Bullet Proof UNDERWRITING - beere&purves · 2021. 1. 4. · Guarantee Issue — General BP010421 CA Fewer Than 26 EE’s CA 26+ EE’s To Calculate a Different Minimum Wage Hourly

Bullet Proof

UNDERWRITING

BEERE&PURVES

Return to TOC Rev. 7/12/21 2

Table of Contents Guarantee Issue ...................................................................................................................................................................... 3

Unique Groups ...................................................................................................................................................................... 11

Legal Doc Guidelines ............................................................................................................................................................ 19

Legal Document Samples ..................................................................................................................................................... 30

BEERE&PURVES


Guarantee Issue

General Guidelines • In order to be considered Guarantee Issue (GI) it is assumed that all requirements listed throughout bulletproof have been met.

• Guarantee Issue makes group insurance available to California businesses employing between 1-100 full-time (F-T) plus full time equivalent

(FTE) employees for at least 50% of the previous calendar quarter. Carriers do; however, apply the timeframe differently.

• Each carrier requires a Quarterly Contribution Return & Report of Wages (DE-9C).

• Due to the length of time in business, not all companies may have access to a DE-9C; therefore, details are provided as to which carrier will

accept payroll in lieu of a DE-9C.

• When all employees are not listed on the DE-9C, each carrier may require additional legal documentation. Please reference the appropriate

business structure section within bulletproof for requirements.

• DE-9C wages are evaluated to determine an employee’s full or part-time status. If part-time employees will not be extended an offer of coverage,

and the DE-9C wages are greater than or equal to the amounts listed in the table below, they are considered full-time and the following

documentation must be provided for both hourly and salaried part-time employees to prove otherwise:

• HOURLY: 30 days of payroll showing wages, withholdings and hours worked.

• SALARY: 30 days of payroll showing salary, withholdings and a letter from the group stating which employees are part-time salaried and if

they work less than 20 or 30 hours (see group application).

Calculating Quarterly Minimum Wage *

CA Fewer Than 26 EE’s CA 26+ EE’s To Calculate a Different Minimum Wage

Hourly = $13.00 Hourly = $14.00 1. Find your hourly minimum wage

20 hrs/wk = $3,380 20 hrs/wk = $3,640 2. Multiply wage by 20 hrs for PT or 30 hrs for FT

30 hrs/wk = $5,070 30 hrs/wk = $5,460 3. Multiply by 13 weeks

*Although the California minimum wage is listed above, minimum wages may vary based on city, county, company size or entity type. Please see the

UC Berkeley Labor Center for more information and follow the above steps to calculate the appropriate quarterly minimum wage.

• It should be noted that the documentation requirements within the Legal Doc Guidelines sections of bulletproof lists the carrier’s preferred

document first. Documents listed thereafter will only be accepted when the first document is unavailable.

https://laborcenter.berkeley.edu/inventory-of-us-city-and-county-minimum-wage-ordinances/

BEERE&PURVES


Guarantee Issue — Owners/Husband & Wife

Husband & Wife Only Groups with No W2 Employees Groups consisting of husband and wife only are no longer permitted per ACA rules.

Husband & Wife Enrollment with W2 Employees A Husband and wife may enroll only when the company has:

• Aetna: one (1) or more W2 enrolled employees.

• Anthem Blue Cross: one (1) or more W2 eligible employees.

• Blue Shield: one (1) or more W2 eligible employees.

• CaliforniaChoice: one (1) or more W2 enrolled employees.

• Cigna + Oscar: one (1) or more W2 enrolled employees.

• Covered CA for Small Business: one (1) or more W2 eligible employees.

• Health Net: one (1) or more W2 eligible employees.

• Kaiser Permanente: one (1) or more W2 eligible employees (husband/wife may qualify as W2 employee if Corp or LLC).

• UnitedHealthcare: one (1) or more W2 enrolled employees.

Owner Only Groups with No W2 Employees Groups consisting of only owners are permitted when they meet specific guidelines.

• Aetna: Owner only groups are no longer permitted per ACA rules.

• Anthem Blue Cross: C-Corp and LLC owner only groups are permitted if they have at least two (2) owners and one (1) of the owners is on the

DE-9C or can sign the Eligibility Statement.

• Blue Shield: Owner only groups are no longer permitted per ACA rules.

• CaliforniaChoice: Owner only groups are no longer permitted per ACA rules.

• Cigna + Oscar: Owner only groups are no longer permitted per ACA rules.

• Covered CA for Small Business: Owner only groups are no longer permitted per ACA rules.

• Health Net: Owner only groups are no longer permitted per ACA rules.

• Kaiser Permanente: Not allowed

• UnitedHealthcare: C-Corp, S-Corp and LLC owner only groups are permitted if they have at least two (2) owners and one (1) of the owners

works the required number of hours (30 hours/week).

Owners Enrollment with W2 Employees Owners may enroll only when the company meets the rules listed below:

• Aetna: Owners may only enroll if the group has one (1) or more W2 enrolled employees.

• Anthem Blue Cross: Owners may enroll if the group has one (1) or more W2 eligible employees.

• Blue Shield: Owners may only enroll if the group has one (1) or more eligible W2 employees.

• CaliforniaChoice: Owners may only enroll if the group has one (1) or more W2 enrolled employees.

• Cigna + Oscar: Owners may only enroll if the group has one (1) or more W2 enrolled employees.

