Laboratory• Midwife• Nurse
• Obstetrician• Oculist• Ophthalmologist• Optician• Optometrist• Oral Surgeon• Osteopath• Pediatrician• Physician• Physiotherapist
• Podiatrist• Practical nurse• Psychiatrist• Psychoanalyst• Psychologist• Psychopathologist• Sanitarium• Specialist• Surgeon
Common expenses that are not eligible for reimbursement include: Cosmetic surgery for non-medical reasons (including liposuction, hair transplantsand electrolysis), weight loss programs (unless physician prescribed for treatment of a specific illness including obesity) and orthodontia services notreceived during the plan year.
FSA expenses must be incurred (i.e. services rendered) during the plan year.
Funds can be withdrawn from an HSA Account for other purposes; however, the withdrawal amount will be subject to taxes and penalties. Pleaseconsult your tax advisor.
*The information in this document represents a summary of information only and does not constitute a guarantee of any benefit nor limit CONEXIS’ability to require additional substantiation of a claim. Please refer to the plan summary that your Health Plan will provide for complete details onthe plan’s benefits, limitations and exclusions for your selected plan. For details concerning your rights and responsibilities with respect to your HSA(including information concerning the terms of eligibility, qualifying High Deductible Health Plan, contributions to the HSA, and distributions from theHSA), please refer to your HSA Custodial Agreement. OTC list available on request.
Qualified expenses must be for out-of-pocket medical care for the diagnosis, cure, mitigation, treatment or prevention ofdisease, or for the purpose of affecting any structure or function of the body.
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Planning
During this phase, there is fact-finding and analysis betweenCONEXIS and the client toidentify past problems, currentissues, and future concerns andto gain an understanding of theobjectives of the implementationprocess.
IMPLEMENTATION PROJECT OVERVIEW
Phase IFACT FINDING
Executing
Phase IISYSTEM DEVELOPING
Monitoring & Controlling
Phase IIIAUDITING
Closing
Phase ITRANSITIONING
Objectives of Phase I of theImplementation Project are:
· Scheduling a kick-off call to introduce the partiesinvolved, their positions and titles, and theirresponsibilities in theimplementation process.
· Gathering information,which is a critical, on-goingpart of the implementationprocess.
· Understanding anddocumenting the businessrules that define and governthe business needs andrequirements of the client.
· Understanding what isneeded for system setup ofthe client.
· Setting a timeframe forweekly status calls toaddress issues that mayarise during the processand to make and documentdecisions about theprocess.
· Creating a project plan thatis updated throughout theprocess detailing tasks,responsibilities, dates, andmilestones.
During the phase, the BusinessRequirements gathered inPhase I are converted toSystem Requirements. Withanalysis complete, designing,constructing, and testing areperformed.
Objectives of Phase II of theImplementation Project are:
· Designing account structure(i.e., plans and rates forCOBRA; maximums andminimums for FSA) toensure consistency between the client, CONEXIS, and the carriers.
· Building account structurein system.
· Scheduling file specificationmeeting(s) between ITcontacts from CONEXISand client.
· Testing both inbound andoutbound eligibility datatransfer.
· Working with third parties asneeded
During this phase, the ProjectPlan is reviewed to ensure thatproject deliverables andmilestones have been met. Bothquantitative and qualitativemeasures are performed.
Objectives of Phase III of theImplementation Project are:
· Auditing by CONEXIS,which consists of threetollgates to ensure accuracyof information concerningbusiness rules, data, andfiles.
· Auditing by client, whichincludes sign-off of issues.
· Web site training.
Throughout the ImplementationProject, the AccountRepresentative is involved,taking part in meetings andcalls, gaining an understandingof the business rules defined bythe client. This ensures thattransition is as seamless aspossible.
Objectives of Phase IV of theImplementation Project are:
· “Going live” with productionsystem allowing webaccess for client andparticipants.
· Transitioning withinCONEXIS fromImplementation to ClientServices.
· Signing-off of project byinvolved parties.
· Reviewing lessons learned.
Note: This is intended as a high-level overview. As the project progresses and questions arise, the CONEXIS Implementation Team isavailable to answer any questions via telephone at (800) 869-6989, X 2400
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DENTAL
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Are there anyindustries that are
ineligible?
Are there anyindustries that
receive anautomatic rate
load?
Do you offer OpenEnrollment to DMO
& DPO groups attheir anniversary
each year?
At OpenEnrollment, do
members have anyrestrictions (such asreduced benefits ora waiting period)?If yes, please providebrief explanation of
restriction:
Is there a waitingperiod for majorservices for newhires (includingEnrollees who
initially waived thewaiting period)?
Aetna
Allied National
BEST Life& Health
Insurance
Blue Shield
CaliforniaChoice®
Delta Dental
Delta Dental/Morgan White
Freedom DentalPlans
(BEN-E-LECT)
DENTAL PLAN COMPARISON CHART
Yes Yes DMO:N/A
DPO:Yes
Yes—Groups with 2-4enrolled will have 12
month wait. 5+ waivedwith prior coverage.
10+ waived automatically
Yes—see WaitingPeriod/Takeover
section on page 140
Golden West
No Yes—see specialconsiderations section
on page 138 for acomplete listing
N/A N/A 12 month wait for major services
No No N/A N/A N/A
Yes—if writtenstandalone
No Enrollment is possible for any
employee to elect dentalplan coverage during
the first 31 days of initial eligibility
An employee or dependent whodoes not enroll within 31 days offirst becoming eligible (or after aqualifying life event) is subject tothe Late Entrant Provision. They would have a 12-month waiting
period for Basic & Major services; and 24-month waiting period for Orthodontia
Waiving of the waiting periodis done at the group level.
Employers with prior dentalcoverage, and their new hires,
will not be required to meet a waiting period prior toservices being rendered
Yes—see SmallEmployer Group
Sales Guide (Ineligible Categories)
No DHMO:Yes
PPO:Yes—but there could belate entrant for memberswho were not previously
enrolled
Yes—see SmallEmployer Group
Sales Guide (Late Entrant
Provision)
DHMO:No
PPO:There could be,
based on plan sold
PPO:Yes
DeltaCare USA:No
PPO:No
DeltaCare USA:Yes
Dual Choice:Yes—for switching between
plans, but not for addinglate enrollees/dependents.
PPO: N/A
Voluntary PPO:Yes—new employees are
subject to a 12 month waitingperiod regardless
of previous coverageDeltaCare USA & Dual Choice:
No
PPO:No
DeltaCare USA:No
Voluntary PPO:Yes
No No DMO:Yes
DPO:Yes
Yes—same as new hire
DMO:No
DPO:Yes
Yes—excludedindustries include
dental offices or otherorganizations
associated with the dental profession
No Yes—all plan changes are available at group anniversary
No 12 month wait for major benefits for lateenrollees and add-ons
with no prior dental plan.No waiting period forindividuals with prior
dental
No No DHMO:Yes
DPPO:Yes
No restrictions—it is a true
open enrollment
All Non-Voluntary DHMO & DPPO:
No waiting period for newhires and no waiting period
for those who initially waived(as long as they enroll duringopen enrollment). Note our
Voluntary plans do have a 12month wait for major services
all enrollees
See page 146
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DENTAL PLAN COMPARISON CHART
Are there anyindustries that are
ineligible?
NoNo DHMO:Yes
DPPO:Yes
DHMO and DPPO:No restrictions
DHMO:No
DPPO:Yes
Are there anyindustries that
receive anautomatic rate
load?
Do you offer OpenEnrollment to DMO
& DPO groups attheir anniversary
each year?
At OpenEnrollment, do
members have anyrestrictions (such asreduced benefits ora waiting period)?If yes, please providebrief explanation of
restriction:
Is there a waitingperiod for majorservices for newhires (includingEnrollees who
initially waived thewaiting period)?
Health Net
KaiserPermanente
Choice Solution
UnitedHealthcare/PacifiCare
Principal LifeInsuranceCompany
MetLife/Safeguard
SelectDent
SmileSaver
Yes—dentaloffices/dental labs
No DMO:Yes
DPO:Yes
No DMO:No
DPO:MetLife offers plans with
and without waitingperiods for major services
Yes Yes DMO:Not available
DPO:Yes—removing the
open enrollment periodis available. Call
your Word & Brownrepresentative
Yes—If a member has beenenrolled in the coverage
before, voluntarilydisenrolled and then enrolls
again (even during theopen enrollment period),he/she is subject to a late
entrant waiting period
DMO:Not available
DPO:No—waiting periods areoptional, however, andavailable upon request
through Request a Quote
HSA California® No No DMO:Yes
DPO:Yes
Yes—same as new hire
DMO:No
DPO:Yes
Yes—dental offices No—however 10% load for groups with
no prior coverage
Yes—must meetparticipation
No No Waiting Period
NoNo DHMO:Yes
PPO:Yes
No No
No No DMO:Yes
DPO:N/A
No DMO:No
DPO:N/A
Reliance Standard
YES—Dentist Offices & Labs, AssociationGroups/MembershipOrgs/Fraternal Orgs,Trusts, and Unions
YES—Jewelry-relatedBusinesses, AutomotiveDealers, Direct Selling
Businesses (House to House,Street Vendors, etc.),
Security/Commodity Dealers,Real Estate Agents/Developers,
Beauty Salons, FuneralServices, Educational Services
and Carve-Out Groups
DMO:N/A
DPO:No
DMO:Not available
DPO:No—waiting periods areoptional, however, andavailable upon request
through Request a Quote
No Open Enrollment. If aninsured is deemed a Late
Entrant, benefits are limitedto exams and cleanings for
adults and exams,cleanings, and fluoride
treatment for children forthe first 12 months
No No DHMO:Yes
DPO:Yes
DHMO:No waiting period
DHMO:No
DPO:Depends on plan
UnitedHealthcare No No DPO:Yes
No DPO:No
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Aetna
Allied National
BEST Life& Health
Insurance
Blue Shield
CaliforniaChoice®
Delta Dental
Delta Dental/Morgan White
Freedom DentalPlans
(BEN-E-LECT)
DENTAL PLAN COMPARISON CHART
DMO:N/A
DPO:Yes—in-network discount applies
Yes
No state restrictions
Yes Yes
Golden West
Do any of your plans cover/include
a discount forimplants?
Do any of your plans
cover/include adiscount for teeth
whitening?
Are employeeswho reside outside
of Californiaeligible?
Any staterestrictions?
Are 1099employees eligible?
Out of NetworkClaim Adjudication
No Yes
No state restrictions
UCR 80th Percentile(option to purchase
90th)
No No Yes
States allowed:AL, DE, DC, FL, GA,
LA, MD, MS, MT, NV,NY, PA, TX, UT & WV
Yes Yes
No50% of primaryenrollees may resideoutside of California
See page 146
DMO Access:Provides discounts fornon-covered services
DPO:No
Yes
Call your Word & Brownrepresentative
No Refer to out of networkclaim adjudication
section on page 136
DHMO:Yes—with
cosmetic rider
PPO:No
No DHMO:No
PPO:Yes
No state restrictions
Yes Either MAC or UCR on PPO
No DMO:No
DPO:Yes
No DMO:N/A
DPO:UCR
No No Yes
Call your Word & Brownrepresentative to
determine any staterestrictions
Yes—if they work full-time for one
employer
2 Options:PPO Network
Allowance or
80th percentile of UCR
No Yes
No state restrictionson DPPO plans
No OON adjudication forDPPO is MAC or UCR
depending uponplan.
Discount benefit only
DMO:N/A
DPO:Yes—In-network discount applies
PPO:No
DeltaCare USA:Yes
DMO:Yes—external bleaching only
DPO:No
No
No Yes
PPO:No
DeltaCare USA:No
133
DENTAL PLAN COMPARISON CHART
Health Net
KaiserPermanente
Choice Solution
UnitedHealthcare/PacifiCare
Principal LifeInsuranceCompany
MetLife/Safeguard
SelectDent
SmileSaver
DENTAL PLAN COMPARISON CHART
Do any of your plans cover/include
a discount forimplants?
Do any of your plans
cover/include adiscount for teeth
whitening?
Are employeeswho reside outside
of Californiaeligible?
Any staterestrictions?
Are 1099employees eligible?
Out of NetworkClaim Adjudication
DMO:No
DPO:Yes—groups of 10+
DMO:Yes—the SGX seriescovers whitening at aspecified copayment
DPO:No
DMO:Employees residing in
CA, TX or FL can accessDMO benefit
DPO:Yes – National Network
DMO:No
DPO:No
DMO:N/A
DPO:80th percentile is standard.MAC, 70th, 90th and 99th
UCR plans available
DMO:Not available
DPO:No—but implant coverage
is available as a majorservice or through aseparate benefit rider
DMO:Not available
DPO:No—but coverage
for teeth whitening isavailable through a
separate benefit rider
Yes
Benefit and ratingrestrictions may apply
No Call your Word & Brown
representative for other percentiles
DHMO:teeth whitening
covered with a copayment
DPPO:Not covered
No DHMO:No—DHMO coverage
is for CA employees only
DPPO:Yes—there are
no state restrictions
Yes 80th percentile of UCR
Yes—on the Voluntary
Deluxe Plus
N/A YesNo state restrictions;
as long as the company is
based in California it willcover all employees
Yes—as long as thecompany can show
that at least twoemployees are on
the payroll
Yes—80th percentile on the Deluxe and
Deluxe Plus
DHMO:External bleaching
only
PPO:No
No DHMO:No
PPO:Yes
No DHMO:No
PPO:UCR
DMO:No
DPO:N/A
DMO:No
DPO:N/A
No Yes N/A
Reliance Standard
DMO:N/A
DPO:No
DMO:N/A
DPO:No
Yes
No state restrictions
Yes The out of network claimallowance level depends on ifthe Managed Care Option isquoted. If the Managed CareOption is chosen, then the outof panel allowance is MAC. Ifthe Managed Care Option isnot chosen, then the out of
panel allowance is U & C 80th
No No No Determined byemployer
PPO & Indemnity: Out of network claims
are paid based on the 80th percentile
of MDR
HSA California® No DMO:No
DPO:Yes
No DMO:N/A
DPO:UCR
DMO:Yes—external bleaching only
DPO:No
UnitedHealthcare DPO:No
DPO:No
Yes—either PPO orIndemnity available in
all 50 states
Yes—no more than25% of the enrolled
population
N/A
NOTE: Contributory Plans are available to groups of 2 if sold with Aetna medical; Voluntary is down to 3 with medical
* When using the Freedom of Choice plans, members may switch between the DMO and PPO plans on amonthly basis by calling member services. Plan changes must be made by the 15th of the month to beeffective the following month.
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH)
California HMO Counties:
Boxes containing a number indicate that these coordinate plans offered by this carrier can bewritten together to create a dual option package. The number indicates the minimum enroll-ment required on each of the coordinate plans. Blank boxes indicate which plans cannot bewritten together. (No dual option available with voluntary plans.)
