


	PacAdvantage Pool

	PairedChoice

	SacAdvantage




	Find a Doctor

	Employer FAQ

	Forms & Brochures

	Order Supplies

	Health Plan Information

	Benefit Information

	Find a Health Plan

Employer Frequently Asked Questions

Eligibility
What size business is eligible to apply for PacAdvantage?
How does PacAdvantage define a small employer?
What eligibility requirements are there for my employees?
What about Workers' Compensation?
Is out-of-state coverage available?
How do I find out about doctors available to out-of-state employees?
Are there requalification requirements?
Can my employees apply or pay on their own?
Can my employees who are on unpaid leave apply for PacAdvantage?

Optional Benefits
Am I required to offer optional benefits coverage?
Are there different qualifications for optional benefits coverage?

Enrollment Requirements
How much must I contribute to my employees' premium?
How many of my employees must enroll in PacAdvantage?
Can I offer another health insurance plan to my employees in addition to PacAdvantage?
What if some of my employees don't want or need health insurance coverage from PacAdvantage?
What must I tell my employees?
How will I be notified if my group is accepted?
When will my group insurance coverage start?

Billing Information
How will PacAdvantage bill me?
What fees are included in my premium?
What are electronic funds transfers (EFT)?

Changes in Status
How do I add new employees and their dependents?
How can my employees and their dependents be dropped from the program?
How do I disenroll employees and their dependents?
Does PacAdvantage have an Annual Open Enrollment period?
How are groups disqualified?
Can I drop my group's optional benefits while keeping our medical insurance coverage?

Eligibility

What size business is eligible to apply for PacAdvantage?
You must employ at least two eligible employees and no more than 50. The majority of the eligible employees must be employed within California. If you are enrolling with two (2) or three (3) eligible employees, we require 100% participation, which means all eligible employees must enroll for coverage. COBRA enrollees are not considered eligible employees.

How does PacAdvantage define a small employer?
A small employer is a person, firm, proprietary or non-profit corporation, partnership, public agency or association that is actively engaged in business or service. This business or service should not be formed primarily for buying health insurances and an employer- employee relationship must exist.

What eligibility requirements are there for my employees?
An eligible employee is someone who is working on a full-time basis with a normal workweek of 30 or more hours, including sole proprietors and partners. It does not include employees who work on a part-time, temporary or substitute basis, or who can waive PacAdvantage coverage because they have coverage through another employer-sponsored plan, Medicare, or Medi-Cal. Employees on paid vacation, maternity or sick leave are considered eligible if their normal workweek is at least 30 hours. Employers may establish waiting periods of up to 365 days that employees must fulfill before becoming eligible. Employers may establish different waiting periods based on classification of employees.

Employers may also offer enrollment through PacAdvantage to permanent employees who work 20 to 29 hours per week if the following requirements are met: 1) employees meet the definition of an eligible employee except for the number of hours worked, 2) employees must have worked at least 20 hours per normal workweek and meet the employer's waiting period, if any, 3) all employees meeting requirement number two must be offered enrollment through PacAdvantage. Employers who choose not to offer coverage to employees working 20 to 29 hours per week must wait until their next PacAdvantage open enrollment to cover these employees. Employers may require an employee to wait longer than the minimum time to qualify for coverage before enrolling.

What about Workers' Compensation?
You must continue to cover Workers' Compensation for 100% of your eligible employees who enroll in the plan unless you're not legally required to do so.

Is out-of-state coverage available?
Good news for California employers with employees working outside the state! Employers may offer health insurance coverage through PacAdvantage to their out-of-state workers. For more information about the PacAdvantage Out-of-State product, contact your broker.

Are there re-qualification requirements?
Once a year, a random sample of employer groups is asked to submit information about their group's eligibility status. At re-qualification, employers must have at least two (2) and no more than 100 eligible employees and meet all the other employer qualifications in order to re-qualify for PacAdvantage. NOTE: ALL employer groups with fewer than five employees are requalified annually.

