employer administrative guide€¦ · hmoandelectopenaccess anthembluecross ..... (866)524-5659...

EMPLOYERADMINISTRATIVE GUIDE

HMO and Elect Open Access

Anthem Blue Cross .................................................................................. (866) 524-5659English/Español, Mon-Fri 8:30 a.m. - 7:00 p.m.

Health Net....................................................................................................(800) 361-3366English/Español, Mon-Fri 8:30 a.m. - 5:00 p.m.

Kaiser Permanente ......................................................................English (800) 464-4000Español (800) 788-0616

7 days a week 7:00 a.m. - 7:00 p.m.

Sharp Health Plan......................................................................................(800) 359-2002English/Español, Mon-Fri 8:00 a.m. - 5:00 p.m.

Western Health Advantage ......................................................................(888) 563-2250English/Español, Mon-Fri 8:00 a.m. - 5:00 p.m.

PPO

Anthem Blue Cross Life and Health Insurance Company ................(866) 524-5659English/Español, Mon-Fri 8:30 a.m. - 7:00 p.m.

Dental

Ameritas Group ..........................................................................................(877) 203-0036English/Español, Mon-Thurs 5:00 a.m. - 10:00 p.m.

Fri. 5:00 a.m. - 4:30 p.m.

FDH Access 100........................................................................................(800) 558-8003English/Español, Mon-Fri 8:30 a.m. - 5:00 p.m.

SmileSaverSM, a division of SafeGuard Health Plans, Inc...................(800) 333-9561English/Español, Mon-Fri 8:00 a.m. - 5:00 p.m.

Vision

EyeMed Vision Care ..................................................................................(866) 939-3633English/Español, Mon-Fri 8:00 a.m. - 6:00 p.m.

Chiropractic/Acupuncture

Landmark Healthcare................................................................................(800) 638-4557English/Español, Mon-Fri 5:00 a.m. - 5:30 p.m.

Contact InformationEmployers:

Administrative and billing questions?(800) 558-8003

Employees:

www.ca l cho ice. com

1

We’re proud to be a part of your health program!

During the coming coverage year, it’s inevitable that you’ll be presented with a

question or situation that needs clarification. This Employer Administrative

Handbook is intended to guide you through different administrative procedures,

as well as answer general questions about the CaliforniaChoice program. Please

feel free to call our Customer Service Center at (800) 558-8003 if you need

further assistance.

Although your application for coverage and monthly billing are processed

by CaliforniaChoice, the Group Service Agreement (contract) for your health

coverage is with each of the applicable Health Plans in the CaliforniaChoice

program. Over the next few weeks you will receive a Group Service Agreement

from each participating Health Plan selected by your employees. Some of the

Agreements may require your signature. The Agreements should be retained

with this Employer Administrative Handbook for future reference.

Keep In A Safe Place

Welcome To CaliforniaChoice®


www.ca l cho ice. com22

Member Privacy Statement

CaliforniaChoice® is proud to provide quality employee benefit products andservices to our customers. Keeping your personal information secure andprotecting your privacy rights are important to you, and it is one of our toppriorities. This statement tells you about the information we request from ourcustomers. It also tells you how we safeguard the personal information andprotect the privacy rights of our current and former customers.

Our Privacy Commitment to YouCaliforniaChoice will safeguard your personal information and protect theprivacy rights of our customers in accordance with state and federal laws.We will accomplish this in ways that are reasonable and consistent with soundbusiness practices.

Protecting Your Health InformationWe do not share your personal health information (such as medicalquestionnaires) except when necessary to conduct underwriting reviews at thetime of your Employer’s initial enrollment through CaliforniaChoice or upon anEmployer requested underwriting review at a subsequent renewal. In certaincircumstances, we may share your personal health information if permitted orrequired by law.

CaliforniaChoice is committed to protecting the confidentiality and security of yourprivate health information. We maintain physical, electronic, and processsafeguards that restrict unauthorized access to your personal health information.These security procedures include locked files and information system securitymeasures such as user passwords, data encryption or firewall technology.

CaliforniaChoice employees are required to comply with our policies andprocedures to protect the confidentiality of your personal health information. Anyemployee who violates our privacy policy is subject to a disciplinary process.

Employee access to private information is limited on a business “need-to-know”basis such as: when necessary to conduct underwriting reviews, or foranonymous statistical analysis.

Information about Our CustomersCaliforniaChoice receives information about you in order to provide customerservice, offer new products or services, administer our products, and fulfillother legal and regulatory requirements. We will provide you with access to thisinformation and the ability to review, amend, correct or copy this information,if we are required to do so under state law. The methods we use to protectthis information are similar to those described above to protect yourhealth information.

The information we receive may vary by product; therefore, the examples thatfollow may not apply to all customers but are designed to show the generalcategories of information that may be received and maintained byCaliforniaChoice:

� Information provided by you on applications, forms, surveys and ourWeb sites, such as your name, address, date of birth, Social Securitynumber, gender, marital status and dependents.

� Information provided by your employer.� Information about your transactions and experiences with

CaliforniaChoice such as: products or services purchased, accountbalances, payment history, policy coverage, and premiums.

(CONTINUED)

www.ca l cho ice. com 3

Information Shared Within the Word & Brown familyof companiesWhile understanding the importance of protecting your personal information,certain information will need to be shared during the normal course of business.We may disclose to the extent permitted by law the personal informationwe receive about you, as described above, within the Word & Brown familyof companies.

Information Shared with OthersWe may disclose the personal information (not your personal health information)we receive, as described above, to the following types of third parties:

� Other third parties as permitted or required by law, such as forcompliance with a subpoena, fraud prevention, or inquiries from state orfederal regulatory agencies.

� Financial service companies with whom we have agreements, such as:insurance companies, insurance brokers or agents, administrators, andservice providers.

We maintain written contracts with third parties to help ensure that thepersonal information we share about our customers is used for a legitimatebusiness purpose.

Access and Amendment of Your RecordsYou have the right to access and amend your records. You may exercise this rightby requesting to us in writing to access and/or amend your records. Please sendsuch requests to:

CaliforniaChoiceATTN: Privacy Office721 South Parker, Suite 300Orange, CA 92868

Changes to our Notice of Privacy Policyand Insurance Information PracticesWe reserve the right to change our privacy policies and insurance informationpractices. If we make any changes to our policies or practices, we will provideyou with a copy of a revised notice as required by applicable law.

Our CommitmentCaliforniaChoice values you as a customer, and we are committed to bringingyou products and services that help you to feel healthier and more secure.Our goal is to always use your information in a responsible business manner.If there are state law requirements that prohibit sharing your information withoutyour written permission, CaliforniaChoice will comply with those requirements.

We maintain physical, electronic, and processsafeguards that restrict unauthorized accessto your personal health information.

Member Privacy Statement

www.ca l cho ice . com4

Access forms, directories, Doctor/Rx search, and plan information 24/7.

Complete up-to-date information is just a click away.

Find what you need fast at www.calchoice.com

Please be advised that some forms and written communications are available on our website in

the following languages: Chinese, Korean, Spanish, Tagalog, and Vietnamese. Employees can

register their applicable, Plan-specific preferred language by completing the Language

Assistance Preference Form also found on our website www.calchoice.com.

5

What’s Inside:Member Privacy Statement

....................................................................................................................................2-3

Top Coverage Issues........................................................................................................................................6

Coverage Eligibility Requirements........................................................................................................................................7

Administration BasicsNew Hire Enrollment ..................................................................................................8Late Enrollee ................................................................................................................9Rehires ..........................................................................................................................9Military Leave ..............................................................................................................9Voluntary/Involuntary Termination—Employees ................................................10Understanding Your Benefit Choices ....................................................................11

Family CoverageDependent Eligibility ................................................................................................12Domestic Partner Eligibility ....................................................................................13Children Of Domestic Partner Eligibility ..............................................................13Terminating Dependents ........................................................................................14Terminating Over-Age Dependents ......................................................................14Enrollment Change Limitations..............................................................................15

Change in Family StatusNew Dependent(s) Enrollment ..............................................................................16

Change in Group PolicyGroup Change Guidelines ................................................................................17-18

About COBRA and Cal-COBRAEmployers Subject To COBRA (Federal)..............................................................19Domestic Partner Eligibility Under COBRA..........................................................20Employer Responsibilities For COBRA..................................................................20Employers Subject To Cal-COBRA (State) ..........................................................21Domestic Partner Eligibility Under Cal-COBRA ..................................................21Employee/Domestic Partner Responsibilities ....................................................22Employer Responsibilities For Cal-COBRA ..........................................................22Length Of Eligibility Continuation Of Coverage ..................................................23HIPAA ..........................................................................................................................23

BillingYour Premium Statement........................................................................................24The Billing Cycle ......................................................................................................25Rate Schedule ..........................................................................................................25Credits/Fees ..............................................................................................................25Group Cancellations ................................................................................................25

Annual Renewal Timeline......................................................................................................................................26

Ancillary and Voluntary BenefitsFDH Access 100 Dental ..........................................................................................27EyeMed Vision Care Program ................................................................................28Voluntary Vision Plan ..............................................................................................28Voluntary Dental 3000 ............................................................................................28

Ancillary BenefitsChiropractic And Acupuncture Programs............................................................29Section 125 Premium Only Plan (POP) ..............................................................29Employee Life Insurance ........................................................................................30Claim Filing Procedures (Loss of Life) ................................................................30Ancillary Dental ..................................................................................................31-33

Frequently Asked QuestionsGeneral Information..................................................................................................34HMO/Elect Open Access ........................................................................................35PPO..............................................................................................................................36FDH Access 100 Dental ..........................................................................................36Dental Plan 1000 or 3000 ....................................................................................37Dental Plan 3500, 4000, or 5000 ........................................................................37

Supply Request Form......................................................................................................................................38



Top Coverage Issues

Most service problems experienced by employees can be easily avoided with a little preventive attention. Here are the most commonlyoverlooked items that can cause delays or coverage lapses:

� Unsigned Applications or Change Request Forms

� Forgetting to add newborns/new spouses to coverage

� Omitting information on forms, such as date of full-time employment, date of birth, etc.

