NO DE9C PROMOTIONS/GUIDELINES

Transcription

1 NO DE9C PROMOTIONS/GUIDELINES Quarterly Wage Report/DE9C not required for: Guideline: Groups of 20+ enrolled with prior coverage Promotion: Groups of 6+ enrolled through 6/15/18 effective dates Copy of last month s prior carrier bill is required for all products selected New groups without prior coverage will need to submit DE9C or payroll records Payroll records are required for employees not listed on the prior carrier bill Promotion: Groups of 5+ enrolled Copy of the Prior Bill required Start-Up groups are not eligible for this promotion Virgin groups are not eligible Completed Attestation Form is required DE9C may be required if prior carrier bill differs from enrollment by 10% DE9C required for ancillary only groups with enrolling employees 65+ years of age. If employee is an owner, proof of ownership will be required Companywide payroll may be requested for groups enrolling with out of state employees to confirm the 51% rule is being met Guideline: Groups of 10+ medically enrolling employees The most recent prior carrier bill is required Groups with a variance of less than 10% between number of employees enrolling and number of employees on the prior carrier bill qualify Virgin Groups are not eligible Groups with a lapse of coverage of more than 3 months are not eligible Promotion: Quarterly Wage Report/DE9C not required for 6 or more enrolled through 12/1/18 Business Documentation required (example: business license/soi) Guideline: Groups of 10+ eligible employees Completed and Signed Participation Certification Form is required WB.GA DE9C Promotion_3.18

2 PARTICIPATION & ALONGSIDE GUIDELINES Participation Alongside 60% participation for all group sizes excluding valid waivers (rounded down). 1-4 enrolled employees: 50% participation 5+ enrolled employees: 30% participation Applies to Medical, Dental and Vision Products 70% participation for mirror plans 65% participation for off exchange plans 25% participation for groups of 5+ enrolling. Applies to Specialty Products 1-2 eligible employees:100% participation 3+ eligible employees: 70% participation Groups offering another carrier s HMO plan must have at least 40% participation and a minimum of 5 employees enrolling. Employees covered by the same employer on another group policy are not considered a valid waiver. Another carrier s HMO or PPO plans can be sold alongside Anthem as long as Anthem receives the required participation. Employees who enroll with Kaiser will be considered invalid waivers. Only one carrier is allowed to be written alongside Blue Shield. Health exchanges are not eligible. At least 25% of the total number of eligible employees must enroll with no fewer than 5 enrolled. Blue Shield must be the sole carrier for dental, vision and life plans Wraps are not allowed If the employer is paying 100% contribution, all eligible employees must enroll. If less than 100% contribution, a minimum of 75% of eligible employees must enroll 66% participation for 1-5 eligible employees, 50% for 6+ eligible, 35% for 6+ eligible choosing HMO, HSP, EPO, or PPO Bronze (through 11/15/17 effective date) 70% of eligible employees must be covered by a group plan A firm is eligible to enroll in CalCPA ProtectPlus if 1 employee is joining the program. The rest of the eligible employees may wrap with Kaiser or waive. Another carrier s HMO or PPO plans can be sold alongside Health Net as long as Health Net receives the required participation. Employees who enroll with Kaiser will be considered invalid waivers. A minimum of 1 W2 must enroll with Kaiser Permanente (cannot be an owner or spouse of an owner) 70% participation is required for all group sizes. Groups must have at least 10 enrolling employees or 50% of the enrollment with Sharp Health plan (whichever is greater). Sharp considers SIMSA and MediExcel valid waivers. 60% participation for all group sizes excluding valid waivers.if the employer is paying 100% contribution, all eligible employees must enroll. Choice Simplified Package: 60% participation between two carriers with 5 CA employees enrolling with UHC is required. Multi-Choice State Package: 60% participation with UHC is required WB.GA Participation.and.Alongside_10.17

3 VALID WAIVERS What is considered a Valid Waiver? Individual Coverage Cross-border coverage Individual Coverage Enrolling as a dependent in a group health plan through a different employer WB.GA Valid.Waivers_11.17

