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Fill Out Your Kaiser Senior Enrollment Form

The Kaiser Senior Enrollment Form is a document that allows individuals with Medicare to apply for the Kaiser Permanente Senior Advantage plans. These plans are tailored for eligible seniors seeking comprehensive healthcare options within the Kaiser network. To get started, fill out the form by clicking the button below.

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Fill Out Your Kaiser Senior Enrollment Form

Article Structure

The Kaiser Senior Enrollment form is an essential tool for individuals looking to join the Kaiser Permanente Senior Advantage Plan. This includes both the standard Medicare Advantage Plan and the Medicare Medi-Cal Plan, also known as HMO D-SNP. The form outlines the eligibility requirements, which include being a U.S. citizen or a lawful resident and living within the plan's service area. It's important to note that to enroll, applicants must already be enrolled in Medicare Part A and Part B. The enrollment window generally occurs annually from October 15 to December 7, with specific circumstances allowing for further enrollment opportunities. After submitting the completed form, the application undergoes a review process to ensure all information is accurate. Following that, applicants will receive details about the start of their coverage, as well as necessary materials like their Kaiser Permanente ID card. The form also includes optional sections for additional information, ensuring that individuals provide the necessary details without the pressure of mandatory fields. Moreover, users can opt for the Advantage Plus package, which offers expanded benefits for a modest additional premium. For those needing assistance, contact options are readily available through both Kaiser Permanente and Medicare, making the process user-friendly and well-supported.

Kaiser Senior Enrollment Example

OMB No. 0938-1378

Expires: 7/31/2023

Individual Plan

Kaiser Permanente Senior Advantage (HMO) or

Kaiser Permanente Senior Advantage Medicare Medi-Cal Plan (HMO D-SNP)

Enrollment form

Northern California or Southern California Region Individual Plan

Who can use this form?

People with Medicare who want to join a Medicare		Have you thought about enrolling on
Advantage Plan		kp.org/enrollonline instead? It’s a
Advantage Plan		kp.org/enrollonline instead? It’s a
To join a plan, you must:		fast, secure, and easy way to apply.
To join a plan, you must:

•Be a United States citizen or be lawfully present

	in the U.S.	What happens next?
•	Live in the plan’s service area
Important: To join a Medicare Advantage Plan, you		Send your completed and signed form to:
must also have both:		Kaiser Permanente – Medicare Unit
•	Medicare Part A (Hospital Insurance)	P.O. Box 232400
• Medicare Part B (Medical Insurance)		San Diego, CA 92193-2400
When do I use this form?		•	We’ll review your form to make sure it’s complete.
You can join a plan:		•	We’ll let Medicare know that you’ve applied for
• Between October 15–December 7 each year (for			Senior Advantage.
	coverage starting January 1)	•	Within 10 calendar days after Medicare confirms
•	Within 3 months of first getting Medicare
			you’re eligible, we’ll let you know when your
•	In certain situations where you’re allowed to join
			coverage starts. Then we’ll send you a
	or switch plans
			Kaiser Permanente ID card and information

Visit Medicare.gov to learn more about when you			for new members.
can sign up for a plan.		•	You can check the progress of your application
What do I need to complete this form?			online at kp.org/medicare/applicationstatus
			(does not apply to HMO D-SNP).
• Your Medicare Number (the number on your red,

	white, and blue Medicare card)	How do I get help with this form?
• Your permanent address and phone number		Call Kaiser Permanente at 1-800-443-0815.
Note: You must complete all items in Section 1.
		TTY users can call 711.
The items in Section 2 are optional — you can’t be		Or, call Medicare at 1-800-MEDICARE
denied coverage because you don’t fill them out.
		(1-800-633-4227). TTY users can call 1-877-486-2048.
Reminders:
		En español: Llame a Kaiser Permanente al
•	If you want to join a plan during fall open
		1-800-443-0815/TTY 711 o a Medicare gratis
	enrollment (October 15–December 7), the plan
		al 1-800-633-4227 y oprima el 2 para asistencia
	must get your completed form by December 7.
		en español y un representante estará disponible
•	We will send you a bill for the plan’s premium.
		para asistirle.
	You can choose to sign up to have your premium

payments deducted from your bank account or your monthly Social Security (or Railroad

Retirement Board) benefit.

