Kaiser Permanente FAQ

Use the links below to find frequently asked questions about individual and small business health insurance coverage. Our Kaiser Permanente FAQ is arranged in four categories: Enrollment, Plan Information, Current Members and Small Group Only FAQs.

Enrollment

Plan Information

Current Members

Small Group Only FAQs

If our FAQ fails to give you any needed information, please contact us through Facebook. We hope to answer all your questions and to make the process of finding medical insurance coverage for you, your family or your business as easy as possible.

Enrollment

How do I apply?

You can apply online or print an application. Use the links below to apply for individual and family or small business coverage:

How long does the application process take?

For individuals and families, completing the application usually takes about 30 minutes per person.

For small businesses, the process is more involved and the time increases depending on how many employees you are enrolling. For smaller groups that can quickly access business documents, the enrollment process could take as little as one to two hours.

The turnaround time for underwriting varies by state. Call 1-877-752-4737 for an update.

When will my coverage be effective and is there a deadline to meet?

For Adults:

Kaiser Permanente plans are effective the 1st and the 15th of the month following the approval of the application. The deadline dates are as follows:

California and Colorado

  • To be effective the 1st of the next month, submit a completed application by the 23rd of the month prior.
  • To be effective the 15th of the month, submit a completed application by the 8th of the same month.

Georgia:

  • To be effective the 1st of the next month, submit a completed application by the 25th of the month prior.
  • To be effective the 15th of the month, submit a completed application by the 10th of the same month.

For Children Under Age 19:

Kaiser Permanente California plans for children are effective the 1st of the month. The deadline is the 15th of the prior month. Note: Not all states are currently offering child-only coverage.

For Small Businesses:

Your coverage will begin on the first of the month. The deadline is not until the first; however, we recommend submitting paperwork at least one to two weeks in advance.

Do I need to have a Social Security Number to enroll?

Kaiser Permanente requires you to have a social security number or Tax ID number to enroll. There is an exception for children under the age of one; these children are not required to have a social security number.

What is HIPAA?

HIPAA (Health Insurance Portability and Accountability Act of 1996) offers health insurance to applicants who have been denied coverage under an individual/family plan. To qualify for HIPAA coverage an applicant must meet the eligibility requirements. One of the requirements is that they must have been on COBRA and have completed the allowed coverage under the COBRA plan. HIPAA plans tend to be more expensive, but offer a viable way of gaining coverage for applicants who do not qualify for a standard individual/family plan.

How long are my rates good for?

Individual and Family:

For those in California that have an effective date between January and June, rates will remain the same until the following January. For those that carry an effective date between July and December, rates will remain the same until the following July. 

In Colorado, rates change every January.  In Georgia, rates change at the annual policy anniversary date.

Your rates could change mid-term if you move to a different rate area or if you switch plans.

Small Business:

For groups that are not yet enrolled, rates will change for effective dates of January 1st and July 1st. To lock in lower rates, we recommend enrolling prior to June 1st or December 1st. Once you are enrolled, your rates lock in for one year from the policy effective date. Your rates could change mid-term if you move to a different rate area or you downgrade plans.

What factors will change my rates?

Individual and Family:

Below are the factors that will cause a subscriber's rates to change:

  • Moving to a Zip Code in a different rate area
  • Rates change in January or July
  • When the subscriber moves into a different age bracket. Adjustments for this reason are applied when the policy renews, which is either January or July, depending on the original effective date.

Small Business:

New enrollee rates are affected by age, zip code, family size and number of subscribers. In Colorado and Georgia, pre-existing conditions may also affect rates.

For existing groups, rates are also affected by annual rate changes as well as how often you use the plan. Each group is given an RAF (Rate Adjustment Factor), and the RAF can increase or decrease year to year based on useage. In simple terms, if you have members in your group with serious health conditions who utilize expensive healthcare services, this can cause the rates of all individuals on the plan to increase.

Should I choose group or individual coverage? Which one is less expensive?

If you qualify for both, be aware that pricing on individual and group plans vary case by case. Subscribers who are concerned they may be denied for a pre-existing health condition will often opt for group coverage because there is no medical underwriting. However, in the case that you may qualify for either, we recommend you get individual health insurance quotes and group health insurance quotes to compare rates and coverage options.