� Not selecting a health plan/benefit level

� Not selecting a Primary Care Physician (PCP)

� Not electing dependent coverage

� Not completing a waiver for dependents

� Not ensuring that checkboxes are clearly marked on forms

� Not using the proper forms

7

Four conditions must be met for an employee to gain and keep coverage. Every employee must:

1 Meet the employer’s established waiting period

2 Be actively working the number of hours required by the employer to be considered eligible (20+ or 30+hours per week)

3 Be a permanent employee who is not eligible for medical healthcare coverage offered by or through a laborunion

4 Be paid on a salary/hourly basis (not 1099 or commissioned)

Coverage Eligibility Requirements



� The employer should fax or mail the original to CaliforniaChoice assoon as possible, but no more than 60 days prior or 30 days after theemployee’s effective date of coverage (please retain a copy of thecompleted application for your records).

Fax: (714) 558-8000Mail: CaliforniaChoice

721 South Parker, Suite 200Orange, CA 92868

� Coverage for new employees and their dependents will be effectiveon the first day of the month following the completion ofthe group’s waiting period.

� New employees will be mailed one or more information packets totheir residence which will include I.D. card(s); a description of theirselected benefit plans; and instructions on how to use the plans.

Note: Please contact CaliforniaChoice Customer Service Center within 7 businessdays to confirm receipt of all mailed items.

New Hire EnrollmentBenefit eligibility is based on the completion of the waiting period by newemployees as set by your company. Employers may request an enrollmentquote for new employees at any time. Along with this handbook, your employerpacket includes Enrollment Quote Request forms, Enrollment Applications, anda current Rate Guide.

Enrolling a New Hire is Easy:

� Complete the Enrollment Quote Request form and fax it to(714) 953-4097 to obtain a customized enrollment quote for newemployees. The enrollment quote will be returned to your attentionwithin a few days, along with an Enrollment Guide, EmployeeEnrollment Application, and Provider Directory (when requested).

� For an immediate quote, visit our website at: www.calchoice.com,login, select “manage my account” and “new hire quote.”

� Employees who wish to obtain coverage through CaliforniaChoice®

must complete the Enrollment Application.

� Employers should provide the group number in the top section of thefront page of the application and employee’s effective date, based onthe group’s waiting period, at the bottom of the reverse side.

Administration Basics

When employers offer life insurance, ALL employees considered eligiblefor medical coverage must enroll in life insurance coverage even ifthey do not wish to enroll in medical or dental coverage throughCaliforniaChoice. Please have each employee complete the EmployeeEnrollment Application for life insurance coverage.

Important

Example:Jane was hired on April 5th. The group has a 90 day waiting period. Jane willcomplete the waiting period and be considered eligible for coverage August 1st.The group may request an Enrollment Quote for Jane at any time. Upon receipt ofthe Enrollment Quote, Jane must complete the Enrollment Application using thecustomized quote. The application should be faxed to (714) 558-8000 no laterthan July 31st. Jane’s benefit coverage will be effective August 1st. (Refer toillustration below.)

April 5

Jane ishired

EnrollmentQuote Request

April 5-July 31

WaitingPeriod Ends

July 5(90 days

per employee)

ApplicationSubmission

July 6-July 31

EffectiveDate

August 1

www.ca l cho ice. com 9

Employee/dependents had previously waivedenrollment* due to other coverage in force butlost that coverage. Loss of coverage must result fromcircumstances beyond the individual’s control.

Late EnrolleeCaliforniaChoice® will allow adding an employee and/or dependents otherthan during Renewal IF the:

Employees must provide the following documentation and submit eachitem to CaliforniaChoice within 30 days of change in family statusor loss of coverage:

� An Enrollment Application (for employee and dependents)� A Change Request Form (dependents only)� Proof of loss of other coverage (i.e. HIPAA Certificate)� Proof of change in family status (i.e. marriage certificate, signed

domestic partner affidavit, Certificate of Registration of DomesticPartnership**, birth certificate, legal adoption documentation)

Coverage will be effective as follows:Change of Family Status:Marriage/Domestic Partnership*—If marriage or creation of domestic partnership occurredbefore the 16th of the month, coverage begins on date of marriage/creation of domesticpartnership; if marriage/creation of domestic partnership occurred on the 16th of themonth or after, coverage begins on the first of month following date of marriage/creationof domestic partnership.

New Baby, Step Child, Adopted Child, Non-Temporary Legal Ward*—If birth/date of placementoccurred before the 16th of the month, coverage begins on date of their birth/placement; ifbirth/date of placement occurred on the 16th or after, child is automatically covered at no costunder Subscriber between date of birth/placement and the first of the following month.

* Although coverage may become effective at any time of the month based on date ofmarriage/domestic partnership/birth/adoption, full premium for increased coverage will be assessed

** Members who are in a same sex partnership or are over the age of 62 are required tosubmit a state-stamped Certificate of Registration of Domestic Partnership from a state orlocal government agency authorized to perform such registrations within 30 days of issue;all others must submit a signed Affidavit of Domestic Partnership.

NOTE: All applicable pre-existing condition limitations will apply for PPO products andthere will be some benefit restrictions for Dental Plans 3500, 4000 and 5000.

*Submitted medical/dental waiver

1Employee/dependents declined to enrollpreviously* due to other coverage in force andEmployer contributions toward that coverage have beenexhausted or dramatically reduced.

2Employee declined to enroll previously* but thenexperienced a change in family status (i.e. employee gotmarried, entered into a domestic partnership, gave birthor adopted child)

3How To Obtain Coverage As A Late Enrollee:

Administration BasicsRehiresA former employee who has been rehired may be eligible for re-enrollmentwithout completing the waiting period if he/she meets the following criteria:

• Employee previously completed your company’s waiting period

• Employee has been rehired within six months of the loss ofCaliforniaChoice coverage with your company

• Employee was previously enrolled with CaliforniaChoice

• Maintain same plans/benefit levels

An enrollment application must be received within 30 days of the employee’sreturn to work, accompanied by a written request to waive the waiting period.Coverage will be effective first of the month following the rehire date.

PLEASE NOTE: If the employee does not meet the criteria indicated above, thencoverage will become effective first of the month following completion of thecompany’s waiting period.

Return from Military LeaveAn employee who was previously covered under the plan and has returned frommilitary leave will be allowed to re-enroll into coverage without completingthe waiting period. Coverage will be effective first of the month followingthe date of return.


Voluntary Termination—EmployeesAn employee may choose to voluntarily withdraw coverage for themselvesand/or their dependents by completing and submitting a Change RequestForm to CaliforniaChoice®. The request will become effective the last dayof the month following receipt of the form by CaliforniaChoice. Thistype of request will not be processed retroactively. The employee will beineligible for re-enrollment until the Renewal period.

Involuntary Termination—EmployeesAll employees who become ineligible for group coverage must be terminatedfrom the group plan. Employers must complete an Employee TerminationNotification Form, and submit to CaliforniaChoice within 30 days fromthe last day employed.

Cal-COBRA law requires you, as the employer,to notify CaliforniaChoice of all employeeterminations within 30 days from their last dayemployed.

Coverage will cease at the end of the monthfollowing the last day employed, forthe employee and his/her dependents.

3 Ways to Notify CaliforniaChoiceof an Employee Termination:

For your convenience, you may notify CaliforniaChoice of anemployee termination by using one of these methods:

1. Faxing a completed Employee TerminationNotification Form* to the CaliforniaChoice MemberProcessing Center at (714) 558-8000.

2. Completing the Employee Termination NotificationForm* on the back of the premium statement of yourinvoice and returning with your premium payment.(Retain a copy for your records.)