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According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-NEW. The time required to complete this information is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

IMPORTANT

Do not send this form or any items with your personal information (such as claims, payments, medical records, etc.) to the PRA Reports Clearance Office. Any items we get that aren’t about how to improve this form or its collection burden (outlined in OMB 0938-1378) will be destroyed. It will not be kept, reviewed, or forwarded to the plan. See “What happens next?” on this page to send your completed form to the plan.

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Name

Kaiser Permanente Medical/Health Record Number (for current or past members)

Please contact Kaiser Permanente if you need information in another language or accessible format (Braille).

Section 1 – All fields in this section are required (unless marked optional)

Select the plan you want to join:

Service areas for some plans do not include the full county. Please refer to the Summary of Benefits for detailed information on plan service areas.

SOUTHERN CALIFORNIA:

Senior Advantage Medicare Medi-Cal Plan South (HMO D-SNP) - $30.50 per month

Special Needs Plan (SNP) - For people who are entitled to both Medicare and state Medicaid benefits

Senior Advantage Inland Empire (HMO) - $0 per month Senior Advantage Kern County - Basic (HMO) - $0 per month Senior Advantage Kern County - Enhanced (HMO) - $29 per month

Senior Advantage Los Angeles and Orange Counties (HMO) - $0 per month Senior Advantage San Diego County (HMO) - $0 per month

Senior Advantage Ventura County (HMO) - $0 per month

NORTHERN CALIFORNIA:

Senior Advantage Medicare Medi-Cal Plan North (HMO D-SNP) - $30.50 per month

Special Needs Plan (SNP) - For people who are entitled to both Medicare and state Medicaid benefits

Senior Advantage Alameda County - Basic (HMO) - $24 per month

Senior Advantage Alameda, Napa, and SF Counties (HMO) - $84 per month Senior Advantage Contra Costa County - Basic (HMO) - $24 per month Senior Advantage Contra Costa County - Enhanced (HMO) - $84 per month Senior Advantage Greater Fresno Area - Basic (HMO) - $15 per month Senior Advantage Greater Fresno Area - Enhanced (HMO) - $75 per month Senior Advantage Greater Sac & Sonoma County - Basic (HMO) - $15 per month Senior Advantage Greater Sac & Sonoma County - Enhanced (HMO) - $75 per month Senior Advantage Marin and San Mateo Counties (HMO) - $89 per month

Senior Advantage San Francisco County - Basic (HMO) - $24 per month Senior Advantage San Joaquin County - Basic(HMO) - $15 per month Senior Advantage San Joaquin County - Enhanced (HMO) - $75 per month Senior Advantage Santa Clara County - Basic (HMO) - $15 per month Senior Advantage Santa Clara County - Enhanced (HMO) - $75 per month Senior Advantage Santa Cruz County (HMO) - $79 per month

Senior Advantage Solano County (HMO) - $89 per month

Senior Advantage Stanislaus County - Basic (HMO) - $15 per month Senior Advantage Stanislaus County - Enhanced (HMO) - $75 per month

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Name

Advantage Plus (optional supplemental benefits package):

Would you also like to add Advantage Plus to your Kaiser Permanente Senior Advantage plan? The Advantage Plus

package is optional. For an additional $16 per month, you can add more benefits (dental, hearing, and extra vision coverage). The monthly premium for Advantage Plus will be added to your Kaiser Permanente Senior Advantage monthly premium. Note: This option is not available under the Senior Advantage Medicare Medi-Cal (HMO D-SNP) plans.

