Rating and 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 Plan 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 4 HMO Kaiser Permanente plans, plus 1 PPO plan for a maximum of 5 plans.

• Groups with 6 or more enrolled subscribers can offer a choice of 1 or more HMO Kaiser Permanente plans, plus 2 PPO plan.

PPO

•   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 49% of the overall group enrollment. For example: A group of 10 subscribers can't have more than 4 out-of-state employees on a PPO plan.