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Virginia

Apply On-Line

You have the option of Applying Online or mailing your application using the instructions below.

You will need the free Adobe Acrobat Reader to read these files. You will not be able to submit these forms via the Internetyou must print the forms, complete them and mail them to the address below.

  1. Complete the Application.
  • Answer all questions completely and accurately.
  • Print, sign, and date the questionnaire.
  • Remember to select the benefit plan of your choice.
  • Include the first month's premium.
  • Premiums are based on the oldest person in the family unit applying for coverage.
  • No forms will be reviewed without the premium.
  1. If you pay by check, please return the completed form to:

    GORDON PAUL
    Kaiser Permanente Personal Advantage Plan
    1368 W. Herndon Avenue, Suite 101
    Fresno, CA 93711


  2. If you pay by credit card, please enter the credit card information on the form and you may fax the completed application to

    1-559-431-0009 Fax

    or you mail mail it to the address above (#2).

Reminder: All questions must be answered and all forms submitted along with the first month's premium to begin the underwriting process. Unanswered questions and/or incomplete forms will result in the application being returned to you.

It will take a full 21 business days, once we receive your application, for a decision regarding your individual membership coverage. You will receive written notification regarding the outcome of our review.
 

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
Eligibility Guidelines

You are applying for health insurance coverage that is subject to medical underwriting.   If you believe that you are HIPAA eligible and have indicated that on your application and if you are denied for the medically underwritten plan, your application will automatically be sent to our HIPAA Department for review.  You may be contacted for further information or verification.

The Health Insurance Portability and Accountability Act was signed by President Clinton in 1996. A significant portion of the law is intended to reduce barriers for Eligible Individuals to obtain health insurance coverage through an individual plan.

Health plan carriers serving the individual market must offer coverage to an eligible individual and may not impose any preexisting condition exclusions with respect to such coverage.

An Eligible Individual is a person who:

  • has had at least 18 months of aggregate Creditable Coverage;
  • has been under a group health plan, a governmental plan, or church plan (or health insurance offered in connection with such plans) during the most recent period of creditable coverage;
  • is not eligible for coverage under a group health plan, Medicare, or Medicaid, and does not have other health insurance coverage;
  • has not had their most recent coverage canceled for nonpayment of premiums or fraud; and
  • has elected and exhausted any option for continuation of coverage ("COBRA" coverage) that was available under the prior plan.

Creditable Coverage means coverage under any of the following:

  • A group health plan;
  • Health insurance coverage;
  • Part A or B of Title XVIII of the Social Security Act (U.S.C. 1395c or 1395);
  • Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), other than coverage consisting solely of benefits under section 1928;
  • Chapter 55 of Title 10, United States Code (10 U.S.C. 1071 et seq.);
  • A medical care program of the Indian Health Service or of a tribal organization;
  • A state health benefits risk pool;
  • A health plan offered under Chapter 89 of Title 5, United States Code (5 U.S.C. 8901 et seq.);
  • A public health plan (as defined in federal regulations); or
  • A health benefit plan under section 5 (e) of the Peace Corps Act (22 U.S.C. 2504(e)).

If you are an Eligible Individual and would like to apply for such coverage, please call (301) 816-6700 for an enrollment kit. If you already have an enrollment kit, mail your signed and completed application along with your Certificate of Credible Coverage in the enclosed business reply envelope.

 

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About Kaiser Permanente Insurance


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