Yes No

LAST Name:

FIRST Name:

Birth Date: (mm/dd/yyyy)

Home Phone Number:

Permanent Residence Street Address (P.O. Box is not allowed):

Gender:

Male Female

Middle Initial:

Mobile Phone Number:

- -

City:

County:

State:

ZIP Code:

Mailing Address, if different from your permanent address (PO Box allowed)

Street Address:

City:

State:

ZIP Code:

E-mail Address:

Your Medicare information:

Medicare Number:

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Name

Answer these important questions:

1.Will you have other prescription drug coverage (like VA, TRICARE) in addition to Kaiser Permanente? Yes No

If “yes,” please list your other coverage and your identification (ID) number(s) for this coverage:

Name of other coverage:
ID # for this coverage:	Group # for this coverage:

2. Are you enrolled in your State Medicaid program? Yes No If “yes,” please provide your Medicaid number:

STOP Please Read This Important Information

If you currently have health coverage from an employer or union, joining Kaiser Permanente could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Kaiser Permanente Senior Advantage. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

IMPORTANT: Read and sign below:

•I must keep both Hospital (Part A) and Medical (Part B) to stay in Kaiser Permanente Senior Advantage.

•By joining this Medicare Advantage Prescription Drug Plan, I acknowledge that Kaiser Permanente will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act Statement below).

•Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.

•The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.

•I understand that people with Medicare are generally not covered under Medicare while out of the country, except for limited coverage near the U.S. border.

•I understand that when my Kaiser Permanente Senior Advantage coverage begins, I must get all of my medical and prescription drug benefits from Kaiser Permanente. Benefits and services provided by Kaiser Permanente and contained in my Kaiser Permanente Senior Advantage “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Kaiser Permanente will pay for benefits or services that are not covered.

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Name

•I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this application means that I have read and understand the contents of this application. If signed by an authorized representative

(as described above), this signature certifies that:

1.This person is authorized under State law to complete this enrollment and

2.Documentation of this authority is available upon request by Medicare.

Advantage Plus optional supplemental benefits conditions of enrollment

If you checked “Yes” to add the Advantage Plus optional supplemental benefits package on page 2, please read the information below.

By completing this enrollment application:

•I agree to adding the Advantage Plus optional supplemental benefits package that gives me (dental, hearing, and extra vision coverage) for $16 per month. This amount is in addition to my Medicare and Kaiser Permanente Senior Advantage premiums.

•I understand that the optional supplemental benefits package adds more benefits to my Kaiser Permanente Senior Advantage coverage, and the terms and conditions can be found in the Kaiser Permanente Senior Advantage Evidence of Coverage.

•I understand that the Advantage Plus optional supplemental benefits package is only available to members enrolled in a Kaiser Permanente Senior Advantage Individual Plan.

•I understand that I must get covered care from network providers, except for emergency or urgently needed services.

•I understand that I can stop my Advantage Plus optional supplemental benefits package coverage anytime. If I disenroll, I won’t be eligible to enroll again until the next Advantage Plus optional supplemental benefits package annual election period for coverage that has a start date of January 1 or I have another Special Enrollment Period.

Signature:

Today’s Date:

If you are the authorized representative, you must sign above and provide the following information:

Name:

Address:

Phone Number: -

Relationship to Enrollee:

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Name

Section 2 – All fields in this section are optional

Answering these questions is your choice. You can’t be denied coverage because you don’t fill them out.

Select one if you want us to send you information in a language other than English.

Spanish

Chinese

Select one if you want us to send you information in an accessible format.

Large Print

Braille

Audio CD

Please contact Kaiser Permanente at 1-800-443-0815 if you need information in an accessible format other than what’s listed above. Our office hours are seven days a week, 8 a.m. to 8 p.m. TTY users should call 711.

Do you work?

Yes

Does your spouse work?

Yes

Paying Your Plan Premium

You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail, phone, or online each month. You can also choose to pay your premium by having it automatically taken out of your Social Security or Railroad Retirement Board (RRB) benefit each month.

If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium. The amount is usually taken out of your Social Security benefit or you may get a bill from Medicare (or the RRB). DON’T pay Kaiser Permanente the Part D-IRMAA.

Please select a premium payment option: If you don’t select a payment option, you will get a bill each month. Get a bill

After you receive your first bill, you can choose a different payment option.

