Get Your Personalized Quote
 
You can get a personalized quote based on the information you enter below. All of the information you provide is for quoting and application purposes only and will be kept confidential.
 
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, check back soon. We expect our updated rates and plans to be available shortly.
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, please return to our website on or after October 31, 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 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.
 
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 1-877-408-3495, (TTY 888-758-6054) for information about our Kaiser Permanente Medicare Plus plans.
 
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.
Kaiser Permanente of Hawaii has established an open enrollment period during the month of November for applicants under the age of 19 who are seeking health coverage.

A child under the age of 19 may apply to enroll in our KP 20/Rx, KP 30/Rx, and KP Basic 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 for Children Plan.
The state of Maryland has established annual open enrollment periods during the months of January and July for applicants under the age of 19 who are seeking individual health coverage.

Outside of these open enrollment periods, a child under the age of 19 may only apply for coverage on his or her own plan due to a valid court order for health benefits for the child.

Children can enroll as dependents on family plans throughout the year.
The District of Columbia has established annual open enrollment periods during the months of January and July for applicants under the age of 19 who are seeking individual health coverage.

Outside of these open enrollment periods, a child under the age of 19 may only apply for coverage on his or her own plan due to a valid court order for health benefits for the child.

Children can enroll as dependents on family plans throughout the year.
The state of Colorado has established annual open enrollment periods during the months of January and July for applicants under the age of 19 who are seeking individual health coverage.

Outside of those periods, single-subscriber coverage is available only in the case of a qualifying event: birth or adoption; marriage or dissolution of marriage; death of a policyholder; loss of employer-sponsored insurance; loss of eligibility under the Colorado Medical Assistance Act or the Children's Basic Health Plan; entry of a valid court order mandating that a child be covered; or loss of other existing coverage for any reason other than fraud, misrepresentation, or failure to pay premium. You may enroll your child at any point during the year within 30 days of a qualifying event.

Children can enroll as dependents on family plans throughout the year.
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.

The plans, benefits and monthly rates listed on this site are valid only through December 31, 2011. If you would like to apply for these plans, we must receive your enrollment application by December 8, 2011. Beginning January 1, 2012, the plans, benefits, and monthly rates for Kaiser Permanente for Individuals and Families plans will change. To apply for one of our 2012 plans, please use the 2012 application. Please note that rates for existing members also changes on January 1, 2012.
 
Your Information *Required
* ZIP Code:
State:
    County:
Tell Us When You’re Applying
Select One Option:
Select 1 Option:
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 15, 2014, through February 15, 2015].

For enrollment during a special enrollment period, subscribers and their dependents may enroll or change health plans following a triggering event, as defined below. This enrollment application and payment of first month premium must be received by Kaiser Permanente within 60 days of the triggering event, unless stated otherwise below. To complete your application for processing for your special enrollment period, we need a signed letter from you describing the triggering event and the triggering event date. Your letter must be received by us at the address shown on page one within 10 days following our receipt of your completed application. If we don’t receive a letter within 10 calendar days, we will cancel your application. You may reapply and submit the letter regarding your triggering event, but you must do so within the 60-day special enrollment period.

If you are applying during a special enrollment period, please enter the date of your triggering event.
Date of triggering event
* If your triggering event is “Loss of health care coverage,” the date of your triggering event is the first day you are without coverage.
* If your triggering event is “Loss of health care coverage,” the date of the triggering event is the last day of full coverage under your prior plan.
*You and your dependent have 60 days before and after the loss of coverage to enroll in or change health plans.

Please call 1-800-494-5314 to determine the start date of coverage for your enrollment.
* If you will be getting federal financial assistance, do not use this form. We can help you apply through the Health Insurance Marketplace.
* If you will be getting federal financial assistance, do not use this form. We can help you apply through healthcare.gov.
* If you will be getting federal financial assistance, do not use this form. We can help you apply through wahealthplanfinder.org.
* If you will be getting federal financial assistance, do not use this form. We can help you through Covered California.
** If you will be getting federal financial assistance, do not use this form. We can help you apply through Connect for Health Colorado.

