Small Business Guidelines

 

This document provides information about Kaiser Permanente small business coverage, eligibility, rate calculation, benefit plan offering, funding policies, and participation and contribution requirements.

Underwriting Guidelines

Get information about Kaiser Permanente's approach to evaluating and offering coverage to new and existing small business accounts.

Refer to this version for groups with 2023 effective dates.

Refer to this version for groups with 2022 effective dates.

New group forms

 
Attestation for Alternative Funded Plans/Composite Rates

Use this form if a group will offer Kaiser Permanente HMO (and PPO) in California while offering an alternative funded plan or composite rate plan out-of-state.

 
Broker Census

Use this form for new and renewing groups.

 
Broker of Record Authorization (New Group)

Your clients must complete this form to grant authorization for you to apply online for coverage on their behalf. Completed forms are uploaded as part of the online submission process.

 

Declination and Waiver of Coverage Forms

  • Submit a Declination of Coverage form to list all eligible subscribers who have declined Kaiser Permanente coverage.
     

Declination of Coverage

 

Waiver of Coverage

Eligible employees can use this form to decline Kaiser Permanente coverage and return to their employer. This form is only for employer records and doesn't need to be submitted to Kaiser Permanente. Employers can use this form to transfer employee information to the Declination of Coverage form.

Waiver of Coverage

 
Employer Application – 2023

Use this form to enroll with a January 2023 effective date or later.

 
Employer Application – 2022

Use this form to enroll with a January – December effective date.

 
Employee Enrollment

Your clients’ employees can use this form to enroll with Kaiser Permanente.

Avoid service delays — The signature must be under the Arbitration Agreement and not above it. If it’s not signed correctly, Small Business Accounts will not enroll the member and will need to request a new signature on the form.

 
Electronic Transfer for Payment

Your clients can use this form to authorize their first month payment by electronic transfer.

 
New Employee Eligibility

Your clients can use this form to document new eligible employees hired in the previous 30 calendar days.

 
Owner/Officer Eligibility Statement

Your clients can use this form to provide proof of eligibility for proprietors, partners, and corporate officers not appearing on their DE 9C form.

 
Payroll attestation

Your clients can use this form if they're a new business (start-up, breakaway or establishing payroll from an existing business) and don't have payroll to document eligible employees.

 

Existing group forms

Attestation for Alternative Funded Plans/Composite Rates

Use this form if a group will offer Kaiser Permanente HMO (and PPO) in California while offering an alternative funded plan or composite rate plan out-of-state.

 
Contact Change Request

Your clients can use this form to change their billing contact, interested party contact, or contract signer information.

Use our new electronic signature form – completed documents will route directly to KP for processing

 
Customer Address or Name Change Request

Your clients can use this form to change their company address, name, or federal tax ID (EIN) number.

Use our new electronic signature form – completed documents will route directly to KP for processing

 
Employee/Dependent Change

Your clients’ employees can use this form to add or remove dependents from their accounts, change addresses, or change names.

Use our new electronic signature form – completed documents will route directly to KP for processing.

 
Employee Enrollment

Your clients’ employees can use this form to enroll with Kaiser Permanente.

Use our new electronic signature form – completed documents will route directly to KP for processing.

 
Employer Attestation for COBRA/ CAL-COBRA & TEFRA Status

Use this form to let us know if you have a COBRA status change from CAL-COBRA to Federal COBRA or Federal COBRA to CAL-COBRA. Write in the effective date of change on the form.

Use our new electronic signature form – completed documents will route directly to KP for processing

 
Federal COBRA application

For groups with 20+ eligible employees, use the Federal COBRA application to cover your client’s former employees and their dependents. For groups with 2–19 eligible employees, your client’s former employees must contact the Kaiser Permanente Member Service Contact Center at 1-800-464-4000 for enrollment assistance.

 
Group Termination

For more information, please contact the Account Management Support Team at 800-790-4661 option 3.

