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How to Apply for Community Health Care Program

There’s a deadline to apply for health care coverage no matter what time of year you apply. It’s important that you submit your application by the Open Enrollment deadlines below.

For a summary of what this plan covers, check out the benefit details.

Open Enrollment 2023

You may apply for Community Health Care Program during the open enrollment period, which runs from November 1, 2022 through January 31, 2023.

To start coverage on: Send your completed paperwork by:
January 1, 2023 December 31, 2022
February 1, 2023 January 31, 2023

1. Fill out this application for health coverage

Kaiser Permanente for Individual and Families Application for Health Coverage
Review our Community Health Care Program Instruction Guide for specific instructions.
Note: Social Security numbers or tax identification numbers are NOT required to apply for the Community Health Care Program, but if you have one please include it on the application.

2. Fill out this form for the Kaiser Permanente Community Health Care Program subsidy. (Be sure to include proof of income when you mail in your application.)

Kaiser Permanente Application for Subsidy form
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:

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 Application for Subsidy form? Find a local organization near you that can help.

3. Send your completed forms and proof of income to one of the following options:

By email: (preferred)
CHC-Applications@kp.org

By Mail:
Kaiser Foundation Health Plan, Inc.
California Service Center
P.O. Box 23127
San Diego, CA 92193-3127

By fax:
1-855-355-5334

Note: Sending your forms to us does not guarantee that your child/children will be approved for the Community Health Care Program. We may ask you for more information to determine eligibility.

When you’ll hear from us: We’ll let you know if we can include you in the Community Health Care Program after we receive and review your completed forms and proof of income.

 

 

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

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