sales certification series study guide

Sales Certification Series

Study Guide

2020-21

Covered California for Small Business

2020-21 Covered California for Small Business Page | 1

Contents

1. Introduction ................................................................................................................................. 1

1.1 Banner Slide ........................................................................................................................... 1

1.2 Objectives .............................................................................................................................. 1

1.3 Code of Conduct .................................................................................................................... 2

2. Overview ...................................................................................................................................... 3

2.1 Section: CCSB Overview......................................................................................................... 3

2.2 Marketplace........................................................................................................................... 4

2.3 Products and Services ............................................................................................................ 4

2.4 Benefits Administration ......................................................................................................... 5

2.5 Health Plans ........................................................................................................................... 6

2.6 Two Tier - Buy Up-Down ........................................................................................................ 7

2.7 Dental Plans ........................................................................................................................... 8

3. Resources .................................................................................................................................... 9

3.1 Online Resources ................................................................................................................... 9

3.2 Online Resources ................................................................................................................. 10

3.3 Tabs and Details .................................................................................................................. 10

3.4 Apply Now ........................................................................................................................... 11

3.5 Agent Resources .................................................................................................................. 11

3.6 Learn about CCSB ................................................................................................................ 12

3.7 CCSB Agent Quick Links ....................................................................................................... 13

3.8 CCSB Online Agent Enrollment Portal ................................................................................. 14

3.9 Login to Portal ..................................................................................................................... 14

3.10 Agent Home ....................................................................................................................... 15

4. Federal Tax Credits .................................................................................................................... 16

4.1 Section: Federal Tax Credits ................................................................................................ 16

4.2 Overview - Tax Credits ......................................................................................................... 17

4.3 VIDEO - Tax Credits .............................................................................................................. 18

5. Eligibility .................................................................................................................................... 20


5.1 Section: Eligibility................................................................................................................. 20

5.2 Employer Eligibility .............................................................................................................. 21

5.3 Enrollment Periods .............................................................................................................. 23

5.4 Employee Eligibility.............................................................................................................. 24

5.5 Group Size ............................................................................................................................ 25

5.6 FTE - Definition .................................................................................................................... 26

5.7 How to Count FTEs .............................................................................................................. 27

6. Enrollment in CCSB .................................................................................................................... 28

6.1 Section: Enrollment ............................................................................................................. 28

6.2 Overview of Enrollment....................................................................................................... 29

6.3 VIDEO: Reference Plan ........................................................................................................ 32

6.4 Obtaining a Quote ............................................................................................................... 34

6.5 Employer Application .......................................................................................................... 35

6.6 Will Need ............................................................................................................................. 36

6.7 Processing Time ................................................................................................................... 37

6.8 Verifying Eligibility ............................................................................................................... 38

6.9 Payment Process ................................................................................................................. 40

6.10 Appeals Process ................................................................................................................. 41

Appeals Process 2 (Slide Layer) ............................................................................................. 42

6.11 Complaint Process ............................................................................................................. 42

6.12 Employer Reporting ........................................................................................................... 43

6.13 Employee Application ........................................................................................................ 44

7. Conclusion ................................................................................................................................. 45

7.1 Conclusion ........................................................................................................................... 45

7.2 Recap of Objectives ............................................................................................................. 46

7.3 Thank you ............................................................................................................................ 46


1. Introduction

1.1 Banner Slide

Narration:

Welcome to Covered California for Small Business.

1.2 Objectives

Narration:


Let's look at the topics that we’ll be covering.

By the end of the course you will be able to list and discuss:

- The Covered California for Small Business (CCSB) marketplace, its benefits to small businesses, and the products, and services offered.

- Online resources available

- How small businesses can be eligible for federal tax credits

- Eligibility and participation requirements for both employers and employees, and

- The enrollment process for both employers and employees

This course will last approximately 35 minutes.

1.3 Code of Conduct

Narration:

Covered California has developed this Code of Conduct to promote ethical sales practices to preserve the integrity of its mission and the trust of its Consumers. Agencies and Agents must comply with the rules laid out in this Code of Conduct as a condition to being certified with Covered California.

Failure to comply with the following rules constitutes a breach of the Agency or Non-Monetary Agent Agreement and thereby justifies Covered California to terminate the Agreement for cause, pursuant to Section E of Exhibit C.