3. By visiting our website at: www.calchoice.com

<P.S.>Please review the invoice received immediately following your request to terminatean employee to ensure that you are no longer being billed for that employee. Ifemployee and premium appear, please contact the CaliforniaChoice CustomerService Center at (800) 558-8003 for immediate assistance.

Please DO NOT send notification of an employee termination until after the last dayof employment. Termination requests made prior to the last day employed cannotbe processed. Also, please DO NOT self-adjust your billing statement. PAYMENT,as billed, will need to be MADE IN FULL. CaliforniaChoice will credit premium onthe billing statement that follows the processing of the termination.

Administration Basics

* Form must be signed and dated by an authorized groupcontact on file within CaliforniaChoice in order for thetermination request to be processed.

11

Understanding Your Benefit Choices


HMO BenefitsUnder an HMO plan, all access to specialistsand hospitalization must be determined through the member’s Primary Care Physician (PCP).

HMOMember

Primary CarePhysician

Specialist

Hospitalization

PPO Benefits

Under a PPO plan, members do notchoose a Primary Care Physician (PCP). PPO members may self-referto specialists. Members can receivecare from 2 levels of in-ne twork doctors or go out-of-network for lower benefits.

(Anthem Blue Cross Life and HealthInsurance Compamy only)

In-NetworkPhysician and Specialist

Out-of-NetworkPhysician and Specialist

In-NetworkHospitalization

orOut-of-NetworkHospitalization

PPOMember

Elect Open AccessUnder the Elect Open Access plan,

Elect Open Access

members must choose a Primary Care Physician (PCP). However, for a $ 40 copay, members may self-refer to anydoctor in thelisting in the CaliforniaChoice® Provider Directory. In-hospital benefits must be determined by a member's PCP.

(Health Net only)Hospitalization

Primary CarePhysician

In-Network PPOPhysicans & Specialists

ElectOpen Access

Member

$25Copay

$40Copay

(Anthem Blue Cross Life and HealthInsurance Compamy only)Members receive comprehensive medicalcoverage and have the option to contributetax-deductible funds into a Health Savings Account (HSA) and accumulate tax-deferred interest. HSA members do not pay taxes on withdrawals when paying for qualifiedmedical expenses.*HSA - Qualified High Deductible Health Plan

HSA*1800

HSA*2500

LowMonthly

Premiums

HSAAccumulate interest

tax-free and use funds for qualified

medical expenses

In-NetworkPhysician Copay

Out-of-NetworkPhysician Copay

80%after

deductible

50%after

deductible

Health Savings Account (HSA) Benefits


New Spouse

Family CoverageWho can be covered? Requirements that MUST be met:

(CONTINUED)

Effective dates

*Although coverage may become effective at any time of the month based on date of marriage/domestic partnership/birth/adoption,full premium for increased coverage will be assessed as described in the Effective Dates column located above.

� New spouse must be legally married to the employee and if requested, submit a copyof marriage certificate

New Baby,Adopted Child,New Stepchild,Non-TemporaryLegal Ward, and

Dependent Children

If birth/date of placement occurredbefore the 16th of the month,coverage begins on the date oftheir birth/placement*

If birth/date of placement occurred onthe 16th or after, child isautomatically covered at no costunder Subscriber between date ofbirth/placement and the first of thefollowing month

Disabled Dependents:

Dependents who are incapable of self-support because of continuous mental or physical disabilitythat existed before the age limit are eligible for coverage until the incapacity ends. Documentationof disability will be requested. One the child reaches the age limit for coverage, verification ofeligibility will occur annually at the child’s birthday.

Dependents must meet all requirements listed in order to be eligible for enrollment

� Born to, a step-child or legal ward of, or adopted by eligible employee , employeespouse or domestic partner

� Financially dependent upon the employee per IRS guidelines� Unmarried or not involved in a domestic partnership� Under age 19 (unless disabled, disability diagnosed prior to age 19) or a full-time

student until the student’s 25th birthday. A full-time student is one taking at least12 semester units (or equivalent hours) in a qualified college, university orvocational school.

If marriage occurred before the 16thof the month, coverage begins on dateof marriage*

If marriage occurred on the 16th ofthe month or after, coverage beginson the first of month following date ofmarriage

13

Domestic Partner

Who can be covered? Requirements that MUST be met:Effective dates


Family Coverage


For a Domestic Partner to qualify, Employee and Domestic Partner must:� Share a common residence� Not be married under either statutory, common law or part of another domestic partnership� Both be 18 years of age or older� Share an intimate and committed relationship� Agree to be jointly responsible for each other’s basic living expenses incurred

during the domestic relationship� Both be mentally competent� Not be related by blood to a degree of closeness that would prohibit marriage in this state� Agree to notify CaliforniaChoice® immediately upon termination of domestic partnershipMembers who are in a same sex partnership or are over the age of 62 are required to sub-mit a state-stamped Certificate of Registration of Domestic Partnership from a state orlocal government agency authorized to perform such registrations within 30 days of issue;all others must submit a signed Affidavit of Domestic Partnership.

During Initial Enrollment or Group’sAnnual Renewal: Coverage begins ongroup’s effective date

Involuntary Loss of Other Coverage:Domestic Partner can be added outsideof Renewal only if he/she loses othercoverage involuntarily. Coverage iseffective the first of following month

Mid-Year Addition: Mid-year additions of adomestic partner will require a state-stamped copy of the Certificate ofRegistration of Domestic Partnership froma state or local government agencyauthorized to perform such registrationswithin 30 days of issue or a signedaffidavit for opposite sex and under age62 domestic partnerships

EFFECTIVE10/1/10 for new

groups and groupsas they come up

for Renewal

New Baby,Adopted Child,New Stepchild,Non-Temporary

Legal Ward, andDependent Children

If birth/date of placement occurredbefore the 16th of the month,coverage begins on the date oftheir birth/placement*

If birth/date of placement occurred onthe 16th or after, child isautomatically covered at no costunder Subscriber between date ofbirth/placement and the first of thefollowing month


Dependents who are incapable of self-support because of continuous mental or physical disabilitythat existed before the age limit are eligible for coverage until the incapacity ends. Documentationof disability will be requested. Once the child reaches the age limit for coverage, verification ofeligibility will occur annually at the child’s birthday.


MEDICAL, CHIRO, VISION and SMILESAVER DENTAL Dependent eligibility:� Born to, a step-child or legal ward of, or adopted by eligible employee , employee

spouse or domestic partner� Under age 26 (unless disabled, disability diagnosed prior to age 26)

AMERITAS DENTAL Dependent eligibility:� Born to, a step-child or legal ward of, or adopted by eligible employee , employee

spouse or domestic partner� Financially dependent upon the employee per IRS guidelines� Unmarried or not involved in a domestic partnership� Under age 19 (unless disabled, disability diagnosed prior to age 19) or a full-time

student until the student’s 25th birthday. A full-time student is one taking at least12 semester units (or equivalent hours) in a qualified college, university or voca-tional school.

For COBRA/Cal-COBRAeligibility informationfor Domestic Partnersand their covereddependents, pleasesee pages 20-21


Terminating DependentsA covered employee’s dependent may lose eligibility for coverage even if theemployee’s coverage continues (i.e. when a dependent child reaches themaximum age for coverage). Coverage for the dependent(s) would terminate atthe end of the month. A CaliforniaChoice® Dependent Qualifying Event Formshould be submitted to CaliforniaChoice in each of the following situations:

� A divorce, annulment, dissolution of marriage, termination of domesticpartnership or legal separation†

� A dependent child ceases to qualify as a dependent

� Death of employee

� Medicare entitlement of employee

Termination of coverage will take place at the end of the month following theevent provided the group notifies CaliforniaChoice of the qualifying event withinthe timeframe allowed by law (within 60 days from qualifying event).

† If divorce or termination of domestic partnership is not final and member

cancels coverage, dependent cannot be reinstated until group’s next

Renewal.

Terminating Over-age DependentsCoverage for dependent children automatically terminates when they reach aspecified age. Age limits vary depending upon the plan.

A notification letter will be sent to the over-age dependent approximately45 days before their coverage terminates. The employer is not involved in thisprocess but should be aware of its occurrence. CaliforniaChoice will advise thedependent to contact the Group Plan Administrator regarding their eligibility forbenefits under COBRA continuation.

Your billing statement will be adjusted automatically according to any changein dependent coverage status for each employee.

Disabled Dependents:Dependents who are incapable of self-support because of a continuous mental or physicaldisability that existed before the age limit are eligible for coverage until the incapacity ends.Documentation of disability will be requested. Once the child reaches the age limit for coverage,re-verification of disability will be required annually. Verification of eligibility will occur annually atthe child’s birthday.

Family Coverage

15

� Marriage/Domestic Partnership

� Birth/Adoption/Non-temporary legal ward of your child

� Court Order

� Moving out of state (HMO to PPO only)

The employee must complete and submit the necessary items (see next page) to CaliforniaChoice® within 30 days of

the qualifying event.