PROVIDER INFORMATION
Customer Service, Bilingual Support,& Broker Services877-238-6200
Commissions 877-238-6200
ClaimsP.O. Box 14094Lexington, KY 40512
Fax (Add-ons/Deletes)888-258-4528
Provider Services888-632-3862
PRODUCTS OFFERED
California PPO Counties:
California Indemnity Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
HMO Network
PPO Network
Indemnity Network
135
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Call your Word & Brown representative
Call your Word & Brown representative
Call your Word & Brown representative
Call your Word & Brown representative
Call your Word & Brown representative
Call your Word & Brown representativeDMO Access
DMO Plus
* *
* *
DMODMO AccessDMO Plus
DMO/DPPOFreedom of Choice Basic†
Freedom of Choice Plus
3-503-50
3-503-50
Contributory Plans Group Size
NOTE: Plans may not be available in all zip codes within a county. Checkwith your Word & Brown representative to confirm if coverage is avail-able for your group location.
Call your Word & Brown representative
DPPOPPO $1000 ActivePPO $1500 PPO $1500 ActivePPO $2000
3-503-503-503-50
DMOVol. DMO AccessVol. DMO PlusVol. PPO $1000 ActiveVol. PPO $1500Vol. PPO $1500 Active
3-503-503-503-503-50
Voluntary Plans Group Size
Coverage waiting period on voluntary plans: must be enrolled on plan for 12 months before becoming eligible for major services
PPO $1,000PPO $1500PPO $2000Vol. PPO $1,000
3-503-503-503-50
Out of State Plans Group Size
Waiting periods will be waived at thegroup level if prior carrier creditablecoverage is provided
PPO 1000Active
PPO 1500
PPO 1500Active
PPO 2000
*
*
*
*
Call your Word & Brown representative
Call your Word & Brown representativeCall your Word & Brown representative
Call your Word & Brown representative
Call your Word & Brown representative
DE
NT
AL
Employees
Dependents
Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statements required?
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
SPECIAL CONSIDERATIONS
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
136
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MINIMUMEMPLOYERCONTRIBUTION
3-50 Standalone (2 with Aetna medical)
3-50 Standalone (2 with Aetna medical)
12 Months
No
100% and 50% of all employees
N/A
◆◆ 75% and 50% of all employees
N/A
50%
OR
25%
No
No
No
N/A
Call your Word & Brown representative
Call your Word & Brown representative
Yes—if written standalone
Call your Word & Brown representative
No—Employer Dental Certification Form needed ifstandalone
Included for groups 10 plus. 12 month wait thencovered 50% in-network only, except for PPO Activewith a 40% out-of-network benefit. Ortho waitingperiod is waived for employees covered by thegroup’s immediately preceding dental plan. Towaive ortho wait, the group’s immediately precedingplan must have covered ortho services
PPO $1500 - Lifetime maximum $1,000PPO $2000 - Lifetime maximum $1,500
Included for groups 10 plus. DMO Plus - $2,300 copayDMO Access - $2,300 copay
Takeover coverage, where prior carrier covered major dentalservices, but excluded orthodontia: Waiting period will notapply to covered major dental services, but will apply toorthodontia (if the new Aetna plan covers orthodontia) forexisting members and new hires.
Takeover coverage, where prior carrier covered both majordental services and orthodontia: Waiting period will not applyto either major dental services or orthodontia for existingmembers and new hires.
Voluntary has an enforced 12 month waiting period on majorservices.
Freedom of Choice plans: members get to choosebetween the DMO and PPO plans on a monthly basis bycalling member services. Plan changes must be made bythe 15th of the month to be effective the following month.
DMO
PPO
Included DMO only - $2,300 copayFreedom of Choice
3-50 Standalone (2 with Aetna medical)
Freedom of Choice Basic Scheduled Fee
PPO $1000 Active, PPO $1500, PPO $1500 Active, Freedom of Choice Plus,Vol. PPO $1000 Active, Vol. PPO $1500, Vol. PPO $1500 Active UCR 80%
PPO $2000 UCR 90%
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH)
California HMO Counties:
PROVIDER INFORMATION
PRODUCTS OFFERED
California PPO Counties:
California Indemnity Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on the CAEmployer Zip code or based on Out-of-State Zip Code(and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
137
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N/A
N/A
All Counties
N/A Standard Base Indemnity** 2-99
N/A
N/A
* Employers may customize base plan benefits shown above by electing these plan options shown above (with rate factors as shown):$1500 annual maximum 1.10$2000 annual maximum 1.17$10 preventive and diagnostic copay .980 month basic services waiting period 1.22$50 deduct. (basic & major services combined) 1.06$100 lifetime deduct. (basic & major services combined) 1.02Endodontics/periodontics to Basic Svcs (10+ EEs only) 1.13Orthodontia $1500 max. benefit ($500/yr) 1.09†
90% U&C 1.04Child Sealants 1.11
No dual option available
NOTE: Plans may not be available in all zip codes within a county. Checkwith your Word & Brown representative to confirm if coverage is avail-able for your group location.
Yes
Insureds can choose any dentist forservices without penalty. However avoluntary discount network using theAIG Dental Network SM is available.Voluntary use of a dentist in thisnetwork may help reduce co-insurance costs.
HMO Network
PPO Network
Indemnity Network
Prepaid/HMO Group Size
PPO Group Size
Indemnity Group Size
†Apply to ortho rates only
**Currently not quoting on our system
N/A
All states are allowed for Out-of-State employees as long asemployer is in an approved state. Allied National is notapproved in WA and NC
Indemnity plans only - with a nationwide passive PPO network
For any "multilocation" group, contact your Word & Brownrepresentative for proper rating. We will rate based on thelocations of the multiple employers offices or Out-of-Stateemployees (i.e. salespeople who work out of their home)
N/A
N/A
DE
NT
AL
Member Support, Customer Service, & Commissions:Allied National 800-825-7531
BillingPremium DepartmentAllied NationalP. O. Box 29188Shawnee Mission, KS 66201-9188Ph. 800-825-7531 • Fax 913-945-4390
ClaimsUnited States Life Insurance Company P.O. Box 1581 Neptune, NJ 07754-1581 800-221-3480
Fax (Add-ons/Deletes)913-945-4390
General Fax #:913-945-4390
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If the group has had a comparable Indemnity/PPODental plan in force, employer may elect Takeover. If Takeover criteria is met and the employer elects it,employees and dependents currently covered by theemployer’s plan will get deductible and waitingperiod credit. Rate factor based on group size andplan design applies to groups with takeover.
Option--0 month Basic Services waiting period maybe elected by employer. Apply 1.22 factor to rates.
Indemnity Base PlansDependent children (under age 19) only. One time$50 deductible then 50% to $1000 lifetime max. perperson while insured. 12 month waiting period.
Option--$1500 lifetime max. per person ($500/year).Apply 1.09 factor to ortho rates only.
Employees
Dependents
Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statements required?
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
ORTHODONTIC COVERAGE
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
138
Yes
Yes
Yes
Same minimum group size for non-carve out group(see Products Offered section on previous page)
2-4
2-99
25%
N/A
N/A
2-99
1 Year
Yes
5-99
◆◆ 75%
◆◆ 50%
100%
100%
100%
50%
Pre-authorization required for all services over $300.
100% family-related groups are now eligible for coverage with a 20%rate load.
Plan administered by Allied National and underwritten by The UnitedStates Life Insurance Company of New York, a member company ofAmerican International Group, Inc.
The following Industries receive an automatic rate load:3843 Dental Equipment and Supplies5813 Drinking Places (Alcoholic Beverages)7929 Bands, Orchestras, Actors, and Other Entertainers and
Entertainment Groups8021 Offices and Clinics of Dentists8111 Legal Services8211 Elementary and Secondary Schools8299 Schools and Educational Services, NEC6531 Real Estate Agents and Managers7941 Professional Sports Clubs and Promoters8661 Religious Organizations8023 Orthodontists
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statement required?
No
Yes—as long as they work full-time and exclusivelyfor one employer. Must be approved by Allied priorto case submission.
No
Yes
Groups of 2-9: Yes 10+ groups: No
Two Usual & Customary options available:80th percentile of HIAA (base)90th percentile of HIAA (1.04 rate factor)
◆◆ 100%
◆◆ 100%** One employee may waive that doesn’t fit ◆◆ category.
SPECIAL CONSIDERATIONS
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH)
California HMO Counties:
Boxes containing a number indicate that these coordinate plans offered by this carrier can bewritten together to create a dual option package. The number indicates the minimumenrollment required on each of the coordinate plans. Blank boxes indicate which plans cannotbe written together
PROVIDER INFORMATION
PRODUCTS OFFERED
California PPO Counties:
California Indemnity Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
139
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PPO Network
N/A
See First Dental Health website for county info at www.firstdentalhealth.com
All Counties
BEST PPO OptionDental(Offered only through Word & Brown)
2+ PPO HighPPO MidPPO Basic1
PPO Voluntary HighPPO Voluntary MidPPO Voluntary Basic1
2-1492-1492-1492-1492-1492-149
Indemnity HighIndemnity MidIndemnity Basic1
Voluntary Indemnity HighVoluntary Indemnity MidVoluntary Indemnity Basic1
2-1492-1492-1492-1492-1492-149
First Dental Health (CA only)www.firstdentalhealth.com
Diversified Dental Services(Nevada)www.ddsppo.com
Dentemax (National)www.dentemax.com
Basic
NOTE: Plans may not be available in all zip codes within a county. Check with your Word & Brown representative to confirm if coverage isavailable for your group location.
Group Size PPO Group Size Indemnity Group Size
Note: Custom Quotes available for groups of 150+. Call your Word & Brown representative.1 Currently not quoted on the Word & Brown system. Call your Word & Brown representative for more
information
BasicSTD/
STD OrthoStar/
Star PlusElite/
Elite Plus
STD/STD Ortho 2
2
Elite/Elite Plus 2
2
2
2
2
2
2
2
2
2
BEST Basic Voluntary1
BEST Standard VoluntaryBEST Basic1
BEST StandardBEST Standard OrthoBEST StarBEST EliteBEST Star PlusBEST Elite Plus
5-995-993-993-993-993-993-993-993-99
Minimum of 2 employees must enroll on each plan. Voluntary plan not available for dual option.
BEST PPO OptionDental
Star/Star Plus
PPO High/Mid/Basic
PPO (All) Indemnity (All)
Indem High/Mid/Basic 5
5
Minimum 10 employees must enroll in order for group to be eligible for Dual Option. A minimumof 5 must enroll on either plan.
BEST PPO & Indemnity
5
5
2
2
2
Yes
There is no minimum, since BEST Health Plans can blendthe rates for a multi-state group. They do prefer at least50% of the group in the state where the business resides.
All states allowed
BEST Health Plans can offer a dual option for groups over 10which would work well for a group with many employees outof state. The group could offer a PPO Plan in California andan Indemnity Plan for all Out-of-State employees
If the group had at least 50% of the employees in CA the groupwould most likely be based on the CA Employer Zip Code
N/A
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Member Support, Customer Service & Commissions:[email protected]
BillingBEST Life and Health Insurance Co. 2505 McCabe WayIrvine, CA 92614-6243
ClaimsBEST Life and Health Insurance Co. P.O. Box 890Meridian, ID 83890800-433-0088Fax 208-893-5040Email: [email protected]
Fax (Add-ons/Deletes)949-724-1603
Yes—if group has a carve out in place with prior dental carrier.
Yes—if group has carve out in place with prior dental carrier.
No
Minimum of 10 employees enrolled as long as priorcoverage exists with all 10 on dental carrier billing.
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Employer-sponsored PPO/Indemnity
Employees
Dependents
Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statements required?
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
MINIMUMEMPLOYERCONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Associations?
Minimum group size
CARVE OUTS*
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
COVERAGE REQUIREMENTS
140
EmployerSponsored 2+
50%
N/A
N/A
No
CA-NoNV-Yes
Yes
Yes
Yes—for groups enrolling less than 5 employees
*Contributory: 2+ / Voluntary: 5+
N/A
N/A
N/A
◆ 60%
N/A
◆ 60%
N/A
5+
N/A
20%
N/A
Two options available:1 80th percentile of UCR (based on Ingenix data)
Word & Brown quote reflects this option
2 90th percentile of UCR (based on Ingenix data) - Apply a1.02 load to rates shown on Word & Brown quote
Employer Sponsored & Voluntary: 12-month wait on all classIII and class IV services, waived for groups of 5 to 9 withcomparable coverage. For groups with 10+ employee livesenrolling, waiver is given to groups without prior comparablegroup coverage. Late entrant provision does not apply during open enrollment.
5+ Optional Adult ortho available for groups with 25+employees enrolling on PPO or Indemnity. Adult ortho$1,000 max. Optional child ortho available for enrolleddependent children through age 20 on groups with 2+employees enrolled on PPO or Indemnity. $1,000 and $1,500Lifetime Max. available
SPECIAL CONSIDERATIONS
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
25+
Supplemental Dental Accident Benefit included in High, MidPPO, Indemnity and IndemnityPlus Basic plans—up to $1,000per accident; and Basic—up to $500 per accident. Children’s Good Vision Benefit—Exam included in all PPO andIndemnity plans. 50% of eligible expenses, once every 12months, for children with ortho coverage. QualSight-LASIKdiscount access plan available. 5% discount on dental bypurchasing vision.
Voluntary Plans5+
Yes
Min. 5 enrolled
100%
N/A
2-4
Voluntary PPO and Indemnity:High or Mid Plans - Optional Child ortho available for groupswith 5+ employees enrolling on PPO or Indemnity. $1,000and $1,500 Lifetime Max. available
Basic Plans - Optional Child ortho available for enrolleddependent children through age 20 of groups with 5+employees enrolling on PPO or Indemnity. $1,000 and$1,500 Lifetime Max. available
*$20 per month admin. fee for groups of 2-5
N/A
N/A
Rate Guarantee
Rates vary by Industry?
1 year; 2 year guarantee available for:Employer contributory: available forgroups with 10+ enrolling and there willbe a 7% loadVoluntary: available for groups with 10-50enrolling and there will be an 8% load
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH) PROVIDER INFORMATION
PRODUCTS OFFERED
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
141
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DHMO Basic DHMO Plus DHMO Deluxe DHMO Voluntary
2-50 2-50 2-50 2-50
Smile Basic Voluntary 75/1000/No Ortho/MACSmile Basic 75/1000/No Ortho/MACSmile Value 50/1500/No Ortho/MACSmile 50/1500/No Ortho/MACSmile Plus 50/1500/Ortho/MACSmile Plus Gold 50/1500/Ortho/U85Smile Deluxe 2000 50/2000/No Ortho/MACSmile Deluxe 50/1500/Ortho/MACSmile Deluxe Plus 2000 50/2000/Ortho/MACSmile Deluxe Gold 50/1500/Ortho/U85
2-502-502-502-502-502-502-502-502-502-50
Smile Basic 75/1000/No Ortho/MACSmile Value 50/1500/No Ortho/MACSmile Deluxe Plus 2000 50/2000/Ortho/MACDHMO BasicDHMO Plus
Blue Shield of California Dental HMO
Blue Shield of California Dental PPO
All Counties
California DHMO Counties:
California DPPO Counties:
Alameda, Butte, Contra Costa, El Dorado, Fresno, Kern, Los Angeles, Marin, Monterey, Napa, Orange, Placer, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, Sutter, Ventura and Yolo
N/ACalifornia Indemnity Counties:
NOTE: Plans may not be available in all zip codes within a county. Check with your Word & Brown representative to confirm if coverage is available for your group location.
