Your Kaiser Permanente AdministrAtion HAndbook · Your guide to providing high-quality health care to your employees Your Kaiser Permanente AdministrAtion HAndbook

Your guide to providing high-quality health care to your employees

Your Kaiser Permanente AdministrAtion HAndbook

How to reach usEmPLoYEr QUEstions

For questions concerning:

■ Contracts ■ Renewals ■ Benefits

mail or fax membership forms to the appropriate kaiser Permanente department below.

SouthernCalifornia NorthernCalifornia

Fax:(858)614-3345 Fax:(858)614-3344

KaiserFoundationHealthPlan KaiserFoundationHealthPlan

P.O.Box23250 P.O.Box23219

SanDiego,CA92193-3250 SanDiego,CA92193-3219

Note:Ifyoufaxthedocument,youneednotmailit.Pleaseincludeyourgroup’sIDnumberon

allcorrespondenceandreviewbillingstatementsforrequestedchanges.

EmPLoYEE (mEmbEr) QUEstions

For questions concerning:

■ Memberbenefitsandclaims ■ Member-billedCOBRAandCal-COBRA(state)

■ Availableservices ■ Applicationsforindividualplans

mEmbEr sErvicE cALL cEntEr

1-800-464-4000English1-800-788-0616Spanish1-800-757-7585Chinese dialects

7a.m.to7p.m.,MondaythroughFriday;7a.m.to3p.m.,SaturdayandSunday(excludingholidays)

onLinE

Onlinesupport—E-mailusyourquestionsatAMT@kp.org.Pleaseincludeyourgroupnumber.Wewill

respondtoyourrequestwithintwobusinessdays.

Forgeneralinformation—FormoreinformationonKaiserPermanente,pleasevisitkaiserpermanente.org.

For group-related questions concerning:

■ Groupmembershipchanges ■ COBRA(federal)

■ Accounttermination ■ Billing/Paymentinformation

▼▼

▼

Please fax contract changes and forms to: 1-800-369-8010

1-800-790-4661,option1

8a.m.to5p.m.,MondaythroughFriday

customer service center

8:30a.m.to5p.m.,MondaythroughFriday

1-800-790-4661,option2Account management team

Everything you need to complete your group enrollment and administer your group health plan is right here.

Howtoreachus..................................................................... insidefrontcover

WelcometoKaiserPermanente.....................................................................3

sEction 1—Completingyourinitialgroupenrollment

Enrollmentchecklist..........................................................................................4

Declination of Coverage Form........................................................................7

Proprietor/Partner/Corporate Officer Form.................................................9

sEction 2—Administeringyourgrouphealthplan

Frequentlyaskedquestionsaboutadministeringgrouphealthplans...12

OnlineAccountServices.................................................................................18

Online Account Services User ID Request Form........................................23

COBRAandCal-COBRA.................................................................................25

Avoidingprocessingdelays...........................................................................26

Forms.................................................................................................................28

Account Change Form........................................................................29

Student Certification...........................................................................31

Termination Report.............................................................................33

Temporarypaymentcoupons...........................................................35

Temporarypaymentenvelopes............................. backcoverpocket

Tableof contEnts

2

3

Welcometo KaisEr PErmanEntE

ThankyouforselectingKaiserPermanenteforyourcompany’shealthcarecoverage.

Welookforwardtoprovidingyouandyouremployeeswithhigh-qualityhealthcare.

Thisbookletcontainsessentialinformationtohelpyoucompleteyournewgroupenrollment

andadministeryourKaiserPermanentehealthcareplan.We’veincludedeverythingyou

need—importantphonenumbers,answerstofrequentlyaskedquestions,andforms.In

thebackofthehandbook,wehavealsoincludedyourtemporarypaymentcouponsand

envelopes.Pleaseusethesecouponsandenvelopestomakemonthlypremiumpayments

untilyoureceiveyourfirstbill.

BesuretoalsotakeadvantageofOnlineAccountServices—aneasyonlinetooldesigned

tohelpyoumanageyourgroup’scoverage.Pleasetakeafewmomentstoreviewinformation

onOnlineAccountServicesonpage18.Ifyouhaveanyquestions,pleasecontactus.

Remember,we’reheretohelp.

■ Forquestionsaboutcompletingyourinitialgroupenrollment,callyour

KaiserPermanentesalesrepresentativeat1-800-730-4661forassistance.

■ Forquestionsaboutadministeringyourgrouphealthplan,refertothe

“Howtoreachus”guideinsidethefrontcoverforcontactinformation.

ThankyouforchoosingKaiserPermanente.Welookforwardtoalongandhealthy

relationshipwithyou.

4

comPlEtingYour initial grouP EnrollmEnt

¸ Enrollment cHEcKlist

Follow these six simple steps to complete your group’s enrollment

Tohelpusprocessyourenrollmentaccurately,pleasecompleteandreturnalltheitemslistedbelow.

