Government guidelines

Preventive services

The preventive services provision of the Affordable Care Act requires coverage of certain preventive services with no cost sharing. The list of preventive services are based on recommendations by the United States Preventive Services Task Forces, the Health Resources and Services Administration and the Centers for Disease Control and Prevention and includes the latest services approved for 2018. Here is additional information that you need to know:

  • The mandate applies to all members enrolled in individual, small and large group plans (fully insured and self-funded), but not to grandfathered, Medicare, or retiree plans.
  • It became effective with plan years beginning on or after September 23, 2010.
  • Grandfathered plans can purchase Kaiser Permanente's Health Care Reform Preventive Services Package without impacting their grandfathered status.

Small businesses

Your small business clients will automatically have the new women’s preventive services added to their coverage at their next renewal on or after August 1, 2012. Adding these services doesn’t affect a plans grandfathered status.

Large businesses

For existing groups:

  • Existing large group customers with nongrandfathered plans will have the women’s preventive services added to their coverage at their next renewal on or after August 1, 2012.
  • Existing large group customers with grandfathered plans can choose whether to purchase the Health Care Reform Preventive Services Package. Adding this package doesn’t affect a plans grandfathered status.
  • Grandfathered plans that currently cover health care reform preventive services at no cost sharing will have the women’s preventive services added to their coverage on or after August 1, 2012, as contracts renew. Adding coverage for these women’s preventive services will not cause these plans to lose their grandfathered status.

For new groups:

  • All new large groups will automatically have the Health Care Reform Preventive Services Package included in their groups plan.

For more information

California legislative overview

Several laws were enacted during the 2018 California legislative session that could impact your business.

For more information, see our health care legislative overview.

COBRA regulations

An important COBRA message from Kaiser Permanente

In 1986, Congress passed the Consolidated Omnibus Budget Reconciliation Act (COBRA) health benefit provisions to provide individuals temporary continuation of health coverage at group rates. The law generally covers health plans offered by employers with 20 or more employees.

The Department of Labor’s Employee Benefits Security Administration has issued final federal COBRA regulations clarifying the timing and content of the federal COBRA notices that all employers are required to provide to their federal COBRA enrollees. The finalized regulations prompted us to review the billing and collection services that we perform to help ensure that we’re doing everything we can to facilitate your clients’ compliance with these regulations.

Since Kaiser Permanente in Northern and Southern California performs billing and collection services for some employers, we’ve created a monthly report that lists:

  • Your federal COBRA enrollees who are billed by Kaiser Permanente
  • Those who have failed to make timely payments
  • Those being terminated (either for nonpayment or for reaching the maximum period of federal COBRA continuation coverage)

We're sending the Kaiser Permanente Billed Federal COBRA Activity Report monthly to by the end of each month. If there is no COBRA membership or activity for the reporting period, you will not receive this report.

Employers are responsible for complying with all COBRA responsibilities, including notifying qualified beneficiaries of federal COBRA rights and processing federal COBRA elections. You have received a signature agreement that delegates the COBRA billing and collection functions to Kaiser Permanente. The Employer Group Application has also been modified to include the signature agreement provision.   

For more information regarding employer requirements under federal COBRA regulations, you should consult your legal advisor. These regulations are available at www.dol.gov/dol/topic/health-plans/cobra.htm.

Medicare creditable coverage information

If a health plan’s prescription drug coverage is as good as or better than Medicare Part D, it’s considered “creditable.” Employers who offer prescription drug coverage to Medicare-eligible individuals are required to notify their beneficiaries unless they are enrolled in a Part D plan. Employers are also required to notify the Centers for Medicare & Medicaid Services (CMS) whether or not their coverage is creditable.

  1. ALL employers must complete and submit this form online and use the Federal ID #: 94-1340523.
  2. To find out if your Kaiser plan is creditable, download the 2019 flyer, 2020 flyer, or 2021 flyer.
  3. If you’d like more information about Part D Creditable Coverage, click here .

* The new laws apply to all commercial plans. Medicare and special programs such as Medi-Cal will not be affected.

