Get Answers To Questions About CalChoice

Broker

CaliforniaChoice is the TPA (Third Party Administrator) that has brought several insurance companies together to allow you and your employees the ability to select different plans of health coverage.

How does CaliforniaChoice solve the “Kaiser Permanente vs. PPO” split?

Brokers often face potentially losing a group sale because half of employees want HMO coverage from Kaiser Permanente (or another HMO) and other employees want PPO coverage. That’s not an issue when selling CaliforniaChoice because a group can have both.

Does CaliforniaChoice allow dual-carrier offerings for groups of 10 or fewer employees?

Many health plans require a certain percentage of all enrollees to be covered. That can mean a group ends up with only one plan choice. With CaliforniaChoice, groups can have members spread across multiple health plans and coverage types. Some employees may be enrolled in HMO or HSA coverage, while others are in a PPO plan. There’s no minimum for any plan type. This is a big differentiator for CaliforniaChoice – and one of many reasons why it continues to attract new membership even after 30 years of doing business.

Can each family member select a different Health Plan?

No, all family members must select the same Health Plan, but each member may choose a different Primary Care Physician (PCP). (i.e. Anthem Blue Cross, Health Net, Kaiser Permanente, Sharp, Sutter Health Plan, UnitedHealthcare, Western Health Advantage)

Will CaliforniaChoice help me save money?

Yes. We all know health insurance is expensive, but CaliforniaChoice helps ease the uncertainty of rising health care costs by allowing you to base your contribution on a specific plan. Each employee can still pick whatever plan best fits his/her individual needs. If there's a difference between the employer contribution and the cost of the coverage the employee selected, it's paid through payroll deduction. The result is, you set a fixed benefit budget, while employees have the flexibility to individually select the benefit plan and health plan they want.

Can I use CaliforniaChoice to move a group away from a Professional Employer Organization (PEO)?

Yes. CaliforniaChoice can be attractive to employers who may have previously affiliated with a PEO. CaliforniaChoice gives an employer the ability to control costs through Defined Contribution. And it gives employees more choice in what coverage they select for themselves or their families. A big plus with CaliforniaChoice is the employer does not give up management of employees. There’s no co-employment relationship.

What is the underwriting process for a group that has experienced some past “shocks” concerning health plan claims and escalating premiums?

All the plans offered by CaliforniaChoice are Affordable Care Act (ACA) compliant plans. That means they are not subject to full underwriting. Insurers cannot deny coverage, exclude pre-existing medical conditions, or charge higher premiums based on the health status of employees. All applicants must be accepted. Premiums are based solely on the applicant’s age, location, and family size. Tobacco use is a consideration in some states, but not in California.

Can any employee or dependent be denied health coverage due to health conditions?

No. In CaliforniaChoice, as with all small group health insurance, coverage is "guaranteed acceptance". This means your employees and their dependents cannot be turned down or their coverage dropped due to prior medical history or current health status. However, an employee or dependent may be denied only for failure to meet the eligibility requirements.

Can my employer group be cancelled because of too many claims?

No. An employer group can be canceled only for non-payment or non-compliance with policy rules.

How do CaliforniaChoice rates compare to Covered California for Small Business?

Covered California for Small Business is one of the state Marketplaces established as part of the federal Affordable Care Act signed into law in 2010. CaliforniaChoice is a private, multi-carrier exchange established in 1996 to help small businesses shop for health insurance for their employees. CaliforniaChoice allows employers to offer multiple health plans from different insurance companies through a single platform. Rates offered by insurers participating in Covered California and CaliforniaChoice are similar. However, a significant advantage offered by CaliforniaChoice is the broader range of plans and value-added benefits for which there is no additional premium. Covered California offers plans from Blue Shield of California, Kaiser Permanente, and Sharp Health Plan. CaliforniaChoice offers twice as many plans – and 100+ coverage choices. CaliforniaChoice health plans include Anthem Blue Cross, Health Net, Kaiser Permanente, Sharp Health Plan, Sutter Health Plan, UnitedHealthcare, and Western Health Advantage. Plan availability varies based on where employees live. Premiums are based on each applicant’s age, location, and family size. Health history and pre-existing conditions do not influence the rates for coverage.

Is out-of-state coverage available?

Yes. The employee must enroll in one of the Anthem PPO Prudent Buyer-Small Group benefit plans available to them (if any).

Will my employees and I be able to keep our current doctors?