Enrollingissimpleandfast,andcanbecompletedbyfaxformostgroups!

1.New Group Application—Ifyouhavenotalreadydoneso,completeandfaxthisformtostartyour

group’sapplicationprocessrightaway.Membershipislimitedtothoseindividualswholiveorworkwithin

theserviceareaZIPcodes.TorequestaNewGroupApplication,pleasecallyoursalesrepresentative.

2.Employee Enrollment Form—Makesureeachemployeecompletes,signs,anddates

hisorherenrollmentapplication.Pleasemakesureemployeeskeepphotocopiesoftheirenrollment

applicationstobeusedalongwiththeirTemporaryMembershipIDs.

3.Declination of Coverage—Alleligibleemployeeswhovoluntarilydeclinetoenrollinthehealthplan

duringtheenrollmentperiodmustcompleteandsigntheDeclinationofCoverage.

4. dE 6 (quarterly wage report)—Includeacopyofyourmostrecentquarterlywagereport.Ifyou

donotfileaDE6,manyotherdocumentsmaysatisfytherequirement(e.g.,afictitiousbusinessname

statement,currentbusinesslicense,legalpartnershipagreement,articlesofincorporation,etc.).Please

consultyoursalesrepresentativetodiscussyouroptions.

5.copy of initial premium—Pleasemakeyourfirstmonth’spremiumcheckpayabletoKaiserPermanente.

Photocopythecompletedpremiumcheckandincludethecopywiththeenrollmentforms.Important:Your

companynamemustbeprintedonthecheck.Also,writeyourpurchasernumberandyourgroup’seffective

dateonyourcheck.Faxtheitemslistedaboveto1-800-369-8010.

5

Ifyouareunabletofaxthedocuments,mailthemtothefollowingappropriateaddress.

(Sendingmaterialsviaovernightdeliverywillexpeditetheenrollmentofyourgroup.)

U.s. mail address overnight delivery address Kaiser Permanente Kaiser Permanente Small Business Unit Small Business Unit P.O. Box 7104 100 S. Los Robles, 4th Floor Pasadena, CA 91109 Pasadena, CA 91109

6.Firstmonth’spremiumcheck—Onceyourgroup’senrollmentisconfirmed,mailtheoriginal

premiumchecktotheappropriateaddresslistedbelow.

northern california groups KaiserFoundationHealthPlan,Inc.

FileNumber73030

P.O.Box60000

SanFrancisco,CA94160-3030

southern california groups KaiserFoundationHealthPlan,Inc.

FileNumber5915

LosAngeles,CA90074-5915

Forassistance,pleasecallyourKaiserPermanentesalesrepresentativeat1-800-730-4661.

6

7

IhavebeenofferedgrouphealthcoveragethroughKaiserFoundationHealthPlan,Inc.(HealthPlan),bymyemployer,

______________________________________________________________________.Groupnumber_______________________.

IvoluntarilychoosenottoenrollintheHealthPlanthroughmyemployeratthistime.Iunderstandmynextopportunity

toenrollmyselformyeligibledependentswillbeduringtheopenenrollmentperiod.TheHealthPlan’sEvidenceof

Coveragealsoinformsthegroupofmyenrollmentrightsdueto:(1)specialenrollmentduetonewdependents,and

(2)specialenrollmentduetolossofothercoverage.

ReasonPrintemployee‘sname Employee’ssignature SocialSecuritynumber Date (mustcheckonebox) ❑Iamcoveredbyother

groupinsurance.

❑Ideclineemployer-sponsoredhealthcoverage.

❑Iamcoveredbyothergroupinsurance.


















dEcLinAtion oF covErAgE

––

––

––

––

––

––

––

––

––

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(Pleasefilloutthisformforanyproprietor,partner,orcorporateofficernotlistedontheDE6.)Toestablishtherelationshipbetweenproprietors,partners,and/orcorporateofficerstothebelow-referencedcompany,pleasecompleteandreturnthisform.

Iattestthat,althoughmynamedoesnotappearonthe DE 6wagereportofthebelow-namedcompany,thefollowingconditionsaretrue:

1. Iamasoleproprietor,partnerofapartnership,orcorporateofficer.

2. Iactivelyworkatthebelow-namedcompany.

3. Idrawwages,dividends,orotherdistributionsfromthebelow-namedcompanyonatleastamonthlybasisandamnoteligibleforgrouphealthcoveragefromanyotheremployment.

4. Iworkonapermanent,full-timebasisforthebelow-namedcompanyforatleast20hoursperweek.

5. Isatisfiedthedesignatedwaitingperiodbeforecoveragebecameeffective.

6. Imustprovide,uponrequestfromKaiserPermanente,acopyofmycompany’sfictitiousnamestatement,DBA,legalpartnershipagreementandScheduleK,articlesofincorporation,ScheduleC,currentbusinesslicense,orcurrentprofessionallicense.