Can employees apply or pay on their own?
Employees must participate as members of an employer group.

Can my employees who are on unpaid leave apply for PacAdvantage?
No, an employee on unpaid leave is not considered an eligible employee. However, if you have an employee who is totally disabled and who was covered through your health insurance policy immediately prior to enrolling in PacAdvantage, this employee is considered eligible to enroll. The prior carrier is responsible for the first 12 months of health care claims for the disabling condition. This is called extension of benefits, and may be terminated when the employee is no longer totally disabled or their extension of benefits has ended. At the time the extension of benefits ends, we will review the employee's eligibility status. We require a copy of your previous health insurance carrier's most recent billing statement in order to verify this employee's initial eligibility. The only exception to the unpaid leave policy is a female employee who is affected by pregnancy, childbirth, or related medical condition up to a maximum of four (4) months, or an employee on leave under the federal Family Medical Leave Act, or other unpaid leaves that require continued coverage to be made available under state or federal law. This specific employee, whether on paid or unpaid leave, is considered eligible to enroll.

Optional Benefits

Am I required to offer optional benefits coverage?
No, employers may choose to offer any or all optional benefits. However, if an employer DOES offer optional benefits, all employees in that group who enroll in medical must also enroll in optional benefits.

Are there different qualifications for optional benefits coverage?
No. All eligible employees and dependents enrolling for health insurance are eligible for optional benefits. If you choose to purchase optional benefits, all employees and dependents who are enrolled through PacAdvantage for health insurance must enroll for all optional benefits offered through PacAdvantage, except for dependents under age two. However, if the employee completes a waiver attesting that he/she receives health coverage through another employer-sponsored plan, Medicare or Medi-Cal, the employee may still enroll for optional benefits. If the employee chooses to enroll, then he/she must enroll for all optional benefits offered by the employer.

Employers who choose not to offer optional benefits coverage during their initial enrollment may add them at Annual Open Enrollment. They can also begin offering optional benefits at any time of the year as long as they have proof of previous coverage that terminated within the past 30 days.

Enrollment Requirements

How much must I contribute to my employees' premium?
For PacAdvantage medical and optional benefits plans, employers are required to contribute an amount equal to at least 50% of the lowest cost employee-only rate for each enrolling employee (Salud health plans are not included in this calculation). You may choose to pay up to 100% of the rate. You must inform all potentially eligible employees of the amount you plan to contribute toward their health insurance. Your employees are responsible for any remaining balance.

For PairedChoice plans, you are required to contribute $100 per month or the cost of an employee's chosen plan, whichever is less. If you choose to offer optional benefits through PairedChoice, you must contribute 100% of the lowest cost dental, vision, or chiropractic/acunpuncture rate.

How many of my employees must enroll in PacAdvantage?
If you contribute 100% of the employee-only rate, then all of your eligible employees must enroll. If you contribute less than 100%of the employee-only rate, then at least 70% must join. (Employees who waive PacAdvantage coverage due to coverage through another employer, Medicare or Medi-Cal are excluded from this calculation.) The only exception is if you have only two (2) or three (3) eligible employees, PacAdvantage requires 100% participation, which means all eligible employees must enroll for coverage regardless of the amount of the employer contribution. There is no minimum participation requirement for dependents.
Example 1: An employer has seven full-time employees (including the owner), one of whom is temporary and one who is covered under a spouse's insurance and intends to remain that way. This leaves five eligible employees, since temporary workers or those who have and want to keep other employer-sponsored coverage, Medicare, or Medi-Cal are not considered eligible. The employer contributes 100% of the employee-only premium, so all five must join PacAdvantage. If you purchase optional benefits insurance, all five employees and/or dependents who purchase health insurance must enroll in all optional benefits except for dependents under age two (2).
Example 2: An employer has 15 full- time employees, three of whom have coverage through another source. This leaves the employer with 12 eligible employees. The employer pays less than 100%of the employee-only premium, so at least 70%, or 9 of the 12 employees, must enroll in PacAdvantage. If you purchase optional benefits insurance, all employees enrolled for health insurance through PacAdvantage must also enroll in all optional benefits offered except for dependents under age two (2).