Yes, if you select an HMO that your doctor is contracted with or if you elect a PPO Plan. If an HMO plan is chosen, benefits are payable only if HMO providers are used. A PPO plan gives employees incentives to use in-network doctors, but you may still choose to use out-of-network providers. Before you and your employees make a selection you will want to know the health plans in which your physician is a participant. For a listing of physicians and networks, go to the online provider directory

Do the plans cover prescription drugs?

Yes, all benefit plans include a variety of copayments for generic and brand name prescriptions.

How does CaliforniaChoice define a dependent?

A dependent is a spouse, a domestic partner, and/or child (must be born to, a stepchild or legal ward of, adopted by, or have an established parent-child relationship with the eligible employee, employee spouse or domestic partner) under the age of 26 (unless disabled, disability diagnosed prior to age 26).

When are children no longer considered eligible dependents?

A child is no longer eligible at the end of the month when he/she reaches an ineligible age based on their current benefit plan:

For Medical, Chiro, Vision and Dental, at the end of the month following 26th birthday.
For Ameritas Dental, at the end of the month following marriage or 26th birthday.

When should my employees choose dependent coverage?

It is very important to make the decision about who will be covered at the time the employee enrolls. After initial enrollment, an employee cannot add dependent coverage until the next renewal period, unless the employee has a qualifying/triggering "Life Event" (adoption, birth, marriage, domestic partner).

What if an employee just does not want health coverage?

An individual employee may decline coverage if he/she wishes; however, his/her dependents will not be able to enroll. In addition, the employee will not be able to enroll with CaliforniaChoice until the employer's next annual renewal period, unless the employee has a qualifying event (i.e. loss of other group coverage; proof must be provided). Remember, your company will still be required to meet all participation requirements to qualify for CaliforniaChoice coverage.

Waiving Coverage: It is extremely important that employees wishing to waive coverage complete the CaliforniaChoice Medical/Dental Waiver portion of the Enrollment Application advising them of their legal rights. Pursuant to the Knox Keene Act, Section 1357(d)(4)(A), employees wishing to waive coverage must execute a written waiver and Employers are required to maintain that waiver on file. Waivers may also be submitted to CaliforniaChoice at (714) 558-8000 for retention in our files.

What about my employees’ dependents? Do they have to be covered, and if so, does the employer have to pay for them?

Dependents do not have to be covered and there is no participation requirement for dependents. The employer is not required to pay for the coverage of any dependent. All CaliforniaChoice plans are available to dependents if elected by the employee. If you, the Employer chooses to contribute towards dependent coverage, the cost for dependent coverage can be payroll deducted from the employee's paycheck. The contribution level must be consistent for all employees since multiple contribution levels are not allowed.

After initial enrollment, an employee cannot add dependent coverage until the next renewal period, unless the employee has a qualifying/triggering "Life Event" (adoption, birth, marriage, domestic partner).

Who is the Group Plan Administrator?

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

Is there a monthly administration fee?

Yes. An administration fee based on number of covered employees as such:

Up to 8 = $30
9–50 = $40
51+ = $50

In addition to the monthly administrative fee which is added to your invoice, the premium amount includes commissions and other fees

How is CaliforniaChoice remunerated for the services it provides?

CaliforniaChoice is remunerated by the monthly administrative fee.

What materials will I receive once I am enrolled?

Upon enrollment, the employer group will receive a welcome kit from CaliforniaChoice confirming your effective date and containing administrative instructions, providing you complete information on how to administer your health insurance throughout the year. Also, the health plans you and your employees select will send information to your office or your employees' homes.

This information explains benefits and exclusions, information on the network of providers (if applicable); instructions on how to use the health plan and benefit plan selected and an identification card.

What tools are available to brokers to help sell the CaliforniaChoice private exchange?

CaliforniaChoice was developed by brokers. It is available exclusively to employers through brokers. No direct business is accepted. CaliforniaChoice provides brokers with a range of sales tools designed to make conversations with clients easier and more effective. Brokers can access value proposition videos that showcase the advantages of the private exchange, as well as print materials including brochures, program highlights, and overview flyers. In addition, our sales representatives are available to support brokers during prospecting and renewal meetings to help answer questions and reinforce the value of CaliforniaChoice.

Are there new business bonuses available on any CaliforniaChoice plans?

CaliforniaChoice and our ancillary exchange partner, ChoiceBuilder, as well as our health plan partners, do periodically offer incentives on some new business sales. Ask your CHOICE Administrators representative about what offers may be currently available.

Can I protect my book of business from direct carrier solicitation using CaliforniaChoice?