You must review the Code of Conduct thoroughly as a condition of your certification, and before moving forward in this course. You may view the entire code by clicking the button below.

http://hbex.coveredca.com/toolkit/webinars-briefings/downloads/Covered_California_for_Small_Business_Agent_Code_of_Conduct_Final.pdf


By clicking the “Next” button, you are certifying that you have carefully reviewed the Covered California for Small Business Agent Code of Conduct.

2. Overview

2.1 Section: CCSB Overview

Narration:

Overview

- Covered California for Small Business (CCSB) marketplace

- Benefits to small businesses and

- Products and services


2.2 Marketplace

Narration:

CCSB Marketplace

Employers can research and compare different plans from competing health insurance

companies

Employers can define their company healthcare budget and offer employees two adjoining

levels of coverage, each with multiple plan options.

2.3 Products and Services


Narration:

CCSB Products and Services

Covered California for Small Business (CCSB) offers several products and services, including:

- A competitive market for health and dental insurance plans

- Access to dozens of coverage options

- Employee choice

- Employer budget control

- Benefits administration

- Enrollment support

- Customer Service

Employers purchasing coverage through CCSB may be eligible for federal tax credits

2.4 Benefits Administration

Narration:

Covered California for Small Business makes benefits administration easy for small businesses by handling a number of administrative tasks, such as:

- Employer online account management

- Employer online bill pay

- Providing a single consolidated bill

- Simple to understand quotes

- Verifying employer and employee applications for eligibility and enrollment


- Handling premium collection and remittance to participating CCSB health insurance plans, and

- Reconciling monthly employer enrollment information with Covered California health plans

2.5 Health Plans

Narration:

Health Insurance Plans Covered California for Small Business offers small employers a number of different health insurance plans. To see the plans available, visit the Covered California for Small Business website. http://www.coveredca.com/forsmallbusiness/plans/ Once enrolled in a plan, employees will receive a welcome letter and their membership information.


2.6 Two Tier - Buy Up-Down

Narration:

Two Tier - Buy Up/Down

Employers can offer two adjacent metal tiers with the option for their employees to buy up or down depending on their healthcare needs and budget.

This allows employers to offer two tiers of coverage to their employees rather than just one.

Tiers must be adjacent to each other, for instance, employers can offer both Silver and Bronze plans but not Gold and Bronze.


2.7 Dental Plans

Narration:

Dental Insurance Plans

Covered California for Small Business offers coverage through quality, name brand, dental insurance companies: For a list of current options, visit the Covered California for Small Business website. http://www.coveredca.com/forsmallbusiness/plans/

Dental benefits may be employee-paid, with no required additional cost to employers.


3. Resources

3.1 Online Resources

Narration:

Online Resources include the following:

- Web page

- Agent Tool Kit and

- Agent Portal


3.2 Online Resources

Narration:

The CCSB webpage, located on the Small Business tab at Coveredca.com, offers resources for

Agents and Employers.

3.3 Tabs and Details

Narration:

On the right side of the screen you’ll find many useful tabs with details on available health and

dental plans, how to obtain a quote, eligibility and federal tax credit information.


3.4 Apply Now

Narration:

Under the tab “Apply Now,” there is contact information, and you can also find links to: - What you need to apply - Applications forms and - Contact information if you need help

3.5 Agent Resources


Narration:

From the Apply Now section, you will also find many resources under the Resources for Participating Employers section.

Under the resources are many applications and forms.

3.6 Learn about CCSB

Narration:

There are also videos to help learn more about Covered California for Small Business. Click to view.


3.7 CCSB Agent Quick Links

Narration:

By clicking the Agent Resources tab in the top bar, you will be directed to the CCSB Agent Quick Links page where you can watch orientation videos and tips on how to sell CCSB. The quick links bar on the right will also direct you to the Application and Forms. You can also click on the Small Business Health & Dental plans and you’ll have immediate access to the Summary of Benefits (SBC’s). You can take a look at the Health and Dental Plans available to Covered California for Small Business enrollees. If you need help, you can click on the Contact Covered California link for a phone number and email address.


3.8 CCSB Online Agent Enrollment Portal

Narration:

The CCSB online agent enrollment portal can be reached through the Covered California website under the Agent Resources tab by clicking CCSB Agent Portal.

