Fillable Form 4899901302: Instructions Account Change Form Colorado Individual (Kaiser Permanente)

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Form 4899901302: Instructions Account Change Form Colorado Individual (Kaiser Permanente)

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The Form 4899901302: Instructions Account Change Form Colorado Individual (Kaiser Permanente) form is 6 pages long and contains:

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  • 15 check-boxes
  • 158 other fields

Country of origin: US
File type: PDF

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Page 1 of 6
489990130 Colorado 2021
Individual and Family Plans
Account Change Form
Colorado
Instructions
• There are different types of plan changes and account changes you can make with this form. Please fill out your personal information in Section A.
Then select what changes you’d like to make in Section B, and continue on to fill out any other sections related to those changes.
• If you’re adding a dependent to your plan, any other coverage they have won’t be automatically canceled. To avoid paying for 2 plans or having
a gap in coverage, please cancel any other coverage they have as of the day before their new coverage starts.
• Note: If you’re entitled to Medicare Part A or enrolled in Medicare Part B, you’re not eligible to change Kaiser Permanente for Individuals and Families
(KPIF) plans. If a family member is entitled to Medicare Part A or enrolled in Medicare Part B, they’re not eligible to change KPIF plans or be added to
your KPIF plan as a new dependent.
4899901302
A. Fill out your information
Please select one: I’m the
subscriber,
spouse/civil union partner, or dependent child 18 and older, or
parent or legal guardian
If you’re making a change, please update the boxes below with your new information.
First name MI Gender:
Male
Female
Undeclared
Last name
Date of birth (mm/dd/yyyy)
Health record number (if any) Social Security number (if any)
-
-
Phone
-
-
Home address (no P.O. boxes, please)
City State ZIP code
Billing address
Check if the same as the home address.
City State ZIP code
Applicants 21 and older: Have you used tobacco at least 4 times per week in the past 6 months (except for religious/ceremonial use)?
Products include cigarettes, cigars, and chewing/smokeless tobacco. Regular tobacco users may pay different premiums.
Yes
No
Page 2 of 6
489990130 Colorado 2021
B. What change(s) do you want to make?
• Please check the boxes below for the changes you wish to make, and on the next page, list each family member affected. We won’t make any changes
for any family members you don’t list.
• The subscriber (or parent or legal guardian for subscribers under 18) can make all the changes below for any family members. Dependents can make
some of the changes — those marked with an asterisk (*) below — only for themselves.
You can make the following changes during open enrollment or a special enrollment period.
(Restrictions apply for special enrollment periods. See kp.org/specialenrollment for more information.)
I wish to change plans.*
I wish to combine accounts.
I wish to add medical coverage for a family member.
I wish to add medical coverage for myself on my family’s account as the subscriber.
You can make the following changes any time during the year. (Note: For these changes, you can skip Sections D and E.)
I’m ending my coverage and I wish to have my spouse/civil union
partner as the subscriber.
I’m ending my coverage on a family plan and wish to continue
on my own on an individual plan.*
I wish to change the subscriber.
I wish to change the parent/legal guardian on a child-only account.
I wish to end medical coverage for myself* or for a family member.
I’m ending my coverage but wish to keep my child(ren) on the plan.
I’m ending my and my spouse’s/civil union partner’s coverage
but wish to keep our child(ren) on the plan.
I wish to make the changes shown in Section A. (If you’re changing
your name, please include legal documentation of the change.)*
Someone on my account stopped using tobacco.
(Please indicate which family member in Section C.)*
Requested effective date (not guaranteed)
(mm/dd/yyyy)
Page 3 of 6
489990130 Colorado 2021
C. Which family members are affected by the change? (Please list below.)
If you have more than 3 dependents with a change, attach a copy of this page and complete the information for those dependents.
Spouse/Civil union partner
Add medical coverage
End medical coverage
First name MI Last name
Choose one: Spouse
Civil union partner
Social Security number (if any)
-
-
Health record number (if any) Date of birth (mm/dd/yyyy)
Gender:
Male
Female
Undeclared