Can I offer another health insurance plan to my employees in addition to PacAdvantage?
No, PacAdvantage cannot be offered with another health plan, except in a situation of a union contract, where an employer offers PacAdvantage to non-union employees. Union employees are not considered eligible employees for purposes of counting eligible employees.

What if some of my employees don't want or need health insurance coverage from PacAdvantage?
Employees can waive coverage through PacAdvantage if they have insurance through another employer-sponsored plan (for example through their spouse), Medicare, or Medi-Cal. These employees must complete a PacAdvantage Certification to Waive/Decline Coverage and employers must not only keep this on file but also collect and submit to PacAdvantage proof that this employee already has coverage. Employees who have waived coverage may enroll in the optional benefits their employer offers but they must enroll in all optional benefits offered by their employer -- they cannot choose dental without vision, for example.

Should an employee who waived lose coverage during the year, they may enroll in PacAdvantage within 30 days of losing that coverage or wait until their employer's next Annual Open Enrollment.

Employees can decline coverage through PacAdvantage if they have an individual policy or just don't want health insurance. These employees must also complete a PacAdvantage Certification to Waive/Decline Coverage that their employers must keep on file.

Declining employees who later change their mind must wait until their employer's next Annual Open Enrollment to enroll in PacAdvantage. Declining employees cannot separately enroll in optional benefits coverage.

What must I tell my employees?
You must inform all eligible employees of the intent to purchase coverage through the plan. This includes employees who could waive coverage in PacAdvantage because they have other coverage through another employer-sponsored plan, Medicare or Medi-Cal. You must give each of your employees a PacAdvantage Employee Handbook. You must tell your employees the amount of the premium you will be paying, including any dependent premiums.

How will I be notified if my group is accepted?
PacAdvantage will notify you if your application is accepted or if there's a problem. If your application is complete, we'll send you written confirmation in four working days. If information is missing, we will contact you or your broker to obtain the information required. If the requested information is not received within four working days, your effective date could be delayed or your eligibility denied. If you or any employee/dependent is not eligible, we will tell you the reason in writing within four working days. You must inform your employee. If the ineligible employee doesn't affect your overall eligibility, we will continue the enrollment process.

When will my group insurance coverage start?
Your effective date of coverage will be the 1st of the next month, upon receipt of complete information, provided your group's completed enrollment material is postmarked by the last day of the month. If we receive an incomplete application, your group's effective date may be delayed until the 1st of the next month.

Billing Information

How will PacAdvantage bill me?
If you pay by mail, we will send you a premium bill each month about 20 days before it is due. Your premium will be due the first of every month—even if you move and your mail hasn't caught up to you. You can pay by check or money order sent in the envelope provided. Your account will not be considered "paid" until we receive the "total due" amount shown on the statement. Don't make adjustments in the billing amount—recent employee changes will be reflected on your next month's statement. When an enrolled employee changes geographic regions of residence but does not change participating health or optional benefits plans, or the employee changes family size categories, the changes in the employee's premium will be calculated and included on the next month's billing statement following the changes. In some cases, the health premium price may change on an employee's birthday, if it places the employee in a new rate category.

Your monthly premium payment should be mailed to: PacAdvantage, PO Box 981028, West Sacramento, CA 95798-1028.

What fees are included in my premium?
Included in your monthly premium is commission/compensation to your health insurance broker, as well as PacAdvantage administration fees. PacAdvantage may also provide compensation to brokers based on performance, persistency, and profitability.

What are electronic funds transfers (EFT)?
EFT is similar to an automatic bank withdrawal. There is no charge for this service, and it could help you avoid late fee charges. Through EFT, PacAdvantage can withdraw your premium amount from a designated bank account within ten working days of the total amount due date. A detailed billing will be sent about 20 days prior to the due date. In order to take advantage of this, you must complete an EFT form and submit it along with a voided check.

