Medicare Healthcare Cost Assistance Benefits Request Form

Medicare Healthcare Cost Assistance Benefits Request Form

Each care provider in the household needs to complete their own request form.
Form Name
For eligible care providers who have Medicare, Healthcare Cost Assistance benefits help with the costs of:
- Monthly premiums for Medicare Part B (up to $200/month in 2026)
- Monthly premiums for Medicare Part D, Supplement, or Advantage plans (up to $50/month in 2026)
- Out-of-pocket expenses, such as deductibles, copayments, coinsurance, and prescriptions for services covered by Medicare (up to $8,000 in 2026)
  Healthcare Cost Assistance amounts may change from year to year.
Use this form:
- To request Healthcare Cost Assistance (HCA) benefits for Medicare this calendar year.
- To request missed reimbursements for Medicare Part B, Medicare Part D, Supplement, and Advantage previous monthly premiums (up to 12 months back*).
* If you're eligible for HCA for Medicare for the current year and eligible for the previous year (up to 12 months back), you can submit the required documents for both years at the same time.

Every year, you request Healthcare Cost Assistance for Medicare by submitting these required documents:
- For Part B: your Social Security letter or Medicare Premium Bill
- For a Part D, Supplement, and/or Advantage plan: your premium bill
For more information, please go to our Medicare HCA benefit webpage.

Medicare Healthcare Cost Assistance Care Provider Agreement

The following agreement concerns my eligibility for, and participation in, the Healthcare Cost Assistance Benefits, provided under the Oregon Homecare Workers Supplemental Trust (referred to in this document as “Carewell SEIU 503”).

I acknowledge:
- To be eligible for Medicare Healthcare Cost Assistance (“HCA”) benefits from Carewell SEIU 503, I must: (a) be enrolled in Medicare Part B, Part D, a Medicare Supplement plan or a Medicare Advantage plan; and (b) meet Carewell SEIU 503’s eligibility requirement of working 40 hours or more per month. My Medicare Healthcare Cost Assistance benefits end 1 month after I work less than 40 hours per month for 2 months in a row.
- Every year, Trust rules require that I submit a Medicare HCA Benefits Request with documentation of my Medicare Part B, Medicare Part D, Medicare Supplement plan, or Medicare Advantage plan premiums, as applicable.
- For proof of my Medicare Part B premium, I must submit a copy of my annual Social Security letter or my CMS Medicare premium bill. If my Medicare Part B premium amount changes, I must submit another Medicare HCA Benefits Request Form to receive the updated reimbursement amount. For proof of my Medicare Part D, Medicare Advantage, or Medicare Supplement plan premiums, I can submit the request for Medicare premium reimbursement through MyCarewell503, or on the Carewell SEIU 503 website (CarewellSEIU503.org) with a copy of the invoice showing the premium amount for my plan(s). Once Carewell SEIU 503 receives all of my paperwork, Carewell SEIU 503 provides me with monthly reimbursements for my premiums up to Carewell SEIU 503’s limit, either by check or by direct deposit into my bank account. Direct deposit is generally faster and safer, and I can sign up online through MyCarewell503 or at CarewellSEIU503.org/deposit.
- Carewell SEIU 503 provides a Benefit Convenience Card (“BCC”) for me to use, to pay covered out-of-pocket medical expenses, up to the annual BCC allowance amount. Covered out-of-pocket expenses include medical and prescription drug copayments, deductibles, and coinsurance expenses for claims covered by my Medicare plan (provided the claims were incurred while I was eligible for Trust benefits). I may not use my BCC to pay for Medicare premium expenses. Medicare premium expenses are reimbursed by Carewell SEIU 503 through the reimbursement process described above.
- Any charges other than those listed above are considered unauthorized charges. I understand that if I use my BCC for unauthorized charges, I am held liable for that overpayment and am obligated to repay those unauthorized charges to Carewell SEIU 503. (See the Overpayments section in the Carewell SEIU 503 Guide to Training and Benefits.)
- I cannot use my BCC for any expenses related to my dental, vision, or hearing benefits. Using the BCC for such expenses is unauthorized and is considered an overpayment that I must pay back to Carewell SEIU 503.
- In order to receive Healthcare Cost Assistance under Carewell SEIU 503, I cannot receive health coverage assistance from another source, such as Medicaid, an employer, COBRA, TRICARE, VA health care program, Peace Corps, or any other type of health coverage that meets the federal minimum essential coverage (MEC) standards for insurance coverage. If I am currently enrolled in, or become newly eligible for, any other coverage that meets MEC standards for insurance coverage throughout the year, I must notify Carewell SEIU 503 immediately by calling Carewell SEIU 503 at 1-844-503-7348.
- I must review and respond to all notices I receive throughout the year from Carewell SEIU 503 and RISE Partnership to ensure there is no delay or interruption in my Trust benefits.
- I am responsible for submitting timely and accurate information to Carewell SEIU 503. Failure to do so could result in a delay in benefits being administered to me. I also understand that submitting this form does not guarantee my Trust benefits and does not enroll me in Medicare Part B, Medicare Part D, a Medicare Supplement plan or a Medicare Advantage plan.
Signature*