3.9 Login to Portal

Narration:

Once there, agents can log into their MyCCSB portal by providing their account type, user name, and password.


MyCCSB gives agents the ability to enroll, manage, and make changes to small group cases-all online. Many of the portal’s key features make the employer application process more intuitive and convenient for the user, including:

- Enrollment and case submission, adding a General Agent to submission if applicable

- Data validation to improve data accuracy

- A user dashboard for viewing and tracking case status

- Case notes and an upload function for required documents

- View & process renewals on both Employer and Employee levels

3.10 Agent Home

Narration:

You can select the Agent Home for: - general agent support for agents currently working with a general agent. - the Become an Agent tab. And - Agents for Small Business.


4. Federal Tax Credits

4.1 Section: Federal Tax Credits

Narration:

Federal Tax Credits

- Overview

- Requirements

- IRS Video


4.2 Overview - Tax Credits

Narration:

The Affordable Care Act provides federal health insurance tax credits to qualified small businesses. Tax credits are only available to employers purchasing health insurance coverage through Covered California for Small Business.

A small business employer may qualify for a tax credit for up to two consecutive taxable years, worth up to 50% of the annual contribution they make toward their employees’ premiums.

Nonprofit and tax-exempt employers can get a tax credit worth up to 35% of their premium contributions.

To qualify, they must:

- Offer group coverage for their full-time employees through Covered California for Small Business.

- Have fewer than 25 full-time equivalent employees

- Pay full-time equivalent employees an average annual salary of less than $55,000. Federal tax credit income limits are adjusted annually as updated IRS publications for the prior tax year become available in the first quarter of the proceeding calendar year. Please refer to IRS Form 8941: Credit for Small Employer Health Insurance Premiums for the most current information.

- Contribute at least 50 percent of full-time employees’ premium costs. And

- Receive the tax credit for no more than two consecutive taxable years.


The tax credits are available to small employers on a sliding scale. Employers with fewer than 10 full-time-equivalent employees with wages averaging less than $25,000 per year may be eligible for the maximum tax credit amount.

The tax credit decreases with additional employees and as salaries for those employees increase.

A tax credit calculator is available on the healthcare.gov website.

Small businesses can use the calculator to determine if they qualify for a tax credit and estimate the amount of their tax credit. Small businesses are encouraged to visit the IRS website or contact their tax professional for additional information on available tax credits and their specific situation.

For more information, please watch the following video.

4.3 VIDEO - Tax Credits


Narration:

Hi, I’m Shannell, and I work for the Internal Revenue Service.

Are you an employer with fewer than 25 employees? Get the credit you deserve - the Small Business Health Tax Credit.

Whether you are a for-profit business or a tax-exempt group, if you pay at least half the cost of premiums for single coverage health insurance for your employees, you may qualify. The credit has been around since 2010, but some of the rules changed for tax years beginning in 2014 or later.

First, the maximum credit increased from 35 to 50 percent, and from 25 to 35 percent for small tax-exempt employers.

Next, to claim the credit, generally employers must offer employees insurance purchased through the small business health options program known as the SHOP Marketplace (CCSB in California).

Finally, in 2014 and subsequent years, the credit is only available to eligible employers for two consecutive taxable years.

Although the maximum credit amount changes, the definition of a small employer has not. Usually, a small employer, for the purpose of the credit, is an employer with fewer than 25 employees and those employees must earn low to moderate wages.

There are other special rules. For example, two half-time employees generally count as one full-time employee. So if you have more than 25 employees and some are not full-time, you may still qualify for the credit.

If you’re a small business, you’ll claim the credit as part of the general business credit on your income tax return using Form 8941. If you have no tax due, you can carry the credit back or forward to other years. Since the credit will be less than the full amount of your premium payments, you will be able to claim a business expense deduction for the difference. That’s both a credit and a deduction for employee health insurance premium payments.

If you’re a tax-exempt employer, you’ll claim the credit on Form 990-T, and for you, the credit is refundable. That means you can get it even if you owe no tax.

For more information, go to irs.gov/aca.