*See Special Considerations on the following page concerning enrollment requirements when Dental PPO is sold with Blue Shield Medical.
Prepaid/HMO Group Size
DPPO Group Size
Suite Deal Dental
Group Size
Blue Shield members with Dental PPO benefits can access a newnationwide provider through DentalBenefits Providers Inc.
Dual Option available to groups of 2 or more eligible employees in any of these combinations:● 2 DPPOs● 2 DHMOs● 1 DPPO + 1 DHMO● 1 DPPO Voluntary + 1 DHMO Voluntary● 1 Voluntary + 1 Non-Voluntary
Non-Voluntary or Non-Voluntary + Voluntary Dual Option: Minimum 50% employer contribution and minimum 75% participation.
Voluntary Dual Option: No employer contribution or participation requirements
Suite Deal Dental:There is a minimum participation requirement of 65% of eligible employees. All plans must beoffered, however enrollment in all 5 plans is not required. Suite Deal Dental package can be soldalongside any Blue Shield of California or Blue Shield of California Life and Health Insurance Companyproducts, or on a stand alone basis.
DHMO Network
DPPO Network
Yes
51% of the full time employees must reside in California
The following states have no dental provider access soDPPO benefits will be paid as out of network: North Dakota, South Dakota, Vermont, Alaska, Montana &Wyoming
All of Blue Shield’s DPPO plans are available
Rates are based on the California Employer zip code
N/A
Member Support, Customer Service,& Commissions:Dental Claim Forms: 888-702-4171
DPPO Member Support and Customer Services: 888-702-4171
DHMO Member Support and Customer Services: 800-585-8111
Commissions: Blue Shield Producer Services 800-559-5905
Dental Benefits Provider 800-445-9090
ClaimsBlue Shield P.O. Box 272590Chico, CA 95927-2590
Add-ons/Deletes) Fax 209-367-6475
2-502-502-502-502-50
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2-50(Single or
Dual Option)
Employees
Dependents
GROUP SIZE
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Smile Basic Voluntary, Smile Basic, Smile Value, Smile & Smile Deluxe 2000: Not CoveredSmile Plus, Smile Plus Gold, Smile Deluxe, Smile Deluxe Plus 2000 & Smile Deluxe Gold: 50% - max. $1000 per calen-dar year. (The annual maximum for orthodontics is in additionto the annual maximum for other covered services.)
DPPO
DHMO Basic: Adult-$2650 Copay/Child-$2350 Copay DHMO Plus: Adult-$1700 Copay/Child $1400 Copay DHMO Deluxe: Adult-$1500 Copay/Child-$1200 Copay DHMO Voluntary: Adult-$2650 Copay/Child-$1800 Copay
DHMO
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statement required?
No
No
No
Yes
No—if standalone dental; Yes—if sold with medical (reconciled). Submit payroll register for employees not listed on DE-6
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
MINIMUMEMPLOYERCONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
SPECIAL CONSIDERATIONS
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
142
Yes—75% of carve-out must enroll
Yes—75% of carve-out must enroll
Yes—75% of carve-out must enroll
If dental only, minimum 8 enrolled employees;If medical and dental, minimum 8 enrolled employees
50%
N/A
N/A
2-50
12 Months
No
2-50Voluntary
N/A
N/A
N/A
DHMO N/ADPPO Smile Basic, Smile Basic Voluntary, Smile Value,
Smile, Smile Plus, Smile Deluxe, Smile Deluxe 2000,and Smile Deluxe Plus 2000 pays OON dentistsbased on the Blue Shield negotiated fee (MaximumAllowable Charge or MAC) schedule. Smile DeluxeGold and Smile Plus Gold U85 pays OON dentistsbased on HIAA 85th percentile.
DHMO No waiting period DPPO No waiting period except for
DPPO voluntary planIndemnity N/A
N/AIndemnity
SPECIAL CONSIDERATIONS
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
A group may add dental off anniversary as long as it isnot within 60 days of the anniversary date of Blue Shieldmedical plan coverage. If within 60 days of renewal, BlueShield asks group to wait until medical renewal and thenadd dental. This does exclude new plans (until the newplans have been on the market for 1 year). The new plansmay only be added at anniversary. Groups can change toa different plan only at the anniversary date of Blue Shieldmedical plan coverage or the effective date of a newdental contract.
If a group cancels coverage, the group must wait 12months to re-apply for coverage.
2-50Suite Deal Dental
2-50(Single or
Dual Option)
◆◆ 75%
N/A
2-50Voluntary
Min. 2
N/A
2-50Suite Deal Dental
65% total eligibleemployees
N/A
Employees
Dependents
100%
N/A
N/A
N/A
50%
N/A
N/A
100%
N/A
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
PRODUCTS OFFERED
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
143
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CaliforniaChoice® has optional dental that can be offered along with medical.Employers may elect to offer one of the following to their employees:
■ All buy-up dental plans: Prepaid 1000 & 3000, EPO 3500, and PPO 4000 & 5000WITHOUT Ortho
■ All buy-up dental plans: Prepaid 1000 & 3000, EPO 3500*, and PPO 4000* &5000* WITH Ortho
■ Voluntary 3000 and FDH Access 100**■ FDH Access 100 only**
Employees may select the best dental plan to fit their needs out of those plansoffered by their employer.
* PPO plans with Ortho are only available to groups with 5 or more eligible employees.
** FDH Access 100 is included in the program at no additional cost and offers services atreduced fees. Employees and dependents (if applicable) must be enrolled for medicalcoverage through the CaliforniaChoice® Program.
HMO Network
FDH 100: All CountiesSmileSaver Plan 1000 & 3000: All Counties
Plan 3500: All Counties
Plan 4000 & 5000: All Counties
Plan 3500 2-50 Plan 4000Plan 5000
2-502-50
Yes
California HMO Counties:
California EPO Counties:
California PPO Counties:
† If employer currently is not offering dental, FDH (First Dental Health) Access 100 Dental Program (if elected) is included at noadditional cost for employees and their dependents enrolled in CaliforniaChoice® medical.
* Plan 3000 also is available on a voluntary basis with no minimum employee participation requirement.
Customer Service CenterCaliforniaChoice® 800-558-8003Member ServiceAmeritas Group 877-203-0036FDH Access 800-558-8003 SmileSaver 800-880-1800CommissionsCaliforniaChoice® 714-542-6992 x4390Dental ClaimsAmeritas Group (EPO/PPO): Ameritas Group
PO Box 82520Lincoln NE 68501877-203-0036Fax 402-467-7336
SmileSaver SmileSaver Attn: Claims Dept. PO Box 30920 Laguna Hills, CA 92654 800-880-1800
Add-ons/DeletesCaliforniaChoice® Fax 800-558-8000
FDH Access 100+ Plan 3000* Plan 1000
2-502-502-50
Prepaid/HMO Group Size
EPO Group Size
PPO Group Size
DUAL OPTION (MIX AND MATCH)
CaliforniaChoice® dental is available only to groups with CaliforniaChoice® medical coverage
FDH Access 100:First Dental Health Access
Plan 1000 & 3000:SmileSaver Dental
PROVIDER INFORMATION
Indemnity Network
PROVIDER INFORMATION
EPO Network
PPO Network
Plan 3500:First Dental Health EPO
Plan 4000 & 5000:Ameritas PPO
51%
All are allowed except Hawaii
PPO and EPO
It is based on the Employer zip
N/A
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HMO N/A
EPO & PPO For groups with 10 or more employees,the 12 month waiting period for majorservices will be waived for individualswho were enrolled under this employer’scomparable group dental plan for 12months or more. All new hires andgroups without prior comparable dentalcoverage are subject to the waitingperiod. Credit will be given for time onthe prior plan. If orthodontia was coveredon comparable prior plan, credit will begiven toward the 24 month ortho waitingperiod.
ORTHODONTIC COVERAGE
FDH Access 100—$3604 copay for child or adult ortho Plan 1000 & 3000—$1600 copay for child/$1950 copay foradult
Plan 3500, 4000 & 5000—Optional benefit* available togroups of 5 or more eligible employees. 50% to No AnnualMaximum/$1000 Lifetime Maximum 24-month wait exceptfor 10+ groups that meet the criteria outlined in waitingperiod waiver section below.
* Orthodontia is an optional benefit chosen for theentire group by the employer.
Employees
Dependents
Employees
Dependents
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
MINIMUMEMPLOYERCONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
HMO
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
144
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
Are Commission-Only employees allowed?Yes, if on DE-6 and showing at least minimumwages and withholdings
Are 1099 employees allowed?No
Any ineligible industries?No
Virgin groups eligible?Yes
DE-6 statement required?Yes
No
No
Yes – coverage available for non-union only. Group must submit union billing to underwriting forverification that all other employees have medical coverage.
2
2-50
2-50
2-50
12 Months
No
2-50 Plan 3000Voluntary
0%
0%
0%
2-50 Plan 3000Voluntary
0%
0%
◆◆ 100%
0%
0%
0%
EPO & PPO
0%
0%
50% of employee only premiumfor lowest cost plan offered
◆◆ 70%
0%
COVERAGE REQUIREMENTSWAITING PERIOD WAIVER/TAKEOVER
SPECIAL CONSIDERATIONSEnrollment for spouse and children is contingent on employeeenrollment. Dependent enrollees for dental cannot differ fromdependent enrollees for medical coverage (except for childrenunder age 3). However, if dependents do not enroll in medical,then any dependent make-up for dental is acceptable.
HMO N/A
EPO Plan 3500 - Out of network claims are paid based uponthe maximum allowable charge or scheduled charge. Forgroups of 2-4 employees, out-of-network restorative is coveredat 50% with no waiting period.
PPO Plan 4000 & 5000 - Out of network claims are paid basedon U & C 80th percentile. For groups of 2-4 employees, out-of-network restorative is covered at 50% with no waiting period.
DeltaCare USA Plan 10A DeltaCare USA 10A Vol.DeltaCare USA Plan 11A DeltaCare USA 11A Vol. DeltaCare USA Plan 12ADeltaCare USA 12A Vol.DeltaCare USA 15BDeltaCare USA 15B Vol.
5-99 5-99 5-99 5-99 5-99 5-995-995-99
Classic PPO Voluntary Plan 1000Classic PPO A Plan 1000 Classic PPO A Plan 1500 Classic PPO A Plan 2000Classic PPO B Plan 1000 Classic PPO B Plan 1500 Classic PPO B Plan 2000 Classic PPO C Plan 1000 Classic PPO C Plan 1500 Classic PPO C Plan 2000Options PPO 1 Plan 1000 Options PPO 1 Plan 1500 Options PPO 1 Plan 2000Options PPO 2 Plan 1000Options PPO 2 Plan 1500Options PPO 2 Plan 2000Options PPO 3 Plan 1000Options PPO 3 Plan 1500Options PPO 3 Plan 2000
5-995-495-495-495-495-495-495-495-495-4950-99 50-9950-9950-9950-9950-9950-9950-9950-99
Prepaid plan Group Size PPO Group Size
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH)
California Prepaid Counties:
PROVIDER INFORMATION
PRODUCTS OFFERED
California PPO Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
Prepaid Network
PPO Network
145
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Boxes containing a number indicate that these coordinate plans offered by this carrier can be writtentogether to create a dual option package. The number indicates the minimum enrollment required oneach of the coordinate plans. Blank boxes indicate which plans cannot be written together
All Counties
All Counties
PPO: Yes—company must be headquartered in CAPrepaid: No
DeltaCare USA
Delta Dental PPO
Classic Voluntary PPOClassic PPO AClassic PPO BClassic PPO COptions PPO 1 (all)Options PPO 2 (all)Options PPO 3 (all)
5
*
*
*
†
†
†
*
*
*
†
†
†
DeltaCareUSA 10A
Non-Volun.
DeltaCareUSA
10A Volun.Dependent
DeltaCareUSA
10A AllVoluntary
DeltaCareUSA 11A
Non-Volun.
DeltaCareUSA
11A Volun.Dependent
DeltaCareUSA
11A AllVoluntary
DeltaCareUSA 12A
Non-Volun.
DeltaCareUSA
12A Volun.Dependent
DeltaCareUSA
12A AllVoluntary
DeltaCareUSA 15B
Non-Volun.
DeltaCareUSA
15B Volun.Dependent
DeltaCareUSA
15B AllVoluntary
Employer can offer PPO with prepaid plan.* For Classic plans, dual choice requires a minimum enrollment of 10 eligible employees (at least 3 enrolled in one
plan and the balance in the other).† For Options plans, dual choice requires minimum enrollment of 50 eligible employees (at least 10 enrolled in one
plan and the balance in the other).
Customer Service, & Bilingual SupportHMO - DeltaCare USA 800-422-4234
PPO & Dual OptionAllied Administrators 415-989-7443
Member Eligibility 800-765-6003
Commissions & Broker Services 877-472-2669
Claims Delta Dental of California P.O. Box 997330 Sacramento, CA 95899-7330 800-765-6003
Add-ons/Deletes Fax 415-439-5861
PPO: 50%
All states allowed
Rates are based on CA employer zip code
PPO is offered out of state
No
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NT
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www.deltadentalins.com
5
*
*
*
†
†
†
*
*
*
†
†
†
5
*
*
*
†
†
†
*
*
*
†
†
†
5
*
*
*
†
†
†
*
*
*
†
†
†
w w w. w o r d a n d b r o w n . c o m
Prepaid Plan No out of network coverage
PPO A and PPO Vol Based on Delta Dental PPO fee allowance
PPO B, PPO C, PPO 1, For non-PPO Delta Dental dentists, out of networkPPO 2 and PPO C coverage is their negotiated fee. For non-Delta
Dental dentists, out-of-network coverage is thelesser of the submitted fee or the fee that satisfiesthe majority of Delta Dental dentists for that servicein the same geographical area.
OUT OF NETWORK CLAIM ADJUDICATION
Employees
Dependents
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
MINIMUMEMPLOYERCONTRIBUTION
Contributory
GROUP SIZE
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
146
MINIMUMEMPLOYERCONTRIBUTION
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statement required?
