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Prior to Applying
 

Paper or plastic? How you choose to pay your first month’s premium may determine whether you apply by paper or continue online. If you would like to pay by check or money order, you will need to submit a paper application. If you would like to use credit/debit cards or electronic transfer from savings/checking, you can apply by paper or online. Whichever way you choose, please start by entering your ZIP code below.

You may be eligible for financial help from the federal government to lower your monthly premium. See if you qualify

If you are a current member with Individual and Family Plans and would like to look at other product options, please contact Member Services at 1-866-298-1499. Please do not use this site to request plan changes.

Paper or plastic? How you choose to pay your first month’s premium may decide whether you apply by paper or continue online. If you would like to pay by check or money order, you will need to submit a paper application. Only credit/debit cards or electronic transfer from savings/checking are accepted online. Whichever way you choose, please start by entering your ZIP code below.

You may be eligible for financial help from the federal government to lower your monthly premium. See if you qualify

Choose your path

How you choose to pay your first month’s premium may decide whether you apply by paper or continue online. If you would like to pay by check or money order, you will need to submit a paper application. Only credit/debit cards or electronic transfer from savings/checking are accepted online. Whichever way you choose, please start by entering your ZIP code below.

You may be eligible for financial help from the federal government to lower your monthly premium. See if you qualify

Kaiser Permanente of Hawaii has established an open enrollment period during the month of November 2011 for applicants under the age of 19 who are seeking their own individual health coverage plan or a child-only plan.

A child under the age of 19 may apply to enroll in our KP 20/Rx or KP 30/Rx plans only during this open enrollment period unless he or she experiences certain qualifying events and submits an application and supporting documentation within 31 days of the qualifying event. For more information on qualifying events and how to apply, call 1-800-494-5314.

A child who has not experienced a qualifying event can still get coverage outside the open enrollment period by enrolling in our KP Basic Plan.
Getting Coverage for Children

If you plan to apply for coverage for a child under age 19, you must do so during our open enrollment periods, March 15 through April 30 and September 15 through October 31. If your child has experienced a qualifying event (divorce; loss of employer-sponsored coverage; loss of Medicaid or other public program's benefits; moving from his or her health plan's service area; birth; or adoption), you may submit an application outside the open enrollment periods within 31 days of the qualifying event. In addition, we will accept applications received within 60 days of the birth or adoption of a child. Simply call 1-800-280-7329.

You will need to submit a paper application with the appropriate support documentation. Please refer to the "Getting Coverage for Children" brochure and "Application" located on the left side of the page for instructions on how to apply.

For additional coverage options for children available through the Washington State Health Insurance Pool (WSHIP) or the federal Pre-existing Condition Insurance Plan (PCIP-WA), contact WSHIP at 1-800-877-5187 or PCIP-WA at 1-877-505-0514.
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website after November 16, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website after October 30, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website on or after November 1, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website on or after December 8, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, please return to our website on or after October 31, 2012, when our 2013 plans and rates will be available.
The benefits and monthly rates listed are valid through December 31, 2012. If you would like to apply for these plans with a 2012 effective date, we must receive your application by December 8, 2012. Beginning January 1, 2013, the plans, benefits, and monthly rates for Kaiser Permanente for Individuals and Families plans will change.

If you would like to apply for coverage with a 2013 effective date, please return to our website on or after December 8, 2012, when our 2013 plans and rates will be available.
If you are applying for coverage with a 2012 effective date, please continue with the application process.

If you would like to apply for coverage with a 2013 effective date, check back soon. We expect our updated rates and plans to be available shortly.
If you are applying for coverage with a 2012 effective date, please continue with the application process to lock in your 2012 rate.

If you would like to apply for coverage with a 2013 effective date, please come back on or after December 20, 2012, when our 2013 plans and rates should be available.

Important notice for existing Kaiser Permanente Individual and Family Plan members. If you're trying to change your plan, please call us so that we can assist you with the appropriate next steps.

 
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* ZIP Code :
State:
    County:
   
Tell Us When You’re Applying
Select One Option:
Select 1 Option:
Select 1 option:
†If you’ll be getting federal financial assistance, don’t use this application. We can help you apply through Connect for Health Colorado.

For help, contact us at 1-800-501-1472 or contact your broker.
For more information on minimum essential coverage and qualifying triggering events, please refer to the
Enrolling During a Special Enrollment Period Guide. To request a copy, please call 1-800-494-5314.
For more information on minimum essential coverage and qualifying triggering events, please refer to the
Enrolling During a Special Enrollment Period Guide. To request a copy, please call 1-800-494-5314.
For more information on minimum essential coverage and qualifying triggering events, please refer to the
Enrolling During a Special Enrollment Period Guide. To request a copy, please call 1-800-494-5314.
For more information on minimum essential coverage and qualifying triggering events, please refer to the
Enrolling During a Special Enrollment Period Guide. To request a copy, please call 1-800-494-5314.
For more information on minimum essential coverage and qualifying triggering events, please refer to the
Enrolling During a Special Enrollment Period Guide. To request a copy, please call 1-800-494-5314.
For more information on minimum essential coverage and qualifying triggering events, please refer to the
Enrolling During a Special Enrollment Period Guide.
For more information on minimum essential coverage and qualifying triggering events, please refer to the
Enrolling During a Special Enrollment Period Guide. To request a copy, please call 1-800-494-5314.
If you selected “A special enrollment period,” choose the triggering event:
Please complete this section if you are applying during a special enrollment period outside of the open enrollment period of November 1, 2016, through January 31, 2017.

For enrollment during a special enrollment period, applicants and their dependents may enroll or change health plans following a triggering event, as defined below. This form and payment of your first month’s premium must be received by Kaiser Permanente within 60 days of the triggering event, unless stated otherwise below.

For more information on minimum essential coverage and qualifying triggering events, please refer to the Enrolling During a Special Enrollment Period Guide. To request a copy, please call 1-800-494-5314.
If you selected “A special enrollment period,” choose the triggering event:
*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 financial assistance, don’t use this form. We can help you apply at healthcare.gov.
*If your triggering event is “Loss of health care coverage, *the date of your triggering event is the last day of full coverage under your prior plan. If your triggering event is loss of Kaiser Permanente coverage, we may review your prior membership records to establish eligibility.
If you are applying during a special enrollment period, please enter the date of your triggering event.
* 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 financial assistance, don’t use this form. We can help you apply at coveredca.com.

* If your triggering event is loss of KFHPNW coverage, we may review your prior membership records to establish eligibility.
† If you’ll be getting federal financial assistance, don’t use this form. We can help you apply at wahealthplanfinder.org.

* If your triggering event is loss of KFHPNW coverage, we may review your prior membership records to establish eligibility.
† If you’ll be getting federal financial assistance, don’t use this form. We can help you apply at the Oregon Health Insurance Marketplace.

*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 financial assistance, don’t use this form. We can help you apply at healthcare.gov.

*If your triggering event is loss of Kaiser Permanente coverage, we may review your prior membership records to establish your eligibility.
†If you’ll be getting federal financial assistance, do not use this form. We can help you apply at healthcare.gov.

Date of triggering event
*You and your dependent have 60 days before and after the loss of coverage to enroll in or change health plans. If you will be getting federal financial assistance, don’t use this form. We can help you apply through marylandhealthconnection.gov.

Please call 1-800-494-5314 to determine the start date of coverage for your enrollment.
Effective Date:
* Is this application only for a child (or children)?:
If you are applying by paper
Click the "Paper application" link on the left to download the file. Fill out the application as instructed, and mail or fax the form.

2014 open enrollment & start dates
Open enrollment is October 1, 2013, through March 31, 2014. If you submit your completed application today, your coverage may start on the effective date above. To make sure your coverage starts on the date you want, please make sure your completed application is received by the following dates:

  • For Colorado: Dec. 23, 2013, for coverage starting Jan. 1, 2014
  • Dec. 15, 2013, for coverage starting Jan. 1, 2014.
  • Jan. 15, 2014, for coverage starting Feb. 1, 2014.
  • Feb. 15, 2014, for coverage starting Mar. 1, 2014.
  • Mar. 15, 2014, for coverage starting Apr. 1, 2014.
  • Mar. 31, 2014, for coverage starting May. 1, 2014.
  • For Oregon: Feb. 17, 2014, for coverage starting Mar. 1, 2014
  • For Oregon: Mar. 17, 2014, for coverage starting Apr. 1, 2014
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If you are applying by paper
Click the "Paper application" link on the left to download the file. Fill out the application as instructed, and mail or fax the form.

2014 open enrollment & start dates
Open enrollment is October 1, 2013, through March 31, 2014. If you submit your completed application today, your coverage may start on the date above. To make sure your coverage starts on the date you want, please make sure your completed application is received by the following :

  • For Colorado: Dec. 23, 2013, for coverage starting Jan. 1, 2014
  • Dec. 15, 2013, for coverage starting Jan. 1, 2014.
  • Jan. 15, 2014, for coverage starting Feb. 1, 2014.
  • Feb. 15, 2014, for coverage starting Mar. 1, 2014.
  • Mar. 15, 2014, for coverage starting Apr. 1, 2014.
  • Mar. 31, 2014, for coverage starting May 1, 2014
  • For Oregon: Feb. 17, 2014, for coverage starting Mar. 1, 2014
  • For Oregon: Mar. 17, 2014, for coverage starting Apr. 1, 2014


Open enrollment
There's a deadline to apply for health care coverage. You can apply only between October 1, 2013, and March 31, 2014 unless you qualify under certain circumstances outlined below under Special Enrollment. This is called the open enrollment period. It's when you can enroll in health plans through the Health Insurance Marketplace in Virginia, or directly through Kaiser Permanente.

To enroll during this 2014 open enrollment period, you must make sure we receive your completed Application for Health Coverage - along with your first month's premium - no later than March 31, 2014.

Special enrollment
After open enrollment, you can still enroll during special enrollment periods in the case of certain events that change your status. Special enrollment periods last 60 days after any of these events, which may include the following:

  • marriage
  • birth or adoption of a child
  • divorce
  • loss of job and employer-sponsored coverage
  • termination of existing coverage

Please include proof of your special event with your application.

*If you are 65+ years of age and Medicare eligible, or are under age 65 and entitled to Medicare on the basis of Social Security disability, call 1-866-949-5142 for information about our Kaiser Permanente Medicare Cost plans.
 