Applicants 21 and older: Have you used tobacco at least 4 times per week in the past 6 months (except for religious/ceremonial use)?
Products include cigarettes, cigars, and chewing/smokeless tobacco. Regular tobacco users may pay different premiums.
Yes
No
Dependent 1
Add medical coverage
End medical coverage
First name MI Last name Gender:
Male
Female
Undeclared
Social Security number (if
any)
-
-
Health record number (if any) Date of birth (mm/dd/yyyy)
Applicants 21 and older: Have you used tobacco at least 4 times per week in the past 6 months (except for religious/ceremonial use)?
Products include cigarettes, cigars, and chewing/smokeless tobacco. Regular tobacco users may pay different premiums.
Yes
No
Dependent 2
Add medical coverage
End medical coverage
First name MI Last name Gender:
Male
Female
Undeclared
Social Security number (if
any) Health record number (if any) Date of birth (mm/dd/yyyy)
-
-
Applicants 21 and older: Have you used tobacco at least 4 times per week in the past 6 months (except for religious/ceremonial use)?
Products include cigarettes, cigars, and chewing/smokeless tobacco. Regular tobacco users may pay different premiums.
Yes
No
Dependent 3
Add medical coverage
End medical coverage
First name MI Last name Gender:
Male
Female
Undeclared
Social Security number (if
any) Health record number (if any) Date of birth (mm/dd/yyyy)
-
-
Applicants 21 and older: Have you used tobacco at least 4 times per week in the past 6 months (except for religious/ceremonial use)?
Products include cigarettes, cigars, and chewing/smokeless tobacco. Regular tobacco users may pay different premiums.
Yes
No
Page 4 of 6
489990130 Colorado 2021
D. Choose your enrollment period
Select one option:
Open enrollment (skip to Section E)
A special enrollment period (continue below)
Choose your qualifying life event. If you had more than one, review your options because effective dates vary by event. Proof of eligibility is also
required. Visit kp.org/specialenrollment or call 1-800-494-5314 for more about qualifying life events.
Loss of minimum essential health coverage (write the last full day you
had coverage)*
Gaining or becoming a dependent through marriage or civil union
partnership
Gaining or becoming a dependent through the birth of a child, adoption,
or placement for adoption or foster care
Note: In this case, you also need to choose between 2 effective date options:
The date of birth, adoption, or placement for adoption or foster care
The first day of the month after gaining the dependent
Losing a dependent through divorce, dissolution of a civil union
partnership, or legal separation
Death of the subscriber or a dependent
Child support order or other court order to cover a dependent
Please choose one of the following for your effective date:
Date the court order is effective
Effective date assigned at time of application
Permanent relocation with access to new plans
Changes in employer health coverage making you eligible for
a premium tax credit
Determination by Department of Insurance Commissioner of
exceptional circumstances
Domestic violence or spousal abandonment occurring within
the household
Contract violation
Loss of short-term health coverage
Eligibility to purchase an individual health plan through an
individual coverage health reimbursement arrangement (ICHRA)
or a qualified small employer health reimbursement arrangement
(QSEHRA)
Release from incarceration
Change in income changing your eligibility for federal
financial assistance through Connect for Health Colorado
Determination by Connect for Health Colorado of
exceptional circumstances
Please write the date of your qualifying life event.
(mm/dd/yyyy)
*
If your qualifying life event is loss of Kaiser Permanente coverage, we may review membership records to check when and why you lost coverage. For
more about minimum essential coverage, visit kp.org/specialenrollment.
Page 5 of 6
489990130 Colorado 2021
E. Choose your health plan
If you indicated that you would like to change plans or add coverage for a family member, please select the plan you would like here. Each family
member you listed in Section C will be moved to the plan you select. If you wish to enroll family members in different plans, please submit a separate
form for each plan.
Bronze
KP CO Bronze 8000/50
KP Select CO Bronze 8000/50
‡
KP CO Bronze 7000/50 RX Copay
KP Select CO Bronze 7000/50 RX Copay
‡
KP CO Bronze 6500/35%/HSA
KP Select CO Bronze 6500/35%/HSA
‡
KP CO Bronze 6500/50
KP Select CO Bronze 6500/50
‡
Silver
KP CO Silver 5000/25 X
KP Select CO Silver 5000/25 X
‡
KP CO Silver 4000/30 RX Copay X
KP Select CO Silver 4000/30 RX Copay X
‡
KP CO Silver 3500/20%/HSA X
KP Select CO Silver 3500/20%/HSA X
‡
KP CO Silver 2500/25 X
KP Select CO Silver 2500/25 X
‡
Gold
