1-100 Small Group underwriting guidelines - Designed for agents and producers Effective January 2021
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1-100 Small Group underwriting guidelines Designed for agents and producers Effective January 2021 45277CABENABC_BV Rev. 08/20
Important contact information
Small Group Underwriting address For Agents & Producers section of website
Anthem
P.O. Box 9042 My user ID:_______________________________________
Oxnard, CA 93031-9042 My password:_____________________________________
Small Group Underwriting To order supplies
New business: newsguwca@anthem.com Fax: 877-255-4015
Existing business: sguwca@anthem.com (fax completed Agent Supply Request form only)
New business telephone: 855-239-9251
Online: brokerportal.anthem.com/apps/ptb/login
For overnight delivery only
Anthem
View these guidelines and other documents online
Small Group Underwriting
Go to anthem.com/ca/ and select Producers. Then, log in
4553 La Tienda Drive
and select Sales and Training. From there, you can view,
Thousand Oaks, CA 91362
download, and print forms and documents.
Small Group Customer Service
Anthem Connect Team
Telephone: 855-854-1429
Telephone: 877-567-1802
Email: small.group@anthem.com
Hours: Monday to Thursday, 5 a.m. to 5 p.m. PT
Hours: Monday to Friday, 8 a.m. to 6 p.m. PT
Friday, 5 a.m. to 3 p.m. PT
Broker Services Email: connect@anthem.com
Telephone: 800-678-4466 Mail: Anthem Connect
Email: agent.support@anthem.com 730 S. Broadway
Hours: Monday to Friday, 8 a.m. to 5 p.m. PT Gilbert, MN 55741
Rapid Quote Summary of Benefits and Coverage links
Telephone: 877-275-3700 } Affordable Care Act (ACA)–compliant plans:
Email: rapidquote@anthem.com sbc.anthem.com
Anthem website
} Producer Toolbox:
anthem.com/ca/ brokerportal.anthem.com/ehb/group/bkr/stl/
product-information
Health care reform resources
thebenefitsguide.com/category/understanding-health- Quote to Enroll
insurance/anthem-resources brokerportal.anthem.com/apps/ptb/login
Quoting tool Broker training for Quote to Enroll, renewals, and
brokerportal.anthem.com/apps/ptb/login renewals with upsells
yourtimematters.com/ca
Dental, vision, life, and disability quoting
Census enrollment
} Anthem Connect Team (2–25 lives): brokerportal.anthem.com/apps/ptb/login
connect@anthem.com
} 26–100 lives: Easy renew
anthemspecialtyquotes@anthem.com anthem.com/easyrenew
Producer news
news.anthem.com/ca
Standard Industrial Classification (SIC) codes
} osha.gov/pls/imis/sicsearch.html
2
Table of contents
Thank you for choosing Anthem............................................1 Section 3
California underwriting business requirements..............15
Section 1
Sole proprietors.............................................................................. 15
Overview of the underwriting process.................................2
Corporations — C-Corp, S-Corp.................................................. 15
What to submit (employer level)...................................................2
Nonprofit organizations and corporations............................. 15
Employee enrollment.......................................................................2
Partnerships — general and limited liability partnerships
Group enrollment solutions...........................................................2 (LLPs).................................................................................................. 15
Completing forms.............................................................................2 Partnership-limited partnerships (LPs)................................... 16
Submission timeline........................................................................3 Limited liability companies (LLCs)............................................ 16
New group submission criteria.....................................................3 Startup companies........................................................................ 16
Professional employer organization (PEO)
Section 2 spinoff groups................................................................................. 16
General underwriting guidelines for Union versus nonunion................................................................ 16
Small Group business..............................................................4 Households...................................................................................... 16
Group eligibility requirements......................................................4
Employee eligibility requirements...............................................4 Section 4
Enrolling rehired employees.........................................................5 General underwriting guidelines for existing business.17
Residents of Hawaii (medical only).............................................5 Open enrollment period............................................................... 17
Contribution........................................................................................5 Benefit modifications.................................................................... 17
Medical plan participation.............................................................6 Benefit modification job aid....................................................... 18
Medical plan names.........................................................................6
Product types.....................................................................................6 Section 5
Network options................................................................................6 Definitions................................................................................22
Dental coverage.................................................................................7
Notes..........................................................................................23
Vision coverage..................................................................................8
Life coverage......................................................................................8
Disability coverage........................................................................ 10
Premium only plan (POP)............................................................. 11
Takeover provisions....................................................................... 12
Prior deductible credit/annual maximum copay/dental
benefit waiting period credit...................................................... 13
Dependent eligibility..................................................................... 13
Federal regulations........................................................................ 13
State regulations............................................................................ 14Thank you for choosing Anthem
At Anthem Blue Cross (Anthem), our goal is to provide you with clear guidance so you can help your clients
choose the best health care options.
We want to help you grow your book of business, increase client retention, and create an
easy-to-do-business-with environment.
Remember, agents are not authorized to bind or guarantee issue coverage. Anthem will make the final
decision to accept or decline a case. Please advise your prospective clients to maintain their current
coverage until we notify them in writing that Anthem has approved their coverage.
While Anthem is committed to keeping all parties informed of any changes to these Small Group underwriting
guidelines in a timely manner, Anthem may change these guidelines at any time without prior notice.
The information contained in these guidelines is intended for use by authorized agents only and should not
be copied or distributed for any other purpose.
1Overview of the underwriting process
Section 1
What to submit (employer level) Group enrollment solutions
The following group-level documentation is required Groups enroll in one of our employee enrollment
when submitting new business: solutions tools.
} A copy of the agent’s final sold quote — Salesforce
} The most current Employer Enrollment Application/ — Online Census Enrollment tool
Fillable Application, including the COBRA/FMLA/
To access the Census Enrollment tool, go to
Cal-COBRA questionnaire; and the last billing statement
brokerportal.anthem.com/ehb/web/bkr/acc/login.htm.
listing COBRA/Cal-COBRA subscribers, if applicable
After logging in, select the Sales and Training tab. Next,
} A copy of the company’s most recent Quarterly State select the Small Group Business Customer Forms tab.