*If you will be getting federal financial assistance, do not use this form. We can help you apply through [marylandhealthconnection.gov].
Note: Application must be accompanied by payment information for your initial premium. Please make certain that you have provided all information requested. Premiums for enrollments beginning on the 15th of the month will be prorated for that month only, after which the standard billing cycle (1st of the month) will apply.
 
2014 open enrollment and start dates
Open enrollment is October 1, 2013, through March 31, 2014. If you submitted your completed application today, your coverage may start on the effective date above. To make sure your coverage starts on the date you want, please make sure your completed application is received by the following:

For All regions(Except Washington)
  • For Colorado: Dec. 23, 2013, for coverage starting Jan. 1, 2014
  • Dec. 15, 2013, for coverage starting Jan. 1, 2014.
  • Jan. 15, 2014, for coverage starting Feb. 1, 2014.
  • Feb. 15, 2014, for coverage starting Mar. 1, 2014.
  • Mar. 15, 2014, for coverage starting Apr. 1, 2014.
  • Mar. 31, 2014, for coverage starting May. 1, 2014.
  • For Oregon: Feb. 17, 2014, for coverage starting Mar. 1, 2014
  • For Oregon: Mar. 17, 2014, for coverage starting Apr. 1, 2014

We will confirm the start date in your acceptance letter. If there is a delay in processing in your application, we'll select the next available start date.
 
Note: Effective dates for applicants under the age of 21 may vary.  
Welcome to our new Kaiser Permanente for individuals and families online website, designed for coverage starting February 1, 2010 and beyond.

Please note: Because you selected an effective date of January 1, 2010, or January 16, 2010, you'll need to use our previous site to help you find the plan that's right for you, get a quote, and apply online. Please click here to apply for January 2010 effective dates. We apologize for any inconvenience.

If you have any questions, please contact your agent, broker or call us at 1-301-816-6767 to get started today!
 

Welcome to our new Kaiser Permanente for Individuals and Families online Web site.

Please note: The site is under construction for our Georgia region. Because you selected a Georgia ZIP code, you'll need to click here to find the plan that's right for you, get a quote, and apply online.

If you have trouble with the link, simply copy this url into your browser:
https://kaiserga.inshealth.com

If you have any questions, please contact your agent or call us at 1-800-538-5064 to get started today!

We apologize for any inconvenience.
 
2014 open enrollment and start dates
Open enrollment is October 1, 2013, through March 31, 2014. If you submitted your completed application today, your coverage may start on the effective date above. To make sure your coverage starts on the date you want, please make sure your completed application is received by the following:

For All regions(Except Washington)
  • For Colorado: Dec. 23, 2013, for coverage starting Jan. 1, 2014
  • Dec. 15, 2013, for coverage starting Jan. 1, 2014.
  • Jan. 15, 2014, for coverage starting Feb. 1, 2014.
  • Feb. 15, 2014, for coverage starting Mar. 1, 2014.
  • Mar. 15, 2014, for coverage starting Apr. 1, 2014.
  • Mar. 31, 2014, for coverage starting May. 1, 2014.
  • For Oregon: Feb. 17, 2014, for coverage starting Mar. 1, 2014
  • For Oregon: Mar. 17, 2014, for coverage starting Apr. 1, 2014

We will confirm the start date in your acceptance letter. If there is a delay in processing in your application, we'll select the next available start date.
2014 open enrollment and start dates
Open enrollment is October 1, 2013, through March 31, 2014. If you submitted your completed application today, your coverage may start on the effective date above. To make sure your coverage starts on the date you want, please make sure your completed application is received by the following:

For All regions(Except Washington)
  • For Colorado: Dec. 23, 2013, for coverage starting Jan. 1, 2014
  • Dec. 15, 2013, for coverage starting Jan. 1, 2014.
  • Jan. 15, 2014, for coverage starting Feb. 1, 2014.
  • Feb. 15, 2014, for coverage starting Mar. 1, 2014.
  • Mar. 15, 2014, for coverage starting Apr. 1, 2014.
  • Mar. 31, 2014, for coverage starting May. 1, 2014.
  • For Oregon: Feb. 17, 2014, for coverage starting Mar. 1, 2014
  • For Oregon: Mar. 17, 2014, for coverage starting Apr. 1, 2014

We will confirm the start date in your acceptance letter. If there is a delay in processing in your application, we'll select the next available start date.
* Are ALL applicants current Kaiser Permanente members?
The 2011 Kaiser Permanente for Individuals and Families rates, benefits, and membership application form are still pending state regulatory review and may be subject to change. However, your application will be processed, and we will notify you of its status.
If you are applying by paper
Click the "Paper application" link on the left to download the file. Fill out the application as instructed, and mail or fax the form.

Enrolling During a Special Enrollment Period

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you can enroll or change your coverage only if you have experienced a situation known as a triggering event. For example, if you get married, have a baby, or lose coverage because you lose your job – all triggering events – you will have a special enrollment period.

A special enrollment period lasts 60 days after the triggering event occurs. That means if you’ve experienced a triggering event, you have 60 days from the day of the triggering event to change or apply for health care coverage for yourself and/or your dependent. You have many important decisions to make about your health care coverage, and we’re committed to helping you understand how these changes will impact you and your family. If you have any questions, we’re here to help.

Triggering-Event Confirmation Required

If you have experienced a triggering event, we’ll need a letter from you that confirms the triggering event along with your application and first month’s premium.

  • We must receive your letter within 10 calendar days of submitting your application. The letter should include your name and address as submitted on the application, explain the triggering event that occurred, and include the date of the event. If you’re completing a paper application, please send this letter along with the application and your first month’s premium.
     
  • If we don’t receive a letter within 10 calendar days, we will cancel your application. You may reapply and submit the letter regarding the triggering event, but you must do so within the 60-day special enrollment period.
     
  • If you apply close to the end of your 60-day special enrollment period, be sure we receive your letter before your special enrollment period ends.
     
By submitting a signed application and a letter, you are confirming that a triggering event occurred. It’s important that we receive your letter because we will rely on it to establish that you’re eligible to enroll during a special enrollment period. If we determine that the triggering event did not occur, we may take legal action, including but not limited to, canceling your coverage retroactively.



What is special enrollment?


In general, you can only change or apply for health care coverage during the standard annual open enrollment period. However, if you have what’s called a "triggering event," you can also enroll or change your coverage during a special enrollment period.

Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if you have a triggering event during open enrollment, you’ll still have a special enrollment period and your coverage may start on a different date than the standard open enrollment effective dates.

From the date of your triggering event, the special enrollment period generally lasts 60 days. That means you have 60 days to change or apply for coverage for you or your dependents.

If you have advance notice


If your triggering event is a loss of coverage that you know about in advance, you may be able to apply for new coverage ahead of time. In this case, you have 60 days before and 60 days after you lose coverage to apply. For example, if you know you’ll be laid off from your job, you can apply up to 60 days before you lose coverage.

If COBRA is available from your former employer, you can continue your employer coverage through COBRA or enroll in an individual or family plan.

In some cases, if there’s a problem with your enrollment or an issue with a plan contract, the Health Insurance Marketplace determines the length of the special enrollment period.

What is my effective date?


The date your coverage starts will depend on the kind of triggering event you have. For more information, please refer to the Enrolling During a Special Enrollment Period guide.

New members, apply online or by mail or fax:

If you apply online:
  • Fill out and submit the online application within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • Upload your supporting documentation.
  • If you prefer to mail or fax your documentation, be sure to download the Documentation of Triggering Event Form. Check the appropriate boxes on the form for your triggering event and the documentation you’re submitting to support it. Then send the form with your documentation within 10 calendar days of submitting your online application.
  • If we don’t get your Documentation of Triggering Event Form and supporting documentation within 10 calendar days, your application will be considered incomplete and may be canceled. You can reapply, but you’ll need to do that within the same special enrollment period and your effective date may be different.
  • If you apply near the end of your special enrollment period, make sure we get your Documentation of Triggering Event Form and supporting documentation before your special enrollment period ends. If we don’t get your documentation within 60 days of your triggering event, your application may be canceled.
  • On the first page of your supporting documentation, be sure to write this information for the primary applicant:
    — First and last name as listed on the application
    — Kaiser Permanente medical record number (if you have one)
    — Home address
    — Date of birth
  • Include your first month’s premium with your application. You can pay with a credit card, debit card, checking account number, or savings account number. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see the Enrolling During a Special Enrollment Period guide for information about what you need to pay.
If you apply by mail or fax:
  • Submit your signed paper application by mail or fax. We must receive your paper application within 60 days of your triggering event. If you apply close to the end of your special enrollment period, make sure we get your application before your special enrollment period ends.
  • You’ll need to provide the exact triggering event and the date of the event under Step 1 on the application.
  • You’ll also need to submit a Documentation of Triggering Event Form. You can download this form by clicking on the link or by calling 1-800-494-5314. See "If you apply online" above for instructions on filling it out. Be sure to mail or fax the Documentation of Triggering Event Form and supporting documentation with your paper application. Your paper application, Documentation of Triggering Event Form, and supporting documentation must be received within 60 days of your triggering event or by the end of your special enrollment period, whichever comes first.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see page 5 for information about what you need to pay.

Current Kaiser Permanente Individuals and Families plan members:

  • Please call 1-866-410-7536 to request an Account Change Form. (For TTY, call 711.)
  • See the Enrolling During a Special Enrollment Period guide for more information on deadlines.

New and current members:

  • We must receive ALL your required materials within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • In some instances, you may submit your completed application up to 60 days in advance of your triggering event to avoid a gap in coverage.
  • If you apply close to the end of your 60-day special enrollment period, you may want to fax us or use express mail to avoid missing the deadline. You can also call 1-800-494-5314 to enroll or make an account change over the phone. (For TTY, call 711.)
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively back to the effective date of coverage. You may also be financially liable for any services that you may have received.

Enrolling During a Special Enrollment Period

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you can enroll or change your coverage if you have experienced a situation known as a triggering event. For example, if you get married, have a baby, or lose coverage because you lose your job — all triggering events — you will have a special enrollment period.