 
HIPAA Authorization

Your clients can use this form to authorize use and/or disclosure of patient health information.

 
Employer Application – 2022

Use this form to enroll with a January – June effective date.

Use this form to enroll with a July – December effective date.

 
Participation and contribution attestation

Your clients must complete this form to attest that their company continues to meet the minimum participation and contribution requirements for small business coverage.

 
Payroll attestation

Your clients can use this form if they're a new business (start-up, breakaway or establishing payroll from an existing business) and don't have payroll to document eligible employees.

 
Primary Administrator Online Access Request

Your clients can use this form to request access to our secure online account services and set up automatic payments for the second month onward.

 
Plan Add/Change Request - 2022

Groups that have already renewed for 2022 and wish to add or discontinue plans should use this form to request a midyear plan change prior to their next renewal.

Use our new electronic signature form – completed documents will route directly to KP for processing

 
Subscriber Termination and Transfer

Your clients can use this form to terminate an employee’s coverage or transfer an employee to a different enrollment unit.

Use our new electronic signature form – completed documents will route directly to KP for processing

 

Employer — new group enrollment

Administrative Handbook

Find everything you need to complete your group enrollment and administer your plan in one place.

  • How to get started with Kaiser Permanente

  • Who to call with your questions

  • Where to get important forms

  • Answers to frequently asked questions

  • English (PDF)

 
Save time, view your contracts online flyer

Learn how to access and view your current and past contracts 24/7 via your online account. 

 
Sample DE 9C

This sample DE 9C is the quarterly wage and withholding report for California employers and is used to report wage and payroll tax withholding information for each employee.

Please note each employee’s health coverage status next to their name as shown in this Sample DE 9C.

 
Employer's confirmation of workers' compensation coverage

Complete this form to confirm you have workers’ compensation coverage for all eligible employees.

 
Small Business Guidelines

This document provides information about Kaiser Permanente small business coverage, eligibility, rate calculation, benefit plan offering, funding policies, and participation and contribution requirements.

English (PDF)

Employer — new group forms

 
Employer Application – 2023

Use this form to enroll with a January 2023 effective date or later.

 
Employer Application – 2022

Use this form to enroll with a January – December effective date.

 
Employee Enrollment

Your clients’ employees can use this form to enroll with Kaiser Permanente.

 
Electronic Transfer for Payment

Use this form to authorize your first month payment by electronic transfer.

Employer — existing group forms

 
Contact Change Request

Use this form to change billing contact, interested party contact, or contract signer information.

Use our new electronic signature form – completed documents will route directly to KP for processing

 
Customer Address or Name Change Request

Use this form to change company address, name, or federal tax ID (EIN) number.

Use our new electronic signature form – completed documents will route directly to KP for processing

 
Employee/Dependent Change

Your employees can use this form to add or remove dependents from their accounts, change addresses, or change names.

Use our new electronic signature form – completed documents will route directly to KP for processing

 
Employee Enrollment

Your employees can use this form to enroll with Kaiser Permanente.

Use our new electronic signature form – completed documents will route directly to KP for processing

 
Electronic Transfer for Payment

Use this form to authorize your first month payment by electronic transfer.

 
Terminating employee coverage
  • Cal-COBRA packet information - When your employees are no longer covered, Cal-COBRA packets can be sent directly to them by writing “Please send Cal-COBRA packet” at the top of the Subscriber Termination and Transfer, and Reinstatement form. Be sure to confirm the correct member mailing address is on file with us prior to submitting the form.
     

  • Federal COBRA application (PDF)- For 20+ eligible employees, use the Federal COBRA application to cover former employees and their dependents. If you have 2–19 eligible employees, your former employees must contact the Kaiser Permanente Member Service Contact Center at 1-800-464-4000 for enrollment assistance.

 
Employer Attestation for COBRA/ CAL-COBRA & TEFRA Status

Use this form to let us know if you have a COBRA status change from CAL-COBRA to Federal COBRA or Federal COBRA to CAL-COBRA. Write in the effective date of change on the form.