The unique benefits of CaliforniaChoice can help brokers minimize the likelihood an employer will be persuaded to leave the program and move to another carrier. CaliforniaChoice offers cost control for employers and well as unparalleled flexibility and freedom of choice for members. When employees are happy, employers are more likely to maintain and renew their CaliforniaChoice coverage.

How do I get CaliforniaChoice if I am already working with individual carriers?

To become a CaliforniaChoice broker, you’ll need a valid California Department of Insurance (DOI) license. If you don’t have a current valid license, visit the DOI website for information about required pre-licensing training, testing, and the broker application process.
If you are already licensed, it’s easy to get started with CHOICE Administrators. Reach out to our Sales Department at 800-542-4218. Or visit our Broker Support page for more information. We’ll help you with new broker paperwork.

Employer

Who/What is CaliforniaChoice?

CaliforniaChoice is the TPA (Third Party Administrator) that has brought several insurance companies together to allow you and your employees the ability to select different plans of health coverage.

Is there a minimum number of employees required to start a CaliforniaChoice plan?

CaliforniaChoice requires a minimum of one employee (not including the business owner or their spouse/domestic partner). For groups of one or two employees, 100% participation is required. For groups of 3-100 employees, 70% of eligible employees must enroll. The employer’s executive office must be in California. At least 51% of eligible employees must reside in California.

How can I offer Kaiser Permanente and Anthem Blue Cross at the same time without two invoices?

One of the many benefits of CaliforniaChoice is streamlined administration. The program offers seven health plans and 100+ coverage options. But no matter how plans are selected by your employees, you get just one monthly bill. It shows all employees’ coverage, the premium, your contribution, and the employees’ deductions. The invoice can easily be paid online at calchoice.com. Or you can set up auto-pay to pay it electronically each month.

What is Defined Contribution, and how can it stop my health insurance costs from rising?

Defined Contribution is the foundation of the CaliforniaChoice program. It allows you to choose the amount you want to contribute to your employees’ benefits. You can choose a Fixed Percentage of cost (50% to 100%) of a selected Tier, Health Plan, and Benefit Level, all plans, or the lowest-cost plan. The amount you select applies to all employees and it is locked in for 12 months until your renewal. At that time, you can adjust your contribution – up or down – and lock down your costs for another year. While costs could increase, you are able to control expenses for your business using CaliforniaChoice.

Will CaliforniaChoice help me save money?

Does my business qualify for a Small Business Health Care Tax Credit if I choose coverage through CaliforniaChoice?

The Small Business Health Care Tax Credit helps small businesses (those with fewer than 25 full-time equivalent employees) pay for health insurance. It is available exclusively to employers that pay at least 50% of employee premiums through Covered California for Small Business. It offers a tax credit of up to 50% (35% for non-profits) of employee premium costs. Average employee salaries must be about $65,000 annually or less. This is a sliding scale tax credit, with the greatest benefit available to employers with 10 or fewer workers. The smaller the business, the bigger the tax credit. For additional information, visit HealthCare.gov.

Is CaliforniaChoice better for my business than a Level-Funded plan?

Level-Funded health plans blend self-insurance and fixed premiums. They offer predictable monthly costs with the potential for a refund if your group has reduced claims. That could be advantageous for employers with a healthier population, but it could pose a risk for others. To avoid higher risks, employers with Level-Funded plans often buy stop-loss insurance (at an additional cost). This caps the employer’s liability even if employees have high claims costs.
A Defined Contribution plan like CaliforniaChoice offers employees traditional health insurance while giving employers more predictability with regard to premiums. The employer chooses the Defined Contribution, which employees use toward their preferred health plans. The employer’s financial exposure is limited to the amount being contributed to employees’ coverage. Companies with diverse employee needs that want to provide more choices for employees may prefer a Defined Contribution plan because of reduced administration.

How do I lower my group’s premiums without losing access to my employees’ favorite doctors?

Employers can control their costs using Defined Contribution, while delivering real choice to employees. With CaliforniaChoice, employees have access to 100+ coverage options. These include PPO, HMO, and HSA-qualified coverage options. Seven carrier and health plan choices. Anthem Blue Cross, Health Net, Kaiser Permanente, and UnitedHealthcare statewide. Sharp Health Plan, Sutter Health Plan, and Western Health Advantage regionally. Your choices are based on where you and your employees live. This broad range of carriers and plan choices means you’ll have greater access to doctors, specialists, and hospitals.

Will my employees and I be able to keep our current doctors?

Can I offer different benefit tiers to management and hourly staff?