Generally, a special enrollment period lasts 60 days after the triggering event occurs. That means if you’ve experienced a triggering event, you have 60 days from the day of the triggering event to change or apply for health care coverage for yourself and/or your dependent. In some situations, if you are aware of a triggering event that will occur in the future, you may be able to apply for new coverage prior to the triggering event. For example, if you know you will experience a loss of coverage or your eligibility for your employer health coverage changes, you have 60 days before your loss of coverage and 60 days after your loss of coverage to apply for health coverage. You have many important decisions to make about your health care coverage, and we’re committed to helping you understand how these changes will impact you and your family. If you have any questions, we’re here to help.

Triggering-Event Confirmation Required

New Applicants Applying Online

If you’ve experienced a triggering event, you’ll choose the triggering event and date of the event prior to beginning the application process.

If you are applying online, you will choose your triggering event and date of the event just before you begin the online application process. You must apply within 60 days of your triggering event. In some instances under the following triggering events, “loss of health care coverage” or “your eligibility for your employer health coverage changes”, you may be allowed to apply 60 days before your triggering event occurs.

Applying by mail or fax

New applicants

If you are sending in a paper application, download and complete the paper application. You will provide your triggering event and the date of your event on your paper application. Your completed paper application must be received with your first month’s premium.

If you apply close to the end of your special enrollment period, be sure we receive your application before your special enrollment period ends.
 
Current Kaiser Permanente Members

If you’ve experienced a triggering event, and need to change your plan, please use an Account Change Form. You will provide your triggering event and date of the event under Section B on this form. Please call 1-800-494-5314 to request a form.

If you apply close to the end of your special enrollment period, be sure we receive your Account Change form before your special enrollment period ends.

You must submit an Account Change form. You will provide your triggering event and the date of the event on the form. Any change to your premium will be reflected in your next month’s invoice.
 
Mail or fax your completed Account Change form before the end of your special enrollment period.
 
If you apply close to the end of your special enrollment period, be sure we receive your Account Change form before your special enrollment period ends.
 

Fax
1-866-920-6471

Mail
Kaiser Permanente
California Service Center — KPIF
P.O. Box 23219
San Diego, CA 92193-9921


By submitting a signed Application for health coverage form or an Account Change form, you are confirming that a triggering event occurred. We will rely on your confirmation, and if we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively.


What is special enrollment?

In general, you can only change or apply for health care coverage during the standard annual open enrollment period. However, if you have what’s called a “triggering event,” you can also enroll or change your coverage during a special enrollment period.

Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if you have a triggering event during open enrollment, you’ll still have a special enrollment period and your coverage may start on a different date than the standard open enrollment effective dates.

From the date of your triggering event, the special enrollment period generally lasts 60 days. That means you have 60 days to change or apply for coverage for you or your dependents.

If you have advance notice

If your triggering event is a loss of coverage that you know about in advance, you may be able to apply for new coverage ahead of time. In this case, you have 60 days before and 60 days after you lose coverage to apply. For example, if you know you’ll be laid off from your job, you can apply up to 60 days before you lose coverage.

If COBRA is available from your former employer, you can continue your employer coverage through COBRA or enroll in an individual or family plan.

In some cases, if there’s a problem with your enrollment or an issue with a plan contract, the Health Insurance Marketplace determines the length of the special enrollment period.

What is my effective date?

The date your coverage starts will depend on the kind of triggering event you have. For more information, please refer to the Enrolling During a Special Enrollment Period guide.

New members, apply online or by mail or fax:

If you apply online:
  • Fill out and submit the online application within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • Upload your supporting documentation.
  • If you prefer to mail or fax your documentation, be sure to download the Documentation of Triggering Event Form. Check the appropriate boxes on the form for your triggering event and the documentation you’re submitting to support it. Then send the form with your documentation within 10 calendar days of submitting your online application.
  • If we don’t get your Documentation of Triggering Event Form and supporting documentation within 10 calendar days, your application will be considered incomplete and may be canceled. You can reapply, but you’ll need to do that within the same special enrollment period and your effective date may be different.
  • If you apply near the end of your special enrollment period, make sure we get your Documentation of Triggering Event Form and supporting documentation before your special enrollment period ends. If we don’t get your documentation within 60 days of your triggering event, your application may be canceled.
  • On the first page of your supporting documentation, be sure to write this information for the primary applicant:
    — First and last name as listed on the application
    — Kaiser Permanente medical record number (if you have one)
    — Home address
    — Date of birth
  • Include your first month’s premium with your application. You can pay with a credit card, debit card, checking account number, or savings account number. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see the Enrolling During a Special Enrollment Period guide for information about what you need to pay.
If you apply by mail or fax:
  • Submit your signed paper application by mail or fax. We must receive your paper application within 60 days of your triggering event. If you apply close to the end of your special enrollment period, make sure we get your application before your special enrollment period ends.
  • You’ll need to provide the exact triggering event and the date of the event under Step 1 on the application.
  • You’ll also need to submit a Documentation of Triggering Event Form. You can download this form by clicking on the link or by calling 1-800-494-5314. See "If you apply online" above for instructions on filling it out. Be sure to mail or fax the Documentation of Triggering Event Form and supporting documentation with your paper application. Your paper application, Documentation of Triggering Event Form, and supporting documentation must be received within 60 days of your triggering event or by the end of your special enrollment period, whichever comes first.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see page 5 for information about what you need to pay.
Current Kaiser Permanente Individuals and Families plan members:
  • Please call 1-866-410-7536 to request an Account Change Form. (For TTY, call 711.)
  • See the Enrolling During a Special Enrollment Period guide for more information on deadlines.
New and current members:
  • We must receive ALL your required materials within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • In some instances, you may submit your completed application up to 60 days in advance of your triggering event to avoid a gap in coverage.
  • If you apply close to the end of your 60-day special enrollment period, you may want to fax us or use express mail to avoid missing the deadline. You can also call 1-800-494-5314 to enroll or make an account change over the phone. (For TTY, call 711.)
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively back to the effective date of coverage. You may also be financially liable for any services that you may have received.


What is special enrollment?


In general, you can only change or apply for health care coverage during the standard annual open enrollment period. However, if you have what’s called a "triggering event," you can also enroll or change your coverage during a special enrollment period.

Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if you have a triggering event during open enrollment, you’ll still have a special enrollment period and your coverage may start on a different date than the standard open enrollment effective dates.

From the date of your triggering event, the special enrollment period generally lasts 60 days. That means you have 60 days to change or apply for coverage for you or your dependents.

If you have advance notice

If your triggering event is a loss of coverage that you know about in advance, you may be able to apply for new coverage ahead of time. In this case, you have 60 days before and 60 days after you lose coverage to apply. For example, if you know you’ll be laid off from your job, you can apply up to 60 days before you lose coverage.

If COBRA is available from your former employer, you can continue your employer coverage through COBRA or enroll in an individual or family plan.

In some cases, if there’s a problem with your enrollment or an issue with a plan contract, the Health Insurance Marketplace determines the length of the special enrollment period.

What is my effective date?

The date your coverage starts will depend on the kind of triggering event you have. For more information, please refer to the Enrolling During a Special Enrollment Period guide.

New members, apply online or by mail or fax:

If you apply online:
  • Fill out and submit the online application within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • Upload your supporting documentation.
  • If you prefer to mail or fax your documentation, be sure to download the Documentation of Triggering Event Form. Check the appropriate boxes on the form for your triggering event and the documentation you’re submitting to support it. Then send the form with your documentation within 10 calendar days of submitting your online application.
  • If we don’t get your Documentation of Triggering Event Form and supporting documentation within 10 calendar days, your application will be considered incomplete and may be canceled. You can reapply, but you’ll need to do that within the same special enrollment period and your effective date may be different.
  • If you apply near the end of your special enrollment period, make sure we get your Documentation of Triggering Event Form and supporting documentation before your special enrollment period ends. If we don’t get your documentation within 60 days of your triggering event, your application may be canceled.
  • On the first page of your supporting documentation, be sure to write this information for the primary applicant:
    — First and last name as listed on the application
    — Kaiser Permanente medical record number (if you have one)
    — Home address
    — Date of birth
  • Include your first month’s premium with your application. You can pay with a credit card, debit card, checking account number, or savings account number. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see the Enrolling During a Special Enrollment Period guide for information about what you need to pay.
If you apply by mail or fax:
  • Submit your signed paper application by mail or fax. We must receive your paper application within 60 days of your triggering event. If you apply close to the end of your special enrollment period, make sure we get your application before your special enrollment period ends.
  • You’ll need to provide the exact triggering event and the date of the event under Step 1 on the application.
  • You’ll also need to submit a Documentation of Triggering Event Form. You can download this form by clicking on the link or by calling 1-800-494-5314. See "If you apply online" above for instructions on filling it out. Be sure to mail or fax the Documentation of Triggering Event Form and supporting documentation with your paper application. Your paper application, Documentation of Triggering Event Form, and supporting documentation must be received within 60 days of your triggering event or by the end of your special enrollment period, whichever comes first.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see page 5 for information about what you need to pay.
Current Kaiser Permanente Individuals and Families plan members:

  • Please call 1-866-410-7536 to request an Account Change Form. (For TTY, call 711.)
  • See the Enrolling During a Special Enrollment Period guide for more information on deadlines.
New and current members:
  • We must receive ALL your required materials within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • In some instances, you may submit your completed application up to 60 days in advance of your triggering event to avoid a gap in coverage.
  • If you apply close to the end of your 60-day special enrollment period, you may want to fax us or use express mail to avoid missing the deadline. You can also call 1-800-494-5314 to enroll or make an account change over the phone. (For TTY, call 711.)
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively back to the effective date of coverage. You may also be financially liable for any services that you may have received.
Enrolling During a Special Enrollment Period

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you can enroll or change your coverage if you have experienced a situation known as a triggering event. For example, if you get married, have a baby, or lose coverage because you lose your job — all triggering events — you will have a special enrollment period.

Generally, a special enrollment period lasts 60 days after the triggering event occurs. That means if you’ve experienced a triggering event, you have 60 days from the day of the triggering event to change or apply for health care coverage for yourself and/or your dependent. In some situations, if you are aware of a triggering event that will occur in the future, you may be able to apply for new coverage prior to the triggering event. For example, if you know you will experience a loss of coverage or your eligibility for your employer health coverage changes, you have 60 days before your loss of coverage and 60 days after your loss of coverage to apply for health coverage.

