Instruction guide for completing the Kaiser Permanente for Individuals and Families Application for Health Coverage

Transcription

1 Kaiser Permanente Community Health Care Program Instruction guide for completing the Kaiser Permanente for Individuals and Families Application for Health Coverage This document provides instructions on how to complete the Kaiser Permanente for Individuals and Families (KPIF) Application for Health Coverage. Be sure to complete the KPIF application before you complete the Kaiser Permanente Subsidy Eligibility Form. Many of the sections on the KPIF application do not apply to you. We have provided a screenshot of the KPIF application and we have shaded those areas that do not apply. For instance, You DO NOT need to: Include any payment with your application. Provide a Social Security number. We are required to ask you for a Social Security number or tax identification number, but neither one is required for the Community Health Care Program. Complete any of the steps after Step 8. You DO need to: Select the KP Platinum 90 health plan in Step 2. Photocopy the form if you are applying for more than 4 family members and include their information in Step 4. Please be sure to sign your application.

2 How to fill out the KPIF application Screenshots of the KPIF application are included below, along with instructions for each step. Please note, you do not need to complete any of the shaded sections as they do not apply to your application. Application for health coverage Individual and Family Plans W h o can use th is application? Y o u m a y u s e t h i s a p p l i c a t i o n t o a p p ly f o r i n d i v i d u a l o r f a m i l y c o v e r a g e f r o m K a is e r P e r m a n e n t e f o r I n d i v i d u a l s a n d F a m ili e s ( K P IF ). I f y o u w a n t c o v e r a g e f o r y o u r f a m i l y o n t h e s a m e K P IF p la n, p le a s e f i l l o u t 1 a p p lic a t io n f o r t h e f a m i l y. I f a f a m i l y m e m b e r w a n t s a d i f f e r e n t h e a lt h p la n, h e o r s h e m u s t c o m p le t e a s e p a r a t e a p p l i c a t i o n. T o b e e l i g i b l e f o r K P IF c o v e r a g e, y o u m u s t l i v e in o u r C a lif o r n ia s e r v ic e a r e a. T o b e e l i g i b l e f o r K P IF c o v e r a g e, y o u c a n 't b e e n t i t l e d t o M e d ic a r e P a r t A o r e n r o l l e d in M e d ic a r e P a r t B. I f y o u q u a l i f y f o r a n d w a n t t o t a k e a d v a n t a g e o f f e d e r a l f in a n c ia l a s s is t a n c e t o h e lp p a y f o r c o p a y s, c o in s u r a n c e, d e d u c t ib le s, o r p r e m i u m s, d o n ' t c o m p le t e t h i s a p p l i c a t i o n. Y o u m u s t a p p l y f o r c o v e r a g e t h r o u g h C o v e r e d C a lif o r n ia a t C o v e r e d C A. c o m. I f y o u 'r e a lr e a d y a m e m b e r, d o n ' t u s e t h i s f o r m. T o c h a n g e y o u r p la n, c a ll Things to re m e m b e r Y o u c a n a p p ly f a s t e r o n l i n e a t b u y k p. o r g / a p p l y. P le a s e a n s w e r a ll q u e s t io n s, a n d t y p e o r p r i n t u s in g i n k o n ly. L e a v e a n e m p t y b o x in b e t w e e n w o r d s, a n d p u t a h y p h e n in t h e b o x f o r h y p h e n a t e d n a m e s. Not applicable I f w e r e c e iv e y o u r c o m p le t e d a p p l i c a t i o n w i t h p a y m e n t b y t h e 1 5 t h o f t h e m o n t h a n d a p p r o v e it, c o v e r a g e w i l l b e e f f e c t iv e o n t h e 1 s t o f t h e n e x t m o n t h. I f w e r e c e iv e y o u r c o m p le t e d a p p lic a t io n w i t h p a y m e n t a f t e r t h e 1 5 t h a n d a p p r o v e it, c o v e r a g e w i l l b e e ff e c t iv e o n t h e 1 s t o f t h e m o n t h a f t e r t h e n e x t m o n t h. I f y o u 'r e a p p l y i n g d u r i n g a s p e c ia l e n r o l l m e n t p e r io d, y o u c a n f i n d in s t r u c t i o n s a t k p. o r g / s p e c i a l e n r o l l m e n t o r c a ll Y o u r a p p l i c a t i o n s u b m is s io n d e a d l i n e a n d e ff e c t iv e d a t e m a y b e d i f f e r e n t t h a n t h e d a t e s lis t e d a b o v e i f y o u a p p ly d u r i n g a s p e c ia l e n r o l l m e n t p e r io d. R e m e m b e r, t h i s n e w e n r o l l m e n t w i l l n o t e n d o t h e r c o v e r a g e t h r o u g h C o v e r e d C a lif o r n ia o r K a is e r P e r m a n e n t e. D o n 't w a n t 2 p la n s? B e s u r e t o e n d y o u r o t h e r p la n t h e d a y b e f o r e y o u r n e w p la n s t a r t s t o a v o id p a y in g 2 p r e m i u m s o r h a v in g a g a p in y o u r c o v e r a g e. I f y o u r a p p l i c a t i o n is i n c o m p l e t e, n o t s i g n e d, d o e s n ' t i n c l u d e y o u r f i r s t m o n t h ' s p a y m e n t, o r d o e s n ' t i n c l u d e r e q u i r e d s p e c i a l e n r o l l m e n t p e r i o d d o c u m e n t a t i o n, i t m a y b e c a n c e l e d. S e n d y o u r c o m p le t e, s ig n e d a p p lic a t io n a n d f i r s t m o n t h 's p r e m i u m p a y m e n t b y m a il t o : K a is e r P e r m a n e n t e f o r I n d i v i d u a l s a n d F a m ilie s P.O. B o x S a n D ie g o, C A O r s e n d i t b y s e c u r e f a x t o : N o t e : C h e c k s m u s t b e m a ile d a n d c a n 't b e f a x e d. N eed help? F o r h e lp w i t h c o m p l e t i n g t h i s a p p l i c a t i o n, p le a s e c a ll Fo r TTY, c a ll Not applicable - W e ' l l p r o v i d e l a n g u a g e a s s i s t a n c e a t n o c o s t t o y o u. I f y o u 'r e w o r k i n g w i t h a b r o k e r, p le a s e c a ll h i m o r h e r f o r a s s is t a n c e.

