Kaiser Permanente for Individuals and Families
How to change plans
Compare options.
Review the plan change options for your clients in your renewal packet. Please carefully consider all the benefits of
the plan. If a plan change is needed, your client will not be able to switch back to their current plan after 30 days
past their new plan’s effective date.
Check the plan change chart.
The charts on the following pages will show whether your clients can change to their desired plan using the Plan
Change Form or whether you need to reapply for an open plan using an application.
If your client can use the Plan Change Form:
Follow the instructions on page 2 to submit the paper form.
Send your Plan Change Form either of the following ways:
fax
mail
Fax the form to:
Mail the form to:
1-866-846-2650
Kaiser Permanente
P.O. Box 203004
Denver, CO 80220-9004
If your client decides to reapply for an open plan and complete an application:
To reapply, your client will need to complete an application that will be used to evaluate whether they qualify for a
new plan. If the application is denied based on a medical condition, your client will continue in their current plan.
They will not be disenrolled.
60095956_KPIF Renewals_Change_plans_brochure.indd 1
10/26/12 1:49 PM
INSTRUCTIoNS
GETTING STARTED
•
•
•
•
•
Complete the Plan Change Form, using ink only. Sign and date the form and keep a copy for your records.
You can submit one Plan Change Form if all family members are changing to the same plan. Otherwise, submit a separate Plan Change Form for
each plan selected.
Complete the “Subscriber Information” section if the subscriber is age 18 or older or if they are the financially responsible party for a subscriber under age 18.
All members age 18 or over must sign the “Plan Change Agreement.” A parent or legal guardian must sign for members under age 18.
Request an effective date. (Effective dates are not guaranteed.)
If your client was enrolled in their current plan before 2000, any plan change will require medical review. If anyone on the account is tobacco user,
their premium will be 20 percent higher. Premiums are based on medical history, tobacco use, plan effective date, age of subscriber, and geographic
location, and are subject to scheduled rate adjustments.
It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding
or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company
or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall
be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
USING THE PLAN CHANGE CHART
The bullets (•) in the charts on the following pages show which plans your client can switch to using the Plan Change Form. If your client would like
to change to a plan without a (•), they must reapply for coverage, complete an application and pass medical review. If the application is not accepted,
your client will continue to be covered under their current plan.
How to use this chart:
• Find the current plan in the left-hand column.
• Find the desired plan in the top row.
• A plan change can be made without reapplying if there’s a (•) in the box where the desired plan column intersects with the row of the current