For help, contact us at 1-800-501-1472 or contact your broker.
*If you will be getting federal financial assistance, do not use this form. We can help you apply through healthcare.gov.
Effective 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 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?

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you have a special enrollment period to enroll or change your coverage if you experience what’s known as a triggering event. Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if your triggering event occurs during open enrollment, you will still have a special enrollment period and your coverage effective date may differ from 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 and/or your dependents.

If you have advance notice

If your triggering event is a loss of coverage and you know about it 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 new coverage. For example, you know that you will be laid off from your job.

In some cases, if there is 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?

Your coverage start date will depend on the type of triggering event you experience.
Under “Loss of health care coverage,” the date of the triggering event is the last day of coverage under your prior plan.
When adding a newborn or newly adopted child or foster child, you have 2 options for listing the date of your triggering event. Choose the date of birth, adoption, or placement, or the first day of the following month. Whichever option you choose will be your effective date.

Please review the chart below to see your effective date.

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.
  • You’ll need to provide the exact triggering event and the date of the event on the application.
  • 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 apply by mail or fax:
  • Submit your signed paper application via 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, be sure we receive 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.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed.
Current Kaiser Permanente Individuals and Families plan members:

Mail or fax an Account Change Form:
  • Please call 1-800-494-5314 to request an Account Change Form.
  • Fill out and submit the form via mail or fax within 60 days of your triggering event. If you make an account change due to a triggering event, be sure we receive your Account Change Form before your special enrollment period ends. You can also call 1-800-494-5314 to make your account change over the phone or fax it to 1-866-846-2650.
  • You’ll need to provide the exact triggering event and date of the event under Section B of the Account Change Form.
New applicants and current members, keep in mind:
  • 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.
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we decide 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 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?

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you have a special enrollment period to enroll or change your coverage if you experience what’s known as a triggering event. Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if your triggering event occurs during open enrollment, you will still have a special enrollment period and your coverage effective date may differ from 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 and/or your dependents.

If you have advance notice

If your triggering event is a loss of coverage and you know about it 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 new coverage. For example, you know that you will be laid off from your job.

In some cases, if there is a problem with your enrollment or an issue with a plan contract, Connect for Health Colorado determines the length of the special enrollment period.

What is my effective date?

Your coverage start date will depend on the type of triggering event you experience.

Under “Loss of health care coverage,” the date of the triggering event is the last day of full coverage under your prior plan.

When adding a newborn or newly adopted child or foster child, you have 2 options for listing the date of your triggering event. Choose the date of birth, adoption, or placement, or the first day of the following month. Whichever option you choose will be your effective date.

Please review the chart below to see your effective date.

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.
  • You’ll need to provide the exact triggering event and the date of the event on the application.
  • 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 apply by mail or fax:
  • Submit your signed paper application via 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, be sure we receive 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.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed.
Current Kaiser Permanente Individuals and Families plan members:

Mail or fax an Account Change Form:
  • Please call 1-800-494-5314 to request an Account Change Form.
  • Fill out and submit the form via mail or fax within 60 days of your triggering event. If you make an account change due to a triggering event, be sure we receive your Account Change Form before your special enrollment period ends. You can also call 1-800-494-5314 to make your account change over the phone or fax it to 1-866-920-6471.
  • You’ll need to provide the exact triggering event and date of the event under Section B of the Account Change Form.
New applicants and current members, keep in mind:
  • 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.
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we decide 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 liable for any services that you may have received.
What is special enrollment?

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you have a special enrollment period to enroll or change your coverage if you experience what’s known as a triggering event. Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if your triggering event occurs during open enrollment, you will still have a special enrollment period and your coverage effective date may differ from 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 and/or your dependents.

If you have advance notice

If your triggering event is a loss of coverage and you know about it 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 new coverage. For example, you know that you will be laid off from your job.

In some cases, if there is a problem with your enrollment or an issue with a plan contract, Covered California determines the length of the special enrollment period.

What is my effective date?