Do I need to have a physical?

For individual plans, you will need to fill out a health questionnaire. Typically, a physical exam is not required; in certain situations however, underwriting may require a physical exam in order to complete the medical review process.

For Small Business coverage, physicals are not required.

What if I have a pre-existing condition?

Adults:

Each applicant's medical history will be reviewed on a case-by-case basis. Medical underwriting determines the approval status. If an applicant receives a denial and feels it is unjust, he/she may appeal the decision. Each denial will state the reason denied, and give instructions on how to make any appeal if necessary. If you are denied and you are a business owner, consider Kaiser Permanente group insurance, which is not subject to medical underwriting.

Children under age 19:

Children under age 19 cannot be denied due to pre-existing conditions. However, they can be rated up.

Small Businesses:

No health questions are asked on group enrollment forms, and there are no denials for pre-existing conditions.

What if I'm pregnant?

Pregnancy is considered a pre-existing condition. Those applying for individual and family plans while pregnant will be automatically denied for private insurance. However, for group applicants there is no medical underwriting to pass. Small group applications are issued automatically, thus applicants applying for group coverage will not be denied for pregnancy or pre-existing conditions.

Is dental coverage available?

Yes, in some states. Kaiser Permanente California offers supplemental dental coverage through Delta Dental. You can apply for coverage by selecting this option on your application. For more information, click Health Insurance with Dental.

When can I add dental?

Individual and Family:

Delta Dental can be added to any Kaiser Permanente California Individual/Family plan within the first 30 days of your effective date. If you choose not to add the dental option when you apply, you may add dental coverage to your plan during open enrollment which is at the end of the year. Please call member services at 1-800-464-4000 for further information on how to add Delta Dental to your plan.

Small Business:

Dental can be added to any of the Kaiser Permanente plans when you enroll. If you choose not to sign up for dental when you apply, you may add dental coverage to your plan during open enrollment, which is the annual anniversary of your policy.

What are my payment options?

Individual and Family:

When you first apply, you can pay the initial premium by credit card or wait to be billed. On future bills, you will be sent a monthly invoice. If you wish to switch to an automatic payment option, you may do so once you receive your first bill. Simply, fill out and mail the Electronic Funds Transfer Form.

Small Business:

You may pay your first payment by check or by Electronic Funds Transfer. Then, you will be billed by mail. Once your enrollment is complete, you have the option of setting up an Online Account. Within this Online Account Service, you may request to have payments transferred automatically from your business bank account.

Plan Information

What is the difference between a copayment plan, deductible plan, and deductible HSA plan?

With a copayment plan you pay a discounted fee for covered medical services.

With deductible plans there are two types: the "HMO" and the "HSA" deductible plans. Under the HMO deductible plans, you pay a flat fee for office visits and prescriptions, if covered. For all other services, your payment will vary depending on the treatment up to the deductible amount. Once the deductible is satisfied, then you pay either a flat fee or a percentage of the remaining balance up to the maximum out-of-pocket amount, after which point, future eligible services will be free for the rest of the calendar year.

Under the HSA deductible plans, you pay for all services, including office visits and prescriptions, up to the deductible amount. Once the deductible is reached, then you pay either a flat fee or a percentage of the remaining balance up to the maximum out-of-pocket amount. After which point, future eligible services will be free for the rest of the calendar year.

Note: Annual preventive services are free under all the plans.

What is an annual out of pocket maximum?

This is the most that you will pay for medical services received in a calendar year. In CA, it includes the deductible, if applicable, as well as any copayments or coinsurance you pay for a covered service. Monthly premiums are ongoing expenses and are not included in the annual out-of-pocket maximum.

 

In CO and GA, the annual out of pocket maximum may or may not include the deductible. Also, copayments for doctor visits and prescriptions do not go towards the maximum, unless the services were first subject to a deductible.

Note: The annual out of pocket maximum does not apply to some specialty services such as drug rehabilitation and some preventative care services.

What is an HMO?

The acronym "HMO" stands for "Health Maintenance Organization". An HMO is an organization where the insurance company, doctors, and medical facilities are networked together in the same company. HMO subscribers choose healthcare professionals from within that network. Kaiser Permanente is an HMO. With the exception of certain group plans, Kaiser Permanente does not give the option of receiving medical coverage outside the network.