plan. If your client has a grandfathered plan (population 1) they will keep that status if there is a (•) in the box of the desired plan.
2
60095956_KPIF Renewals_Change_plans_brochure.indd 2
10/26/12 1:49 PM
PLAN CHANGE CHART
GRANDFATHERED PLANS — PoPULATIoN 1 To 1
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
$1,000 Deductible Plan (80%)
with Rx
•
•
•
•
•
•
•
•
$2,000 HSA-Qualified
Deductible HMO Plan (100%)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
$2,000 Deductible Plan (70%)
with Rx
•
•
•
•
•
•
$3,000 HSA-Qualified
Deductible HMO Plan (100%)
•
•
•
•
•
•
•
•
•
•
•
$5,000 Deductible Plan (60%)
with Rx (Children’s)
•
•
•
$2,000 Deductible Plan (70%)
•
•
•
$3,000 Deductible Plan (70%)
with Rx
•
•
•
•
•
$35 Copayment Plan with Rx
$40 Copayment Plan with Rx
•
$5,000 HSA-Qualified
Deductible HMO Plan (100%)
$30 Copayment Plan
$5,000 Deductible Plan (70%)
•
$4,000 HSA-Qualified
Deductible HMO Plan (100%)
$20 Copayment Plan with Rx
$3,000 Deductible Plan (70%)
with Rx
$2,000 Deductible Plan (70%)
$2,000 HSA-Qualified
Deductible HMO Plan (80%)
$3,000 HSA-Qualified
Deductible HMO Plan (100%)
$2,000 Deductible Plan (70%)
with Rx
$2,500 HSA-Qualified
Deductible HMO Plan (100%)
$1,500 Deductible Plan (80%)
with Rx
$1,000 Deductible Plan (80%)
with Rx
$40 Copayment Plan with Rx
CURRENT PLAN
$35 Copayment Plan with Rx
REQUESTED PLAN
•
•
$1,500 Deductible Plan (80%)
with Rx
•
$2,500 HSA-Qualified
Deductible HMO Plan (100%)
•
$2,000 HSA-Qualified
Deductible HMO Plan (80%)
$4,000 HSA-Qualified
Deductible HMO Plan (100%)
$5,000 Deductible Plan (70%)
•
•
•
$5,000 HSA-Qualified
Deductible HMO Plan (100%)
3
60095956_KPIF Renewals_Change_plans_brochure.indd 3
10/26/12 1:49 PM
PLAN CHANGE CHART
GRANDFATHERED PLANS To oPEN PLANS — PoPULATIoN 1 To 5
KP Deductible HMO
6000/50
KP Deductible HMO
7500/50
KP Deductible HMO
5000/40/Rx
•
$30 Copayment Plan
•
•
•
KP 5500/0/HSA/Rx
•
KP 4500/0/HSA/Rx
•
Important note: Please be aware that if you drop
coverage from this set of grandfathered plans, you will
not be able to re-enroll in these plans at a later date.
At that time, you will have to reapply for membership
in a new set of plans.
KP 3500/0/HSA/Rx
$20 Copayment Plan with Rx
CURRENT PLANS
KP Deductible HMO
3500/40/Rx
KP Deductible HMO
3000/30/Rx
KP Deductible HMO
2000/30/Rx
KP Deductible HMO
1500/30/Rx
KP Deductible HMO
1000/30/Rx
REQUESTED PLAN
$35 Copayment Plan with Rx
•
•
•
•
•
•
•
•
•
•
•
$40 Copayment Plan with Rx
•
•
•
•
•
•
•
•
•
•
•
$1,000 Deductible Plan (80%) with Rx
•
•
•
•
•
•
•
•
$2,000 HSA-Qualified Deductible HMO Plan (100%)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
$1,500 Deductible Plan (80%) with Rx
•
$2,500 HSA-Qualified Deductible HMO Plan (100%)
$2,000 Deductible Plan (70%) with Rx
$3,000 HSA-Qualified Deductible HMO Plan (100%)
•
$2,000 HSA-Qualified Deductible HMO Plan (80%)
$5,000 Deductible Plan (60%) with Rx (Children's)
$2,000 Deductible Plan (70%)
•
$3,000 Deductible Plan (70%) with Rx
$4,000 HSA-Qualified Deductible HMO Plan (100%)
•
•
$5,000 Deductible Plan (70%)
