2027 Carewell Annual Paperwork

Form Name
Carewell 2027 Annual Paperwork

Steps for Healthcare Cost Assistance

Step 1 - Complete and submit this form

By completing the 2027 Annual Paperwork, you’re taking the first step to find a Carewell-approved Marketplace health (medical) insurance plan, and the financial support to put it in place!

This form collects the information needed to support your enrollment on the Marketplace and to help guide you to the steps to request and receive Healthcare Cost Assistance.

Step 2 - Enroll in a Carewell-approved plan on the Marketplace

This paperwork is not an application for health (medical) insurance. You choose a Carewell-approved plan for your area and enroll on the Marketplace.

When you enroll in a Carewell-approved Marketplace plan, you can request Healthcare Cost Assistance benefits. If eligible, this benefit covers 100% of your net monthly individual medical premiums, as well as $8,500 in 2027 for covered out-of-pocket medical expenses. You can self-enroll on the Marketplace, enroll with your own insurance agent, or self-schedule an appointment with one of our partner agents at the end of this form.

Step 3 - Submit required plan documents

Healthcare Cost Assistance participation rules require you to provide proof of your Marketplace plan each year by providing plan information from the Marketplace and/or your insurance carrier.

If you have an enrollment appointment with one of our partner insurance agents, they submit this information for you or help download the documents for you to submit.

Once you have completed the 2027 Annual Paperwork, you can download a PDF of your signed documents.

If you have any questions about this paperwork, call 1-844-503-7348, Monday – Friday, 8 AM – 6 PM PST.

We're here to help!

Contact Information
Name

First NameMiddle InitialLegal Last Name
Mailing address

Street Address

Street Address Line 2

CityState

Zip Code
Is your mailing address the same as your home address?
Home address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Preferred phone number
Format: (000) 000-0000.
Phone type
Is it ok to leave a detailed voice message at this number?

Personal Information
Homecare provider number
Please enter your homecare provider number in the box above. This is usually a 6-digit number. You can find this number on your paystub.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last four digits of Social Security Number (SSN)
Preferred language (dropdown)

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 Health Insurance Marketplace 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 SEIU 503, 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 Health Insurance Marketplace, 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 by providing plan information from the Marketplace and/or my insurance carrier.
  
  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 one of Carewell SEIU 503’s health insurance partner agents, they 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 the Health Insurance Marketplace 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 a portion of the tax credits may be available for them.
- In order to receive Healthcare Cost Assistance from Carewell SEIU 503, I must be enrolled in a Marketplace plan, Medicare, VA, CHAMPVA or TRICARE. I cannot receive Healthcare Cost Assistance for more than one type of coverage. For example, I cannot receive Healthcare Cost Assistance for a Marketplace plan and Medicare, or for VA and Medicare. Once someone becomes eligible for Medicare, they can only receive Medicare Healthcare Cost Assistance.
- If I am currently enrolled in, or become newly eligible for Medicaid, Medicare, employer, spousal, or any other type of health coverage that meets the federal minimum essential coverage (MEC) standards for insurance coverage 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 Carewell SEIU 503 benefits.
- I am responsible for submitting timely and accurate information to the Health Insurance Marketplace, Carewell SEIU 503, and any Carewell SEIU 503 health insurance partner agent (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 Carewell SEIU 503 benefits or Marketplace health insurance.

Next steps to enroll directly on the Marketplace

Next steps to enroll with partner health insurance agency, Valley Insurance Professionals (VIP)

Next steps to enroll with a Russian/Ukrainian-speaking partner health insurance agent

Next steps to enroll with a Cantonese/Mandarin-speaking partner health insurance agent

Next steps when you need assistance to enroll