Tax Withholding Report (DE9C) with the current Then, select Excel Census Tool.
employment status of all employees listed (payroll may
be required)* Completing forms
— 1st quarter due with state by 4/30
Please ensure all questions are answered and signatures
— 2nd quarter due with state by 7/31
and dates obtained. Please confirm the following
— 3rd quarter due with state by 10/31 before submitting:
— 4th quarter due with state by 1/31 } No alterations to preprinted materials will be accepted.
} If “takeover” coverage, a copy of the prior carrier’s — Only the employer may fill in, change, or modify the
last month’s group billing for all lines of coverage Employer Application.
with status of all listed employees — Only the employee may fill in, change, or modify the
} A completed Electronic Debit Payment form for 100% Employee Application.
of the first month’s premium, made payable to Anthem } Whenever an individual has a language barrier and
(If electronic debit is not agreed to, a company check requires assistance to properly complete the
may be accepted, subject to additional processing time.) application, the application must be submitted with a
} Anthem is required by the IRS and Centers for Medicare signed Anthem Statement of Accountability/Translator
& Medicaid Services (CMS) regulations to collect Social Statement from the group or the agent.
Security numbers
Employee enrollment
} Each eligible employee or owner must complete an
application or waiver.
} Agents must keep a copy of the Employee Application
or waiver.
* See section 3, “California underwriting business requirements,” for sole proprietors, partners, or corporate officers not appearing on the Quarterly State Tax Withholding Report (DE9C).
2Overview of the underwriting process
Section 1
Submission timeline New group submission criteria
For new group submission, make sure all required Underwriting is based on the following criteria:
forms are completed accurately and included with } Employee and dependent eligibility
your submissions.
} Employer contribution
} Anthem will accept new group submissions for the
} Employee participation
following effective dates:
— First of the month — by the 5th working day of } Evidence of insurability will be required for life benefit
amounts over guaranteed amount; evidence of
the month
insurability is also required for late entrants
— 15th of the month — by the 12th calendar day of
} Long–term disability for groups of 2–5 eligible
the month
employees is medically underwritten; evidence of
} If Anthem requests any additional information prior to insurability is required
making a new group determination, it should be
received within 10 days of the original request.
} If the information submitted is incomplete and
subsequently not received in a timely manner, the
group’s application may be withdrawn for the
month requested.
} It is the agent’s responsibility to notify the
Underwriting department prior to approval if a change
in the requested effective date is to be considered.
A request for change will be required in writing from
the employer.
Note: Effective date changes will not be
accepted after approval.
3General underwriting guidelines for Small Group business
Group eligibility requirements Ineligible for group coverage:
— Owner only — owners on their own or with their
An employer who meets the employer eligibility
spouse/domestic partners, officers, or partners
requirements under the ACA and under the California Small
Group regulations is eligible for guarantee issue and — Carve-out groups
guaranteed renewal under a small group health plan. — Employer groups with less than 51% of employees
} A small employer is defined as an employer employing working in California
an average of at least one, but no more than 100, full- — Seasonal, temporary, and substitute employees,
Section 2
time (including full-time-equivalent) employees during
defined as employees hired with a planned future
the preceding calendar year or preceding calendar
termination date
quarter and who employs at least one employee on the
first day of the plan year. For purposes of determining — Contract employees (1099), employees compensated
employer eligibility in the small employer market, on a 1099 basis
California adopted the federal method for counting full- — Sole proprietors, spouses of sole proprietors,
time employees and
partners of a partnership, and the spouses of
full-time-equivalent employees (SB 125, 2015).
those partners
} A group must be a person, firm, proprietary, or nonprofit
corporation, partnership, public agency, or Guaranteed — Employees who do not reside within the
Association. The employer must be actively engaged in 48 contiguous states, Alaska, Puerto Rico, or
business or service. the United States Virgin Islands
} A group must have and maintain business licensure A group wanting to reapply for Anthem may be ineligible if
and/or appropriate state filings, allowing the company they have not complied with prior requirements. Categories
to conduct business in California.
include, but are not limited to:
} A group must not have been formed primarily for the } Canceled for nonpay.
purpose of obtaining health insurance.
} Termination for recertification noncompliance.
} A group must involve a bona fide employer-employee
relationship. To be considered for coverage, all prior cases must be in
} An individual who wholly owns the company on their own or good standing, with all requirements complete.
with their spouse or domestic partner, the spouses of sole
proprietors, partners of a partnership and their spouses, a Employee eligibility requirements
2% S corporation shareholder, a worker described in Section } Permanent employees who are actively engaged on
3508 of Title 26, Internal Revenue Code, or a leased a full-time basis in the conduct of the business of the
employee (as defined in 26 U.S.C. § 414(n)(2)) does not small employer, with a normal work week of an
qualify as an employee for purposes of group eligibility.
average of 30 hours per week over the course of a
Aggregation rules -- All employers treated as a single month, at the small employer’s regular place of
employer under section 414(b), (c), (m,) or (o) of the IRS business, who have met any statutorily authorized
code are treated as a single employer for purposes of applicable waiting-period requirements.
determining group size. Therefore, all employees of a
controlled group of entities under section 414(b) or (c), an } Sole proprietors or partners of a partnership, if they are
affiliated service group under section 414(m), or an entity actively engaged on a full-time basis (average of 30 hours
in an arrangement described under section 414(o) are per week over the course of a month) in the employer’s
taken into account in determining whether the members small business and included as employees under a
of the controlled group or affiliated service group health care service plan contract of a small employer.
together are an applicable large employer. } Permanent employees who work at least 20 hours, but
Affiliated companies — Under common control are not more than 29 hours, are deemed to be eligible
required to enroll separately unless they are eligible to employees if all four of the following apply:
file a combined tax return for the purposes of state — The employee otherwise meets the definition of
taxation. In determining group size, affiliated companies an eligible employee except for the number of
eligible to file a combined tax return for purposes of hours worked.
state taxation are considered one employer, even if they
are not presently filing together. — The employer offers the employees health coverage
under a health benefit plan.