IunderstandthatthisinformationmaybesubjecttoverificationandagreetoprovideKaiserFoundationHealthPlan,Inc.,withanyinformationnecessarytodoso.IalsounderstandthatfailuretomeettheaboveconditionsmayresultindenialorterminationofgrouphealthcoveragefromKaiserFoundationHealthPlan,Inc.,forthebelow-namedcompany.

XProprietor,partner,orcorporateofficer’ssignature

Printproprietor,partner,orcorporateofficer’sname

Title

Date

Companyname

XProprietor,partner,orcorporateofficer’ssignature

Printproprietor,partner,orcorporateofficer’sname

Title

Date

Companyname

ProPriEtor/PArtnEr/ corPorAtE oFFicEr Form

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administEringYour grouP HEaltH Plan

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Accounting and billing

▲WhomdoIcontactwithbillingquestions?

YoumayuseOnlineAccountServicestochecktheenrollmentstatusofyouremployees,verifybills,

andconfirmreceiptofpayment.Visitemployers.kaiserpermanente.org,selectyourcompany’s

region,andclickon“Accessaccount.”

YoumayalsocalltheCustomerServiceCenterat1-800-790-4661,option1,from8a.m.to5p.m.,

MondaythroughFriday.

▲WherecanIfindmygroup’srates?

PleaserefertoyourrenewedGroupAgreementcontract,whichwillbemailedtoyouatleast30days

priortoyourgroup’sanniversarydateeachyear.

benefits

▲WherecanIfindinformationaboutmygroup’sbenefits?

PleaseseeyourGroupAgreementcontract.

▲Whomdomyemployeescalliftheyhavebenefitquestions?

YouremployeesandtheirfamiliesmaycallourMemberServiceCallCenterat1-800-464-4000,from

7a.m.to7p.m.weekdays,and7a.m.to3p.m.weekends(excludingholidays).

cobrA and cal-cobrA

▲HowdoIputsomeoneonCOBRAorCal-COBRA?

PleaserefertotheCOBRA/Cal-COBRAsectiononpage25ofthisbooklet.

FaQFrequently asked questions aboutadministeringgrouphealthplans

13

contract and rates

▲HowcanIgetacopyofmyGroup Agreement contractorfindoutaboutrates?

CalltheAccountManagementTeamat1-800-790-4661,option2,from8:30a.m.to5p.m.,Monday

throughFriday.

Account authorization

▲CanIauthorizeotherpeopletoaccessandadministermygroupaccount?YoucanassignanemployeeoryourbrokerasanInterestedParty.AnInterestedPartyisanindividual

authorizedtoaccessandadministerprivateinformationaboutyourgroupaccountonyourbehalf.

ToassignanInterestedParty,pleasecalltheCustomerServiceCenterat1-800-790-4661,option1,

toobtainaPurchaserContactChangeForm.Faxthecompletedformto1-800-369-8010.Ifyouhave

furtherquestions,pleasecalltheCustomerServiceCenterat1-800-790-4661,option1,from8a.m.

to5p.m.,MondaythroughFriday.

dates

▲HowcanIfindoutmygroup’srenewal/anniversarydate?

PleaserefertoyourGroupAgreementcontract.

▲Whatisanevent date?

Aneventdateisthedateofaqualifyingeventthatresultedeitherintheenrollmentofanemployeeor

intheadditionordeletionofadependent.

Examples of event dates:

■ Dateofbirth ■ Datecoveragewaslost ■ Dateofhire

■ Dateofmarriage ■ Dateofadoption ■ Dateofrehire

FaQ

14

dental

▲HowandwhencanIaddDeltaDentalcoverage?

YoucanaddDeltaDentalcoverageonyourgroup’srenewal/anniversarydate.ForDeltaDentalof

Californiahighlightsandrates,calltheAccountManagementTeamat1-800-790-4661,option2,

8:30a.m.to5p.m.,MondaythroughFriday.

dependents

▲Whatisthemaximumagelimitfordependentchildren?

Childrencanstayonagroupplanuntiltheyare19;studentscanremainontheplanuntilthey

are24ifthesubscribercompletestheStudentCertificationForm.Disableddependentsmay

remainontheplanaslongastheymeettheeligibilityrequirementsfordisableddependents.

PleaserefertoyourGroupAgreementfordetails.

▲HowdoIaddordeletedependents?

Toaddordeleteadependent,completeanAccountChangeForm(providedonpage29of

thisbooklet).YoumayalsoaddordeletedependentselectronicallyusingOnlineAccount

Services.Visitemployers.kaiserpermanente.organdselectyourcompany’sregion;thenclick

on“Accessyouraccount”(seepage18formoreinformation).

▲Arefamilymemberscovered?

