ELIGIBILITY

You may be eligible for Kaiser Permanente's guaranteed issue and guaranteed renewable small group health plans if you meet and continue to meet certain requirements. These requirements are defined in the Affordable Care Act (ACA) and the California small group law and as outlined in Kaiser Permanente's Small Business Guidelines. They include:

  • You must offer health plan coverage to 100% of your eligible employees.

  • You must have at least one but no more than 100 full-time and full-time-equivalent (FTE) employees for at least 50% of your business's working days for the previous calendar quarter or previous calendar year. 

  • A full-time employee is a permanent employee actively engaged in the conduct of business on a full-time basis. It doesn't include a sole proprietor or their spouse, and a partner or their spouse. A full-time employee must have a normal workweek averaging 30 hours per week over the course of a month, work at your regular place of business, be subject to withholding on a W-2 form, and have met their group's waiting period, if applicable.

  • FTE employees are a combination of employees, each of whom individually isn't a full-time employee (because they're not employed on average at least 30 hours per week), but who, in combination, are counted as the equivalent of a full-time employee.

  • A minimum of one W-2 employee (not including the sole proprietor owner, partners, their spouse or legal domestic partner) is required.

  • You must ensure that at least 50% of eligible employees are covered by group coverage.

  • Affiliated companies under common control are required to apply for coverage separately, unless they're eligible to file a combined tax return for the purposes of state taxation. In determining group size, affiliated companies eligible to file a combined tax return for purposes of state taxation are considered one employer, even if you're not presently filing together.

  • You must have a workers' compensation insurance when required by law.

INELIGIBILITY

Your business is ineligible for small group coverage if it’s wholly owned by you or you and your spouse, and you don’t have at least one eligible employee other than you or your spouse. Contractors (1099), seasonal and temporary employees, private household help, and domestic help are ineligible for coverage.

RE-ENROLLMENT AND REINSTATEMENT

Re-Enrollment - If your coverage was terminated voluntarily or involuntarily, then you may request a new effective date for coverage to re-enroll as a new group provided you qualify for small group coverage. A new group number and contract will be issued. 

Reinstatement - For groups where your Kaiser Permanente coverage was terminated for less than 60 days, you may request reinstatement of your prior contract to avoid a gap in coverage. Kaiser Permanente will consider this request provided unpaid premiums are paid and you qualify for small group coverage.

Common ownership - If you've obtained a new business name and/or tax ID number, or if you're a former group customer, the same re-enrollment rules will apply to a group with common ownership. Common ownership groups may include, but aren't limited to: like ownership, like business, like membership or demographics.

 

GENERAL RULES AND REQUIREMENTS

  • Your minimum contribution must be at least 50% of the employee premium for the lowest-priced Kaiser Permanente medical plan you offer.

  • It's your responsibility to ensure that you don't apply a waiting period of more than 90 days (in accordance with the ACA). The effective date of coverage for new employees and their eligible family dependents is always on the first of the month and that date must not go beyond the maximum 90-day waiting period.

  • Kaiser Permanente writes alongside other groups (also known as slice) if the rates are also age-banded. We won’t write alongside a carrier with composite rates, nor do we support composite rates from an employer.

  • Groups can only move at renewal from CaliforniaChoice to Kaiser Permanente or from Kaiser Permanente to CaliforniaChoice (regardless of current Kaiser Permanente enrollment).

  • Kaiser Permanente doesn't write in slice position along CaliforniaChoice or Covered California (Kaiser Permanente is offered as an option within this exchange).

Plan and Benefit Options

Chiropractic/acupuncture

For 2020 Plan Designs

Combined Coverage is included for the following ACA-compliant metal plans:

  • Platinum 90 HMO 0/10 + Child Dental Alt

  • Gold 80 HMO 500/30 + Child Dental Alt

  • Silver 70 HMO 1650/55 + Child Dental Alt

  • Silver 70 HMO 1800/55 + Child Dental Alt

For 2021 Plan Designs
 

Combined Coverage is included for the following ACA-compliant metal plans:

  • Platinum 90 HMO 0/10 + Child Dental Alt

  • Gold 80 HMO 0/30 + Child Dental Alt

  • Gold 80 HMO 1000/40 + Child Dental Alt

  • Silver 70 HMO 1650/55 + Child Dental Alt

  • Silver 70 HMO 2100/55 + Child Dental Alt

  • Silver 70 HMO 2600/55 + Child Dental Alt

  • Bronze 60 HMO 5400/60 + Child Dental Alt

Chiropractic/acupuncture for grandfathered (nonmetal)

 

Optional chiropractic/acupuncture coverage is available for grandfathered (nonmetal) plans, except for HSA-qualified high deductible health plans (HDHP).