You have many important decisions to make about your health care coverage, and we’re committed to helping you understand how these changes will impact you and your family. If you have any questions, we’re here to help.

New Applicants Applying Online

If you’ve experienced a triggering event, you’ll choose the triggering event and the date of the event prior to beginning the application process. You must download and submit the Documentation of triggering event form and check the appropriate box to confirm your triggering event and supporting documentation. The completed Documentation of triggering event form and supporting documentation must be submitted within 10 calendar days of submitting your online application. See the Special Enrollment Period Guide for more details.
  • If you are applying online, you will choose your triggering event and date of the event just before you begin the online application process. You must apply within 60 days of your triggering event. In some instances under the following triggering events, “loss of health care coverage” or “your eligibility for your employer health coverage changes”, you may be allowed to apply 60 days before your triggering event occurs.
     
  • Be sure to download the Documentation of triggering event form, check the box for your triggering event and the documentation you are submitting to support your triggering event, and send it with your documentation within 10 calendar days of submitting your online application.
     
  • If we don’t receive your Documentation of triggering event form and supporting documentation within 10 calendar days, we will cancel your application. You may reapply submit the Documentation of triggering event form and supporting documentation, but you must do so within the special enrollment period.
     
  • On the first page of your documentation, be sure to write the information for the primary applicant:
     
  • 1) First and last name as listed on the application
    2) Kaiser Permanente medical record number (if known)
    3) Home address
    4) Date of birth
     
  • If you apply close to the end of your special enrollment period, be sure we receive your Documentation of triggering event form and supporting documentation before your special enrollment period ends.
     
Applying by mail or fax

New applicants
  • If you are sending in a paper application, download and complete the paper application.
     
  • Download and complete the Documentation of triggering event form and submit it with your application and supporting documentation.
     
  • On the first page of your documentation, be sure to write the information for the primary applicant:
     
  • 1) First and last name as listed on the application
    2) Kaiser Permanente medical record number (if known)
    3) Home address
    4) Date of birth
     
  • Include your first month’s premium.
     
  • Mail or fax your completed paper application, along with the Documentation of triggering event form and supporting documentation before the end of your special enrollment period.
     
  • If you apply close to the end of your special enrollment period, be sure we receive your paper application, along with the Documentation of triggering event form and supporting documentation before your special enrollment period ends. 
Current Kaiser Permanente Members

If you’ve experienced a triggering event, and need to change your plan, please use an Account Change form. You will provide your triggering event and date of the event under Section B on this form. Please call 1-800-494-5314 to request a form. You are required to download and submit a completed Documentation of triggering event form and provide supporting documentation of your triggering event when you submit the Account Change form.
  • Call 1-800-494-5314 to request an Account Change form.
     
  • Download and complete the Documentation of triggering event form and submit it with your Account Change form and supporting documentation.
     
  • You will provide your triggering event and the date of the event on the Account Change form. You will reconfirm your triggering event and the date of the event on the Documentation of triggering event form. Any changes to your premium will be reflected in your next month’s invoice.
     
  • On the first page of your documentation, be sure to write the information for the primary applicant:
     
  • 1) First and last name as listed on the application
    2) Kaiser Permanente medical record number (if known)
    3) Home address
    4) Date of birth
     
  • Mail or fax your completed Account Change form, along with the Documentation of triggering event form and supporting documentation before the end of your special enrollment period.
     
  • If you apply close to the end of your special enrollment period, be sure we receive your Account Change form, along with the Documentation of triggering event form and supporting documentation before your special enrollment period ends. 
Fax
1-866-816-5139

Mail
Kaiser Permanente
California Service Center — KPIF
P.O. Box 23219
San Diego, CA 92193-9921

By submitting a signed Application for health coverage form or an Account Change form, a Documentation of triggering event form, and supporting documentation, you are confirming that a triggering event occurred. It’s important that we receive your Documentation of triggering event form and supporting documentation because we will rely on them to establish that you’re eligible to enroll during a special enrollment period. If we determine that the triggering event did not occur, we may take legal action, including but not limited to, terminating your coverage.

Special Enrollment Period Guide

Documentation of triggering event form

Triggering events and effective dates

Your coverage start date will depend on the triggering event that you experience. Please review this chart to see your effective date.

Type Receipt of application or Account Change form Effective date
Loss of health care coverage or change in eligibility for employer coverage due to changes in employer coverage On or before last date of coverage First day of the month following the last date of coverage
After loss of coverage or change in employer coverage: Between the 1st and the 15th of the month First day of the following month
After loss of coverage or change in employer coverage: Between the 16th and the last day of the month First day of the second following month
Marriage or domestic partnership registration Any day of the month First day of the month following receipt of application
Birth, adoption, or placement for adoption or foster care Any day of the month Date of birth, adoption, or placement for adoption or foster care
Permanent relocation, release from incarceration, court order, change in eligibility for federal financial assistance, change in immigration status, status as an American Indian/Native Alaskan, misinformation about your current coverage, or provider network changes Between the 1st and 15th of the month First day of the following month
Between the 16th and the last day of the month First day of the second following month
Determination by Covered California Any day of the month Any day of the month as determined by Covered California, including a retroactive date

We will confirm the start date in your acceptance letter. If there is a delay in processing in your application, we'll select the next available start date.

We will confirm the start date in your acceptance letter. If there is a delay in processing in your application, we'll select the next available start date.
Special Enroll Period


Effective Date

Your coverage start date will depend on the triggering event that you experience. Please review this chart to see your effective date.

TypeReceipt of Application for Health Coverage or Account Change Form Effective date
Loss of health care coverage or change in eligibility for employer coverage due to changes in employer coverageOn or before last date of coverageDate of event
Any day of the month after loss of coverage or change in employer coverageFirst day of the month following receipt of application
Marriage or civil union registrationOn or before the eventDate of event
Any day of the month after the eventFirst day of the month following receipt of application
Birth, adoption, or placement for adoption or foster careAny day of the monthDate of birth,adoption, or placement for adoption or foster care
Determination by Connect for Health ColoradoAny day of the monthAny day of the month as determined by Connect for Health Colorado, including a retroactive date
Any other triggering eventBetween the 1st and 15th of the monthFirst day of the month following receipt of application
Between the 16th and the last day of the monthFirst day of the second month following receipt of application

We will confirm the start date in your acceptance letter. If there is a delay in processing in your application, we'll select the next available start date.

We will confirm the start date in your acceptance letter. If there is a delay in processing in your application, we'll select the next available start date.

Enrolling During a Special Enrollment Period

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you can enroll or change your coverage if you have experienced a situation known as a triggering event. For example, if you get married, have a baby, or lose coverage because you lose your job — all triggering events — you will have a special enrollment period.


Generally, a special enrollment period lasts 60 days after the triggering event occurs. That means if you’ve experienced a triggering event, you have 60 days from the day of the triggering event to change or apply for health care coverage for yourself and/or your dependent. In some situations, if you are aware of a triggering event that will occur in the future, you may be able to apply for new coverage prior to the triggering event. For example, if you know you will experience a loss of coverage or your eligibility for your employer health coverage changes, you have 60 days before your loss of coverage and 60 days after your loss of coverage to apply for health coverage.

You have many important decisions to make about your health care coverage, and we’re committed to helping you understand how these changes will impact you and your family. If you have any questions, we’re here to help.

Triggering-Event Confirmation Required

New Applicants Applying Online

If you’ve experienced a triggering event, you’ll choose the triggering event and date of the event prior to beginning the application process.
  • If you are applying online, you will choose your triggering event and date of the event just before you begin the online application process. You must apply within 60 days of your triggering event. In some instances under the following triggering events, “loss of health care coverage” or “your eligibility for your employer health coverage changes”, you may be allowed to apply 60 days before your triggering event occurs.
     
Applying by mail or fax

New applicants
  • If you are sending in a paper application, download and complete the paper application. You will provide your triggering event and the date of your event on your paper application. Your completed paper application must be received with your first month’s premium.
     
  • If you apply close to the end of your special enrollment period, be sure we receive your application before your special enrollment period ends.
     
Current Kaiser Permanente Members

If you’ve experienced a triggering event, and need to change your plan, please use an Account Change Form. You will provide your triggering event and date of the event under Section B on this form. Please call 1-800-494-5314 to request a form.

If you apply close to the end of your special enrollment period, be sure we receive your Account Change form before your special enrollment period ends.
  • You must submit an Account Change form. You will provide your triggering event and the date of the event on the form. Any change to your premium will be reflected in your next month’s invoice.
     
  • Mail or fax your completed Account Change form before the end of your special enrollment period.
     
  • If you apply close to the end of your special enrollment period, be sure we receive your Account Change form before your special enrollment period ends.
     
Fax
1-866-816-5139

Mail
Kaiser Permanente
California Service Center — KPIF
P.O. Box 23219
San Diego, CA 92193-9921

By submitting a signed Application for health coverage form or an Account Change form, you are confirming that a triggering event occurred. We will rely on your confirmation, and if we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively.




Effective Date

Your coverage start date will depend on the triggering event that you experience. Please review this chart to see your effective date.

TypeReceipt of application or Account Change formEffective date
Loss of health care coverage or change in eligibility for employer coverage due to changes in employer coverageOn or before the last date of coverageFirst day of the month following the last date of coverage
After loss of coverage or change in employer coverage: Between the 1st and the 15th of the monthFirst day of the following month
After loss of coverage or change in employer coverage: Between the 16th and the last day of the monthFirst day of the second following month
MarriageAny day of the monthFirst day of the month following receipt of application
Birth, adoption, or placement for adoption or foster careAny day of the monthDate of birth, adoption, or placement for adoption or foster care
Permanent relocation, release from incarceration, change in eligibility for federal financial assistance, change in immigration status or status as an American Indian/Native AlaskanBetween the 1st and 15th of the monthFirst day of the following month
Between the 16th and the last day of the monthFirst day of the second following month
Determination by the Health Insurance MarketplaceAny day of the monthAny day of the month as determined by the Health Insurance Marketplace, including a retroactive date

We will confirm the start date in your acceptance letter. If there is a delay in processing in your application, we'll select the next available start date.

We will confirm the start date in your acceptance letter. If there is a delay in processing in your application, we'll select the next available start date.

