Updated Qualifying Event Rules- Kaiser

Effective July 11, Qualifying Event2016, Kaiser Permanente is requiring an updated qualifying event (triggering event) form, in order to qualify California applications from Kaiser individuals and families outside of the normal open enrollment season.

Examples of triggering event documentation include

Kaiser’s New Rules For A Qualifying Event – What it’s about

The purpose of Kaiser Permanente’s new form is to clarify what qualifies as a Permanent Relocation.  Kaiser Permanente applications received outside of the normal open enrollment period must include the new form and documentation of qualifying health coverage from the prior insurance carrier in the last 60 days, plus one of the following:

  1. Utility Bill
  2. Copy of Rent Agreement

View the new rates: Get your personalized quote directly from Kaiser

Kaiser Permanente Individual and family plans website

A Closer Look at Permanent Relocation as a Qualifying Event

The Department of Health & Human Services, skilled at making simple programs far more difficult, issued some “help” in January 2016, as exemplified below:

If an individual moves to a new Exchange service area (i.e. state) and meets the requirements in 45 C.F.R. § 155.305(a)(3)—as explained in Questions 1 and 4 above—with respect to the new location, then the individual will meet the Marketplace residency requirement in the new location.

Did you enjoy that?  The document goes so far as to define the meaning of “intends to reside.” [ref: Q3. What does “intends to reside” mean?]

If you enjoy plowing through such rhetoric, read the full document here.  However, you would be much better served reading Michelle Andrews’ excellent contribution to Kaiser Health News, written last January.

If not, here’s another helping hand from our friends at the DEPARTMENT OF HEALTH & HUMAN SERVICES’ Centers for Medicare & Medicaid Services’ Center for Consumer Information and Insurance Oversight:

Q12. How does someone qualify for the Permanent Move S E P to enroll in a QHP or change their enrollment in a QHP?

To qualify for the Permanent Move S E P under 45 C.F.R. § 155.420(d)(7), a QI or his or her dependent must gain access to new QHPs as a result of a permanent move. 4 For the purposes of qualifying for this S E P, a move is considered permanent if a QI (or his or her dependents) moves and meets the Marketplace residency requirement—as described in Questions 1 and 4 with respect to a new location. An individual who moves to a new location temporarily without an intent to reside there or otherwise meeting the Marketplace residency requirement, including for personal pleasure or to obtain medical care, does not qualify for the Permanent Move S E P. Similarly, an individual who moves permanently, but does not gain access to new QHPs as a result of the move, would not qualify for the Permanent Move S E P. For example, this may occur if an individual permanently moves within the same apartment building, neighborhood, town, or county, depending on the QHPs offered in the individual’s service area.

Yummy!

Should I Buy The Obamacare Kaiser Plan?

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The Obamacare Kaiser Plan

The Obamacare Kaiser Plan can be purchased through CoveredCA, but Kaiser offers a similar plan if you apply to Kaiser, directly.  So which Kaiser plan is a better buy?

Obamacare Kaiser CoverageCAKaiser Permanente Direct   Questions?  Get Assistance

The chart below helps answer this question and compares the Kaiser Obamacare plan vs. Kaiser Direct

 
Obamacare Kaiser Plan Comparison ChartKaiser ObamacareKaiser Direct
Affordable Monthly Premium Cost$209 monthly$209 monthly
Insurance ProviderVia Covered CaliforniaVia Kaiser Permanente
Plan DescriptionLowest Cost "Minimum Coverage" PlanLowest Cost "Minimum Coverage" Plan
Price Quote AssumptionsAge 26, No Family, San Jose, CAAge 26, No Family, San Jose, CA

The above chart illustrates little difference between the two Kaiser plans.  Yet there are major differences involving the Obamacare Kaiser plan. You must read the rest of this article carefully to make an informed decision for your family.

Look: We found the Best Dental PPO Plan in Northern Calif.

