Blue Shield of California is committed to providing comprehensive and flexible health insurance solutions to meet the needs of today’s diverse workforce. For companies in California, Blue Shield offers a single national coverage solution, ensuring employees are covered no matter where they are.

Selecting the best health insurance plans can be overwhelming. At Skyline Benefit, Our mission is to simplify this process and assist our clients every step of the way. Today, we delve into Blue Shield of California underwriting guidelines to facilitate a seamless enrollment process and ensure maximum coverage for your employees.

What Are the Eligibility Requirements for Small Employers?

Must Qualify as a Small Employer

  • To be eligible for Blue Shield small group health plans, your business must meet the criteria  for a small employer.

Engagement in Business or Service:

  • The business must be actively in operations and not dormant.

Maintain Business Licensure:

  • Your company must hold and maintain all necessary licenses, permits, and authorizations to conduct business legally in California.

Workers’ Compensation:

  • All employees must be covered by workers’ compensation as required by law.

What Are the Different Medical Plan Options Blue Shield of California


Blue Shield of California provides a range of medical group plan options to meet the diverse needs of your employees. These plans are into four metal tiers: Platinum, Gold, Silver, and Bronze. Each tier represents different benefits and premiums, offering flexibility and choice based on your healthcare needs and budget.

When Does New Group Coverage Become Effective?

Coverage Effective Dates:

  • For enrollments between the 1st and 15th of any month, coverage must begin by the 1st of the following month.
  • For enrollments between the 16th and the end of the month, coverage must start by the 1st of the second following month.

Effective Dates:

  • Employers can choose a later effective date within a quarter for which small group market rates are available.

Acceptance of Quoted Rates:

  • Employers have 30 days to accept coverage at the quoted rates. Once accepted, changes to the plan can be made within the first 30 days of the group’s effective date.

Waiving Waiting Periods:

  • Employers can choose to waive the waiting period for new hires during the initial group enrollment.

How Does HMO Service Area Affect Eligibility?

Location Requirements:

  • The employer’s business must be located within the specific HMO service area to offer HMO plans.

Residency Restrictions:

  • HMO plans are not suitable for employees residing outside California. Employees must live or work within the HMO service area.

Special Programs:

  • The Away From Home Care® program allows students, long-term travelers, and out-of-state workers to maintain enrollment.

What Are the Dependent Eligibility Criteria?

Spouses and Domestic Partners:

  • Legally married spouses or domestic partners not covered as employees can receive coverage.


  • Coverage extends to an employee’s, spouse’s, or domestic partner’s children under 26 years old.

Disabled Dependents:

  • Over-age dependent children with disabilities may have their coverage extended with proper medical certification and documentation.

What Are the Submission Requirements for New Businesses?

Processing Time:

  • As an Employer, you should ensure all  documents are submitted accurately and on time to avoid delays.

Evaluation Criteria:

  • Underwriting is based on contribution and participation. Groups may be declined for reasons such as lack of a bona fide employer/employee relationship or if more than 49% of employees are outside California.


Understanding and meeting the eligibility requirements for Blue Shield of California Underwriting guidelines for small group health plans is essential for small employers. It’s important to note that only Blue Shield can make the final decision to accept ordecline coverage for a case or assign an effective date. Prospective groups should maintain their current coverage until Blue Shield confirms acceptance in writing. By adhering to the guidelines and ensuring proper documentation, businesses can secure comprehensive health coverage for their employees, ensuring their well-being and enhancing overall productivity.

Need more information on Blue Shield of California Underwriting guidelines?

Skyline Benefit is an independent group health insurance broker in Fullerton, CA that offers affordable and flexible health insurance options. Selecting the best group health insurance plans can be overwhelming; our mission is to simplify the process and help our clients every step of the way.

Schedule a consultation today. Call us now at (714) 888-5112

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