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Covered California for Small Business –
New Blue Shield Plans

Starting July 1, Covered California for Small Business (CCSB) is offering new Blue Shield plans, providing more options for enrollees. These plans include the Access+ HMO Network with Platinum, Gold, and Silver metal tier options, as well as the Bronze Trio HMO 7000/70. The two most popular Blue Shield High Deductible Health Plans (HDHP), Silver Full PPO Savings 2300/25% and Bronze Full PPO Savings 7000 plans, are also now available.

All of these plans offer benefits such as Wellvolution, Teladoc Mental Health, Nurse Help 24/7, LifeReferrals 24/7, and the Blue Card program for when members are outside of California.

For assistance, please contact our Quotes team at quotes@claremontcompanies.com or 800.696.4543.

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Forms and Documents

Form/Document Name Carrier Coverage Effective
Date		 Last
Updated
Reliance Matrix Designation of Beneficiary Form 2019 Reliance Matrix Disability, Medical, Vision 09/28/2019 08/01/2023
Life, Dental, Vision, Disability Enrollment Form Reliance Matrix 09/28/2019
RelianceStandard RSLsmartchoice Checklist rev8.16 Reliance Matrix 09/28/2019
SmartChoice Binder & Recurring Payment Authorization Form Reliance Matrix 09/28/2019
SmartChoice Enrollment Card Reliance Matrix 09/28/2019
TASC Universal Subscription Agreement TASC 09/28/2019
TASC USA Purchaser Details TASC 09/28/2019
UHC 2023 Group Acceptance Change Form Product & Benefit Selection Form 4 1 23 UnitedHealthcare 04/26/2023
2023 Humana Employee Application Liberty DHMO Humana 11/10/2022
2023 Humana Employee Application Dental, Vision and Life Humana 11/10/2022
2023 Humana Employer Group Application CA DHMO Humana 11/10/2022
2023 Humana Employer Group Application Dental, Vision and Life Fillable Humana 11/10/2022
2023 Humana List Enrollment.xlsm Humana 11/10/2022
Copy of Metlife eCensus Format ALL COVERAGES.xls MetLife 05/10/2021
Employer Application (1 of 3) MetLife 05/10/2021
Federal COBRA Election Form MetLife 05/10/2021
Master App Page ER Broker signed (2 of 3) MetLife 05/10/2021
MetLife Checklist (3 21) MetLife 05/10/2021
Metlife Statement of Responsibility Form MetLife 05/10/2021
Service Fee Disclosure and Authorization Ease 0719 MetLife 05/10/2021
Specialty Business New Group Submission Checklist 0720 MetLife 05/10/2021
Specialty Business New Group Submission Form 0720 MetLife 05/10/2021
Principal California Employer Application Principal 09/28/2019
Principal Electronic Consent Form Principal 09/28/2019
Principal Installation Form Principal 09/28/2019
Principal Employee Dental & Vision Enrollment Form Principal 09/28/2019
Principal checklist rev 6.19 Principal 09/28/2019
Critical Illness and Accident Enrollment Form Reliance Matrix 09/28/2019
CCSB 2023 FED COBRA Election Form English Covered California for Small Business 04/26/2023
CCSB 2023 New Business Late Submission Acknowledgement Covered California for Small Business 04/26/2023
CCSB Appeal Request ENG Covered California for Small Business 04/26/2023
CCSB Checklist 2023 Covered California for Small Business 04/26/2023
CCSB COBRA Cancellation Form English Covered California for Small Business 04/26/2023
CCSB Complaint Form ENG Covered California for Small Business 04/26/2023