4 START-UP GROUP REQUIREMENTS Requirements Groups with 1-19 enrolled employees and groups with no existing health coverage must submit a copy of the most recently filed DE9C. If not available, two consecutive weeks of payroll records are required. A signed and completed Conditions of Enrollment form is required. The company's first 30 days of payroll records must be submitted within the first 45 days of the requested effective date. 1-4 enrolling: Start-up group must have been in business for a minimum of at least 4 weeks. Payroll records must cover the 4 weeks preceding the requested effective date for at least 1 eligible employee. 5+ enrolling: Start-up groups that have been in business for less than 4 weeks are eligible if the business has been operating for at least one pay period. Evidence of time in business and eligibility must be supported by payroll records. 1-4 enrolling: At least one common law employee must enroll and have 6 weeks of payroll. The other common law employees are required to be on payroll for at least one week on or prior to the effective date (or from start date to current, whichever is greater). If the owner is not on payroll, provide ownership documents. 5+ enrolling: One week of payroll is required for a contingent approval. The remaining payroll to complete one month is contingent. If the owner is not on payroll, provide the Owner/Partner form. Ownership documents may be requested at the Underwriter s discretion. Groups established less than 90 days before the effective date will need to submit at least 30 days of payroll records. Groups with 1-5 eligible employees are not eligible. 6+ enrolling: Requires 4 weeks of payroll. Start-up groups require a minimum of 6 weeks of payroll. Promotion: 4 weeks of payroll through 12/1/18 Start-up groups require a minimum of 6 weeks of payroll. Start-up groups that have been in business for at least 6 weeks are eligible. Evidence of time in business must be supported by payroll records. The payroll records must cover the 6 weeks preceding the requested effective date for at least one eligible employee. The group must have and maintain business licenses and/or appropriate state filings allowing the company to conduct business in the state of California. WB.GA Start-Up.Groups_2.18

5 PROFESSIONAL EMPLOYER ORGANIZATION (PEO) GUIDE Guideline for staying with a PEO Guideline for leaving a PEO In addition to meeting standard Underwriting Guidelines, groups must provide the following: (1) Letter from the PEO confirming that they do not offer coverage to the group. (2) Copy of PEO contract. If less than 6 enrolling employees, group must also provide at least 6 weeks of company-wide payroll to establish group eligibility. Groups that are currently with a PEO are not eligible for coverage. Groups that are currently with a PEO are not eligible for coverage. (1) Copy of the contract termination letter sent from the PEO to the employer verifying the cancellation of the leasing arrangement as well as the date. (2) Copy of the most current quarterly wage report filed by the PEO or at least 1 month of current consecutive payroll. (1) Copy of PEO client invoice billed to the worksite business, which includes names of each employee previously leased to the worksite employer. (2) Signed Conditions of Enrollment form. (3) Company s first 30 days complete payroll records within 45 days of the effective date. (1) Copy of the letter sent from the PEO to the client business verifying the cancellation of the leasing arrangement will be required. (2) If a copy of a payroll is submitted that separates the formerly leased employees by business location, the group will be considered a qualified group. 1) Sub-group s home office must be located in California. (2) Statement of Compliance portion of the Employer Application must be signed by an authorized representative of the sub-group, not a PEO representative. (3) PEO sub-group Letter. (4) Quarterly Wage & Tax Report (DE-9C) and payroll ledger including summary totals for the most current three months. (5) Most recent PEO invoice matching payroll salary information. Groups leaving a PEO on the enrollment effective date must provide: (1) Explanation from the employer with a description and date of the PEO split-off scenario. (2) One week of payroll from the new payroll company with the balance for the month due within 30 days of the effective date. Groups that left a PEO prior to the enrollment effective date must provide: (1) Explanation from the employer with a description and date of the PEO split-off scenario. (2) Payroll under the company (not the PEO) from start to current is required - must be at least one week. For BOTH scenarios: If payroll is not equal to one month, group will be approved contingent on the remainder of payroll. 1-4 life groups will need at least 6 weeks of payroll for one common-law employee. (Continued on back) WB.GA PEO.Guidelines_11.17