• Covered CA for Small Business: Owners may only enroll if the group has one (1) or more W2 eligible employees.

• Health Net: Owners may only enroll if the group has one (1) or more eligible W2 employees, or an officer who is also a W2 eligible employee.

• Kaiser Permanente: Owners may only enroll if the group has one (1) or more eligible W2 employees, or an officer who is also a W2 eligible

employee.

• UnitedHealthcare: Owners may only enroll if the group has one (1) or more W2 enrolled employees.

BEERE&PURVES


Guarantee Issue

Aetna (1-100 enrolled) • The group must have been actively in business and employed a minimum of one (1) but not more than 100 F-T + FTE employees for a minimum

of 50% of previous calendar quarter or 50% of the prior calendar year.**

• At least 51% of all eligible employees must reside in California.

• At least one (1) eligible NON-SPOUSE / NON-OWNER W2 employee must enroll in Medical.

• Husband and Wife only groups are not eligible.

• Owner only groups are not eligible.

• The group must have and must maintain the business licenses and/or appropriate state filings allowing the company to conduct business in the

state of California.

• Groups are not Guarantee Issue if they terminated health coverage with Aetna within the past 12 months.

**Start-up groups in operation less than 3 months that meet all other eligible requirements and provide 2 consecutive weeks of payroll records will be

accepted as Guarantee Issue immediately.

Aetna eff. month Payroll on or before Aetna eff. month Payroll on or before

January 11/15 July 5/15

February 11/15 August 5/15

March 11/15 September 5/15

April 2/15 October 8/15

May 2/15 November 8/15

June 2/15 December 8/15

Anthem Blue Cross (1-100 enrolled) • The group must have been actively in business and employed a minimum of one (1) but not more than 100 F-T + FTE employees for a minimum



• At least one (1) eligible NON-SPOUSE / NON-OWNER must be eligible to enroll in Medical.


• Owner only groups are not eligible unless they are a C-Corp or an LLC.



**Start-up groups that meet all other eligibility requirements and provide 30 days of payroll within 45 days of the effective date will be accepted as

Guarantee Issue immediately.

Anthem eff. month Payroll on or before Anthem eff. month Payroll on or before







BEERE&PURVES


Guarantee Issue

Blue Shield (1-100 enrolled) • The group must have been actively in business and employed a minimum of one (1) but not more than 100 F-T + FTE employees for a minimum



• At least one (1) eligible NON-SPOUSE / NON-OWNER (or an owner qualifying as a common law employee) W2 employee must enroll in Medical.





• Start-up groups with 1 common law employee enrolled with W-4’s for all W2 employees, legal docs, and start-up companies/spin-off Group

Eligibility Statement will be accepted.

Blue Shield eff. month Payroll on or before Blue Shield eff. month Payroll on or before







CaliforniaChoice (1-4 enrolled) • The group must have been actively in business and employed a minimum of one (1) but not more than four (4) F-T + FTE employees for a

minimum of four (4) continuous weeks prior to the requested effective date.

• At least 51% of all employees must reside in California.






CalChoice eff. month Payroll on or before CalChoice eff. month Payroll on or before







BEERE&PURVES


Guarantee Issue

CaliforniaChoice (5-100 enrolled) • All groups with at least five (5) medically enrolling employees but not more than 100 F-T + FTE employees are eligible as long as the business

can provide at least one (1) week of payroll prior to the requested effective date.

• Payroll ledger from business start date to current should include the following items: (a) employee names; (b) employee wages; (c) employee

wage withholdings; (d) wage summary totals; and (e) run date. If less than one (1) month of payroll is available, the balance for the month is due

within 30 days of the requested effective date.







CalChoice eff. month Payroll requirement

January—December One week of payroll

Cigna + Oscar (1-100 enrolled) • The group must have been actively in business and employed a minimum of one (1) but not more than four (4) F-T + FTE employees for a

minimum of four (4) continuous weeks prior to the requested effective date.**

• At least 51% of all employees must reside in California.

• 50% of enrolling employees must reside in Cigna+Oscar service area






**Start-up groups with at least 2 weeks of payroll prior to the requested effective date that provide all relevant legal documents will be accepted.

Cigna + Oscar eff.

month Payroll on or before

Cigna + Oscar eff.

month Payroll on or before







BEERE&PURVES


Guarantee Issue

Covered CA for Small Business (1-100 enrolled) • All groups with at least one (1) medically enrolling employees but not more than 100 F-T + FTE employees are eligible as long as the business

can provide at least two (2) weeks of payroll prior to the requested effective date.

• Payroll ledger from business start date to current should include the following items: (a) employee names; (b) employee wages; (c) employee

wage withholdings; (d) wage summary totals; and (e) run date. If less than one (1) month of payroll is available, the balance for the month is due

within 30 days of the requested effective date.

• At least one (1) eligible NON-SPOUSE / NON-OWNER W2 employee must be eligible to enroll in Medical.





**Start-up groups must be in business with employees hired at minimum one (1) day prior to the requested effective date. Must provide two (2) weeks

of payroll if applicable; otherwise, employee offer letters may be submitted.

CCSB eff. month Payroll requirement

January—December Two weeks of payroll

Health Net (1-5 enrolled) • The group must have been actively in business and employed a minimum of one (1) but not more than five (5) F-T + FTE employees for a

minimum of 50% of the previous calendar quarter or 50% of the prior calendar year.