Your coverage start date will depend on the type of triggering event you experience.
Under “Loss of health care coverage,” the date of the triggering event is the last day of coverage under your prior plan.
When adding a newborn or newly adopted child or foster child, you have 2 options for listing the date of your triggering event. Choose the date of birth, adoption, or placement, or the first day of the following month. Whichever option you choose will be your effective date.

Please review the chart below to see your effective date.

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.
  • You’ll need to provide the exact triggering event and the date of the event on the application.
  • 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 your triggering event. Then, send the form 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, your application will be considered incomplete and it may be canceled. You may reapply and submit the Documentation of Triggering Event Form and supporting documentation, but you must do so within the special enrollment period.
  • If you apply near 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. If documentation isn’t received within 60 days of your triggering event, your application may be canceled.
  • On the first page of your supporting 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 with your application. You can pay with a credit card, debit card, checking account number, or savings account number.
If you apply by mail or fax:
  • Submit your signed paper application via 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, be sure we receive 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.
  • Follow the instructions under “If you apply online” for the Documentation of Triggering Event Form. 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.
Current Kaiser Permanente Individuals and Families plan members:

Mail or fax an Account Change Form:
  • Please call 1-800-494-5314 to request an Account Change Form.
  • Fill out and submit the form via mail or fax within 60 days of your triggering event. If you make an account change due to a triggering event, be sure we receive your Account Change Form before your special enrollment period ends. You can also call 1-800-494-5314 to make your account change over the phone or fax it to 1-858-614-3344.
  • You’ll need to provide the exact triggering event and date of the event under Section B of the Account Change Form.
  • Follow the instructions under “If you apply online” for the Documentation of Triggering Event Form. Be sure to mail or fax the Documentation of Triggering Event Form and supporting documentation with your Account Change Form. Your Account Change Form, 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.
New applicants and current members, keep in mind:
  • 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.
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we decide that the triggering event did not occur, we may take legal action, including, but not limited to, terminating your coverage. You may also be 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.
California
Triggering event type Receipt of Application Effective Date
Loss of health care coverage or change in eligibility for employer health 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
Gaining or becoming a dependent through marriage or domestic partnership registration Any day of the month First day of the month following receipt of application
Gaining a dependent through 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 or first day of the month following the event
Losing a dependent through divorce, dissolution of domestic partnership, or legal separation Between the 1st and the 15th of the month First day of the month following receipt of application
Between the 16th and the last day of the month First day of the second month following receipt of application
Death of a subscriber or dependent Any day of the month First day of the month following receipt of application
Court order Any day of the month Date the court order is effective
Permanent relocation, change in eligibility for federal financial assistance, change in immigration status or 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
Release from incarceration Between the 1st and the 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
Grandfathered plan renews outside of open enrollment On or before last date of coverage First day of the month following the last date of coverage
After last date of coverage: between the 1st and the 15th of the month First day of the following month
After last date of coverage: between the 16th and the last day of the month First day of the second following month

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 FormEffective 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
Colorado
Triggering Event Type Receipt of Application Effective Date
Loss of health care coverage or change in eligibility for employer health coverageOn or before 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 month after the triggering eventFirst 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
Gaining or becoming a dependent through 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
Gaining a dependent through birth, adoption, or placement for adoption or foster careAny day of the monthDate of birth, adoption, or placement for adoption or foster care or first day of the month following the event
Losing a dependent through divorce, dissolution of a civil union registration or legal separationBetween the 1st and 15th of the monthFirst day of the following month following receipt of application
Between the 16th and the last day of the monthFirst day of the second month following receipt of application
Death of a subscriber or dependentAny day of the monthFirst day of the month following receipt of application
Court order to cover a childAny day of the monthDate the court order is effective
Permanent relocation, 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
Release from incarcerationBetween 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
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