$5,000 HSA-Qualified Deductible HMO Plan (100%)
•
4
60095956_KPIF Renewals_Change_plans_brochure.indd 4
10/26/12 1:49 PM
PLAN CHANGE CHART
NoN-GRANDFATHERED CLoSED PLANS — PoPULATIoN 2 To 5
KP 3500/0/HSA/Rx
KP Deductible HMO
1000/30/Rx
KP Deductible HMO
1500/30/Rx
KP Deductible HMO
2000/30/Rx
KP 4500/0/HSA/Rx
KP Deductible HMO
3000/30/Rx
KP Deductible HMO
3500/40/Rx
KP 5500/0/HSA/Rx
KP Deductible HMO
5000/40/Rx
KP Deductible HMO
6000/50
KP Deductible HMO
7500/50
REQUESTED PLAN
$35 Copayment Plan with Rx
•
•
•
•
•
•
•
•
•
•
•
$40 Copayment Plan with Rx
•
•
•
•
•
•
•
•
•
•
•
$1,000 Deductible Plan (80%) with Rx
•
•
•
•
•
•
•
•
$2,000 HSA-Qualified Deductible HMO Plan (100%)
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
CURRENT PLANS
$1,500 Deductible Plan (80%) with Rx
•
$2,500 HSA-Qualified Deductible HMO Plan (100%)
$2,000 Deductible Plan (70%) with Rx
$3,000 HSA-Qualified Deductible HMO Plan (100%)
•
$2,000 HSA-Qualified Deductible HMO Plan (80%)
$5,000 Deductible Plan (60%) with Rx (Children’s)
$2,000 Deductible Plan (70%)
•
$3,000 Deductible Plan (70%) with Rx
$4,000 HSA-Qualified Deductible HMO Plan (100%)
•
•
$5,000 Deductible Plan (70%)
$5,000 HSA-Qualified Deductible HMO Plan (100%)
•
5
60095956_KPIF Renewals_Change_plans_brochure.indd 5
10/26/12 1:49 PM
PLAN CHANGE CHART
2011 CLoSED PLANS — PoPULATIoN 3 To 5
KP Deductible HMO
2000/30/Rx
KP 4500/0/HSA/Rx
KP Deductible HMO
3000/30/Rx
KP Deductible HMO
3500/40/Rx
KP 5500/0/HSA/Rx
KP Deductible HMO
5000/40/Rx
KP Deductible HMO
6000/50
KP Deductible HMO
7500/50
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
KP 4000/30/Rx
•
•
KP HSA 3000/20/Rx
•
•
KP 5000/30
•
•
KP 1500/30/Rx
KP 2000/30/Rx
KP HSA 2500/20/Rx
KP 3000/30/Rx
KP Deductible HMO
1500/30/Rx
•
KP HSA 2000/20/Rx
KP 3500/0/HSA/Rx
•
CURRENT PLANS
KP Deductible HMO
1000/30/Rx
REQUESTED PLAN
KP 7500/30
6
60095956_KPIF Renewals_Change_plans_brochure.indd 6
10/26/12 1:49 PM
PLAN CHANGE CHART
ENDURA PLANS — PoPULATIoN 4 & 5 To 5
KP Deductible HMO
2000/30/Rx
KP 4500/0/HSA/Rx
KP Deductible HMO
3000/30/Rx
KP Deductible HMO
3500/40/Rx
KP 5500/0/HSA/Rx
KP Deductible HMO
5000/40/Rx
KP Deductible HMO
6000/50
KP Deductible HMO
7500/50
KP Deductible HMO
1500/30/Rx
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
KP 5500/0/HSA/Rx
•
•
KP Deductible HMO 5000/40/Rx
•
•
KP 3500/0/HSA/Rx
•
CURRENT PLANS
KP Deductible HMO
1000/30/Rx
REQUESTED PLAN
KP 3500/0/HSA/Rx
KP Deductible HMO 1000/30/Rx
KP Deductible HMO 1500/30/Rx
KP Deductible HMO 2000/30/Rx
•
KP 4500/0/HSA/Rx
KP Deductible HMO 3000/30/Rx
KP Deductible HMO 3500/40/Rx
KP Deductible HMO 6000/50
•
•
KP Deductible HMO 7500/50
7
60095956_KPIF Renewals_Change_plans_brochure.indd 7
10/26/12 1:49 PM
Kaiser Permanente for Individuals and Families
PLAN CHANGE FoRM
FOR MEMBER PLAN DOWNGRADES FROM POPULATION 1 TO 1
SUBSCRIBER INFoRMATIoN (Or financially responsible party for subscribers under age 18)
Last name
First name
Medical record number (MRN)
Gender
Street address
Day phone
MI
Date of birth (dd/mm/yyyy)
City
Home
Work
State
Evening phone
Home
ZIP
Work
Check if address and/or phone number has changed.