Facts About Obamacare Kaiser That Media Has Under-Reported

Of course, there are many positive attributes of the Covered California Obamacare Kaiser plan. We will present topics in a pros and cons format, to give you both sides of the story, the advantages and the disadvantages of Obamacare Kaiser.

Important Differences Between Kaiser Obamacare and Kaiser Direct

ACTION PROS CONS SOLUTION
Apply To Kaiser Directly The same 6 “mirrored” plans are offered on the CovCA exchange and directly from Kaiser.  However, Kaiser offers 4 additional plans to choose from when you apply directly. You will receive no APTC subsidy, assuming you are eligible, when you apply to Kaiser directly. Work with a Certified Agent who could submit your application to both markets.  Under the ACA, only a Certified Insurance Agent is legally qualified to assist you both on and off exchange. Certified Agents cannot charge a fee.
Apply To Kaiser via Covered California (Obamacare Kaiser) You may qualify for a substantial APTC subsidy. If your income is too low, you may be ineligible for a Kaiser health plan, and get involuntarily placed into Medi-Cal, losing your doctor mid-year. Ask a Certified Agent to review your eligibility, because it is more complicated than simply looking at the CovCA 2016 Subsidy Chart.
CovCA application data must be verified (affirmed or denied) by the county social services agency. The decision to affirm or deny your eligibility is made weeks or months after the coverage has started, leaving you without options if they revoke your insurance mid-year (outside of “open enrollment).
If your income is too high, you may have to repay the IRS. Ask your Certified Agent to lower the monthly APTC subsidy to give a safety margin.  When you file your tax return, you will get the difference paid to you, if you are eligible for it.

Need more details? The Coverage California Blog has just released a Special Report on the Risk Factors of purchasing Obamacare through Covered California.

Caution is advised when you buy Kaiser Obamacare through CoveredCA:  You could lose control of your coverage, because the State of California (via your county Social Services office) has the power to take away your insurance plan (mid-year in some cases) and send your case to Medi-Cal to be reviewed for Medi-Cal coverage.

Silver Lining For Obamacare Kaiser

The silver lining is that some Medi-Cal recipients are allowed to keep Kaiser and pay virtually nothing.  To see if you qualify, talk to an experienced Certified Agent. We believe the starting point of comparing KAISER DIRECT vs. OBAMACARE KAISER plans should be under the guidance of a Certified Insurance Agent.  Only certified agents are legally qualified to compare plans from both sources.  Under the Affordable Care Act, Certified Agent Services are free for all Californians.

Conclusion

In summary, if you buy a Kaiser Direct health plan, you have more choices and you will probably get what you apply for.  If your income is between 134% and 400% of the Federal Poverty Level, you may wish to consider the advantages of receiving premium assistance from Covered California.  Get professional guidance!

Contact a local Certified Insurance Agent to get free assistance navigating your options.   Click to register for assistance or phone (408) 252-7300.
Eventbrite - Shopping For Obamacare And Better Covered California Insurance

Should We Change Our Company Kaiser Health Plan To Covered California?

Question: We are a non-profit organization located in California; is there any advantage if we change our company Kaiser health plan to Covered California?

Answer: Yes, non-profits (and for-profits) can take advantage of a special tax credit under the Patient Protection And Affordable Care Act, if eligible.

Question: Assuming we already have a group Kaiser policy, Is there any disadvantages if we change our company Kaiser health plan to Covered California?

Answer: Kaiser Permanente has “mirrored” group employee health plans, on and off the Covered California marketplace exchange. Therefore, if you change your company Kaiser plan to Covered California, your employees should enjoy the same level of benefits.

Question: Are premium rates lower if we change our company Kaiser health plan to Covered California?

Answer: The rates could be slightly lower, because Covered California group Kaiser rates do not include Pediatric Dental. This is a preferred omission for many small group employers who already offer a company dental plan.

There are additional benefits of offering the group edition of Covered California, including employee access to PPO plans with no minimum participation required. However, enrolling employees with Covered California group edition takes a little longer than normal, and Covered California requires your applications be submitted via a Certified Insurance Agent:

So start the process early, 45 to 60 days is ideal.