4General underwriting guidelines for Small Group business
— All similarly situated individuals are offered an employer group, to receive group coverage from a
coverage under the health benefit plan. Hawaii–authorized insurer. This would ensure that
— The employee worked at least 20 hours per normal all the state requirements are met.
workweek for at least 50% of the weeks in the
previous calendar quarter. The health care service Contribution
plan may request any necessary information to
Employers may choose their preferred approach for
document the hours and time period in question,
contributing to employee medical premiums. Payroll
including, but not limited to, payroll records and
Section 2
deduction is required, if contributory. Employers have
employee wage and tax filings.
the following contribution options:
— Please see page 8 for additional life and
Medical
disability guidelines.
} Traditional: A minimum contribution of 50% of each
} Employees must reside within the 48 contiguous
employee’s monthly health premium
states, Alaska, Puerto Rico, or the United States
Virgin Islands. } Fixed dollar: Any fixed-dollar amount $100 or greater
(in $5 increments) for each covered employee’s
Note: Owners may demonstrate that they meet
health premium
the eligible employee criteria by providing W-2s
or completing an Eligibility Statement. } Percentage and plan: A minimum of 50% toward a
specific plan, chosen by the employer
Enrolling rehired employees Note: During the annual open enrollment period of
November 15 to December 15, contribution
If an enrollee’s employment ends and the employee is
requirements will not be enforced. The effective date
later rehired, certain restrictions apply. If the employee
will be January 1 of the following year.
is rehired within 31 days of termination, coverage will
resume with no lapse upon our receipt of a written Life
request from the employer group. } Basic life: Minimum employer contribution (not
including dependent coverage) is 25% for
If the employee is rehired more than 31 days from
contributory plans and 100% for noncontributory
termination but not more than 91 days, coverage shall
plans. Payroll deduction is required, if contributory.
restart effective on the rehire date. The rehired
employee will not be subject to applicable group- } Optional life: 100% employee paid. Payroll
imposed waiting periods and must complete a new deduction is required.
Employee Enrollment Application. } Voluntary life: 100% employee paid. Payroll
deduction is required.
If the employee is rehired more than 91 days (13 weeks)
after the termination date, the employee is considered Disability
a new employee, subject to applicable group-imposed } Short-term disability: Minimum employer
waiting periods, and must complete a new Employee contribution (not including dependent coverage)
Enrollment Application. The group is responsible for is 25% for contributory plans and 100% for
notifying us immediately if an employee is rehired and noncontributory plans. Payroll deduction is
will be continuing coverage. required, if contributory.
} Voluntary short-term disability: 100%
Residents of Hawaii (medical only) employee paid. Payroll deduction is required.
Hawaii alert — Because Anthem is neither a } Long-term disability: Minimum employer
Hawaii–authorized insurer nor a Hawaii health contribution (not including dependent coverage)
care contractor, our benefits may not match the is 25% for contributory plans and 100% for
requirements of the Prepaid Health Care Act. We noncontributory plans. Payroll deduction is
recommend that you receive direct quotes for either required, if contributory.
an individual policy for employees who live and work } Voluntary long-term disability: 100% employee paid.
in Hawaii, or if there are several employees within Payroll deduction is required.
5Medical plan participation The metal structure represents actuarial values (AVs) and
can be used to compare how overall cost sharing differs
The group participation requirements are: across plans. Minimum and maximum AVs for each type of
— 70%: Groups with 1-14 eligible employees plan include:
— 50%: groups with 15 or more eligible employees — Platinum 88%/92%
— Minimum participation is 100%, — Gold 78%/82%
if noncontributory — Silver 68%/72%
Anthem may conduct periodic audits to confirm — Bronze 58%/62%
participation levels.
The group must maintain the corresponding minimum Product types
Section 2
participation levels in order to remain eligible. Groups are } Preferred provider organization (PPO): Allows
subject to cancellation or nonrenewal if participation falls
members to go directly to any in-network provider.
below the required minimum.
There is no need to choose a primary care physician
Note: During the annual open enrollment period of (PCP) or receive a referral to see other doctors.
November 15 to December 15, participation requirements } Health maintenance organization (HMO): Requires
will not be enforced. The effective date will be January 1 of
members to choose a PCP. A referral is required to see
the following year.
other doctors.
For purposes of calculating participation, the following } Health savings account (HSA): A savings account
are considered valid waivers, subject to receipt of
for certain plans that members can fund with pretax
a declination and proof of other coverage, such as:
dollars and use to pay for qualified health care
— Employer-sponsored group coverage through expenses, including prescriptions. This is often
another employer used with a consumer-driven health plan.
— Medi-Cal
— Medicare Network options
— United States military coverage PPO
— Individual waiver on and off the exchange } Prudent Buyer PPO network: Access to nearly
Note: An owner of multiple entities will not be considered 60,000 California doctors and specialists, and more
a valid waiver if the owner is declining due to coverage than 330 hospitals.
under another entity in which they hold ownership. } Select PPO network: Access to more than
Dual coverage by the same employer would not be 40,000 California doctors and specialists, and more
considered a valid waiver. than 300 hospitals.
Note: Employers may choose only one PPO network.
Medical plan names
} Anthem Platinum: Provide the highest level HMO
of benefits, and employees often pay less when they } CaliforniaCare HMO network: Access to more than
receive care. However, these plans have the highest 42,000 California doctors and specialists, and more
monthly premiums. than 330 hospitals.