KP CO Gold 2000/20
KP Select CO Gold 2000/20
‡
KP CO Gold 1500/20
KP Select CO Gold 1500/20
‡
KP CO Gold 0/20 RX Copay
KP Select CO Gold 0/20 RX Copay
‡
For applicants under 30 or with hardship exemptions
Catastrophic plans are available to applicants who will be younger than 30 on the effective date, or who provide a certificate of exemption 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.
KP CO Catastrophic/KP Select CO Catastrophic
‡
This plan does not offer pediatric dental benefits. If you are applying for this plan and have children under age 19 who will be covered, you must
purchase pediatric dental coverage separately.
I do not have children under age 19 who will be covered under this plan.
I hereby attest that I have or will purchase pediatric dental essential health benefit (EHB) coverage.
X
Applicant’s signature
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 Evidence of Coverage for a particular plan, please go to kp.org/plandocuments, call 1-800-632-9700, or contact your broker.
‡
If you live in the Colorado Springs service area, your plan will be in the KP Select network. Please see the KPIF Enrollment Guide for important information
on plans in the KP Select network.
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Page 6 of 6
489990130 Colorado 2021
F. Sign the form
• If a broker has assisted you with this account/plan change, by signing below, you are giving permission to that broker to act on your behalf regarding
this account/plan change.
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.
I understand that Kaiser Permanente will rely on the information provided in this form. If any information is found to be fraudulent or intentionally
misrepresented, then Kaiser Permanente may choose to terminate coverage back to the coverage effective date.
• I verify that no one listed on this form who is changing plans or being added as a dependent is entitled to Medicare Part A or enrolled in Medicare Part B.
Note: The subscriber and all dependents 18 and older making a change must sign the form. If there are more than 4 dependents 18 and older
signing, please attach a copy of this page with the additional signatures.
X
Subscriber/new subscriber (parent or legal guardian for subscribers under 18)
Date (mm/dd/yyyy)
X
Spouse/civil union partner
Date (mm/dd/yyyy)
X
Dependent (18 and older)
Date (mm/dd/yyyy)
X
Dependent (18 and older)
Date (mm/dd/yyyy)
X
Dependent (18 and older)
Date (mm/dd/yyyy)
X
Dependent (18 and older)
Date (mm/dd/yyyy)
Contact information
Mail to: Kaiser Permanente
P.O. Box 203004
Denver, CO 80220-9004
Or fax toll free to:
Membership Administration
1-866-846-2650
Questions? Call
1-866-410-7536
All plans are offered and underwritten by Kaiser Foundation Health Plan of Colorado, 10350 E. Dakota Ave., Denver, CO 80247.
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____________________________________________________________________
̀
NONDISCRIMINATION NOTICE
̌
Kaiser Foundation Health Plan of Colorado (Kaiser Health Plan) complies wit
h
applicable Federal civil rights laws and does not discriminate on the basis of race,
color, national origin, age, disability, or sex. Kaiser Health Plan does not exclude
people or treat them differently because of race, color, national origin, age, disability,
or sex. We also:
́ ̀ ̀
• Provide no cost aids and services to people with disabilities to communicate
effectively with us, such as:
• Qualifi
ed sign language interpreters
• Written information in other formats, such as large print, audio, and
accessible electronic formats
̀
• Provide no cost language services to people whose primary language is not
Englis
h, such as:
́
• Quali
fied interpreters
̀
• Information written in other languages
If you need these serv
ices, call 1-800-632-9700 (TTY: 711)
If you believe that Kaiser Health Plan has failed to provi
de these services or
discriminated in another way on the basis of race, color, national origin, age,
disability, or sex, you can file a grievance by mail at: Customer Experience
Department, Attn: Kaiser Permanente Civil Rights Coordinator, 2500 South Havana,
Aurora, CO 80014, or by phone at Member Services: 1-800-632-9700.
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 https://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, DC 20201, 1-800-368-1019,
1-800-537-7697 (TDD). Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
̀ ́̀ ̀
HELP IN YOUR LANGUAGE
ATTENTION: If you speak English, language assistance services, free of charge,
are available to you. Call 1-800-632-9700 (TTY: 711).
አአማማርርኛኛ (Amharic) ማማስስታታወወሻሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት
ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ 1-800-632-9700 (TTY: 711).
(Arabic): ةيبرعلا.