5. Eligibility

5.1 Section: Eligibility

Narration:

Eligibility

- Requirements for Employers

- Enrollment Periods

- Criteria for Employees

- Determining Group Size, and

- FTE: Definition and Calculation


5.2 Employer Eligibility

Narration:

Employer Eligibility

How is eligibility determined for purchasing Health Insurance plans through CCSB?

Currently, to be eligible, small businesses must have 1 to 100 full-time equivalent employees.

Besides the owner and spouse, and other specific limitations, the business must have at least

one employee who receives a W-2 tax form at the end of the year.

The business must offer, at a minimum, coverage to all full-time employees’ through CCSB. This

excludes self-employed 1099 contractors.

--


Additionally, employers with 50 or more full-time equivalent employees must offer coverage to

dependent children, or they may be subject to a penalty by the IRS. For more information on

this penalty, please visit the IRS page by clicking this link: https://www.irs.gov/affordable-care-

act/employers/aca-information-center-for-applicable-large-employers-ales

They must offer coverage to all eligible full-time employees and have employee participation of

at least 70%.

Employers specify the amount they want to contribute toward their employees’ premiums and

must contribute at least 50% toward the least expensive plan offered to employees.

Sole proprietorships without any employees are not eligible; however, these sole proprietors

may be eligible to buy through the individual marketplace operated by Covered California.

Groups who do not meet participation or contribution requirements may still purchase coverage

through CCSB but only during the Special Annual Enrollment Period that falls between


November 15 and December15 of each year.

5.3 Enrollment Periods

Narration:

Prospective employers have the option to enroll during any month of the year. Once the

employer is enrolled in a group plan, coverage, and premiums are guaranteed for 12 months

from the coverage effective date.

For active employer groups, the annual open enrollment period for renewal begins at least 30

days before the start of the next plan year.

For example, the open enrollment period for an employer whose plan year begins in January will

begin no later than December 1 of the previous year.


Covered California for Small Business will notify employers, agents, and General Agents when it is time to prepare for their annual open enrollment renewal period.

5.4 Employee Eligibility

Narration:

To qualify as an eligible employee with CCSB, an individual must meet the following criteria:

- Work at least an average of 30 hours per week, measured on a monthly basis, or

- Be a Part-time employee who works between 20-29 hours a week and for whom the employer has elected to offer health care coverage.

Part-time employees must have worked at least 20 hours per normal workweek for at


least 50 percent of the weeks in the previous

calendar quarter.

Health issuers may request necessary information to document the hours and time period in question, including, but not limited to, payroll records and employee wage and tax filings.

- Additionally, employees must be permanent and actively engaged in the business of the employer.

5.5 Group Size

Narration:

The employer is responsible for calculating the total count of Full Time Equivalent employees


- The group size is determined by calculating the total number of “Full-Time Equivalent” (FTE) employees.

- Part-time employees count in the total FTE employee count.

- The total count cannot exceed 100 FTEs.

- Applicable Large Employer (ALE) rules apply to employer groups with at least 50 FTEs.

- Employers with more than 100 FTE employees are not eligible to newly enroll in the CCSB marketplace. Those employers who meet initial FTE eligibility requirements but grow above 100 FTEs in future years may still renew their coverage with CCSB.

Please refer to information found at this link:

IRS - Identifying Full-Time Employees

https://www.irs.gov/uac/small-business-health-care-tax-credit-questions-and-answers-determining-ftes-and-average-annual-wages

5.6 FTE - Definition

Narration:

Full-Time Equivalent (FTE) Employee - Definition

· An FTE is not an actual employee but a calculation involving all part-time and full-time employees who worked during the preceding period.

· This count is based on the previous calendar year.

· If the employer did not exist in the prior calendar year or calendar quarter, the employer shall determine the average number of employees who are reasonably expected to work on business days in the current calendar year.


5.7 How to Count FTEs

Narration:

Let’s take a look at the FTE calculator at healthcare.gov https://www.healthcare.gov/shop-

calculators-fte

You can enter the number of full time employees you have, so if you enter the number 3, it

populates in the field, giving you a total so far of 3 full-time employees. Then, if you enter the

monthly hours from your part-time employees, for instance, 4 of them, for a total of 304 hours.

That is then calculated and returns a result. Although it’s the hours of 7 people, it calculates as 5

full-time employees.