} Anthem Gold: Provide richer benefits than the Silver } Select HMO network: Access to more than
and Bronze plans, and employees pay less when they 26,000 California doctors and specialists, and nearly
receive care. However, the monthly premium is higher 250 hospitals.
than with those plans. } Priority Select HMO: This network is built around
} Anthem Silver: Offer affordable monthly premiums, but those participating medical groups and independent
compared to the Bronze plans, employees pay less when practice associations demonstrating the most efficient
they receive care. practice patterns and hospital referrals in these
} Anthem Bronze: Feature broad benefits and the lowest Southern California counties: Los Angeles, Orange,
monthly premiums, but employees pay more when Riverside, San Bernardino, and San Diego.
they receive care; deductibles, copays, and cost shares Note: Employers may choose only one HMO network.
may be higher than with the other plans.
6General underwriting guidelines for Small Group business
Employers must select a network for each plan type. group has at least five net eligible employees; a
For example, the employer may offer employees plans minimum of two employees must enroll in each
available in the Select HMO network alongside the option; and the two plans offered must have at least a
Prudent Buyer PPO network. Not all network options 10% differential of the employee-only tier premium.
are available in every area. } Dual option with a DHMO must be with an Anthem
DHMO (dental Enrollment Verification Form must
Dental coverage be provide with backup).
} For PPO plans with orthodontia, a minimum of five
Section 2
Dental Net DHMO
employees must enroll.
Available for 2–100 employees; a minimum of two
employees must enroll: Voluntary dental plans
} Participation: 2–4 eligible employees: 65% of eligible Available for groups of 5–100 eligible employees:
employees (and a minimum of two employees) } A minimum of five employees must enroll in the
not covered under another dental plan are required stand-alone dental products; there is no further
to enroll. participation requirement.
} Participation: 5–100 eligible employees: A minimum } Dual option is allowed with five or more employees
of 25% net eligible employees must enroll with a enrolling in each option. The plans must have at least
minimum of two. 10% differential in premium rates based on single rate.
} Dual option offerings are available to small groups Dual option is not allowed between two DHMO plans.
with at least five net eligible employees, but the plans Dual option must be between an Anthem PPO and
must have at least a 10% differential in premium an Anthem DHMO plan, or between two Anthem
rates. The 10% differential is calculated based on a PPO plans.
comparison of the single rate for each quoted plan.
Eligibility guidelines
} Dual option is not allowed between two DHMO plans.
Dual option must be between an Anthem PPO and } Group must be headquarterd in California.
Anthem DHMO plan. } Seasonal and temporary employees are not eligible.
} Dual option participation guidelines require a minimum } Dental offices and clinics are not eligible.
of at least two enrolled in each option. The group must } Any changes to the definition of an employee are
also meet the minimum participation percentage stated subject to underwriting approval.
in the “Participation” sections above.
} See page 4 of underwriting guidelines for definition of
} Orthodontic coverage for adults and children is an eligible employee.
included in all Dental Net DHMO plans.
} Waiting periods are not required for Dental Net Pediatric dental
DHMO plans (including plans with optional dental All of our Small Group health plans include pediatric
implant coverage). dental essential health benefits, which provide important
Note: Dental Net DHMO office numbers are required. coverage for children up to age 19. Benefits include
preventive care; fillings; and more extensive services,
Essential Choice such as medically necessary orthodontia.
} Participation: Group size 2–4: Minimum is 65%
participation, and at least two employees must enroll.
} Participation: Group size 5–100: Minimum participation
percentage is 25% net eligible employees, and at least
two employees must enroll.
} Dual Option PPO plans (employer can select two plans
to offer to employees) available for employer-
sponsored plans. A dual option is available if the
7Vision coverage } Availability: Group must have at least two eligible
employees for basic life, short-term, and long-term
Anthem now offers Blue View VisionSM. disability. Group must have the greater of 20%
participation or five eligible employees enroll for
Employer sponsored optional supplemental life or optional voluntary life.
} Available for 2–100 employees. Group must have the greater of 20% participation of
10 eligible employees enroll for voluntary short-term
} A minimum of two employees must enroll.
disability or voluntary long-term disability.
} Dual option is available (employer can select two plans
24-month rate guarantee.
Section 2
}
to offer to employees). Employer may choose a
maximum of two plans, but may not pair a voluntary } Valid and appropriate SIC must be used for quoting.
plan with an employer-sponsored plan. Dual option Rates are subject to change if appropriate SIC is not used.
requires at least 10 eligible employees. Two or more } Group must be in good financial status. Groups in
employees must enroll in each option. bankruptcy are not eligible. Certain SIC codes are not
eligible for coverage.
Voluntary vision
} Group must have been in business at least one year for
} Available for 5–100 employee Small Groups; a minimum short-term disability, long-term disability, voluntary
of five subscribers must enroll. Choose a maximum of short-term disability, and voluntary long-term disability.
two plans.
} Employees must be actively at work. Employees must be
} Dual option is available (employer can select two plans U.S. citizens working in the U.S. or approved foreign
to offer to employees). Employer may choose a nationals with U.S. work visas working in the U.S.
maximum of two plans, but may not pair a voluntary
plan with an employer-sponsored plan. Dual option } Retiree coverage is not available.
requires at least 10 eligible employees. Five or more } 1099 workers or contractors are not eligible for coverage.
employees must enroll in each option. } May be sold with other Anthem and its affiliates’ products
} Voluntary vision is available as a stand-alone product or or as stand-alone.
in conjunction with medical, dental, and/or life. } Employees must work at least 30 hours per week to
Pediatric vision be eligible.
All of our Small Group health plans include pediatric
} Groups must maintain the minimum participation
vision essential health benefits, which provide coverage for levels to remain eligible. Groups may not be renewed
vision exams and glasses or contacts for children up to age if participation falls below the required minimum.