Making enrollment changes during the coverage year islimited to the following events:



Change in Family StatusNew Dependent(s) EnrollmentEmployees who acquire a new dependent (i.e. newborn, new spouse, etc.) areable to change their coverage outside of the Renewal period. Even employeeswho previously waived coverage during Renewal become eligible to enrollthemselves and their new dependent(s) when a qualifying change in familystatus occurs. Newly acquired dependents must be added within 30 days ofthe qualifying event by completing and submitting the necessary items (seechart at right) to CaliforniaChoice®.

Although coverage may become effective at any time of the month based ondate of marriage/domestic partnership/birth/adoption, full premium forincreased coverage may be assessed as described in the chart on the right.

Member MUST notify CaliforniaChoiceof change in family status within 30 days

Submit the Following:New Dependent:

Newborn Child • Change Request Form• Proof of Birth (copy of birth announcement,

birth certificate or hospital card)

Stepchild • Change Request Form• Proof of Marriage, or creation of a DomesticPartnership to stepchild’s parent/legal guardian(copy of marriage certificate or Certificate ofRegistration of Domestic Partnership and/orSigned Domestic Partner Affidavit)

Spouse • Change Request Form• Proof of Marriage (copy of marriage certificate)• Date of Marriage

* If marriage occurred before the 16th of the month,coverage begins on date of marriage; if marriageoccurred on the 16th of the month or after, coveragebegins on the first of month following date of marriage

* If birth occurred before the 16th of the month, coveragebegins on the date of their birth; if birth occurred on the16th or after, child is automaticallycovered at no costunder Subscriber between date of birth and the first ofthe following month

RegisteredDomestic Partner

• Change Request Form• Certificate of Registration of Domestic Partnership

and/or signed Domestic Partner Affidavit**• Date of Issuance of Domestic Partnership

* If the acquisition of the Domestic Partnership occurredbefore the 16th of the month, coverage begins on date ofacquisition; if the acquisition of the Domestic Partnershipoccurred on the 16th of the month or after, coveragebegins on the first of month following date of acquisition

Adopted Child/Non-TemporaryLegal Ward

• Change Request Form• Proof of Placement/Acceptance

(legal documentation)* If date of placement/acceptance occurred before the16th of the month, coverage begins on first of themonth of their date of placement/acceptance month;if date of placement/acceptance occurred on the 16thor after, child is automatically covered at no cost underSubscriber between date of placement/acceptance andthe first of the following month

* If marriage or creation of Domestic Partnershipoccurred before the 16th of the month, coverage beginson date of marriage or creation of Domestic Partnership;if marriage or creation of Domestic Partnership occurredon the 16th of the month or after, coverage begins onthe first of month following date of marriage or creationof Domestic Partnership

** Members who are in a same sex partnership or areover the age of 62 are required to submit a state-stamped Certificate of Registration of DomesticPartnership from a state or local government agencyauthorized to perform such registrations within30 days of issue; all others must submit a signedAffidavit of Domestic Partnership

None

25th of the month prior to requestedeffective date (if Renewal, within 30days of anniversary date, but benefitscannot be accessed until groupreceives written confirmation ofapproval from CaliforniaChoice®)

Prior to requested effective date (Plancannot be accessed without ID Cards)

Within 30 days of requested effectivedate (Plan cannot be accessed withoutID Cards)

None

None

Within 30 days of Renewal

25th of the month prior to requestedeffective date (if Renewal, within 30days of anniversary date, but benefitscannot be accessed until groupreceives written confirmation ofapproval from CaliforniaChoice®)

17

Group Change GuidelinesThe following charts identify various changes you may make to your groupcoverage policy (when permitted) and the change requirements. Visitcalchoice.com to download required forms.

Mail or fax completed forms to: CaliforniaChoice®

721 South Parker, Suite 200Orange, CA, 92868Fax: (714) 558-8000


Change in Group Policy

*1st of the month effective date only.

One of the following:• Employer’s written notification providing new addressand specifying billing and/or street address andreferencing group number. Street address cannotbe a P.O. Box or outside of California

• Employer Change Request Form

• Dental Buy-Up Application• Reconciled DE-6



One of the following:• Employer letterhead providing new company nameand referencing old name and group number.


One of the following:• Employer-written request providing contact name, jobtitle, phone, fax and e-mail and referencing group #


• Employer contribution must be a minimum of50% of the lowest cost plan for each employee,excluding Salud.


At any time

At any time once ayear and at Renewal

Renewal Only


At any time

At any time

Renewal Only

At any timeonce a year (but notto replace buy-updental) and atRenewal

Change Type When Allowed* Deadline to Submit Requirements To Process

Address

Buy-Up Dental1000, 3000, 3500,

4000 & 5000(See page 31-32 for

eligibility requirements)

Chiropractic/Acupuncture Plan

(Change)

Chiropractic/Acupuncture Plan

(Add)

Company Name

Contact Person

Contribution

FDH Access 100Dental

Federal Tax IDNumber

Life Insurance

Pay Period forEnrollment Quote

Section 125

Termination ofCoverage

Voluntary Dental3000

Voluntary Vision

Waiting Period

Working Hoursrequired for Coverage

Eligibility

At any time


At any time

At any time

At any time with 30days notice

At any time once ayear and at Renewal,butnot to replace buy-up dental

At any timeonce a year

Renewal Only

Renewal Only


• Employer letterhead providing new tax ID numberand referencing group number signed by authorizedpersonnel

• Employer Change Request Form• Reconciled DE6

• Employer-written request

One of the following:• Employer Change Request Form• Optional Benefits Application (requested effective datemust be included)

and• $100 (Fee amount will be billed on next invoice)

• Employer-written request to include last dayof coverage

• Voluntary Dental Application• Must enroll one or more employees

• Voluntary Vision Application• Must enroll one or more employees



*1st of the month effective date only.

Requirements To ProcessDeadline to SubmitWhen Allowed*Change Type

Visit www.calchoice.com to download required forms.

Mail or fax completed forms to: CaliforniaChoice®

721 South Parker, Suite 200Orange, CA, 92868Fax: (714) 558-8000

Change in Group Policy

None

25th of the month prior to requestedeffective date (if Renewal, within 30days of anniversary date, but benefitscannot be accessed until group receiveswritten confirmation of approval fromCaliforniaChoice)

None (change effective upon entry)

None

30 days prior to requested effective date(termination will be effective no earlierthan the last day of the month followingrequest)

25th of the month prior to requestedeffective date (if Renewal, within30 days of anniversary date, but benefitscannot be accessed until group receiveswritten confirmation of approval fromCaliforniaChoice)

Within 30 days of requested effectivedate (Plan cannot be accessed withoutID Cards)



19

COBRA (Federal) and Cal-COBRA (State) laws allow for continuation of grouphealth benefits to individuals who lose coverage as a result of certain “qualifyingevents” (e.g. termination of employment, death of employee, reduction of workhours, divorce, legal separation, Medicare entitlement, and loss of dependentchild status).

The law defines “group health benefits” as medical, dental, chiropractic, vision,prescription drug programs, and any self-insured arrangements that providesimilar benefit coverage. These individuals are allowed to retain the types ofcoverage they had prior to the event taking place and must be given the samerights as active eligible employees with respect to Renewal periods, changingplans or benefits and adding or terminating dependents.

Employers Subject to COBRA (Federal)Generally, a company is subject to the provisions of Federal COBRA if it offers agroup health plan and has 20 or more employees on at least 50 percent ofits typical business days during the preceding calendar year.

Both full-time and part-time employees are considered as employees forpurposes of this rule regardless of whether or not they are eligible for coverageunder the employer’s group health plan. However, under the 1999 final IRSregulations, an employer is only required to count common-law employees whendetermining whether they meet the 20-employee requirement. Self-employedindividuals, agents, independent contractors and corporate directors arenot treated as employees for COBRA purposes and need not be counted.Employers must aggregate employees from all divisions, subsidiaries and anyother entities that make up a controlled group of corporations. In general, acontrolled group of corporations may consist of a parent-subsidiary controlledgroup, brother-sister controlled group, or a combined group as defined under theIRS Code Section 414b.

In addition, under the 1999 proposed IRS rules, a part-time employee may becounted as a fraction of a full-time employee, with the fraction equal to thenumber of hours an employee must work in order to be considered a full-timeemployee, not to exceed 40 hours per week. Under these same rules, employersare also permitted to use daily or pay period methods of counting.

It is the sole responsibility of the employer to notify its employees or members ofthe availability, terms, and conditions of COBRA continuation and providethem with the necessary information/forms for COBRA election. Suchresponsibility will be satisfied if the former member is notified within 14 daysafter the last day of coverage under the Group Plan.

In the case of terminating employees/dependents and loss of dependent childstatus, upon proper notification, a letter from CaliforniaChoice® will be sent to theindividual informing them to contact the Group Plan Administrator to verifyif they are eligible for COBRA continuation.

