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2022-KPIF-ACF-1 664802885 KPWA 2022
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 1-800-290-8900 for more about qualifying life events.
Loss of minimum essential health coverage (write the last full day you
Did you lose coverage with us (KFHPWA) that was provided by
If Yes, you have 2 options for continuing your coverage with us.
Coverage that begins automatically the day after your
employer coverage ends.
Coverage that begins based on when we receive your
application. Please see kp.org/specialenrollment under
“Loss of minimum essential health coverage” for more details.
Gaining or becoming a dependent through marriage or domestic
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 the birth or placement of the child with you
Child support order or other court order to cover a dependent
Note: In this case, you also need to choose between 2 effective
The date of the child support order or other court order to
cover a dependent
The first day of the month after the court order date
Permanent relocation with access to new plans
Changes in employer health coverage making you eligible for
a premium tax credit
Determination by Washington Healthplanﬁnder of exceptional
Eligibility to purchase an individual health plan through
an individual coverage health reimbursement arrangement
(ICHRA) or a qualified small employer health reimbursement
Domestic violence or spousal abandonment occurring within
Loss of COBRA health coverage due to discontinuation of
Please write the date of your qualifying life event.
your qualifying life event is loss of KFHPWA coverage, we may review membership records to check when and why you lost coverage. For more about
minimum essential coverage, visit kp.org/specialenrollment.
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.
x Silver HD
Available in King, Kitsap, Pierce,
Snohomish, Spokane, and Thurston
Virtual Plus Bronze
Choose your dental plan
If you want to add dental coverage, please choose your dental plan here.
Under the Affordable Care Act, pediatric dental coverage is required. If
your account change form includes children 18 and younger and you
don’t enroll them in our pediatric dental plan, we’ll contact you to submit
an Attestation of Pediatric Coverage with proof of other pediatric dental
Pediatric Dental #09140
amily Dental #09145