• At least 51% of all eligible AND enrolling employees must reside in California.

• At least one (1) eligible NON-SPOUSE / NON-OWNER W2 employee must eligible to enroll in Medical.



• Owner & W2 eligible officer allowed if employed for 50% of the prior calendar quarter.

• Copy of statement of information

• DE-9C



Health Net eff. month Payroll on or before Health Net eff. month Payroll on or before







BEERE&PURVES


Guarantee Issue

Health Net (6-100 enrolled) • The group must have been actively in business and employed a minimum of six (6) enrolled employees but not more than 100 F-T + FTE

employees for a minimum of four (4) continuous weeks of payroll, with a minimum of 2 weeks prior to the requested effective date.

• At least 51% of all eligible and enrolling employees must reside in California.




• Owner & W2 eligible officer allowed if employed for 50% of the prior calendar quarter.

• Copy of statement of information

• DE-9C



Health Net eff. month Payroll on or before Health Net eff. month Payroll on or before







Kaiser Permanente (1-100 enrolled) • All groups with at least one (1) medically enrolling employees but not more than 100 F-T + FTE employees are eligible as long as the business

can provide at least two (2) weeks of payroll prior to the requested effective date.


• At least one (1) eligible NON-SPOUSE / NON-OWNER must be eligible to enroll in Medical.

• Husband and Wife only groups are eligible if either the Husband or Wife is a W-2 employee on the DE9C

• Owner only groups are not eligible unless they have an eligible W-2 Employee. Owner/Officer may qualify as W-2 Employee

• The group must have and must maintain the business licenses and/or appropriate State filings allowing the company to conduct business in the


Start-up groups that meet all other eligibility requirements and provide 30 days of payroll within 45 days if the effective date will be accepted as

Guarantee Issue immediately.

Kaiser eff. month Payroll on or before Kaiser eff. month Payroll on or before







BEERE&PURVES


Guarantee Issue

UnitedHealthcare (1-100 enrolled) • The group must have been actively in business and employed a minimum of one (1) eligible employee but not more than 100 F-T + FTE

employees for a minimum of two (2) continuous weeks prior to the requested effective date.

Groups applying with 2 weeks of payroll must also provide appropriate legal docs based on entity type and a copy of the Federal Tax ID

appointment letter. Non-Profit Corps are excluded from applying with 2 weeks of payroll, they must have a 940 or 941 to apply.

• UHC does not require 51% of all eligible employees to reside in California. Contact your Sales Team to discuss rules.



• Owner only groups are not eligible unless they are a C-Corp, S-Corp or LLC.



UHC eff. month Payroll on or before UHC eff. month Payroll on or before







BEERE&PURVES


Unique Groups

Carve-Outs

Aetna

Ineligible Types: Location; Management vs. Non-Management; and Salary vs. Hourly

Eligible Types: Union vs. Non-Union

Eligible Plans: All

Guarantee Issue (GI): Yes, when all conditions listed below have been met.

Rules: • Total group size (union and non-union) must be 100 or fewer F-T + FTE employees AND

• 5-100 F-T + FTE employees must be enrolled and maintained within Aetna's California Network Service

Area AND

• 25% of the carve-out population must enroll with Aetna.

Documentation: • Group must prove that Union employees are covered by the Union plan, i.e. copy of healthcare billing

statement for previous month.

• Declinations are not required for union employees waiving coverage (considered a valid waiver).

Anthem Blue Cross



Eligible Plans: All



• 1-100 F-T + FTE employees must be enrolled and maintained within Anthem Blue Cross AND

• 1-4 F-T + FTE employees: 65% of the carve-out population must enroll with Anthem Blue Cross OR

• 5-100 F-T + FTE employees: 25% of the carve-out population must enroll with Anthem Blue Cross.

Documentation: • Union roster is required for identifying Union members AND

• Declinations are not required for Union employees waiving coverage (considered a valid waiver).

Blue Shield



Eligible Plans: All


Rules: • Total group size (union and non-union), must be 100 or fewer F-T + FTE employees AND

• 1-100 F-T + FTE employees must be enrolled and maintained with Blue Shield AND

• 1-5 eligibles: 65% of the carve-out population must enroll with Blue Shield OR

• 5-100 F-T + FTE employees: 25% of the carve-out population must enroll with Blue Shield.

• Since union members are considered valid waivers, Blue Shield will write owners only for a non-union

carve-out.

Documentation: • A copy of the collective bargaining agreement showing that the employer pays contributions to the trust

fund AND

• The statement of ERISA Rights form and the union trust fund Summary Plan Description.

BEERE&PURVES


Unique Groups

Carve-Outs

CaliforniaChoice



Eligible Plans: All



• 70% of the carve-out population must enroll with CaliforniaChoice.

Documentation: • Union employees must be marked “U” on the DE-9C.

• A Union billing statement must be reconciled against the DE-9C.


Cigna + Oscar



Eligible Plans: All



• 60% of the carve-out population must enroll with CaliforniaChoice.


• A Union billing statement must be reconciled against the DE-9C.


Covered CA for Small Business



Eligible Plans: All



• 70% of the carve-out population must enroll with Covered CA for Small Business.



Health Net



Eligible Plans: All



• 1-100 F-T + FTE employees must be enrolled and maintained with Health Net AND

• 1-5 eligibles: 66% of the carve-out population must enroll with Health Net OR

• 6-100: F-T + FTE employees 50% of the carve-out population must enroll with Health Net.