Employeescanenrollspouses,domesticpartners,biologicalchildren,adoptedchildren,

stepchildren,childrenoftheirdomesticpartners,orchildrenforwhomtheemployeehas

obtainedlegalguardianshipasdescribedintheGroupAgreement.

FaQcontinued

15

Enrollment

▲HowdoIenrollanewemployee?

Onceanewemployeehascompletedthenew-hireeligibilityperiod,theemployeeneedsto

completeandsignanEnrollmentForm.Youmayenrollnewemployeeselectronicallyusing

OnlineAccountServices.Visitemployers.kaiserpermanente.organdselectyourcompany’s

region.Clickon“Accessyouraccount”(seepage18formoreinformation).Ifyoudonothave

accesstotheInternet,sendcompletedenrollmentformsviafaxormailto:

northern california southern california KaiserFoundationHealthPlan KaiserFoundationHealthPlan



Fax:(858)614-3344 Fax:(858)614-3345

▲HowdoIgetanEnrollment FormoranAccount Change Form?

YoumayrequestformsbycallingtheCustomerServiceCenterat1-800-790-4661,

option1,8a.m.to5p.m.,MondaythroughFriday.OryoumayvisitourWebsiteat

kp.org/ca/smallbusinesscustomertodownloadandprinttheseandotherforms.

▲HowdoIfindoutifyouhavereceivedanEnrollment Formoran Account Change Form?

CalltheCustomerServiceCenterat1-800-790-4661,option1,from8a.m.to5p.m.,Monday

throughFriday.Wecanverifywhetherwehavereceivedfaxedformsafter72hours.Mostformsare

processedwithin7to10daysofreceipt.

▲Whendoescoverageforarehirebecomeeffective?

Coverageforarehireiseffectiveonthefirstofthemonthfollowingthedateofrehire,iftherehire

dateiswithinoneyearoftheoriginalterminationdate.Iftherehiredateislaterthanoneyear

followingtermination,theemployeeisconsideredtobeanewhireandmustsatisfythenew-hire

eligibilityperiod.

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▲Whatislossofcoverage?

Lossofcoverageiswhenanemployeeloses

grouphealthcarecoveragethroughnofault

ofhisorherown.Theemployeeiseligible

forcoverageonagroupplanonthefirstof

themonthfollowingthedateofloss.When

completingtheEnrollmentForm,check

“Other”intheenrollmentboxandwritein

lossofcoverage.(Inthiscase,theeventdate

isthedatecoveragewaslost.)

▲Whatisanew-hireprobationaryperiod?

Thenew-hireprobationaryperiodisthelength

oftimeanemployeemustwaitbeforebecoming

eligibleforhealthcoverageonthefirstofthe

followingmonth.Youselectyournew-hire

probationaryperiodwhenyouactivateorrenew

yourcontract.

▲Whatisopenenrollment?

Openenrollmentistheperiodoftimeduring

whichyouareallowedtoofferhealthcare

coveragetoemployeeswhodidnotelect

coveragewhentheybecameeligibleandto

addemployeeswhowishtochangetheirhealth

carriers.Employeesmayalsoadddependents

notpreviouslyenrolledduringthistime.

Openenrollmentusuallyoccursduringthe

monthbeforetheanniversaryofyourcompany’s

enrollmentinKaiserPermanente.

▲Howmanyhoursdoesmyemployee havetoworktobeeligibleforhealth coverage?

Employeesmustwork20hoursormoreperweek.

Youmaydetermineyourcompany’sowneligibility

requirementsaslongaseligibleemployeeswork

atleast20hoursperweek.

17

identification card▲HowcanmyemployeesobtainservicespriortoreceivingKaiserPermanente identificationcards?

Employeescanreceivecareatourfacilitiesanytimeafteryourgroup’scoveragebecomes

effective.AnemployeewillsimplyfillouttheTemporaryMembershipIDFormfoundinthe

enrollmentbookandpresentittothereceptionist,alongwithacopyofhisorherEnrollment

FormandpictureID.

▲HowcanmyemployeesreplacetheirKaiserPermanenteidentificationcards?

EmployeescancallourMemberServiceCallCenterat1-800-464-4000from7a.m.to7p.m.

weekdays,and7a.m.to3p.m.weekends(excludingholidays).

information online▲CanIdownloadinformationandformsfromyourWebsite?

Foryourconvenience,thefollowingdocumentscanbedownloadedandprintedatanytimefrom

ourWebsiteatemployers.kp.org.

■ AccountChangeForm

■ SubscriberTerminationandTransferForm

■ COBRAInformationSheetandCOBRAEnrollmentForm

■ PlanChangeRequestForm

■ ContinuationofCoverageOptions

■ RequestforScheduleA

■ StudentCertification

■ DisabledDependentEnrollmentApplication

termination▲HowdoIterminateanemployee’scoverage?