3 If you are applying outside of open enrollm ent, please see the Special Enrollm ent Period Guide and Form in this packet, or visit kp.org/childhealthprogram to learn more about the requirem ents. Not applicable STEP 1 : Check your eligibility Are you or anyone else in your family either entitled to Medicare Part A or enrolled in Medicare Part B? Yes No If you selected "Yes," those of you who are entitled to Medicare Part A or enrolled in Medicare Part B can't enroll in an individual and fam ily plan. Please visit kp.org/m edicare to learn more about your Medicare plan options or apply for coverage. STEP 2: Tell us when you're applying Select 1 option: Open enrollment A special enrollment period If you're applying during a special enrollment period, please w rite the date of y o u r triggering event (or qualifying life event). For more information on minimum essential coverage and qualifying triggering events, please visit k p.org /specialen rollm en t or call If you selected "A special enrollment period," choose the triggering event: Loss of health care coverage (write the last full day you had coverage)* Gaining or becoming a dependent through marriage or domestic partnership registration Gaining or becoming a dependent through the birth of a child, adoption, foster care, or placement for adoption or foster care (Please choose your effective date.) The date of birth, adoption, foster care, or placement for adoption or foster care The first day of the month after gaining the dependent Losing a dependent through divorce, dissolution of domestic partnership, or legal separation Death of the subscriber or a dependent Child support order or other court order to cover a dependent Permanent relocation Release from incarceration Change in eligibility fo r federal financial assistance through Covered California1 Change in eligibility for employer health coverage Determination by Covered California Misinformation about coverage Provider network changes *lf your triggering event is loss of Kaiser Permanente coverage, we may review your prior membership records to establish eligibility. If you'll b e getting federal financial assistance, don't use this form. We can help you apply at CoveredCA.com. Check the box for the Kaiser Perm anente - Platinum 90 HMO plan. STEP 3: Choose your health plan Choose 1 health plan. If any family members are applying for different health plans, please submit a separate application for each plan. Not applicable Not applicable Bronze Kaiser Permanente - Bronze 60 HDHP HMO 5500/40% Kaiser Permanente - Bronze 60 HMO Kaiser Permanente - Bronze 60 HDHP HMO S ilve r Kaiser Permanente - Silver 70 HMO Off Exchange Kaiser Permanente - Silver 70 HMO 2000/45 Kaiser Permanente - Silver 70 HDHP HMO 2700/15% Gold Kaiser Permanente - Gold 80 HMO Kaiser Permanente - Gold 80 HMO Coinsurance Platin um Kaiser Permanente - Platinum 90 HMO Minimum coverage plan To purchase a minimum coverage plan, applicants must be younger than 30 on the effective date, or provide a certificate of exemption from Covered California that shows hardship or lack of affordable coverage. exemption if you are 30 and older. To see if you qualify, please go to m arketp lace.cm s.g o v/ap p licatio n s-an d -fo rm s/h ard ship -exem p tio n.p d f and follow the instructions. Kaiser Permanente - Minimum Coverage HMO For information about health and dental benefits and lim itations, cost-sharing amounts, and premiums, please review the details in your enrollment materials. To request a copy of the Membership Agreement, Disclosure Form, and Evidence of Coverage please go to kp.org/plandocuments, call or contact your broker. Not applicable STEP 4: Choose your optional adult dental plan Dental coverage is included in your health plan for child members until the end of the month in which the member turns 19. Kaiser Permanente offers an optional dental insurance plan to adults, which includes those individuals whose eligibility for pediatric dental services has ended. This optional coverage is available for an additional charge. Our optional adult dental coverage is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP), and administered by Delta Dental of California, one of the nation's largest and most experienced dental benefits providers. Please choose 1 option below. Yes, I agree to enroll in the KPIC dental insurance plan. Kaiser Permanente Insurance Company, a subsidiary of Kaiser Foundation Health Plan, Inc., underwrites the dental insurance p lan. Once enrolled, I can't cancel m y dental coverage without canceling my reg u lar health coverage, unless I m ake th e change during open enrollment ora special enrollment period. No. I'm not interested in optional dental coverage.

4 4 Any individual to be covered can be the primary applicant. If you have more than 1 family member to be covered, you can add them in the dependents section. If you have a Social Security number or a tax identification number, please include it. If you don t, please leave it blank. STEP 5: Enter your information Primary applicant First name In an individual plan, the primary applicant is the person who will be covered by the health plan. In a family plan, the primary applicant is the family member on the health plan who is authorized to make changes to the account. If this application is only for a child under 18, the child is the primary applicant. Social Security number (if any) - - Date of birth (mm/dd/yyyy) Former medical record number (if any) Home address (no P.O. boxes, please) State (if any) Gender: Male Female Phone - - City State ZIP code County Mailing address (if different than home address) City State ZIP code Preferred language spoken (if not English) Preferred language read (if not English) address (optional) I understand that Kaiser Permanente may contact me via . If there are more family members to be covered, add their information here. Do not repeat the primary applicant s information. If you are applying for more than 4 family members, photocopy this page, provide the information requested below, and submit it with this application. STEP 5: Enter your information (continued) Parent or legal guardian (if the primary applicant is a child under 18) First name Gender: Male Female Date of birth (mm/dd/yyyy) Social Security number (if any) - - Spouse/domestic partner to be covered A domestic partner is a person registered and legally recognized as your domestic partner by California. First name Choose one: Spouse Social Security number (if any) - - Former medical record number (if any) State (if any) Gender: Male Female Date of birth (mm/dd/yyyy) Domestic partner If you have more than 2 dependents to be covered, please fill out an extra copy of this page Dependents to be covered and submit it with your application. 1 First name Former medical record number (if any) Relationship to primary applicant State (if any) Gender: Male Female Social Security number (if any) - - Date of birth (mm/dd/yyyy)