Am I covered when I travel?

Yes. Kaiser Permanente will cover you for emergencies and urgent care anywhere in the world, subject to the provisions of your policy.. The deductibles and copayments associated with your plan will apply. For more information, please view the Traveling Member Brochure. To receive care in other Kaiser Permanente regions, please view the Visiting Member Brochure.

Can I choose my own primary care physician?

Yes. You may choose your own personal physician from the Kaiser Permanente primary care doctors available in these specialties: internal medicine, family medicine, and pediatrics. Also, women may select an available obstetrician/gynecologist as their primary care physician.

Can I switch to a different Kaiser Permanente primary care physician?

Yes. You may switch to another Kaiser Permanente primary care physician for any reason.

Is maternity/pregnancy covered?

All of the plans include maternity benefits, except for these individual plans:

  • $40/3000 HMO Deductible Plan
  • $50/5000 HMO Deductible Plan
  • $40/4000 HSA Deductible Plan

However, if you are on one of these plans and you get pregnant, you can downgrade your plan to the $0/$5,000 HSA Deductible Plan, which does cover maternity.

Under the plans that cover maternity, there is no charge for scheduled prenatal care exams. Delivery is covered under hospitalization and the cost varies according to your chosen plan.

Which plan is best for maternity coverage?

For individuals and families, we recommend either the $25 Copayment Plan or the $30/1500 Deductible Plan for those who are thinking of having children. Under both plans, the routine prenatal care exams are no charge. The difference is that your out-of-pocket expenses differ for all other services, including the delivery. Under the $25 Copayment Plan, the delivery would be a flat fee of $200 per day. Under the $30/1500 Deductible Plan, the delivery would be subject to the $1500 deductible plus $500 per day. The $30/1500 Plan has a considerably lower premium than the $25 Copayment Plan, which is what makes it a competitive option. Obtain a health insurance quote to compare the rates and benefits. For small businesses, we recommend choosing a $5 to $30 copayment plan, or going with the $30/$1500 Deductible Plan.

Is infertility covered?

Kaiser Permanente does not cover infertility on any of the Individual and Family Plans. Limited infertility benefits are available only on two of the California Group Health Insurance plans (the $5 and $15 Copayment Plans).

Are prescription drugs covered?

Individual and Family:

Yes. Some plans cover prescription drugs for a copay. This can be before the deductible is met whereas other plans cover prescriptions after the deductible is met. The exception to this is the California Individual $50 copayment plan, the $30/$2700 deductible plan, and the $50/$5000 deductible plan which do not cover prescriptions at all.

Small Business:

Yes. All Copayment Plans cover prescription drugs with a copayment. Regular (non HSA) Deductible Plans cover prescription drugs with a copayment before the deductible is met. The $0/$2000, $0/$2700 and $30/$3000 Deductible Plans with HSA do not cover prescription drugs until after the deductible is met. Then, these plans offer prescription drugs with a copayment.

Do the plans cover vision exams and optical eyewear?

Individual and Family:

Eye exams for refraction are covered without charge under all the plans, except the HSA Deductible Plans, where the charge is subject to a deductible. Eyewear is not covered.

Small Business:

An eye exam for refraction is covered without a charge under the Copayment Plans and the HMO Deductible Plans. Under the HSA Deductible Plans, all eye exams are subject to the deductible.

Optical eyewear is covered under the $15 and $5 Copayment Plans, which offer a two-year allowance of $150 for eyewear. Otherwise, members enrolled under a small group plan are eligible for a 20 percent discount for eyewear purchased from Kaiser Permanente.

Are alternative medicine and chiropractic care covered?

Individual and Family:

Chiropractic benefits are included under the $30/1500 HMO Deductible Plan only. The coverage allows for 20 visits at a copayment of $15 per visit.

Small Business:

Kaiser Permanente offers an optional Chiropractic Group Plan which provides members with up to 20 chiropractic visits per year for a $15 copayment per visit.