Changes in Status

How do I add new employees and their dependents?
Newly enrolling employees must complete the PacAdvantage Employee Enrollment Application and send it in within 45 days prior to or within 60 days after becoming eligible. There are no retroactive effective dates. If the employee/dependent is determined eligible, PacAdvantage will notify you and bill you the following month for the new employee and/or dependents. If an employee/dependent is found not eligible, the employer must inform them of their eligibility status.

How can my employees and their dependents be dropped from the program?
An employee or dependent may be dropped for several reasons: If his or her employer is no longer eligible; if the employee or dependent is no longer eligible; or if either party commits fraud or misrepresentation toward the program or the health plan. We call this "disenrollment." The disenrollment will occur at the end of a month in which we deem the employee was not eligible.

How do I disenroll employees and their dependents?
You must notify PacAdvantage of your intention to disenroll an employee, which will occur at the end of a month. To notify PacAdvantage, you may:

Call your PacAdvantage representative at 877-735-5742
Fax the disenrollment request, termination date and reason to 916-786-6905
Put your request in writing and send to: PacAdvantage 2901 Douglas Blvd., Suite 305 Roseville, CA 95661-9027
Email customerservice@pacadvantage.org

PacAdvantage will allow a disenrollment date up to 30 days prior to the date we are notified. Example: An employee leaves your company on 1/25/02. You notify us on 2/10/02. We will disenroll the employee as of 1/30/02. In the case of fraud or misrepresentation, PacAdvantage may disenroll the employee and/or dependent(s) as of the date of the fraud or misrepresentation. If the program determines that the enrolled person never qualified for enrollment, the disenrollment may take place as early as the original effective date of coverage. PacAdvantage will inform you in writing which employee or dependent disenrolled and the effective date of the disenrollment.Your premium will be adjusted according to the effective date of the disenrollment. If an employee is disenrolled, that employee can only be reinstated if their reinstatement request is received within 15 days of the disenrollment date, or the date PacAdvantage was initially notified of the disenrollment.

Does PacAdvantage have an Annual Open Enrollment period for renewing coverage?
Yes. PacAdvantage has an open enrollment period once a year. Annual Open Enrollment materials are sent to employers approximately 60 days prior to their yearly anniversary date. During open enrollment, enrolled employees may transfer between health and optional benefits plans, change their copayments and deductibles, and elect to cover their dependents. Those who previously declined coverage may also enroll at this time and employers may also elect to add optional benefits coverage.

How are groups disqualified?

Employers who no longer meet the qualification requirements to be a small employer will be disqualified. When they again meet the qualifications, they may reapply to the program.
Employers who fail to pay their invoices by the due date will be disqualified. PacAdvantage will send you a notice 31 days following the total amount due date disqualifying you and telling you how to reinstate your group in PacAdvantage. You may apply for reinstatement no later than 15 days after the notification of disqualification. If your group is not reinstated, you are not eligible to reapply to the program.
If you have committed an act of fraud or misrepresentation to circumvent the law or rules governing PacAdvantage, you will be disqualified and will not be permitted to re-join the program.
If you have enrolled in optional benefits coverage,100% of your employees must enroll in the PacAdvantage health insurance coverage, or you will be disqualified.
If you request in writing to be disenrolled, you will be disenrolled. You must let us know at least 30 days before your requested disenrollment date. When you're disqualified for any reason other than your request, we will send you and each employee the reason for and effective date of disqualification and the final coverage date. In all cases, when you are disqualified from health insurance, you are also disqualified from optional benefits insurance.

Can I drop my group's optional benefits while keeping our medical insurance coverage?
Yes. An employer can disenroll their group's optional benefits coverage while keeping health insurance as long as they remain eligible. Such a request must be made in writing 30 days in advance of the disenrollment. Once the disenrollment occurs, the group will not be eligible to re-enroll for one year from the date of disenrollment. The group may then re-enroll during its next scheduled Annual Open Enrollment.

© 2005 PacAdvantage · Terms of Use · Privacy Policy · Site Map