Eventbrite - Shopping For Obamacare And Better Covered California Insurance

December Kaiser Insurance Renewals Report Large Rate Increases

The editor of KaiserPlanet.org is raising concerns about December Kaiser Insurance Renewals that have gone through the roof.

We examined two December Kaiser insurance renewals and discovered rate increases of 38.0% and 31.6%, respectively.  Yet, the Kaiser Permanente “recommended” renewal plan was not the best choice for the employer in each of these two cases.

Other 2015 Kaiser Permanente health plan renewals were quite reasonable.  Why this polarization of plan costs?

“We found grandfathered plans suffered less, while non-grandfathered plan renewals were battered by several factors.”

For example, many December renewals are the direct result of the so-called “grandmothering” strategy of delaying your normal plan anniversary date to the last month of the year.

December Kaiser Insurance Renewals Report Large Rate Increases

What is happening now in California is a combination of several factors…

  1. Expiration of .90 to .95 Risk Adjustment Factors (RAFs)
  2. Expiration of pre-ACA pricing methodology e.g. 10-year age brackets
  3. Introduction of ACA rating rules e.g. 1-year age brackets for adults
  4. Families with more than one child begin to pay extra for each child up to 3
  5. Separate premium charge based on actual spouse birthdate
  6. Mandated Pediatric Dental and Vision
  7. New taxes and surcharges to fund Covered California subsidies
  8. Replacement of “grandmothered plans” with metal tier plans

Small Group Insurance Rate Increases are infuriating San Francisco start-ups and small family employers throughout the bay area.

“We are dumbstruck how Kaiser has mismanaged the communication of these changes, by not better educating small employers of what was coming.”

Further, in many of these renewals, Kaiser has made the decision to map the old plan to a more expensive renewal plan, bypassing what seem to be better-valued health plan options for the employer. Basically, it’s an unsolicited plan upgrade, but right when a small business can afford it the least.

Fortunately, there are strategies to mitigate the high cost of Kaiser rate increases.

“Kaiser is available through many channels, including PEOs, public and private exchanges and, of course direct. If you understand changing markets and where to look, you can often find better value.”

For more information about finding alternative Kaiser health plans or to contact the editor of KaiserPlanet.org, click here.

 

Affordable Care Act Tax Provisions for Small Employers

Some of the many Affordable Care Act tax provisions for small employers require the employer to provide an EIN (Employer Identification Number) on a W-9 form.  Employees who have not previously provided social security numbers may also have to do so (see additional details on this IRS webpage).

If you have 50 or fewer employees, you can purchase affordable insurance through the Small Business Health Options Program also known as SHOP.  Find a San Francisco Bay Area agent/broker who is certified to answer questions about SHOP and guide you through the regulatory changes.

Responsibility For Distribution Of SBCs (Kaiser)

Responsibility For Distribution Of SBCs (Kaiser)

What you should know

Summary of Benefits and Coverage (SBC) documents summarize important information about Kaiser Permanente’s health coverage options in a standard format developed by the Department of Health and Human Services. “SBCs” allow employees to easily compare benefits and coverage offered by Kaiser Permanente and other carriers.

You can search for SBCs at www.kp.org (make sure they are properly dated), review the Kaiser Permanente SBC guide, or ask a local broker to provide these forms, which may save a lot of time.

Responsibility for distribution of SBCs (Kaiser)

Under the Affordable Care Act, Kaiser small business employers are required to provide SBCs to participants and beneficiaries of the Kaiser Permanente plans that they offer. You may provide SBCs in either a paper or electronic format (read more about the safe harbor rule with electronic distribution).

For SBCs or a Glossary of Medical and Health Coverage Terms in Spanish or Chinese, go to the KP.org online literature order and tracking systemKaiser Permanente is not responsible for the content or policies of external Internet sites..

If you need help with SBCs, call our Kaiser enrollment assistant at 408.475.8219 or request a telephone session here.