19. Members can see any provider in the Blue View VisionSM
Basic life
network, which includes retailers such as 1-800 CONTACTS®,
LensCrafters®, and Target Optical®. } Benefit options:
Group size 2–9 Group size 10–100
Adult exam only
Flat-amount benefit options of Flat benefit amount from $15,000 to
All Small Group health plans include an adult $15,000, $25,000 $500,000 in $1,000 increments ($10,000
exam-only benefit. $30,000, $50,000 benefit available for groups that also offer
optional life)
Life coverage Salary-based benefit option of 1x Salary-based benefit options of 1x, 2x, 3x,
annual earnings 4x, or 5x annual earnings
These are the general guidelines we use when evaluating
Guaranteed issue is $50,000 Guaranteed issue amount varies by group
groups. Life and disability underwriting guidelines differ
from medical underwriting guidelines. This is not a Census must be submitted for quoting.
complete list of all life and disability underwriting Census must include:
requirements. Each group is evaluated during the — Gender.
underwriting process. Basic underwriting guidelines are
subject to change at a life underwriter’s discretion. — Age or date of birth.
— Class designation (if benefits vary by class).
Underwriting guidelines apply to all life and disability
products. Additional guidelines for each product are — Salary (if benefits are salary based).
shown below: — Name or employee ID.
8General underwriting guidelines for Small Group business
} Groups of 2–9, age-banded rates. Groups of 10+,
Group size 10–100
composite rates.
Flat amounts from $10,000 to $500,000 in $5,000 increments
} Participation requirements:
1x, 2x, 3x , 4x, or 5x annual earnings
— All eligible employees must participate when
} Census must be submitted for quoting. Census
coverage is entirely employer paid. (Religious waiver
must include:
allowed with written documentation.)
— Gender.
} 75% of eligible employees must participate when
— Age or date of birth.
Section 2
employee contribution is required.
} These participation requirements are the same — Class designation (if benefits vary by class).
for basic life sold with or without medical and — Salary (if benefits are salary based).
for basic life sold with or without other life and
— Elected coverage amounts.
disability products.
— Name or employee ID.
} Contribution requirements: Minimum employer
contribution (not including dependent coverage) } Age-banded rates.
is 25% for contributory plans and 100% for } Supplemental life must be sold with basic life.
noncontributory plans. Voluntary life is sold as stand-alone.
} Benefit may vary by class, based on employer offering by } Participation requirement: Greater of 20% of eligible
class, up to maximum number of classes: 2–9, one class; employees or five employees must enroll. Example:
10+, five classes. No more than 2.5x difference in life A group with 10 employees will need to have five
benefit amount between classes. It is acceptable to create employees enroll to satisfy the “greater of” requirement.
a class with a $50,000 maximum benefit for those } Contribution requirement: 100% employee paid.
employees desiring no imputed income for tax purposes.
} Supplemental life only — employees must be enrolled
No open enrollment allowed. Annual enrollments are in basic life coverage.
allowed for contributory coverage; late enrollees are } Initial open enrollment is included for 30 days from
subject to evidence of insurability.
group effective date. For groups with a voluntary life
Basic dependent life benefit of more than $100,000, the initial open
enrollment guaranteed issue limit is $100,000.
} Benefit options:
} Takeover coverage: Standard one-time open
Group size 2–9 Group size 10–100
enrollment is included for 30 days from group
$10,000 spouse/$5,000 each child $20,000 spouse/$10,000 each child
effective date for takeover coverage on groups with
$5,000 spouse/$2,500 each child $15,000 spouse/$7,500 each child 10 or more eligible lives.
$10,000 spouse/$5,000 each child
— For groups with voluntary life employee guaranteed
$5,000 spouse/$2,500 each child
issue limit of more than $100,000, the initial open
$2,000 spouse/$1,000 each child
enrollment employee guaranteed issue limit is
$100,000. For example, if the group’s employee
} Dependent coverage cannot exceed 50% of the guaranteed issue limit is $200,000, the initial
employee amount. open enrollment employee guaranteed issue limit
} Child coverage begins on 15th day following birth and is $100,000.
ends at age 26. — For groups with voluntary life employee guaranteed
} Family unit rate structure. issue limit of less than $100,000, the initial open
} All dependent life amounts are guaranteed issue. enrollment employee guaranteed issue limit is the
group’s employee guaranteed issue limit. For
Supplemental life/voluntary life example, if the group’s employee guaranteed issue
} Benefit options: limit is $50,000, the initial open enrollment employee
guaranteed issue limit is $50,000.
9— For groups with voluntary life spouse guaranteed Disability coverage
issue limit of more than $10,000, the initial open
enrollment spouse guaranteed issue limit is $10,000. Short-term disability and long-term disability
For example, if the group’s spouse guaranteed issue } Benefit options:
limit is $20,000, the initial open enrollment spouse
Group size 2–9 Group size 10–100
guaranteed issue limit is $10,000.
Short-term disability Short-term disability
— For groups with voluntary life spouse guaranteed — Flat amount $250 per week — Flat amount of $100, $150,
issue limit of less than $10,000, the initial open $200, or $250
— 60% of weekly earnings
Section 2
enrollment spouse guaranteed issue limit is the
— 67% of weekly earnings — 40% of weekly earnings
group’s spouse guaranteed issue limit. For example, (must be noncontributory) — 50% of weekly earnings
if the group’s spouse guaranteed issue limit is
$5,000, the initial open enrollment spouse — 55% of weekly earnings
guaranteed issue limit is $5,000. — 60% of weekly earnings
— 67% of weekly earnings
— This is not an annual open enrollment.
(must be noncontributory)
— Future enrollments require evidence of insurability — 70% of weekly earnings
for late enrollees and increases in coverage, (must be noncontributory)
regardless of amount. Long-term disability Long-term disability
— Requests for takeover or grandfathering of voluntary — 60% of monthly earnings — 40% of monthly earnings
life amounts must be reviewed and approved by Life — 50% of monthly earnings
& Disability Underwriting. — 60% of monthly earnings
} New coverage: Initial open enrollment is included for — 67% of monthly earnings
(must be noncontributory)
30 days prior to group effective date for groups that have
never offered supplemental or voluntary life. Employees } Census must be submitted for quoting. Census
and dependents may enroll up to the guaranteed issue must include:
limits without evidence of insurability. — Gender.