Mental Health Parity

Updates to cost share for some mental health and chemical dependency services

To comply with requirements of the Mental Health Parity and Addiction Equity Act (MHPAEA), we’ve made changes to cost share for some mental health and chemical dependency services. As 2015 contracts renew or are amended, we’re revising Evidence of Coverage (EOC) documents to reflect those updates. The changes don’t affect rates or access to care.

For details on what’s new for large and small groups, see below.

Changes for large groups

When it’s prescribed by a plan physician, we cover care at licensed residential treatment facilities in our service area. Facilities must provide 24-hour individualized treatment for chemical dependency or mental health. The following services are covered when they’re above the level of custodial care at one of these facilities:

  • individual or group chemical dependency or mental health counseling
  • medical services
  • room and board
  • social services
  • medication monitoring
  • drugs prescribed by a plan provider as part of the patient’s care, in accord with our drug formulary guidelines, and administered in the facility by medical personnel
  • discharge planning

Additionally, the non-Medicare EOCs’ cost-share disclosures will be revised as follows (for the purpose of this notification, “non-Medicare EOCs” means all EOCs other than Senior Advantage EOCs):

  • In all EOCs, we’ve added a disclosure of the cost share for chemical dependency day treatment and intensive outpatient services. The cost share for chemical dependency day treatment and intensive outpatient services is the same cost share as outpatient surgery, up to a maximum of the cost share for primary care visits.
  • In EOCs where the cost share for hospital inpatient care is “no charge” and the cost share for chemical dependency residential treatment is a copayment, the cost share for chemical dependency residential treatment has been revised to be “no charge.”
  • In EOCs where the deductible doesn’t apply to outpatient surgery, the deductible doesn’t apply to the following mental health or chemical dependency services either:
    • partial hospitalization programs
    • intensive outpatient programs
    • day treatment programs

We’ve already made the coverage and cost share changes reflected in this notice. When members receive services, they’ll pay the cost share shown in this notice. If your EOC doesn’t currently reflect the changes described above, you may see these changes in your EOC at renewal. If you have any questions about changes we’ve made to meet MHPAEA requirements, please contact your Kaiser Permanente representative.

Changes for small groups

Unless otherwise specified, the changes in this notification only apply to non-Medicare EOCs. For the purpose of this notification, “non-Medicare EOCs” means all EOCs other than Kaiser Permanente Senior Advantage when Medicare is secondary coverage.

Global changes

The following changes affect EOCs for all plans:

  • We’ve added a disclosure of the cost share for chemical dependency day treatment and intensive outpatient services to the EOC. The cost share is $5 per day, except as described below under “Additional changes to specific plans.”
  • When it’s prescribed by a plan physician, we cover care at licensed residential treatment facilities in our service area. Facilities must provide 24-hour individualized treatment for chemical dependency or mental health. The following services are covered when they’re above the level of custodial care at one of these facilities:

    • individual or group chemical dependency or mental health counseling
    • medical services
    • room and board
    • social services
    • medication monitoring
    • drugs prescribed by a plan provider as part of the patient’s care, in accord with our drug formulary guidelines, and administered in the facility by medical personnel
    • discharge planning

This change also applies to Medicare EOCs.

Additional changes to specific plans

Plan names vary slightly by year. Names also are different for plans sold through CaliforniaChoice® .

Plan names

Change

Gold 80 HRA 2000/30 (2015)

Gold 2000/30 Deductible HMO + HRA (2014)

Cost share for chemical dependency day treatment and intensive outpatient programs is 20% coinsurance (up to a maximum of $5 per day), not subject to the plan deductible.

Silver 70 HMO 1000/40 (2015)

Silver 1000/40 Deductible HMO (2014)

Silver HMO B (CaliforniaChoice 2015)

Cost share for chemical dependency day treatment and intensive outpatient programs is 30% coinsurance (up to a maximum of $5 per day), not subject to the plan deductible.

Silver 70 HMO 1500/45 (2015)

Silver HMO C (CaliforniaChoice 2015)

  • Mental health and chemical dependency outpatient services are not subject to the plan deductible.
  • Cost share for chemical dependency day treatment and intensive outpatient programs is 20% coinsurance (up to a maximum of $5 per day), not subject to the plan deductible.

