Eligibility

Under California law, small group health plans must include at least one Eligible Employee. An Eligible Employee cannot be the sole proprietor, the spouse of a sole proprietor, a partner in a partnership, or the spouse of a partner. If your business does not meet these requirements, Blue Shield of California’s Individual and Family Plans may be an alternative option to meet your coverage needs.

Additionally, federal requirements stipulate a small business must be headquartered in the same state as the company issuing coverage. If your business is located outside California, we are unable to provide coverage.

This chart briefly outlines basic eligibility requirements for employees and their dependents. You can find more detailed information in the Administrator's Guide.  

Type of enrollee Requirement for coverage
Employee – Full-time
  • Works an average of 30 hours per week on a permanent, year-round basis.
  • Performs job duties at your company's usual place of business.

Employee – Part-time

Only applies to groups who have purchased this coverage
  • Works 20 to 29 hours per normal work week on a permanent year-round basis for at least 50% of the working days in the previous calendar quarter.
Employee – Temporary Not eligible for Blue Shield group coverage.
Sole owner or partner of a partnership
  • Works an average of 30 hours per week; or
  • Works 20-29 hours per week and group has purchased coverage for part-time employees.
  • Performs job duties at your company’s usual place of business.
  • Qualifies as an employee under your company’s health coverage plan contract.
  • The group meets all small employer eligibility requirements.
Spouse Legally married spouse who is not legally separated from the employee and who is not covered for benefits as an employee.
Domestic partner
 

Domestic partners are covered under the same terms and conditions as spouses. A domestic partnership must meet the following requirements:

  • Both partners are 18 years of age or older except as provided in Section 297.1 of the California Family Code.
  • The partners have chosen to share an intimate and committed relationship of mutual caring.
  • The partners are (a) not currently married to someone else or a member of another domestic partnership, and (b) not so closely related by blood that legal marriage or registered domestic partnership would otherwise be prohibited.
  • Both partners are capable of consenting to the domestic partnership; and
  • The partners have filed a Declaration of Domestic Partnership with the California Secretary of State.
  • Employers may permit partners who meet the above criteria but have not filed a Declaration of Domestic Partnership to be eligible for coverage as a Domestic Partner under the Plan.
  • The partners have not terminated the domestic partnership.
Dependent Children Child of an employee (or employee's spouse or domestic partner) by birth, legal guardianship, legal adoption, or placement for adoption, who is under age 26 or older if disabled.
Disabled over-age
dependent children

If a disabled child who is covered under a Blue Shield plan reaches the maximum age limit, coverage may continue if the child meets both of the following criteria:

  • Incapable of self-sustaining employment because of a mentally or physically disabling injury, illness, or condition, and
  • Chiefly dependent on the member for economic support.
Individuals ineligible
for group coverage

If part-time and temporary employees who are not eligible for your group coverage express interest in finding a plan that’s right for them, they can apply directly to Blue Shield for health coverage through an Individual and Family Plan.

Please contact your Blue Shield account manager for more information.

Eligibility limitations may vary among groups, so please consult the Group Health Service Contract, Evidence of Coverage, Group Policy/Certificate of Insurance or contact your Blue Shield account manager for special provisions related to your company.

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