Arbitration fact sheet

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.

Kaiser Permanente Broker Code of Conduct

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.

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

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

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.

Renewal date change requests

Effective May 1, 2022, Kaiser Permanente Small Group implemented an updated renewal date change request policy.

Existing groups wanting to align their renewal date with another carrier’s health plan renewal date may only request this change if the new renewal date is on January 1 of the following year.

• An employer will receive a rate increase when the renewal date changes to the new rate period.
• For grandfathered (nonmetal) plans only, an employer’s Risk Adjustment Factor (RAF) may be adjusted if the employer’s new renewal date is at least 6 months later than the current renewal date.
• Rates established by a plan are in effect for no less than 12 months from the date of issuance or renewal of the plan contract.
• To facilitate a renewal month change, a group must request an early contract termination and a new 12-month effective on the new date. Any applicable rate increases in effect on the new date will apply.

New groups may request to align their renewal date with another existing carrier’s renewal date within 30 days of the original effective date. The new renewal effective date must be within 6 months of the original effective date. For example, if the original effective date is January 1, the proposed effective date can be no later than June 1.

To move forward with this voluntary process, new and existing groups must request the Renewal Date Change Request form and new groups must submit proof of the other carrier’s new policy.

For questions or assistance, new groups may contact their assigned Sales Associate, and existing groups may email the Account Management Support Team at AMT@kp.org.
 

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).

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

Payroll attestation forms are no longer required for startup groups with 1-5 eligible employees. However, groups enrolling non-emancipated minors are still 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 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.