2024 Non-VIP Annual Paperwork

HIPAA Authorization Form
The Health Insurance Portability and Accountability Act (HIPAA) was signed into law in 1996. The purpose of this law is to establish national standards to protect individuals' personally identifiable information and to set out rules for all those who may access this information. We have you review and sign this form annually so you know what kind of data will be collected, who might have access to it, and how it will be disclosed while we assist you in enrolling in health insurance and participating in the Healthcare Cost Assistance Program.

1. WHAT MAY BE COLLECTED AND/OR DISCLOSED?

All information provided on your application for health insurance and/or enrollment is considered your protected health information, whether via website enrollment, direct enrollment, phone enrollment, or on paper, including information on all members of your tax filing household, and all past, present, and future periods of health care information (as defined by HIPAA).

2. WHO IS AUTHORIZED TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION?

There are several partners who work together to ensure the Healthcare Cost Assistance Program Benefits are administered successfully. This may include Valley Insurance Professionals, Inc., our licensed insurance partner, who may collect your protected health information through the process of assisting you or your family to apply for health insurance, RISE Partnership, Carewell SEIU 503 Benefits, the Oregon Homecare Workers Supplemental Trust, the Oregon Homecare Workers Benefit Trust and their providers. Your protected health information may be shared between the partners listed above, as well as with any applicable state or federal insurance marketplace or insurance exchange, or insurance company or carrier, as necessary to apply for, renew or service your insurance coverage, or administer your benefits for the Healthcare Cost Assistance Program.

3. WHAT IS THE PURPOSE OF THE USE OR DISCLOSURE OF MY INFORMATION?

Your information may be used or disclosed to assist RISE Partnership, Carewell SEIU 503 Benefits, the Oregon Homecare Workers Supplemental Trust and the Oregon Homecare Workers Benefit Trust in the administration of your benefits under the applicable Trusts.

4. HOW LONG IS THIS AUTHORIZATION VALID?

This Authorization Form is valid beginning the date of this Agreement and expires ten years from the date of execution of this Authorization Form.

5. ACKNOWLEDGMENT

I understand that the information used or disclosed under this Authorization Form may be subject to re-disclosure by the person(s) or facility receiving it, subject to the federal privacy regulation. I have the right to refuse to sign this Authorization Form; however, I understand my refusal may impact my ability to obtain Healthcare Cost Assistance. If signed, I have the right to revoke this authorization, in writing, at any time. I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions. I further understand that if I have a spouse, child(ren) or other members of my tax filing household listed on my application for health insurance, their personally identifiable information (PII) may also be disclosed to the entities listed above. I acknowledge that I have informed my spouse, child(ren) or other members of my tax filing household of this disclosure.
Care Provider Signature*

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Statement of Understanding

Relating to Oregon Homecare Workers Supplemental Trust ("Trust")
I, the undersigned, hereby understand that:*

The Trust does not provide employer-sponsored or "group" medical coverage. Medical insurance obtained through the Marketplace is 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.My Protected Health Information may be shared between the Trust, RISE Partnership, Carewell SEIU 503 Benefits and their partners for the purpose of administering the Healthcare Cost Assistance benefit available under the Trust to eligible care providers.In order to receive Healthcare Cost Assistance from the Trust, I must select a health insurance plan that has been approved by the Board of Trustees, that is based on my location, and I must continue to meet the Trust’s eligibility requirementsThe Trust requires that if I qualify for an Advance Premium Tax Credit (APTC), I must elect to receive monthly APTC from the federal government and I must apply the full amount of each monthly APTC to the premium for the Trust approved health insurance plan in which I enroll.The Trust will NOT provide Healthcare Cost Assistance for my spouse or dependents, even though APTC may be available for them.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 Carewell SEIU 503 Benefits and the Trust at (844) 503-7348, or I can visit CarwellSEIU503.org for more contact options.IT IS MY RESPONSIBILITY TO PAY MY PREMIUMS. I further understand that, according to Marketplace rules, past due premiums owed to my insurance carrier must be paid before my next plan’s coverage will begin (effectuate). If my premiums change, I understand that I must submit my new premium information to the Trust.I must review and respond to all notices I receive throughout the year from the Health Insurance Marketplace, my health insurance carrier, the Trust, RISE Partnership and Carewell SEIU 503 Benefits to ensure there is no delay or interruption in my health insurance and/or Trust benefits.I am responsible for submitting accurate information to the Health Insurance Marketplace, Carewell SEIU 503 Benefits and the Trust, and failure to do so could result in a delay of 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.

Statement of Understanding

Continued
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:

I understand that when I sign or authorize my health insurance application, I do so under penalty of perjury, which means I have provided 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 understand that I am not eligible to be enrolled in a Marketplace plan if I am enrolled in Medicare Part A and/or B.I know that I must tell the Health Insurance Marketplace if anything changes or is different than what I provide on my application within 60 days of the change. I may visit HealthCare.gov or call 1-800-318-2596 to report any changes. I understand that a change in my information could affect my eligibility, and the eligibility of member(s) of my household. I understand that these changes must also be reported to Carewell SEIU 503 Benefits and the Trust.To make it easier to determine my eligibility for help paying for health coverage in future years, I have the option to allow the Marketplace to use income data, including information from my tax returns, for the next 5 years (the maximum number of years allowed). The Marketplace will send me a notice and let me make any changes, and I can opt out at any time. If I choose to opt out, I understand my Qualified Health Plan may not auto-enroll the following year, so I must take action each year during Open Enrollment to ensure I am enrolled in health insurance coverage.
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2024 Non-VIP Annual Paperwork

Your Contact Information

HIPAA Authorization Form

Statement of Understanding

Statement of Understanding