COVERAGE REQUIREMENTS
Prepaid plan 5-99
3 Options
See Special
Considerations
May be eligible if not paid via 1099 – Call your Word & Brown representative
No
Non voluntary: Yes Voluntary: No
Yes
Prepaid plan: No; PPO: Yes
5-99
1 Year
Prepaid plan: NoNon-Voluntary PPO: YesVoluntary PPO: No
Classic non-voluntary
PPO or Dual Option 5-49
Included: Adult: $1900 Copay; Child: $1700 Copay
Adult: Available for groups of 50-99, 50%—$1000 or $1500 separate lifetime maximum per patient
Child: Available if 10 or more employees enroll. 50%—$1000 separate lifetime maximum per patient. For groups of 50-99, $1000 or $1500 separate lifetime maximum per patient
Available if at least 10 employees enroll on PPO and at least 5employees enroll on prepaid dental plan
Prepaid plan No Waiting Period
Non-Voluntary PPO No Waiting Period
Voluntary PPO One year waiting period for some benefits.Waiting period can be waived with prior fee for service or comprehensive prepaid HMO coverage with no break in coverage
Prepaid plan
Non-Voluntary PPO
Dual Option
Prepaid plan 5-99
Non-Voluntary PPO, Premier or
Dual Option 5-49
◆◆ 100%
◆◆ 100%
◆◆ 100%
◆◆ 100%
GROUP SIZEOptions PPO
or Dual Option
50-99
75%
0%
N/A
Employees
For Dependents
% of Total Cost:
MINIMUM EMPLOYER CONTRIBUTION
Contributory
Non-Contributory
GROUP SIZEPARTICIPATION
◆◆ Those covered by another plan are NOT considered eligible in calculating participation. In order to NOT be considered eligible, the other coverage must be a group plan. If an employee or dependent declines to enroll when they become eligible, they cannot enroll at a later date unless they show proof of loss of coverage
75%
0%
N/A
Classic Voluntary PPO 5-99
0%
0%
N/A
N/A
N/A
Child: Available if 25 or more employees enroll. 50%—$1000 separate lifetime maximum per patient.
Voluntary PPOVoluntary PPO
5-99
3 Options
See Special
Considerations
◆◆ 80%
N/A
Employees
Dependents
Minimum of 5enrollees
N/A
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?Yes, if full time, permanent employeesManagement/Non-management?See footnote below*Union/Non-union?See footnote below*Minimum group sizeSame minimum group size as for non-carve out group. (see ProductsOffered section on previous page)
CARVE OUTS*
* Carve-out (i.e. all types such as management, union, etc.) is available and will requireemployer offer benefits to all classes of employees. Delta Dental PPO will be offered toone population such as management employees and DeltaCare USA will be offered tothe remaining employees. Employer must provide DE-6 identifying the carve-out. Thecarved-out group will receive level 2 rates.
SPECIAL CONSIDERATIONS Transferring a group from an existing Delta Dental or prepaid HMO to small group program is not allowed. Businesses enrolling with the prepaid dental HMO plan maycustomize their employer contribution and enrollment guidelines choosing from these three options:
A) Non-Voluntary enrollmentMinimum employer contribution is 75% of employee and dependent cost. Ifcontribution is 100%, then all eligible employees and dependents must enroll. Ifcontribution is less than 100%, then at least 80% of eligible employees must enroll.Minimum of 5 employees must be enrolled.
B*) Voluntary Dependent enrollment Minimum employer contribution is 75% of employee cost. Employer must providepayroll deduction for dependent coverage. Minimum of 5 employees must enroll butthere is no dependent participation requirement. 80% of eligible employees must enroll. (*Option B rates are shown in our quote.)
C) All-Voluntary enrollmentNo minimum employer contribution but employer must provide payroll deductions foremployees and dependents electing to enroll. Minimum of 5 employees must enroll.
The pregnancy enhancement for Delta Dental PPO groups now includes coverage for thefollowing additional benefits during the year(s) in which a patient is pregnant:1. One additional oral exam; and 2. One of the following:
● An additional prophylaxis (D1110)● Periodontal scaling/root planning, per 4 quadrant (D4341/D4342)
A waiver form is mandatory for all employees declining Delta Dental coverage.
Deductible Rollover Credit is no longer available.
The following industries are ineligible: DeltaCare USA: Law firms and associations; seasonal employment; high turnover 2
Delta Dental PPO: Associations and Trusts1 (except #8661); beauty & barber shops; dentistoffices, dental labs and medical labs; employment agencies; high turnover 2; internationalaffairs; misc. business services; misc. services not elsewhere classified; partnerships;private households; religious organizations (except churches #8661); seasonal employees(Christmas/part-time help); seasonal employees (agriculture);Voluntary PPO: All industries eligible
1 Management and the administrative staff of Associations and Trusts are eligible under Level 1.Use SIC Code 8741
2A business has “high turnover” if 20% or more of the average number of its employees duringthe past 12 months were newly hired for reasons other than the growth of the business.
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH)
California HMO Counties:
PROVIDER INFORMATION
Customer Service, Bilingual Support,& Broker Services800-800-1397
Commissions 800-800-1397
ClaimsDelta Dental InsuranceCompanyP.O. Box 1809Alpharetta, GA 30023-1809
Fax (Add-ons/Deletes)601-956-3795
PRODUCTS OFFERED
California PPO Counties:
California Indemnity Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
PPO Network
Indemnity Network
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HMO Network
N/A
All counties
All counties
N/A
Delta Dental PPO
Yes—PPO & Premier can be written together
Delta Dental Premier
Yes
N/A
States allowed: AL, DE, DC, FL, GA, LA, MD, MS, MT, NV,NY, PA, TX, UT, WV
PPO and Premier (Indemnity)
Rates are based on out-of-state zip code
All enrollments must be received by the 20th of the month fora 1st of the following month effective date
DE
NT
AL
Platinum PlanGold Plan
1+1+
Delta Dental Premier® Group Size
Platinum PlanGold Plan
1+1+
Delta Dental PPO Group Size
Employees
Dependents
Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statements required?
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
SPECIAL CONSIDERATIONS
HMO
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
PPO
Indemnity
Dual Option
COVERAGE REQUIREMENTS
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MINIMUMEMPLOYERCONTRIBUTION
N/A
N/A
N/A
N/A
1
1+
Call your Word & Brownrepresentative
No
N/AYes
Yes
No
Yes
No
PPO Delta Dental-approved PPO feesPremier®
(Indemnity) Plan allowance based on fees that satisfy the majority of Delta DentalDentists or the submitted fees,whichever is less
N/A
N/A
Platinum Plan: Child only - 0-40-50. $1,000 lifetimemax., $350 per calendar year. Separate $100 lifetimedeductibleGold Plan: N/A
Same as PPO
N/A
Call your Word & Brown representative
Call your Word & Brown representative
Call your Word & Brown representative
Call your Word & Brown representative
Call your Word & Brown representative
Call your Word & Brown representative
Call your Word & Brown representative
Call your Word & Brown representative
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
California HMO Counties:
California PPO Counties:
California Indemnity Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
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N/A
All Counties
Customer Service, Bilingual Support & Broker Services 888-886-7973
Commissions 888-886-7973
Claims Phone 888-886-7973 Fax 559-733-1314 Email [email protected]
Add-ons/Deletes Fax 559-733-2325
Network ChangesPlease email request in writing to:[email protected]
Yes—available for out of state employees for AZ, CA,CO, ID, TX, and UT-based employers
No minimum
All are allowed
All
One rate based on employer location
None
N/A DE
NT
AL
PRODUCTS OFFERED
DUAL OPTION (MIX AND MATCH)
Employer may offer one plan from the ten plan offerings or may offer all tenplan options from which the employees may select.
PROVIDER INFORMATION
PRODUCTS OFFERED
Dental HMO Network
Dental PPO Network
Indemnity Network
N/A
First Dental HealthInterplan Health GroupDentemaxSafeguard DentalConnection Dental by PPO USA
UCR Plans Available
Calendar Year Max
Lifetime Deductible
Preventative
Basic
Endo/Perio
Major
Ortho
$750
$0
80%
80%
50%
50%
FreedomOne
$1,000
$0
100%
50%
50%
50%
FreedomTwo
$1,250
$0
100%
90%
50%
50%
FreedomThree
$1,500
$100
100%
80%
50% (2-9 lives)80% (10+ lives)
50%
FreedomFour
$2,000
$100
100%
80%
50%
FreedomFive
$2,500
$100
100%
80%
50%
50%
FreedomSix
None
$100
100%
80%
0%
FreedomSeven
$1,000
$0
1st $100
Next $500
Next $1,000
FreedomEight
$1,500
$0
1st $100
Next $1,000
Next $1,200
FreedomNine
$1,500
$0
1st $200
Next $1,000
Next $1,000
FreedomTen
50%$350 Annual$1000 Lifetime
100%
80%
50%
Office Visit Copay $20 $20 $20 $0 $0 $0 $0 $0 $0 $0
50%$350 Annual$1,000 Lifetime
For minordependents to age 19 and fulltime students to age 23
50%$350 Annual$1,000 Lifetime
50%$350 Annual$1,000 Lifetime
50%$350 Annual$1,000 Lifetime
50%$500 Annual$1,500 Lifetime
Minimum Group Size: 2 enrolled Six PPO Networks Two Out of Network Options Available
50% (2-9 lives)80% (10+ lives)
50% (2-9 lives)80% (10+ lives)
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Employees
Dependents
Employees
Dependents
Employees
For Dependents
RATING INFORMATION
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?Yes
Management/Non-management?Yes
Union/Non-union?Yes
Minimum group sizeMust meet 75% participation rule
CARVE OUTS*
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
Are Commission-Only employees allowed?No
Are 1099 employees allowed?Yes—as long as they work full time, for one employer
Any ineligible industries?Yes—excluded industries include dental offices orother organizations associated with the dentalprofession
Virgin groups eligible?Yes—subject to a twelve month wait for major benefits
DE-6 statements required?Yes
Employer Paid
Group
0-50% of the lowest priced plan
N/A
2-99
12 Months
Yes
Voluntary
Minimum 2
N/A
N/A
N/A
Minimum 2
N/A
2 Options:PPO Network Allowance or80th percentile of UCR
75%—Minimum 2
N/A
Voluntary
0 – 100%
N/A
SPECIAL CONSIDERATIONS
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
Available on plans 4, 5 and 10 for dependent childrento age 19 (to age 23 for full time student).
Employer Paid: No waiting period for groups and add-ons with prior dental plans. Late enrollees andvirgin groups have a 12 month wait for major benefits
Voluntary: No waiting period for members withcomparable coverage. 12 month wait for majorbenefits for members with no prior coverage
Groups can elect to have additional waiting periodswaived for an additional fee of 10%
This is a fully insured product. No administration feeapplies.
Employer Sponsored: Employer may make one planavailable or all ten plans available as an option.
Voluntary: Minimum of 2 enrolled, no otherparticipation guidelines.
A $25 monthly billing fee will be added to theemployer’s invoice
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH)Boxes containing a number indicate that these coordinate plans offered by this carrier can bewritten together to create a dual option package. The number indicates the minimum enroll-ment required on each of the coordinate plans. Blank boxes indicate which plans cannot bewritten together
PROVIDER INFORMATION
PRODUCTS OFFERED
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
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Customer Service, Member Service,Commissions 800-995-4124
BOR Changes Fax 805-987-2205
Provider Relations 800-995-4124, option 4
ClaimsGolden West Dental P.O. Box 5347 Oxnard, CA 93031-5347
BillingGolden West Dental P O Box 5066Oxnard, CA 93031-5066
Fax (Add-ons/Deletes)805-987-7491
2-1242-1242-124 2-1242-1242-124
10-124
10-124
5-124
Golden West
Golden West/WellPointTrue Advantage (Standard)
True Advantage (Select)
Pref.Choice
2†
2†
PrepaidL2
PrepaidL3
† Must have a minimum of 10 eligible employees & 75% participation for dual option. A minimum of 2 employees must enroll on each plan.
* Must have 25% of the eligible employees not covered elsewhere or a minimum of 5members enrolled in the voluntary PPO plan and 2 members enrolled in the voluntaryprepaid plan.
2†
2†
2†
2†
True Advantage (Standard)*
True Advantage (Select)*
Voluntary True Advantage (Standard)*
Prepaid L2 Prepaid L3 Preferred Choice Voluntary Prepaid L2Voluntary Prepaid L3 Vol. Preferred Choice
Vol.L3
Vol.L2
All Counties
All Counties
N/A
California HMO Counties:
California PPO Counties:
California Indemnity Counties:
NOTE: Plans may not be available in all zip codes within a county. Check withyour Word & Brown representative to confirm if coverage is available for yourgroup location.
Vol. Pref.Choice
Prepaid/HMO Group Size
PPO Group Size
Indemnity Group Size
Vol. True Advantage *
HMO Network
PPO Network
N/A
* * * * *
Groups of 125+ may be submitted to Golden West underwriting for a custom quote. Call your Word & Brown representative * Waiver of major services wait is available to groups with at least 12 months of comparable coverage with a prior carrier.
There is a 5% load to rates to waive the waiting period.
Yes
90%
N/A
PPO dental
CA zip codes
N/A
DE
NT
AL
Standalone DHMO or PPO:Employer must contribute a minimum of 50% of employee’smonthly premium
Dual Choice:Employer must contribute a minimum of 75% of employee’smonthly DHMO premium and thesame dollar amount toward the PPO
Non-Voluntary
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Employees
Dependents
Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statement required?
RATING INFORMATION
PARTICIPATION
Contributory (EE contributes to premium)
Non-Contributory (ER pays 100% of premium)
MINIMUM EMPLOYER CONTRIBUTION
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
DMO
ORTHODONTIC COVERAGE
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
Indemnity
Dual Option
COVERAGE REQUIREMENTS
152
Requires prior approval from Golden West
Requires prior approval from Golden West
Requires prior approval from Golden West
N/A
DHMOOnly2-124
Yes
No
Yes
Yes—needs authorization by carrier prior to submission
No
See Products Offered section on previous page
1 Year
No
HMO N/APPO Standard Fee plans: Out of network claims will be paid
based on the MAC schedule. Member is responsible forcoinsurance plus any charges over the fee scheduleSelect plans: Out of network reimbursement is set at a level that is within the common range of fees billed by a majority of dentists for a procedure in a given geographic region
Included: Adult/Child: $1795 Copay
Prepaid ortho and/or vision plans can be added at noadditional cost by requesting it at the time of theemployer application submission. PPO ortho option isalso available for additional premium—plans P1000,P1500 & P2000
HMO No Waiting Period PPO 12 Month waiting period for major services.
Employees will receive credit for timecovered under this employer's prior plan.
Waiver of major services wait is available togroups with at least 12 months of comparable coverage with a prior carrier.There is a 5% load to rates to waive thewaiting period
PPO: If less than 12 months in business, prior approval requiredfrom Golden West.
HMO: Cosmetic/Elective benefit rider available for additional cost.See brochure Exhibit E for benefits and coverages.
HMO: Each family member may now select their own dental,orthodontic and vision provider. Up to 3 providers per family (3 general dentists, 3 orthodontists, and 3 vision providers).
Golden West PPO plans are underwritten by UNICARE: GoldenWest / WellPoint Network.