Documentation: • Union roster identifying union employees AND

• Collective Bargaining Agreement must be provided.


BEERE&PURVES


Unique Groups

Carve-Outs

Kaiser Permanente

Ineligible Types: Location; Management vs Non-Management; and Salary vs Hourly

Eligible Types: Union vs Non-Union

Eligible Plans: All

Guarantee Issue (GI): Yes, when all conditions listed below have been met

Rules: Total group size of eligible population must be 100 or fewer FT + FTE employees (union employees who are not

considered eligible are not counted under group size)

Documentation: Union Roster

UnitedHealthcare



Eligible Plans: All



• All included classes must meet participation guidelines for the class

Documentation: • Copy of the Union bill

• Letter from the group representative or broker, on employer letterhead, including:

• class description of the carve-out population;

• union employees must have medical coverage through their union

• Declinations are not required for union employees waiving coverage (considered a valid waiver)

BEERE&PURVES


Unique Groups

Consolidation of Companies

Aetna

To determine eligibility, the following conditions must be met:

• The same 5 or fewer owners must collectively hold controlling interest of 80% of all businesses needing to be consolidated OR

• Owner must file an Affiliation Schedule (Form #851) allowing for a combined tax return for all companies needing to be consolidated AND

• Complete Multiple Companies form or Associated companies form AND

• Employees must total 100 or fewer F-T + FTEs.

Anthem Blue Cross


• Letter from the company’s tax advisor (e.g. CPA, Attorney, Controller) certifying that all companies are affiliated and eligible to file consolidated tax

returns for State taxation AND


Blue Shield


• Copies of the Statement of Information or Articles of Incorporation reflecting all officers and owners OR

• Copies of all Partnership Agreements listing all partners’ names AND

• The employer’s CPA must provide a letter stating all business entities are eligible to file a combined tax return AND


CaliforniaChoice


• Each company must share a minimum of 50% common ownership AND

• Each company must have a related industry AND

• Each company must have at least 1 medically enrolled common-law employee who is not an owner or spouse of the owner AND

• Each company's home office must be located in California with a minimum of 51% of eligible employees residing in California AND

• Total number of employees, for all combined groups, may not exceed 100 F-T + FTEs.

Required Documentation:

• Employer must complete the Common Ownership Statement AND

• If less than 5 eligible employees enroll, proof of common ownership is required if the owner is not listed on the DE-9C.

Cigna + Oscar


• Letter from the company’s tax advisor (e.g. CPA, Attorney, Controller) certifying that all companies are affiliated and eligible to file consolidated tax

returns for State taxation AND




• Each company must have at least 1 medically eligible common-law employee who is not an owner or spouse of the owner AND

• Each company's home office must be located in California AND

• Total number of employees, for all combined groups, may not exceed 100 F-T + FTEs.

Required Documentation: A letter on company letterhead stating the companies are affiliated and eligible to file consolidated tax returns for state

taxation.

Health Net


• Letter from a CPA certifying that all companies are affiliated and eligible to file consolidated tax returns for State taxation AND


Kaiser Permanente


• Complete the employer eligibility question on the Employer application (sections 2A & 2B)

BEERE&PURVES


Unique Groups

Consolidation of Companies

UnitedHealthcare


• Common Ownership form AND

• Copies of the Statement of Information reflecting all officers and owners AND

• Copies of all Partnership Agreements listing all partners’ names AND

• The employer’s CPA must provide a letter stating all business entities are eligible to file a combined tax return AND


BEERE&PURVES


Unique Groups

PEO

Aetna

Exiting a PEO: • They must meet the definition of a Small Group employer AND

• Any group leaving a PEO must provide copy of the contract termination letter from the PEO to the client

containing the termination date AND

• Employer must provide 2 weeks of payroll established under their company name, not the PEO.

Remaining in a PEO: • Groups enrolled with a PEO in any type of co-employer relationship (benefits, workers’ comp, etc.) are not

eligible.

• Groups filing a DE-9C and using ‘payroll only services’ are eligible subject to meeting the standard

underwriting

• guidelines.

• Groups indicating they use payroll services must provide a copy of the De-9C or prior carrier bill to validate

they are not part of a PEO

Anthem Blue Cross

Exiting a PEO: • Group must provide a copy of the PEO chargeback invoice that has been billed to the group address. It

must include names of each previously leased employee AND

• Completed and signed Conditions of Enrollment form AND

• Within 45 days of approval, the group is required to provide 30 days of complete companywide payroll.

Remaining in a PEO: Anthem will not consider PEOs of this type.

Blue Shield

Exiting a PEO: • A copy of the letter sent from the PEO to the client business verifying the cancellation of the leasing

arrangement will be required AND

• If a copy of a payroll register from the PEO is submitted with the new group application, separating the

formerly leased employees by business location, the group will be considered a qualified group.

Remaining in a PEO: Blue Shield will not consider PEOs of this type.

CaliforniaChoice

Exiting a PEO: • An employer letter describing the PEO spin-off scenario including the group’s official split off date AND

• Groups with 1-4 enrolled must provide 4 weeks of payroll prior to the requested effective date, and groups

with 5+ enrolled must provide a minimum of one week of payroll from the new company and the balance

for the month due within 30 days of the effective date.

