Statement of Understanding

Form Name

Placeholder Salesforce Name

The following section pertains to my eligibility for, and participation in, the Healthcare Cost Assistance Benefits, provided under the Oregon Homecare Workers Supplemental Trust “Trust.”

1) I understand that (please check each statement to verify you understand):

The Trust does not provide employer-sponsored or “group” medical coverage. Medical insurance obtained through the Marketplace is considered individual or family coverage. If I move, stop doing homecare or personal support work or my hours change, my insurance will not be automatically canceled. However, these events may impact my eligibility to receive Healthcare Cost Assistance and out-of-pocket expense assistance from the Supplemental Trust.The Trust will provide a Benefit Convenience Card (“BCC”) for me to use, to pay both my monthly premium payments, and for covered out-of-pocket medical expenses, up to the annual BCC allowance. The out-of-pocket expenses include the deductible on my approved Marketplace plan, copayments and coinsurance expenses, including those for covered prescriptions. Any charges other than those listed above are considered unauthorized charges. I understand that if I use my BCC for unauthorized charges, I will be held liable for that overpayment and will be obligated to repay those unauthorized charges back to the Supplemental Trust. (See Carewell Training & Benefits Guide under Overpayments section).In addition to the Healthcare Cost Assistance benefits I receive through the Oregon Homecare Workers Supplemental Trust, I am also eligible to receive dental, vision and hearing coverage at no premium cost to me, through the Oregon Homecare Workers Benefit Trust. I understand that if I choose to enroll in an additional dental plan through the Marketplace, it is my responsibility to pay those premium payments each month out of my own pocket. I acknowledge that 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 will be considered an overpayment that I must pay back to the Trust.In order to receive Healthcare Cost Assistance, Trust rules require that I provide proof of my enrollment each year. There are two ways to provide this proof. 1) I can use the Trust’s provider, Valley Insurance Professionals (VIP) to help me enroll, and then VIP will send my enrollment information to the Trust on my behalf; or 2) I can provide proof of my enrollment by submitting my Marketplace Eligibility Notice and either my premium bill or the My Plans and Programs page from my 2025 Marketplace (Healthcare.gov) application. If I don’t provide these supporting documents, I understand that my Benefit Convenience Card will be suspended until the required documents are submitted and approved.The Trust requires that if I qualify for an Advance Premium Tax Credit (APTC) or a State sponsored Tax Credit, I must elect to receive and apply the full amount of all monthly Tax Credits available to me, toward the premium for the Trust approved health insurance plan for which I enroll. If I do not apply the full amount of Tax Credits toward the premium, I may be required to reimburse the Supplemental Trust at tax time. (See Carewell Training & Benefits Guide under Overpayments section).In order to receive Healthcare Cost Assistance under the Trust, I cannot be enrolled in more than one type of health coverage. This includes health coverage offered through Medicare (Parts A and/or B), Medicaid, CHIP, 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 of these coverage types throughout the year, I will notify Valley Insurance Professionals and the Trust immediately. I may call Valley Insurance Professionals at (503) 974-8471 or Carewell SEIU 503 Benefits at (844) 503-7348, or I can visit CarwellSEIU503.org for more contact options.

Name:

First NameMiddle NameLast Name

Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email:

example@example.com

Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth:

Date

Signature

Date

CONSENT FOR BROKER ASSISTANCE

I, the undersigned, hereby authorize the team of agents at Valley Insurance Professionals (“VIP”), the insurance broker for the Oregon Homecare Workers Supplemental Trust (“Trust”) and Carewell SEIU 503 Benefits, to act as my “Agent of Record” relating to any health insurance plan in which I enroll, whether I apply directly or through the applicable Federal or State Marketplace. I understand that VIP has a team of licensed insurance agents, working under Lisa Schneider, as the Principal Broker (NPN: 14864065), that are assigned to assist care providers and their families. The following section pertains to my Marketplace application for health insurance, whether via website enrollment, direct enrollment, phone enrollment, or on paper. The term “eligibility,” when used below, shall be in reference to Marketplace eligibility and not Carewell SEIU 503 benefits, funded by the Trusts:

2) I understand that (please check each statement to verify you understand):

By signing this form, I am consenting to the team of agents at Valley Insurance Professionals (NPN: 13387995) to assist with my Marketplace eligibility determination and/or enrollment in to a Qualified Health Plan (“QHP”), with or without Advance Premium Tax Credits (APTC) and/or Cost Share Reductions (“CSR”). This consent may include a) conducting online person searches to access my current and/or any previous year’s Marketplace enrollment using my Personally Identifiable Information (“PII”); b) completing an application, with Marketplace eligibility determination, plan selection and/or enrollment; c) ongoing account/enrollment maintenance; d) verifying prior coverage/application information; and/or e) plan terminations, per my request.This consent form will remain in effect indefinitely, until terminated or rescinded by either party, by providing written notice. The rescission request will be effective sixty (60) days from the date of receipt. I further understand the request should be delivered in writing and sent either by certified mail or emailed to info@valleyinsurancepro.com. Valley Insurance Professionals is required to maintain records for ten (10) years.I am signing or authorizing my application under penalty of perjury, which means I have, or will, provide true answers to all the questions on the application to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information. I further understand that I do not have to share additional personal information about myself or my health with my agent, beyond what is required on the application for eligibility and enrollment purposes.

Click here to see VIP's Notice of Privacy Practices.

Name

First NameMiddle NameLast Name

Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code

Date of Birth

Date

Preferred language

Email

example@example.com

Primary phone

Please enter a valid phone number.Format: (000) 000-0000.

Okay to leave message at this number?

Signature

Date

If you have questions about this form, you can call the Carewell SEIU 503 Benefits Team at 1-844-503-7348.

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