6. Enrollment in CCSB

6.1 Section: Enrollment

Narration:

Enrolling in CCSB

- Overview

- Getting a Quote

- Employer Enrollment Steps

- Needed Information

- Application Processing

- Verifying Eligibility

- Payment Process

- Appeals or Concerns

- Reporting and

- Employee Application


6.2 Overview of Enrollment

Narration:

Here is an overview of the process of enrolling in Covered California for Small Business (CCSB). Click each of the tabs on the right to view.

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Metal Tiers

- Small businesses applying through CCSB have the option to select from four “Metal Tiers”

levels of coverage: Platinum, Gold, Silver, and Bronze.

- Employers determine the level of coverage they want to offer to their employees by

choosing one or two adjacent levels of the four metal tiers.


- In other words, employers can choose bronze and silver, or silver and gold, but not bronze

and gold levels.

------------------------

Employer Contribution

Employers decide how much of a contribution they will make toward an employee’s monthly premium, then choose a reference plan from a metal tier level that fits their budget needs.

- Employers define their contribution by choosing a reference plan within their selected plan level(s). If an employer’s reference plan is no longer available at renewal, it must select a new reference plan during the employer’s annual election period or a default alternative reference plan will be auto selected.

- The reference plan helps the employer control budgeting for premium contributions before employees select their plans.

- The employer selects the reference plan from a metal tier and commits to contributing at least 50% of the employee’s lowest cost premium.

- This dollar amount stays consistent regardless of which plan the employee chooses.

- If the employee chooses a more expensive plan, the employer’s contribution remains the same and the employee pays the difference.

- Reference plan contribution allows the Employer to set a healthcare budget for their company.

- Employees select the specific health and dental plans that meet their coverage needs and budget, from the available adjacent metal tiers selected by the employer.


----------------------------

Employee choice

Under the employer’s defined contribution arrangement, employees can then select from any of dozens of health plans offered within the one or two metal tier(s) selected by their employer.

The employer can choose to cover employees’ dependents, however they are not required to pay for that coverage.

If the FTE number is at least 50, the employer is required to offer coverage to all dependent children up to the age of 26. If the employer chooses to not offer dependent coverage, the employer may be subject to an Employer Shared Responsibility payment.

Refer to Section 4980H of the Internal Revenue Code for more information.

----------------------------

Employee Enrollment

Qualified employers can enroll on the first of any month they choose, or at the annual renewal


of their existing plan.

- Once enrolled, the employer’s coverage and premiums are set for 12 months.

- Once employees are added to their employer’s plan, their coverage, and premium rates are guaranteed until the end of that employer’s plan year.

- Employers may allow employees to change their selected plan after the effective date of coverage during the first thirty days of the new plan year, provided that the newly selected plan is offered by the same health issuer.

6.3 VIDEO: Reference Plan

Narration:


You know providing health coverage is a great way to attract and retain your employees. It’s a big decision, whether you’re starting to provide a health insurance benefit plan for the first time, or renewing your plan for the upcoming year. And, it can be a challenge to find the best options for your budget. Covered California for Small Business is here to help. We know that offering your employees a way to choose their own health plans can be challenging, given the rising cost of health insurance. Small group employers have been faced with increasing health insurance premiums that have outpaced inflation for the last decade. Balancing the rising cost of health insurance and your desire to control cost while helping your employees get the best possible access to physician and hospital networks can be challenging. Moving from one carrier to another, on an endless chase for low premiums, disrupts your employees’ access to care. And one network or health plan may not fit every need. Is there a better way? Well, we have a good news for you. With our fresh approach to offering health coverage, you can be in the driver’s seat to control your health insurance budget and determine your defined contribution level by using a reference plan strategy. Covered California for Small Business takes the financial decision important to the business owner and separates it from the benefit selection decision which is important to the employee. Employer defined contribution is very similar to a gift card given to an employee that could be used to cover all or some of their health insurance costs. It’s like giving the employee a gift card for health insurance. For employees, one size does not fit all. Getting health coverage is like buying a car. A family of 7 would probably not have much interest in a hybrid sub-compact. Why should health insurance be any different? Here’s how it works… Covered California for Small Business offers you access to four levels of coverage: bronze, silver, gold and platinum. We make it easy for you to choose, not one level, but two adjoining levels of coverage you pick.