•You can have your monthly payment automatically deducted from your bank account. Please call us at

1-888-236-4490 (TTY 711) to request a Medicare Autopay Selection Form or if you have any questions.

•To pay by credit or debit card, visit kp.org/payonline or call us at 1-888-236-4490 (TTY 711). You will need your account information from your bill to make a payment.

Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check.

I get monthly benefits from:

Social Security

RRB

PRIVACY ACT STATEMENT

The Centers for Medicare & Medicaid Services (CMS) collects information from Medicare plans to track beneficiary enrollment in Medicare Advantage (MA) or Prescription Drug Plans (PDP), improve care, and for the payment of Medicare benefits. Sections 1851 and 1860D-1 of the Social Security Act and 42 CFR

§§422.50, 422.60, 423.30 and 423.32 authorize the collection of this information. CMS may use, disclose and exchange enrollment data from Medicare beneficiaries as specified in the System of Records Notice (SORN) “Medicare Advantage Prescription Drug (MARx)”, System No. 09-70-0588. Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.

Office Use Only:

Name of staff member/agent/broker (if assisted in enrollment):

Plan ID #:

Effective Date of Coverage:

ICEP/IEP:

AEP:

SEP (type):

Not Eligible:

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Name

Attestation of Eligibility for an Enrollment Period

Typically, you may enroll in a Medicare Advantage plan only during the annual enrollment period from October 15 through December 7 of each year. There are exceptions that may allow you to enroll in a Medicare Advantage plan outside of this period.

Please read the following statements carefully and check the box if the statement applies to you. By checking any of the following boxes you are certifying that, to the best of your knowledge, you are eligible for an Enrollment Period. If we later determine that this information is incorrect, you may be disenrolled.

I am new to Medicare.

I am enrolled in a Medicare Advantage plan and want to make a change during the Medicare Advantage Open Enrollment Period (MA OEP).

I recently moved outside of the service area for my current plan or I recently moved and this plan is a new option for me.

I moved on (insert date)

I recently was released from incarceration. I was released on (insert date)

I recently returned to the United States after living permanently outside of the U.S. I returned to the U.S. on

(insert date)

I recently obtained lawful presence status in the United States. I got this status on (insert date)

I recently had a change in my Medicaid (newly got Medicaid, had a change in level of Medicaid assistance, or lost Medicaid)

on (insert date)

I recently had a change in my Extra Help paying for Medicare prescription drug coverage (newly got Extra Help, had a change

in the level of Extra Help, or lost Extra Help) on (insert date)

I have both Medicare and Medicaid (or my state helps pay for my Medicare premiums) or I get Extra Help paying for my Medicare prescription drug coverage, but I haven’t had a change.

I am moving into, live in, or recently moved out of a Long-Term Care Facility (for example, a nursing home or long-term care

facility). I moved/will move into/out of the facility on (insert date)

I recently left a PACE program on (insert date)			/			/
I recently left a PACE program on (insert date)			/			/

I recently involuntarily lost my creditable prescription drug coverage (coverage as good as Medicare’s). I lost my drug

coverage on (insert date)

I am leaving employer or union coverage on (insert date) /

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Name

I belong to a pharmacy assistance program provided by my state.

My plan is ending its contract with Medicare, or Medicare is ending its contract with my plan.

I was enrolled in a plan by Medicare (or my state) and I want to choose a different plan. My enrollment in that plan started on

(insert date)

I was enrolled in a Special Needs Plan (SNP) but I have lost the special needs qualification required to be in that plan. I was

disenrolled from the SNP on (insert date) /

I was affected by an emergency or a major disaster as declared by a Federal, state, or local government entity. One of the other statements here applied to me, but I was unable to make my enrollment because of the natural disaster.

I am in a plan that was recently taken over by the state because of financial issues. I want to switch to another plan.

I am in a plan that’s had a star rating of less than 3 stars for the last 3 years. I want to join a plan with a star rating of 3 stars or higher.