With CaliforniaChoice, you don’t need to offer different tiers of coverage to different employee groups. The program offers participants access to all four Affordable Care Act (ACA) tiers: Bronze, Silver, Gold, and Platinum. Each tier offers a different percentage of shared health care costs, ranging from 10% to 40% (with the health plan paying the other 90% to 60%). This can significantly increase the number of plans, doctors, and specialists available to you and your employees.

Can each family member select a different Health Plan?

Can any employee or dependent be denied health coverage due to health conditions?

Do the plans cover prescription drugs?

Yes, all benefit plans include a variety of copayments for generic and brand name prescriptions.

Can my employer group be cancelled because of too many claims?

No. An employer group can be canceled only for non-payment or non-compliance with policy rules.

What about my employees’ dependents? Do they have to be covered, and, if so, does the employer have to pay for them?

How does CaliforniaChoice define a dependent?

When are children no longer considered eligible dependents?

A child is no longer eligible at the end of the month when he/she reaches an ineligible age based on their current benefit plan:

For Medical, Chiro, Vision and Dental, at the end of the month following 26th birthday.
For Ameritas Dental, at the end of the month following marriage or 26th birthday.

When should my employees choose dependent coverage?

What if an employee just does not want health care coverage?

What if I have employees living in different counties across California or out of state?

Whether your employees are local, spread across California, or partially out of state, CaliforniaChoice will work for you. Members can choose from seven health plans – four operating statewide and three regional choices. One of our statewide plan partners is Anthem Blue Cross, who offers a variety of HMO and PPO plans. Many of the PPO plans are also available to out-of-state employees.

Is out-of-state coverage available?

Yes. The employee must enroll in one of the Anthem PPO Prudent Buyer-Small Group benefit plans available to them (if any).

Who is the Group Plan Administrator?

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

How much time will it take to manage CaliforniaChoice monthly?

CaliforniaChoice simplifies administration for you, your team, and your employees. Whether you have one employee, 20, 60, or 100, you’ll get a single, consolidated monthly bill. It lists all employees, their coverage levels, your contribution, and employee payroll deductions. Plus, you can pay your bill and easily manage employees’ benefits online at calchoice.com.

Is there a monthly administration fee?

Yes. An administration fee based on number of covered employees as such:

Up to 8 = $30
9–50 = $40
51+ = $50

In addition to the monthly administrative fee which is added to your invoice, the premium amount includes commissions and other fees.

How is CaliforniaChoice remunerated for the services it provides?

CaliforniaChoice is remunerated by the monthly administrative fee.

What materials will I receive once I am enrolled?

How do I get a CaliforniaChoice quote without talking to a salesperson?

If your group is already enrolled in CaliforniaChoice, you can get a new hire quote via the employer portal on our website.

If you do not have insurance through CaliforniaChoice, you can request a quote using the MyCalChoice website. One of our broker partners licensed in California will work with you to create a custom quote.

Employee

Who/What is CaliforniaChoice?

CaliforniaChoice is the TPA (Third Party Administrator) that has brought several insurance companies together to allow you and your employees the ability to select different plans of health coverage.

Who is my Health Plan?

Your Health Plan is the participating insurance company you selected under the CaliforniaChoice program to provide your health care. (i.e. Anthem Blue Cross, Health Net, Kaiser Permanente, Sharp, Sutter Health Plan, UnitedHealthcare, Western Health Advantage)

Can I keep my current doctor if my company switches to CaliforniaChoice?

It’s highly likely. CaliforniaChoice features a broad range of health plans and provider networks. There are four health plans available statewide: Anthem Blue Cross; Health Net; Kaiser Permanente; and UnitedHealthcare. There are also three health plans operating regionally: Sharp Health Plan (in San Diego and Imperial counties); Sutter Health Plan (in Northern California), and Western Health Advantage (also in Northern California). Each plan offers a variety of coverage choices; a dozen provider networks are available across our roster of plans. Your current doctor is likely a part of one of these networks.

Will my employees and I be able to keep our current doctors?

How do I compare plan benefits if my employer gives me multiple plan options?

One of the many advantages of CaliforniaChoice is that it allows members to find a plan that best fits your individual or family health care needs. We offer HMO, PPO, and Health Savings Account-qualified plans. What works for you may differ from your coworkers, but we give you the choice. We also have an online plan comparison tool to help you review plans not just based on your premium, but also on costs, benefit type, and quality. You can also use our online provider search tool to find plans associated with your favorite doctor, search for a new doctor, or review plans based on Affordable Care Act metal tier, or hospital and provider network affiliations.