Remaining in a PEO: • Use verbiage from CaliforniaChoice’s PEO sub-group Letter to create an employer letter AND

• The Statement of Compliance portion of the Employer Application must be signed by an authorized

representative of the sub-group, not a PEO representative AND

• In lieu of a DE-9C, the group must submit a payroll ledger for the most current 3 months including group

company name, employee names, SS#s, wages, withholdings, and payroll salary information AND

• Home office must be located in California AND

• Address provided on the Employer Application must be the group’s physical location AND

• COBRA provisions must be based on the group’s group size, not the PEO’s group size AND

• FMLA provisions apply to a sub-group when the PEO is providing staffing services and when compliance

is determined by the PEO.

Cigna + Oscar

Exiting a PEO: • Employer letter requesting termination of PEO relationship or confirmation from the PEO that the group

has termed AND

• 2 weeks of companywide payroll

Remaining in a PEO: Cigna + Oscar will not consider PEOs of this type.


Exiting a PEO: Two (2) weeks of payroll

Remaining in a PEO: • 30 days of chargeback invoices AND

• The most recent PEO invoice matching payroll salary information AND

• Home office must be located in California

BEERE&PURVES


Unique Groups

Health Net

Exiting a PEO: • Group must submit the quarterly wage report prepared by the PEO. If the PEO does not prepare a

quarterly wage report for each employer, payroll (chargeback invoice) from the PEO may be submitted.

• First 2 weeks of payroll prepared by the employer or payroll company to verify they have severed the PEO

relationship.

• 6+ enrolling: at least 4 weeks of payroll (chargeback invoices) required.

• Less than 6 enrolling: payroll for 50% of the previous calendar quarter required.

Remaining in a PEO: See Exiting a PEO for information.

Kaiser Permanente

Exiting a PEO: • Must be 1-100 FTE

• Legal documentation to validate group qualifies for small group coverage.

• Letter on group letterhead or from the PEO explaining that it’s terminated its agreement with the PEO

• Copy of the group’s PEO payroll or invoices showing PEO subgroup name and employees for 2 weeks

Remaining in a PEO: • A Copy of the Group’s PEO chargeback invoices for the last 3 months, including the name of the leased

employees, OR

• For startup groups, Copy of the Group’s PEO invoices for the last 2 weeks including the name of the

leased employees

UnitedHealthcare

Exiting a PEO: 1-9 eligible:

• Will be considered for small group coverage with a coverage date on or after the termination date of the

PEO arrangement AND

• The employer group must meet the definition of an AB 1672/1083 employer and must have maintained 1-

100 employees for 50% of the previous calendar quarter or 50% of the previous calendar year to be

considered guaranteed issue AND

• The employer group must have offered the employees’ health insurance previously through the PEO AND

• A copy of the contract termination letter sent from the PEO to the client (employer) business. This letter is

generated by the PEO and verifies the cancellation of the leasing arrangement as well as the cancellation

date AND

• Prior carrier bill from the PEO with the employee census confirming prior coverage AND

• 2 weeks payroll from a legitimate payroll company. Payroll must be in the name and tax ID of the individual

group and not the PEO.

• If payroll is unavailable:

• 6 weeks of chargeable invoices

• Employer letter signed by officer stating that the company has cancelled its contract with the PEO

and the date of cancellation; approval is contingent on UHC receiving 30 days of payroll records for

all employees within 45 days of the effective date.

10+ eligible:

• Participation Certification form

Remaining in a PEO: • Contract must be entered into only with the “client company” (the employer group) of the PEO that meets

the definition of a small employer AND

• Only an officer of the client company may enter into, and sign, the insurance contract; it cannot be signed

by the PEO and/or PEO “co-employer” AND

• UnitedHealthcare must be the sole provider of health insurance AND

• If the employer group currently has UnitedHealthcare health coverage offered or sponsored through a

PEO that is covered as an active UnitedHealthcare mid-market group (ADP or Administaff, for example),

they will not be considered eligible for coverage as a separate small employer unless they terminate their

PEO relationship AND

• Payroll report must be provided from a legitimate payroll record service, issued in the name and tax ID

number of the individual employer group, and may not contain employees of any other PEO client

company.

• A small group employer that utilizes the services of the PEO for payroll purposes alone and the PEO

otherwise does not act as a “co-employer,” UnitedHealthcare will offer coverage to the small group client

company without requiring the employer to terminate their PEO contract.

BEERE&PURVES


Unique Groups

Spin-Off

Aetna

• Group must be a current Aetna group customer AND

• A letter from the group or broker indicating the group is enrolling as a spin off. Letter needs to include the name of the group they are spinning off

from AND

• Ownership documents showing that the company is a newly formed separate entity AND

• A minimum of 2 weeks payroll. If the group that is spinning off has been in business longer than 2 weeks, payroll will be required for amount of

time in business to a maximum of 6 consecutive weeks.

Anthem Blue Cross

• A spin-off is treated as a start-up AND

• A minimum of 30 days payroll is required within 45 days of requested effective date.

Blue Shield

• At least 50% of the employees in the spin-off group must have been enrolled in Blue Shield through the former business AND

• The new group does not have shared ownership with the business they have separated from AND

• All enrollment documents are required (master application, subscriber applications, refusals, business check, etc.) AND

• Ownership paperwork and eligibility verification for the owner is required AND

• A copy of the most recent payroll register is required. If no payroll register is available, a W-4 form for all employees will be initially required, with

subsequent submission of the first complete payroll register required within 30 days of the group’s effective date.

