Guide to Fill Out the Enrollment Information Form
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- Hubert Simon
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1 Guide to Fill Out the Enrollment Information Form The Trust will need to know your monthly premium information to update your benefits on your Benefit Convenience Card or send you a Benefit Convenience Card. Submit the Enrollment Information Form to the Trust Administrative Office after you reenroll into your individual medical insurance, anytime your premium changes or anytime your medical coverage changes. The Trust Administrative Office needs this information so that they can start processing or updating your benefits. What you will need to complete this form The information you need to provide to the Trust Administrative Office includes your current medical coverage insurance plan name, your premium amount (gross premium), Advanced Premium Tax Credit (APTC) amount, and the start date of your coverage for that premium amount. You can get this information from your insurance carrier or your Health Insurance Marketplace. Note: Once you submit this information and it is received by the Trust Administrative Office, it can take up to 20 business days to see that information reflected on your Benefit Convenience Card. Page 1 of 7
2 Finding your premium information Where you find your premium information will depend on whether you are renewing a plan through the Marketplace or enrolling for the first time. Finding your premium information in a letter from your carrier. You can find your 2019 premium information on the letter from your insurance carrier that talks about your 2019 plan information. If you had a phone enrollment appointment with Valley Insurance Professionals or the Healthcare Enrollment Team, check to see if they are submitting this information for you. Your new plan for 2019 We found another Marketplace plan that may meet your needs. Starting in January, you ll automatically be enrolled in Kaiser OR Silver 2500/30. Your new premium Your 2018 monthly payment is $400. This reflects a monthly premium of $500 minus $100 of financial help per month. Starting in January your estimated monthly payment will be $450. This reflects an estimated monthly premium of $550 minus the same amount of financial help you re getting now. You ll see your new monthly payment when you receive your January bill. Important: This is only an estimate based on current information we have, including the amount of financial help you got in It also doesn t reflect any changes to your enrollment, such as adding additional members to your coverage. To find out how much financial help you qualify for in 2019 and your new premium amount, update your Marketplace application. See below for more information. In this case: The 2019 Insurance Plan Base Premium (Gross) is $550 The 2019 Advanced Premium Tax Credit (APTC) is $100 The 2019 Insurance Plan Premium after Tax Credit (net) is $450 And would be reported on the Enrollment Information Form as: Page 2 of 7
3 Finding your premium information online in the Marketplace. If you have a healthcare.gov account, you can also find your premium information online by following these steps: 1. Go to Click Log In in the upper right corner 2. Enter your login information and click Log In 3. Once you re logged in, click My Profile on the left side of the screen. Page 3 of 7
4 4. Now click My Applications & Coverage 5. You ll now be able to view a summary of your needed premium information. In this case: The 2019 Insurance Plan Base Premium (Gross) is $500 The 2019 Advanced Premium Tax Credit (APTC) is $100 The 2019 Insurance Plan Premium after Tax Credit (net) is $400 And would be reported on the Enrollment Information Form as: Page 4 of 7
5 Completing the Enrollment Information Form 1. Carefully read through the Get Started section of the form there is important information in this. 2. Scroll down the page and note the action you have taken. 3. Use the calendar to set up an appointment time. Please Note: The appointment you are scheduling is only to fill out the form on the next page. You are not setting an appointment here to call or meet with anyone. Page 5 of 7
6 4. Fill in required information, which is noted by a red asterisk (*). 5. Fill out remaining Personal Information. Please note the two agreements at the top of this section. Required information is indicated by red asterisk (*). Page 6 of 7
7 6. Complete your Insurance Plan Information, using the drop-down menus to select Carrier Name, Plan Name, your reason for completing the form, and insurance start date. If you are re-enrolling for 2019, your Insurance Start Date is January 1, Next, enter your Premium Information. For information on where to find these amounts, please see Finding your premium information on page 2 of this guide. Your premium information allows the Trust Administrative Office to determine and correctly administer assistance. 8. Complete the Family Information questions to let the Trust Administrative Office know if anyone else is enrolled on your same plan. 9. If you have any questions or further information to note, you can enter that in the Notes section (you can also contact your Healthcare Enrollment Team with questions at (Portland Metro Area) or toll-free at ). Check the boxes to show you have read and understood the statements. Click Complete Appointment to finish the form. 9OE1066 Page 7 of 7
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