You can then allow your employees to select from affordable, quality, popular health insurance plans from brand-name insurance companies that best meet their needs. With all that choice, can you better manage your health plan budget? Let’s look at the following example. Employer XYZ would like to offer good benefits but control costs by setting their defined contribution level to 50% of employee premium cost for a Silver PPO reference plan. Employees would have the flexibility to choose a plan from Silver and Gold tiers to meet their needs.

Covered California allows the employer to set their defined contribution level without dictating to the employee the level of benefit or the providing health insurance carrier. For example, an employer can set the contribution level to 50% of total premium from the selected reference plan, or equivalently, a total employer contribution of $2,500.00 per month.

With this level of contribution, the employee may apply this “gift card” towards a health insurance plan that meets their needs and the needs of their families. In this example, Mary is an employee of XYZ company. She’s a single mom with a couple of kids looking for coverage she can afford. Here we can see the reference plan her employer is offering compared with the two health plan options she is considering for her family. With the Kaiser Silver HMO plan, she’ll be paying a lower monthly premium than with the Health Net Silver PPO. In both cases, the employer contribution is the same. Here is an example where an employee can choose a less expensive plan and pay a lower monthly premium or pitch in more and select a richer benefit or different carrier. John is a single male employee who receives an employer contribution of $302 toward his monthly premium. He can use this contribution toward a Silver PPO plan or a Gold PPO plan. With the Blue Shield Gold PPO plan that pays more for his frequent doctor visits and medications and reduces his out-of-pocket costs, his monthly premium payment is slightly higher than the Health Net Silver PPO plan. The slide illustrates the employee’s ability to


compare the benefits from different plans and pick the plan that is right for them. Jocelyn is a young and healthy employee, wanting to have coverage just in case. She decides to choose a Silver HMO plan with a lower monthly payment. The takeaway here is that the benefit decision is with the employee, where it should be. The defined contribution approach through Covered California for Small Business allows the employer to finitely control their budget without impacting the benefit and plan choices offered to employees. Covered California for Small Business also allows employers to control costs when renewing their health benefit plan for the upcoming year. In this example, when you renew your health benefit plan, you can change your reference plan from a Silver PPO plan in current year to a Silver HMO plan for next year in order to maintain the same budget level despite rising insurance premiums. With Covered California for Small Business, you are in control of your health care budget, while your employees are allowed to choose their own health plan. Feels good when everyone’s in control.

6.4 Obtaining a Quote

Narration:

To obtain a quote, please visit the Covered California for Small Business homepage and click “Get a Quote” under the Explore Small Business tab.

Please allow up to 3-5 business days to receive your initial CCSB quote. The quote will reflect rates for all CCSB plans.

Quotes can also be obtained through major commercial quote engines.

You can also work with one of our five General Agents:

- Claremont

- Dickerson

- LISI

- Rogers Benefit Group


- Warner Pacific

- Beere & Purves

- Benefit Mall

6.5 Employer Application

Narration:

Employer Application

The first step is to fill out the Covered California for Small Business (CCSB) Application for Employers.

- The paper application can be downloaded from the CCSB website

- Online applications for employers are available.

Employers can apply through:

- A Covered California Certified Insurance Agent

- US Postal Mail and

- The Employer Portal


6.6 Will Need

Narration:

Understanding the employer application and the information required by the health plan is the key to submitting a complete and successful application. Here is a list of information needed with the application for determining employer eligibility for Covered California for Small Business.

- Employer name, as reported to the Employment Development Department (EDD)

- Federal Employer Identification Number (FEIN)

- State Employer Identification Number (SEIN)

- A copy of their California Business License

- DE-9C reconciled by the employer (or 30-day payroll if in business less than 3 months)

- Total number of full-time equivalent employees (including total number of part-time employees working 20 to 29 hours per week)

- Standard Industry Classification (SIC) code and

- Total number of eligible employees


6.7 Processing Time

Narration:

Processing Time

Covered California’s goal is to connect small businesses with quality brand name health insurance as quickly and easily as possible. To expedite processing of small business applications, ensure that all information and forms are completed and submitted 5 business days prior to the requested effective date.

The average time it takes to process a clean employer and employee application package is three to four business days. The actual processing time may vary if there is an inconsistency in the application information that must be verified.