What is the difference between an HMO and PPO in the CaliforniaChoice portfolio?

Across all health plans, CaliforniaChoice includes dozens of choices. In 2026, you can choose from 4 PPOs and 8 HMOs in the Bronze metal tier. In the Silver tier, you can choose from 5 PPO and 21 HMO plans. There are 6 PPO and 38 HMO choices in the Gold tier. At the Platinum tier level, members have one PPO and 30 HMO options available. In 2027, these numbers could change. Contact our Customer Service Center by telephone at 800-558-8003 or via email CustomerService@CalChoice.com, for the latest plan and tier info.

How do I find the “cheapest” plan in the CaliforniaChoice program?

During your group’s open enrollment, you will receive a personalized enrollment worksheet clearly showing the premium for each option available to you. This includes the total premium, and the share that you will pay for your selected plan. Your worksheet will also highlight the benefits of each plan, including specific plan information like in-network and out-of-network copays, Rx benefits, and deductibles.

Can I choose a plan based on a specific hospital like Cedars-Sinai or Hoag?

You can. Our online Provider Directory lets you search for a provider based on your ZIP Code, physician’s gender, or carrier affiliation. You can filter further based on physician name, specialty, distance, spoken language, health plan metal tier, plan type (PPO or HMO), hospital, and Medical Group/IPA

Can each family member select a different Health Plan?

Do the plans cover prescription drugs?

Yes, all benefit plans include a variety of copayments for generic and brand name prescriptions.

Are virtual doctor visits (telehealth) a part of the CaliforniaChoice program?

Telehealth is an increasingly popular benefit offered by the health plans in the CaliforniaChoice program. Specific benefits vary by plan type. Many participating insurers provide dedicated virtual care platforms. Through your health plan’s member portal, you or a covered family member can log in and schedule a virtual visit. You can also contact the CaliforniaChoice Customer Service team for details. Call 800-558-8003 or send an email to CustomerService@calchoice.com.

Can any employee or dependent be denied health coverage due to health conditions?

Can my employer group be canceled because of too many claims?

No. An employer group can be canceled only for non-payment or non-compliance with policy rules.

Can I add coverage for my spouse, domestic partner, or dependents through my employer’s CaliforniaChoice plan?

You can add coverage for a spouse, domestic partner, or children to your plan. Cost will be based on their age at the time of application.

How does CaliforniaChoice define a dependent?

When are children no longer considered eligible dependents?

A child is no longer eligible at the end of the month when he/she reaches an ineligible age based on their current benefit plan:

For Medical, Chiro, Vision and Dental, at the end of the month following 26th birthday.
For Ameritas Dental, at the end of the month following marriage or 26th birthday.

When should my employees choose dependent coverage?

How do I switch my plan if I have a “life event” like having a baby or getting married?

If you experience a Qualifying Life Event, you have 60 days to update your CaliforniaChoice coverage. Log into the CaliforniaChoice member portal to initiate your change. Or contact CaliforniaChoice Customer Service at 800-558-8003 for assistance.
Qualifying events can include household changes like marriage, divorce, legal separation, or death of an insured person. Birth, adoption, legal separation, or becoming a foster parent also qualify. Other reasons for change can be losing employer-sponsored insurance or loss of government health coverage. Moving to a new ZIP Code or an area where your current health plan’s network is unavailable also makes you eligible to select a new health plan.

When is my company’s annual Renewal?

Your company's annual Renewal period is usually two months prior to the anniversary date (your company's initial effective date). All changes made during annual Renewal are effective on the company's anniversary date. Check with the Group Plan Administrator for the exact date.

What if I work in California but live in another state? Will I still be covered?

Your health plan availability is determined by where you live, even if your employer is based in California and you reside elsewhere. Your enrollment worksheet will show your plan choices.

Is out-of-state coverage available?

Yes. The employee must enroll in one of the Anthem PPO Prudent Buyer-Small Group benefit plans available to them (if any).

What materials will I receive once I am enrolled?

Will I get one ID card or multiple ID cards if I choose Medical, Dental, and Vision?

Members receive a welcome kit from CaliforniaChoice and a health plan ID Card for their selected coverage from the insurer.

What is a copayment?

The amount the member must pay for medical services (doctor visits, drug prescriptions, hospitalizations, etc.).

Who/What is my Primary Care Physician?