N/A
SPECIAL CONSIDERATIONS
WAITING PERIOD WAIVER/TAKEOVER
HMO
PPO
Indemnity
Standalone DHMO or PPO:Employer can contribute 0-49% ofemployee’s monthly premiumDual Choice:Employer can contribute 0-74% ofemployee’s monthly premium
Voluntary
Voluntary
Min. 2
N/A
N/A
N/A
PPOOnly
5-124
25% orMin. 5
N/A
N/A
N/A
Dual Op.7-124
HMO: Min. 2PPO: 25% or
Min. 5
N/A
N/A
N/A
DHMOOnly2-124
◆◆ 75%
N/A
100%
N/A
PPOOnly
10-124
◆◆ 75%
N/A
100%
N/A
Dual Op.10-124
◆◆ 75%
N/A
100%
N/A
Non-Voluntary
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH)Boxes containing a number indicate that these coordinate plans offered by this carrier can be written togetherto create a dual option package. The number indicates the minimum enrollment required on each of thecoordinate plans. Blank boxes indicate which plans cannot be written together
PROVIDER INFORMATION
PRODUCTS OFFERED
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
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Dental
Customer Service, Member Service,& Claims
Fax (Add-ons/Deletes)
All Counties except: Alpine, Amador, Calaveras, Colusa, Del Norte, Glenn, Inyo, Imperial, Kings, Lake, Lassen, Mariposa,Mendocino, Modoc, Mono, Napa, Nevada, Plumas, San Benito,Shasta, Sierra, Siskiyou, Tehama, Trinity, and Tuolumne
All Counties
N/A
Yes
866-249-2382
Health Net
Health Net
* Groups must have at least 2 eligible employees enrolling for a dual option with a minimum of 1 active employeeenrolled on the DPPO plan and 1 active employe enrolled on the DHMO plan. The total enrolled population mustmeet or exceed 75% of the group's total eligible employees.
California HMO Counties:
California PPO Counties:
California Indemnity Counties:
NOTE: DHMO plans may not be available in all zip codes within a county. Check with your Word & Brown representative to confirm if coverage is availablefor your group location.
Health Net Dental HMO products are provided by Dental Benefit Providers of California, Inc., (“DBP”) and Health Net Dental PPO and indemnity productsare underwritten by Unimerica Insurance Company (together, “the DBP Entities”). Obligations of DBP and Unimerica Insurance Company are not theobligations of or guaranteed by Health Net, Inc. or its affiliates
1 Plans also are available on a voluntary basis for DHMO if participation is less than 50%, or contribution is less than 50%, or no prior group dentalcoverage
2 Voluntary DPPO rates are available to groups with less than 50% contribution or who do not have proof of prior coverage
916-935-4420
HMO Group Size PPO Indemnity
2-50 2-50
Employer-Paid:HN Plus 150-S
1
HN Plus 225-S 1
N/A
PPO Network
Group Size
DPPO allowed in all states; DHMO coverage is available inCalifornia only
51%
PPO Only
CA Employer Zip Code
Refer to dental underwriting guidelines for more info
HMO Network
DE
NT
AL
2-50 2-50
Voluntary:HN Plus 150(V)-S
1
HN Plus 225(V)-S 1
2-50 2-50 2-50 2-50 2-50 2-50
Employer-Paid and Voluntary 2:PPO Plus D5075-196-1000-SPPO Plus D5075-196-1500-SPPO Pref Value D5075-185-1000-SPPO Pref Value D5075-185-1500-SPPO Value D5075-185-1000-SPPO Value D5075-185-1500-S
HN Plus150-S
HN Plus225-S
HN Plus150(V)-S
HN Plus225(V)-S
PPO PlusD5075-196-
1000-S
PPO PlusD5075-196-
1500-S
PPO PrefValue
D5075-185-1000-S
PPO PrefValue
D5075-185-1500-S
PPO ValueD5075-185-
1000-S
PPO ValueD5075-185-
1500-S
HN Plus 150-S ● ● ● ● ● ● ● ● ●
HN Plus 225-S ● ● ● ● ● ● ● ● ●
HN Plus 150(V)-S ● ● ● ● ● ● ● ● ●
HN Plus 225(V)-S ● ● ● ● ● ● ● ● ●PPO Plus D5075-196-1000-S ● ● ● ● ● ● ● ● ●
PPO Plus D5075-196-1500-S ● ● ● ● ● ● ● ● ●
PPO Pref ValueD5075-185-1000-S ● ● ● ● ● ● ● ● ●
PPO Pref ValueD5075-185-1500-S ● ● ● ● ● ● ● ● ●
PPO Value D5075-185-1000-S ● ● ● ● ● ● ● ● ●
PPO Value D5075-185-1500-S ● ● ● ● ● ● ● ● ●
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Choice of $1000 or $1500 orthodontic lifetimemaximum for children and adults. Available togroups with 10 or more enrolled employees or forgroups of 2-9 enrolled employees with proof ofimmediately prior indemnity orthodontic coverage
PPO
Employees
Dependents
Employees
Dependents
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
SPECIAL CONSIDERATIONS
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
COVERAGE REQUIREMENTS
154
Dental
Yes—available when Health Net is the sole carrier and75% of the eligible employees enroll. The DE-6 and/orpayroll must clearly define the class of employeeswhich may be selected from (i.e. carved out) the entiregroup.
Same as above
Same as hourly/salary above
2 active employees
DHMO2-50 (Vol.)
HMO
2-50
1 Year
No
DHMO2-50
Min. 2
N/A
◆ 50%
N/A
2
N/A
50%
N/A
HMO No Waiting Period
PPO No Waiting Period
All employees (except owners or 1099 employees) mustbe covered by Workers' Compensation.
Voluntary rates apply to all DHMO and DPPO groups with noprior dental coverage regardless of the employer contribution oremployee participation.
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statement required?
Yes
Yes—if the group first meets AB1672 and 1099 employee isaffiliated with group long enough to be tied to company througha federal tax return & can meet the definition of a full-timeemployee. This can be demonstrated in the form of oneSchedule C and Form 1099-Misc from the most recent year.
No
Yes
Yes—reconciled
DHMO N/A
DPPO Out-of-network claims are paid based on the 80th percentile of UCR
DPPO2-50
◆ 75%
N/A
75%
N/A
PPO
2-50
1 Year
No
Group Size
Rate Guarantee
Rates vary by Industry?
DHMO2-50
DPPO2-50
Call your Word & Brown representative for details on two employer-paid and two voluntary Health Net vision PPO plans.
50%
N/A
N/A
50%
N/A
N/A
HMOHN Plus 150(V)-S and HN Plus 225(V)-S: $1695 Copay for adults and children
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH) PROVIDER INFORMATION
PRODUCTS OFFERED
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
EPO Network
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HMO Network
DE
NT
AL
SmileSaver Plan 1000 & 3000: All Counties
Plan 3500: All Counties
Plan 4000 & 5000: All Counties
Yes
California HMO Counties:
California EPO Counties:
California PPO Counties:
Customer ServiceHSA California® 866-251-4718Member ServiceAmeritas Group 877-203-0036SmileSaver 800-880-1800CommissionsHSA California 714-542-6992 x4390Dental ClaimsAmeritas Group (EPO/PPO): Ameritas Group
PO Box 82520Lincoln NE 68501877-203-0036Fax 402-467-7336
SmileSaver SmileSaver Attn: Claims Dept. PO Box 30920 Laguna Hills, CA 92654 800-880-1800
Fax (Add-ons/Deletes)HSA California 866-251-4724
51%
All are allowed except Hawaii
PPO and EPO
It is based on the Employer zip
N/A
HSA California has optional dental that can be offered along with medical.Employers may elect to offer one of the following to their employees:
■ All buy-up dental plans: Prepaid 1000 & 3000, EPO 3500, and PPO 4000 & 5000WITHOUT Ortho
■ All buy-up dental plans: Prepaid 1000 & 3000, EPO 3500*, and PPO 4000* &5000* WITH Ortho*
■ Voluntary 3000
Employees may select the best dental plan to fit their needs out of those plansoffered by their employer.
* PPO plans with Ortho are only available to groups with 5 or more eligible employees.
Plan 3500 2-50 Plan 4000Plan 5000
2-502-50
* Plan 3000 also is available on a voluntary basis with no minimum employee participation requirement.
Plan 3000* Plan 1000
2-502-50
Prepaid/HMO Group Size
EPO Group Size
PPO Group Size
HSA California dental is available only to groups with HSA California medical coverage
Plan 1000 & 3000:SmileSaver Dental
PPO Network
Plan 3500: First Dental Health Network
Plan 4000 & 5000:Ameritas PPO
Employees
Dependents
Employees
Dependents
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
CARVE OUTS*
PLAN ELIGIBILITY REQUIREMENTS
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
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MINIMUMEMPLOYERCONTRIBUTION
2-50
2-50
2-50
12 Months
No
2-50 Plan 3000Voluntary
0%
0%
0%
2-50 Plan 3000Voluntary
0%
0%
◆◆ 100%
0%
0%
0%
0%
0%
50% of employee only premiumfor lowest cost plan offered
◆◆ 70%
0%
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
No
No
Yes – coverage available for non-union only. Group must submit union billing to underwriting forverification that all other employees have medical coverage.
2
Are Commission-Only employees allowed?Yes, if on DE-6 and showing at least minimumwages and withholdings
Are 1099 employees allowed?No
Any ineligible industries?No
Virgin groups eligible?Yes
DE-6 statement required?Yes
OUT OF NETWORK CLAIM ADJUDICATION
HMO N/A
EPO Plan 3500 - Out of network claims are paid based uponthe maximum allowable charge or scheduled charge. Forgroups of 2-4 employees, out-of-network restorative is coveredat 50% with no waiting period.
PPO Plan 4000 & 5000 - Out of network claims are paid basedon U & C 80th percentile. For groups of 2-4 employees, out-of-network restorative is covered at 50% with no waiting period.
HMO N/A
EPO & PPO For groups with 10 or more employees,the 12 month waiting period for majorservices will be waived for individualswho were enrolled under this employer’scomparable group dental plan for 12months or more. All new hires andgroups without prior comparable dentalcoverage are subject to the waitingperiod. Credit will be given for time onthe prior plan. If orthodontia was coveredon comparable prior plan, credit will begiven toward the 24 month ortho waitingperiod.
ORTHODONTIC COVERAGE
Plan 1000 & 3000—$1600 copay for child/$1950 copay for adult
Plan 3500, 4000 & 5000—Optional benefit* available togroups of 5 or more eligible employees. 50% to No AnnualMaximum/$1000 Lifetime Maximum 24-month wait exceptfor 10+ groups that meet the criteria outlined in waitingperiod waiver section below.
* Orthodontia is an optional benefit chosen for theentire group by the employer.
HMO
EPO & PPO
WAITING PERIOD WAIVER/TAKEOVER
SPECIAL CONSIDERATIONSEnrollment for spouse and children is contingent on employeeenrollment. Dependent enrollees for dental cannot differ fromdependent enrollees for medical coverage (except for childrenunder age 3). However, if dependents do not enroll in medical,then any dependent make-up for dental is acceptable.
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH)
California DHMO Counties:
Boxes containing a number indicate that these coordinate plans offered by this carrier can bewritten together to create a dual option package. The number indicates the minimum enroll-ment required on each of the coordinate plans. Blank boxes indicate which plans cannot bewritten together
PROVIDER INFORMATION
PRODUCTS OFFERED
California PPO Counties:
California Indemnity Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
PPO Network
Indemnity Network
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DHMO Network
DHMO—DeltaCare® USA eligible zip codes
PPO—Delta Preferred Counties
FFS—Delta Premier (all counties)
DeltaCare® USA
Delta PPOPPO
*
FFS
2-50 PPO
Customer Service CenterKaiser Permanente Choice Solution800-580-9626
Fax (Add-ons/Deletes)800-566-8514
Commissions800-542-4218, Ext. 4390
ClaimsCHOICE Administrators®
721 South Parker, Suite 200Orange, CA 92868
Prepaid/DHMO Group Size
PPO Group Size
Indemnity Group Size
2-50 FFS
* PPO—only available if employee resides in PPO plan service areaFFS—only available to employees outside PPO plan service areaDHMO—only available to employees residing in DHMO service area
Delta Premier
Yes
51%
All states eligible
Fee for Service Only
Employee zip codes
Employer may only elect dental at initial or open enrollment. Employer cannot elect dental as a standalone product.
DHMO *
PPO
*
2-50 DHMO
DE
NT
AL
Employees
Dependents
Employees
Dependents
Are Commission-Only employees allowed?Yes—if on DE-6 and showing at least minimum wages and withholdings
Are 1099 employees allowed?No
Any ineligible industries?No
Virgin groups eligible?Yes
DE-6 statement required?No—payroll OK
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
SPECIAL CONSIDERATIONS
DHMO
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
PPO
FFS
COVERAGE REQUIREMENTS
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No waiting period
Yes
No
No
Non-union only
2
All plans
2-50
2-50
12 Months
No
◆◆ 100%
0%
50%
0%50% of employee only premium
for lowest cost plan offered
◆◆ 70%
0%
PPO Delta-approved fee schedule
FFS Plan allowance based on fees that satisfy themajority of Delta dentists or submitted fees (whichever is less)
Yes—$1,500 lifetime maximum
Yes—$1,500 lifetime maximum
DHMO—only available if employee resides in DHMOplan service area
PPO—only available if employee resides in PPO planservice area
FFS—only available to employees outside PPO planservice area
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH)
These coordinate plans offered by this carrier can be written together to createa dual option package.
PROVIDER INFORMATION
PRODUCTS OFFERED
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
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SafeGuard DentalVisit www.safeguard.net
MetLife DentalVisit www.metlife.comAny PPO Plan ●
Dual Choice requires a minimum group size of 10 eligible with a minimum combinedparticipation of 7 employees with at least 5 employees enrolled on the PPO and 2employees enrolled on the DHMO.
Co-Insurance Levels AvailableSGX50*SGX85*SGX100SGX150ASGX185ASGX225SGX245SGX290Standalone & dual optionplans available
All Counties except: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte,Glenn, Inyo, Imperial, Kings, Lake, Lassen, Mariposa, Mendocino, Modoc,Mono, Napa, Nevada, Plumas, San Benito, Shasta, Sierra, Siskiyou,Tehama, Trinity, and Tuolumne
All Counties
N/A
DHMO: Small Group: 90% min must reside in CA Large Group: Done on a case by case basis and must go through underwriting.
PPO: No requirement
California Prepaid DHMO Counties:
California PPO Counties:
California Indemnity Counties:
NOTE: Plans may not be available in all zip codes within a county. Check withyour Word & Brown representative to confirm if coverage is available for yourgroup location.