CaliforniaChoice

The first available effective date is the first of the month, on or following the group’s official split-off date. Employees from the original company can

maintain their original date of hire for the purposes of satisfying any waiting periods applied by the Employer.

Documentation Requirements:

• Letter from Employer, on company letterhead, describing the split-off scenario, including the official split-off date AND

• Payroll ledger (from business start date to current under the new company structure) should include:

(a) company name; (b) employee names; (c) employee wages; (d) employee wage withholdings; (e) wage summary totals; (f) run date.

• If less than one month of payroll is available, the balance for the month is due within 30 days of the effective date.

• Groups with less than 5 enrolling must have at least 1 eligible employee with 4 weeks of payroll.

Owner Eligibility requirements for each enrolling owner/partner (not listed on the payroll with at least a minimum wage salary):

If less than 5 medically enrolled, legal documents could be required by underwriting.

Cigna + Oscar

A spin off is treated as a new group and must meet all underwriting qualifications for a Small Group in order to be accepted for Cigna+Oscar coverage.


The first available effective date is the first of the month, on or following the group’s official split-off date. Employees from the original company can

maintain their original date of hire for the purposes of satisfying any waiting periods applied by the Employer.

• Two (2) weeks of company wide payroll

Health Net

• Prior carrier bill or ID cards for all employees (from the previous employer) AND

• Minimum of 4 weeks of payroll is required; with 2 weeks of payroll required prior to requested effective date of 4 weeks AND

• Ownership documents showing that the company is a newly formed, separate entity AND

• Letter from the group or broker, on company letterhead, indicating the group is enrolling as a spin-off.

If the group did not have coverage under the previous business entity, or if the majority of those enrolling were not employed by or did not have

coverage through the previous business entity, the group will not be considered for coverage.

Kaiser Permanente

• DE9C /payroll records of the original group to document employees

• 2 weeks of payroll

• Attestation form

UnitedHealthcare

• The group must be spinning off from a company whose medical coverage resides with UnitedHealthcare AND

• Despite being a newly formed business, they are not subject to 50% of the previous calendar quarter/year rule AND

• A letter from the employer, on company letterhead, stating their request to spinoff and their requested effective date AND

• Standard group submission and underwriting rules apply.

BEERE&PURVES


Legal Doc Guidelines

Sole Proprietor A Sole Proprietor is determined by the Social Security Number (SSN) on the Schedule C; always considered a single owner.

Aetna

• Current Schedule C must be submitted unless not available due to the length of time in business OR

• California Business License

Anthem Blue Cross


• California Business License OR

• Fictitious Business Name Filing.

Blue Shield

In business < 1 year


• Fictitious Business Name Filing

• When less than six (6) enrolling, group must show proof of compensation (draw checks).

• 25+ enrolled: Officer Affidavit

In business > 1 year

• Current Schedule C must be submitted unless not available due to the length of time in business.


Note: 5+ enrolled with prior carrier bill (less than 10% variance between enrollment and bill) and Eligibility/Participation Attestation form do not have to

provide owners compensation or ownership documentation

CaliforniaChoice

(if less than 5 medically enrolling)

• Schedule C (for preceding calendar year) OR

• Current California Business License OR

• Fictitious Business Name Filing dated prior to requested effective date.

Cigna + Oscar

• IRS Schedule C AND

• 1040 Form

Cigna+Oscar requires legal documents for groups with 2 or less enrolled.


In business < 3 months



In business > 3 months




Health Net

If < 25 enrolled

• Current Schedule C OR

• Fictitious Business Name Filing OR

• California Business License.

If > 25 enrolled

• Proof of Eligibility form.

Legal documents are listed in preferred order.

BEERE&PURVES



Sole Proprietor A Sole Proprietor is determined by the Social Security Number (SSN) on the Schedule C; always considered a single owner.

Kaiser Permanente

Kaiser Permanente requires a two-step validation:

Required to validate business

• Business License, OR

• Fictitious business name filing, OR

• Schedule C

Required to validate business ownership

• Business license (with owner’s name on the document)

• Fictitious business name filing

Schedule C

UnitedHealthcare


• 1-9 enrolling or family only groups: California Business License listing the owner’s name AND an IRS or Sec. of State letter indicating the issued

tax ID number.

• 10+ eligible: group must complete Participation Certification form.


• 1-9 enrolling or family only groups: IRS Schedule C (Form 1040)


Note: Groups comprised only of family members must provide separate tax documentation. A DE-9C may also be required with current legal and/or

tax documents if ownership is in question.


BEERE&PURVES



Corporations Corporations established out-of-state also require a Certificate of Qualification or Statement by Foreign Corporation.

Aetna

C-Corp:

• IRS form 1120

• Statement of Info (filed and stamped listing all officers)

• Articles of Incorporation (filed and stamped listing all officers)

S-Corp:

• IRS form 1120 S Schedule K with Schedule E

• Statement of Info (filed and stamped listing all officers)

• Articles of Incorporation (filed and stamped listing all officers)

Anthem Blue Cross

• Statement of Information (substitutes include a C-Corp Form 1120, S-Corp Schedule K-1 or 1120S, listing the names of all officers) OR

• Statement by Domestic Stock OR

• Articles of Incorporation filed and stamped listing names of all officers.

