Carewell SEIU 503 Healthcare Cost Assistance (HCA) benefits help care providers enrolled in a Carewell-approved Marketplace plan to pay for individual health (medical) insurance premiums and eligible out-of-pocket medical expenses.

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

Use this form to request HCA benefits if you are:

• Do not have access to other forms of health insurance coverage.
• Are newly eligible for Carewell benefits and requesting HCA benefits for the first time. 
• Are continuing to use HCA benefits. This form must be submitted every year for approval.
• Are reporting new premium information (either yearly, regaining eligibility, or any time your premium amount changes).
• Are updating name or address (must also be updated with payroll vendor and the Marketplace). 
• Are 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:

1. A copy of your Marketplace Eligibility Notice

2. A copy of your premium bill or My plans & programs page from your HealthCare.gov account

Since the Providence premium bills do not contain the plan name, if Providence is your insurance carrier, you need to submit:

• The “My plans & programs” page; or
• Your letter that has your plan name and premium breakdown from Providence or the Marketplace (HealthCare.gov).

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

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.

Contact Information

 

Health Coverage Information

 

To request Healthcare Cost Assistance benefits for your Carewell-approved Marketplace plan, 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 into your Healthcare.gov account, go your 2024 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

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:

• In order to receive Healthcare Cost Assistance from Carewell SEIU 503, I must select a health insurance Marketplace plan that has been approved by Carewell SEIU 503, which is based on my location. I must also continue to meet Carewell SEIU 503's eligibility requirements.
• Carewell SEIU 503 does not provide employer-sponsored or "group" medical coverage. Medical insurance obtained through the Marketplace (HealthCare.gov) is considered individual or family coverage. If I move, stop doing homecare or personal support work, my hours change, I become eligible for other coverage, or I enroll in a plan not approved by Carewell, my insurance is not automatically canceled. However, these events may impact my eligibility to receive Healthcare Cost Assistance from Carewell SEIU 503.
• Carewell SEIU 503 provides a Benefit Convenience Card ("BCC") for me to use, to pay my monthly premium payments (if applicable), and to pay for covered out-of-pocket medical expenses, up to the annual BCC allowance amount. The out-of-pocket expenses include the deductible on my approved Marketplace plan, and medical copayments and medical 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 am held liable for that overpayment and am obligated to repay those unauthorized charges back to Carewell SEIU 503. (See the Overpayments section in the Carewell SEIU 503 Guide to Training and Benefits.)
• 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 (HealthCare.gov), it is my responsibility to pay those premium payments each month out of my own funds.
• 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, Carewell SEIU 503's rules require that I provide proof of my enrollment each year. There are 2 ways to provide this proof.

  1) I can use Carewell SEIU 503’s partner, Valley Insurance Professionals (VIP), to help me enroll, and then VIP sends my enrollment information to Carewell SEIU 503 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 program” page from my 2026 Marketplace (HealthCare.gov) application.

  If I do not provide these supporting documents, I understand that my Benefit Convenience Card will be turned off until the required documents are submitted and approved.
• Carewell SEIU 503 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. I must then apply the Tax Credits toward the premium for the Carewell SEIU 503 approved health insurance plan I enroll in. If I do not apply the full amount of Tax Credits toward the premium, I may be required to reimburse Carewell SEIU 503 at tax time. (See the Overpayments section in the Carewell SEIU 503 Guide to Training and Benefits).
• If I use VIP's enrollment services, VIP may provide my Protected Health Information (PHI) to Carewell SEIU 503, RISE Partnership, and Carewell SEIU 503's other providers, for the purpose of administering the Healthcare Cost Assistance benefits available under Carewell SEIU 503 to eligible care providers.
• IT IS MY RESPONSIBILITY TO MAKE PAYMENTS TO MY INSURANCE CARRIER FOR MY HEALTH (MEDICAL) PREMIUMS. If my premiums change, I understand that I must submit my new premium information to Carewell SEIU 503, along with the required documentation.
• According to Marketplace (HealthCare.gov) rules, past due premiums owed to my insurance carrier must be paid before my coverage for the next plan year begins.
• Carewell SEIU 503 does NOT provide Healthcare Cost Assistance for my spouse or dependents, even though Tax Credits may be available for them.
• In order to receive Healthcare Cost Assistance under Carewell SEIU 503, 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 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 the Marketplace (HealthCare.gov), Carewell SEIU 503, and VIP (if applicable). 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 benefits and does not enroll me in Trust benefits or Marketplace health insurance.