Prepaid/DHMO PPO/Indemnity
HMO Network
PPO Network
Member Services800-275-4638
ClaimsMetLife Dental ClaimsP.O. Box 981282El Paso, TX 79998888-466-8673
Fax (Add-ons/Deletes)888-505-7446
Contributory & Non-Contributory availableon all SGX plans. *Plan available to large group only (51+)
In-network100/90/60100/80/50100/80/50100/80/50
Out-of-network100/80/50100/80/5080/80/5080/60/40
Deductibles Available$50 In/Out (Waived for Preventative Services)
CYM Available$1,000, $1,500 & $2,000
Ortho Available$1,000 & $1,500
Any DHMO Plan
SafeGuard VisionVisit www.safeguard.net
Vision Network
Yes—PPO: National NetworkDHMO: Texas and Florida
Endo, Oral & Perio Services Available in Basic or Major Services.Other Co-Insurance Levels, Deductible, CYM & Ortho options available. Call your Word & Brown representative
DHMO: Networks in CA, TX & FLPPO: All states eligible
DHMO Plans: TX & FLPPO Plans: All
California Employer Zip Code
No
DE
NT
AL
EmployeesFor Dependents% of Total Cost:
DHMO 50% / Min. 5PPO 75% / Min. 2Dual Option 10 eligible / Min. 7 (Min. 2 on HMO & 5 on PPO)Vision 75% / Min. 5
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RATING INFORMATION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
SPECIAL CONSIDERATIONS
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
160
2000 Calendar Year Maximum, 70th, 90th and 99th UCRand Maximum Allowable Charge (MAC) options areavailable. Call your Word & Brown representative forquote.
Dental rates are available on either 3 tier or 4 tier basis.
Yes†
Yes†
Yes†
PPO - 2 enrolling employeesDHMO - 5 enrolling employeesDual-Option - 10 eligible, 7 enrolling employees 5 onPPO and 2 on HMO0
N/AN/A
PPO
Min. 2
1 Year*
No
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statement required?
Yes
No
Dental offices and dental labs
Yes (Vol. PPO or Vol. DHMO)
No
DHMO N/ADPPO Southern California: 80th percentile of HIAA
Northern California: 80th percentile of HIAACan quote 70th, 90th and 99th percentile of HIAA and MaximumAllowable Charge (MAC). Call your Word & Brown representativefor details
DHMOIncluded - Child/Adult: $1,450 - $2,095 Copay
Indemnity-based orthodontic options (maximum$1000 or $1500 per calendar year) available for adultsand children with a minimum of 25 employeesenrolled in the PPO. Minimum group size is 5 withproof of immediate (no lapse) prior orthodonticindemnity coverage.
PPO
Dual Option
Min. 7
1 Year*
No
Group Size
Dental Rate Guarantee
Rates vary by Industry?
2 and above
† MetLife must be the only carrier and 100% of eligible carveout population must enroll
* Except for DHMO plans - large group (51+) have a 2 year rate guarantee
MINIMUM EMPLOYER CONTRIBUTION
DHMO Below 50% / Min. 5PPO Endo/Oral/Perio in Basic/Class II - 40% / Min. 5
Endo/Oral/Perio in Major/Class III - 30% / Min. 5
Dual Option DHMO & PPO w/Endo/Oral/Perio in Basic/Class II - 40% / Min. 7 (Min. 2 on HMO & 5 on PPO)
DHMO & PPO w/Endo/Oral/Perio in Major/Class III- 30% / Min. 7 (Min. 2 on HMO & 5 on PPO)
DHMO No waiting period
PPO Contributory - No waiting period (If groupwants to include a waiting period, call yourWord & Brown representative for a customquote.)Non-contributory - 12 month waiting periodon major services. Credit given with priorcoverage. If group wants no waiting period,call your Word & Brown representative for acustom quote
DHMO
Min. 5
1 Year*
No
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH)
California EPO Counties:
PROVIDER INFORMATION
PRODUCTS OFFERED
California PPO Counties:
California POS Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
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EPO Network
Principal Dental Series II (PDS II)Group SizeEPO, PPO or POS
Dual Choice with PPO: Available for groups of 10+ lives through the localsales office. First Dental Health
PPO NetworkThe Principal Plan Dental
Indemnity NetworkN/A
3-150
Customer & Broker Services949-553-1616
Adds/TermsFax 949-553-1898
Commissions800-388-4793
BOR ChangesFax 515-235-5538
Claims800-247-4695
Yes—contact your Word & Brown representative
Contact your Word & Brown representative. If quoting EPOor POS, all employees must be in California
All states available through Request-a-Quote. Contact your Word & Brown representative
PPO & Indemnity—contact your Word & Brown representative
Contact your Word & Brown representative
Contact your Word & Brown representative
Alameda, Butte, Contra Costa, El Dorado, Fresno, Imperial, Kern, Kings, Los Angeles,Madera, Marin, Mendocino, Merced, Monterey, Napa, Orange, Placer, Riverside,Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San LuisObispo, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma,Stanislaus, Sutter, Tulare, Tuolumne, Ventura & Yolo
All Counties
Alameda, Butte, Contra Costa, El Dorado, Fresno, Imperial, Kern, Kings, Los Angeles,Madera, Marin, Mendocino, Merced, Monterey, Napa, Orange, Placer, Riverside,Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San LuisObispo, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma,Stanislaus, Sutter, Tulare, Tuolumne, Ventura & Yolo
California Indemnity Counties: N/A
POS NetworkPrincipal POS
DE
NT
AL
Employees
For Dependents
% of Total Cost:
Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statements required?
RATING INFORMATION
PARTICIPATION
Contributory
Voluntary
GROUP SIZE
GROUP SIZE
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
SPECIAL CONSIDERATIONS
Dental - 10 enrolled lives for child ortho, 25 lives foradult or adult/child ortho
Voluntary Dental – Contact your Word & Brown representative
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
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MINIMUMEMPLOYERCONTRIBUTION
50th percentile60th percentile70th percentile75th percentile80th percentile
85th percentile 90th percentile95th percentile99th percentile
Yes
No
Yes
Yes
No
25%
N/A
75%
50%
100%
0%
N/A
Non-contributory
50–99%
0%
N/A
Contributory
0-49%
0%
N/A
Voluntary
Yes
Yes
Yes
10 enrolled lives
Benefit Waiting Period will not apply to Preventativeservices. You may elect a benefit waiting period forBasic services, Major services and Additional BenefitRiders.
1. For Retiree coverage, please contact your Word & Brown representative.
2. Annual enrollment period options are available.
3. Domestic Partner coverage is available.
4. Additional Benefit Riders are available.
5. No out of network for EPO and POS plans.
6. For groups over 150 lives, please contact your Word & Brown representative.
7. 3 & 4 life groups must quote 2 or more coverages.
8. Voluntary coverage is not available for groups under 10 lives.
Employees
Dependents
Non-Contributory
100%
50%
Employees
Dependents
3-150 employer paid 10-150 voluntary
Voluntary w/o prior<20 lives: 1 year>20 lives: 1 or 2 year
Dental or Vol w/prior<10 lives: 1 year>10 lives: 1 or 2 year
Yes
3-150 employer paid10-150 voluntary
3-150 employer paid10-150 voluntary
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OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH)
California HMO Counties:
PROVIDER INFORMATION
PRODUCTS OFFERED
California PPO Counties:
California Indemnity Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
HMO Network
PPO Network
Member Support,Customer Service, Commissions800-659-2223, ext. 0-82149
ClaimsP.O. Box 82510Lincoln, NE 68501800-497-7044
Fax (Add-ons/Deletes)402-309-2583
N/A
N/A
All Counties
Indemnity3-19*
N/A
Yes
No minimum
All states allowed
Indemnity with nationwide passive PPO
Rates are based on the firm’s home office (i.e. wherebilled)
No
Ameritas PPO
Group Size
Plan A: 100/80/50$1000 max., $50 deductible (3 per family)Vision Care option available
Plan B: 100/80-90/100 step-up in Basic/50$1500 max., $50 deductible (3 per family)Ortho benefit (all insureds)Vision Care option available * Large Group available upon request
DE
NT
AL
N/A
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Employees
Dependents
Employees
Dependents
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
SPECIAL CONSIDERATIONS
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statements required?
All insureds eligible. 50% to $1000 lifetime benefitwith a 24 month elimination period.
Yes
Yes
Yes
Down to 3 insured employees
3-19
25% of the total
cost
3-19
2 Years
No, some loaded industries considered higher risk
Yes
Yes
Yes
Yes
No
Indemnity:Insureds can choose any dentist with 90% of dentists in-network. Reimbursement outside of network is 80% ofUCR. Maximum Allowable Charge (MAC) option available for plans A and B and pays out-of-network dentist basedon Reliance Standard negotiated fee.
Groups of 3-5 eligible employees: 100%Groups of 6-9 eligible employees: all but one
Groups of 10-19 eligible employees: 75%
100% of eligible employees
12 month Basic Services elimination period waivedand credit given for calendar year deductibles paidfor groups that had a similar coverage in force for atleast 18 months prior to effective date. A rate factorof 10% is applied to takeover groups.
3-19
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH)
California HMO Counties:
Boxes containing a number indicate that these coordinate plans offered by this carrier can bewritten together to create a dual option package. The number indicates the minimum enroll-ment required on each of the coordinate plans. Blank boxes indicate which plans cannot bewritten together
PROVIDER INFORMATION
PRODUCTS OFFERED
California PPO Counties:
California Indemnity Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
HMO Network
Indemnity Network
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N/A3-993-993-99
3-993-993-99
N/A
www.firstdentalhealth.comwww.ppousa.comwww.kernfmc.com
Silver
Gold *
SelectDent Group Silver PlanGold PlanPlatinum Plan
SelectDent Voluntary Standard PlanDeluxe PlanDeluxe Plus
N/A
N/A
All Counties
N/A
Yes—available for out of state employees of California based companies
Platinum *Standard *Deluxe *
HMO Group Size
PPO Group Size*
Indemnity Group Size
* Groups of 100+ call your Word & Brown representative for a custom quote
Silver Gold Platinum Standard Deluxe
UCR Plans Available
* All plans require three eligible employees with at least three enrolling in Voluntary and at least 75% enrolling in Group plan
Group Plans Voluntary Group Plans
Customer Service & Bilingual Support866-545-4500
Websitewww.healthedgeinc.comwww.healthedgeonline.com (user ID needed)
Broker Sales & Commissions866-616-4888 [email protected]
Claims and EligibilityHealthEdge Administrators, Inc.PO Box 11210Bakersfield, CA 93389866-545-4500Fax 661-616-4850
Fax (Add-ons/Deletes)661-616-4889
California Employer Zip
Deluxe/Deluxe Plus (UCR)
PPO Network
50%
All None
Deluxe Plus
Deluxe Plus *
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
*
* * * * *
Check with your Word & Brown representative to confirm if coverage is availablefor your group location.
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SPECIAL CONSIDERATIONS
No Waiting Periods on any plans effective 04/01/07
No
Yes—as long as they work full-time and exclusivelyfor one employer. Must be approved by HealthEdgeprior to case submission
Yes
Yes
No (but we reserve the right to request one)
Employees
Dependents
Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statement required?
RATING INFORMATION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation. In order to NOT be considered eligible, the other coverage must be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?Yes
Management/Non-management?Yes
Union/Non-union?Yes
Minimum group sizeGroup Plan: 3 active employees with at least 75%enrolling
Voluntary Plan: 3 active employees with at leastthree enrolling
CARVE OUTS*
HMO
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Renewals
Rates vary by Industry?
PPO
Voluntary
COVERAGE REQUIREMENTS
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MINIMUMEMPLOYERCONTRIBUTION
3-99
12 Months
12 Months
No
SelectDent Voluntary Deluxe and Deluxe Plus:Out of Network claims paid at 80th percentile ofIngenix MDR
SelectDent Silver, Gold, Platinum & Standard:Out of Network claims based on the PPO FeeSchedule
N/A
Group
0%-50% of the lowest premium
N/A
N/A
Voluntary
0%-100%
N/A
N/A
Dependent children to age 19 (to age 23 for full timestudent). Services paid at 50% to a lifetime maximum of$1000 on Gold Plan ($350 cym) or $1500 on Platinum Plan($500 cym).
Group Voluntary
Min. 3
◆100%
N/A
◆3 Life
N/A
Min. 3
◆75%
N/A
◆3 Life
N/A
Deluxe ($400 cym) & Deluxe Plus ($700 cym).
Employees
For Dependents
% of Total Cost:
IndemnityDental PPO Plan Group (Gold & Platinum) UCR availableVoluntary (Deluxe & Deluxe +)
WAITING PERIOD WAIVER/TAKEOVER
1) Three life groups with related employees require home office approval
2) Husband/Wife groups require a minimum of four to enroll
3) 5% discount when enrolling in dental and vision together
PROVIDER INFORMATION
DMO Network
DPO Network
Indemnity Network
SmileSaver Dental Plan
PPO USA
HMO Network
PPO Network
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
PRODUCTS OFFERED
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COVERAGE AREA
DUAL OPTION (MIX AND MATCH)
Boxes containing a number indicate that these coordinate plans offered by thiscarrier can be written together to create a dual option package. The numberindicates the minimum enrollment required on each of the coordinate plans.Blank boxes indicate which plans cannot be written together
Choice+ Indemnity
Customer Service, Member Service & CommissionsSmileSaver ClaimsPO Box 30920Laguna Hills, CA. 92654800-880-1800Choice+ ClaimsSecurity LifePO Box 1527Latham, NY 12110800-300-9566
Group Billing & EligibilityHMO—SmileSaver 800-750-4303PPO & Dual Option—Kelsey National 800-366-5656 x3
Fax (Add-ons/Deletes)SmileSaver 949-360-3695PPO/Dual Option 310-391-6534
2-999 2-9992-999 2-999
3-9993-9993-999
PPO Opt. 18
PPO Opt. 25
DHMO3000
*
*
DHMO1000
DHMO2000
* For employer sponsored dual option, group must have at least 2 enrollees on HMO and 3 enrollees on PPO or indemnity. Group must meet regular participation requirements. (see next page for details).
† If voluntary dual option, no minimum group size or participation requirement.Minimum of 1 on PPO and 2 on DHMO.
*
*
*
*
* Employer sponsored dual option requires a minimum of 5 enrollees (2 on the HMO and 3 on the PPO)† These plans also are available on a voluntary basis.
Choice+ PPO Opt. 18Choice+ PPO Opt. 25Choice+ PPO Opt. 26
DHMO 1000* DHMO 2000 †
DHMO 3000 †
SM 600 (Voluntary)
DHMO3000 Vol.
DHMO2000 Vol.
Covered Zip Codes: 90000-90299, 90500-90669, 91200-91399, 91600-91899, 92000-92099, 92500-92699, 92800-92899, 93000-93099, 93500-93599, 93100-93499, 93900-94299, 94800-95299, 95600-95899
All Counties
All Counties
California Prepaid DHMO Counties:
California PPO Counties:
California Indemnity Counties:
NOTE: Plans may not be available in all zip codes within a county. Check withyour Word & Brown representative to confirm if coverage is available for yourgroup location.
SM 600
3-999
PPO Opt. 26 * * *Indemnity * * *
†
†
†
†
†
†
†
†
Prepaid/DHMO Group Size
PPO Indemnity Group Size
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
Yes—Employer Sponsor minimum of 3 employees underIndemnity/PPO. Voluntary groups minimum of 1 under theIndemnity/PPO.