Enrolling During a Special Enrollment Period

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you can enroll or change your coverage if you have experienced a situation known as a triggering event. For example, if you get married, have a baby, or lose coverage because you lose your job — all triggering events — you will have a special enrollment period.


Generally, a special enrollment period lasts 60 days after the triggering event occurs. That means if you’ve experienced a triggering event, you have 60 days from the day of the triggering event to change or apply for health care coverage for yourself and/or your dependent. In some situations, if you are aware of a triggering event that will occur in the future, you may be able to apply for new coverage prior to the triggering event. For example, if you know you will experience a loss of coverage or your eligibility for your employer health coverage changes, you have 60 days before your loss of coverage and 60 days after your loss of coverage to apply for health coverage.
You have many important decisions to make about your health care coverage, and we’re committed to helping you understand how these changes will impact you and your family. If you have any questions, we’re here to help.

Triggering-Event Confirmation Required

New Applicants Applying Online

If you’ve experienced a triggering event, you’ll choose the triggering event and date of the event prior to beginning the application process.
  • If you are applying online, you will choose your triggering event and date of the event just before you begin the online application process. You must apply within 60 days of your triggering event. In some instances under the following triggering events, “loss of health care coverage” or “your eligibility for your employer health coverage changes”, you may be allowed to apply 60 days before your triggering event occurs.
     
Applying by mail or fax

New applicants
  • If you are sending in a paper application, download and complete the paper application. You will provide your triggering event and the date of your event on your paper application. Your completed paper application must be received with your first month’s premium.
     
  • If you apply close to the end of your special enrollment period, be sure we receive your application before your special enrollment period ends.
     
Current Kaiser Permanente Members

If you’ve experienced a triggering event, and need to change your plan, please use an Account Change Form. You will provide your triggering event and date of the event under Section B on this form. Please call 1-800-494-5314 to request a form.

If you apply close to the end of your special enrollment period, be sure we receive your Account Change form before your special enrollment period ends.
  • You must submit an Account Change form. You will provide your triggering event and the date of the event on the form. Any change to your premium will be reflected in your next month’s invoice.
     
  • Mail or fax your completed Account Change form before the end of your special enrollment period.
     
  • If you apply close to the end of your special enrollment period, be sure we receive your Account Change form before your special enrollment period ends.
     
Fax
1-866-920-6470

Mail
Kaiser Permanente
California Service Center — KPIF
P.O. Box 23219
San Diego, CA 92193-9921

By submitting a signed Application for health coverage form or an Account Change form, you are confirming that a triggering event occurred. We will rely on your confirmation, and if we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively.

Special Enroll Period


Effective Date

Your coverage start date will depend on the triggering event that you experience. Please review this chart to see your effective date.

TypeReceipt of application or Account Change formEffective date
Loss of health care coverage or change in eligibility for employer coverage due to changes in employer coverageOn or before the last date of coverageFirst day of the month following the last date of coverage
After loss of coverage or change in employer coverage: Between the 1st and the 15th of the monthFirst day of the following month
After loss of coverage or change in employer coverage: Between the 16th and the last day of the monthFirst day of the second following month
Marriage or civil union registrationAny day of the monthFirst day of the month following receipt of application
Birth, adoption, or placement for adoption or foster careAny day of the monthDate of birth, adoption, or placement for adoption or foster care
Permanent relocation, release from incarceration, change in eligibility for federal financial assistance, change in immigration status or status as an American Indian/Native AlaskanBetween the 1st and 15th of the monthFirst day of the following month
Between the 16th and the last day of the monthFirst day of the second following month
Determination by Hawai’i Health ConnectorAny day of the monthAny day of the month as determined by Hawai’i Health Connector, including a retroactive date

We will confirm the start date in your acceptance letter. If there is a delay in processing in your application, we'll select the next available start date.


What is special enrollment?


In general, you can only change or apply for health care coverage during the standard annual open enrollment period. However, if you have what’s called a “triggering event,” you can also enroll or change your coverage during a special enrollment period.

Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if you have a triggering event during open enrollment, you’ll still have a special enrollment period and your coverage may start on a different date than the standard open enrollment effective dates.

From the date of your triggering event, the special enrollment period generally lasts 60 days. That means you have 60 days to change or apply for coverage for you or your dependents.

If you have advance notice

If your triggering event is a loss of coverage that you know about in advance, you may be able to apply for new coverage ahead of time. In this case, you have 60 days before and 60 days after you lose coverage to apply. For example, if you know you’ll be laid off from your job, you can apply up to 60 days before you lose coverage.

If COBRA is available from your former employer, you can continue your employer coverage through COBRA or enroll in an individual or family plan.

In some cases, if there’s a problem with your enrollment or an issue with a plan contract, the Health Insurance Marketplace determines the length of the special enrollment period.

What is my effective date?

The date your coverage starts will depend on the kind of triggering event you have. For more information, please refer to the Enrolling During a Special Enrollment Period guide.

New members, apply online or by mail or fax:

If you apply online:
  • Fill out and submit the online application within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • Upload your supporting documentation.
  • If you prefer to mail or fax your documentation, be sure to download the Documentation of Triggering Event Form. Check the appropriate boxes on the form for your triggering event and the documentation you’re submitting to support it. Then send the form with your documentation within 10 calendar days of submitting your online application.
  • If we don’t get your Documentation of Triggering Event Form and supporting documentation within 10 calendar days, your application will be considered incomplete and may be canceled. You can reapply, but you’ll need to do that within the same special enrollment period and your effective date may be different.
  • If you apply near the end of your special enrollment period, make sure we get your Documentation of Triggering Event Form and supporting documentation before your special enrollment period ends. If we don’t get your documentation within 60 days of your triggering event, your application may be canceled.
  • On the first page of your supporting documentation, be sure to write this information for the primary applicant:
    — First and last name as listed on the application
    — Kaiser Permanente medical record number (if you have one)
    — Home address
    — Date of birth
  • Include your first month’s premium with your application. You can pay with a credit card, debit card, checking account number, or savings account number. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see the Enrolling During a Special Enrollment Period guide for information about what you need to pay.
If you apply by mail or fax:
  • Submit your signed paper application by mail or fax. We must receive your paper application within 60 days of your triggering event. If you apply close to the end of your special enrollment period, make sure we get your application before your special enrollment period ends.
  • You’ll need to provide the exact triggering event and the date of the event under Step 1 on the application.
  • You’ll also need to submit a Documentation of Triggering Event Form. You can download this form by clicking on the link or by calling 1-800-494-5314. See "If you apply online" above for instructions on filling it out. Be sure to mail or fax the Documentation of Triggering Event Form and supporting documentation with your paper application. Your paper application, Documentation of Triggering Event Form, and supporting documentation must be received within 60 days of your triggering event or by the end of your special enrollment period, whichever comes first.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see page 5 for information about what you need to pay.
Current Kaiser Permanente Individuals and Families plan members:
  • Please call 1-866-410-7536 to request an Account Change Form. (For TTY, call 711.)
  • See the Enrolling During a Special Enrollment Period guide for more information on deadlines.
New and current members:
  • We must receive ALL your required materials within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • In some instances, you may submit your completed application up to 60 days in advance of your triggering event to avoid a gap in coverage.
  • If you apply close to the end of your 60-day special enrollment period, you may want to fax us or use express mail to avoid missing the deadline. You can also call 1-800-494-5314 to enroll or make an account change over the phone. (For TTY, call 711.)
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively back to the effective date of coverage. You may also be financially liable for any services that you may have received.

We will confirm the start date in your acceptance letter. If there is a delay in processing in your application, we'll select the next available start date.

Enrolling During a Special Enrollment Period

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you can enroll or change your coverage if you have experienced a situation known as a triggering event. For example, if you get married, have a baby, or lose coverage because you lose your job — all triggering events — you will have a special enrollment period.

Generally, a special enrollment period lasts 60 days after the triggering event occurs. That means if you’ve experienced a triggering event, you have 60 days from the day of the triggering event to change or apply for health care coverage for yourself and/or your dependent. In some situations, if you are aware of a triggering event that will occur in the future, you may be able to apply for new coverage prior to the triggering event. For example, if you know you will experience a loss of coverage or your eligibility for your employer health coverage changes, you have 60 days before your loss of coverage and 60 days after your loss of coverage to apply for health coverage.

You have many important decisions to make about your health care coverage, and we’re committed to helping you understand how these changes will impact you and your family. If you have any questions, we’re here to help.

Triggering-Event Confirmation Required

New Applicants Applying Online

If you’ve experienced a triggering event, you’ll choose the triggering event and date of the event prior to beginning the application process.
  • If you are applying online, you will choose your triggering event and date of the event just before you begin the online application process. You must apply within 60 days of your triggering event. In some instances under the following triggering events, “loss of health care coverage” or “your eligibility for your employer health coverage changes”, you may be allowed to apply 60 days before your triggering event occurs.
     
Applying by mail or fax

New applicants
  • If you are sending in a paper application, download and complete the paper application. You will provide your triggering event and the date of your event on your paper application. Your completed paper application must be received with your first month’s premium.
     
  • If you apply close to the end of your special enrollment period, be sure we receive your application before your special enrollment period ends.
     
Current Kaiser Permanente Members

If you’ve experienced a triggering event, and need to change your plan, please use an Account Change Form. You will provide your triggering event and date of the event under Section B on this form. Please call 1-800-494-5314 to request a form.

If you apply close to the end of your special enrollment period, be sure we receive your Account Change form before your special enrollment period ends.
  • You must submit an Account Change form. You will provide your triggering event and the date of the event on the form. Any change to your premium will be reflected in your next month’s invoice.
     
  • Mail or fax your completed Account Change form before the end of your special enrollment period.
     
  • If you apply close to the end of your special enrollment period, be sure we receive your Account Change form before your special enrollment period ends.
     
Fax
1-866-920-6473

Mail
Kaiser Permanente
California Service Center — KPIF
P.O. Box 23219
San Diego, CA 92193-9921

By submitting a signed Application for health coverage form or an Account Change form, you are confirming that a triggering event occurred. We will rely on your confirmation, and if we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively.

Special Enroll Period


Effective Date

Your coverage start date will depend on the triggering event that you experience. Please review this chart to see your effective date.