6.8 Verifying Eligibility

Narration:

Verifying Eligibility If information submitted from either the employer or employee does not meet eligibility requirements for Covered California for Small Business, or is inconsistent with the information reported on the DE-9C (the EDD Quarterly Contribution Return and Report of Wages) or other verification documents, CCSB will:

· Notify the employer or employee of the ineligibility or inconsistency · Make a reasonable effort to identify and address the cause of the inconsistency · Give the employer or employee 30 days to present documents that can support the application or resolve the inconsistency.


Notification If CCSB has not received verification documents within 30 days, CCSB will notify the employer or employee that their eligibility has been denied. Notices of eligibility approval or denial are sent to every employer that applies for CCSB. Employers have the right to appeal denial decisions. After receiving a complete and correct application with all required documentation, CCSB will issue a notification of eligibility to employers and employees.

Process

- Covered California's verification process includes the following steps: - Verifying that the employer has offered coverage to the employee through the use of the

Employment Development Department (EDD) form DE-9C. - Checking the employee’s attested information with employer-supplied information. - Collecting only the minimum required information to verify eligibility.


6.9 Payment Process

Narration:

Payment Process

It’s important to remember that, in order for coverage to start, no less than 85% of the initial payment must be received by Covered California by the invoice due date.

Unlike the individual market, Covered California is a payment aggregator for the Covered California for Small Business market, which means that the employer will receive one invoice from CCSB for all coverage regardless of the carrier.

CCSB will invoice and collect both initial and subsequent monthly premiums from employers and provide payment to the appropriate health plan on behalf of the small business.


6.10 Appeals Process

Narration:

Appeals Process

After receiving a complete and correct application with all required documentation, Covered California has two weeks to issue a notification of eligibility to employers and employees. If a notification of denial of eligibility is received, employers and employees have the right to appeal.

- Appeals can be initiated by completing the form located on the employer resources web page http://www.coveredca.com/PDFs/Request-for-Appeal-English.pdf, and by submitting as instructed.

-----------------------------

- The consumer can also contact the CCSB Service Center and submit the appeal in writing within 90 days of the denial date.

- Once a valid appeal is submitted according to the instructions on the form, a decision must be provided via written notice within 90 days.

Appeals are adjudicated independently and must consider any evidence submitted by the appellant.


Appeals Process 2 (Slide Layer)

6.11 Complaint Process

Narration:

Complaint Process

Covered California is committed to supporting small businesses, and invites all employers and employees to call Covered California for Small Business’s Service Center with any complaints or concerns. You may also visit the small business website and complete the Complaint Form provided under Employer Resources.


There are other California state resources available to support consumers.

The Office of the Patient Advocate provides a great overview of the health care industry, with a glossary of terms, patient rights, and a step-by-step guide showing consumers how to deal with a problem or file a complaint against their health insurance company.

You can also contact the California Department of Managed Health Care (DMHC) or the California Department of Insurance (CDI) for support depending on the consumer’s plan.

6.12 Employer Reporting

Narration:

Required Employer Reporting


Employers are required to report any changes in employee eligibility to Covered California via the Change Form available on the Covered California for Small Business Employer Resources page or through the agent portal.

Examples of employee changes that should be reported include:

- Marriage

- Divorce

- Newborns

- Address change

Changes must be reported within 30 days of the event.

Employers can download the Change Request Form from the resources web page.

6.13 Employee Application

Narration:

Employee Application

The employee application collects all information necessary to determine the employee’s eligibility and lets them select and enroll in one of the Covered California health plans offered by their employer.

Employees who are offered coverage by their employers through CCSB can apply using the Covered California for Small Business Application for Employees located online.


Completed CCSB applications can be submitted in one of the following ways:

- Through a Covered California Certified Insurance Agent

- By US Postal Mail

- Fax: (949) 809-3264

7. Conclusion

7.1 Conclusion

Narration:

Conclusion


7.2 Recap of Objectives

Narration:

You have completed the course Covered California for Small Business. You are now able to identify and discuss the following items:

- Covered California for Small Business (CCSB) market, benefits, products and services - How small businesses can be eligible for federal tax credits - Eligibility and participation requirements for both employers and employees

- Enrollment process for both employers and employees - Online resources

7.3 Thank you

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