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 Health insurance Marketplace in GeorgiaAny day of the monthAny day of the month as determined by the Health insurance Marketplace in Georgia, including a retroactive date
Georgia
Triggering Event Type Receipt of Application Effective Date
Loss of health care coverage or change in eligibility for employer health 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 following the triggering event 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
Gaining or becoming a dependent through marriage Any day of the month First day of the month following receipt of application
Gaining a dependent through 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 or first day of the month following the event
Losing a dependent through divorce or legal separate Between the 1st and the 15th of the month First day of the month following receipt of application
Between the 16th and the last day of the month First day of the second month following receipt of application
Death of a subscriber or a dependent Any day of the month First day of the month following receipt of application
Court Order to cover child Any day of the month Date the court order is effective
Permanent relocation, change in eligibility for federal financial assistance, change in immigration status or status as an American Indian/Native American Between the 1st and the 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
Release from incarceration Between the 1st and the 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 the Health Insurance Marketplace Any day of the month Any day of the month as determined by the Health Insurance Marketplace, including a retroactive 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
What is special enrollment?

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you have a special enrollment period to enroll or change your coverage if you experience what’s known as a triggering event. Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if your triggering event occurs during open enrollment, you will still have a special enrollment period and your coverage effective date may differ from 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 and/or your dependents.

If you have advance notice

If your triggering event is a loss of coverage and you know about it 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 new coverage. For example, you know that you will be laid off from your job.

In some cases, if there is 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?

Your coverage start date will depend on the type of triggering event you experience.
Under “Loss of health care coverage,” the date of the triggering event is the last day of coverage under your prior plan.
When adding a newborn or newly adopted child or foster child, you have 2 options for listing the date of your triggering event. Choose the date of birth, adoption, or placement, or the first day of the following month. Whichever option you choose will be your effective date.

Please review the chart below to see your effective date.

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.
  • You’ll need to provide the exact triggering event and the date of the event on the application.
  • 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 apply by mail or fax:
  • Submit your signed paper application via 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, be sure we receive 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.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed.
Current Kaiser Permanente Individuals and Families plan members:

Mail or fax an Account Change Form:
  • Please call 1-800-494-5314 to request an Account Change Form.
  • Fill out and submit the form via mail or fax within 60 days of your triggering event. If you make an account change due to a triggering event, be sure we receive your Account Change Form before your special enrollment period ends. You can also call 1-800-494-5314 to make your account change over the phone or fax it to 1-866-920-6470.
  • You’ll need to provide the exact triggering event and date of the event under Section B of the Account Change Form.
New applicants and current members, keep in mind:
  • 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.
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we decide 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 liable for any services that you may have received.
Hawaii
Triggering Event Type Receipt of Application Effective Date
Loss of health care coverage or change in eligibility for employer health 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 following the triggering event 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
Gaining or becoming a dependent through marriage or civil union registration Any day of the month First day of the month following receipt of application
Gaining a dependent through 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 or first day of the month following the event
Losing a dependent through divorce, dissolution of a civil union registration or legal separation Between the 1st and the 15th of the month First day of the month following receipt of application
Between the 16th and the last day of the month First day of the second month following receipt of application
Death of a subscriber or dependent Any day of the month First day of the month following receipt of application
Court order to cover a child Any day of the month Date the court order is effective
Permanent relocation, change in eligibility for federal financial assistance, change in immigration status or status as an American Indian/Native Alaskan 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
Release from incarceration Between the 1st and the 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 the Health Insurance Marketplace Any day of the month Any day of the month as determined by the Health Insurance Marketplace, including a retroactive 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
What is special enrollment?

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you have a special enrollment period to enroll or change your coverage if you experience what’s known as a triggering event. Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if your triggering event occurs during open enrollment, you will still have a special enrollment period and your coverage effective date may differ from 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 and/or your dependents.

If you have advance notice

If your triggering event is a loss of coverage and you know about it 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 new coverage. For example, you know that you will be laid off from your job.

In some cases, if there is 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?

Your coverage start date will depend on the type of triggering event you experience.
Under “Loss of health care coverage,” the date of the triggering event is the last day of coverage under your prior plan.
When adding a newborn or newly adopted child or foster child, you have 2 options for listing the date of your triggering event. Choose the date of birth, adoption, or placement, or the first day of the following month. Whichever option you choose will be your effective date.