SBC RESOURCES:

Kaiser Permanente and Tax Form 1095-A

Kaiser Permanente and Tax Form 1095-A

(Excerpts from a Kaiser Permanente Northern California FAQ released in January 2015)

What is Form 1095-A? What do I do with it?

If you or anyone in your household enrolled in a health plan through the health insurance marketplace in 2014, you’ll get Form 1095-A, Health Insurance Marketplace Statement from the marketplace. You should receive it in the mail by early February. Keep Form 1095-A with other important tax information, like your W-2 forms and other tax records. You’ll use information from the form to fill out your 2014 federal income tax return.

Consumers use the information included on Form 1095-A, Health Insurance Marketplace Statement, to complete Form 8962, Premium Tax Credit (PTC). Consumers file Form 8962 with their 1040 tax returns if they want to claim the premium tax credit or if they received advance payments (APTC) made to their insurance company.

Suggestion:  Did you know you can get free assistance with your insurance policy from a local Certified Insurance Agent…and there is No added cost to your policy?  The only requirement is that you reside in California.  If interested, just email a request to info@covered-ca.com or leave a voice mail or text message at 1.408.475.8219

1.  I’ve heard that my health coverage may impact my taxes. Is that true?

Yes, your 2014 health coverage affects your income taxes in two ways.

1)  Federal tax law requires everyone to have health insurance or to be eligible for an exemption from this requirement in 2014. If you and/or your dependents did not have qualifying health coverage, then you may owe a penalty.

For more information on exemptions for not having health coverage, visit:
https://www.healthcare.gov/fees-exemptions/exemptions-from-the-fee/.

2)  If you received federal financial assistance, you will need to report the amount you received throughout the year to the IRS on your taxes.

a) If the amount of assistance was less than the premium tax credit that you qualified for, then you should receive a credit.

b) If the amount of assistance you received was more than the premium tax credit that you qualified for, then you may need to pay some or all of the advance payment of the premium tax credit back.

c) You may have to complete one or two new tax forms.

d) You may have to get a health coverage exemption or pay a penalty with your tax return if you didn’t have health coverage in 2014. Some exemptions may not be available now. To learn whether you may qualify for an exemption, you should contact your marketplace.

For more information on how health coverage may impact taxes, contact your marketplace, or visit https://www.healthcare.gov/taxes/ or http://www.irs.gov/ACA.

2.  How was my federal financial assistance calculated?

The amount of Advance Premium Tax Credit (APTC — also called federal financial assistance for premium payment) that was paid on your behalf to Kaiser Permanente to lower your premiums in 2014 was based on the income and family size you estimated when you applied for health coverage, as well as the cost of the second lowest priced silver plan offered through your health insurance marketplace.

Based on your actual income and dependent information for 2014, your APTC premium tax credit will be recalculated and will be compared to the amount of the advance payments made to Kaiser Permanente for your premiums now that you’re filing your taxes. Keep in mind that any change to actual income or change in dependents from what you estimated could increase or decrease the actual premium tax credit for which you qualify in 2014.

If, based on your final 2014 information, the amount of assistance was

— less than you were entitled to, you may receive a credit on your taxes, or

 more than you were entitled to, you may need to pay some or all of the advance payment back.

3.  What do I need to file my taxes?

If anyone in your household enrolled in a health plan through the marketplace in 2014, you’ll need to use the 1095-A statement, which you will receive from the marketplace, when you file your federal income taxes. You should receive it in the mail by early February. Keep your 1095-A statement with your W-2 forms and other tax records.

Consumers use the information included on the 1095-A statement to complete Form 8962, Premium Tax Credit (PTC). Consumers file Form 8962 with their 1040 tax returns if they want to claim the premium tax credit or if they received advance payments (APTC) made to their insurance company.

For more information on the 1095-A statement, contact your marketplace, or visit https://www.healthcare.gov/taxes/ or http://www.irs.gov/ACA.