6 PROFESSIONAL EMPLOYER ORGANIZATION (PEO) GUIDE Guideline for staying with a PEO Guideline for leaving a PEO In addition to meeting standard Underwriting Guidelines, groups must provide the following: Employers are no longer required to leave PEOs. A DE-9C or quarterly wage report from the PEO is required if the PEO provides them for its employer groups. IF one is not available, a payroll will be allowed. However, the quarterly wage report and/or payroll must demonstrate that the group meets the definition of a small employer. (1) PEO termination letter. (2) At least two weeks of acceptable payroll under the company name, not the PEO. (3) Proof of prior coverage under PEO. Groups that are currently with a PEO are not eligible. (1) A letter from the group stating that it will no longer be leasing employees from the PEO (2) 6 weeks of payroll for leased employees from the PEO (3) Business documentation is still required PEO may not act as a co-employer. Groups that use PEO payroll services alone are eligible. (1) Copy of the prior carrier bill from the PEO with employee census confirming prior coverage. (2) Copy of the contract termination letter sent from the PEO to the employer that verifies the cancellation of the leasing arrangements as well as the cancellation date. (3) At least two weeks of payroll from a legitimate payroll company issued in the name and Tax Identification Number of the individual employer group, not the PEO. In the event of a DE-9C or payroll is unavailable, groups must provide the following: (1) Copy of the six weeks of charge back invoices from the PEO to establish AB1672/SB125. (2) Copy of the PEO Benefit Register or prior carrier bill. (3) Letter from the company owner/officer stating the company has cancelled its contract with the PEO and the effective date of cancellation plus 30 days of payroll records for all employees. The employer group must have offered the employees health insurance previously through the PEO. WB.GA PEO.Guidelines_11.17

7 OWNER ONLY GROUPS Will the carriers write an Owner Only Group? Aetna will not write a group without at least 1 non-owner W2 employee. Yes. Anthem will accept Owner Only groups as long as the groups business entity is a type of Corporation such as LLC, S-Corp or C-Corp. Anthem requires at least 2 owners and at least one owner must be able to sign the Eligibility Statement. Blue Shield will not write a group without at least 1 non-owner W2 employee. CaliforniaChoice will not write a group without at least 1 non-owner W2 employee. CalCPA will not write a group without at least 1 non-owner W2 employee. Yes. Health Net will accept an officer only group as long as the officers are not shareholders and at least 1 officer is listed on the DE9C. Yes. Kaiser Permanente will accept owner only group as long as there are 2+ owners and one of them is a W2 employee. Sharp Health Plan will not write a group without at least 1 non-owner W2 employee. Yes. UnitedHealthcare will accept Owner Only groups as long as the groups business entity is a type of Corporation such as LLC, S-Corp or C-Corp with at least 2 eligible owners. If there is only 1 owner, the group must have at least 1 common-law W2 employee to be considered a Small Employer. WB.GA Owner Only Groups_1.18

8 HUSBAND & WIFE GROUPS Will the carriers write a Husband & Wife Group? Husband & Wife groups are not eligble for coverage Husband & Wife groups are not eligble for coverage Yes. Blue Shield will accept Husband & Wife groups as long as both are not owners. The group cannot be a Sole Proprietor. All other group types are acceptable such as LLC, S-Corp, C-Corp and Partnerships where the spouse is the only W2 employee Husband & Wife groups are not eligble for coverage Yes. CalCPA will accept Husband & Wife groups. Both the Husband and the Wife can be an owner or a partner as long as they are both working full-time Husband & Wife groups are not eligble for coverage Husband & Wife groups are not eligible for coverage Husband & Wife groups are not eligble for coverage Husband & Wife groups are not eligble for coverage WB.GA Husband.Wife.Guide_11.17

9 COMMON OWNERSHIP/AFFILIATED COMPANIES Guidelines Groups who have more than one business with different TINs may be eligible to enroll as one group if the following are met: (a) One owner has controlling interest of all businesses to be included (b) Companies that are affiliated and that are eligible to file a combined income tax return for purposes of state taxation shall be considered one employer (c) All groups filed under one combined tax return are considered one group (d) There are 100 or fewer employees in the combined groups (e) Business with equal controlling interest may be considered if the owners of the company designate an individual to act on behalf of all the groups (f) A completed Common Ownership form must be submitted (g) Underwriting reserves the right to final underwriting review and may consider common ownership on a case-by-case underwriting exception Companies that are affiliated and eligible to file a combined tax return for purposes of state taxation shall be considered one employer. A letter from the employer s CPA which states the groups are eligible to file consolidated tax returns is required. (a) Copies of all associated Articles of Incorporation, Partnership Agreements (b) Letter from the employer s CPA stating that all business entities are eligible to file a combined state tax return (a) Each company must share a minimum of 50% common ownership (b) Companies must have a related industry (The groups would be able to file payroll taxes jointly) (c) The total number eligible for all combined groups may not exceed 100 (d) Completed Common Ownership Statement (e) Proof of related industries may be required by the Underwriter Small employers qualify to enroll as a single employer are required to submit a letter from a CPA certifying how they are eligible. The CPA must not be an owner or employee of the groups seeking coverage. The letter must be on CPA letterhead and it must explicitly state how the groups are eligible to enroll under a single policy Business entities that are affiliated and eligible to file a combined tax return for purposes of state taxation will be considered 1 employer and must apply as 1 employer and provide statement from CPA/tax attorney. (a) Copies of the filed/stamped Statement of Information reflecting all officer/owners, or signed/dated Partnership Agreements listing all partners names (b) A letter from the employer s CPA stating that all business entities are eligible to file a combined tax return WB.GA Common.Ownership_11.17