5 5 STEP 6: Choose an authorized representative (if you have one) You can give a trusted friend or relative permission to talk about this application with us, see your information, or act for you on matters related to this application only. This person is called an authorized representative. First name Phone - - By signing, you ve appointed this person as your legally authorized representative to get official information about this application, and to act for you on matters related to this application. Primary applicant (parent or legal guardian for children under 18) STEP 7: Sign the application agreement Important: All applicants and dependents 18 and older must read, sign, and date below. If the primary applicant is a child under 18, then his or her parent or legal guardian must sign. By signing, the parent or legal guardian agrees to be responsible for paying all premiums, copays, coinsurance, and deductibles for all the applicants listed on this application. A copy of your agreement with your signature is as valid as the original. If signatures are missing, we will cancel the application. I understand that Kaiser Foundation Health Plan, Inc., will rely on the information provided in this application. If any information is found to be fraudulent or intentionally misrepresented, then Kaiser Foundation Health Plan, Inc., may choose to terminate coverage back to the coverage effective date. Primary applicant (parent or legal guardian for children under 18) Spouse/domestic partner Dependent (18 and older) Dependent (18 and older)

6 6 STEP 8: Sign the Kaiser Foundation Health Plan, Inc., arbitration agreement I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the ERISA claims procedure regulation, and any other claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my heirs, relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), any contracted health care providers, administrators, or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in KFHP, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), 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 our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the Membership Agreement, Disclosure Form, and Evidence of Coverage. Primary applicant (parent or legal guardian for children under 18) Spouse/domestic partner Dependent (18 and older) Dependent (18 and older) Stop you do not have to complete Step 9 of the KPIF application to apply for CHP.

7 NOTES

8 Please recycle November 2017

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10 Primary applicant Application for health coverage Individual and Family Plans Who can use this application? Things to remember You may use this application to apply for individual or family coverage from Kaiser Permanente for Individuals and Families (KPIF). If you want coverage for your family on the same KPIF plan, please fll out 1 application for the family. If a family member wants a different health plan, he or she must complete a separate application. To be eligible for KPIF coverage, you must live in our California service area. To be eligible for KPIF coverage, you can t be entitled to Medicare Part A or enrolled in Medicare Part B. If you qualify for and want to take advantage of federal fnancial assistance to help pay for copays, coinsurance, deductibles, or premiums, don t complete this application. You must apply for coverage through Covered California at CoveredCA.com. If you re already a member, don t use this form. To change your plan, call You can apply faster online at buykp.org/apply. Please answer all questions, and type or print using ink only. Leave an empty box in between words, and put a hyphen in the box for hyphenated names. If we receive your completed application with payment by the 15th of the month and approve it, coverage will be effective on the 1st of the next month. If we receive your completed application with payment after the 15th and approve it, coverage will be effective on the 1st of the month after the next month. If you re applying during a special enrollment period, you can fnd instructions at kp.org/specialenrollment or call Your application submission deadline and effective date may be different than the dates listed above if you apply during a special enrollment period. Remember, this new enrollment will not end other coverage through Covered California or Kaiser Permanente. Don t want 2 plans? Be sure to end your other plan the day before your new plan starts to avoid paying 2 premiums or having a gap in your coverage. If your application is incomplete, not signed, doesn t include your frst month s payment, or doesn t include required special enrollment period documentation, it may be canceled. Send your complete, signed application and frst month s premium payment by mail to: Kaiser Permanente for Individuals and Families P.O. Box San Diego, CA Or send it by secure fax to: Note: Checks must be mailed and can t be faxed. Need help? For help with completing this application, please call For TTY, call 711. We ll provide language assistance at no cost to you. If you re working with a broker, please call him or her for assistance. In California, all plans are offered and underwritten by Kaiser Foundation Health Plan, Inc., One Kaiser Plaza, Oakland, CA California 2018 Page 1 of 9

11 Primary applicant STEP 1: Check your eligibility Are you or anyone else in your family either entitled to Medicare Part A or enrolled in Medicare Part B? Yes No If you selected Yes, those of you who are entitled to Medicare Part A or enrolled in Medicare Part B can t enroll in an individual and family plan. Please visit kp.org/medicare to learn more about your Medicare plan options or apply for coverage. STEP 2: Tell us when you re applying Select 1 option: If you selected A special enrollment period, choose the triggering event: Open enrollment Loss of health care coverage (write the last Death of the subscriber or a dependent A special enrollment period full day you had coverage)* Child support order or other court order If you re applying during a special enrollment Gaining or becoming a dependent to cover a dependent period, please write the date of your triggering through marriage or domestic partnership event (or qualifying life event). Permanent relocation registration Gaining or becoming a dependent through Release from incarceration the birth of a child, adoption, foster care, Change in eligibility for federal fnancial or placement for adoption or foster care assistance through Covered California For more information on minimum essential (Please choose your effective date.) coverage and qualifying triggering events, Change in eligibility for employer health please visit kp.org/specialenrollment or The date of birth, adoption, foster care, coverage call or placement for adoption or foster care Determination by Covered California The frst day of the month after Misinformation about coverage gaining the dependent Provider network changes Losing a dependent through divorce, dissolution of domestic partnership, or legal separation *If your triggering event is loss of Kaiser Permanente coverage, we may review your prior membership records to establish eligibility. If you ll be getting federal fnancial assistance, don t use this form. We can help you apply at CoveredCA.com. STEP 3: Choose your health plan Choose 1 health plan. If any family members are applying for different health plans, please submit a separate application for each plan. Bronze Silver Gold Platinum Kaiser Permanente Kaiser Permanente Kaiser Permanente Kaiser Permanente Bronze 60 HDHP HMO 5500/40% Silver 70 HMO Off Exchange Gold 80 HMO Platinum 90 HMO Kaiser Permanente Kaiser Permanente Kaiser Permanente Bronze 60 HMO Silver 70 HMO 2000/45 Gold 80 HMO Coinsurance Kaiser Permanente Kaiser Permanente Bronze 60 HDHP HMO Silver 70 HDHP HMO 2700/15% Minimum coverage plan To purchase a minimum coverage plan, applicants must be younger than 30 on the effective date, or provide a certificate of exemption from Covered California that shows hardship or lack of affordable coverage. We won t be able to process your application without the certificate of exemption if you are 30 and older. To see if you qualify, please go to marketplace.cms.gov/applications-and-forms/hardship-exemption.pdf and follow the instructions. Kaiser Permanente Minimum Coverage HMO For information about health and dental benefits and limitations, cost-sharing amounts, and premiums, please review the details in your enrollment materials. To request a copy of the Membership Agreement, Disclosure Form, and Evidence of Coverage for a particular plan, please go to kp.org/plandocuments, call , or contact your broker California 2018 Page 2 of 9