If none of these statements applies to you or you’re not sure, please contact Kaiser Permanente at 1-800-443-0815 (TTY users should call 711) to see if you are eligible to enroll. We are open seven days a week, from 8 a.m. to 8 p.m.

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Get Kaiser Senior Enrollment PDF Form

Form Characteristics

Fact Name	Detail
Governing Laws	Medicare Advantage Plans are governed by Title XVIII of the Social Security Act.
Eligibility Criteria	Applicants must be U.S. citizens or lawfully present, reside in the plan's service area, and maintain Medicare Part A and Part B.
Application Period	The enrollment occurs between October 15 and December 7 each year for coverage starting January 1.
Submission Details	Completed forms should be sent to the Kaiser Permanente Medicare Unit at P.O. Box 232400, San Diego, CA 92193-2400.
Contact Information	For assistance, call Kaiser Permanente at 1-800-443-0815 or Medicare at 1-800-MEDICARE.

Guidelines on Utilizing Kaiser Senior Enrollment

Filling out the Kaiser Senior Enrollment form is an important step in choosing the right health plan for your needs. After completing this form, it will be sent to Kaiser Permanente for processing. They will check the form for completeness and inform you about your coverage start date and provide essential membership information.

Begin with Section 1, where all fields are mandatory. Indicate which plan you would like to join by selecting the appropriate option based on your region.
Next, fill in your personal information: last name, first name, middle initial, and birth date. Provide your permanent residence street address, email address, gender, and phone numbers.
Enter your Medicare Number, found on your Medicare card, ensuring that all numbers are accurate.
Answer the important questions regarding any additional prescription drug coverage and whether you are enrolled in your State Medicaid program.
If prompted, decide if you want to add the optional Advantage Plus benefits package by selecting "Yes" or "No." You will need to include the additional amount in your monthly premium.
Review the important information section. Carefully read the terms, ensuring you understand the implications of joining Kaiser Permanente, including the requirement to keep both Medicare Part A and Part B.
Sign and date the form. By signing, you acknowledge that all information provided is true and that you understand the terms outlined in the form.
Make a copy of your completed form for your records before submitting it.
Finally, mail the completed and signed form to the designated address provided for Kaiser Permanente's Medicare Unit.

What You Should Know About This Form

What is the Kaiser Senior Enrollment form used for?

The Kaiser Senior Enrollment form is specifically designed for individuals who have Medicare and wish to enroll in a Medicare Advantage Plan offered by Kaiser Permanente. These plans include options like the Kaiser Permanente Senior Advantage (HMO) and the Medicare Medi-Cal Plan (HMO D-SNP). It allows applicants to provide necessary information and express their choice of plans while ensuring that all required criteria are met.

Who is eligible to use the Kaiser Senior Enrollment form?

To use this form, individuals must meet certain eligibility criteria. First, they must be citizens of the United States or legally residing in the country. Second, they must reside within the service area of the plan selected. Additionally, applicants must have both Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) to be eligible for enrollment in a Medicare Advantage Plan.

When can one submit the Enrollment form?

The Enrollment form can be submitted during specific periods. Generally, the annual open enrollment period runs from October 15 to December 7 each year, with coverage starting on January 1. Additionally, individuals can submit their enrollment request within three months of initially becoming eligible for Medicare. There are also certain exceptional situations that may allow for enrollment or plan changes outside these general windows.

What information is required to complete the form?

To successfully complete the Enrollment form, applicants need to provide their Medicare Number, which is found on their Medicare card. Along with that, other essential information, such as permanent address, phone number, and personal identification details like name and birth date, is required. Section 2 of the form contains optional information, and not filling this section will not affect eligibility.

How can one receive assistance with the Enrollment form?

Help is readily available for those needing assistance with the Enrollment form. Applicants can call Kaiser Permanente's customer service at 1-800-443-0815. For those using TTY services, the number is 711. Medicare also offers support at 1-800-MEDICARE (1-800-633-4227). Spanish-speaking representatives are available as well, providing assistance in another language if needed.