10 WAITING PERIOD OPTIONS Waiting Period Options First of the month following 30 days from the date of hire First of the month following 60 days from the date of hire First of the month following one month from the date of hire First of the month following two months from the date of hire, not to exceed 90 days First of the month following 30 days from the date of hire First of the month following 60 days from the date of hire On the 91st day following the date of hire First of the month following 30 days from the date of hire First of the month following 60 days from the date of hire First of the month following 30 days from the date of hire First of the month following 60 days from the date of hire First of the month following one month from the date of hire First of the month following 30 days from the date of hire First of the month following 60 days from the date of hire Not Applicable Maximum waiting period is 90 days Employer may select a different waiting period for rehired employees, but it must not exceed 90 days First of the month following 30 days from the date of hire First of the month following 60 days from the date of hire WB.GA Waiting.Period.Guide_10.17

11 DE9C FILING DATES SUMMARY California DE9C Quarterly Wage Report Filing Requirements The chart below reflects a quarterly guide to the California filing date requirements for the Quarterly Wage Report Form DE9C. After the end of each quarter, groups are allowed until the end of the following month to file the DE9C with the state. For example: As the 1st Quarter ends on March 31st, the filing of the DE9C can be ready as early as April 1st and must be done by April 30th. Guide for Filing Dates Listed on the DE9C Quarter Quarter Ended Due By Delinquent After 1st Quarter 03/31 04/01 04/30 2nd Quarter 06/30 07/01 07/31 3rd Quarter 09/30 10/01 10/31 4th Quarter 12/31 01/01 01/31 Acceptance of DE9C Quarterly Wage Reports The chart below reflects a monthly guide for carriers acceptability of each quarter DE9C provided for groups applying for coverage. It is based on the time frame the state allows groups to file their quarterly wage report. For example, if a group applying for coverage submits their case in January, the carrier would accept a 3rd or 4th quarter DE9C for the previous year as proof of eligibility since the third quarter is currently available and groups have until the end of January to file 4th quarter. If a group applying for coverage did not submit their case until February, the carrier would only accept the 4th quarter DE9C for the previous year as the group should have filed this on January 31st or prior. 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter Acceptance of DE9C Quarterly Wage Reports Month applying for coverage DE9C Report to submit January 3rd or 4th Quarter February We begin requesting 4th Quarter only March 4th Quarter April 4th of 1st Quarter May We begin requesting 1st Quarter only June 1st Quarter July 1st or 2nd Quarter August We begin requesting 2nd Quarter only September 2nd Quarter October 2nd or 3rd Quarter November We begin requesting 3rd Quarter only December 3rd Quarter WB.GA DE9C Filing Dates Guide_11.17

12 2018 PAYROLL GUIDE Minimum Wage $10.50 Employers with 1-25 employees Full-Time Payroll Part-Time Payroll Hours Worked Amount Earned Hours Worked Amount Earned Weekly 30 $ Weekly 20 $ Bi-Weekly 60 $ Bi-Weekly 40 $ Semi-Monthly 65 $ Semi-Monthly $ Monthly 130 $ 1, Monthly $ Quarterly 390 $ 4, Quarterly 260 $ 2, Minimum Wage $11.00 Employers with 26+ employees Full-Time Payroll Part-Time Payroll Hours Worked Amount Earned Hours Worked Amount Earned Weekly 30 $ Weekly 20 $ Bi-Weekly 60 $ Bi-Weekly 40 $ Semi-Monthly 65 $ Semi-Monthly $ Monthly 130 $ 1, Monthly $ Quarterly 390 $ 4, Quarterly 260 $ 2, WB.GA Payroll.Chart.Guide.CA_10.17

13 NEW HIRE RATING GUIDE Requirements New Hire rates will be based on the member s age at the group s effective date. New Hire rates will be based on the member s age at the group s effective date. New Hire rates will be based on the member s age on January 1st of the given year. New Hire rates will be determined by the member s current age at enrollment. New Hire rates will be based on the member s age at the group s effective date. WB.GA New Hire Rating Guide_11.17