TypeReceipt of application or Account Change formEffective date
Loss of health care coverage or change in eligibility for employer coverage due to changes in employer coverageOn or before the last date of coverageFirst day of the month following the last date of coverage
After loss of coverage or change in employer coverage: Between the 1st and the 15th of the monthFirst day of the following month
After loss of coverage or change in employer coverage: Between the 16th and the last day of the monthFirst day of the second following month
Marriage or domestic partnership registrationAny day of the monthFirst day of the month following receipt of application
Birth, adoption, or placement for adoption or foster careAny day of the monthDate of birth, adoption, or placement for adoption or foster care
Permanent relocation, release from incarceration, change in eligibility for federal financial assistance, change in immigration status or status as an American Indian/Native AlaskanBetween the 1st and 15th of the monthFirst day of the following month
Between the 16th and the last day of the monthFirst day of the second following month
Determination by the Health Insurance MarketplaceAny day of the monthAny day of the month as determined by the Health Insurance Marketplace, including a retroactive date

We will confirm the start date in your acceptance letter. If there is a delay in processing in your application, we'll select the next available start date.


What is special enrollment?


In general, you can only change or apply for health care coverage during the standard annual open enrollment period. However, if you have what’s called a “triggering event,” you can also enroll or change your coverage during a special enrollment period.

Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if you have a triggering event during open enrollment, you’ll still have a special enrollment period and your coverage may start on a different date than the standard open enrollment effective dates.

From the date of your triggering event, the special enrollment period generally lasts 60 days. That means you have 60 days to change or apply for coverage for you or your dependents.

If you have advance notice

If your triggering event is a loss of coverage that you know about in advance, you may be able to apply for new coverage ahead of time. In this case, you have 60 days before and 60 days after you lose coverage to apply. For example, if you know you’ll be laid off from your job, you can apply up to 60 days before you lose coverage.

If COBRA is available from your former employer, you can continue your employer coverage through COBRA or enroll in an individual or family plan.

In some cases, if there’s a problem with your enrollment or an issue with a plan contract, the Health Insurance Marketplace determines the length of the special enrollment period.

What is my effective date?

The date your coverage starts will depend on the kind of triggering event you have. For more information, please refer to the Enrolling During a Special Enrollment Period guide.

New members, apply online or by mail or fax:

If you apply online:
  • Fill out and submit the online application within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • Upload your supporting documentation.
  • If you prefer to mail or fax your documentation, be sure to download the Documentation of Triggering Event Form. Check the appropriate boxes on the form for your triggering event and the documentation you’re submitting to support it. Then send the form with your documentation within 10 calendar days of submitting your online application.
  • If we don’t get your Documentation of Triggering Event Form and supporting documentation within 10 calendar days, your application will be considered incomplete and may be canceled. You can reapply, but you’ll need to do that within the same special enrollment period and your effective date may be different.
  • If you apply near the end of your special enrollment period, make sure we get your Documentation of Triggering Event Form and supporting documentation before your special enrollment period ends. If we don’t get your documentation within 60 days of your triggering event, your application may be canceled.
  • On the first page of your supporting documentation, be sure to write this information for the primary applicant:
    — First and last name as listed on the application
    — Kaiser Permanente medical record number (if you have one)
    — Home address
    — Date of birth
  • Include your first month’s premium with your application. You can pay with a credit card, debit card, checking account number, or savings account number. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see the Enrolling During a Special Enrollment Period guide for information about what you need to pay.
If you apply by mail or fax:
  • Submit your signed paper application by mail or fax. We must receive your paper application within 60 days of your triggering event. If you apply close to the end of your special enrollment period, make sure we get your application before your special enrollment period ends.
  • You’ll need to provide the exact triggering event and the date of the event under Step 1 on the application.
  • You’ll also need to submit a Documentation of Triggering Event Form. You can download this form by clicking on the link or by calling 1-800-494-5314. See "If you apply online" above for instructions on filling it out. Be sure to mail or fax the Documentation of Triggering Event Form and supporting documentation with your paper application. Your paper application, Documentation of Triggering Event Form, and supporting documentation must be received within 60 days of your triggering event or by the end of your special enrollment period, whichever comes first.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see page 5 for information about what you need to pay.
Current Kaiser Permanente Individuals and Families plan members:
  • Please call 1-866-410-7536 to request an Account Change Form. (For TTY, call 711.)
  • See the Enrolling During a Special Enrollment Period guide for more information on deadlines.
New and current members:
  • We must receive ALL your required materials within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • In some instances, you may submit your completed application up to 60 days in advance of your triggering event to avoid a gap in coverage.
  • If you apply close to the end of your 60-day special enrollment period, you may want to fax us or use express mail to avoid missing the deadline. You can also call 1-800-494-5314 to enroll or make an account change over the phone. (For TTY, call 711.)
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively back to the effective date of coverage. You may also be financially liable for any services that you may have received.

We will confirm the start date in your acceptance letter. If there is a delay in processing in your application, we'll select the next available start date.

Enrolling During a Special Enrollment Period

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you can enroll or change your coverage if you have experienced a situation known as a triggering event. For example, if you get married, have a baby, or lose coverage because you lose your job — all triggering events — you will have a special enrollment period.


Generally, a special enrollment period lasts 60 days after the triggering event occurs. That means if you’ve experienced a triggering event, you have 60 days from the day of the triggering event to change or apply for health care coverage for yourself and/or your dependent. In some situations, if you are aware of a triggering event that will occur in the future, you may be able to apply for new coverage prior to the triggering event. For example, if you know you will experience a loss of coverage or your eligibility for your employer health coverage changes, you have 60 days before your loss of coverage and 60 days after your loss of coverage to apply for health coverage.

You have many important decisions to make about your health care coverage, and we’re committed to helping you understand how these changes will impact you and your family. If you have any questions, we’re here to help.

Triggering-Event Confirmation Required

New Applicants Applying Online

If you’ve experienced a triggering event, you’ll choose the triggering event and date of the event prior to beginning the application process.
  • If you are applying online, you will choose your triggering event and date of the event just before you begin the online application process. You must apply within 60 days of your triggering event. In some instances under the following triggering events, “loss of health care coverage” or “your eligibility for your employer health coverage changes”, you may be allowed to apply 60 days before your triggering event occurs.
     
Applying by mail or fax

New applicants
  • If you are sending in a paper application, download and complete the paper application. You will provide your triggering event and the date of your event on your paper application. Your completed paper application must be received with your first month’s premium.
     
  • If you apply close to the end of your special enrollment period, be sure we receive your application before your special enrollment period ends.
     
Current Kaiser Permanente Members

If you’ve experienced a triggering event, and need to change your plan, please use an Account Change Form. You will provide your triggering event and date of the event under Section B on this form. Please call 1-800-494-5314 to request a form.

If you apply close to the end of your special enrollment period, be sure we receive your Account Change form before your special enrollment period ends.
  • You must submit an Account Change form. You will provide your triggering event and the date of the event on the form. Any change to your premium will be reflected in your next month’s invoice.
     
  • Mail or fax your completed Account Change form before the end of your special enrollment period.
     
  • If you apply close to the end of your special enrollment period, be sure we receive your Account Change form before your special enrollment period ends.
     
Fax
1-866-920-6475

Mail
Kaiser Permanente
California Service Center — KPIF
P.O. Box 23219
San Diego, CA 92193-9921

By submitting a signed Application for health coverage form or an Account Change form, you are confirming that a triggering event occurred. We will rely on your confirmation, and if we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively.

Special Enroll Period


Effective Date

Your coverage start date will depend on the triggering event that you experience. Please review this chart to see your effective date.

TypeReceipt of application or Account Change formEffective date
Loss of health care coverage or change in eligibility for employer coverage due to changes in employer coverageOn or before the last date of coverageFirst day of the month following the last date of coverage
After loss of coverage or change in employer coverage: between the 1st and the 20th of the monthFirst day of the following month
After loss of coverage or change in employer coverage: between the 21st and the last day of the monthFirst day of the second following month
Marriage or domestic partnership registrationAny day of the monthFirst day of the month following receipt of application
Birth, adoption, or placement for adoption or foster careAny day of the monthDate of birth, adoption, or placement for adoption or foster care
Permanent relocation, release from incarceration, change in eligibility for federal financial assistance, change in immigration status or status as an American Indian/Native AlaskanBetween the 1st and 20th of the monthFirst day of the following month
Between the 21st and the last day of the monthFirst day of the second following month
Determination by Washington HealthplanfinderAny day of the monthAny day of the month as determined by Washington Healthplanfinder, including a retroactive date

We will confirm the start date in your acceptance letter. If there is a delay in processing your application, we’ll select the next available start date.


What is special enrollment?


In general, you can only change or apply for health care coverage during the standard annual open enrollment period. However, if you have what’s called a “triggering event,” you can also enroll or change your coverage during a special enrollment period.

Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if you have a triggering event during open enrollment, you’ll still have a special enrollment period and your coverage may start on a different date than the standard open enrollment effective dates.

From the date of your triggering event, the special enrollment period generally lasts 60 days. That means you have 60 days to change or apply for coverage for you or your dependents.

If you have advance notice

If your triggering event is a loss of coverage that you know about in advance, you may be able to apply for new coverage ahead of time. In this case, you have 60 days before and 60 days after you lose coverage to apply. For example, if you know you’ll be laid off from your job, you can apply up to 60 days before you lose coverage.

If COBRA is available from your former employer, you can continue your employer coverage through COBRA or enroll in an individual or family plan.

In some cases, if there’s a problem with your enrollment or an issue with a plan contract, the Health Insurance Marketplace determines the length of the special enrollment period.

What is my effective date?

The date your coverage starts will depend on the kind of triggering event you have. For more information, please refer to the Enrolling During a Special Enrollment Period guide.