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Every year, use this form to upload the required documentation to request Healthcare Cost Assistance (HCA) benefits for Medicare.

Note: The Trusts only allow any reimbursement, or payment claims, up to 1 year from the date of service. If you're eligible for HCA for Medicare for the current year and eligible for the previous year (up to 12 months back), you can submit the required documents for both years at the same time.
Which Medicare premium(s) are you requesting HCA benefits for (you can select more than 1 option):*

For Part B: submit your Social Security letter or Medicare Premium BillFor a Part D, Supplement, and/or Advantage plan: submit your premium bill
Which premium(s) do you need reimbursements for:*

Medicare Part B PremiumMedicare Advantage Plan, Supplement Plan, or Part D (Rx) Plan Premium
Medicare Part B Premium

Reimbursement up to $200/month in 2026. Proof of Part B premium must be provided when you first become eligible and then yearly.

Please select the year and include the amount you are requesting reimbursement(s) for.

Note: Requests for reimbursement must be submitted to Carewell SEIU 503. The Trusts will only allow any reimbursement or payment claims up to 1 year from the date of service.
Medicare B: Click the "Add Claim" button below if you need to claim another year.*
Medicare Advantage Plan, Supplement Plan, or Part D (Rx) Plan Premium

Reimbursement up to $50/month in 2025. Proof of premium for a Medicare Advantage Plan, Supplement Plan, or Part D Plan must be provided when you first become eligible and then yearly.

Please select the year and include the amount you are requesting reimbursement(s) for.

Note: Requests for reimbursement must be submitted to Carewell SEIU 503. The Trusts will only allow any reimbursement or payment claims up to 1 year from the date of service.
Medicare Advantage, Supplement, Part D (Rx): Click the "Add Claim" button below if you need to claim another year.*
Directions on how to upload files

If you DO have the files online:
1. Click on “Browse Files” on this online form
2. Select the file(s) you would like to attach/upload

If you DON’T have the files online:
1. Use your phone to take a photo of any forms and documents that you need to send to us. Make sure to take a complete picture of the form and that your name is included. We can’t read or use blurry photos.
2. Click on “Browse Files” on this online form
3. Select the file(s) you would like to attach/upload
Attach/upload forms and/or documents:*

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I certify that the information provided on this form is true and that I have incurred the expenses described on this form solely relating to my own medical coverage and expenses. I also certify that I have not already received reimbursement from Carewell SEIU 503 or any other source for any of the above-listed amounts.

I understand that if I receive medical coverage through a Qualified Health Plan from the Health Insurance Marketplace, I need to cancel my Marketplace Qualified Health Plan the day my Medicare coverage becomes active. If I don’t, I may be charged for Marketplace plan premiums.

You can cancel your Marketplace plan by:
- Calling the Marketplace at 1-800-318-2596 and requesting the cancellation of your Marketplace plan or online at HealthCare.gov; or
- Getting assistance from the agents at Valley Insurance Professionals — call 1-844-503-7348 to schedule an appointment.
Signature*

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Today's Date*

MonthDayYear
Date
Today's Date*
Amount in dollars for Medicare Part B Premium
Amount in dollars for Medicare Advantage, Supplement, or Part D Plan
Amount in dollars for Medical Out-of-Pocket Expenses
Date*

MonthDayYear
Date
Upload files (proof of premium payment, explanation of benefits, pharmacy receipt) *

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