Please review the chart below to see your effective date.

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.
  • You’ll need to provide the exact triggering event and the date of the event on the application.
  • 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 apply by mail or fax:
  • Submit your signed paper application via 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, be sure we receive 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.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed.
Current Kaiser Permanente Individuals and Families plan members:

Mail or fax an Account Change Form:
  • Please call 1-800-494-5314 to request an Account Change Form.
  • Fill out and submit the form via mail or fax within 60 days of your triggering event. If you make an account change due to a triggering event, be sure we receive your Account Change Form before your special enrollment period ends. You can also call 1-800-494-5314 to make your account change over the phone or fax it to 1-866-920-6471.
  • You’ll need to provide the exact triggering event and date of the event under Section B of the Account Change Form.
New applicants and current members, keep in mind:
  • 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.
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we decide 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 liable for any services that you may have received.
Oregon
Triggering Event TypeReceipt of ApplicationEffective Date
Loss of health care coverage or change in eligibility for employer health coverageOn or before 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 month following the triggering eventFirst 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
Gaining or becoming a dependent through marriage or domestic partnershipAny day of the monthFirst day of the month following receipt of application
Gaining a dependent through birth, adoption, or placement for adoption or foster careAny day of the monthDate of birth, adoption, or placement for adoption or foster care or first day of the month following the event
Losing a dependent through divorce or legal separationBetween 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
Death of a subscriber or dependentAny day of the monthFirst day of the month following receipt of application
Court order to cover a childAny day of the monthDate the court order is effective
Permanente relocation, 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
Release from incarcerationBetween 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 Oregon Health Insurance MarketplaceAny day of the monthAny day of the month as determined by the Health Insurance Marketplace

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
What is special enrollment?

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you have a special enrollment period to enroll or change your coverage if you experience what’s known as a triggering event. Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if your triggering event occurs during open enrollment, you will still have a special enrollment period and your coverage effective date may differ from 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 and/or your dependents.

If you have advance notice

If your triggering event is a loss of coverage and you know about it 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 new coverage. For example, you know that you will be laid off from your job.

In some cases, if there is a problem with your enrollment or an issue with a plan contract, Washington Healthplanfinder determines the length of the special enrollment period.

What is my effective date?

Your coverage start date will depend on the type of triggering event you experience.
Under “Loss of health care coverage,” the date of the triggering event is the last day of coverage under your prior plan.
When adding a newborn or newly adopted child or foster child, you have 2 options for listing the date of your triggering event. Choose the date of birth, adoption, or placement, or the first day of the following month. Whichever option you choose will be your effective date.

Please review the chart below to see your effective date.

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.
  • You’ll need to provide the exact triggering event and the date of the event on the application.
  • 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 apply by mail or fax:
  • Submit your signed paper application via 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, be sure we receive 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.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed.
Current Kaiser Permanente Individuals and Families plan members:

Mail or fax an Account Change Form:
  • Please call 1-800-494-5314 to request an Account Change Form.
  • Fill out and submit the form via mail or fax within 60 days of your triggering event. If you make an account change due to a triggering event, be sure we receive your Account Change Form before your special enrollment period ends. You can also call 1-800-494-5314 to make your account change over the phone or fax it to 1-866-920-6471.
  • You’ll need to provide the exact triggering event and date of the event under Section B of the Account Change Form.
New applicants and current members, keep in mind:
  • 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.
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we decide 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 liable for any services that you may have received.
Washington
Triggering Event TypeReceipt of ApplicationEffective Date
Loss of health care coverage or change in eligibility for employer health coverageOn or before 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 23rd of the month following the triggering event First day of the following month
After loss of coverage or change in employer coverage: between the 24th and the last day of the monthFirst day of the second following month
Gaining or becoming a dependent through marriage or domestic partnership registrationAny day of the monthFirst day of the month following receipt of application
Gaining a dependent through birth, adoption, or placement for adoption or foster careAny day of the monthDate of birth, adoption, or placement for adoption or foster care, or first day of the month following the event
Losing a dependent through divorce, dissolution of domestic partnership, or legal separationBetween the 1st and the 23rd of the monthFirst day of the following month following receipt of application
Between the 24th and the last day of the monthFirst day of the second following month following receipt of application
Death of a subscriber or dependentAny day of the monthFirst day of the month following receipt of application
Court order to cover a childAny day of the monthDate the court order is effective
Permanent relocation, change in eligibility for federal financial assistance, change in immigration status or status as an American Indian/Native AlaskanBetween the 1st and the 23rd of the monthFirst day of the following month
Between the 24th and the last day of the monthFirst day of the second following month
Release from incarcerationBetween the 1st and the 23rd of the monthFirst day of the following month
Between the 24th 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
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

