Image
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.
Live or Work Rule Overview
The Department of Managed Healthcare (DMHC) regulates California HMO health plans, including the Kaiser Permanente, Health Net and Blue Shield of California HMO plans currently available to SFHSS 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, SFHSS 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.
HMO Plan Guidelines for 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 Permanente and Blue Shield of California.
HMO Plan Member Dependents
Kaiser Permanente members 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 of CA Access+ HMO and Trio HMO members must live or work in a Blue Shield of California Access+ or Trio 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).
Primary Care Physician Assignment
Employees who enroll in Kaiser under the Live or Work Rule must select a primary care physician based on the zip code of their qualifying work location. Employees who enroll in Blue Shield under the Live or Work Rule must select a primary care physician and associated medical group based on the zip code of the qualifying work location. Additional requirements regarding eligibility and obtaining service under the Live or Work Rule are detailed in each plan’s Evidence of Coverage
SFHSS Live or Work Rule Policy
An active employee member may enroll in either the Kaiser Permanente or Blue Shield of California 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.
SFHSS Requirements for Enrolling in an HMO Plan Under the Live or Work Rule
- The employee member must notify SFHSS that he or she is invoking the Live or Work Rule for enrollment in an HMO health plan. If the member does not notify SFHSS, the member’s home address will be used to determine service area eligibility. Call SFHSS Member Services at (628) 652-4700.
- Enrollment under the Live or Work Rule can only take place during Open Enrollment, within 30 days of hire, or within 30 days of a qualifying event.
- The employee member must complete a Live or Work Enrollment Application Form, providing both home and work address. The qualifying work location will be the primary address listed on the application.
- The employee member must submit all other required eligibility documentation by required deadlines.
- It is the responsibility of the employee member to read and understand Live or Work Rule information provided in the HMO Plan’s Evidence of Coverage. The Evidence of Coverage provides detailed information regarding dependent eligibility, selection of primary care physician and medical group, restrictions on accessing urgent and emergency care, and payment/reimbursement policies. Evidence of Coverage documents are available on sfhss.org.
- After enrollment, medical ID cards are sent to the employee at the qualifying work address. An employee assigned to a regional office must make arrangements to access ID cards and plan materials delivered to the Regional Office. After receiving ID cards the member may contact the plan to establish a home address for any subsequent mailings.
Live or Work Rule Details Defined in Plan's Evidence of Coverage
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. SFHSS 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. SFHSS can assist you in reviewing each plan’s Evidence of Coverage and guidelines regarding Live or Work.