Kaiser Permanente policies

Break-in break-away (BIBA)

The Kaiser Permanente break-in/break-away policy provides customers with 101 or more employees flexibility to explore benefit solutions through pooled purchasers — joint powers authorities, trust funds, multiple employer welfare arrangements (MEWAs), and other types of arrangements. The policy is intended to keep rates neutral, help prevent unfair competition, and allow customers to make decisions based on service and overall value.

For more information download the Break In Break Away Policy flyer.

Coordination of Benefits — UPDATE

Coordination of Benefits for members with more than 1 Kaiser Permanente plan has been postponed

You may have heard that Kaiser Permanente would start coordinating benefits for members with more than 1 Kaiser Permanente plan, who get services from Kaiser Permanente providers, on January 1, 2018. Due to the complexity of making this change in California,we’ve postponed implementation until further notice.

However, coordination of benefits already in effect for other situations will continue as before. This includes cases where members:

  • Get services from non–Kaiser Permanente providers — for example, contracted providers or because of a referral
  • Have a Kaiser Permanente plan and a non–Kaiser Permanente plan
  • Have a Kaiser Permanente HMO or deductible HMO plan and a Kaiser Permanente self-funded, point-of-service (PPO and Out-of-network tiers only), PPO, or out-of-area plan  

Claims administration for ancillary services (such as Dental, Chiropractic and Acupuncture), not covered under the base medical benefit, are at the vendor’s discretion.

If you have any questions, please contact your Kaiser Permanente representative.

Please note: This postponement only applies in California. In all other regions, benefits for members with multiple Kaiser Permanente plans will continue to be coordinated as before.

Crossover guidelines

Sometimes employers have business needs that require them to change their Kaiser Permanente plan in the middle of their accumulation period. Depending on the kinds of changes made, a midyear1 plan change may impact employees’ credits toward their deductibles and/or out-of-pocket maximum.

Use the Crossover Guidelines to help clarify when these credits transfer to the new plan and when they reset to zero2. If you have questions, please contact your Kaiser Permanente representative.

1 Small Business employers are only allowed to change plans at renewal.

2 The guide applies to the following plan types only: 

  • Traditional HMO
  • Traditional HMO with coinsurance
  • Deductible HMO
  • Deductible HMO with HRA
  • HSA-qualified deductible HMO
Large Group Deductible Funding Policy

Kaiser Permanente deductible plans are designed to give your large group clients affordable health plan options and, are priced based on the assumption that members participate in sharing the costs of care.

When your large group clients fund their employees’ deductibles, coinsurance or copayments—either directly or through reimbursements—they change the way employees use their plan and may invalidate the way we set up benefits and pricing.

As a result, Kaiser Permanente restricts large group employers from funding or directly reimbursing employees for the costs of their care, except through the plan options and parameters outlined in our Deductible Funding Policy. To help keep your large group clients informed with the latest, download and print this policy. If you have questions, please contact your Kaiser Permanente representative.

Full-time-equivalent employees

A group’s number of full-time-equivalent employees (FTEEs) is calculated by combining its number of:

  • full-time employees who work at least 30 hours per week on average
  • part-time employees who don’t work at least 30 hours per week on average, but who are counted toward the total number of FTEEs in proportion to the hours they work
Small business policy updates

Underwriting Guidelines

Kaiser Permanente Small Group Underwriting Guidelines are updated twice annually. Review the policies below that will be included in the next update of our Underwriting Guidelines (PDF).

Multiple plan options for groups with 5 or fewer subscribers

You can now offer multiple plan options to your employees based on the number of enrolled Kaiser Permanente subscribers you have.

  • Groups with 1 to 5 enrolled subscribers can now offer a choice of up to 4 Kaiser Permanente HMO plans plus 1 PPO plan for a maximum of 5 Plans.

Making it easier to set up new groups

Effective immediately, Kaiser Permanente Small Group California employers will no longer need to submit eligibility documentation when they enroll a new group in coverage.

We will no longer collect the following for new group submissions, including submissions already in progress.

  • Business eligibility validation documents, such as a business license
  • Employee and business owner validation documents, which include:

                  o DE 9C, payroll records, payroll attestation form, new hire eligibility form or tax documentation

  • Declination of Coverage (Employer Attestation)

                  o Employers are required to retain completed copies for their records

Startup groups with 1-5 eligible and groups with enrolling non-emancipated minors are required to submit a payroll attestation form. Kaiser Permanente reserves the right to ask for additional documentation.

Out-of-state PPO Coverage Increases

Starting October 2021, up to 49% of subscribes may enroll on OOS PPO coverage – that’s up from 30%.

Waiting period changes

Waiting period changes for 2015 — On August 15, 2014, Gov. Jerry Brown signed legislation repealing language in the Health and Safety Code and the Insurance Code that limited health plan contracts to imposing waiting periods of no more than 60 days.

Effective January 1, 2015, California employers and health plans are subject to the 90-day federal regulations of the Affordable Care Act (ACA). In addition, groups are allowed up to a one-month orientation period before the waiting period begins. It’s the responsibility of the group to administer the orientation period in conjunction with the waiting period. 

As a reminder, your clients are responsible for their own compliance under the ACA’s waiting period rule. Kaiser Permanente can’t undertake this compliance obligation on your clients’ behalf.

What you should know

  • Kaiser Permanente is required to obtain representation from each employer group stating that their group is in compliance with the ACA’s waiting period rule. To obtain this representation, refer to our most current commercial Group Agreement.  
  • By agreeing to the terms of our current commercial Group Agreement, your clients are satisfying this requirement and are also representing that they aren’t imposing a waiting period in excess of 90 days on employees who meet their other eligibility requirements, including a one-month orientation period, if any. 
  • Starting January 1, 2015, Kaiser Permanente no longer collects information about group waiting periods. Instead, we will rely on each employer group to monitor its new employees’ eligibility dates and let us know when to enroll employees. 
  •  Your clients must provide Kaiser Permanente with an enrollment date for each new subscriber 

    As a reminder, the effective date for new subscribers and dependents enrolling in Small Business coverage is always the first of the month. No other coverage start dates can be accepted, and premiums can’t be prorated.

Information may have changed since publication.

* We reserve the right to modify this policy at any time.