Silver 1500/45 Deductible HMO (2014)

Mental health and chemical dependency outpatient services are not subject to the plan deductible.

Bronze 60 HMO 5000/60 (2015)

Bronze 5000/60 Deductible HMO (2014)

Bronze HMO B (CaliforniaChoice 2015)

Cost share for chemical dependency day treatment and intensive outpatient programs is 30% coinsurance (up to a maximum of $5 per day), not subject to the plan deductible.

Bronze 60 HSA 3500/30 (2015)

Bronze 3500/30 Deductible HMO + HSA (2014)

Bronze HMO A (CaliforniaChoice 2015)

Cost share for chemical dependency day treatment and intensive outpatient programs is 30% coinsurance (up to a maximum of $5 per day), not subject to the plan deductible.

$40/$2,000 Deductible HMO Plan HSA (2014, 2015)

Cost share for chemical dependency day treatment and intensive outpatient programs is 30% coinsurance (up to a maximum of $5 per day), not subject to the plan deductible.

$40/$3,000 Deductible HMO Plan HSA (2014, 2015)

Cost share for chemical dependency day treatment and intensive outpatient programs is 30% coinsurance (up to a maximum of $5 per day), not subject to the plan deductible.

$30/$3,000 HSA-Qualified Deductible HMO Plan (2014, 2015)

Cost share for chemical dependency day treatment and intensive outpatient programs is 30% coinsurance (up to a maximum of $5 per day), not subject to the plan deductible.

$30/$1,500 Deductible HMO Plan with HRA (2014, 2015)

Cost share for chemical dependency day treatment and intensive outpatient programs is 20% coinsurance (up to a maximum of $5 per day), not subject to the plan deductible.

$30/$2,500 Deductible HMO Plan with HRA (2014, 2015)

Cost share for chemical dependency day treatment and intensive outpatient programs is 20% coinsurance (up to a maximum of $5 per day), not subject to the plan deductible.

We’ve already made the coverage and cost share changes reflected in this notice. When members receive services, they’ll pay the cost share shown in this notice. If your EOC doesn’t currently reflect the changes described above, you may see these changes in your EOC at renewal. If you have any questions about changes we’ve made to meet MHPAEA requirements, please contact your Kaiser Permanente representative.

SB 1168/HR 2851—continuation of coverage for college students

Effective January 2009,* California law SB 1168 protects coverage for dependent students on leave. A similar federal law, HR 2851, goes into effect in October, as contracts renew. Here’s what you need to know about the new legislation:

  • Commercial health plans and insurers are prohibited from terminating coverage for full-time dependent students over 18 during a break in the school calendar or a medically necessary academic leave of absence.
  • Coverage continues for up to one year or until coverage is scheduled to terminate under the plan’s terms and conditions, whichever comes first.
  • Documentation of the medical necessity must be submitted to Kaiser Permanente if our health plan certifies the students for coverage.

More information and helpful downloads

Information about the coverage will be included in student certification notices mailed to members beginning in April. To find out more:

Taxes

Minimum essential coverage and 1095 IRS reporting forms

The Affordable Care Act requires most U.S. citizens to have health coverage that meets a government standard — known as minimum essential coverage — or be subject to a potential tax penalty.

Starting in January, health plan subscribers will get one or more 1095 tax forms for the previous tax year, depending on their plan.

The forms apply to everyone with health coverage, except those who purchased a catastrophic plan through a health insurance marketplace such as Covered California. The form they’ll receive depends on the type of health plan they have:

 

Type of plan

Form

Individual and family through a marketplace

1095-A

Individual and family direct from carrier

1095-B

Small group (50 or fewer employees)

1095-B

Fully insured large group (more than 50 employees)

1095-B and 1095-C

Self-funded large group (more than 50 employees)

1095-C

 

Filing tax returns

When your employees fill out their tax returns, they should report any federal financial assistance they received toward health coverage. Additional tax forms will determine if the taxpayer receives a credit or owes payment. Subscribers will need to file Form 8962 to claim the premium tax credit or if advance payments were made to Kaiser Permanente.