There cannot be more than 10% employees out-of-state
Contact your Word and Brown representative
The plan offering is the same as selected by the employer
They are rated the same as their employer in California
N/A
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Employees
Dependents
Employees
Dependents
DHMO No Waiting Period PPO 12 Month Waiting Period. Waiver available for
groups of 10 or more employees who were enrolled under the employer’s prior dental plan. The insured employees will receive credit for the time covered under the employer’s prior dental plan toward total or partial satisfaction of the major and/or ortho waiting period. (Proof of prior coverageis required.)
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statement required?
RATING INFORMATION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
ORTHODONTIC COVERAGE
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
Dual Option
COVERAGE REQUIREMENTS
2-999; Stand alone DHMO 1000: 2-999
1 Year (2 years with approval)
No
Choice Plus plans no longer have a $22 admin fee.
DHMO members must use panel provider. Family members can use up to3 dental offices.Copays in DHMO brochure are for services performed by a panel generaldentist. If a panel specialist is used, the copays in subscriber contractapply.DHMO application and payment must be received by the 17th for 1st of thefollowing month effective date.Precious metals for restorative services, if used, will be charged to theDHMO memberSM 10 Vision Plan is included on DHMO. Buy-up SM 30 Vision is availablefor PPO enrollees of dual option group on a voluntary basis for $1 perfamily unit.
PPO/Indemnity: No DHMO: Yes
PPO/Indemnity: No DHMO: Yes
PPO/Indemnity: Yes DHMO: No
Yes
DHMO: No PPO & Indemnity: Yes
DHMOSM 600: Adult $2400 Copay/Child $2200 Copay* All other DHMOs: Adult $1950 Copay/Child $1600 Copay*
PPO
DHMO 5-7
2-999
75%
N/A
N/A
◆ 100%*
N/A
DHMO 2000/30008-99
DHMO 10-999
◆ 75%
N/A
PPO Indem.
3-7
◆ 100%*
◆ 50%
PPO Indem. 8-999
◆ 75%
◆ 50%
SM 6005-999
Min. 2
N/A
DHMO Vol.2-999
N/A
N/A
N/A
◆100%*
N/A
◆ 75%
N/A
◆ 100%
◆ 100%
◆ 100%
◆ 100%
N/A
N/A
Yes
Yes
Yes
2 for standalone DHMO 1000;5 for Dual Choice and standalone DHMO plans
Optional: Adult $2400 Copay/Child $2200 Copay
* Phase 1 ortho treatment not covered to include: extractions,study, models, tracings & photographs.† If employer elects Indemnity ortho, 100% of PPO/Indemnityenrollees with children must participate. There is a 24 month orthowait except for 10+ groups with takeover.
Indemnity
SPECIAL CONSIDERATIONS
WAITING PERIOD WAIVER/TAKEOVER
ORTHODONTIC COVERAGE
Standalone PPO or Dual Option – Employer may elect one of twoortho options:
1) DHMO ortho—Adult $1950 Copay/Child $1600 Copay* 2) Indemnity ortho—Child only: 50% - $500 maximum
per calendar year with lifetime maximum of $1000†
DHMO N/A
PPO & Indemnity Out of network claims are paidbased on the 80th percentile of MDR
Employees
For Dependents
% of Total Cost:
MINIMUM EMPLOYER CONTRIBUTION
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HMO Network
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
DUAL OPTION (MIX AND MATCH) PROVIDER INFORMATION
PRODUCTS OFFERED
Is Coverage Offered for Out-of-State employees? What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
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Customer Service, Member Service,Commissions800-228-3384
ClaimsHMO Claims:PO Box 25181, Santa Ana, CA 92799-5181800-622-6389
Fax (Add-ons/Deletes)714-513-6397
Alameda, Alpine, Amador, Butte, Calaveras, Colusa, Contra Costa, Del Norte, El Dorado,Fresno, Glenn, Humboldt, Imperial, Inyo, Kern, Kings, Lake, Lassen, Los Angeles,Madera, Marin, Mariposa, Mendocino, Merced, Modoc, Monterey, Napa, Nevada,Orange, Placer, Plumas, Riverside, Sacramento, San Benito, San Bernardino, SanDiego, San Francisco, San Joaquin, San Luis Obispo, San Mateo, Santa Barbara, SantaClara, Santa Cruz, Shasta, Sierra, Siskiyou, Solano, Sonoma, Stanislaus, Sutter,Tehama, Trinity, Tulare, Tuolumne, Ventura, Yolo & Yuba
HMO: No
SignatureValue SM
*Plan 140 ‡
*Plan 142 ‡
*Plan 144 ‡
*Plan 146 ‡
2-50 2-50 2-502-50
PacifiCare Dental HMO
California HMO Counties:*
* Plans quoted on the Word & Brown system ‡ Available as a voluntary plan. Not quoted through the Word & Brown system.
Prepaid/HMO Group Size
NOTE: Plans may not be available in all zip codes within a county. Check with your Word & Brown representative to confirm if coverage is available for yourgroup location.
N/A
PPO
CA Employer Zip code
None
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NOTE: All HMO plans can be sold as voluntaryor contributory and the rates are the same
• Offers two plan options (i.e., a high and low deductible PPO, or an Indemnity and a PPO) for eligible groups
• Access to our national PPO network of 113,000 providers• Available to groups with 10+ enrolled employees• Available combinations:
HMO/PPOHMO/INOHMO/Indemnity
PPO/PPOPPO/INOHMO/Indemnity
Other combinations available upon request. Please contact your Word & Brown representative.
5 eligible enrolled
10 eligible enrolled
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MINIMUMEMPLOYERCONTRIBUTION
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HMO No Waiting Period
*Only new hires and eligible employees not listed on the group'sprior carrier's billing are subject to a 12-month waiting period forMajor Services; however, waiting period may be waived for anyemployee upon proof of prior like coverage.
WAITING PERIOD WAIVER/TAKEOVER
Employees
Dependents
Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statement required?
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by
COVERAGE REQUIREMENTS
Yes
Yes
Yes
See Products Offered section on previous page
No
Yes—no more than 25% of group can be 1099
No
Yes
Yes—DE-6, 2 weeks payroll or prior carrier bill
N/A
Adult/Child: $1895 Copay
An employer must be actively engaged in business orservice for at least 6 weeks of the preceding calendar quarterand have at least 2, but no more then 50 permanent, active,full-time eligible employees during this period.
Employees declining coverage must sign the Refusal ofEmployee and/or Dependent Coverage form. Not availablefor voluntary.
2-50
N/AN/A
25%†
2-50Voluntary
No employercontribution
required*
EmployeesFor Dependents% of Total Cost:*If employer contributes less than 50%, the group is considered voluntary.†Must meet participation requirement
2-50HMO
◆◆ 75%
N/A
2-50 HMO(Vol.)
Min. 2
N/A
100%
N/A
100%
N/A
For all plans – Orthodontic treatment must be provided by aPacifiCare Dental panel orthodontist. Orthodontic referralsmust be submitted by the patient’s assigned dental providerto PacifiCare Dental.
SPECIAL CONSIDERATIONS
HMO
* Must meet participation requirement
Group Size
Rate Guarantee
Rates vary by Industry?
HMO: 2-50
12 mo. rate guarantee
No
• Offers two plan options (i.e., a high and low deductible PPO, or an Indemnity and a PPO) for eligible groups
• Access to our national PPO network of 113,000 providers• Available to groups with 10+ enrolled employees• Available combinations:
HMO/PPOHMO/INOHMO/Indemnity
PPO/PPOPPO/INOHMO/Indemnity
Other combinations available upon request. Please contact your Word & Brown representative.
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
California DPO Counties:
PROVIDER INFORMATION
PRODUCTS OFFERED
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
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DPO Network
Customer Service, Member Service,Commissions800-896-4830
ClaimsUnitedHealthcare DentalAttn: Claims UnitP.O. Box 30567Salt Lake City, UT 84130-0567
Add-ons/Deletes FaxCall your Word & Brown representative
Yes—PacifiCare products: no more than 25% outside aPacifiCare state.
UnitedHealthcare products: no more than 25% of thegroup may be located in Vermont or Washington.
DPO P3350-VoluntaryDPO P3434DPO P3439DPO P3486DPO P4216DPO P4879DPO P4883DPO P4980
2-50 2-50 2-50 2-502-502-50 2-50 2-50
UnitedHealthcarewww.myuhcdental.comwww.employerservices.com
PPO or Indemnity
Dependent upon the type of plan and the state.
Out of state scenarios should be presented to the UHCSales Operation Specialist for guidance in rating questions
DPOGroup Size
DUAL OPTION (MIX AND MATCH)
All Counties
51% of the Eligible Employees. If there is not 51% of theeligible employees in any state, special guidelines apply.Contact your Word & Brown representative.
Call your Word & Brown representative
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5 eligible enrolled
10 eligible enrolled
Employees
Dependents
Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statements required?
RATING INFORMATION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
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MINIMUMEMPLOYERCONTRIBUTION
Yes
Yes
Yes
2
No
Yes—no more than 25% of the enrolled population
No
Yes
Yes—DE-6, payroll or prior carrier billing statement
Out of network option of 85th and 90th of HIAA
2-50 PPO
50%N/A
25%†
2-50PPO
◆◆ 75% of eligible employees, not less than 50%
N/A
2-50 PPO(Vol.)
Min. 2
N/A
100%
N/A
100%
N/A
PPO: 2-50
12 mo. rate guarantee
No
2-50Voluntary
EmployeesFor Dependents% of Total Cost:*If employer contributes less than 50%, the group is considered voluntary.†Must meet participation requirement
DPO No Waiting Period
*Only new hires and eligible employees not listed on the group'sprior carrier's billing are subject to a 12-month waiting period forMajor Services; however, waiting period may be waived for anyemployee upon proof of prior like coverage.
WAITING PERIOD WAIVER/TAKEOVER
ORTHODONTIC COVERAGE
WAITING PERIOD WAIVER/TAKEOVER
An employer must be actively engaged in business orservice for 45 days.
Employees declining coverage must sign the Refusal ofEmployee and/or Dependent Coverage form except forvoluntary options.
SPECIAL CONSIDERATIONS
DPOChildren only - most common plan: $1,000 lifetimemaximum. These riders require minimum of 10eligible with 8 enrolled
50%50%50%
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VISION
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OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
PROVIDER INFORMATION
PRODUCTS OFFERED
California Vision Indemnity Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
Indemnity Network
Outlook Vision Services (National)www.outlookvision.com
The BEST Life Stand Alone Vision plans are available either as stand alonefor groups with 5 or more employees enrolling, or bundled with anotherBEST Life product for groups with 2 or more employees enrolling.
All counties
There is no minimum
Yes—BEST Life's Vision Indemnity plan is available to allstates in the country
There are no restrictions on which states can receive out-of-state coverage. BEST Life's Stand Alone Vision plan is available to all states within the country
Out-of-State employees can enroll on the Stand AloneVision plan, which is an Indemnity plan availablethroughout the United States.
Rates are based on the CA Employer Zip code
None
PlanExam/Lenses/Frames/ContactsPlan A 12/12/12/12 monthsPlan B 12/12/24/12 monthsPlan C12/12/24/24 monthsPlan D12/24/24/24 monthsPlans come with the choice of $0, $10 or $25 deductible, and contact lenses maybe covered in lieu of frames and lenses or in addition to frames and lenses.
PROVIDER INFORMATION
Member Support, Customer Service & Commissions:[email protected]
BillingBEST Life and Health Insurance Co. 2505 McCabe WayIrvine, CA 92614-6243
ClaimsBEST Life and Health Insurance Co. P.O. Box 890Meridian, ID 83680800-433-0088Fax 208-893-5040Email: [email protected]
Fax (Add-ons/Deletes)949-724-1603
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Employees
Dependents
Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
Wage & tax reports required?
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
SPECIAL CONSIDERATIONS
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
EmployerSponsored 5+
50%
N/A
N/A
Bundled: 2+, Stand alone: 5+
0%
N/A
N/A
Claims payments are based on a per service maximum
Voluntary Plans5+
Yes
60% participation of eligible employees. On groupswhere employer contributes 100% requires 100%
participation of eligible employees.
5+
1 year
N/A
20% participation of eligible employees
N/A
Yes—if group has a carve out in place with prior vision carrier
Yes—if group has a carve out in place with prior vision carrier
No
Minimum of 10 employees or more enrolling, if previously insured this way
There are no waiting periods for BEST Life's StandAlone Vision plan
No
These employees are not eligible unless written with medical
No
Yes
Yes—for groups enrolling less than 5 employees
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OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
California HMO Counties:
PRODUCTS OFFERED
California PPO Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
N/A
All Counties
51%
Yes
Hawaii not allowed
All PPO plans are available out of state
One rate for all in- and out-of-state employees
Employer paid groups from 2+, minimum participation 75%
Customer Service, Bilingual Support & Broker Services 877-601-9083
Commissions/BOR Changes 877-601-9083
Fax 714-619-4663
Add-ons/Deletes Fax 714-619-4663
ClaimsNo claim forms are required for in-networkservices. Out of network form C-4669-61 isavailable at blueshieldca.com.
Mailing AddressBlue Shield of CaliforniaP.O. Box 25209Santa Ana, CA 92799-5209
Email: [email protected]
PROVIDER INFORMATION
California Indemnity Counties:N/A
• Frequencies of 12/24/24, 12/12/24 and 12/12/12. • Lens benefits on a 24 month plan are available at 12 months with a qualifying change of prescription.• Frame allowances of $100, $120 and $130. The $130 plans include photochromic, progressive lens .
(no-line bifocal) and anti-reflective coating. • All plans include polycarbonate lenses for dependent children. • In and out of network benefits. • No waiting period, no claim forms for in-network services. • Eye exams are covered with a $0 copayment on all plans.• Voluntary vision for 10 eligible employees.• 3 hardware copays ($25, $15 and $0).• Low vision testing and equipment covered up to $1,000.• Plano sunglasses covered in lieu of lens and frames for those who have had PRK or LASIK surgery.
PPO Network
Indemnity Network
HMO Network
MESVision
N/A
N/A
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Employees
Dependents
Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statement required?
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
MINIMUMEMPLOYERCONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
SPECIAL CONSIDERATIONS
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary byIndustry?
