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.


Should I Buy The Obamacare Kaiser Plan?


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

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.


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

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.