Blue Shield

In business < 1 year:

• Articles of Incorporation filed and stamped listing names of all officers OR

• Statement of Information, listing owners/offices with State Endorsement stamp AND



In business > 1 year:

• IRS Schedule K-1 (Form 1120s) for all enrolling Owners/Officers OR

• W-2.




CaliforniaChoice

(required if less than 5 medically enrolling)

• Statement of Information listing owners/partners with State Endorsement stamp prior to requested effective date OR

• Schedule E for preceding calendar year to include owners/partners name OR

• Articles of Incorporation with State Endorsement dated prior to requested effective date.

Cigna + Oscar

• Owner Affidavit

• IRS Schedule K-1 (Form 1120s) totaling 100%

• IRS Form 1120 (pages 1 & 2)

• IRS Form 1125-E OR IRS Schedule G

• Statement of Information filed and stamped listing all officers

Corporations established out of state will also need to provide a Statement by Foreign Corporation in addition to the above documentation.



In business < 3 months:

• Articles of Incorporation filed and stamped AND

• Corporate meeting minutes listing all officer’s names.

In business > 3 months:

• Statement of Information filed and stamped


BEERE&PURVES



Corporations Corporations established out-of-state also require a Certificate of Qualification or Statement by Foreign Corporation.

Health Net

If < 25 enrolled

• IRS Form 1120 listing all owners and percentage of stock owned OR

• Articles of Incorporation filed and stamped listing names of all officers OR

• Statement by Domestic Stock Corporation / Statement of Information (an unstamped document may be accepted with a printout from the

California Business Portal if at least one officer listed is also listed on the printout as the Agent for Service of Process. The signature date must

also be consistent with the filing date. Otherwise, the document must be stamped or contain a pre-printed file number from the State.) AND

• Statement of Designation by Foreign Corporation.

If > 25 enrolled

Proof of Eligibility form.

Kaiser Permanente


Required to validate business (domestic)

• Active web confirmation

Required to validate business ownership (domestic)

• Statement of Information

• Tax Form 1120 with Schedule 1125-E (for C Corporation)

• Schedule K-1 1120S (for S Corporation)

Required to validate business (foreign)


Required to validate business ownership (foreign)

• Statement and Designation by Foreign Corporation

• Statement of Information (foreign)

• Tax Form 1120 with Schedule 1125-E (for C Corp)

• Schedule K-1 1120S (for S Corp)

UnitedHealthcare

S-Corps and C-Corps In business <1 year:

• 1-9 enrolling or family only groups: Articles of Incorporation AND an IRS or Sec. of State letter indicating the issued tax ID number.


In business > 1 year (S-Corps):

• IRS Schedule K-1 (Form 1120s) for all enrolling and/or waiving Owners/Officers


• In business > 1 year (C-Corps):

• IRS Form 1120 (pages 1 & 2) AND IRS 1120 Schedule G AND IRS Form 1125E, which includes all owners. If 1120 does not list all owners, a

letter from CPA identifying owners and percent of ownership is required.


Note: Groups comprised only of family members must provide separate tax documentation. A DE-9C may also be required with current legal and/or tax

documents if ownership is in question. Non-Profit Corps must have a 940 or 941 to apply for coverage.


BEERE&PURVES



Partnerships

Aetna

• Current Schedule K–1 (1065 Partner's Return) OR

• Partnership Agreement and Federal Tax ID Appointment Letter

Anthem Blue Cross


• Partnership Agreement and Federal Tax ID Appointment Letter

Blue Shield


• Partnership Agreement filed and stamped and signed by all partners OR

• Business license OR

• DBA filing




• IRS Schedule K-1 (Form 1065) for each enrolling partner OR

• Tax extensions are not permitted




CaliforniaChoice


• Legal Notarized Partnership Agreement dated and notarized prior to the requested effective date OR

• Schedule K-1 (1065 Partner's Return) for preceding calendar year.

Cigna + Oscar

• IRS Schedule K-1 (Form 1120s) totaling 100% OR

• Partnership Agreement and Federal Tax ID Appointment Letter.

• Cigna+Oscar requires legal documents for groups with 2 or less enrolled.




• Federal Tax ID Appointment letter



• Partnership Agreement AND Federal Tax ID Appointment letter (if Schedule K-1 is not yet available)

Health Net

If < 25 enrolled

• Current Schedule K-1 (1065 Partner's Return) OR

• Statement of Partnership Authority OR

• Partnership Agreement; deemed acceptable per underwriter’s discretion OR

• Fictitious Business Name Statement listing both names OR

• Tax Certificate listing both names.

If > 25 enrolled



BEERE&PURVES



Partnerships

Kaiser Permanente



• Schedule K-1 (Form 1065), OR

• Statement of Partnership Authority (filed), AND

• General Partnership Agreement and Federal Tax ID, AND

• Appointment letter


• Schedule K-1 (Form 1065)

• Statement of Partnership Authority (filed)

• General Partnership Agreement and Federal Tax ID


UnitedHealthcare


• 1-9 enrolling or family only groups: Partnership Agreement filed and stamped and signed by all partners and an IRS or Secretary of State letter

indicating issued Tax ID



• IRS Schedule K-1 (Form 1065) for each enrolling and/or waiving partner OR

• Partnership Agreement signed by all partners if K-1 has not been filed





BEERE&PURVES



Limited Partnerships (LP) LPs established out-of-state also requires a Foreign Limited Partnership Application for Registration (form # LP-5) filed and stamped by the Secretary

of State.