12 Primary applicant STEP 4:Choose your optional adult dental plan Dental coverage is included in your health plan for child members until the end of the month in which the member turns 19. Kaiser Permanente offers an optional dental insurance plan to adults, which includes those individuals whose eligibility for pediatric dental services has ended. This optional coverage is available for an additional charge. Our optional adult dental coverage is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP), and administered by Delta Dental of California, one of the nation s largest and most experienced dental benefits providers. Please choose 1 option below. Yes, I agree to enroll in the KPIC dental insurance plan. Kaiser Permanente Insurance Company, a subsidiary of Kaiser Foundation Health Plan, Inc., underwrites the dental insurance plan. Once enrolled, I can t cancel my dental coverage without canceling my regular health coverage, unless I make the change during open enrollment or a special enrollment period. No. I m not interested in optional dental coverage. STEP 5: Enter your information Primary applicant First name In an individual plan, the primary applicant is the person who will be covered by the health plan. In a family plan, the primary applicant is the family member on the health plan who is authorized to make changes to the account. If this application is only for a child under 18, the child is the primary applicant. Social Security number (if any) - - Date of birth (mm/dd/yyyy) Former medical record number (if any) State (if any) Gender: Phone Male Female - - Home address (no P.O. boxes, please) City State ZIP code County Mailing address (if different than home address) City State ZIP code Preferred language spoken (if not English) Preferred language read (if not English) address (optional) I understand that Kaiser Permanente may contact me via California 2018 Page 3 of 9 (continues)

13 Primary applicant STEP 5: Enter your information (continued) Parent or legal guardian (if the primary applicant is a child under 18) First name Gender: Male Female Date of birth (mm/dd/yyyy) Social Security number (if any) - - A domestic partner is a person registered and legally recognized as your Spouse/domestic partner to be covered domestic partner by California. First name Choose one: Spouse Social Security number (if any) - - Former medical record number (if any) State (if any) Gender: Date of birth (mm/dd/yyyy) Male Female Domestic partner If you have more than 2 dependents to be covered, please fill out an extra copy of this page Dependents to be covered and submit it with your application. 1 First name Social Security number (if any) - - Former medical record number (if any) State (if any) Gender: Date of birth (mm/dd/yyyy) Male Female Relationship to primary applicant 2 First name Social Security number (if any) - - Former medical record number (if any) State (if any) Gender: Date of birth (mm/dd/yyyy) Male Female Relationship to primary applicant California 2018 Page 4 of 9

14 Primary applicant STEP 6: Choose an authorized representative (if you have one) You can give a trusted friend or relative permission to talk about this application with us, see your information, or act for you on matters related to this application only. This person is called an authorized representative. First name Phone - - By signing, you ve appointed this person as your legally authorized representative to get offcial information about this application, and to act for you on matters related to this application. Primary applicant (parent or legal guardian for children under 18) STEP 7: Sign the application agreement Important: All applicants and dependents 18 and older must read, sign, and date below. If the primary applicant is a child under 18, then his or her parent or legal guardian must sign. By signing, the parent or legal guardian agrees to be responsible for paying all premiums, copays, coinsurance, and deductibles for all the applicants listed on this application. A copy of your agreement with your signature is as valid as the original. If signatures are missing, we will cancel the application. I understand that Kaiser Foundation Health Plan, Inc., will rely on the information provided in this application. If any information is found to be fraudulent or intentionally misrepresented, then Kaiser Foundation Health Plan, Inc., may choose to terminate coverage back to the coverage effective date. Primary applicant (parent or legal guardian for children under 18) Spouse/domestic partner Dependent (18 and older) Dependent (18 and older) California 2018 Page 5 of 9

15 Primary applicant STEP 8: Sign the Kaiser Foundation Health Plan, Inc., arbitration agreement I understand that (except for Small Claims Court cases, claims subject to a Medicare appeals procedure or the ERISA claims procedure regulation, and any other claims that cannot be subject to binding arbitration under governing law) any dispute between myself, my heirs, relatives, or other associated parties on the one hand and Kaiser Foundation Health Plan, Inc. (KFHP), any contracted health care providers, administrators, or other associated parties on the other hand, for alleged violation of any duty arising out of or related to membership in KFHP, including any claim for medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), 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 our right to a jury trial and accept the use of binding arbitration. I understand that the full arbitration provision is contained in the Membership Agreement, Disclosure Form, and Evidence of Coverage. Primary applicant (parent or legal guardian for children under 18) Spouse/domestic partner Dependent (18 and older) Dependent (18 and older) California 2018 Page 6 of 9

