Eligibility Guidelines

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 enrolled in a valid health plan. For purposes of calculating participation, the following are considered valid health plan waivers:

  • Covered by another employer’s health plan through a spouse, domestic partner, or parent

  • Covered by another health plan offered by this employer

  • Covered by another employer they work for

  • Group coverage through COBRA or Cal-COBRA

  • Covered by Medicare, Medi-Cal, or TRICARE (military or VA benefits)

  • Covered by an individual health plan

• 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.

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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.For Corporations and LLC's only:a corporate officer is considered a W-2 or common-law employee when on payroll.The officers can be husband and wife,domestic partrners,or unrelated. 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 Small Group permits our coverage to be written alongside another carrier's coverage ("sliced") only if that other coverage is a fully insured, age-rated, ACA-compliant small group metal or grandfathered (nonmetal) health plan.

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