  • If you offer chiropractic/acupuncture coverage, all subscribers and dependents must participate.

  • You can add coverage only at renewal.

  • You can discontinue coverage anytime up to 4 months before your renewal date or at renewal.

Infertility

The optional infertility benefit is available to groups with 20 or more eligible employees where Kaiser Permanente is the sole carrier.

  • This benefit will be added to all HMO plans, when selected.

  • All metal PPO plans include this infertility benefit.

     
You can only add or cancel this benefit upon renewal if the benefit isn’t part of your original contract. 

Supplemental Family dental plans (optional)

  • Supplemental family dental plans are available only to those enrolled in a Kaiser Permanente medical plan.

  • If you choose a family dental plan, all subscribers and dependents must participate.

  • The DeltaCare HMO family dental plan isn’t offered with PPO medical plans.

  • Kaiser Permanente family dental plans cover the entire family, including adults and dependent children up to age 26 (if you offer dependent coverage). Supplemental family dental plans are not a substitute for ACA required child dental coverage of members under 18 years old.

Child Dental

  • All metal HMO and PPO plans cover the ACA-defined essential health benefits, which include child dental services.

  • HMO members are enrolled in a separate child dental benefit underwritten by Delta Dental of California.

  • PPO medical plan members receive child dental PPO benefits as part of their medical coverage and not as a separate plan.

  • Child dental services apply to all members under 19 years old. If a child turns 19 before the current contract renews, coverage is extended until the contract renewal date.

Child vision

Durable Medical Equipment

  • Child vision benefits are included on all ACA plans.

  • High-level features include routine vision exam and eyewear (eye-glasses and contact lenses). See benefits for any exclusions and limitations.

  • Supplemental and base DME coverage is included on all ACA plans.

At the Dentist
Caring Child

 Rating & Policy Information

General Rating Information

Plan rates include many variables, such as benefit costs associated with the delivery of health care for all our small group customers as a whole. We then adjust the plan rates according to rating factors applicable to the plan type — grandfathered (nonmetal) or metal. Final rates are based on actual group enrollment. Rates are guaranteed for 12 months and are valid only from the effective date stated in the group contract.

The rate calculation for ACA-compIiant metal plans is different from the rate calculation for grandfathered (nonmetal) plans. 

    Metal plan rating 

Metal plan rates are calculated using 2 factors — rating area and member age. Claims or utilization experience isn't used to determine member premium rates. 

        Rating area 

  • If your business is located inside California, rates are based on physical address (ZIP code and county) of your business.

  • If your business is located outside of California, it's assigned to rating area 4. 

  • A post office box or other purchased address can't be used as your address. If we discover that you're using an address other than your business's physical location, we may rescind or terminate your coverage.

    
        Member age

  • Each family member has a separate rate based on his or her age as of the effective date of the group contract. This rate will be used for the full contract year and updated yearly at renewal. 

  • If a family has more than 3 children under age 21, the premium for each additional child after the third will be $0. 

  • Age bands are 0-14, 15, 16, 17, 18, 19, 20, every age from 21 to 63, and 64+.

  • All plans include child dental for members under 19 years old as of the group contract effective date. HMO plans apply the cost of child dental only to the 0-14, 15, 16, 17, 18 age bands. PPO plans include the cost of child dental coverage in the overall rate.

Multiple plans options (MPO)

You're eligible to offer a choice of plans to your employees. The number of medical plans you can offer is based on the number of enrolled Kaiser Permanente subscribers:

  • Groups with 1 to 5 enrolled subscribers can offer a choice of up to 3 Kaiser Permanente plans.

  • Groups with 6 or more enrolled subscribers can offer a choice of one or more Kaiser Permanente plans.

PPO

•   A group can't offer more than one PPO plan.
•   Kaiser Permanente must be the sole carrier for all medical coverage.
•   You must offer the PPO plan to all eligible employees.

If you have out-of-state employees, the maximum subscribership can't exceed 30% of the overall group enrollment. For example: A group of 10 subscribers can't have more than 3 out-of-state employees on a PPO plan.