16 Primary applicant STEP 9: Enter frst month s payment details Payment information First name of person responsible for payment of person responsible for payment Address City State ZIP code Payment options Credit card Debit card Visa MasterCard Discover American Express Cardholder s frst name as it appears on card Cardholder s last name as it appears on card Card number Expiration date (mm/yyyy) Cardholder s signature Electronic payment Checking account Savings account I authorize Kaiser Foundation Health Plan, Inc. (KFHP), and the designated fnancial institution to accept this transfer of the frst month s premium amount from my checking or savings account when my application is processed by KFHP. Bank name Routing number Account number Account holder s frst name Account holder s last name Account holder s signature Check Money order Write the name of the primary applicant on the check. Mail payment with your application to the address listed on page California 2018 Page 7 of 9

17 Primary applicant Automatic monthly payments This optional service allows you to automatically pay your monthly premiums electronically on the 1st day of the month (unless it falls on a weekend or holiday). If you d like to sign up, please fll out your information below. To cancel or update automatic payments, go to kp.org/payonline or call the Member Service Contact Center at Billing information Is this information the same as your frst month s payment details? Yes No If no, please fll out this section. First name of person responsible for payment of person responsible for payment Billing address City State ZIP code Payment options Debit cards can t be used for automatic monthly payments. Credit card Visa MasterCard Discover American Express Cardholder s frst name as it appears on card Cardholder s last name as it appears on card Card number Expiration date (mm/yyyy) Cardholder s signature Electronic payment Checking account Savings account I authorize Kaiser Foundation Health Plan, Inc. (KFHP), and the designated fnancial institution to accept this transfer from my checking or savings account. Bank name Routing number Account number Account holder s frst name Account holder s last name Account holder s signature California 2018 Page 8 of 9

18 Primary applicant For applicants using an Agent/Broker/KPIF representative If you used an agent/broker/kpif representative, please make sure he or she completes this page. A Kaiser Permanente representative includes any agent/broker/kpif representative who has helped you decide which plan to enroll in or helped you fill out the application. Agent/Broker/KPIF representative frst name The broker of record may receive monetary and/or nonmonetary payments from KPIF in connection with the purchase of this coverage. Note: Premiums are the same whether or not you use an agent/broker/kpif representative. To be completed by your Kaiser Permanente appointed agent/broker/kpif representative after completion of this application: Notice to agent, broker, KPIF representative: If you have assisted the applicant in submitting the application, the law requires that you attest to this assistance. If, in making this attestation, you state as true any material fact you know to be false, you will be subject to a civil penalty of up to ten thousand dollars ($10,000), as authorized under California Health and Safety Code section (c) or Insurance Code section , in addition to any other applicable penalties or remedies available under current law. You must answer the following question by selecting Yes or No: I assisted the applicant in submitting this application. To the best of my knowledge, the information on this application is complete and accurate. I explained to the applicant, in easy-to-understand language, the risk to the applicant of providing inaccurate information, and the applicant understood the explanation. Yes No Agent/Broker/KPIF representative Agent/Broker/KPIF representative (frst, middle, last) (please print) Address City State ZIP code KPIF appointed broker ID number Phone Fax address California 2018 Page 9 of 9

19 Kaiser Permanente does not discriminate on the basis of age, race, ethnicity, color, national origin, cultural background, ancestry, religion, sex, gender identity, gender expression, sexual orientation, marital status, physical or mental disability, source of payment, genetic information, citizenship, primary language, or immigration status. Language assistance services are available from our Member Services Contact Center 24 hours a day, seven days a week (except closed holidays). Interpreter services, including sign language, are available at no cost to you during all hours of operation. We can also provide you, your family, and friends with any special assistance needed to access our facilities and services. In addition, you may request health plan materials translated in your language, and may also request these materials in large text or in other formats to accommodate your needs. For more information, call (TTY users call 711). A grievance is any expression of dissatisfaction expressed by you or your authorized representative through the grievance process. A grievance includes a complaint or an appeal. For example, if you believe that we have discriminated against you, you can file a grievance. Please refer to your Evidence of Coverage or Certificate of Insurance, or speak with a Member Services representative for the disputeresolution options that apply to you. This is especially important if you are a Medicare, MediCal, MRP, MediCal Access, FEHBP, or CalPERS member because you have different disputeresolution options available. You may submit a grievance in the following ways: By completing a Complaint or Benefit Claim/Request form at a Member Services office located at a Plan Facility (please refer to Your Guidebook for addresses) By mailing your written grievance to a Member Services office at a Plan Facility (please refer to Your Guidebook for addresses) By calling our Member Service Contact Center toll free at (TTY users call 711) By completing the grievance form on our website at kp.org Please call our Member Service Contact Center if you need help submitting a grievance. The Kaiser Permanente Civil Rights Coordinator will be notified of all grievances related to discrimination on the basis of race, color, national origin, sex, age, or disability. You may also contact the Kaiser Permanente Civil Rights Coordinator directly at One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C , , (TDD). Complaint forms are available at