New plan
Requested effective date (01/mm/yyyy)
(must be the 1st of the month)
FAMILY MEMBERS To BE ENRoLLED
T
F
List all family members under your current plan who are changing to the same plan. Attach an additional sheet if needed to list more children.
Submit a separate form for each plan selected.
Spouse
Domestic partner
Child
Child
Child
Child
Last name
Last name
Last name
MI
MRN
MI
MRN
MI
MRN
First name
MI
MRN
First name
MI
MRN
First name
Last name
Last name
A
R
First name
First name
D
PLAN CHANGE AGREEMENT
Benefits vary
vary among plans, so make sure you are comfortable with all the benefi
benefits
ts of your selected plan. If you’d like to see a more detailed list
of benefits, please call 1-303-338-3800 for a copy of the Membership Agreement. This will help you be certain you don’t accidentally forfeit a
benefit you want.
If we accept your application, we will tell you the date that the new coverage begins. If you change your plan, once 30 days have
have passed
from your new plan’s effective date, you will not be able to change back to your previous plan. Your current plan account must be paid up
to the new plan effective date in order to change plans.
I understand the difference between my current benefits and the new plan benefits and accept that change.
Subscriber (age 18 or older)/Financially responsible party
Date
X
Spouse/Domestic partner
Date
X
Dependent (age 18 or older)
Date
X
Dependent (age 18 or older)
Date
X
8
60095956_KPIF Renewals_Change_plans_brochure.indd 8
10/26/12 1:49 PM
Kaiser Permanente for Individuals and Families
PLAN CHANGE FoRM
FOR MEMBER PLAN DOWNGRADES FROM POPULATION 1, 2, 3, 4 TO 5
SUBSCRIBER INFoRMATIoN (Or financially responsible party for subscribers under age 18)
Last name
First name
Medical record number (MRN)
Gender
Street address
Day phone
MI
Date of birth (dd/mm/yyyy)
City
Home
Work
State
Evening phone
Home
ZIP
Work
Check if address and/or phone number has changed.
Requested effective date (01/mm/yyyy)
(must be the 1st of the month)
New plan
FAMILY MEMBERS To BE ENRoLLED
List all family members under your current plan who are changing to the same plan. Attach an additional sheet if needed to list more children.
Submit a separate form for each plan selected.
Spouse
Domestic partner
Child
Child
Last name
First name
Last name
First name
A
R
First name
Last name
ToBACCo HISToRY
T
F
MI
MRN
MI
MRN
MI
MRN
Has anyone on this account used any tobacco products in any amount in the past 12 months? (Tobacco
(Tobacco products include cigarettes, pipes, cigars,
snuff, chewing, or any other tobacco products.) If YYes,
es, list the member(s)’ names. Yes No
Name(s) of tobacco users
Name(s) of tobacco users
D
Name(s) of tobacco users
Name(s) of tobacco users
PLAN CHANGE AGREEMENT
Benefits vary
vary among plans, so make sure you are comfortable with all the benefi
benefits
ts of your selected plan. If you’d like to see a more detailed list
of benefits, please call 1-303-338-3800 for a copy of the Membership Agreement. This will help you be certain you don’t accidentally forfeit a
benefit you want.
If we accept your application, we will tell you the date that the new coverage begins. If you change your plan, once 30 days have passed
from your new plan’s effective date, you will not be able to change back to your previous plan. Your current plan account must be paid up
to the new plan effective date in order to change plans.
I understand the difference between my current benefits and the new plan benefits and accept that change.
Subscriber (age 18 or older)/Financially responsible party
Date
X
Spouse/Domestic partner
Date
X
Dependent (age 18 or older)
Date
X
Dependent (age 18 or older)
Date
X
9
60095956_KPIF Renewals_Change_plans_brochure.indd 9
10/26/12 1:49 PM