COBRA enrollees will only be allowed to continue on their current coverage(Health Care Service Plan/Benefit Plan). Enrollees who expect to move to anarea where their current Health Plan is not available should contact theCaliforniaChoice Customer Service Center at (800) 558-8003.

COBRA Basics:� COBRA is designed to extend health benefits to people

who lose their coverage due to a COBRA Qualifying Event

� Generally, a company is subject to the provisions ofFederal COBRA if it offers a group health plan and has 20or more employees on 50% of its “typical business days”during the preceding calendar year

� It is the sole responsibility of the employer to notify itsemployees or members of the availability, terms, andconditions of COBRA continuation

(CONTINUED)

About COBRA



The following is a brief summary of the COBRA administration servicesoffered by CONEXIS for CaliforniaChoice groups:

1) Once CaliforniaChoice receives a COBRA Enrollment Application,CONEXIS (a company contracted by CaliforniaChoice) will send aconfirmation of COBRA election letter and courtesy invoice to COBRAenrollees. COBRA enrollees will be charged the current premium ineffect for the employer, but with an additional 2% charge foradministration.

2) For the duration of the continuation coverage, CONEXIS will send acourtesy invoice to the COBRA participant for continuationcoverage premiums.

3) COBRA participant payments collected by CONEXIS are forwardedto CaliforniaChoice.

4) Because COBRA Enrollees must be treated the same as your activeeligible employees, COBRA enrollees will be allowed to amendcoverage for themselves and/or their dependents or add anyadditional applicable benefits offered by the former employer. (Lifeinsurance not included.)

5) CONEXIS will notify each COBRA participant of their possibleconversion and extension rights near the end of their COBRAcontinuation coverage period.

6) CONEXIS will track each participant and notify them andCaliforniaChoice of termination of their COBRA coverage.

NOTE: The services listed above do not alleviate a group’sresponsibilities under COBRA law. These services only apply tonon-direct bill groups.

Direct Bill Groups: Groups who have elected to be billed for theirCOBRA participants. For additional information on Direct Bill, pleasecontact our Customer Service Center at (800) 558-8003.

COBRA ComplianceMade Simple

Domestic Partner Eligibility under COBRADomestic Partners do not meet the definition of a Qualified Beneficiaryas defined under COBRA law. Therefore, Domestic Partners are not eligiblefor the same COBRA rights as a Qualified Beneficiary.

The Domestic Partner is only eligible for COBRA Continuation of Coverageif he/she remains a dependent under the employee’s election. He/shedoes not have a separate election right under COBRA law because he/she isnot a Qualified Beneficiary. If an employee experiences a COBRA qualifying event,the Domestic Partner is only eligible to continue his/her health insurance benefitsif the employee also continues his/her benefits under COBRA. He/she cannotmake an election separate from the employee. In addition, dependentqualifying events do not apply to Domestic Partners.

Employer Responsibilities for COBRA

� The employer must continue to comply with all COBRArequirements (including proper notification of all active planparticipants, notification of all qualified beneficiaries following qualifyingevent, etc.)

� The employer must send a completed COBRA EnrollmentApplication to CaliforniaChoice® for all qualified beneficiarieswho elect COBRA continuation coverage. (The completed COBRAenrollment application must be returned to the employer to forwardto CaliforniaChoice within the regulated time frames.)

About COBRA

21www.ca l cho ice. com

Employers Subject to Cal-COBRA (State)Generally, a company is subject to the provisions of Cal-COBRA if it offers agroup health plan and only has 2 to 19 eligible employees on at least 50percent of its typical business days during the preceding calendar year.

All full-time employees, part-time employees and self-employed persons(e.g. partners in a law firm) are considered employees for the purposes of thisrule regardless of whether or not they are eligible for coverage under theemployer’s group health plan. Leased employees also count as employees.However, all agents or independent contractors (and their employees, agentsand independent contractors), as well as corporate directors, are treated asemployees only if they are eligible for coverage under the group health plan.

Employers must aggregate employees from all divisions, subsidiaries and anyother entities that make up a controlled group of corporations. In general, acontrolled group of corporations may consist of a parent-subsidiary controlledgroup, brother-sister controlled group, or a combined group as defined by IRSCode Section 414b.

Unlike COBRA, it is the responsibility of the Health Plans to send out notificationsto former employees/dependents of their rights to continue coverage under Cal-COBRA. The Health Plans in the CaliforniaChoice® program have contracted withCONEXIS to provide those services. (See next page for information on Cal-COBRAservices offered by CONEXIS.)

Upon notification of a qualifying event, CONEXIS will automatically notify thosemembers of their Cal-COBRA rights by sending an election notice to the qualifiedbeneficiaries’ last known address via first class mail and give them theopportunity to elect to continue their coverage through Cal-COBRA.

Domestic Partner Eligibility under Cal-COBRAUnder a new law entitled the Insurance Equality Act, effective January 1, 2005, anycoverage offered to the spouse of an employee must also be offered to a registereddomestic partner. CaliforniaChoice is offering this benefit to non-Registered DomesticPartners as well.

The Domestic Partner is eligible for Cal-COBRA Continuation of Coverage and hasthe same election rights as a spouse.

� Generally, a company is subject to the provisions ofCal-COBRA if it offers a group health plan and only has2 to 19 eligible employees on at least 50% of its typicalbusiness days during the preceding calendar year

� All full-time, part-time and self-employed persons(e.g. partners in a law firm) are considered employees

� Unlike COBRA, it is the responsibility of the Health Plansto send out notifications to former members of theirrights to continue coverage under Cal-COBRA

Cal-COBRA Basics:

(CONTINUED)

About Cal-COBRA


About Cal-COBRAEmployee/Dependent ResponsibilitiesIf a covered dependent loses his/her eligibility due to divorce, legal separation,death of employee or loss of dependent child eligibility, the employee ordependent must notify CaliforniaChoice® of the event (within 60 days) bycompleting and returning a Cal-COBRA Dependent Qualifying EventNotification form to CaliforniaChoice. Coverage will be terminated at the endof the month following the qualifying event date. The dependent must submit aCOBRA Enrollment Application to elect COBRA.

Employer Responsibilities for Cal-COBRA

� The Employer must notify CaliforniaChoice of employee addresschanges within 30 days of the employee providing such informationto the Employer

� The Employer must notify CaliforniaChoice of employee terminations,employee deaths, and reductions in hours that cause a loss ofcoverage within 30 days of the event taking place

The following is a brief summary of the Cal-COBRA administration servicesoffered by CONEXIS for CaliforniaChoice groups:

1) Following notification of termination of employment, employee death,a reduction in hours, or receipt of the Cal-COBRA Dependent QualifyingEvent Notification Form, CONEXIS will send informationto the member including their Cal-COBRA rights and a Cal-COBRAelection form.

2) At this point CONEXIS will make arrangements for the Cal-COBRAenrollees to make their payments directly to CONEXIS.

3) Cal-COBRA enrollees will be charged the current premium ineffect with the employer, but with an additional 10% chargefor administration.

4) CONEXIS will notify Cal-COBRA enrollees of their options duringthe annual Renewal period.

Because Cal-COBRA enrollees must be treated the same as your activeeligible employees, Cal-COBRA enrollees will be allowedto add any additional applicable benefits offered by the former employeras well as any eligible dependents not previously coveredunder Cal-COBRA (except life insurance coverage).

5) CONEXIS will notify each Cal-COBRA participant of their possibleconversion near the end of their Cal-COBRA continuation period.

6) CONEXIS will track each Cal-COBRA participant and notify themand CaliforniaChoice® of termination of their Cal-COBRA coverage.

Cal-COBRA ComplianceMade Simple

23

Length of Eligibility for Continuation of CoverageIn September 2002, California passed a state law extending the maximumamount of time for continuation coverage under Cal-COBRA regulations.

Under Cal-COBRA regulations, anyone with a Qualifying Event resulting in theircontinuation coverage period beginning on January 1, 2003 or thereafter willbe eligible for 36 months of coverage. COBRA coverage beginning prior to thisdate is not eligible for this extension.

If the group’s coverage through CaliforniaChoice® is terminated, all members,including those who have elected COBRA/Cal-COBRA continuation coverage willbe terminated. The employer’s obligation to the COBRA/Cal-COBRA qualifiedbeneficiaries is to provide them with the same coverage currently provided toactive employees.

A company’s obligation to comply with COBRA is the same regardlessof the number of employees it has during the current year.

Health Insurance Portability andAccountability Act of 1996 (HIPAA)In October of 1996, the Health Insurance Portability and Accountability Act of1996 (HIPAA) was signed into law. In April of 1997, Federal regulations werepublished to assist Planholders (Employers) to comply with this law.

The major components of the law apply to medically insured members and areas follows:

� A Certificate of Coverage must be provided to all insured employeesand their dependents when their coverage ends. CaliforniaChoice willautomatically send this certificate upon termination and additionalcopies upon request.

