Enrollment Kit - health net (medical)
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This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.
Completed Group Service Agreement
Group Service Agreement - Effective 1/1/2020
Enrollment Applications signed and dated by employees within 60 days of requested effective date.
Enrollment Application - Effective 1/1/2020
Completed Declination of Coverage section for employees not electing coverage. ID cards may be required to verify participation.
Most recent prior carrier billing statement is required in certain situations such as when a group wants ER dental rates, to verify COBRA enrollment, or LOA.
The most recent DE-9C reconciled. For new hires not appearing on the DE-9C, 2 weeks of current payroll records are required (W-4’s are not acceptable). For owners/partners not appearing on the DE-9C or showing part-time wages on the DE-9C, provide required ownership documentation. For groups of 25+ enrolling employees, the owners/partners only need to complete the Proof of Eligibility Statement For Sole Proprietor, Partner or Corporate Officer Form.
Owner-only groups are not eligible. There must be a minimum of one W-2 employee who is not a spouse of the owner or partner.
Workers’ Compensation is required except those not required by law to be covered by Workers’ Compensation.
When a company has a DBA (Doing Business As), a copy of the Fictitious Business Name Statement must be provided to link the legal name to the DBA.
1099 employees are not eligible.
Life: “Flat” benefit schedules only. Some SIC classifications are excluded. Groups of 2-9 require 100% participation and no more than 25% of employees may be age 60 or older.
Broker Licensing: Online Commercial Licensing Portal
| After approval, prior carrier termination letter must be submitted by the employer or broker. |
For other useful or older documents, please refer to the Forms database.
Important Reminder: To help your client comply with ACA requirements, provide a copy of the appropriate Summary of Benefits and Coverage (SBC) to each employee at the Enrollment Meeting, via email or by posting on an internal company website. For the most recent information regarding
Health Net’s SBCs, please go to the SBC Page or contact your Word & Brown Representative.