What happens after submitting the Enrollment form?

Once an individual has submitted the completed Enrollment form, Kaiser Permanente will review it to ensure that it is complete. The organization will then inform Medicare about the enrollment application. If everything is in order and the applicant is confirmed eligible, the new member will receive a notification regarding the start date of their coverage, as well as a Kaiser Permanente ID card. Applicants can monitor their application’s status online at kp.org/medicare/applicationstatus.

Common mistakes

Filling out the Kaiser Senior Enrollment form can be straightforward, but mistakes can lead to delays or issues in enrollment. A common mistake is not signing the form. All applicants must provide their signature to confirm the accuracy of the information provided. Without a signature, the application will be considered incomplete and may not be processed.

Another frequent error is providing an incorrect Medicare Number. This number is essential for verification and enrollment. Double-checking the number for accuracy can save time and avoid unnecessary back-and-forth communication with Kaiser Permanente.

Some individuals forget to complete Section 1, which is mandatory. All fields in this section must be filled out, including name, address, and phone number. Leaving even one item blank can lead to a rejection of the application. Remember that all personal information should be accurate and up to date.

Many applicants also make the mistake of using a P.O. Box for their permanent address. The form specifically states that a physical street address is required. Using a P.O. Box can result in denial of the application or failure to receive important documents in a timely manner.

In addition, failure to check the preferred plan options can cause issues. People might accidentally select a plan that does not match their eligibility or needs. It’s crucial to review the available plans carefully and select the one that fits best before submitting the form.

Some skip reading the instructions and important information listed on the form. Ignoring these details can lead to misunderstandings, such as deadlines for submission or premium payment options. Taking the time to read the guidance can provide clarity and prevent mistakes.

It’s also vital to ensure the contact information is correct. If the phone number or email address is incorrect, Kaiser Permanente will not be able to reach the applicant for follow-up questions or confirmation of enrollment.

Finally, people sometimes overlook the optional questions in Section 2. While answering these is not mandatory and will not affect enrollment, providing additional information can lead to better service and more personalized care. Filling out as much information as possible is recommended.

Documents used along the form

The Kaiser Senior Enrollment form is an essential document for individuals looking to enroll in a Kaiser Permanente Senior Advantage Plan. However, it often accompanies other important forms that ensure a smooth enrollment and transition into the plan. Below is a list of additional forms that may be needed during this process.

Medicare Part A and Part B Enrollment Forms: These forms are necessary if you are not yet enrolled in Medicare parts A and B. Completing these forms is crucial for being eligible for Kaiser’s Medicare Advantage Plans.
Kaiser Permanente Evidence of Coverage (EOC): This document outlines the benefits, services, and limitations of the Kaiser plan. Understanding this information helps you make informed decisions about your healthcare coverage.
Kaiser Permanente Authorization to Disclose Health Information: By signing this form, you allow Kaiser to share your health information with designated individuals. This can be vital for family members or caregivers who need access to your medical history.
Medicare Advantage Plan Enrollment Guide: This guide provides detailed instructions on how to enroll in a Medicare Advantage Plan. It offers tips on the enrollment process, deadlines, and plan options available to you.

Having these additional documents ready can help prevent delays in your enrollment and ensure that you have a clear understanding of your coverage. Taking action promptly will bring you one step closer to receiving the care you need.

Similar forms

The Kaiser Senior Enrollment form shares similarities with several other documents related to health insurance enrollment. Here are ten such documents:

