Healthcare Cost Assistance (HCA) Benefits Request Form

Healthcare Cost Assistance (HCA) Benefits Request Form
The Carewell SEIU 503 Healthcare Cost Assistance (HCA) benefit helps care providers enrolled in an approved Marketplace plan to pay for individual health insurance premiums and eligible out-of-pocket expenses.

For more information, please go to our HCA benefit webpage.

Use this form to request HCA benefits if you are:
- Not eligible for other forms of health insurance coverage, such as Oregon Health Plan, coverage through another employer, or coverage through your spouse.
- Newly eligible for Carewell benefits and requesting HCA benefits.
- Continuing to use HCA benefits. This form must be submitted every year for approval.
- Updating your income.
- Reporting new premium information (either yearly or when regaining eligibility).
- Updating name or address (must also be updated with your payroll vendor(s) and the Marketplace).
- Changing coverage (for example moved to Medicaid, Medicare, spousal coverage, other employer coverage, or ending coverage).
Do NOT use this form if you have family enrolled on the plan with you. Complete the Medical Premium Reimbursement Claim Form instead.

NOTE:

Completing this form does not enroll you in health coverage or guarantee that you will be eligible to receive HCA benefits.

Complete this form AFTER you are enrolled or have updated your information with the Health Insurance Marketplace.

You must submit this form along with these 2 documents and the annual paperwork:
1. A copy of your Marketplace Eligibility Notice
2. A copy of your premium bill (or sign in to your Healthcare.gov account, go your 2025 application, and click on "My plans & programs").

To view samples of the Marketplace Eligibility Notice and the premium bill, click here.

If have not filled out the Annual Paperwork yet, click here to fill it out.

Did you get help enrolling in an approved plan from Valley Insurance Professionals (VIP)? If so, you do NOT need to submit this form. VIP will submit all the information on your behalf.
If you would like help from Valley Insurance Professionals, call 1-844-503-7348 to schedule an appointment with them. We are available Monday- Friday, 8 am - 6 pm PST.

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Health Coverage Information
Why are you filling out this form?*

Updating information, reporting changes, renewing/reapplying for HCA benefitsNewly requesting HCA benefits for the first time
Which State do you have health coverage in?*

OregonWashingtonIdahoCalifornia
Which plan in Oregon are you on?*
Which plan in Washington are you on?*
Which plan in Idaho are you on?*
Which plan in California are you on?*
It looks like you may not be on an approved plan, which generally means you aren't eligible to receive HCA benefits. However, if you are enrolled in a non-approved plan through a health insurance Marketplace, you may receive temporary Healthcare Cost Assistance to help with the costs of your premiums and out-of-pocket expenses for your current health insurance plan.

Please give us a call at 1-844-503-7348, 8 am - 6 pm, PST Monday-Friday.

Premium Information

Enter the dollar amount of your premiums below. You should be able to find this information on the bill from your insurance carrier or your Marketplace Eligibility Notice.

To view samples of the Marketplace Eligibility Notice and the premium bill, click here.

If the gross premium amount is not on the premium bill, you can take the premium amount from the premium bill and add it to the Advance Premium Tax Credit (APTC) amount from the Eligibility Notice to get the gross premium amount to enter in the Gross premium field below.

You will get a bill from your insurance carrier once your enrollment or re-enrollment information is processed. Carewell SEIU 503 will need to know your monthly premium information to update the benefits on your Benefit Convenience Card. You should be able to find most of the following information in a letter from your insurance carrier or in your healthcare.gov account.
Insurance plan monthly Advance Premium Tax Credit (APTC or subsidy) amount*
Enter the dollar amount of your APTC here. You should be able to find this information in a letter from your insurance carrier or in your healthcare.gov account or in the Marketplace eligibility notice.
Cascade Care Savings (if you live in Washington) amount *
You should be able to find this information in a letter from your insurance carrier. Cascade Care Savings is a new state-funded premium subsidy program that will lower monthly premium payments for eligible customers starting in 2023. These savings are available exclusively through Washington Healthplanfinder.
Total monthly premium amount (cost of the premium that you pay every month)*
This is the amount calculated based on the amounts you entered above for your base premium and Advance Premium Tax Credit. If you believe the amount of your net premium is incorrect, please double-check your response to the base premium and APTC questions.
Gross premium amount = your total monthly premium + your monthly APTC
Effective health coverage start date *

MonthDayYear
Your start date usually depends on when you select a plan. For plans selected by December 15 during Open Enrollment, coverage starts January 1. For plans selected from December 16 through January 15, coverage starts February 1.When you enroll during a Special Enrollment Period, your coverage generally starts the 1st of the next month. For example, if you select a plan on February 28, your coverage can start March 1.

Household Information

You will be reimbursed only for your portion of the premium, and not the cost for family coverage. Please fill out the information below to alert Carewell SEIU 503 if you have multiple people enrolled on your insurance plan.

Your tax household size is the number of people you claim on your tax return: tax filer + spouse (if any) + tax dependents (if any). It is NOT the number of people who live in your household.

For more information about income and tax household size, click here.
Number of people in your tax filing household:*
Your tax household size is the number of people you claim on your tax return: tax filer + spouse (if any) + tax dependents (if any). It is NOT the number of people who live in your household.
Number of people enrolled in this plan (enter 1 if it's just you):*
If this number is greater than 1, please use the Medical Premium Reimbursement Claim Form (linked at the beginning of this form).
Annual Household Income (as listed on your Eligibility Notice)*

You must submit this form along with these 2 documents:

1. A copy of your Marketplace Eligibility Notice
2. A copy of your premium bill (or sign in to your Healthcare.gov account, go to your 2025 application, and click on "My plans & programs").

To view samples of the Marketplace Eligibility Notice and the premium bill, click here.

Directions on how to add files

If you DO have the files on your device:
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 on your device:
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 “Add Files” on this online form
3. Select the file(s) you would like to attach/add
Attach/add Your Marketplace Eligibility Notice*

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Attach/add Your Premium Bill *

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Healthcare Cost Assistance Benefit Request Terms
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Healthcare Cost Assistance (HCA) Benefits Request Form

Health Coverage Information

Premium Information

Household Information