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Why Choose Health Net?
✔ Lowest rates in the market – Affordable options without compromising quality.
✔ Robust PPO network – Competes with major carriers like Anthem and Blue Shield.
✔ Flexible HMO options – Networks to fit nearly every group statewide and every budget.
✔ Simplified underwriting – Only 25% participation required for groups with 5+ enrolling. No DE9C or prior carrier bill needed.
✔ Easy-to-sell benefits – $0 deductible HMO plans + four years of rate stability.
✔ Nationwide coverage – Cigna network access for out-of-state employees + state plurality rules for group qualification.
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Login To PrismBlue Shield of California provides comprehensive health plans for small businesses with high-quality, accessible, and affordable healthcare for employees. Key Q3-2025 updates are outlined below.
Relaxed Participation Program
Small Business Incentive Program
Specialty Bundled Savings Program
The 10% specialty discount is a perpetual program that applies to the dental and/or vision premiums when these plans are added to a new or existing small business medical group. Learn more.
Questions?
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Article last updated: March 4, 2025.
Most of your clients have upcoming deadlines under the federal prescription drug benefits reporting (RxDC) requirements. Here’s a summary of the requirements, carrier support initiatives, and critical submission deadlines to ensure timely compliance.
Under Section 204 of the 2021 Consolidated Appropriations Act (CAA), insurance companies and employer-based health plans must submit information regarding prescription drug benefits and health care spending. The information must be submitted to the Centers for Medicare and Medicaid Services (CMS) by June 1st of each year for the prior year’s coverage.
The CMS requires the following information be submitted by insurance companies and employers:
Anthem will follow the same process as in prior years and will file on behalf of their fully insured and ASO clients for the benefits they administer and maintain. This includes ASO groups who opt-in to the D1 reporting. To submit all required information and ensure reporting accuracy, they will request some information from their clients.
Week of February 17th – Large Group, Small Group, and National Account clients were notified about required RxDC filings and necessary actions.
Early June 2025 – RxDC Filing Confirmation
For more information, please visit Anthem’s CAA/Transparency Resource Center.
Blue Shield will collect D1 Premium Contribution data from groups between February 19, 2025 and April 19, 2025. Blue Shield will also submit D2 for all groups and D3-D8 for groups with prescription drug benefits under a Blue Shield health benefit plan. If a group does not have prescription drug benefits with Blue Shield, they should coordinate submission of D3-D8 with their pharmacy/prescription drug benefits carrier.
Key Details
Who Needs to Submit The Survey?
Any group (or broker/delegate on behalf of the group) who would like Blue Shield to submit D1 Premium data on their behalf to the CMS. This includes:
Third-Party Administrators (TPAs) and Pharmacy Benefit Managers (PBMs) may assist in reporting. Groups that miss the deadline will not be included in Blue Shield’s filing and may be subject to non-compliance if they do not report the required data directly to the CMS by the June 1, 2025 deadline.
Other Details
Information Requested
Health Net will not require any data from employer groups to complete Plan List (P2) and Data File (DI) submissions with the CMS on behalf of their clients. No action or any fees are required by employer groups or brokers. This includes groups with members enrolled in Health Net through CaliforniaChoice.
Fully insured employer groups will need to complete the Kaiser Permanente RxDC data collection form by March 31, 2025.
Information Requested
Self-funded groups: Kaiser Permanente representatives will reach out to each self-funded group, via email, with instructions and offline forms that will be prepopulated with the group’s information along with blank fields for the group to complete and return to Kaiser Permanente.
Specific CA Small Groups: Covered California for Small Business (CCSB) and CaliforniaChoice groups do not need to complete the form as these exchanges will be providing the needed data for all the employers they serve, aggregated at the exchange level, to Kaiser Permanente.
Kaiser Permanente plans to submit all applicable reports and required responses for all employer groups to CMS by the June 1, 2025 deadline. To learn more, view the Kaiser Permanente RxDC FAQs.
Sharp Health Plan will request employer contribution data via a Request for Information (RFI) survey and will file on behalf of the group. Deadline: April 18, 2025.
UnitedHealthcare will complete the CAA Prescription Drug (RxDC) reporting for its fully insured and self-funded/level funded groups, including those with OptumRx as the integrated PBM. However, groups with these will need to complete the Request for Information (RFI) tool for RxDC reporting between February 1, 2025, and March 31, 2025.
To support its customers with this important filing, UnitedHealthcare will be submitting the P2 (Group Health Plan), D1 (Premium and Life Years) and D2 (Spending by Category) files for all employers who had active coverage during the reference year (2024). However, completion of the submission requires gathering some information not currently maintained in their system.
UnitedHealthcare will also submit the D3-D8 data files for customers with OptumRx as an integrated PBM. UnitedHealthcare has access to all data required to complete the submission of the D3-D8 data files. Customers who use any other PBM, including OptumRx Direct, must work with that PBM to submit the D3-D8 files.
Resources
Western Health Advantage will request employer contribution data via a Request for Information (RFI) survey and will file on behalf of the group. Deadline: April 15, 2025.
Covered California for Small Business (CCSB) serves as an administrator of their participating Health Plan Issuers and is not an insurance company nor an employer-based health plan. Therefore, CCSB is not subject to RxDC data collection requirements on behalf of their employer groups. Claremont recommends that the employer follow the reporting guidelines for the enrolled carrier(s).
CCSB’s Small Business Service Center is available to help with questions at 855.777.6782.
CaliforniaChoice serves as an administrator of their participating Health Plan Issuers and is not an insurance company nor an employer-based health plan. Therefore, CaliforniaChoice is not subject to RxDC data collection requirements on behalf of their employer groups.