Employers are responsible for notifying CaliforniaChoice of an employee’s newaddress information within 30 days of an address change. Because of theobligations imposed by Federal and State laws, CaliforniaChoice cannotbe responsible for misdirected HIPAA/COBRA/Cal-COBRA information as aresult of the failure to provide correct residence address information for allinsured employees.

NOTE: Life Insurance coverage may allow for disability extensions and policyconversion based on policy guidelines. The Employer is responsible for initialnotification of these rights. For more information, please see a copy of the masterpolicy at www.calchoice.com under “Benefits, Life Insurance, Life MasterPolicy” or contact our Customer Service Center at (800) 558-8003.

Related COBRA Laws

Anyone with a Qualifying Event resulting in theircontinuation coverage period beginning onJanuary 1, 2003 may qualify for up to 36 monthsof coverage



Your Premium StatementEach month you will receive a Premium Statement including your policyinformation and total balance due, Invoice Pages breaking down employeecoverage information and, if applicable, Invoice Adjustment Pages reflectingany changes, credits or adjustments made to your account.

� POLICY INFORMATION reflects your current optional benefits,COBRA status, domestic partner eligibility, renewal date, minimumhours for eligibility and new hire waiting period. The informationprovided reflects your account information as it exists on record as ofthe statement date.

� The TOTAL BALANCE DUE is always the outstanding balance as ofthe statement date. Payments or adjustments made after that datewill be reflected on your next statement.

� Your INVOICE PAGES will list all employees currently enrolled in theplan, including their ages and zip codes, their coverage, a breakdownof their premiums and employer contributions.

� The ADJUSTMENT PAGE will reflect employee plan changes madesince the last statement. Please pay special attention to this area toverify adjustments.

You should always return the remittance portion of the premium statement withyour payment and indicate the group number on your check. Please do notstaple/tape your check to the remittance portion.

Do not self-adjust or submit changes on your statement. Changes can onlybe processed using the correct forms. Please use the forms provided inyour administrative kit or log on to our website at calchoice.com. Forms can bedownloaded or printed from the site and may be faxed or mailedto CaliforniaChoice®.

<P.S.>

What the Employee ChangeCodes Mean on Your StatementListed below are the employee change codes that may appear on your statements:

Billing

A AdditionAC Add COBRAC Change PlanCA Change AgeCE Change Enroll DateCI Change InformationCO CorrectionDA Dependent AddDT Dependent TerminationER Employee ReinstatementGR Group ReinstatementNE No Longer EligibleNT New TerminationRA Retroactive AddRC Retroactive Change PlanRDA Retroactive Dependent AdditionRDT Retroactive Dependent TerminationT TerminationRT Retroactive TerminationVC Life Volume Change

25

The Billing CycleYour premium statements are produced and mailed by CaliforniaChoice® atthe beginning of each month for the following month’s coverage. Here isan example:

� Premium payments need to be received by the due date indicated oneach statement and should be paid as billed. Adjustments processedafter the statement date will reflect on your next statement.

� All payments are applied to your oldest open balance first, withany remaining portion being applied to subsequent balances.

Note: premiums are always due prior to the month of coverage.

Rate ScheduleRate Schedules are guaranteed for the group’s plan year. However, individualemployee rates are subject to change based on age band, zip code orcoverage changes. Listed below are examples of the age band categories:

LIFETABLE

Credits/FeesIf there is a credit on your account due to an overpayment or adjustment, thecredit will reflect on the invoice following the date of the credit. The amount duefor the invoice following the credit will be reduced by the credit amount.

The billing fee is based on the total number of employees enrolled in any coveragethrough CaliforniaChoice at the time of invoicing and is, therefore, subject tochange on a monthly basis. Billing fees are as follows:

1-8 employees $209-20 employees $2521+ employees $30

(In addition to the monthly billing fee, CaliforniaChoice is remunerated from thesubscriber payment collected)

Premium payments not received by the statement due date will be subject to a10% late fee. Returned checks must be replaced immediately with a cashier’scheck or money order - company checks will not be accepted. There is a $25fee for all returned checks. If there are 3 or more returned checks within a 12-month period, payment with certified funds will be required forone year.

Group CancellationsShould premium payments not be received by the 14th day of the coveragemonth a Prospective Notice of Cancellation shall be sent to the group notifyingthe group that if payment is not received within the ensuing 15 days that thegroup will be terminated for non-payment. In such a case, a Notice ConfirmingTermination of Coverage will be mailed.

Voluntary cancellations of coverages require a minimum of 30 days advancednotice. Requests should be made in writing, on company letterhead, and signedby authorized personnel.

0-1920-2425-2930-3435-3940-4445-4950-5455-5960-6465-6970-7475-7980-8485-8990-9495-99100+

MEDICALTABLE

0-2930-3940-4950-5455-5960-6465+


Billing


� Approximately 60 days prior to the group anniversary date, CaliforniaChoice® will send the renewal premiums based on your employees’current Health Plan/Benefit selections.

� The Annual Renewal takes place two months prior to your anniversary date. For example:

During Renewal, your employees will have the opportunity to change their current Health Plan/Benefit selections and add eligible dependents notpreviously covered on the program. Employees who previously waived are eligible to enroll at this time. Coverage will be made effective the first ofthe renewal month.

You may contact your Renewal Specialist for assistance with your group’s renewal.

(Please note: ALL applicable pre-existing conditions limitations will apply for PPO products.)

Annual Renewal Timeline

JULY 1Company Anniversary Date

Requested Changesgo into effect

JUNE 1Renewal Ends

All Renewal Change RequestForms need to be received by

this date

MAY 1Renewal Begins

Employer will receiverenewal package by

this date

27

FDH Access 100 DentalThis dental plan is a value-added, start-up program for those Employers who donot currently offer dental coverage to their Employees. This coverage maybe included in your benefits package at no cost to the employer or employees. Itis not meant to take the place of the more comprehensive dental programsoffered by CaliforniaChoice® or other dental providers.

How It Works:

� New employee enrollment in FDH Access 100 is automaticupon enrollment in CaliforniaChoice medical coverage.

� Dependent enrollment is automatic upon enrollment inCaliforniaChoice medical coverage.

� When medical coverage terminates for an employeeand/or dependents, coverage in FDH Access 100 willautomatically terminate.

FDH Access 100 Dental Participation Requirements

Employer: Must currently offer medical coverage throughCaliforniaChoice to all eligible employees

No current dental plan being offered to anyemployees (by either another dental carrieror CaliforniaChoice)

Employee: Contingent upon employer eligibility, and:

Employee must be enrolled in theCaliforniaChoice medical program and residein California

Dependent: Contingent upon employee eligibility, and:

Dependent must be enrolled in theCaliforniaChoice medical program

All change requests submitted to the CaliforniaChoice Client AdministrationDepartment related to medical coverage will automatically be changed as it mayrelate to FDH Access 100 Dental.

<P.S.>

Ancillary and Voluntary Benefits



AlamedaContra CostaFresnoImperialLos AngelesMarinMontereyNapa

OrangeRiversideSacramentoSan BernardinoSan DiegoSan FranciscoSan JoaquinSan Luis Obispo

San MateoSanta BarbaraSanta ClaraSanta CruzSonomaTulareVentura

Our innovative mix of Optional and Voluntarybenefits helps employers offer morecoverage while limiting healthcare costs.

and selected zip codes of other counties.

EyeMed Vision Care ProgramAll CaliforniaChoice® medical and/or dental enrollees are automatically eligiblefor discounts on eye exams, lenses, frames, contacts and LASIK proceduresthrough the EyeMed Vision Care Program. These discounts are honored at over2500 locations nationwide. For details, go to www.calchoice.com, select “OurBenefits” and “Vision.”

How It Works:

� New employee enrollment in EyeMed is automatic upon enrollment forCaliforniaChoice medical and/or dental coverage with no monthly premium.

� Employees must present their ID card at the time of service to obtainthe applicable discount.

Voluntary Vision PlanCaliforniaChoice members can enroll in the voluntary vision benefit in addition tothe automatic EyeMed Vision Care Program. For a low monthly premium (paid bythe employee), the Voluntary Vision plan allows them to saveadditional costs related to exams, frames, lenses and more.

How Voluntary Plans Work:

� The employer must offer the plan.

� The employee must pay for premiums.

Voluntary Dental Plan 3000Dental Plan 3000 is a prepaid dental plan offered by SmileSaverSM throughCaliforniaChoice. When offered to employees as a voluntary plan, all premiumsare paid by the employee. Employees must reside in California. Services areprovided by SmileSaver participating dentists. The plan is available to employerslocated in the following counties:

Ancillary and Voluntary Benefits

29

Chiropractic and Acupuncture ProgramsCaliforniaChoice® offers each employer group a choice of two Chiropractic plans.One of those plans also includes Acupuncture services. These services are pro-vided through Landmark Healthplan. Please see our Optional Benefits brochurefor plan details. You may contact our Customer Service Center at (800) 558-8003or go online at www.calchoice.com for additional information.