For more information on Form 8962 and Form 1040, visit http://www.irs.gov/ACA. You can also find copies of Form 8962 and Form 1040 on http://www.irs.gov/ACA.

4.  What is Form 1095-A? What do I do with it?

If you or anyone in your household enrolled in a health plan through the health insurance marketplace in 2014, you’ll get Form 1095-A, Health Insurance Marketplace Statement from the marketplace. You should receive it in the mail by early February. Keep Form 1095-A with other important tax information, like your W-2 forms and other tax records. You’ll use information from the form to fill out your 2014 federal income tax return.

Consumers use the information included on Form 1095-A, Health Insurance Marketplace Statement, to complete Form 8962, Premium Tax Credit (PTC). Consumers file Form 8962 with their 1040 tax returns if they want to claim the premium tax credit or if they received advance payments (APTC) made to their insurance company.

For more information on Form 1095-A, contact your marketplace, or visit
https://www.healthcare.gov/taxes/ or http://www.irs.gov/ACA.

5.  If I’m the main household subscriber, will I get one 1095-A statement or multiple 1095-A statements, for each member of the family?

If you are all on the same plan, you’ll get one statement, which has all the members of your household listed. If you are on separate plans, you’ll get separate 1095-A statements.

For more information on Form 1095-A, contact your marketplace, or visit
https://www.healthcare.gov/taxes/ or http://www.irs.gov/ACA.

6.  What if I enrolled in a health plan through the marketplace during a special enrollment period? Will I still get a 1095-A marketplace statement?

Yes, you will receive a 1095-A marketplace statement for the period of enrollment in the health plan through the marketplace.

For more information on Form 1095-A, contact your marketplace, or visit https://www.healthcare.gov/taxes/ or http://www.irs.gov/ACA.
7.  Will I have to pay a penalty if I was covered 10 months in 2014?

For more information, talk to your tax professional if you have one or visit http://www.irs.gov/uac/Am-I-required-to-make-an-Individual-Shared-Responsibility-Payment%3F.

8.  What is Form 8962?

Consumers file Form 8962, Premium Tax Credit (PTC), with their tax return if they want to claim the premium tax credit or if they received advance payments (APTC) made to their health plan. For more information on Form 8962, and to find a copy of Form 8962, visit http://www.irs.gov/ACA.

9.  What does reconciliation mean?

When you file your federal taxes, consumers who received federal financial assistance (also called subsidies) will use the information on Form 1095-A to complete Form 8962, Premium Tax Credit (PTC). You will use Form 8962 to compare how much your health plan received for 2014 premiums that were advance payments of your premium tax credit (based on an estimate of the amount you would be entitled to) to the final premium tax credit you qualify for. For more information, contact your marketplace, or visit https://www.healthcare.gov/taxes/ or http://www.irs.gov/ACA.

10.  How do I get a copy of my Form 1095-A? (I lost it or never received it.)

Contact your marketplace for another copy of Form 1095-A.

For Georgia and Virginia members: You can download a copy at HealthCare.gov in a new section of My Account.

For Colorado members: you can download a copy of your form under “my documents” in your Connect for Health Colorado account starting Tuesday, February 3, 2015.

For more information on Form 1095-A, refer to the Form 1095-A instructions, contact your marketplace, or visit https://www.healthcare.gov/taxes/ or http://www.irs.gov/ACA.

11.  Where can I get help filing my taxes?

Consumers may get free assistance with filling out their taxes. This may include free access to tax software programs, or free in-person assistance. For more information, visit http://www.irs.gov/freefile or http://www.irs.gov/VITA.

Consumers can also seek professional tax assistance. For more information about choosing a tax professional, visit http://www.irs.gov/Tax-Professionals.

If you have additional questions about your taxes, visit http://www.irs.gov/ACA.

12.  Why did I get more than one 1095-A?

Just as some households receive multiple W-2s if individuals have multiple jobs, some households will get multiple Form 1095-As if they were covered under different plans or made changes to their income or dependent information during the year. Be sure to keep all the 1095-As you get and keep them with your important tax documents.