CCSB Delta Dental Claim Form Covered California for Small Business 04/26/2023
CCSB Q1 Q2 2023 EE Application Fillable ENG Covered California for Small Business 04/26/2023
CCSB Q1 Q2 2023 EE Application SPA Covered California for Small Business 04/26/2023
CCSB Q1 Q2 2023 EE Change Form ENG Covered California for Small Business 04/26/2023
CCSB Q1 Q2 2023 EE Change Form SPA Covered California for Small Business 04/26/2023
CCSB Q1 Q2 2023 ER Change Form ENG Covered California for Small Business 04/26/2023
CCSB Q1 Q2 2023 ER Change Form SPA Covered California for Small Business 04/26/2023
CCSB Q3 Q4 2023 EE Application ENG Covered California for Small Business 04/26/2023
CCSB Q3 Q4 2023 EE Application SPA Covered California for Small Business 04/26/2023
CCSB Q3 Q4 2023 EE Change Form ENG Covered California for Small Business 04/26/2023
CCSB Q3 Q4 2023 EE Change Form SPA Covered California for Small Business 04/26/2023
CCSB Q3 Q4 2023 ER Change Form ENG Covered California for Small Business 04/26/2023
CCSB Q3 Q4 2023 ER Change Form SPA Covered California for Small Business 04/26/2023
2023 Humana Checklist Humana 11/10/2022
CB 2023 Case Submission Checklist Eff 7 1 2022 ChoiceBuilder 04/26/2023
CB 2023 COBRA Employee Enrollment Application ChoiceBuilder 04/26/2023
CB 2023 Confirmation of Eligibility Eff 3 1 2023 SPA ChoiceBuilder 04/26/2023
CB 2023 Confirmation of Eligibility Eff 3 1 2023 ChoiceBuilder 04/26/2023
CB 2023 EE Termination Form ChoiceBuilder 04/26/2023
CB 2023 Employee Change Request Form ChoiceBuilder 04/26/2023
CB 2023 Employee Enrollment Application ChoiceBuilder 04/26/2023
CB 2023 ER Application Eff 12 1 2022 ChoiceBuilder 04/26/2023
CB 2023 ER Application Eff 7 1 2023 ChoiceBuilder 04/26/2023
CB 2023 ER Change Request Form Eff 12 1 2022 ChoiceBuilder 04/26/2023
CB 2023 Late Case Submission Acknowledgement ChoiceBuilder 04/26/2023
CB 2023 Prior Carrier Cancellation ChoiceBuilder 04/26/2023
CB Exception Request Form ChoiceBuilder 04/26/2023
ChoiceBuilder Checklist 2023 ChoiceBuilder 04/26/2023
C+O 2023 ACH Form Cigna + Oscar 11/10/2022
C+O 2023 Employee Enrollment form Cigna + Oscar 11/10/2022
C+O 2023 Employee Waiver Form Cigna + Oscar 11/10/2022
C+O 2023 Partnership Verification Form Cigna + Oscar 11/10/2022
Cigna + Oscar Checklist Cigna + Oscar 11/10/2022
CCSB 2023 ER Application ENG Covered California for Small Business 04/26/2023
BSCA 2023 Subscriber Change Request Q3 Q4 Blue Shield of California 04/10/2023
BSCA MGA EEA Combo 2023 Q3 V1b.xlsm Blue Shield of California 05/30/2023
2023 CC ACH Payment Form CaliforniaChoice 04/12/2022
2023 CC Case Submission Acknowledgement CaliforniaChoice 10/29/2020
2023 CC Case Submission Checklist CaliforniaChoice 04/12/2022
2023 CC Employee Change Request Eff 7 2023 CaliforniaChoice 04/26/2023
2023 CC Employee Enrollment Eff 4 2023 CaliforniaChoice 04/01/2023
2023 CC Employee Enrollment Eff 7 2023 CaliforniaChoice 04/26/2023
2023 CC Employee Change Request Eff 4 2023 CaliforniaChoice 04/01/2023
2023 CC Employer Application Eff 4 2023 CaliforniaChoice 04/26/2023
2023 CC Employer Application Eff 7 2023 CaliforniaChoice 04/26/2023
2023 CC Employer Change Request Eff 4 2023 CaliforniaChoice 04/26/2023
2023 CC Employer Change Request Eff 7 2023 CaliforniaChoice 04/26/2023
2023 CC Owner Partner Statement CaliforniaChoice 04/12/2022
2023 CCHP Decline Waive Form ENG Chinese Community Health Plan 11/10/2022
