Active employees have the option of invoking the Live or Work Rule, which may allow them to be eligible for HMO coverage based on primary work location.
The Department of Managed Healthcare (DMHC) regulates California HMO health plans, including the Kaiser Permanente and Blue Shield of California HMO plans currently available to HSS members. Per the DMHC, you must live or work in one of the zip codes in the plan’s service area to obtain service from the HMO. Consequently, HSS members can access HMO health plans based on a home or work address, in accordance with how each plan interprets and administers the Live or Work Rule.
The information below offers a general summary of each plan’s requirements. Note that dependent service area eligibility requirements differ for Kaiser and Blue Shield.
|Kaiser Permanente||Kaiser member must live or work in a Kaiser HMO service area, as determined by zip code.||Eligible dependents of an enrolled Kaiser member, such as spouse, domestic partner or child, may live anywhere inside or outside the Kaiser HMO service area.|
|Blue Shield||Blue Shield member must live or work in a Blue Shield of California HMO service area, as determined by zip code.||Eligible dependents of an enrolled Blue Shield member, such as spouse, domestic partner or child, must live or work in a Blue Shield HMO service area (unless dependent qualifies for out-of-area “Away From Home Care” per Blue Shield).|
An active employee member may enroll in either the Kaiser or Blue Shield HMO if he or she lives or works in a zip code included in the plan’s service area. (Enrollment must take place during Open Enrollment, within 30 days of hire, or within 30 days of a qualifying event.) An employee assigned to a single work location must use his or her primary work address to qualify for enrollment under the Live or Work Rule. An employee assigned to multiple work locations may use the central or regional office address as the qualifying work address. Member dependents must comply with each plan’s individual requirements, as listed in the plan’s Evidence of Coverage document.
Before invoking the Live or Work Rule, make sure that you have a qualifying work address and understand how to access service for yourself and any dependents. HSS recommends that you contact our office to review your individual situation with a Benefits Analyst so you get all the information you need to make an appropriate decision regarding HMO enrollment under the Live or Work Rule. HSS can assist you in reviewing each plan’s Evidence of Coverage and guidelines regarding Live or Work.
Kaiser Permanente Traditional Plan HMO Evidence of Coverage January-December 2017
Blue Shield Access+ HMO Evidence of Coverage January-December 2017