New members, apply online or by mail or fax:

If you apply online:
  • Fill out and submit the online application within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • Upload your supporting documentation.
  • If you prefer to mail or fax your documentation, be sure to download the Documentation of Triggering Event Form. Check the appropriate boxes on the form for your triggering event and the documentation you’re submitting to support it. Then send the form with your documentation within 10 calendar days of submitting your online application.
  • If we don’t get your Documentation of Triggering Event Form and supporting documentation within 10 calendar days, your application will be considered incomplete and may be canceled. You can reapply, but you’ll need to do that within the same special enrollment period and your effective date may be different.
  • If you apply near the end of your special enrollment period, make sure we get your Documentation of Triggering Event Form and supporting documentation before your special enrollment period ends. If we don’t get your documentation within 60 days of your triggering event, your application may be canceled.
  • On the first page of your supporting documentation, be sure to write this information for the primary applicant:
    — First and last name as listed on the application
    — Kaiser Permanente medical record number (if you have one)
    — Home address
    — Date of birth
  • Include your first month’s premium with your application. You can pay with a credit card, debit card, checking account number, or savings account number. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see the Enrolling During a Special Enrollment Period guide for information about what you need to pay.
If you apply by mail or fax:
  • Submit your signed paper application by mail or fax. We must receive your paper application within 60 days of your triggering event. If you apply close to the end of your special enrollment period, make sure we get your application before your special enrollment period ends.
  • You’ll need to provide the exact triggering event and the date of the event under Step 1 on the application.
  • You’ll also need to submit a Documentation of Triggering Event Form. You can download this form by clicking on the link or by calling 1-800-494-5314. See "If you apply online" above for instructions on filling it out. Be sure to mail or fax the Documentation of Triggering Event Form and supporting documentation with your paper application. Your paper application, Documentation of Triggering Event Form, and supporting documentation must be received within 60 days of your triggering event or by the end of your special enrollment period, whichever comes first.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see page 5 for information about what you need to pay.
Current Kaiser Permanente Individuals and Families plan members:
  • Please call 1-866-410-7536 to request an Account Change Form. (For TTY, call 711.)
  • See the Enrolling During a Special Enrollment Period guide for more information on deadlines.
New and current members:
  • We must receive ALL your required materials within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • In some instances, you may submit your completed application up to 60 days in advance of your triggering event to avoid a gap in coverage.
  • If you apply close to the end of your 60-day special enrollment period, you may want to fax us or use express mail to avoid missing the deadline. You can also call 1-800-494-5314 to enroll or make an account change over the phone. (For TTY, call 711.)
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively back to the effective date of coverage. You may also be financially liable for any services that you may have received.

We will confirm the start date in your acceptance letter. If there is a delay in processing your application, we’ll select the next available start date.
Special Enroll Period


Effective Date

Your coverage start date will depend on the triggering event that you experience. Please review this chart to see your effective date.

Effective dates
TypeReceipt of applicationEffective date
Loss of health care coverageAny day of the monthFirst day of the month following the loss of coverage
Marriage or domestic partnership registrationAny day of the monthFirst day of the month following the event
Birth, adoption, or placement for adoption or foster careAny day of the monthDate of birth, adoption, or placement for adoption or foster care
Permanent relocation, change in eligibility for federal financial assistance, change in employer coverage, change in immigration status, or status as an American Indian/Native AlaskanBetween the 1st and 15th of the monthFirst day of the following month
Between the 16th and the last day of the monthFirst day of the second following month
Determination by the HealthCare.govAny day of the monthAny day of the month as determined by the HealthCare.gov including a retroactive date
If you are applying by paper
Click the "Paper application" link on the left to download the file. Fill out the application as instructed, and mail or fax the form.


Enrolling During a Special Enrollment Period

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you can enroll or change your coverage if you have experienced a situation known as a triggering event. For example, if you get married, have a baby, or lose coverage because you lose your job — all triggering events — you will have a special enrollment period.

Generally, a special enrollment period lasts 60 days after the triggering event occurs. That means if you’ve experienced a triggering event, you have 60 days from the day of the triggering event to change or apply for health care coverage for yourself and/or your dependent. In some situations, if you are aware of a triggering event that will occur in the future, you may be able to apply for new coverage prior to the triggering event. For example, if you know you will experience a loss of coverage or your eligibility for your employer health coverage changes, you have 60 days before your loss of coverage and 60 days after your loss of coverage to apply for health coverage.

You have many important decisions to make about your health care coverage, and we’re committed to helping you understand how these changes will impact you and your family. If you have any questions, we’re here to help.

Triggering-Event Confirmation Required

New Applicants Applying Online

If you’ve experienced a triggering event, you’ll choose the triggering event and date of the event prior to beginning the application process.
  • If you are applying online, you will choose your triggering event and date of the event just before you begin the online application process. You must apply within 60 days of your triggering event. In some instances under the following triggering events, “loss of health care coverage” or “your eligibility for your employer health coverage changes”, you may be allowed to apply 60 days before your triggering event occurs.
     
Applying by mail or fax

New applicants
  • If you are sending in a paper application, download and complete the paper application. You will provide your triggering event and the date of your event on your paper application. Your completed paper application must be received with your first month’s premium.
     
  • If you apply close to the end of your special enrollment period, be sure we receive your application before your special enrollment period ends.
     
Current Kaiser Permanente Members

If you’ve experienced a triggering event, and want to change your plan, we’ll need a completed application.

We must receive your completed application within 60 days of your triggering event.
  • Mail or fax your completed application before the end of your special enrollment period.
     
  • If you apply close to the end of your special enrollment period, be sure we receive your application before your special enrollment period ends.
     
Fax
301-388-1615

Mail
Membership Administration Dept./KPIF 5W
Kaiser Permanente
2101 East Jefferson St., Suite 100
Rockville, MD 20852-9995

By submitting a signed Application for health coverage form, you are confirming that a triggering event occurred. We will rely on your confirmation, and if we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively.

Special Enroll Period


Effective Date

Your coverage start date will depend on the triggering event that you experience. Please review this chart to see your effective date.

TypeReceipt of application or Account Change formEffective date
Loss of health care coverage or change in eligibility for employer coverage due to changes in employer coverageOn or before the last date of coverageFirst day of the month following the last date of coverage
After loss of coverage or change in employer coverage: Between the 1st and the 15th of the monthFirst day of the following month
After loss of coverage or change in employer coverage: Between the 16th and the last day of the monthFirst day of the second following month
MarriageAny day of the monthFirst day of the month following receipt of application
Birth, adoption, or placement for adoption or foster careAny day of the monthDate of birth, adoption, or placement for adoption or foster care
Permanent relocation, release from incarceration, change in eligibility for federal financial assistance, change in immigration status or status as an American Indian/Native AlaskanBetween the 1st and 15th of the monthFirst day of the following month
Between the 16th and the last day of the monthFirst day of the second following month
Determination by the Health Insurance Marketplace in VirginiaAny day of the monthAny day of the month as determined by the Health Insurance Marketplace in Virginia, including a retroactive date
What is special enrollment?

In general, you can only change or apply for health care coverage during the standard annual open enrollment period. However, if you have what’s called a "triggering event," you can also enroll or change your coverage during a special enrollment period.

Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if you have a triggering event during open enrollment, you’ll still have a special enrollment period and your coverage may start on a different date than the standard open enrollment effective dates.

From the date of your triggering event, the special enrollment period generally lasts 60 days. That means you have 60 days to change or apply for coverage for you or your dependents.

If you have advance notice

If your triggering event is a loss of coverage that you know about in advance, you may be able to apply for new coverage ahead of time. In this case, you have 60 days before and 60 days after you lose coverage to apply. For example, if you know you’ll be laid off from your job, you can apply up to 60 days before you lose coverage.

If COBRA is available from your former employer, you can continue your employer coverage through COBRA or enroll in an individual or family plan.

In some cases, if there’s a problem with your enrollment or an issue with a plan contract, the Health Insurance Marketplace determines the length of the special enrollment period.

What is my effective date?


The date your coverage starts will depend on the kind of triggering event you have. For more information, please refer to the Enrolling During a Special Enrollment Period guide.

New members, apply online or by mail or fax:

If you apply online:
  • Fill out and submit the online application within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • Upload your supporting documentation.
  • If you prefer to mail or fax your documentation, be sure to download the Documentation of Triggering Event Form. Check the appropriate boxes on the form for your triggering event and the documentation you’re submitting to support it. Then send the form with your documentation within 10 calendar days of submitting your online application.
  • If we don’t get your Documentation of Triggering Event Form and supporting documentation within 10 calendar days, your application will be considered incomplete and may be canceled. You can reapply, but you’ll need to do that within the same special enrollment period and your effective date may be different.
  • If you apply near the end of your special enrollment period, make sure we get your Documentation of Triggering Event Form and supporting documentation before your special enrollment period ends. If we don’t get your documentation within 60 days of your triggering event, your application may be canceled.
  • On the first page of your supporting documentation, be sure to write this information for the primary applicant:
    — First and last name as listed on the application
    — Kaiser Permanente medical record number (if you have one)
    — Home address
    — Date of birth
  • Include your first month’s premium with your application. You can pay with a credit card, debit card, checking account number, or savings account number. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see the Enrolling During a Special Enrollment Period guide for information about what you need to pay.
If you apply by mail or fax:
  • Submit your signed paper application by mail or fax. We must receive your paper application within 60 days of your triggering event. If you apply close to the end of your special enrollment period, make sure we get your application before your special enrollment period ends.
  • You’ll need to provide the exact triggering event and the date of the event under Step 1 on the application.
  • You’ll also need to submit a Documentation of Triggering Event Form. You can download this form by clicking on the link or by calling 1-800-494-5314. See "If you apply online" above for instructions on filling it out. Be sure to mail or fax the Documentation of Triggering Event Form and supporting documentation with your paper application. Your paper application, Documentation of Triggering Event Form, and supporting documentation must be received within 60 days of your triggering event or by the end of your special enrollment period, whichever comes first.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see page 5 for information about what you need to pay.
Current Kaiser Permanente Individuals and Families plan members:
  • Please call 301-468-6000 or 1-800-777-7902 to request an Account Change Form. (For TTY, call 711.)
  • See the Enrolling During a Special Enrollment Period guide for more information on deadlines.
New and current members:
  • We must receive ALL your required materials within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • In some instances, you may submit your completed application up to 60 days in advance of your triggering event to avoid a gap in coverage.
  • If you apply close to the end of your 60-day special enrollment period, you may want to fax us or use express mail to avoid missing the deadline. You can also call 1-800-494-5314 to enroll or make an account change over the phone. (For TTY, call 711.)
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively back to the effective date of coverage. You may also be financially liable for any services that you may have received.

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you can enroll or change your coverage if you have experienced a situation known as a triggering event. For example, if you get married, have a baby, or lose coverage because you lose your job — all triggering events — you will have a special enrollment period.