UsetheTerminationReportonpage33.AllformsmustbereceivedbyKaiserPermanente

withintwomonthsofthedateoftermination.Theeffectivedateisalwaysthefirstofthemonth

followingthedateoftermination.

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onlinE account servicesit’s easier electronicallyNomatterwhatsizeyourbusinessis,youcantakeadvantageofKaiserPermanente’stime-saving

e-businessfunctions.

our Web site is simple to use—you’ll be surprised at just how easy it is to manage your account online.

You’ll have round-the-clock access to help ensure the accuracy of your bills and reduce processing times.

register for our e-business services today.

Efficienteligibilitymanagement

Visitemployers.kaiserpermanente.organdselectyourcompany’sregion.Clickon“Accessyour

account.”Fromthere,youcan:

■ take a tour of our online services.

■ register. WhenyoufilloutaUserIDRequestForm,we’llmailyouaccessand

sign-oninstructions.

■ sign in.Useyourusernameandpasswordtoaccessandmanageyouraccount

anytimeusingouronlineadministrationtools.

Withouronlineservices,youcanlogonanytimetoenrollorterminateemployeesandtheirdependents

andamenddemographicinformation.Mosttransactionsarecompletedimmediately.Pleaseprintacopy

ofthecompletedformsforyourrecords.

Promptcustomerservice

Useouronlinefunctionstochecktheenrollmentstatusofyouremployeesandtheirdependents,

verifybills,andconfirmreceiptofpayments.OurWebsiteoffersconvenientcommunicationwith

ourAccountManagementTeam.

19

Onlinebillpayment

There’snomorewaitingforbillstoarriveinthemail—withourpaperlessbillingfunction,we’lle-mail

youwhenyourbillisreadyforviewing(youwillcontinuetoreceiveapaperbillinthemail).Youcan

submityourpaymentelectronically.Onlinedataentryandcommunicationbetweenyourgroupand

KaiserPermanentehelpimproveaccuracyofinformation.

WhatareOnlineAccountServices?

OnlineAccountServicesaresecurefeaturesdevelopedspecificallytohelpemployersmanage

theirKaiserPermanenteaccounts.Theseservicesallowyouto:

■ Addorterminateemployeeanddependentcoverage*

■ Changeemployeeanddependentdemographicinformation

■ Viewalistofsubscribersandtheircovereddependents

■ Viewyourbalancedue

■ Viewtransactionhistory

■ Viewyourmonthlybill

■ Payyourbill

Aretheseservicesfree?

Yes.

Areenrollmentchangesimmediatelycompleted?

Demographicandcoveragechangesarecompletedimmediately.(Coveragechangesmayinclude

addinganewborn,newspouse,orotherdependents,aswellasterminations.)Thatmeanstheyare

registeredonoursystemwhenyouclickthe“Submit”button.Terminationsareeffectivethefirstday

ofthefollowingmonth.Whentheonlinesystemcan’tmatchtheenrolleetoanexistingrecordwith

100percentaccuracy,theinformationwillbesenttoanaccountadministrationrepresentativefor

manualprocessing.Ourservicegoalistoprocesstheseenrollmentswithintwobusinessdays.

*Whenaddinganemployee,pleaseprintacopyoftheEnrollmentForm,havetheemployeesign

theform,andkeepitforyourrecords.

onlinE account services

20

onlinE account services continued

CanIstilltransmitmembershipinformationviaelectronicfiletransfer?

Yes.Infact,weencourageit.Sendingmembershipchangeselectronicallyisagreatwaytogo.

However,theonlinefunctionscanstillbenefityouby:

■ Providingaquickwaytogetastatusonyouraccountwithoutmakingaphonecall

■ Allowingyoutoworkaccordingtoyourschedule,withoutlimitingyoutoKaiserPermanente’s

servicehours

WillIstillreceiveapaperbill?

Yes,youwillalsoreceiveapaperbill.

DoIhavetousetheInternetforeverything?

No.WeareofferingyoutheuseoftheInternetasanadditional,convenientwaytoworkwith

KaiserPermanente.WebelieveitmakestheadministrationofyourKaiserPermanentehealthcare

planeasier.ThinkofOnlineAccountServicesasa“healthplanATM,”asitprovidesyouwithfast

service.Youwillstillhaveanassignedaccountadministrationrepresentativewhoisavailablefrom

8a.m.to5p.m.,MondaythroughFriday,forone-on-onecustomerservice.

WillthisservicehandleCOBRAenrollments?

Yes,youcanprocessCOBRAenrollmentsusingOnlineAccountServices.*

*ThisfeaturedoesnotapplytoCOBRAplansdirectlybilledtothemember.

21

WillmyemployeeshaveaccesstotheOnlineAccountServicessite?