1-800-632-9700 (TTY :.)
Ɓasɔ
ɔ Wu
ɖu
(Bassa) Dè ɖɛ nìà kɛ dyéɖé gbo: Ɔ jǔ ké m Ɓàsɔ
ɔ
-wùɖù-po-nyɔ
jǔ
ní, nìí, à wuɖu kà kò ɖò po-poɔ
ɓɛìn m
gbo kpáa. Ɖá 1-800-632-9700 (TTY: 711)
中中文文 (Chinese) 注注意意：：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電
1-800-632-9700（TTY：711）。
        : هجوت (Farsi) یسراف
  
(711 :TTY) 1-800-632-9700
   
Français (French) ATTENTION: Si vous parlez français, des services d'aide
linguistique vous sont proposés gratuitement. Appelez le 1-800-632-9700 (TTY: 711).
Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen
kostenlos sprachliche Hilfsdienstleistungen zur Verfügung.
Rufnummer: 1-800-632-9700 (TTY: 711).
Igbo (Igbo) NRỤBAMA: Ọ bụrụ na ị na asụ Igbo, ọrụ enyemaka asụsụ, n’efu, dịịrị gị.
Kpọọ 1-800-632-9700 (TTY: 711).
日日本本語語 (Japanese) 注注意意事事項項：：日本語を話される場合、無料の言語支援をご利用い
ただけます。1-800-632-9700（TTY: 711）まで、お電話にてご連絡ください。
한한국국어어 (Korean) 주주의의: :
한국어를
사용하시는
경우, 언어
지원
서비스를
무료로
이용하실
수
있습니다. 1-800-632-9700 (TTY:
711) 번으로
전화해
주십시오.
Naabeehó (Navajo) Díí baa akó
nínízin: Díí saad bee yáníłti’go Diné Bizaad, saad bee
áká’ánída’áwo’déé’, t’áá jiik’eh, éí ná hóló, koji’ hódíílnih 1-800-632-9700 (TTY:
711).
̖̖ ̖ ̖

Nepali) 
      
     1-800-632-9700 (TTY: 711)  
Afaan Oromoo (Oromo) XIYYEEFFANNAA: Afaan dubbat
tu Oroomiffa, tajaajila
gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-800-632-9700 (TTY: 711).
Pусский (Russian) ВНИМАНИЕ: eсли вы говорите на русском языке, то вам
доступны бесплатные услуги перевода. Звоните 1-800-632-9700 (TTY: 711).
Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios
gratuitos de asistencia lingüística. Llame al 1-800-632-9700 (TTY: 711).
Tagalog (Tagalog) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang
gumamit ng mga serbisyo ng tulong sa wika nang walang bayad.
Tumawag sa 1-800-632-9700 (TTY: 711).
Tiếng Việt (Vietnamese) CHÚ Ý : Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ
ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-632-9700 (TTY: 711).
Yorùbá (Yoruba) AKIYESI: Ti o ba nso ede Yoruba ofe ni iranlowo lori ede wa fun
yin o. E pe ero ibanisoro yi 1-800-632-9700 (TTY: 711).
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Form 4899901302: Instructions Account Change Form Colorado Individual (Kaiser Permanente)

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