20 Kaiser Permanente no discrimina a ninguna persona por su edad, raza, etnia, color, país de origen, antecedentes culturales, ascendencia, religión, sexo, identidad de género, expresión de género, orientación sexual, estado civil, discapacidad física o mental, fuente de pago, información genética, ciudadanía, lengua materna o estado migratorio. La Central de Llamadas de Servicio a los Miembros (Member Service Contact Center) brinda servicios de asistencia con el idioma las 24 horas del día, los siete días de la semana (excepto los días festivos). Se ofrecen servicios de interpretación sin costo alguno para usted durante el horario de atención, incluido el lenguaje de señas. También podemos ofrecerle a usted, a sus familiares y amigos cualquier ayuda especial que necesiten para acceder a nuestros centros de atención y servicios. Además, puede solicitar los materiales del plan de salud traducidos a su idioma, y también los puede solicitar con letra grande o en otros formatos que se adapten a sus necesidades. Para obtener más información, llame al (los usuarios de la línea TTY deben llamar al 711). Una queja es una expresión de inconformidad que manifiesta usted o su representante autorizado a través del proceso de quejas. Una queja incluye una queja formal o una apelación. Por ejemplo, si usted cree que ha sufrido discriminación de nuestra parte, puede presentar una queja. Consulte su Evidencia de Cobertura (Evidence of Coverage) o Certificado de Seguro (Certificate of Insurance), o comuníquese con un representante de Servicio a los Miembros (Member Services) para conocer las opciones de resolución de disputas que le corresponden. Esto tiene especial importancia si es miembro de Medicare, MediCal, MRP (Major Risk Medical Insurance Program, Programa de Seguro Médico para Riesgos Mayores), MediCal Access, FEHBP (Federal Employees Health Benefits Program, Programa de Beneficios Médicos para los Empleados Federales) o CalPERS ya que dispone de otras opciones para resolver disputas. Puede presentar una queja de las siguientes maneras: completando un formulario de queja o de reclamación/solicitud de beneficios en una oficina de Servicio a los Miembros ubicada en un centro del plan (consulte las direcciones en Su Guía) enviando por correo su queja por escrito a una oficina de Servicio a los Miembros en un centro del plan (consulte las direcciones en Su Guía) llamando a la línea telefónica gratuita de la Central de Llamadas de Servicio a los Miembros al (los usuarios de la línea TTY deben llamar al 711) completando el formulario de queja en nuestro sitio web en kp.org Llame a nuestra Central de Llamadas de Servicio a los Miembros si necesita ayuda para presentar una queja. Se le informará al coordinador de derechos civiles (Civil Rights Coordinator) de Kaiser Permanente de todas las quejas relacionadas con la discriminación por motivos de raza, color, país de origen, género, edad o discapacidad. También puede comunicarse directamente con el coordinador de derechos civiles de Kaiser Permanente en One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA También puede presentar una queja formal de derechos civiles de forma electrónica ante la Oficina de Derechos Civiles (Office for Civil Rights) en el Departamento de Salud y Servicios Humanos de los Estados Unidos (U. S. Department of Health and Human Services) mediante el portal de quejas formales de la Oficina de Derechos Civiles (Office for Civil Rights), en ocrportal.hhs.gov/ocr/portal/lobby.jsf, o por correo postal o por teléfono a: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C , , (línea TDD). Los formularios de queja formal están disponibles en

21 Kaiser Permanente 禁止以年齡 種族 族裔 膚色 原國籍 文化背景 血統 宗教 性別 性別認同 性別表達方式 性取向 婚姻狀況 生理或心理殘障 支付來源 遺傳資訊 公民身份 主要語言或移民身份為由而對任何人進行歧視 計劃成員服務聯絡中心提供語言協助服務 ; 每週七天 24 小時晝夜服務 ( 法定節假日除外 ) 本機構在全部辦公時間內免費為您提供口譯服務, 其中包括手語 我們還可為您 您的親屬和朋友提供任何必要的特別補助, 以便您使用本機構的設施與服務 此外, 您還可請求以您的語言提供健康保險計劃資料之譯本, 並可請求採用大號字體或其他版本格式提供此類資料的譯本, 藉以滿足您的需求 若需詳細資訊, 請致電 (TTY 專線使用者請撥 711) 冤情申訴係指您或您的授權代表透過冤情申訴程序所表達的不滿陳訴 申訴冤情包括投訴或上訴 例如, 如果您認為自己受到本機構的歧視, 則可提出冤情申訴 若需瞭解可供您選擇的適用爭議解決方案, 請參閱您的 承保範圍說明書 (Evidence of Coverage) 或 保險證明書 (Certificate of Insurance), 或者與計劃成員服務代表交談 對於 Medicare MediCal MRP MediCal Access FEHBP 或 CalPERS 計劃成員, 這尤其重要 ; 原因在於, 為這些成員提供的爭議解決方案選擇有所不同 您可透過以下方式提出冤情申訴 : 於設在本計劃服務設施的某個計劃成員服務處填妥一份 投訴或保險福利索償 / 請書 ( 請參閱您的 通訊地址指南冊, 以便查找相關地址 ) 將您的冤情申訴書郵寄至設在本計劃服務設施的某個計劃成員服務處 ( 請參閱您的 通訊地址指南冊, 以便查找相關地址 ) 免費致電本機構的計劃成員服務聯絡中心, 電話號碼是 (TTY 專線使用者請撥 711) 在本機構的網站上填妥一份冤情申訴書, 網址是 kp.org 如果您在提交冤情申訴書的過程中需要協助, 請致電本機構的計劃成員服務聯絡中心 涉及種族 膚色 原國籍 性別 年齡或身體殘障歧視的一切冤情申訴都將通告給 Kaiser Permanente 的民權事務協調員 (Civil Rights Coordinator) 您也可與 Kaiser Permanente 的民權事務協調員直接聯絡 ; 聯絡地址是 One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 您還可以採用電子方式透過民權辦公處 (Office for Civil Rights) 的投訴入口網站 (Civil Rights Complaint Portal) 向美國衛生與公共服務部民權辦公處 (U.S. Department of Health and Human Services, Office for Civil Rights) 提出民權投訴, 網址是 ocrportal.hhs.gov/ocr/portal/lobby.jsf; 或者按照如下聯絡資訊採用郵寄或電話方式聯絡 : U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C , , (TDD 專線 ) 可從網站上下載投訴書, 網址是