Generally, a special enrollment period lasts 60 days after the triggering event occurs. That means if you’ve experienced a triggering event, you have 60 days from the day of the triggering event to change or apply for health care coverage for yourself and/or your dependent. In some situations, if you are aware of a triggering event that will occur in the future, you may be able to apply for new coverage prior to the triggering event. For example, if you know you will experience a loss of coverage or your eligibility for your employer health coverage changes, you have 60 days before your loss of coverage and 60 days after your loss of coverage to apply for health coverage.

You have many important decisions to make about your health care coverage, and we’re committed to helping you understand how these changes will impact you and your family. If you have any questions, we’re here to help.

Triggering-Event Confirmation Required

New Applicants Applying Online

If you’ve experienced a triggering event, you’ll choose the triggering event and date of the event prior to beginning the application process.
  • If you are applying online, you will choose your triggering event and date of the event just before you begin the online application process. You must apply within 60 days of your triggering event. In some instances under the following triggering events, “loss of health care coverage” or “your eligibility for your employer health coverage changes”, you may be allowed to apply 60 days before your triggering event occurs.
     
Applying by mail or fax

New applicants
  • If you are sending in a paper application, download and complete the paper application. You will provide your triggering event and the date of your event on your paper application. Your completed paper application must be received with your first month’s premium.
     
  • If you apply close to the end of your special enrollment period, be sure we receive your application before your special enrollment period ends.
     
Current Kaiser Permanente Members

If you’ve experienced a triggering event, and want to change your plan, we’ll need a completed application.

We must receive your completed application within 60 days of your triggering event.
  • Mail or fax your completed application before the end of your special enrollment period.
     
  • If you apply close to the end of your special enrollment period, be sure we receive your application before your special enrollment period ends.
     
Fax
301-388-1615

Mail
Membership Administration Dept./KPIF 5W
Kaiser Permanente
2101 East Jefferson St., Suite 100
Rockville, MD 20852-9995

By submitting a signed Application for health coverage form, you are confirming that a triggering event occurred. We will rely on your confirmation, and if we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively.

Special Enrollment Period

*If you will be getting federal financial assistance, do not use this form. We can help you apply through [marylandhealthconnection.gov].


What is special enrollment?


In general, you can only change or apply for health care coverage during the standard annual open enrollment period. However, if you have what’s called a “triggering event,” you can also enroll or change your coverage during a special enrollment period.

Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if you have a triggering event during open enrollment, you’ll still have a special enrollment period and your coverage may start on a different date than the standard open enrollment effective dates..

From the date of your triggering event, the special enrollment period generally lasts 60 days. That means you have 60 days to change or apply for coverage for you or your dependents.

If you have advance notice

If your triggering event is a loss of coverage that you know about in advance, you may be able to apply for new coverage ahead of time. In this case, you have 60 days before and 60 days after you lose coverage to apply. For example, if you know you’ll be laid off from your job, you can apply up to 60 days before you lose coverage.

If COBRA is available from your former employer, you can continue your employer coverage through COBRA or enroll in an individual or family plan.

In some cases, if there’s a problem with your enrollment or an issue with a plan contract, the Health Insurance Marketplace determines the length of the special enrollment period.

What is my effective date?

The date your coverage starts will depend on the kind of triggering event you have. For more information, please refer to the Enrolling During a Special Enrollment Period guide.

New members, apply online or by mail or fax:

If you apply online:
  • Fill out and submit the online application within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • Upload your supporting documentation.
  • If you prefer to mail or fax your documentation, be sure to download the Documentation of Triggering Event Form. Check the appropriate boxes on the form for your triggering event and the documentation you’re submitting to support it. Then send the form with your documentation within 10 calendar days of submitting your online application.
  • If we don’t get your Documentation of Triggering Event Form and supporting documentation within 10 calendar days, your application will be considered incomplete and may be canceled. You can reapply, but you’ll need to do that within the same special enrollment period and your effective date may be different.
  • If you apply near the end of your special enrollment period, make sure we get your Documentation of Triggering Event Form and supporting documentation before your special enrollment period ends. If we don’t get your documentation within 60 days of your triggering event, your application may be canceled.
  • On the first page of your supporting documentation, be sure to write this information for the primary applicant:
    — First and last name as listed on the application
    — Kaiser Permanente medical record number (if you have one)
    — Home address
    — Date of birth
  • Include your first month’s premium with your application. You can pay with a credit card, debit card, checking account number, or savings account number. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see the Enrolling During a Special Enrollment Period guide for information about what you need to pay.
If you apply by mail or fax:
  • Submit your signed paper application by mail or fax. We must receive your paper application within 60 days of your triggering event. If you apply close to the end of your special enrollment period, make sure we get your application before your special enrollment period ends.
  • You’ll need to provide the exact triggering event and the date of the event under Step 1 on the application.
  • You’ll also need to submit a Documentation of Triggering Event Form. You can download this form by clicking on the link or by calling 1-800-494-5314. See "If you apply online" above for instructions on filling it out. Be sure to mail or fax the Documentation of Triggering Event Form and supporting documentation with your paper application. Your paper application, Documentation of Triggering Event Form, and supporting documentation must be received within 60 days of your triggering event or by the end of your special enrollment period, whichever comes first.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed. If you’ve recently had a child and you want your plan to start on your child’s date of birth, see page 5 for information about what you need to pay.
Current Kaiser Permanente Individuals and Families plan members:

  • Please call 301-468-6000 or 1-800-777-7902 to request an Account Change Form. (For TTY, call 711.)
  • See the Enrolling During a Special Enrollment Period guide for more information on deadlines.
New and current members:
  • We must receive ALL your required materials within 60 days of your triggering event or by the last day of your special enrollment period, whichever comes first.
  • In some instances, you may submit your completed application up to 60 days in advance of your triggering event to avoid a gap in coverage.
  • If you apply close to the end of your 60-day special enrollment period, you may want to fax us or use express mail to avoid missing the deadline. You can also call 1-800-494-5314 to enroll or make an account change over the phone. (For TTY, call 711.)
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we determine that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage retroactively back to the effective date of coverage. You may also be financially liable for any services that you may have received.
Select the method in which the application will be completed.
You may choose to complete the application online or on paper. If you choose to complete the application electronically (online), you also agree to receive a response from Kaiser Permanente electronically. You will have an opportunity to print a copy of your completed application and Kaiser Permanente's responses for your records.
 
Online Application
  (Using this preferred method helps ensure that your application is complete and may expedite processing)
  • You will complete the application online.

  • 4. If you do not wish to provide your email address, please follow instructions to download and mail a paper   application.

    If you think you might like to download the paper application, please do so now. Once you have started the online application, you will not be able to return to this page to download it.

    To download and complete a paper application click the link below.

 
1. Provide Your Personal Information and Medical History
Depending on the type of plan you're applying for, you may need to have the following information on hand.
  • Medical History information for applicants, including medications and treating physician information
  • Medical History information for Applicants, including medications and treating physician information
The signature of each Applicant who is an adult will be required to personally submit an electronic signature on his or her own behalf to authorize release of medical information.
   
1. Sign the Application
    You'll need to sign the application with an e-signature letting us know that you understand the agreements and authorizations of the application. The signature of each Applicant who is an adult will be required to personally submit an electronic signature on his or her own behalf to sign the application.
    You'll need to sign the application with an e-signature letting us know that you understand the agreements and authorizations of the application. The signature of each Applicant who is an adult will be required to personally submit an electronic signature on his or her own behalf to sign the application.
   
   
2. Mailing Instructions
    To download and complete a paper application click the link below.
    Paper Application
    If you select to download and complete a paper application, please mail your application to:

Kaiser Permanente
California Service Center - KPIF
P.O. Box 23219
San Diego, CA 92193-9921
1. Please provide all of the information that’s needed about you and your family.

2. Sign the online application with an e-signature. If you’re using the paper application, please sign in ink. A signature    is needed for each person age 18 or over who will be covered.

3. Submit your application.

4. If you are applying by mail or fax, download the paper application, fill it out, and mail or fax it to us. If you are
   applying because of a triggering event, download the Documentation of triggering event form and submit it with
   your application and supporting documentation.


  Paper Application
4. If you are applying by mail or fax, download the paper application, fill it out, and mail or fax it to us. If you are
   applying because of a triggering event, download the Documentation of triggering event form and submit it with
   your application and supporting documentation.


  Paper Application
  Special Enrollment Period Guide
  Documentation of triggering event form
4. If you are applying by mail or fax, download the paper application, fill it out, and mail or fax it to us. If you are
   applying because of a triggering event, download the Documentation of triggering event form and submit it with
   your application and supporting documentation.


To download and complete a paper application click the link below.

Paper Application
    • English
      Click the "Paper application" link on the bottom to download the file. Fill out the application as instructed, and mail or fax the form.


    • Spanish (español)
      Haga clic en el enlace "Paper application" (solicitud en papel) en la parte de abajo para descargar el archivo. Llene la solicitud siguiendo las instrucciones, y env�ela por fax o por correo postal.

Membership Administration Dept./KPIF 5W
Kaiser Permanente
Suite 100
2101 East Jefferson St.
Rockville, MD 20852-9995

Fax Number: 855-414-2796

Employer Services Dept./KPIF 5W
Kaiser Permanente for Individuals and Families
2101 East Jefferson St.
Rockville, MD 20852-9995

Or send it by secure fax to: 1-855-414-2796

4. If you do not wish to provide your email address, please follow instructions to download and mail a paper   application.

If you think you might like to download the paper application, please do so now. Once you have started the online application, you will not be able to return to this page to download it.

To download and complete a paper application click the link below.

4. If you are applying by mail or fax, download the paper application, fill it out, and mail or fax it to us. If you are
   applying because of a triggering event, download the Documentation of triggering event form and submit it with
   your application and supporting documentation.

  Paper Application
  Special Enrollment Period Guide
  Paper Application
  Special Enrollment Period Guide
  Paper Application
  Special Enrollment Period Guide
  Paper Application
  Special Enrollment Period Guide
  Paper Application
  Special Enrollment Period Guide
  Paper Application
  Special Enrollment Period Guide
  Paper Application
  Special Enrollment Period Guide
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60485412 Colorado January 2017
60323809 Colorado January 2016
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