Aetna


• Partnership agreement

Anthem Blue Cross



Blue Shield




• DBA filing









CaliforniaChoice




Cigna + Oscar

Limited partnerships are not written by Cigna + Oscar


Limited Partners of a LP are not eligible for coverage unless they appear on a DE-9C.

Health Net

If < 25 enrolled

• Schedule K-1 (1065 Partner's Return) OR

• Certificate of Limited Partnership OR


• Fictitious Business Name Statement showing both names OR

• Tax Certificate showing both names AND

• Foreign LP Application of Registration.

If > 25 enrolled


Kaiser Permanente






• Certificate of Limited Partnership

UnitedHealthcare

Limited Partnerships are not underwritten by UnitedHealthcare.


BEERE&PURVES



Limited Liability Partnership (LLP) LLPs established out-of-state also requires a Registered LLP Certificate of Registration (Form #LLP-1) filed and stamped by the Secretary of State.

Aetna


• Partnership agreement

Anthem Blue Cross



Blue Shield




• DBA filing









CaliforniaChoice




• Certificate of Limited Partnership with state endorsement stamp prior to the requested effective date.

Cigna + Oscar

• IRS Schedule K-1 (Form 1120s) totaling 100% OR





• Partnership Agreement OR

• Federal Tax ID Appointment letter


• Current Schedule K-1 (if Partners are not listed on the DE9C) OR

• Partnership Agreement and Federal Tax ID Appointment letter (if Schedule K-1 not available yet)

Health Net

If < 25 enrolled


• Registered Limited Liability Partnership Registration OR


• Fictitious Business Name Statement showing both names OR

• Tax Certificate showing both names AND

• LLP Certificate of Registration.

If > 25 enrolled



BEERE&PURVES



Limited Liability Partnership (LLP) LLPs established out-of-state also requires a Registered LLP Certificate of Registration (Form #LLP-1) filed and stamped by the Secretary of State.

Kaiser Permanente



• Schedule K-1 (Form 1065), OR

• State-certified application to register an LLP



• State-certified application to register an LLP

• Partnership Agreement and Federal Tax ID


UnitedHealthcare


• 1-9 enrolling or family only groups: Partnership Agreement filed and stamped and signed by all partners and an IRS or Secretary of State letter

indicating issued Tax ID


In business >1 year:

• IRS Schedule K-1 (Form 1065) for each enrolling and/or waiving partner OR

• Partnership Agreement signed by all partners if K-1 has not been filed





BEERE&PURVES



Limited Liability Corporation (LLC) LLCs established out-of-state also require a LLC Application of Registration (Form #LLC-5) filed and stamped by the Sec. of State.

Aetna

• IRS form 1040 with Schedule K-1 form 1065

• Statement of Information stamped and filed

• Articles of Organization (with Operating Agreement) stamped and filed

Anthem Blue Cross


• Statement of Information stamped and filed by state of California prior to the date required for GI OR

• Articles of Organization (with Operating Agrmt) stamped and filed by state of California prior to date required for GI

Blue Shield


• Articles of Organization (with Operating Agrmt) stamped and filed by state of California prior to date required for GI OR

• Statement of Information stamped and filed by state of California prior to the date required for GI.

• < 6 enrolling: groups must show proof of compensation (draw checks)




• Schedule C OR Schedule F




CaliforniaChoice



• LLC Statement of Info listing owners/partners with State Endorsement stamp prior to requested effective date.

Cigna + Oscar

• IRS Schedule K-1 (Form 1120s) totaling 100%

• Articles of Organization with Operating Agreement

LLC’s established out of state will also need to provide a Certificate of Qualification in addition to the above documentation.





• Statement of Information stamped and filed by state of California prior to the date required for GI.



• Current Schedule C (single member LLC) OR

• Articles of Organization (with Operating Agrmt) or Statement of Information (if Schedule K-1 or Schedule C are not yet available)

Health Net

If < 25 enrolled


• IRS Form 1120 listing all owners and percentage of stock owned OR


• Statement of Information (an unstamped document may be accepted with a printout from the California Business Portal if at least one officer listed

is also listed on the printout as the Agent for Service of Process. The signature date must also be consistent with the filing date. Otherwise, the

document must be stamped or contain a pre-printed file number from the State.) AND

• LLC Application of Registration.

If > 25 enrolled



BEERE&PURVES



Limited Liability Corporation (LLC) LLCs established out-of-state also require a LLC Application of Registration (Form #LLC-5) filed and stamped by the Sec. of State.

Kaiser Permanente





• Statement of Information (filed)

• Schedule C

• Schedule K-1 (1120S)


• Tax Form 1120 with Schedule 1125-E

UnitedHealthcare


• 1-9 enrolling or family only groups: LLC Operating Agreement signed by all managers/members/parties AND an IRS or Sec. of State letter

indicating the issued tax ID number.



• Copies of appropriate tax returns (requirements based on how LLC was formed see Partnership or Sole Proprietorship) OR

• LLC Operating Agreement signed by all managers/members/parties if tax documents have not been filed yet


Note: Groups comprised only of family members must provide separate tax documentation. A DE-9C may also be required with current legal and/or tax

documents if ownership is in question.


BEERE&PURVES


Legal Document Samples

BEERE&PURVES


Legal Document Samples

BEERE&PURVES


Contact us today at 888.722.3373

for assistance.