22 Language Assistance Services English: Language assistance is available at no cost to you, 24 hours a day, 7 days a week. You can request interpreter services, materials translated into your language, or in alternative formats. Just call us at , 24 hours a day, 7 days a week (closed holidays). TTY users call 711. :Arabic خدمات الترجمة الفورية متوفرة لك مجان ا على مدار الساعة كافة أيام األسبوع. بإمكانك طلب خدمة الترجمة الفورية أو ترجمة وثائق للغتك أو لصيغ أخرى. ما عليك سوى االتصال بنا على الرقم على مدار الساعة كافة أيام األسبوع )مغلق أيام العطالت(. لمستخدمي خدمة الهاتف النصي يرجي االتصال على الرقم )711(. Armenian: Ձեզ կարող է անվճար օգնություն տրամադրվել լեզվի հարցում` օրը 24 ժամ, շաբաթը 7 օր: Դուք կարող եք պահանջել բանավոր թարգմանչի ծառայություններ, Ձեր լեզվով թարգմանված կամ այլընտրանքային ձևաչափով պատրաստված նյութեր: Պարզապես զանգահարեք մեզ` հեռախոսահամարով` օրը 24 ժամ` շաբաթը 7 օր (տոն օրերին փակ է): TTY-ից օգտվողները պետք է զանգահարեն 711: Chinese: 您每週 7 天, 每天 24 小時均可獲得免費語言協助 您可以申請口譯服務 要求將資料翻譯成您所用語言或轉換為其他格式 我們每週 7 天, 每天 24 小時均歡迎您打電話 前來聯絡 ( 節假日休息 ) 聽障及語障專線 (TTY) 使用者請撥 711 :Farsi خدمات زبانی در 24 ساعت شبانروز و 7 روز هفته بدون اخذ هزينه در اختيار شما است. شما می توانيد برای خدمات مترجم شفاهی ترجمه جزوات به زبان شما و يا به صورتهای ديگر درخواست کنيد. کافيست در 24 ساعت شبانروز و 7 روز هفته )به استثنای روزهای تعطيل( با ما به شماره تماس بگيريد. کاربران TTY با شماره 711 تماس بگيرند. Hindi: ब न क स ल गत द भ ब य स व ए, कदन 24 घ ट, सप त ह स त कदन उपलब ध ह आप ए द भ ब य स व ओ बलए, ब न क स ल गत स मब य अपन भ म अन व द रव न बलए, य व बपप प र र प बलए अन र ध र स त ह स वल हम पर, कदन 24 घ ट, सप त ह स त कदन (छ ट ट य व ल कदन द रहत ह ) ल र TTY उपय ग त 711 पर ल र Hmong: Muajkwc pab txhais lus pub dawb rau koj, 24 teev ib hnub twg, 7 hnub ib lim tiam twg..koj thov tau cov kev pab txhais lus, muab cov ntaub ntawv txhais ua koj hom lus, los yog ua lwm hom.tsuas hu rau , 24 teev ib hnub twg, 7 hnub ib lim tiam twg (cov hnub caiv kaw). Cov neeg siv TTY hu 711. Japanese: 当院では 言語支援を無料で 年中無休 終日ご利用いただけます 通訳サービス 日本語に翻訳された資料 あるいは資料を別の書式でも依頼できます お気軽に までお電話ください ( 祭日を除き年中無休 ) TTY ユーザーは 711 にお電話ください Khmer: ជ ន យភ ស គ ម នឥតអស ថ ល ដល អនកឡ យ 24 ឡម ង ម យថ ល 7 ថ ល ម យអ ទ ត យ អនកអ ចឡសន ស ឡសវ អនកបកប រប ស ភ រ ប ដលប នបកប របឡ ជ ភ ស ប ម រ ឬជ ទ រង ផ ស ងឡទ ត រ ន ប ត ទ រស ព ទមកឡយ ង ត មឡលម ប ន 24 ឡម ងម យ ថ ល 7 ថ ល ម យអ ទ ត យ (ប ទថ ល បណ យ) អនកឡរប TTY ឡ ឡលម 711 Korean: 요일및시간에관계없이언어지원서비스를무료로이용하실수있습니다. 귀하는통역서비스, 귀하의언어로번역된자료또는대체형식의자료를요청할수있습니다. 요일및시간에관계없이 번으로전화하십시오 ( 공휴일휴무 ). TTY 사용자번호 711. Navajo: Saad bee 1k1 a ayeed n1h0l= t 11 jiik 4, naadiin doo bib22 d99 ah44 iikeed tsosts id yisk32j9 damoo n1'1dleehj9. Atah halne 4 1k1 adoolwo[7g77 j0k7, t 1adoo le 4 t 11 h0hazaadj9 hadily22 go, 47 doodaii n11n1 l1 a[ 22 1daat eh7g77 bee h1dadilyaa go. Koj9 hodiilnih , naadiin doo bib22 d99 ah44 iikeed tsosts id yisk32j9 damoo n1 1dleehj9 (Dahodiyin biniiy4 e e aahgo 47 da deelkaal). TTY chodeeyool7n7g77 koj9 hodiilnih 711

