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.
Our goal is to process your new group enrollment easily and efficiently in order to provide you and your client with a quick approval. The following list outlines MediExcel's case submission requirements.
- Group Application Form filled out completely
- Completed & signed Enrollment Application for each enrolling employee
- Deposit check made out to MediExcel Health Plan for the first month's coverage
- Employer Ownership paperwork (required if the names of the owner(s)/partners do not appear on the most recent DE-9C). Documentation may include:
- For a sole proprietor: [Business license, fictitious business name statement, or schedule C tax form]
- For a partnership/LLC: [Business license (showing all names), fictitious business name statement (showing all names), or schedule K tax form (for each partner)]
- For a corporation: [Corporation documents, articles of incorporation, or statement of information]
- Broker paperwork [License number, broker agreement and completed W-9]
- Declination of Coverage Form for each eligible employe declining coverage [if MediExcel is the only coverage offered (e.g., no California health plan was offered to employees)]
Please include the following documents depending on the size of the group:
- Small groups are one to 100 benefits-eligible employees
- DE-9C is required
- To reconcile the DE-9C, please indicate the appropriate code next to each employee's name:
- T - Terminated [indicate term date]
- E - Eligible and enrolling
- W - Eligible and waiving for other group or individual coverage
- I - Ineligible [part-time, seasonal, waiting period]
- Large groups are 101 or more benefits-eligible employees
- Complete employee roster form each employee, including:
- Eligiblity for benefits
- Health plan selected
|After approval, prior carrier termination letter must be submitted by the employer or broker.|
For other useful for 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 Anthem Blue Cross SBCs, please go to the SBC Page or contact your Word & Brown Representative.