How It works:

� Employer pays 100% of a low monthly premium.

� Once offered, employee/dependent enrollment is automatic uponenrollment for CaliforniaChoice medical coverage.

� When medical coverage terminates for an employee and/ordependents, this coverage will automatically terminate.

Ancillary BenefitsSection 125 Premium Only Plan (POP)Electing this optional benefit allows the Employer to take salary deductions forcertain health and insurance programs on a pre-tax basis. The Employee’sinsurance premium deduction (the amount the Employee pays toward medical/dental insurance for himself and/or dependents) is taken out of gross wages.By reducing the gross wage amount, this in turn reduces payroll taxes for boththe Employer and the Employees.

At the time your company completed its initial enrollment into CaliforniaChoice,you were given the opportunity to elect the Section 125 program at a one-timeenrollment fee. If you did not take advantage of this benefit at that time, you mayadd the Section 125 program. Please call our Customer Service Center or yourinsurance broker for enrollment information.

If your company does not currently offer these benefits and you would like moreinformation, please contact your broker.

<P.S.>Chiropractic and AcupunctureParticipation Requirements

Employer: Must currently offer medical coverage throughCaliforniaChoice

Must pay 100% of Chiropractic plan premium

Employee: Must be enrolled in the CaliforniaChoicemedical program and reside in California



Employee Life InsuranceAt the time your company completed initial enrollment into the CaliforniaChoice®

program, you were given the opportunity to provide employee life insurancecoverage.

If you declined this coverage initially, you are allowed to add employee lifeinsurance at anytime throughout the year, subject to medical underwriting.Please contact your insurance broker for enrollment requirements.

Program Overview

� The minimum amount of insurance coverage per employeeis $10,000.

� The Employer is required to pay 100% of the lifeinsurance premium.

� ALL employees considered eligible for medical coverage mustenroll in life insurance coverage—even if they waive medicaland dental (a completed application is required).

� You may select to cover your employees at:

1) The same amount for all employees, (from $10,000, inincreasing increments of $5,000, to the maximum amount,based on your number of eligible employees).

OR

2) A classification schedule allowing you to set up 4amounts of coverage, with the highest amount ofinsurance selected no more than 2.5 times the lowestamount of insurance selected.

Claim Filing Procedures (Loss of Life)Claim Filing Requirements for Employers:

1) Contact our Customer Service Center at (800) 558-8003.

2) Complete Form GG-3017B: Life, AD&D and Waiver of PremiumClaim Information

3) Complete Termination of Employment/Employee form

4) Once the above requirements are all completed in full, all itemsshould be faxed or mailed to CaliforniaChoice at the addresslisted below:

Attn: Life ClaimsCaliforniaChoice721 South Parker, Suite 200Orange, CA 92868Fax: (714) 558-8000

Upon receipt of this information, CaliforniaChoice will send a claim filing packetdirectly to the beneficiary of the deceased employee instructing them how toproceed and who to contact to file their claim.

Ancillary Benefits

Employee Dental InsuranceAt the time your company completed initial enrollment into the CaliforniaChoice® program, you were given the opportunity to provide employee dental coverage. If youdeclined this coverage initially, you are allowed to add employee dental insurance at anytime throughout the year, subject to underwriting. Please contact your insurancebroker for enrollment requirements.

31

Participation Requirements

Employer

Employee Eligibility is contingent upon Employer eligibility AND the following:� Expected to meet the established waiting period� Actively working number of hours required by Employer to be eligible� A permanent employee� Paid on a salary/hourly basis (not 1099 or commissioned)� Employees hired after plan installment are subject to waiting period.

Dependent Spouse Eligibility is contingent upon Employer eligibility AND the following:� Legally married to the Employee

Dependent Children � Born to, a step-child or legal ward of, or adopted by eligible employee , employee spouse or domestic partner� Financially dependent upon the employee per IRS guidelines� Unmarried or not involved in a domestic partnership� Under age 19 (unless disabled, disability diagnosed prior to age 19) or a full-time student until the student’s

25th birthday. A full-time student is one taking at least 12 semester units (or equivalent hours) in a qualifiedcollege, university or vocational school.

Ancillary Dental


(CONTINUED)

Plan 1000, Plan 3000, Plan 3500†, Plan 4000†, Plan 5000†

†Only groups with 5 or more eligible employees qualify for Orthodontia benefits

Disabled Dependents:Dependents who are incapable of self-support because of continuous mental or physical disability that existed before the age limit areeligible for coverage until the incapacity ends. Documentation of disability will be requested. One the child reaches the age limit forcoverage, verification of eligibility will occur annually at the child’s birthday.


� Currently offering medical coverage through CaliforniaChoice to all eligible employees� No current dental plan being offered to any employees (by another dental carrier)� 70% of all eligible employees must enroll in the ancillary dental program (they are not required to enroll in medical in order to

enroll in dental)� The Employer must contribute a minimum of 50% of the Employee premium of the lowest cost medical plan available to

employee� Employees selecting Dental 3500, 4000 or 5000 are subject to a 12-month waiting period for major services; 24 months

for Orthodontia. Takeover credit is available to groups consisting of 10+ eligible employees with comparable prior groupdental plan and no lapse in coverage.

� Employer must submit the following to receive takeover credit towards waiting period for major services and Orthodontia:• Prior dental most recent billing statement• Prior dental billing statement from up to 12 months prior to the CaliforniaChoice requested effective date.• If electing Ortho and Ortho is not itemized on the statement, the Certificate Booklet is required.

� If group qualifies for takeover credit, all employees enrolling at initial enrollment receive the takeover credit. New hiresadded after initial enrollment will be subject to the 12 month waiting period for major services.

� Deductible takeover is not available


Participation Requirements

Ancillary DentalPlan 1000, Plan 3000, Plan 3500†, Plan 4000†, Plan 5000†

†Only groups of 5 or more eligible employees qualify for Orthodontia Benefits

Domestic Partner Employee and Domestic Partner must fall into all of the following categories:

� Share a common residence

� Neither is married under either statutory, common law or part of another domestic partnership

� Both be 18 years of age or older

� Share an intimate and committed relationship

� Agree to be jointly responsible for each other’s basic living expenses incurred during thedomestic relationship

� Both be mentally competent

� Not related by blood to a degree of closeness that would prohibit marriage in this state

� Agree to notify CaliforniaChoice® immediately upon termination of domestic partnership

Members who are in a same sex partnership or are over the age of 62 are required to submit a state-stamped Certificate of Registration of Domestic Partnership from a state or local government agencyauthorized to perform such registrations within 30 days of issue; all others must submit a signedAffidavit of Domestic Partnership.

For COBRA/Cal-COBRAeligibility information forDomestic Partners and theircovered dependents, pleasesee pages 20-21

EFFECTIVE 10/1/10for new groups and groups

as they come up for Renewal

Dependent Children


Dependents who are incapable of self-support because of continuous mental or physical disabilitythat existed before the age limit are eligible for coverage until the incapacity ends. Documentationof disability will be requested. Once the child reaches the age limit for coverage, verification ofeligibility will occur annually at the child’s birthday.


SMILESAVER DENTAL Dependent eligibility:� Born to, a step-child or legal ward of, or adopted by eligible employee , employee spouse or domestic partner� Under age 26 (unless disabled, disability diagnosed prior to age 26)

AMERITAS DENTAL Dependent eligibility:� Born to, a step-child or legal ward of, or adopted by eligible employee , employee spouse or domestic partner� Financially dependent upon the employee per IRS guidelines� Unmarried or not involved in a domestic partnership� Under age 19 (unless disabled, disability diagnosed prior to age 19) or a full-time student until the student’s

25th birthday. A full-time student is one taking at least 12 semester units (or equivalent hours) in a qualifiedcollege, university or vocational school.

33

How to Contact the Customer Service Center for Ancillary (Buyup) Dental Plans

Employers should call the CaliforniaChoice® Customer Service Center at (800) 558-8003 if they:

� Have questions related to administrative procedures

� Need to obtain an additional directory of Dental Offices

Dental Plan 1000 and 3000

Issue:

SmileSaverSM,a division of SafeGuard Health Plans, Inc.,

Member Services:(800) 333-9561

� Have not received their permanent I.D. card(s) within 3-4 weeks after receivingtheir confirmation of acceptance letter

� Need to replace a lost I.D. card(s)

� Have questions about how to use the plan

� Have questions about benefits

� Have a problem or complaint related to service

� Receive a bill from their Dental Office or any other dental facility for servicesapproved by their Dental Office

� Need to file a claim for Emergency dental services

Employee should contact:

Dental Plan 3500, 4000 and 5000

CaliforniaChoice Customer Service Center:(800) 558-8003

� Need to replace a lost I.D. card

� Need claim forms

Ameritas Group(877) 203-0036

� Have a question about benefits

� Want to inquire about a submitted claim

Issue: Employee should contact:


Ancillary Dental


Frequently Asked Questions

General Information

Who/What is CaliforniaChoice®?CaliforniaChoice is the administrator that has brought several healthcare planstogether to allow you and your employees the ability to select different plans ofhealth coverage.