Sometimes a consumer may receive a “Corrected” Form 1095-A. You should use the most recent Form 1095-A that you receive when you complete your taxes. For more information on Form 1095-A, refer to the Form 1095-A instructions, contact your marketplace, or visit https://www.healthcare.gov/taxes/ or http://www.irs.gov/ACA.

13.  What if I think information on my Form 1095-A is incorrect?

For information that you believe is incorrect on Form 1095-A, consumers should contact their marketplace call center for research and resolution.

For more information on Form 1095-A, refer to the Form 1095-A instructions, contact your marketplace, or visit https://www.healthcare.gov/taxes/ or http://www.irs.gov/ACA.

14. What if I already filed my tax return before I got my 1095-A, or before I got a corrected one?

You may have to file an amended federal income tax return. This means you’ll have to file a corrected version of your return with the IRS.

For more information about filing an amended tax return contact your tax professional if you have one, and/or your marketplace or visit https://www.healthcare.gov/taxes/. The IRS also has information about filing an amended return, visit https://www.healthcare.gov/taxes/marketplace-health-plan/.

15.  Will I get a 1095-A if I’m ONLY enrolled in a stand-alone dental plan or a minimum coverage plan (previously called catastrophic plan)?

No, you won’t get a 1095-A statement if you’re enrolled in a minimum coverage plan. These plans don’t qualify for subsidies. However, if you are enrolled in a stand-alone dental plan and a health plan, you may receive a 1095-A statement.

Suggestion:  Did you know you can get free assistance with your insurance policy from a local Certified Insurance Agent…and there is No added cost to your policy?  The only requirement is that you reside in California.  If interested, just email a request to info@covered-ca.com or leave a voice mail or text message at 1.408.475.8219

Kaiser Premium Assistance From Covered California

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Q: Is it possible to have a Kaiser Health Plan and a tax credit subsidy from Covered California?  Yes!

You potentially qualify as a California resident based on income, for example:

  • A single 32 year-old may qualify with household income under $46,000.
  • A family of 5 may qualify with household income under $110,000, as outlined in this chart.

See our related story to view premium rate examples of Kaiser premium assistance.

Premium Subsidy For Kaiser Members?GoldenGateBridge-Santa Clara

Caution Is advised, so get sound advice!  Qualifying for premium assistance can be more complicated than it seems and there could be complications.  One of the benefits of the new law is getting free consumer assistance from Certified Insurance Agents, the only professionals authorized by the State of California to explain the coverage difference of purchasing Kaiser directly or via a health care exchange.  Request a meeting with a Certified agent in the San Francisco Bay Area here.

Remember, in order to apply for coverage outside of the Open Enrollment window, you must have a Special Event.  Read more about Special Event Qualifying Events here.

Questions?  Get Kaiser Premium Assistance and Enrollment Help Now

4 Actions Employers Must Complete By October 1st

New Healthcare Laws Require Employers To Act Soon:

(Re-posted with permission from Coverage-CA.com)

  1. Download and properly distribute Summary Benefit Coverage forms by the appropriate deadline.  For a quick reference, download a free PDF Summary of SBC Requirements, which outlines employer requirements and deadlines.
  2. Heath Exchange Notices- This Department of Labor (DOL) regulation may surprise small employers who do not offer employee healthcare coverage:  The requirement hits them, too. Basically, the DOL requires that every employer hand out a disclosure form.  Further, the DOL has adopted different notices for different employer situations.  Make sure you are using the correct notice: Read more here.
  3. COBRA Notices- Amend existing COBRA notices to include new Department of Labor required language for employer COBRA disclosures.  Your COBRA administrator or vendor should be updating this notices.
  4. Move the money:  It is time to allocate monies you received in July, on behalf of your employees i.e. the Medical Loss Ratio (MLR) rebates.  Can you keep the refund?  Read our article about this very question.

Read the full article, at Coverage-CA, 4 Actions Employers Must Complete By October 1st