No.Thesiteisonlyfortheuseofyourdesignatedcompanyrepresentativetomanageyourhealth

planaccountsonline.EmployeeswhohaveselectedKaiserPermanenteastheirhealthplancanuse

ourWebsite,members.kaiserpermanente.org,to:

■ Requestroutineappointments*

■ Usethehealthanddrugencyclopedias

■ Contactapharmacistwithanonurgentquestion*

■ Accessotherusefulfeaturestohelpthemmanagetheirhealthcare

CanIcreateanadditionaluserIDforanotherperson?

Absolutely.KaiserPermanentewillprovideyouwithoneuserIDthatgivesyouadministrator

privileges.ThatIDallowsyoutocreateadditionaluserIDsforthoseyouwishtoaccessthesite

andtovarytheirprivilegesaccordingtotheirresponsibilities.(Youwillfindthisfunctionunder

the“Accountaccess”drop-downmenuwithinOnlineAccountServices.)

WhencanIbeginusingOnlineAccountServices?

AssoonasyoureceiveyourpurchaserID,youcanpreviewOnlineAccountServicesbytakingasite

tour.AttheendofthetouryoucandownloadaUserIDRequestForm(thisformcanalsobefound

onpage23ofthishandbook)andfaxittous.YoushouldreceiveauserIDandpasswordinthemail

withinsevenbusinessdayssoyoucanbeginusingthesite.Pleasenotethatyoumustlistyourselfas

the“Requester”ontheform.Forsecuritypurposes,wewillonlymailtheuserIDandpasswordtoyou.

*Someservicesarenotavailableinallareas.

22

23

Note:Forsecuritypurposes,onceauserIDisestablished,aconfirmationletterthatcontainstheuserIDandtemporarypasswordwillbesenttotheindividualresponsibleforthegroup’scontract.

Accountstoaccess

Requestersignature Title

Name(pleaseprint) Phonenumber

Mailcompleteformto: Orfaxto: KaiserPermanente KaiserPermanente CustomerServiceCenter CustomerServiceCenter P.O.Box23758 Attn:WebSecurityAdministrator SanDiego,CA92193-9915 (858)614-3315 Attn:WebSecurityAdministrator

Pleasecompleteallsectionsofthisform(excepttheshadedareaatthebottom,whichwillbecompletedbyKaiserPermanente).

Purchasername Date

Groupadministrator(contact)name

Mailingaddress

City State ZIPcode

Phonenumber Faxnumber

E-mailaddress(required)

Authenticationcode

() ()

()

Please enter 4 to 10 letters and/or numbers as your authentication code, and keep this code in your records for future reference. (if your administrator-level password needs to be transferred to a different individual, or becomes disabled and needs to be reactivated, this code will help us authenticate the request.)

Purchaser/Groupnumber(6digits) Billingunit/Subgroup(4digits)

Datereceived: Datecreated:

AssigneduserID: Temporarypassword:

online Account services usEr id rEQuEst Form

24

25

Federalandstatelawsrequireemployersandhealthplanstooffercontinuedhealthcoverage

toeligibleterminatedemployeesandtheirdependents.Thechartbelowshowsinformationon

benefits,rates,andeligibility.IfyouneedfurtherinformationonCOBRA,pleasecalltheCustomer

ServiceCenterat1-800-790-4661,option1,8a.m.to5p.m.,MondaythroughFriday.

IfyouneedfurtherinformationonCal-COBRA,pleasecalltheMemberServiceCallCenterat

1-800-464-4000,7a.m.to7p.m.,MondaythroughFriday,and7a.m.to3p.m.,weekends(exceptholidays).

cobrA cal-cobrAbenefits same as the group plan

Yes Yes

ratesTheoriginalgrouppremiums,plusapplicableadministrativefee

Theoriginalgrouppremiums,plusapplicableadministrativefee

Eligibility

Forgroupsof20ormore

employees:allfamilymembers

whowerecoveredunderthe

originalgroupplancoverage

Forgroupsof19orfewer

employees:allfamilymembers

whowerecoveredunderthe

originalgroupplancoverage

For individual memberinformation or an application

Thegroupadministrator

mustcalltheCustomerService

Centerat1-800-790-4661.

Theemployeewhois

terminatingmustcallthe

MemberServiceCallCenterat

1-800-464-4000.

cobrA cal-coBra

and

26

Avoiding processing delays

Topreventprocessingdelays,youshouldsubmitcompletedEnrollmentForms

throughoutthemonth—assoonasyoureceivethemfromyouremployees.Delays

inprocessingareoftenduetomissingandinaccurateinformation.Usethefollowing

checklisttohelpmakecertainallthenecessaryinformationiscompleteandcorrect.

Formscanbefaxedormailedto:

NorthernCalifornia SouthernCaliforniaKaiserFoundationHealthPlan KaiserFoundationHealthPlan



Fax:(858)614-3344 Fax:(858)614-3345

Haveyouincludedthefollowing?

