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How to Apply for Community Health Access Program – Important Deadlines

There’s a deadline to apply for Community Health Access Program.

Open Enrollment 2019

You may apply for CHAP during the open enrollment period, which runs from November 1, 2018 through December 15, 2018.

Send completed paperwork by:
December 15, 2018

To start coverage on:
January 1, 2019

Apply for the Community Health Access Program in 3 steps

1. Fill out this application for health coverage

Kaiser Permanente for Individual and Families ApplicationMaryland | Virginia

For the Summary of Benefits and Coverage for the the Gold 0/20 – HMO plan, click here or visit, choose from Maryland or Virginia, then select Gold 0/20 HMO. A paper copy can be obtained at any time without charge by calling Kaiser Permanente Member Services at 1-800-464-4000, TTY 711, 24 hours a day, seven days a week. You’ll need the plan name, which is stated above.

Note: Social Security numbers (SSN) or tax identification numbers (TIN) are NOT required to apply for the Community Health Access Program, but if you have an SSN or TIN please include it on the application.

Need more help filling out the application?
Review our Community Health Access Program Instructions GuideMaryland | Virginia for specific instructions.

2. Fill out this form for the Kaiser Permanente Community Health Access Program subsidy.

Kaiser Permanente Subsidy Eligibility form – Maryland | Virginia

Be sure to include proof of income when you mail in your application. Here are the best ways to show proof of your income:

If you get a paycheck or direct deposit, we need:

  • your last 2 paycheck stubs, or
  • your most recent W-2, or
  • your most recent wage or tax statement

If you work for yourself, we need:

  • a Schedule C and page 1 of your last federal tax return (showing your adjusted gross income), or
  • a completed Profit and Loss Statement form

If you get paid in cash, we need:

  • a signed letter of income from your employer on company letterhead

If you have income from other sources (e.g. social security, unemployment benefits):

  • include documentation showing proof (e.g. a benefit statement)

Need help completing the Subsidy Eligibility form? Find a local organization near you that can help.

3. Mail your completed forms and proof of income to:

Kaiser Foundation Health Plan, Inc.
California Service Center
P.O. Box 939095
San Diego, CA 92193-9095

Note: Mailing your forms to us does not guarantee that you or your family will be approved for the Community Health Access Program. We may ask you for more information to determine your eligibility.

We’ll let you know if we can include you in the Community Health Access Program after we receive and review your completed forms and proof of income.


* Continued eligibility for the Community Health Access Program is not guaranteed. We reserve the right to close enrollment or change the CHAP eligibility requirements at any time.

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