} No annual open enrollment. Evidence of insurability is — Age or date of birth.
required for late enrollees and increases in coverage, — Class designation (if benefits vary by class).
regardless of amount. — Salary.
} Evidence of insurability is required for all coverage, — ZIP code (required for short-term disability).
amounts above guaranteed issue limits.
— Occupations (for long-term disability).
Supplemental/voluntary dependent life — Elected coverage amount.
} Benefit options: — Name or employee ID.
Spouse -- flat benefit available from $10,000 to $50,000 in } Groups of 2–9, age-banded rates. Groups of 10+,
$5,000 increments composite rates.
Child -- $5,000, $10,000, $15,000; cannot exceed 50% of spouse amount
} Participation requirements:
} Dependent coverage cannot exceed 50% of the — All eligible employees must participate when
employee amount. coverage is entirely employer paid. (Religious waiver
} Child coverage begins on 15th day following birth and allowed with written documentation.)
ends at age 26. — 75% of eligible employees must participate when
} Family unit rate structure. employee contribution is required.
} Short-term and long-term disability are available
independent of each other.
} Contribution requirements: The minimum employer
contribution for short-term disability insurance
coverage is 25% for contributory plans and 100%
for noncontributory plans.
10General underwriting guidelines for Small Group business
} No open enrollment allowed. Timely enrollment is } New coverage: Initial open enrollment is included for
required for new employees. Employees hired after 30 days prior to group effective date for groups that
the effective date of the plan will become eligible for have never offered voluntary short-term and long-term
insurance after completing the waiting period disability. Employees may enroll up to the guaranteed
specified in the policy. issue limits without evidence of insurability.
} Short-term disability does not replace the state- } No annual open enrollment. Evidence of insurability is
mandated benefits of CA, NY, NJ, HI, PR, or RI. This plan required for late enrollees and increases in coverage,
will integrate or offset with the state-mandated coverage, regardless of amount.
Section 2
where employees covered by such plans exist at time of } Evidence of insurability is required for all coverage
claim. If the census data provided for a quote includes amounts above guaranteed issue limits.
state location at the employee level, the state-mandated
} Preexisting condition limitation applies to voluntary
plan benefits will be considered in setting our pricing.
short-term and voluntary long-term disability.
} Preexisting condition limitation applies to
} Quote for voluntary long-term disability assumes
long-term disability.
participation in Social Security. Groups that do not
Voluntary short-term and long-term disability participate in Social Security or have other state or
} Benefit options: local disability plans must be quoted by Life &
Disability Underwriting.
Groups of 10–100
This information is intended to be a brief outline of life
Voluntary short-term disability
and disability underwriting guidelines and not intended
— Flat amount of $100, $200, or $250 per week
to be a complete description of the underwriting policies.
— 50% of weekly earnings
Each group is underwritten individually, and other
— 55% of weekly earnings underwriting factors apply. Anthem and its affiliates may
— 60% of weekly earnings decline to quote on a group. Groups in certain SIC
Long-term disability classifications are not eligible for coverage. In the event
— 50% of monthly earnings of a conflict between a proposal and this document,
— 60% of monthly earnings the terms of the proposal will prevail.
} Census must be submitted for quoting. Census Premium only plan (POP)
must include:
— Gender. POP is an IRS-approved change in the payroll process that
— Age or date of birth. allows employers to use pretax salary dollars to pay
employees’ share of benefit premiums. Any size employer
— Class designation (if benefits vary by class).
can take advantage of this special provision of Section
— ZIP code (required for voluntary short-term disability). 125 of the IRS code.
— Occupations (for long-term disability and voluntary Note: The IRS prohibits certain individuals from
long-term disability). participating in POPs:
— Elected coverage amount.
} Sole proprietors
— Name or employee ID.
} Partners within a partnership, including LLC and LLP
} Age-banded rates.
} Owners of an S-Corp
} Participation requirement: Greater of 20% of eligible
employees or 10 employees must enroll. Establishing a POP arrangement through WageWorks, Inc.
is convenient. The cost of a POP is only $125 per year.
} Voluntary short-term and voluntary long-term Groups with 10 or more eligible employees on medical
disability are available independent of each other. and life plans will receive the first year’s POP services
} Contribution requirements: no employer contribution. from WageWorks at no charge. Submit a separate check
} Takeover coverage: No standard one-time open for the POP premium, made payable to Anthem, along
enrollment for takeover coverage. Evidence of with the POP application.
insurability is required for late enrollees and
increases in coverage, regardless of amount. 11For more information about POP, contact WageWorks Anthem with accurate member eligibility dates, taking into
at 800-876-7548 (8 a.m. to 5 p.m. CT) or go to account any group-imposed waiting period. In accordance
ezpop.com. For tax advice, consult your tax adviser. with SB 1034, groups are responsible for ensuring that
For complete details, order the Employer’s Guide any group-imposed waiting period is consistent with
to the Premium Only Plan, available online at Section 2708 of the Federal Public Health Service Act
www11.anthem.com/easyrenewsite/home.html. (42 U.S.C. § 300gg-7).
Note: The POP application cannot be processed until Waiting period options are as follows:
group medical and/or dental, vision, and life coverage has — First of the month following date of hire
Section 2
been approved. Therefore, the POP effective date assigned — First of the month following one month from
by WageWorks may be later than the effective date of the date of hire
group’s medical, dental, vision, and life coverage.
— First of the month following two months from the
Rating policies date of hire, not to exceed 90 days2
The employer has the option to waive the waiting period
} All rates will be based on actual enrollment. for all new hires at the initial group enrollment only.