■ Groupnumber

■ Enrollment/Billingunitnumber/plan

■ Medicalrecordnumber(ifknown)foreachsubscriberanddependent

■ Dateofbirthforeachsubscriberanddependent

■ SocialSecuritynumberforeachsubscriberanddependent

■ Fulladdresses

■ Signatureofthesubscriber

■ Dateofhireorqualifyingevent

Remembertokeepacopyforyourrecords.

Avoiding processing delays

28

Usethefollowingformstorequestchangestoyouraccount.Ifyouneedadditionalforms,youcanmake

copiesoftheoriginalsorcalltheCustomerServiceCenterat1-800-790-4661,option1,from8a.m.to

5p.m.,MondaythroughFriday,toordermore.Youcanalsodownloadandprinttheseformsonlineat

anytimethroughourWebsiteatemployers.kaiserpermanente.org.

Account Change Form:Usethisformtoenrollnewemployees,addordeletedependents,ormake

addressornamechanges.Seepage29.

Student Certification:Thesubscribermustcompletethisformcertifyingthatthedependentqualifies

forcoverageasaneligiblestudent.Seepage31.

Termination Report:Completethisformtoshowterminationstoyouraccount.Seepage33.

FormsAccount Change Form

Student Certification

Termination Report

temporary payment coupons

29

C. Kaiser Foundation Health Plan Arbitration Agreement: I understand that (except for small claims court cases, claims subject to a Medicare appeals procedure and, if my group must comply with the Employee Retirement Income Security Act, certain benefit-related disputes) any dispute between myself, my heirs, or other associated parties on the one hand, and the Health Plan, its health care providers, or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in the Health Plan, including any claim for medical or hospital malpractice, for premises liability or relating to the coverage for or delivery of services or items, irrespective of legal theory, must be decided by binding arbitration under California law and not by lawsuit or resort to court process, except as applicable law provides for judicial review of arbitration proceedings. I agree to give up my right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the Evidence of Coverage.

TO BE COMPLETED BY EMPLOYER

Company name (required) Date of hire (required)

Group number (required) Enrollment unit/plan (required) Effective date of coverage (required)

REQUESTED CHANGE(S)

❑ Add dependents (complete sections A, B, C) ❑ Delete dependents (complete sections A, B)

Reason (see “Change reason table”) Event date

❑ Name change (complete sections A, B, C) From To

❑ Address (complete section A)

❑ Telephone (complete section A)

Employee signature Date

ACCOUNT CHANGE FORMPlease print or type in black ink only. Read instructions on the back. Make a copy for your records.

A. EMPLOYEE INFORMATION

Social Security number

E-mail

Home phone Work phone

Home address Apt. no. City State ZIP

Name (Last, First, MI) Medical record number

Do any of your dependents listed above live at another address? ❑ Yes ❑ No If yes, complete the following:

Name (Last, First, MI) Address

B. FAMILY INFORMATION For additional dependents, attach a separate sheet and please put the employee’s name at the top.

❑ Spouse ❑ Domestic partner Gender Social Security number

Name (Last, First, MI): ❑ M ❑ F

Date of birth MM/DD/YY Medical record numberFormer last name (if any):

❑ Child ❑ Student Gender Social Security number


Date of birth MM/DD/YY Medical record numberRelationship:







change reason table

Adddependentreason Eventdate

Acquiredstudentstatus* Datestudentstatuswasobtained

Familyadoption* Dateofadoption

Lossofcoverage Datecoveragewaslost

Newspouse(marriage)* Dateofmarriage

Movedintoservicearea Movedate

Newbornaddition Dateofbirth

Openenrollment Openenrollmenteffectivedate

Deletedependentreason Eventdate

Lossofstudentstatus Dateofstatuschange

Divorce Dateofdivorce

Memberdeceased* Dateofdeath

Deletedependent(s) Dependentterminationdate

Openenrollment Openenrollmenteffectivedate

*Additionaldocumentationmayberequired.

Account change Form

Generalinstructions

1. Pleaseprintlegiblyinblackink.

2. Theemployermustcompletethefirstsectionlabeled“Tobe

completedbyemployer.”

3. Theemployerisresponsibleforconfirmingallinformationprior

tosubmitting,especiallyeffectivedatesastheseaffecthealth

planpremiums.

4. Theemployee/subscribermustcompletesectionsAthroughC.

Seerightcolumnfordetailedinstructions.

5. Besuretosignanddatethebottomoftheform.

6. Oncetheformiscomplete(includingcompletedemployersection),

thesubscribershouldmakeacopyforhis/herrecords.

7. Allchangestoaccounts,includingeffectivedatesandchildor

studentstatus,willbemadeinaccordancewiththecontractual

agreementbetweenthepurchaserandKaiserPermanente.