COVERAGE REQUIREMENTS
Yes—a minimum of 8 enrolled employees
Yes—a minimum of 8 enrolled employees
Yes—a minimum of 8 enrolled employees
8 enrolled for carve-outs; 2 enrolled for regular plans25%
0%
N/A
75%
N/A
No
No
None
Yes
No
2+ enrolled
2+
N/A
There are no waiting periods required by Blue Shieldof California. A group may impose its own waitingperiod
No
2+
2 Years for standalone
Retirees are not eligible for coverage
100%
N/A
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OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
Avesis California Insured Vision Plan Counties:
PRODUCTS OFFERED
California Indemnity Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
Avesiswww.avesis.comPlan #905
N/A
Plan A -12/12/12/12
Exam - each 12 months
S/V, B/F, T/F lenses - each 12 months
Frames - up to $150 retail ($50 wholesale) - each 12 months
Contact lenses - $130 each 12 months in lieu of materials
Progressive Lenses - each 12 months -20% off UCR + $50 credit
All Counties
N/A
Minimum 5 enrolled for employer-paidMinimum 10 enrolled for voluntary
Yes—nationally
All states covered
Insured Vision Plan only
Single rate for all areas
Employer paid groups: minimum employer contribution of75% or 50% if tied to medical
Camden Broker Services 213-616-0640
Commissions 213-616-06403255 Wilshire Blvd., #1610Los Angeles, CA 90010
Avesis Claims/Member Services 800-522-0258
Avesis Eligibility Dept.-Adds/Terms Fax 213-384-0084
Avesis Customer Care Department Fax 866-871-1632
Avesis Insured Vision Plan: In-networkPlan B -12/12/24/12
Exam - each 12 months
S/V, B/F, T/F lenses - each 12 months
Frames - up to $150 retail ($50 wholesale) - each 24 months
Contact lenses - $130 in lieu of materials
Progressive Lenses - each 12 months -20% off UCR + $50 credit.
Plan C -12/24/24/24
Exam - each 12 months
S/V, B/F, T/F lenses - each 24 months
Frames - up to $150 retail ($50 wholesale) - each 24 months
Contact lenses - $130 each 24 monthsin lieu of materials
Progressive Lenses - each 24 months -20% off UCR + $50 credit
Insured Vision Plan Network
Indemnity Network
Exam: $45
SPECTACLE LENSES:Standard Single Vision $ 35.00Standard Bifocal $ 45.00Standard Trifocal $ 55.00Standard Lenticular $ 120.00Progressive $ 45.00Specialty Lenses Corresponding Standard Lens reimbursement
FRAME: $40.00
CONTACT LENSES:Elective $ 130.00Medically Necessary: $ 250.00
All reimbursement amounts listed above are up to the posted dollar amount.
LASIK:$150 plus 25% (In-network)$150 in lieu of all other services (Out-of-Network)
Avesis Insured Vision Plan: Out-of-network
PROVIDER INFORMATION
The Camden Insurance AgencyVision Plan of AmericaAn affiliate of
The Avesis Insured Vision Plan is brought to you by CamdenInsurance, an affiliate of Vision Plan of America, and isunderwritten by Fidelity Security Life. Policy #VC-16; Form M9059 V
IS
IO
N
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Employees
Dependents
Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statement required?
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
MINIMUMEMPLOYERCONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
SPECIAL CONSIDERATIONS
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
N/A
N/A
N/A
5 - employer-paid10 - voluntary
75% of employer-paid or 50% if tied to medical
0% for voluntary
75% of employer-paid or 50% if tied to medical
N/A
75% of employer-paid or 50% if tied to medical
N/A
No
No
No
Yes
No
5+ employer-paid10+ voluntary
5+ employer-paid10+ voluntary
Each 15 days
10+ voluntary
No waiting periodsNo pre-approvals*
*Except for medically necessary contact lenses
No
5+ employer-paid
2 years
The Camden Insurance AgencyVision Plan of AmericaAn affiliate of
Limitations: This plan is designed to cover eyeexaminations and corrective eyewear. It is alsodesigned to cover visual needs rather than cosmeticoptions. Should the member select options that are notcovered under the plan, as shown in the schedule ofbenefits, the member will pay a discounted fee to theparticipating Avesis provider. Benefits are payable onlyfor services received while the group and individualmember's coverage is in force.
Exclusions: There are no benefits under the plan forprofessional services or materials connected with andarising from: 1) Orthoptics of vision training; 2)Subnormal vision aids and any supplemental testing;3) Plano (non-prescription) lenses, sunglasses; 4) Twopair of glasses in lieu of bifocal lenses; 5) Any medicalor surgical treatment of eye or support structures; 6)Replacement of lost or broken lenses, contact lensesor frames, except when the member is normallyeligible for services; 7) Any eye examination orcorrective eyewear required by an employer as acondition of employment; 8) Services or materialsprovided as a result of Workers Compensation Law, orsimilar legislation, required by any governmentalagency whether Federal, State or subdivision thereof.
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OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
PRODUCTS OFFERED
PROVIDER INFORMATION
www.vsp.com
Indemnity Vision and Indemnity Voluntary Vision
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
Vision coverage is available throughout the state
Yes—contact your Word & Brown representative
Customer & Broker Services949-553-1616
Adds/TermsFax 949-553-1898
Commissions800-388-4793
BOR ChangesFax 515-235-5538
Claims800-247-4695
Less than 25% of group can reside outside of California
Vision is available in all states except Maryland and Vermont
Indemnity. Vision is not available in Maryland or Vermont.
Rates are based on CA employer zip code, with nodifference in rates for other locations
Yes—see Special Considerations
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Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE6 statement required?
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Voluntary
GROUP SIZE
GROUP SIZE
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
SPECIAL CONSIDERATIONS
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
Yes
Yes
Yes
10 enrolled lives
Yes
No
Yes
Yes
No
10-150
N/A
Waiting periods do not apply.
No
12 months
1. Contacts are only available if medically necessary.
2. Contact lens benefit is in lieu of the lens and frame,when contacts are chosen.
3. Annual enrollment period applies.
4. For groups over 150 lives, please contact yourWord & Brown representative.
5. Retirees are not eligible for coverage.
6. Members are eligible for a vision discount plan, theVSP Access Program, at no extra cost.
25%
N/A
25%
N/A
10-150
0 to 100%
0%
N/A
10-150
Employees
Dependents
Non-Contributory
100%
N/A
Employees
Dependents
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OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
California HMO Counties:
PRODUCTS OFFERED
California PPO Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
N/A
All Counties
90%
Yes
All states are allowed
All PPO plans are available out of state
One rate for all in- and out-of-state employees
No
Customer Service, Bilingual Support& Broker Services:800-880-1800
Commissions949-425-4304
Fax (Add-ons/Deletes)949-360-3695
ClaimsSafeGuardVision Claims Dept.P.O. Box 8100Laguna Hills, CA 92654-8100
PROVIDER INFORMATION
California Indemnity Counties:N/A
PPO Vision Plan OptionsV85D $25E/$0M - 12/12/24, $85 Frame Allowance, $25 Exams Copay/$0 Materials CopayV85D $10E/$25M - 12/12/24, $85 Frame Allowance, $10 Exams Copay/$25 Materials CopayV85C $25E/$0M - 12/24/24, $85 Frame Allowance, $25 Exams Copay/$0 Materials CopayV85C $10E/$25M -12/24/24, $85 Frame Allowance, $10 Exams Copay/$25 Materials CopayV125A $0E/$0M -12/12/12, $125 Frame Allowance, $0 Exams Copay/$0 Materials CopayV125A $10E/$25M -12/12/12, $125 Frame Allowance, $10 Exams Copay/$25 Materials CopayV125D $0E/$0M -12/12/24, $125 Frame Allowance, $0 Exams Copay/$0 Materials CopayV125D $10E/$25M -12/12/24, $125 Frame Allowance, $10 Exams Copay/$25 Materials Copay
* Range of plans from $30 to $125 retail frame allowance and Hardware Only plans available—ask your Word & Brown representative for details.
Vision Benefits● In and Out of Network Benefits● Ultraviolet protection as a standard benefit● Polycarbonate lens coverage for children● Plans available with progressive lenses—ask your Word & Brown
representative for details.● Plans available for groups as small as five● Voluntary or employer-paid plans● Two year rate guarantee● Extensive, fully credentialed, network of eye professionals contracted with
Ophthalmologists, Optometrists & Opticians. Contracted with all models of practice private, group & retail chains. Chains include Sears, JC Penney, selected Walmarts, Target & Sterling Optical.
● Laser vision correction discounts● Anything that is not covered at a co-pay is available at a 20% discount
PPO Network
Indemnity Network
HMO Network
SafeGuard
N/A
N/A
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Employees
Dependents
Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
DE-6 statement required?
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
MINIMUMEMPLOYERCONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
SPECIAL CONSIDERATIONS
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
Group Size
Rate Guarantee
Rates vary byIndustry?
COVERAGE REQUIREMENTS
Yes—a minimum of 5 enrolled employees
Yes—a minimum of 5 enrolled employees
Yes—a minimum of 5 enrolled employees
5 enrolled 0%
0%
N/A
25%
N/A
No
No
None
Yes
No
5+
5+
N/A
There are no waiting periods required. A group mayimpose its own waiting period
No
5+
24 months
SafeGuard Vision PPO Network
100%
N/A
OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
California HMO Counties:
PRODUCTS OFFERED
California PPO Counties:
California Indemnity Counties:
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
PPO Network
Indemnity Network
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HMO Network
N/A
Yes—as long as the company is based in California
Customer Service, BilingualSupport & Broker Services866-616-4888800-521-3605
Commissions866-616-4888
Claims800-521-3605
Fax (Add-ons/Deletes)661-616-4889
Directory Informationwww.enrollwitheyemed/access or 866.723.0596
Employer Paid: minimum 75% of eligible Voluntary: No minimum participation required
None
The same plan is the same as the employers plan
Neither
See Certificate of Benefits for full guidelines, restrictions andlimitations
All
N/A
www.enrollwitheyemed.com/access
N/A
N/A
PROVIDER INFORMATION
VI
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Eye Examination Silver Gold PlatinumPlan #9657974 Plan #9657941 Plan #9657925
Frequency Once Every 12 Months Once Every 12 Months Once Every 12 MonthsCo-Pay $10 $10 $0
Eyeglass LensesFrequency Once every 24 Months Once Every 12 Months Once Every 12 Months
Co-Pay $20 $10 $0 Frames
Frequency Once every 24 Months Once Every 12 Months Once Every 12 MonthsCo-Pay $0 $0 $0
Employees
Dependents
Employees
Dependents
Are Commission-Only employees allowed?No
Are 1099 employees allowed?Yes—as long as they work full-time and exclusivelyfor one employer. Must be approved by HealthEdgeprior
Any ineligible industries?None
Virgin groups eligible?Yes
DE-6 statements required?No—but we deserve the right to request one
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
◆ Those covered by another plan are NOT considered eligible in calculating participation
◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?Yes
Management/Non-management?Yes
Union/Non-union?Yes
Minimum group sizeGroup: A minimum of 75% of eligible employeesmust participate
Voluntary: No minimum participation required
CARVE OUTS*
SPECIAL CONSIDERATIONS
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
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MINIMUMEMPLOYERCONTRIBUTION
2-99
See Brochure for pricing
No
2 years
NoneN/A
N/A
N/A
N/A
N/A
N/A
50% of lowest Premium
N/A
N/A
N/A
N/A
N/A 1) 5% discount when enrolling in dental and vision together
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OUT-OF-STATE COVERAGE
CALIFORNIA COVERAGE AREA
CA HMO Counties:
PRODUCTS OFFERED
Is Coverage Offered for Out-of-State employees?
What is the minimum % of employees required in CA?
What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?
What states are allowed (or not allowed) for Out-of-State Coverage?
Are rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?
Any other rules, restrictions or guidelines not mentioned:
Copayment plan M-Plus — unlimited benefit starting at$3.50/month
All counties
California only
No out-of-state coverage for HMO plan
No out-of-state coverage for HMO plan
N/A
N/A
N/A
Vision Plan of AmericaBroker Services/Member Eligibility Dept.800-400-4VPA (4872)
Commissions 800-400-48723255 Wilshire Blvd., #1610Los Angeles, CA 90010
Accounting/Billing Department 213-384-2600 (A-P Ext. 104) and (Q-Z Ext. 105)
Provider Relations Department 213-384-2600 Ext.103
Add-ons/Deletes800-400-4872, Ext 8Fax 213-384-0084
Website - Sales/Service/Infowww.visionplanofamerica.com
Low Cost
PROVIDER INFORMATION
National Insured Vision PlanAvailable from CIA: Camden Insurance Agency
Visionplanofamerica.com/providers
All providers operate in a “privatepractice” setting
HMO Network
VI
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Minimum 2 lives required
Plan 1 - (12/12/12/12)Plan 2- (12/12/24/12)Plan 3 - (12/24/24/24)
•Various copayment options•Standard $100 retail frame allowance•Stand alone or bundled with dental•No waiting periods•No claim forms•All plans include LASIK copayment plan(LASIK administered by QualSight)
•Contact lenses in addition to
Voluntary participation - 2+ livesEmployer paid participation - 2+ lives
Individual plans available - stand alone or bundled with dental
Full Service Bundled Dental/Vision PlansAvailable for groups and individuals. Single premiumplans include dental, vision and ortho
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Employees
Dependents
Are Commission-Only employees allowed?
Are 1099 employees allowed?
Any ineligible industries?
Virgin groups eligible?
Wage & tax reports required?
Employees
For Dependents
% of Total Cost:
RATING INFORMATION
MINIMUM EMPLOYER CONTRIBUTION
PARTICIPATION
Contributory
Non-Contributory
GROUP SIZE
GROUP SIZE
EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?
Management/Non-management?
Union/Non-union?
Minimum group size
CARVE OUTS*
SPECIAL CONSIDERATIONS
WAITING PERIOD WAIVER/TAKEOVER
PLAN ELIGIBILITY REQUIREMENTS
OUT OF NETWORK CLAIM ADJUDICATION
* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.
Group Size
Rate Guarantee
Rates vary by Industry?
COVERAGE REQUIREMENTS
N/A
N/A
N/A
2 - employer-paid2 - voluntary
50% of employer-paidor 0% for voluntary
No
No
No
Yes
No
HMO: 2+
HMO2+
N/A
No waiting periodsNo pre-approvals*No claim forms
*Except for medically necessary contact lenses
No
2 years
N/A
N/A
HMO
N/A
2+
Employees
Dependents N/A
2+
Limitations: This plan is designed to cover eyeexaminations and corrective eyewear. It is alsodesigned to cover visual needs rather than cosmeticoptions. Should the member select options that are notcovered under the plan, as shown in the schedule ofbenefits, the member will pay a discounted fee to theparticipating Avesis provider. Benefits are payable onlyfor services received while the group and individualmember's coverage is in force.
Exclusions: There are no benefits under the plan forprofessional services or materials connected with andarising from: 1) Orthoptics of vision training; 2)Subnormal vision aids and any supplemental testing;3) Plano (non-prescription) lenses, sunglasses; 4) Twopair of glasses in lieu of bifocal lenses; 5) Any medicalor surgical treatment of eye or support structures; 6)Replacement of lost or broken lenses, contact lensesor frames, except when the member is normallyeligible for services; 7) Any eye examination orcorrective eyewear required by an employer as acondition of employment; 8) Services or materialsprovided as a result of Workers Compensation Law, orsimilar legislation, required by any governmentalagency whether Federal, State or subdivision thereof.
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