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?

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you have a special enrollment period to enroll or change your coverage if you experience what’s known as a triggering event. Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if your triggering event occurs during open enrollment, you will still have a special enrollment period and your coverage effective date may differ from 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 and/or your dependents.

If you have advance notice

If your triggering event is a loss of coverage and you know about it 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 new coverage. For example, you know that you will be laid off from your job.

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

What is my effective date?

Your coverage start date will depend on the type of triggering event you experience.
Under “Loss of health care coverage,” the date of the triggering event is the last day of coverage under your prior plan.
When adding a newborn or newly adopted child or foster child, you have 2 options for listing the date of your triggering event. Choose the date of birth, adoption, or placement, or the first day of the following month. Whichever option you choose will be your effective date.

Please review the chart below to see your effective date.

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.
  • You’ll need to provide the exact triggering event and the date of the event on the application.
  • 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 apply by mail or fax:
  • Submit your signed paper application via 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, be sure we receive 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.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed.
Current Kaiser Permanente Individuals and Families plan members:

Mail or fax an Account Change Form:
  • Please call 1-800-494-5314 to request an Account Change Form.
  • Fill out and submit the form via mail or fax within 60 days of your triggering event. If you make an account change due to a triggering event, be sure we receive your Account Change Form before your special enrollment period ends. You can also call 1-800-494-5314 to make your account change over the phone or fax it to 301-388-1615.
  • You’ll need to provide the exact triggering event and date of the event under Section B of the Account Change Form.
New applicants and current members, keep in mind:
  • 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.
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we decide 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 liable for any services that you may have received.
Virginia
Triggering Event Type Receipt of Application Effective Date
Loss of health care coverage or change in eligibility for employer health 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 following the triggering event 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
Gaining or becoming a dependent through marriage Any day of the month First day of the month following receipt of application
Gaining a dependent through 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 or first day of the month following the event (triggering event date)
Death of a subscriber or dependent Any day of the month First day of the month following receipt of application
Court Order to cover child Any day of the month Date the court order is effective (triggering event date)
Losing a dependent through divorce or legal separation, permanent relocation, change in eligibility for federal financial assistance, release from incarceration 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 the Health Insurance Marketplace in Virginia Any day of the month Any day of the month as determined by the Health Insurance Marketplace in Virginia


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
What is special enrollment?

You may change or apply for health care coverage during an annual open enrollment period. Outside of the open enrollment period, you have a special enrollment period to enroll or change your coverage if you experience what’s known as a triggering event. Examples of triggering events include getting married, having a baby, and losing coverage because you lost your job. Even if your triggering event occurs during open enrollment, you will still have a special enrollment period and your coverage effective date may differ from 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 and/or your dependents.

If you have advance notice

If your triggering event is a loss of coverage and you know about it 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 new coverage. For example, you know that you will be laid off from your job.

In some cases, if there is a problem with your enrollment or an issue with a plan contract, Maryland Health Connection determines the length of the special enrollment period.

What is my effective date?

Your coverage start date will depend on the type of triggering event you experience.
Under “Loss of health care coverage,” the date of the triggering event is the last day of coverage under your prior plan.
When adding a newborn or newly adopted child or foster child, you have 2 options for listing the date of your triggering event. Choose the date of birth, adoption, or placement, or the first day of the following month. Whichever option you choose will be your effective date.