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

Who is my healthcare plan?Your healthcare plan is the participating plan selected under the CaliforniaChoiceprogram to provide healthcare coverage. Each one of your employees made theirselection during initial enrollment.

Can I change my healthcare plan?Yes, but only during the annual Renewal period or when the employee moves toan area where there are no medical providers under their current healthcare plan.(It is important to notify CaliforniaChoice of an address change immediately.)

Can each family member select a different Healthcare plan?No, all family members must select the same healthcare plan.

What is my benefit design/plan?The level of coverage/benefits is on your enrollment application and relates toco-payments or coverage for doctor visits, hospitalizations, etc. (i.e. HMO, ELECTOpen Access, and PPO plans).

Can each family member select a different benefit plan?No, all family members must select the same benefit plan.

Can I change my benefit design/plan?Yes, but only during the annual Renewal period for your company.

When can dependents obtain coverage?Eligible dependents may be added at the employee’s initial enrollment, whenacquired (newborn/adoption/marriage/domestic partnership), or during the annualRenewal period. Other than during the annual Renewal period,* dependents may onlybe added when first eligible (i.e. newborns and newly acquired dependents maybe enrolled within 30 days of the qualifying event: date of birth, adoption,marriage, domestic partnership). Please refer to “New Dependent(s) Enrollment”on page 16 for instructions.

When is my company’s annual Renewal?Your company’s annual Renewal period is usually two months prior to theanniversary date (your company’s initial effective date). All changes made duringthe annual Renewal are effective on the company’s anniversary date. Check withthe Group Plan Administrator for the exact date.

*See “Late Enrollee” on page 9 for further information.

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35

HMO and Elect Open AccessWhat is a copayment?The amount the member must pay for medical services (doctor visits, drugprescriptions, hospitalizations, etc.).

Who is my Primary Care Physician?A Primary Care Physician can be a family practitioner, internist, or pediatrician.At the time of enrollment, you may have selected (or been assigned) a PrimaryCare Physician for yourself and each dependent. The Primary Care Physiciancoordinates all healthcare and medical needs including basic care, preventiveservices, referrals to specialists, and hospitalization arrangements.

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

Can I change my Primary Care Physician?Yes, contact your Health Plan’s Member Services Department (some restrictionsmay apply).

What if I need to see a specialist?Under the HMO plans, your Primary Care Physician, in consultation with acontracted Medical Group or IPA, will determine the proper treatment and makereferrals to specialists when necessary. A change in Primary Care Physician orHealth Plan could cause a problem if you are in the middle of specialist treatment.

Under the Elect Open Access benefit design, you may self-refer to any doctor inthe Elect Open Access listing. Your in-hospital benefits must still be determinedby your Primary Care Physician.

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

What if I need to see a doctor while away from home?If you are away from home and cannot see your Primary Care Physician, you willonly be covered for emergency treatment that is medically necessary. Contactyour Primary Care Physician first to obtain authorization. If you are unable to getin touch with your Primary Care Physician, contact the Health Plan’s MemberServices Department.

What if I have an emergency situation?In the event of any emergency, contact your Primary Care Physician first.Depending on the nature of the emergency, your physician will either: help overthe phone; make an appointment for you to come in as soon as possible; or makea referral to an emergency room or urgent care facility.

If the emergency is life threatening, such as a heart attack, or is critically serious,such as a broken leg, go directly to the nearest medical facility. However, you (ora family member) must contact your Primary Care Physician within 24 hours. Ifyou are unable to get in touch with your Primary Care Physician, contact theHealth Plan’s Member Services Department.

What if I receive a bill?Although you should not receive bills for medical care provided or approved byyour Primary Care Physician, you may receive a bill in error. In that event, contactyour Health Plan’s Member Services Department for assistance.

What if medical services are needed before permanent I.D. cardsare received?The member should present his/her temporary I.D. card to the Primary CarePhysician he/she selected for services. The physician’s office may then contactCaliforniaChoice, who will assist with verifying coverage.

What if a prescription is needed before permanent I.D. cardsare received?The member should make sure the pharmacy they wish to use works with theirHealth Plan. The member will need to pay the full amount of the prescription upfront, but may request reimbursement by retaining the paid receipt and contactingthe Member Services Department of their Health Plan.

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PPO PlansWhat if a prescription is needed before permanent I.D. cardsare received?The member should make sure the pharmacy they wish to use works with theirhealthcare plan. Some plans require a deductible be met prior to prescriptioncopays. The member will need to pay the full amount of the prescription upfront, but may request reimbursement by retaining the paid receipt and callingthe Health Plan’s Member Services Department after his/her permanent I.D.card has been received.

HSA 1800 & 2500:The member may obtain prescriptions without an I.D. card. The member willneed to pay the full amount of the prescription up front and then submit (as anyother claim) to Anthem Blue Cross for reimbursement. Just like your othermedical expenses, benefits will not be paid until your deductible has been met.

If hospitalization is necessary, what hospital will I use?The accredited hospital you choose to use is up to you, but remember thatmedical services will be covered at a greater percentage at hospitals listed inthe network. Check with your healthcare service plan member servicesdepartment if you are unsure if the hospital you are considering is a provider inthe network for your Health Plan. In an emergency situation, always go to thenearest available hospital.

FDH Access 100 Dental PlanWhat is my dental benefit design?FDH Access 100 Plan.

May I or my dependents obtain FDH Access 100 Dental Coveragebut not be enrolled in the medical program?No, only those persons who meet all eligibility requirements (i.e. enrolled in themedical program) qualify for FDH Access 100 dental coverage.

Can each family member go to a different dental office?Yes, each family member may utilize a different dental office each time they seekservice, but the dental office/dentist must be an FDH Access 100 provider.

Who should I call with questions about coverage?Members covered by the FDH Access 100 Dental should call theCaliforniaChoice® Customer Service Center at (800) 558-8003 (8:00 a.m. to5:00 p.m. weekdays) if they:

� Need to replace a lost I.D. card(s)� Have questions about how to use the plan� Need to obtain a list of dental offices in their area



Anthem Blue Cross is pending regulatory approval.



Dental Plan 1000 or 3000What is my dental benefit design?Dental Plan 1000 or 3000.

May I or my dependents obtain Plan 1000 or 3000 coverage, but notbe enrolled in the medical program?Yes, but when dependents are covered by both the medical and dental programs,the dependents must be the exact same individuals.

Can each family member go to a different dental office?Yes, but they must use the dental office they most recently selected.

What if I receive a bill?You should not receive bills for dental care provided or approved by your dentaloffice. Contact the SmileSaverSM Member Services Department at (800) 333-9561for assistance.

Dental Plan 3500, 4000 or 5000May I or my dependents obtain Dental Plan 3500, 4000 or 5000coverage but not be enrolled in the medical program?Yes, but when dependents are covered by both the medical and dental programs,

the dependents must be the exact same individuals.Can each family member go to a different dental office?Yes, each family member can go to a different dentist each time they seek service.

What if I need to see a dentist while away from home?You are not restricted to see any specific dentist. However, the benefits will becovered at a lower amount for major services provided by a non-contracting dentist.(EPO 3500 – In-network providers available in California only.)

What if I receive a bill?If you take your claim form with you to your dental visit, the dentist will generallycomplete all of the paperwork and send you a bill for the amount to be paid byyou only.

CaliforniaChoiceSupply Request Form

____ Employer Change Request Form

____ Employee Enrollment Packet

____ New Hire Enrollment Quote Request Form

____ Student Verification Form

____ COBRA/Cal-COBRA Enrollment Form

____ Domestic Partner Affidavit

Group #:____________

This Form May Be Photocopied and Used As Necessary

Mail Supplies To:

Attn: ________________________________________________________

Company: ____________________________________________________

Address: ______________________________________________________

Phone: ______________________________________________________

Forms can also be downloaded at www.calchoice.com after your employer login.

Date:____________

____ Renewal Change Request

____ Change Request Form

____ Death Claim Packet

____ Beneficiary Change Form

____ Misc.

Mail or Fax Supply Request Form To:

CaliforniaChoice Supply Request721 South Parker, Suite 200, Orange, California 92868FAX (714) 953-4097

Supplies Requested:

QuantityQuantity


Please be advised that some forms and written communications are available on our website in

the following languages: Chinese, Korean, Spanish, Tagalog, and Vietnamese. Employees can

register their applicable, Plan-specific preferred language by completing the Language

Assistance Preference Form also found on our website (www.calchoice.com).

Healthcarefor the way WE LIVE®

800.558.8003www.calchoice.com

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