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.

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).

Multi-market solution group eligibility guidelines

• Broker must be licensed and appointed in each additional market.
• The multi-market solution is only offered for standard plans and does not apply to exchanges or level-funded plans.
• There is no longer a need to validate via the Secretary of State's website for business licensure or check the employer in multiple markets (except HI—Department of Labor (DOL) # required) or “single state validation” because these are extensions of the first group.
• Small group size is defined by state law, and any market with enrollment must adhere to it.
• Group size is determined by pooling all FTEs/employees across all markets.
• California has a threshold of 100 for small groups and requires the majority* of employees to reside in their specific market to issue a small group contract.
• GA has a threshold of 50 for small groups and requires the majority* of employees to reside in their specific market to issue a small group contract.
• All other market groups must have up to 50 employees. (A total group size greater than 50 cannot be issued small group contracts outside of CA/CO.)
• Each region is rated individually and valid for the entire renewal period.
• Clients will continue to receive a contract and billing invoice from each service area which have a Kaiser Permanente small group plan contract.
  

Change in our participation requirements for slice groups

Effective January 1, 2025, when a new group enrollment is sliced against another health plan carrier, they must have these minimum eligible employees' requirements.

• Less than 20 eligible employees - at least one eligible employee is enrolled.
• Between 20 to 50 eligible employees - at least three eligible employees are enrolled.
• 51+ eligible employees - at least five eligible employees are enrolled.
• Applies to only new sales and not to existing renewals.

_{*Kaiser Permanente is only required to offer a small group contract if the majority is met. We may issue a small group contract with ACA provisions/protections that a large group doesn’t provide. Colorado small groups must have between 1-100 employees.}

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.