} For Small Group plans, the rate for the family is based The group’s waiting period is applied to all employees in
on the combined ages of the employee, spouse, all the group, with no exceptions for any eligible employee.
dependents 21 and older, and up to the three oldest
Note: Dual waiting periods are not allowed. Does not apply
dependents 20 or younger. The premium is determined
to life and disability coverage.
by the employer’s principal business ZIP code.1
} Dental, vision, and life products require SIC code to Takeover provisions
determine rate.
} Dental and vision require the number of eligible Small Group takeover provisions comply with the following:
employees to determine rate. } Any carrier providing replacement coverage with respect
} Medicare primary and secondary rates are the same. to hospital, medical, or surgical expense or service
benefits within a period of 60 days from the date of
Rate and benefit guarantee discontinuance of a prior contract or policy providing
such hospital, medical, or surgical expense or service
} Medical rates are guaranteed for a minimum of benefits will immediately cover all employees and
12 months. The anniversary month will determine the dependents who were validly covered under the previous
timing of future adjustments. contract or policy providing such hospital, medical, or
} Dental rates are guaranteed for 24 months. surgical expense or service benefits at the date of
discontinuance and are within the definitions of
} Life rates are guaranteed for 24 months. eligibility under the succeeding carrier’s contract and
} Dental and vision require the number of eligible who would otherwise be eligible for coverage under the
employees to determine rate. succeeding carrier’s contract, regardless of any
} Vision rates and benefits are guaranteed for provisions of the contract relating to active full-time
24 months. employment or hospital confinement or pregnancy.
} Rates will adjust for age at contract anniversary. } However, with respect to employees or dependents
who are totally disabled on the date of discontinuance
Waiting periods of the prior carrier’s contract or policy and entitled to
an extension of benefits pursuant to subdivision (b) of
Pursuant to SB 1034 (2014), Anthem will not impose a Section 1399.62, or pursuant to subdivision (d) of
waiting period. Groups are responsible for providing Section 10128.2 of the Insurance Code, the succeeding
1 The principal business address means the principal business address registered with the state or, if a principal business address is not registered with the state, or is registered solely for purposes of service of process
and is not a substantial worksite for the policyholder’s business, the business address within the state where the greatest number of employees of such policyholder works. If, for a network plan, the group policyholder’s
principal business address is not within the service area of such plan, and the policyholder has employees who live, reside, or work within the service area, the principal business address for purposes of the network
plan is the business address within the plan’s service area where the greatest number of employees work as of the beginning of the plan year. If there is no such business address, the rating area for purposes of the
network plan is the rating area that reflects where the greatest number of employees within the plan’s service area live or reside as of the beginning of the plan year.
2 If it exceeds 90 days, the effective date will be the first of the month following one month from the date of hire.
12General underwriting guidelines for Small Group business
carrier is not required to provide benefits for services — Child for whom the eligible employee has assumed
or expenses directly related to any conditions that a parent-child relationship (does not include foster
caused the total disability. children), as indicated by intentional assumption of
parental status or assumption of parental duties by
Prior deductible credit/annual maximum the eligible employee (The employee for the
copay/dental benefit waiting period credit annuitant must certify at the time of enrollment of
the child and annually thereafter.)
} For new group submissions, Anthem provides credit for
deductibles met under prior takeover group medical or Note: In the case of birth, adoption, or placement for
Section 2
prior takeover group dental coverage if proof of the adoption, the child will be covered for the first 31 days
actual dollar amount is submitted with the first claim. from the date of birth, adoption, or placement for
This provision does not apply to new hires. adoption. To continue the plan beyond the 31 days,
Anthem must receive an application for coverage of a
} Credit for a pharmacy deductible is not available,
dependent child within 60 days of the child’s eligibility.
except when the member’s prior takeover group
Coverage will be effective beginning on the date of birth or
coverage was an aggregate plan (for example, HSA).
adoption or placement for adoption following our receipt
} Credit for the annual maximum copay is not available, of the completed Employee Enrollment Application.
except when the takeover group is moving from
A child will be considered adopted from the earlier of: 1) the
Anthem Large Group coverage.
moment of placement in a group member’s home; or 2) the
} Anthem provides credit for the dental benefit waiting date of an entry of an order granting custody of the child to
periods if Anthem receives proof of 12 months of prior the group member. The child will continue to be considered
creditable dental coverage at enrollment and there is adopted unless the child is removed from the member’s
no lapse in coverage between carriers. home prior to issuance of a legal decree of adoption.
Note: If both parents are covered subscribers through the
Dependent eligibility same employer, their children may be covered as
dependents of either, but not both, of the subscribers.
An eligible employee may be required to provide proof of
Parents have 60 days from the time of the birth, adoption,
dependency. Dependent coverage is available to the following:
or placement for adoption to submit applications for their
} Lawful spouse dependent children. New spouses and/or domestic
} Registered domestic partner (Family Code Section 297) partners also have 60 days from date of marriage or
affidavit of domestic partnership.
} Disabled dependent child, who at the time of becoming
age 26, is incapable of self-sustaining employment by
reason of a physically or mentally disabling injury, Federal regulations
illness, or condition, and is chiefly dependent on the
} Federal Tax Equity and Fiscal Responsibility Act
subscriber for support and maintenance (A disabled
(TEFRA); Department for Environment, Food and Rural
dependent may be eligible for benefits beyond his or
Affairs (DEFRA); and COBRA legislation was enacted to
her 26th birthday. The employee will be required to
regulate employee health care coverage. Based on this
submit physician certification of the child’s condition.)
legislation and the limitations of the Anthem
} An employee’s, spouse’s, or registered domestic agreement, if a business employs, on average, fewer
partner’s child under age 26: than 20 employees in a year and any employee
— Natural child becomes age 65, then their primary carrier must be
— Newborn child Medicare. For these employees who are 65 years old
and choose to retain their Anthem Small Group
— Stepchild coverage, Anthem will apply contract benefits as a
— Legally adopted child secondary carrier for Medicare benefits paid or payable.