2023 CCHP Employee Enrollment Form ENG Chinese Community Health Plan 11/10/2022
2023 CCHP Master Group Application ENG Chinese Community Health Plan 11/10/2022
2023 CCHP Termination Disenrollment Request Chinese Community Health Plan 05/10/2021
2023 CCHP SmGroup Check List.dox Chinese Community Health Plan 11/10/2022
CB 2023 ACH Payment Form ChoiceBuilder 04/26/2023
DD 2023 Employer Vision Application Allied Benefit Suite 05/25/2023
2023 Beam Enrollment CSV template Dual ALL LINES ER LIFE Beam Benefits 04/26/2023
2023 Beam BCSV Template ALL LINES VOL LIFE Beam Benefits 04/26/2023
2023 Beam ER Application Life CA Beam Benefits 11/10/2022
2023 Beam ER Application CA Beam Benefits 11/10/2022
2023 Beam ACH Recurring Payment Beam Benefits 11/10/2022
2023 Beam Checklist Beam Benefits 11/10/2022
2023 Beam EE Application Life Beam Benefits 11/10/2022
2023 Beam EE Enrollment Form Dental & Vision Beam Benefits 11/10/2022
BSCA 2023 Employee Application Q1 Q2 Blue Shield of California 04/10/2023
BSCA 2023 Employee Application Q3 Q4 Blue Shield of California 04/10/2023
BSCA 2023 Group Change Request Q1 Q2 Blue Shield of California 04/10/2023
BSCA 2023 Group Change Request Q3 Q4 Blue Shield of California 04/10/2023
BSCA 2023 Master Group Application Q3 Q4 Blue Shield of California 04/10/2023
BSCA 2023 Master Group Application Q1 Q2 Blue Shield of California 04/10/2023
BSCA 2023 Refusal of Coverage form Q1 Q2 Blue Shield of California 04/10/2023
BSCA 2023 Refusal of Coverage form Q3 Q4 Blue Shield of California 04/10/2023
BSCA 2023 Small Group Initial Payment Form Blue Shield of California 04/10/2023
BSCA 2023 Small Group Owner Eligibility Statement Blue Shield of California 04/10/2023
BSCA 2023 Subscriber Change Request Q1 Q2 Blue Shield of California 04/10/2023
2023 Delta SBP CA Census Template Allied Benefit Suite Dental 05/25/2023
ABS AXA Employer Verification Info Allied Benefit Suite Dental 05/25/2023
ABS AXA Employee Enrollment Form Allied Benefit Suite Dental 05/25/2023
ABS Personal Protection ER Application Allied Benefit Suite Dental 05/25/2023
ABS Submission Checklist Allied Benefit Suite 05/25/2023
Allied Benefit Suite Checklist 2023 Allied Benefit Suite 05/25/2023
CalCOBRA Enrollment Form Allied Benefit Suite 05/25/2023
DD 2023 ACH Payment Form Allied Benefit Suite 05/25/2023
DD 2023 CA Enrollment DeltaVision Allied Benefit Suite 05/25/2023
DD 2023 CA Enrollment Dental DeltaCare USA DeltaVision Allied Benefit Suite 05/25/2023
DD 2023 CA Enrollment Dental DeltaCare USA Allied Benefit Suite 05/25/2023
DD 2023 CA Enrollment Dental Dual Choice PPO DeltaCare USA Allied Benefit Suite 05/25/2023
DD 2023 CA Enrollment Dental Dual Choice PPO DeltaCare USA DeltaVision Allied Benefit Suite 05/25/2023
DD 2023 CA Enrollment Dental Dual Choice PPO PPO Allied Benefit Suite 05/25/2023
DD 2023 CA Enrollment Dental Dual Choice PPO PPO DeltaVision Allied Benefit Suite 05/25/2023
DD 2023 CA Enrollment Dental PPO DeltaVision Allied Benefit Suite 05/25/2023
DD 2023 CA Enrollment Dental PPO Allied Benefit Suite 05/25/2023
DD 2023 COBRA Status Questionaire Allied Benefit Suite 05/25/2023
DD 2023 Employer Dental and Vision Application Allied Benefit Suite 05/25/2023
DD 2023 Employer Dental Application Allied Benefit Suite 05/25/2023

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