Subscribers may have to pay a tax penalty if they:

  • had a coverage gap lasting more than 3 months
  • had more than one coverage gap in 2016
  • can’t claim an exemption in 2016

Subscribers may receive corrected forms, so it’s important to use the most current forms to ensure accuracy of information. Also note that not filing a return could affect a subscriber’s eligibility for federal assistance.

Review our fact sheet and Q&A for more information on minimum essential coverage and employer reporting or see below for information on each form.

1095-A, Health Insurance Marketplace Statement

  • For subscribers in plans purchased through a marketplace only. Excluding those who purchased a catastrophic plan.
  • The marketplace will mail out 1095-A forms starting in January 2017.
  • If a subscriber has questions about their form or need a corrected form, they need to contact the marketplace.
  • Reconciles advance premium tax credit to verify income and eligibility for assistance.
  • Needed to complete IRS form 8962.
  • The 1095-A requires the subscriber to file a 1040 tax form rather than a 1040EZ.
  • Lists all dependents along with the subscriber.
  • Lists coverage periods.
  • Subscribers with multiple plans will get separate forms for each plan. Nondependent children may get their own 1095-A.

1095-B, Health Coverage

  • For subscribers who purchased individual and family plans directly from Kaiser Permanente, including Charitable Hospital Coverage. Also for fully insured small and large group subscribers.
  • 2015 tax year forms were mailed by Kaiser Permanente between February 26 and March 15, 2016.
  • 2015 tax year form corrections: Corrected 1095-B forms were produced and mailed in April. They will continue to be produced and mailed on an ongoing basis, as corrections come in through December 31, 2016.
  • 2016 tax year forms will be mailed by Kaiser Permanente in January 2017.
  • Medicare, Medi-Cal, or Children’s Health Insurance Program subscribers receive their forms from the respective government agency.
  • Kaiser Permanente subscribers will also get a cover letter that explains:
    • what 1095-B is and why they’re getting it
    • what they need to do
    • contact information for replacement forms

1095-C, Employer-Provided Health Insurance Offer and Coverage

• For employees in large group plans who were eligible for benefits at least one month in 2015.

• Mailed by the end of March 2016 by the employer or plan sponsor.

• Employers who self-fund must also report which employees and dependents are covered.

• 1095-C identifies:

o Employee and employer

o Months during the year the employee was offered group coverage

o Cost of the cheapest monthly premium the employee could have paid under the plan

o Months of coverage in which the employee and/or dependents were enrolled in a self-funded plan

• If subscribers had benefits-eligible jobs with more than one employer during 2015, they’ll get a separate 1095-C from each employer.

• If subscribers weren’t eligible for benefits but averaged 30 or more hours per week in at least one calendar month during 2015, they should get a 1095-C.

• Subscribers and dependents covered through a self-funded plan will need to fill out Part 3 of 1095-C to show months of coverage.

• Subscribers in fully insured large group coverage will get both 1095-C from their employer and 1095-B from Kaiser Permanente:

o 1095-C tells subscribers the months of the previous year they were offered coverage by their employer

o 1095-B tells subscribers the months of the previous year they had coverage in a fully insured plan issued by Kaiser Permanente (including Kaiser Permanente Insurance Company)

• Subscribers in self-funded large group coverage will only get a 1095-C, sent from their employer.

• Those who waived coverage will get a 1095-C from their employer showing they were offered coverage.

Contact information

  • For questions about 1095-A, visit Covered California or call 800-300-1506.
  • For 1095-A duplicate forms, the subscriber must contact the marketplace.
  • For questions about 1095-B, contact Kaiser Permanente Member Services at 844-477-0450.
  • For questions about 1095-C, subscribers should ask the employer.
  • For more info on 1095-B from Kaiser Permanente, visit kp.org/proofofcoverage .
  • For more info on 1095-B from a government agency, visit the appropriate agency website.
  • Registered members can download duplicate or receive electronic forms at kp.org/proofofcoverage .
  • For tax information, visit IRS.Gov/aca or call the IRS at 800-829-1040.
  • For information on tax exemptions, visit healthcare.gov .

‡ Kaiser Permanente cannot give legal or financial advice. To find out more about claiming the subsidy as an offset against payroll taxes, contact the Internal Revenue Service .

This information was accurate at the time of posting. For the most current information, contact your sales executive.