— Ward of legal guardian
13} When a member is covered by both Medicare and calendar year. This law also applies to an eligible
Anthem, and Anthem is secondary, the total benefit employer who wasn’t in business during any part of
provided by Medicare and Anthem should equal the preceding calendar year if the employer employed
but not exceed the benefits of group members 2 to 19 employees for at least 50% of the working
who do not have Medicare coverage. days in preceding calendar quarter.
} Anthem is secondary to Medicare when one of the } Employers with a single employee aren’t eligible
following criteria is met: for Cal-COBRA.
— If a member is required to pay an additional Under California law AB 1401, Cal-COBRA provides
Section 2
premium for any part of Medicare and chooses continuation of coverage for groups of 2 to 19 eligible
not to enroll in that part, Anthem will pay per employees for at least 50% of the working days in the
contract benefits as primary. preceding calendar year.
— If a member is eligible for any part of Medicare An employee and/or eligible dependents are eligible
that is premium-free and chooses not to enroll for continuation of coverage under Cal-COBRA if
in that part, Medicare would be considered coverage was terminated due to any of the following
primary and the member’s Anthem plan would qualifying events:
be secondary. Anthem will estimate Medicare’s } Death of the plan subscriber, for continuation of
benefit prior to Anthem coordinating coverage dependent coverage.
for deductibles and coinsurance.
} Employee’s termination of employment or
Anthem is secondary to Medicare when the following reduction of hours.
criteria are met:
} Spouse’s divorce or legal separation from
— The employer has fewer than 20 employees and the subscriber.
the member is age 65.
} Loss of dependents status of enrolled child.
— Members under 65 are eligible for Medicare due
} Subscriber becoming entitled to Medicare.
to a disability.
} Loss of eligibility status of enrolled family member.
— Members are enrolled following the first
30 months of kidney dialysis treatments for Anthem is currently administering Cal-COBRA.
end-stage renal disease. However, brokers and agents are responsible for
submitting Cal-COBRA questionnaires, applications,
} COBRA — Participation in the employee’s benefit
and remittance checks with new business.
plan, as well as coverage under whatever medical
programs are provided by the employer to Note: Cal-COBRA rates are 110% of the group rate.
employees and their dependents, may be Effective January 1, 2008, AB 910 amended existing
continued under a federal law known as COBRA law to extend the continuation of coverage rights for
for groups that employ 20 or more employees over-age dependents who are: 1) incapable of
for at least 50% of the previous calendar year. self-sustaining employment by reason of physically or
— The employer is responsible for administration mentally disabling injury, illness, or condition; and
(within the guidelines established by the 2) chiefly dependent on the subscriber for support
federal government for compliance by and maintenance. The law sets out new notification
employer groups). timelines, and requires subsequent health care
service plans and health insurers to honor continued
coverage unless there is a demonstration that the
State regulations
child no longer meets eligibility requirements.
Cal-COBRA (SB 719) became effective January 1, 1998.
This legislation provides for the continuation of
coverage for employees and eligible dependents for
groups that employed fewer than 20 employees at
least 50% of the working days in the previous
14California underwriting business requirements
Sole proprietors Nonprofit organizations and corporations
A sole proprietor employer must employ at least IRS Publication 557 has several types of 501(c)
one common-law employee as anyone who performs organizations, such as:
services for an employer that has the right to control } 501(c)(3) — Religious, educational, charitable,
and direct what will be done and how it will be done scientific, literary, testing for public safety.
as defined by federal law and/or IRS guidelines.
} 501(c)(1) — Corporations organized under Act of
Required documents: Congress (including federal credit unions).
} Quarterly State Tax Withholding Report Nonprofit companies must provide the following:
and/or payroll
} Quarterly State Tax Withholding Report, if available,
Business and ownership documents — select one or some other objective indicia of employment
of the following:
} Anthem Eligibility Statement
} Schedule C
} California secretary of state “active”
} Current California business license web confirmation
} Fictitious business name filing } IRS letter 501(c)(3)
Section 3
If owner is not on the quarterly wage report, please } IRS application for exempt status
submit completed Anthem Eligibility Statement.
Members of the clergy who do not appear on the
Single owners and spouses or domestic partners Quarterly State Tax Withholding Report should submit
of single owners don’t constitute the qualifying a Schedule SE or Form 4361 with IRS approval.
W-2 employee.
Partnerships — general and limited liability
Corporations — C-Corp, S-Corp partnerships (LLPs)
Corporations must provide the following: A partnership employer must employ at least one
} Quarterly State Tax Withholding Report, common-law employee as anyone who performs
or payroll report. services for an employer that has the right to control
and direct what will be done and how it will be done
If officer(s) is not on the quarterly wage report, please
as defined by federal law.
also submit the following:
Partnerships must provide all of the following:
} Anthem Eligibility Statement
} Current Schedule K–1 (Form 1065) (If this is not
And one of the legal documents below:
available due to the length of time in business or
} Statement of Information (Articles of Incorporation because there is an extension to file, a Partnership
with stamped meeting minutes listing the names Agreement and federal tax ID appointment letter
of the officers may be considered). may be substituted.)
} Tax Form 1120 with Schedule 1125-E (for C-Corp). } Anthem Eligibility Statement
} For S-Corps, Form 2553 signed by all officers. } Quarterly State Tax Withholding Report, if available,
Corporations established out of state will also need or some other objective indicia of employment
to provide a Certificate of Qualification or Statement } Limited liability partnerships registered out of
by Foreign Corporation in addition to the above state will also require a Registered Limited
documentation. Liability Partnership Certificate of Registration
If the percentage of ownership is zero, the enrolling filed and stamped with the California secretary
corporate officer must appear on the Quarterly State of state.
Tax Withholding Report. Single owners and spouses or domestic partners of
Two percent S-Corp shareholders, owners, and officers or partners don’t constitute the qualifying
spouses or domestic partners of officers or partners W-2 employee.
do not constitute common-law employees.
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