23 Punjabi: ਬ ਨ ਬ ਸ ਲ ਗਤ ਦ, ਬਦਨ ਦ 24 ਘ ਟ, ਹਫਤ ਦ 7 ਬਦਨ, ਦ ਭ ਸ ਆ ਸ ਵ ਵ ਤ ਹ ਡ ਲਈ ਉਪਲ ਧ ਹ ਤ ਸ ਇ ਦ ਭ ਸ ਏ ਦ ਮਦਦ ਲਈ, ਸਮ ਗਰ ਆ ਨ ਆਪਣ ਭ ਸ ਬਵ ਚ ਅਨ ਵ ਦ ਰਵ ਉਣ ਲਈ, ਜ ਬ ਸ ਵ ਖ ਫ ਰਮ ਟ ਬਵ ਚ ਪਰ ਪਤ ਰਨ ਲਈ ਨਤ ਰ ਸ ਦ ਹ ਸ ਬਸਰਫ਼ ਸ ਨ ਤ, ਬਦਨ ਦ 24 ਘ ਟ, ਹਫ਼ਤ ਦ 7 ਬਦਨ (ਛ ਟ ਆ ਵ ਲ ਬਦਨ ਦ ਰਬਹ ਦ ਹ ) ਫ਼ ਨ ਰ TTY ਦ ਉਪਯ ਗ ਰਨ ਵ ਲ 711 ਤ ਫ਼ ਨ ਰਨ Russian: Мы бесплатно обеспечиваем Вас услугами перевода 24 часа в сутки, 7 дней в неделю. Вы можете воспользоваться помощью устного переводчика, запросить перевод материалов на свой язык или запросить их в одном из альтернативных форматов. Просто позвоните нам по телефону , который доступен 24 часа в сутки, 7 дней в неделю (кроме праздничных дней). Пользователи линии TTY могут звонить по номеру 711. Spanish: Contamos con asistencia de idiomas sin costo alguno para usted 24 horas al día, 7 días a la semana. Puede solicitar los servicios de un intérprete, que los materiales se traduzcan a su idioma o en formatos alternativos. Solo llame al , 24 horas al día, 7 días a la semana (cerrado los días festivos). Los usuarios de TTY, deben llamar al 711. Tagalog: May magagamit na tulong sa wika nang wala kang babayaran, 24 na oras bawat araw, 7 araw bawat linggo. Maaari kang humingi ng mga serbisyo ng tagasalin sa wika, mga babasahin na isinalin sa iyong wika o sa mga alternatibong format. Tawagan lamang kami sa , 24 na oras bawat araw, 7 araw bawat linggo (sarado sa mga pista opisyal). Ang mga gumagamit ng TTY ay maaaring tumawag sa 711. Thai: เราม บร การล ามฟร สาหร บค ณตลอด 24 ช วโมง ท กว นตลอดช วโมงทาการของเราค ณสามารถขอให ล าม ช วยตอบคาถามของค ณท เก ยวก บความค มครองการด แล ส ขภาพของเราและค ณย งสามารถขอให ม การแปล เอกสารเป นภาษาท ค ณใช ได โดยไม ม การค ดค าบร การ เพ ยงโทรหาเราท หมายเลข ตลอด 24 ช วโมงท กว น (ป ดให บร การในว นหย ดราชการ) ผ ใช TTY โปรดโทรไปท 711 Vietnamese: Dịch vụ thông dịch được cung cấp miễn phí cho quý vị 24 giờ mỗi ngày, 7 ngày trong tuần. Quý vị có thể yêu cầu dịch vụ thông dịch, tài liệu phiên dịch ra ngôn ngữ của quý vị hoặc tài liệu bằng nhiều hình thức khác. Quý vị chỉ cần gọi cho chúng tôi tại số , 24 giờ mỗi ngày, 7 ngày trong tuần (trừ các ngày lễ). Người dùng TTY xin gọi 711.

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25 Kaiser Permanente Subsidy Eligibility Form 2018 The Community Health Care Program provides a subsidy to help pay your monthly premiums and most out-of-pocket medical costs under the Kaiser Permanente Platinum 90 HMO plan. The Kaiser Permanente subsidy is offered as part of Kaiser Permanente s Community Health Care Program. Eligibility for the Kaiser Permanente Community Health Care Program will be considered for individuals who are uninsured and: Live in a specifc Kaiser Foundation Health Plan, Inc., service area; check kp.org/communityhealthcareprogram for more information. Are under 19 years of age at the time of the effective date of the Kaiser Permanente plan. The Community Health Care Program will also be open to 19- to 26-year-olds in certain counties. Check kp.org/communityhealthcareprogram for more information. Live in a household with incomes less than 300% of the federal poverty level. Do not have access to any other public or private health coverage including, but not limited to, Medi-Cal, Medicare, a job-based health plan, or coverage through Covered California. Children under 19 years of age living in households with income between 0 266% of the federal poverty level are eligible for Medi-Cal. Even if you have an affordability exemption from the federal government you must still meet all the eligibility criteria listed above to be approved for Kaiser Permanente s Community Health Care Program. U.S. citizenship is not an eligibility requirement. Enrollment in Kaiser Permanente s Community Health Care Program is available during the Individuals and Families annual open enrollment and special enrollment periods. In general, the special enrollment period is 60 days after a triggering event such as marriage, birth or adoption of a child, divorce, or loss of job and job-based health coverage. Enrollment into this charitable, subsidized program is limited and subject to availability. How to apply for Kaiser Permanente s Community Health Care Program Step 1 Complete 2 separate documents: For health coverage complete the Kaiser Permanente for Individuals and Families application. For the Kaiser Permanente subsidy complete this form for all applicants in your household. Please complete the Kaiser Permanente for Individuals and Families application before you complete the Kaiser Permanente Subsidy Eligibility form. Step 2 Include the following documents: Proof of your most current household s gross income: If employer paid include your last 3 paycheck stubs, W-2 forms, or wage and/or tax statements. If self-employed include Schedule C and page 1 (the adjusted gross income page) of last year s federal income tax return or a proft and loss form. If paid in cash include a signed letter of income from your employer. See Section 4 of this form for additional examples of proof of income. If you have received an affordability exemption from the federal government, documentation is required. Proof of your most current household s income deductions. See section 4 for examples. Please note: The information including, but not limited to, name, income, and address, that you provide on this form will be used or disclosed by Kaiser Permanente to determine your eligibility for Kaiser Permanente s subsidy and your eligibility for other health care or social service programs, or for any other purpose required by law. If you apply for a Kaiser Permanente subsidy through a community organization, that organization may use your information to determine your eligibility for another health care or social service program, or for any other purpose required by law CHC Subsidy Eligibility Form NCAL 1