Kaiser Permanente policies

Coordination of Benefits in California — 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 you may have business needs that require you to change Kaiser Permanente plans in the middle of the accumulation period. Depending on the kinds of changes made, a midyear1 plan change may effect your 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
Deductible funding policy

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

When your 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 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 clients informed with the latest, download and print this policy. If you have questions, please contact your Kaiser Permanente representative.

Full-time-equivalent employees

Per Kaiser Permanente policy, your number of full-time-equivalent employees (FTEEs) is calculated by combining the 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).

Kaiser Permanente Small Group slice carrier policy clarification

Kaiser Permanente Small Group permits our coverage to be written alongside another carrier’s coverage (“sliced”) only if that other coverage is a fully insured, age-rated, ACA-compliant small group metal or grandfathered (nonmetal) health plan.

Plans that don’t qualify to be sliced and can’t be written alongside our coverage are non-ACA plans, composite-rated plans, level-funded or self-funded plans or association health plans (AHPs), including coverage for an AHPs issued by a carrier regulated by the California Department of Insurance.

The current policy set forth in the Underwriting Guidelines and the Employer Application will be modified with these clarifications accordingly. This is effective immediately.

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.

Information may have changed since publication.