Note: All Kaiser Permanente members can access a select network of complementary health providers to receive a 25 percent discount off regular rates for chiropractic, acupuncture, and massage therapy services. Some Kaiser Permanente benefit plans include coverage for certain of these discounted services. Plan benefits must be used before those discounted services are available.

What is meant by "per encounter"?

On Copayment Plans, this is the flat fee* a subscriber pays each time they go in to for labwork or X-ray. For example, if a subscriber went in one day and had six X-rays, they would pay $10. Then if the same subscriber went in the next day and had eight X-rays, they would still only pay the per encounter copay of $10.

*Note: On non-Copayment Plans, the charge for most labwork and X-rays is subject to the deductible.

What is the cost for a physical exam?

Starting with plans effective January 1, 2011, there is no charge for an annual routine physical exam.

Are there special plans for seniors on Medicare?

The Senior Advantage program combines Medicare and Kaiser Permanente coverage into one, which means more benefits, more convenience, and more services than traditional Medicare. Seniors who are currently on Medicare may apply for Kaiser Permanente's Senior Advantage program. For more information, you may contact Senior Advantage at 1-877-882-2703 or go to KP for Seniors.

Are there programs for low-income families?

Kaiser Permanente offers the Steps Program for low-income families, and the Child Health Plan program for children under 19.  However, both programs are currently not accepting new applications.  For more details, please call:

  • Steps Program at 1-800-255-5053
  • Child Health Plan Program at 1-800-464-4000
Are there Kaiser Permanente HSA plans?

Yes. The Kaiser Permanente Insurance Company offers a variety of high deductible health plans that are compatible with a Health Savings Account. If you are enrolled in one of these plans and would like to open a health savings account, you may set up an HSA Account with Wells Fargo or the financial institution of your choice.

What is an HSA?

“HSA” stands for "Health Savings Account". When you enroll in one of the HSA-compatible deductible plans, you have the option of opening up an HSA account with Wells Fargo or the financial institution of your choice. Having an HSA enables you to set aside money for medically related expenses.  Also, the funds in an HSA bank account are not subject to income tax at the federal level.

Current Members

What if I move?

If you move, you will need to contact Kaiser Permanente and change your address on file. This may affect your rates and eligibility.

How can I add a family member to an existing plan?

Individual and Family:

You will need to complete an application for a new member. In California, Kaiser Permanente is no longer offering family plans, so this person will be on their own plan. However, if you have a grandfathered plan that was in place before March 23, 2010, you may be able to add this person to your plan, which may save you a lot of money. If you do not have a grandfathered plan, go ahead and apply for individual health insurance in the regular way. If you think your plan may qualify as grandfathered, please call 1-877-752-4737 for more information.

Small Business:

Complete and submit the Employee Change Form. Call 1-877-752-4737 and select option 3 to request a copy of the form. Be aware that unless there is a qualifying event, you will need to wait until open enrollment to add family members.

Small Group Only FAQs

If I'm self-employed or own a small business, do I qualify for group coverage?

You will need a minimum of 2 eligible individuals. Combinations may include 2 owners, a husband and wife, 1 owner and 1 employee, etc. Your group must have between 2 and 50 subscribers to qualify for a small group plan. Exceptions may apply. For assistance with your particular Group, contact KaiserQuotes.com at 1-877-752-4737, option 3.

What is your minimum employer contribution requirement?

There is a required minimum company contribution of 50 percent of the employee only rate for the under 30-age category of the least expensive plan that is enrolled for. However, if the company offers an alternate competitor plan, it is required to be the equal dollar amount; whichever is greater. Any part of the cost not paid by the employer must be collected from the employees through payroll deduction.

Do my employees on a group plan need to reside in a specific area?

All new membership under a group plan is limited to those individuals who live or work within the Kaiser Permanente service area.

What is an open enrollment for small business?

Open enrollment occurs each year. It is the month prior to your plan anniversary or renewal date. Kaiser Permanente will send you a renewal proposal packet approximately two months before your renewal date. During open enrollment, you can switch plans, or add employees or dependents that previously opted out, for example. If no changes are needed, no action is required. If you are interested in making a change or need more information, complete the Renewal Change Instruction form found in the renewal proposal packet, or contact KaiserQuotes.com at 1-877-752-4737.

 
 
 
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