Get Answers To Questions About CalChoice

General

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 the Group Plan Administrator?

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

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, Cigna + Oscar, Health Net, Kaiser Permanente, Sharp, Sutter Health Plus, UnitedHealthcare, Western Health Advantage)

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, Cigna + Oscar, Health Net, Kaiser Permanente, Sharp, Sutter Health Plus, UnitedHealthcare, Western Health Advantage)

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.

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.

Do the plans cover prescription drugs?

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

What if an employee just does not want health care 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.

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.

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.

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 26^th birthday
For Ameritas Dental, at the end of the month following marriage or 26^th birthday.

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.

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).

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 .

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.

Is out-of-state coverage available?

Yes. The employee must enroll in one of the Anthem PPO or Cigna + Oscar EPO benefit plans available to them (if any).

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.

HMO Plans

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.

PPO Plans

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.

Dental DMHO MET100, MET185, SmileSaver 1000 & 3000

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.

Dental PPO 3000, PPO 3500, PPO 4000, and PPO 5000

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.

Additional Questions?

For additional questions about eligibility, enrollment, COBRA plans, administrative or customer services issues, please call our Customer Service Center at 800-558-8003 Monday through Friday 8:00 am. – 5:00 pm or e-mail us at CustomerService@Calchoice.com, and a CaliforniaChoice specialist will be glad to assist you.

For referral to a broker in your area call CaliforniaChoice at 888-542-4218.

CaliforniaChoice is dedicated to helping insure California small businesses. We look forward to serving you with quality, affordable health care choices.

Support

General

HMO Plans

PPO Plans

Dental DMHO MET100, MET185, SmileSaver 1000 & 3000

Dental PPO 3000, PPO 3500, PPO 4000, and PPO 5000

SUPPORT

Address

Office Hours

Customer Service

Sales

Department of Insurance License

SUPPORT

Address

Office Hours

Customer Service

Sales

Department of Insurance License