Like last year, CaliforniaChoice is facilitating the RxDC for its employers and their plans for the 2024 reference year (reporting due June 1, 2025). CaliforniaChoice will coordinate directly with their carriers to facilitate all reporting obligations. There is no action required from the employer.
The carriers are actively assisting your clients with federal reporting compliance and will require specific information from each employer group. Watch for direct communication from the carriers and follow their instructions. If you or your clients need assistance we can connect you with appropriate carrier representatives.
Questions?
Contact The Answer Team at 800.696.4543 or info@claremontcompanies.com.
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Blue Shield of California will soon distribute its annual Medical Loss Ratio (MLR) Employer Survey to small business groups with fewer than 150 employees. This important survey, mandated by the Affordable Care Act (ACA), must be completed by March 31, 2025. The survey helps Blue Shield calculate whether premium rebates are due to members based on the percentage of premium dollars spent on medical care rather than administrative costs.
Employers Must Provide:
The information collected helps determine if Blue Shield of California met its MLR requirements for 2024. If the carrier didn’t meet the minimum threshold for spending premium dollars on medical care, rebates would be issued to affected customers by September 30, 2025.
It’s important to understand that while the survey collects 2023 information, it’s used for statistical sampling purposes to calculate potential 2024 MLR rebates.
To learn more about the MLR survey process and requirements, please review the Blue Shield of CA Broker Alert and MLR FAQs.
Questions?
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In the face of the devastating wildfires in Southern California, Blue Shield of California is ensuring members retain access to critical medical resources and services, including:
Blue Shield of California is here to support members through the hardships of wildfires, offering help, hope, and access to care they need during this challenging time.
For more details on available resources, members can visit Blue Shield’s website or contact customer service directly using the number on their Blue Shield ID card or 800.393.6130.
Questions?
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In a historic milestone for Blue Shield of California, Lois Quam has been appointed CEO, becoming the first woman to lead the organization in its 86-year history. She joined the company as president in 2024 after serving as CEO of Pathfinder and brings decades of leadership experience, including a position at the U.S. Department of State, where she led the Global Health Initiative.
Renowned for her vision and ability to address complex challenges, Quam is well-prepared to guide Blue Shield toward its mission of delivering accessible and equitable healthcare to all Californians. Her leadership is expected to usher in a period of innovation, collaboration, and meaningful change, advancing the organization’s goal of improving health outcomes across the state.
To further enhance and improve access to care for its nearly six million members, Blue Shield has established a new nonprofit corporate entity named Ascendiun, which became effective January 1. Paul Markovich, who served as Blue Shield’s CEO for 12 years, has been named president of Ascendiun. These strategic changes highlight Blue Shield’s unwavering commitment to delivering quality, affordable healthcare for all Californians. Learn more.
Questions?
Contact The Answer Team at 800.696.4543 or info@claremontcompanies.com.
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Blue Shield of California offers tailored, comprehensive health benefits for small businesses, ensuring high-quality, accessible, and affordable healthcare for employees. Below are the key updates for Q2-2025.
Reminder: Blue Shield withdrew three dental plans effective January 1, 2025:
For more information, refer to the Q2-2025 Blue Shield Specialty Sales Guide.
The Relaxed Participation Program has been extended through December 31, 2025.
The 10% specialty discount is a perpetual program that is applied to the dental and/or vision premium when a dental and/or vision plan is added to a new or existing small business medical group. Learn more.
Questions?
Contact The Answer Team at 800.696.4543 or info@claremontcompanies.com.
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Blue Shield of California remains committed to providing small businesses and their employees with accessible, affordable, high-quality health benefits. Below is a summary of the 2025 updates to the pharmacy program and Tandem network.
As part of the Pharmacy Care Reimagined initiative, Blue Shield is implementing several pharmacy updates for 2025, including:
The 10% specialty discount is a perpetual program that is applied to the dental and/or vision premium when a dental and/or vision plan is added to a new or existing small business medical group. Learn more.
The Relaxed Participation promotion has been extended through December 31, 2025.
Questions?
Contact The Answer Team at 800.696.4543 or info@claremontcompanies.com.
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Blue Shield of California continues to deliver comprehensive health benefits tailored to the needs of small businesses and their employees – offering healthcare that is accessible, affordable, high quality, and universal. Here’s a summary of the changes for 2025.
The 10% specialty discount is a perpetual program that is applied to the dental and/or vision premium when a dental and/or vision plan is added to a new or existing small business medical group. Learn more.
The Relaxed Participation promotion has been extended through December 31, 2025.
Questions?
Contact The Answer Team at 800.696.4543 or info@claremontcompanies.com.
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Miss the Q1-2025 Blue Shield Small Business Broker Roadshow? Watch it on demand for valuable insights and updates to help you during the upcoming open enrollment period.
Highlights Include:
Questions?
Contact The Answer Team at 800.696.4543 or info@claremontcompanies.com.
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Starting September 1, 2024, all Stanford Medicine providers and hospitals are in-network for Blue Shield Commercial HMO and PPO members. This includes Stanford Hospital, Lucile Packard Children’s Hospital, Tri-Valley Hospital, Stanford Medicine Partners, and Packard Children’s Health Alliance.
However, Stanford Hospital and Stanford Medicine Partners are out-of-network for Blue Shield’s Individual and Family Plan (IFP) PPO and Trio HMO networks. Lucile Packard Children’s Hospital, Packard Children’s Health Alliance, and Tri-Valley Hospital are in-network for these plans.
Questions?
Contact The Answer Team at 800.696.4543 or info@claremontcompanies.com.
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Your success is important to us, and we’re actively working on new solutions to support you throughout the year. To get the latest news via text messaging in the future, simply provide your cell phone number here.