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 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:
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.
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:
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.
A group’s number of full-time-equivalent employees (FTEEs) is calculated by combining its number of:
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).
You can now offer multiple plan options to your employees based on the number of enrolled Kaiser Permanente subscribers you have.
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.
o DE 9C, payroll records, payroll attestation form, new hire eligibility form or tax documentation
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.
Starting October 2021, up to 49% of subscribes may enroll on OOS PPO coverage – that’s up from 30%.
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.
Information may have changed since publication.
* We reserve the right to modify this policy at any time.