Please review the chart below to see your effective date.

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.
  • You’ll need to provide the exact triggering event and the date of the event on the application.
  • 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 apply by mail or fax:
  • Submit your signed paper application via 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, be sure we receive 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.
  • Include your first month’s premium with your application. Checks or money orders must be mailed with the application and cannot be faxed.
Current Kaiser Permanente Individuals and Families plan members:

Mail or fax an Account Change Form:
  • Please call 1-800-494-5314 to request an Account Change Form.
  • Fill out and submit the form via mail or fax within 60 days of your triggering event. If you make an account change due to a triggering event, be sure we receive your Account Change Form before your special enrollment period ends. You can also call 1-800-494-5314 to make your account change over the phone or fax it to 301-388-1615.
  • You’ll need to provide the exact triggering event and date of the event under Section B of the Account Change Form.
New applicants and current members, keep in mind:
  • 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.
  • By submitting a signed application or Account Change Form, you are confirming that a triggering event occurred. If we decide 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 liable for any services that you may have received.
Maryland
Triggering Event Type Receipt of Application Effective Date
Loss of health care coverage or change in eligibility for employer health 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 following the triggering event 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
Gaining or becoming a dependent through marriage or entering into a domestic partnership Any day of the month First day of the month following receipt of application
Gaining a dependent through 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 or first day of the month following the event (triggering event date)
Death of a subscriber or dependent Any day of the month First day of the month following receipt of application
Court Order to cover child Any day of the month Date the court order is effective (triggering event date)
Losing a dependent through divorce, dissolution of a domestic partnership, or legal separation, permanent relocation, change in eligibility for federal financial assistance, release from incarceration 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 Maryland Health Connection Any day of the month Any day of the month as determined by Maryland Health Connection
We will notify you of your effective date in your acceptance letter, if we approve your application. We will do our best to honor your desired effective date. If for some reason there is a delay in processing your application, we will select the next available effective date.  
We will notify you of your effective date in your acceptance letter, if we approve your application. We will do our best to honor your desired effective date. If for some reason there is a delay in processing your application, we will select the next available effective date.  
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 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 your application, we’ll select the next available start date.
Note: Effective dates for applicants under the age of 19 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.
 
The earliest your coverage will begin is the first or 15th of the month following receipt of a completed application and first month's premium. Coverage will not be back dated.

For California Residents Only: You may get a quote and apply for individual coverage. If family members want to get a quote or apply for coverage, each family member will need to fill out their quote and/or application separately.
For Hawaii Residents Only: You may get a quote and apply for individual coverage. If family members want to get a quote or apply for coverage, each family member will need to fill out their quote and/or application separately.

Is this a child-only quote?

 

 

Person(s) Covered *Date of Birth Gender Smoker
* Primary Applicant
Spouse
Domestic Partner
Child
Child
Child
A domestic partner is a person legally recognized as your domestic partner in a valid Certificate of Registered Domestic Partnership issued by the state of Oregon.
*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 Plus plans.
**Partner means a Domestic Partner, and, with respect to District of Columbia applicants only, it also includes a Legal Partner (any same-sex relationship recognized as valid by any other jurisdiction, such as civil unions). This definition of Partner applies whenever this term is used in this application.
**The term "Partner" includes both a Domestic Partner, and a Legal Partner (any same-sex relationship recognized as valid by any other jurisdiction, such as civil unions) and applies whenever used in this application. A copy of your certificate of domestic partnership or a domestic partner affidavit must accompany the application prior to the application processing.
*If you will be getting federal financial assistance, do not use this form. We can help you apply through [marylandhealthconnection.gov].
**The term "Partner" means a Domestic Partner, whenever used in this application.
 
60323809 Colorado January 2016
60230810 January 2015 Colorado
FWIDAPP0116
FWIDAPP0115
GA-60231313
GA-60315310
FOIDAPP0116