Use our new electronic signature form – completed documents will route directly to KP for processing

 
Group Termination

For more information, please contact the Account Management Support Team at 800-790-4661 option 3.

 
Grievance/Complaint Form

Grievance/Complaint Form is required by CA AB2470 to be provided to the group and for the group to provide it to their employees. Instructions for use and where to submit it are included in the form.

 
Payroll attestation

Use this form if you're a new business (start-up, breakaway or establishing payroll from an existing business) and don't have payroll to document eligible employees.

 
Plan Add/Change Request — 2022

Use this form to request a midyear change to add or discontinue plans prior to your next renewal.

Use our new electronic signature form – completed documents will route directly to KP for processing

 
Subscriber Termination, Transfer and Reinstatement

Use this form to terminate an employee’s coverage or transfer an employee to a different enrollment unit.

Use our new electronic signature form – completed documents will route directly to KP for processing

 
Small Business Change of Ownership
 
Medicare Part D Creditable Coverage Disclosure to CMS Form

Employers who offer prescription drug coverage to Medicare-eligible individuals are required to notify their beneficiaries and the Centers for Medicare & Medicaid Services (CMS) if their coverage is creditable or not.

  1. ALL employers must complete and submit the online Disclosure to CMS form and use the Federal ID #: 94-1340523.

  2. Reference these flyers to determine which plans offer creditable coverage 2023 flyer (PDF), or 2022 flyer (PDF).

Find out more information about Part D Creditable Coverage from CMS .

Employer — recertification

 
Small business recertification

Small business recertification is required annually to confirm that your business still meets the criteria of a small business as defined by the state of California and still qualifies for small business coverage with us.

 
Recertification booklet

Reference this booklet to review the recertification process, answers to frequently asked questions, a summary of your appeal rights, and a checklist of documents you’re required to submit.

 
Documents required for recertification

To ensure your recertification is processed quickly and accurately, please submit the following documents along with a copy of your current business license.

  1. Current DE 9C
    The DE 9C form is the quarterly wage and withholding report for California employers and is used to report wage and payroll tax withholding information for each employee.

    Please note each employee’s health coverage status next to their name as shown in this Sample DE 9C (PDF).

     

  2. Employer's confirmation of workers' compensation coverage (PDF)
    Complete this form to confirm that you have workers’ compensation coverage for all eligible employees in your small business.

     

  3. Declination and Waiver of Coverage Forms

    • Use the Declination of Coverage form to list all eligible subscribers who have declined Kaiser Permanente coverage. This form doesn't need to be submitted to Kaiser Permanente.

      Declination of Coverage
      English (PDF) | Español (PDF) | 中文 (PDF) | Tiếng Việt (PDF)

       

    • Waiver of Coverage. Your clients' eligible employees can use this form to decline Kaiser Permanente coverage and return to their employer. This form is only for employer records and doesn't need to be submitted to Kaiser Permanente. Employers can use this form to transfer employee information to the Declination of Coverage form.

      Waiver of Coverage

  1. Owner/officer eligibility statement (PDF)
    Use this form to provide proof of eligibility for proprietors, partners, and corporate officers not appearing on the DE 9C. Additional tax forms may be requested.

     

  2. Participation and contribution attestation (PDF)
    Complete this form to attest that your company continues to meet the minimum participation and contribution requirements for small business coverage.

 

If you have additional questions, please call the Recertification Team at

877-490-4983.

Methods to submit your required recertification documents.

Fax: 866-233-7847
Email: recert@kp.org
Mail: Kaiser Permanente
Small Group
Recertification Team
P.O. Box 7094
Pasadena, CA 91109-9641

 
New employee eligibility documentation
 
Employee/dependent change request
 
Employee enrollment form
 
Subscriber termination and transfer
 
Contact change request
Customer address or name change