A Primary Care Physician can be a family practitioner, internist, or pediatrician. At the time of enrollment, you may have selected (or been assigned) a Primary Care Physician for yourself and each dependent. The Primary Care Physician coordinates all health care and medical needs including basic care, preventive services, referrals to specialists, and hospitalization arrangements.

Can each family member select a different Primary Care Physician?

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

Can I change my Primary Care Physician?

Yes, contact your Health Plan's Member Services Department using the phone number on your medical I.D. card. Some plans may allow you to change your PCP through their website. (some restrictions may apply)

What if I need to see a specialist?

Under the HMO plans, your Primary Care Physician, in consultation with a contracted IPA or Medical Group, will determine the proper treatment and make referrals to specialists when necessary. A change in Primary Care Physician or Health Plan could cause a problem if you are in the middle of treatment with a specialist.

If hospitalization is necessary, what hospital will I use?

Primary Care Physicians work with specific hospitals; check your I.D. card, the provider directory or ask your Primary Care Physician. In an emergency situation, always go to the nearest available hospital.

What if I need to see a doctor while away from home?

If you are away from home and cannot see your Primary Care Physician, you will only be covered for emergency treatment that is medically necessary. Contact your Primary Care Physician first to obtain authorization. If you are unable to get in touch with your Primary Care Physician, contact the Health Plan's Member Services Department on your I.D. card.

What if I have an emergency situation?

In the event of any emergency, contact your Primary Care Physician first. Depending on the nature of the emergency, your physician will either: help over the phone; make an appointment for you to come in as soon as possible; or make a referral to an emergency room or urgent care facility. If the emergency is life threatening, such as a heart attack, or is critically serious, such as a broken leg, go directly to the nearest medical facility.
However, you (or a family member) must contact your Primary Care Physician within 24 hours. If you are unable to get in touch with your Primary Care Physician, contact the Health Plan's Member Services Department on your I.D. card.

What if I receive a bill?

Although you should not receive bills for medical care provided or approved by your Primary Care Physician, you may receive a bill in error. In that event, contact your Health Plan's Member Services Department on your I.D. card for assistance.

What if medical services are needed before permanent I.D. cards are received?

The member should present his/her temporary I.D. card to the Primary Care Physician he/she selected for services. The physician's office may then contact CaliforniaChoice who will assist with verifying coverage.

What if a prescription is needed before permanent I.D. cards are received?

The member should make sure the pharmacy they wish to use works with their Health Plan. The member will need to pay the full amount of the prescription up front, but may request reimbursement by retaining the paid receipt and contacting the Member Services Department of their Health Plan.

What if a prescription is needed before permanent I.D. cards are received?

The member should make sure the pharmacy they wish to use is contracted with their health plan. Some plans require a deductible be met prior to prescription copays. The member will need to pay the full amount of the prescription up front, but may request reimbursement by retaining the paid receipt and calling the Health Plans Member Services Department after his/her permanent I.D. card has been received.

If hospitalization is necessary, what hospital will I use?

The accredited hospital you choose to use is up to you, but remember medical services will be covered at a greater percentage at those hospitals listed in the network. Check with your Health Plan's Member Services Department if you are unsure if the hospital you are considering is a provider in the network for your Health Plan. In an emergency situation, always go to the nearest available hospital.

What is a copayment?

The copayment is the amount the insured/member must pay for dental services.

May I or my dependents obtain DHMO MET100, MET185, SmileSaver 1000 & 3000 coverage but not be enrolled in the medical program?

Yes.

Can each family member go to a different dental office?

Yes, each family member can go to a different dental office/dentist. If you and/or your dependents would like to change your dental office/dentist, contact Customer Service Department at (800) 880-1800.

What if I receive a bill?

Although you should not receive bills for dental care provided or approved by your dental office, you may receive a bill in error. Contact the Customer Service Department at (800) 880-1800 for assistance.

Employee Continued

May I or my dependents obtain PPO 3000, PPO 3500, PPO 4000, or PPO 5000 coverage but not be enrolled in the medical program?

Yes.

Can each family member go to a different dental office?

Yes, each family member can go to a different dentist each time they seek service.

What if I need to see a dentist while away from home?

You are not restricted to see any specific dentist. However, the benefits will be covered at a lower amount for major services provided by a non-contracting dentist.

What if I receive a bill?

If you take your dental claim form with you to your dental visit, the dentist will generally complete all the paperwork and send you a bill only for the amount you are responsible to pay.

My Employer chose the PPO 5000 (without the orthodontia option). Can I enroll in the PPO 5000 and add the orthodontia option?

No, the orthodontia option must be elected by your Employer.

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