Medicare Enrollment Form: This form is used for individuals who want to enroll in Medicare plans, outlining eligibility requirements and necessary personal information.
Medicaid Application: Similar in purpose, this application is for those seeking Medicaid coverage, requiring details about income and residency.
Medicare Part D Enrollment Form: This form allows seniors to enroll in prescription drug coverage and gathers similar health insurance information and eligibility.
Special Needs Plan (SNP) Application: Like the Kaiser Enrollment form, this document caters to individuals with specific health needs, detailing eligibility criteria and covering important personal information.
Health Insurance Marketplace Application: Used to enroll in healthcare plans under the Affordable Care Act, this application similarly collects demographic information and income details.
Retirement Health Benefits Enrollment Form: This document is for retirees enrolling in health benefits offered by their previous employer, focusing on service area and eligibility as well.
Long-Term Care Insurance Application: Similar to the Kaiser Senior Enrollment form, it gathers personal and medical information to determine eligibility for long-term care coverage.
VA Health Care Enrollment Form: This form is used by veterans for accessing health care services, collecting comparable information regarding service area residency and personal data.
Supplemental Health Insurance Application: This document is used by individuals looking to enhance their existing health coverage, requiring similar eligibility and personal information.
Group Health Insurance Enrollment Form: For those enrolling in employer-sponsored plans, this form collects relevant information and eligibility, paralleling the Kaiser Enrollment process.

Dos and Don'ts

Things to Do When Filling Out the Kaiser Senior Enrollment Form:

Complete all required fields in Section 1 accurately, including your Medicare Number.
Double-check your contact information to ensure it is current and correctly formatted.
Read the instructions carefully, making sure you understand each step.
Consider enrolling online at kp.org/enrollonline for a faster process.
Review your form before submission to correct any errors or omissions.

Things to Avoid When Filling Out the Kaiser Senior Enrollment Form:

Do not leave any required fields blank; incomplete forms can delay processing.
Avoid submitting personal information, like medical records or payment information, to the PRA Reports Clearance Office.
Do not rush through the form; taking your time can prevent mistakes.
Do not use a P.O. Box for your permanent address, as it is not permitted.
Refrain from providing inaccurate information, as it may lead to disenrollment from the plan.

Misconceptions

Misconception 1: All people with Medicare can use this form.

This form is specifically designed for individuals who are both eligible for Medicare and wish to enroll in Kaiser Permanente's Medicare Advantage plans. Only U.S. citizens or those legally present in the U.S. can apply using this form.

Misconception 2: You can submit any extra information with the enrollment form.

The instructions clearly state that personal information, such as claims, payments, or medical records, should not be submitted to the PRA Reports Clearance Office. Doing so could lead to the documents being destroyed.

Misconception 3: The enrollment period is open year-round.

Enrollment for Kaiser Permanente’s plans typically occurs during specific periods, primarily between October 15 and December 7 each year. There are also other limited opportunities based on certain life events.

Misconception 4: Section 2 of the form is mandatory.

Section 2 contains optional items. A person can omit this information without risking denial of coverage. Only Section 1 must be completed in full.

Misconception 5: Only your Medicare Number is necessary for enrollment.

While your Medicare Number is a required item, the form also asks for other personal details, including your address and phone number, which are essential for completing the enrollment.

Misconception 6: You cannot enroll if you have other prescription drug coverage.

Having additional prescription drug coverage is not a barrier to joining Kaiser Permanente. However, the form requires you to disclose any other coverage you have during the enrollment process.

Key takeaways

Eligibility Requirements: To fill out the Kaiser Senior Enrollment form, you need to be a U.S. citizen or lawfully present, and reside within the plan’s service area.
Medicare Coverage: You must have both Medicare Part A and Part B before enrolling in a Medicare Advantage Plan.
Application Period: The open enrollment period for joining a plan runs from October 15 to December 7 each year. Submit your completed form by December 7 to get coverage starting January 1.
Optional Information: While some sections of the form require completion, others are optional. Not filling them out won’t impact your eligibility.
Submission Process: After completing the form, send it to Kaiser Permanente’s Medicare Unit in San Diego, CA. Ensure it is signed and dated before submission.
Check Your Status: You can track your application’s progress online at kp.org/medicare/applicationstatus. Keep in mind this does not apply to HMO D-SNP applications.
Billing Options: Kaiser Permanente will send you a bill for your plan's premium. You can choose to have it automatically deducted from your bank account or from your Social Security benefits.
Help Is Available: If you need assistance while filling out the form, call Kaiser Permanente at 1-800-443-0815 or Medicare at 1-800-MEDICARE.

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