InstructionsforcompletingsectionsTobecompletedbyemployer:Theemployermustcompleteallfields

toensurewehavecorrectaccountandreasoninformation.Theemployer

isresponsibleforconfirmingallinformationsubmittedby thesubscriber,

especiallyeffectivedatesastheseaffecthealthplan premiums.

Requestedchanges:Thesubscribermustalwayscompletethissection,

evenwhenmakingminorchangestotheaccount.Thisensuresour

informationiscurrent.Pleasemarktheboxifyouraddressortelephone

numberisnew.

SectionA:Thesubscribermustcompletethissection.

SectionB:Thesubscribermustindicatetherequestedchangebeing

madetotheaccountandcompleteallfieldsforanydependentsbeing

enrolled.Wewillverifytheeligibilityofthesedependentsduringthe

enrollmentprocess.Besuretoincludeanyformerlastnamesforboth

spousesanddependents.Alsoindicatetheappropriaterole.Thestudentrole

shouldonlybemarkedifthedependentqualifiesasanoveragedependent

attendingschool.Pleasecontactyouremployerregardingtheemployer’s

rulesforoveragedependentstudents.AcompletedStudentCertification

Formmayberequired.

SectionC:Thesubscribermustcompletethissection.

31

requirements for dependent student coverage

■ Mustbeenrolledinanaccreditedinstitution

■ Mustbedependentuponsubscriberforsupport

■ Mustbeunmarried

■ Mustbeyoungerthanage24

■ Unitsrequiredaredeterminedbytheemployer

Dependent’sname Dependent’smedicalrecordnumber

Dateofbirth(MM/DD/YY) Dependent’sSocialSecuritynumber

Schoolname

Schooladdress City State ZIP

StudentIDnumber Numberofunitscarried

Subscriber’sname Subscriber’smedicalrecordnumber

GroupID

Icertifythatthedependentshownmeetsalloftherequirementsforcoverageonmyaccount.

Iunderstandthehealthplancoverageforthisdependentwillterminateonthefirstdayofthe

monthfollowingthedatethatanyoneoftheserequirementsisnolongermet.

Subscriber’ssignature

SocialSecuritynumber Date

Employee:Returncompletedformtoyouremployer.

X

student certification

33

termination report

Groupnumber Enrollmentunit

Groupname Datesubmitted

Contactname Areacodeandphonenumber

subscriber name subscriber social Family account termination termination reason* security number number effective date

* termination reasons • Employmentterminated• Subscriberdeceased• Layoff/Leaveofabsence• Retired• Changedinsurancecarriers• Nevereligible—enrolledinerror• COBRAtimelimitreached (forpurchaser-administeredCOBRAonly)• Transfertopurchaser-administeredCOBRA (AttachCOBRAelectionform.)• Transfertonewpurchaser/enrollmentunitnumber (AttachsignedEnrollmentForm.)

mailing addresses and fax numbersNorthernCaliforniaKaiserFoundationHealthPlanP.O.Box23219SanDiego,CA92193-3219Fax:(858)614-3344

SouthernCaliforniaKaiserFoundationHealthPlanP.O.Box23250SanDiego,CA92193-3250Fax:(858)614-3345

Completethisformtoshowterminationstoyouraccount.

35

temporary payment coupons

Yourpaymentisduebythe25thofthemonthpriortothemonthofcoverage.Dependingonthetimingofyournewgroupsetup,youmaynotreceiveastatementfromusforupto60days.

Foryourconvenienceinmakingpaymentsduringthistime,wehaveincludedtwotemporarypaymentcoupons.Pleasecompleteandsendacouponwithyourpaymentuntilyourfirststatementarrives.Simplypaythesameamountasyourfirstmonth’spremiumsubmittedwithyournewgroupapplication.Returnthecouponandyourpaymentinoneoftheenvelopesprovided.YoumayalsovisitourWebsiteatemployers.kaiserpermanente.orgtoprintthesepaymentcoupons.

rEtUrn tHis Portionwithyourpaymentintheenvelopeprovided.

Groupname Groupnumber

Applytothemonth/yearof:

Estimatedpaymentamount:

rEtUrn tHis Portionwithyourpaymentintheenvelopeprovided.

Groupname Groupnumber

Applytothemonth/yearof:

Estimatedpaymentamount:

Month Year

foldandtear

foldandtear

Month Year

36

temporary payment envelopes

Mailyourmonthlypaymentusingthesepre-addressedremittance

envelopes.Ifyouneedadditionalenvelopes,pleasecallthe

CustomerServiceCenterat1-800-790-4661,option1,from8a.m.

to5p.m.,MondaythroughFriday.

kaiserpermanente.org

25651

Documents

Your Kaiser Permanente AdministrAtion HAndbook · Your guide to providing high-quality health care to your employees Your Kaiser Permanente AdministrAtion HAndbook