*This list is meant to be informative and is not intended to be all-inclusive. Other policies and guidelines may apply.
Covered California Small Group (SHOP) Underwriting Guidelines
- GROUP SIZE: 1-50 eligible employees
- RATE GUARANTEE: 12 months
- RATES: Rates are based on three factors: 1) age, 2) employee ZIP Code, and 3) family composition. There is a single age band for ages 0-20 and ages 64+. All other ages have their own, individual age band. Employee and spouse are rated separately based on age. Child dependents are rated separately based on age. Child dependents are rated separately for the first three children for ages 0-20. The fourth child and up in this age band are not rated. Child dependents ages 21-25 are rated individually. Family rates are the sum of all of the individual rates.
- FEES: There are no additional employer or employee fees in SHOP.
- CONTRIBUTION: Employers first select the metal tier (Platinum, Gold, Silver, or Bronze) they want to offer their employees. Then, within that metal tier, they select an anchor plan they wish to tie their contribution to. SHOP will offer a % of selected anchor plan contribution scenario, applied to employee and dependent coverage when offered to dependents. Employers are required to contribute a minimum of 50% of the employee-only premium of that anchor plan for each employee electing coverage. Note that the amount of the contribution will vary by the age of the employee and any dependent contributions being offered. There is no requirement to contribute to dependent coverage. When the employer contributes 100% of the employee premium for the anchor plan, 100% of the employees must enroll.
- PARTICIPATION: There is a 70% minimum participation requirement. Valid waivers are excluded. Valid waivers include other employer sponsored coverage, coverage under Medi-Cal, Medicare, TriCare, or Federal employee program. Coverage under an individual policy is not a valid waiver.
- CARVE OUTS: Not allowed except for union carve-outs.
- 1099 EEs: Not allowed.
- COBRA/CALCOBRA: No restriction on the number of COBRA or Cal-COBRA participants associated with the group.
- OUT OF AREA: A minimum of 51% of the employees must reside within California. Out of state rates will be based upon employer ZIP code for plans available for out of state coverage.
- MULTIPLE PLANS: SHOP through Covered CA offers multiple plans at both the employer and employee levels. Employers pick a metal tier and the employees get to pick from that tier.
- WAITING PERIODS: Employer must sign an attestation that says that all employees being offered coverage must have completed any employer-imposed waiting period.
- BUSINESS AGE: Must be able to provide payroll records for at least 30 days.
- SUBMISSION DATES: Preferably by the second week in the month for a 1st of the following month effective date.
- GOOD THROUGH DATES: Rates are good through the end of the calendar quarter quoted.
- RATES FOR DEPENDENTS: Dependent rates wil be based on employee zip code regardless of dependent location.
- PEDIATRIC DENTAL: Pediatric dental will be offered to all eligible employees. Multiple carriers will be offered at two different coverage levels. It is at the employee discretion whether or not to purchase pediatric dental for some or all enrolling child dependents. Eligible children are between the ages of 0-18 inclusive. Pediatric dental is 100% voluntary so employer contribution to child dependent medical coverge does not apply to pediatric dental coverage.