RCUH Policies and Procedures
Kaiser Permanente Senior Advantage (HMO)
Enrollment form Hawaii Region Group Plan
Filling out and returning the enrollment form is your first step to becoming a Kaiser Permanente Senior Advantage member. If you and your spouse are both applying, you’ll each need to fill out a separate form. For help completing the enrollment form, call our Member Services at 1-800-805-2739 (TTY 711), seven days a week, 8 a.m. to 8 p.m.
How to fill out this form
1. Answer all questions and print your answers using black or blue ink. Fill in check boxes with an X.
2. Sign the form on page 7 and date it. Make sure you’ve read all the pages before you sign.
3. Mail the original, signed form to:
Kaiser Permanente – Medicare Unit
P.O. Box 232407
San Diego, CA 92193-9914
4. Make a copy for your records. If required, submit a copy to your employer group, union or trust fund.
We’ll review your form to make sure it’s complete. Then we’ll let you know by mail that we’ve received it.
We’ll let Medicare know that you’ve applied for Senior Advantage.
Within 10 calendar days after Medicare confirms your enrollment, we’ll first let you know the start date for your coverage. Next, we will send you a Kaiser Permanente ID card and your new member package within 10 days of your start date.
To check on the status of your application, please visit kp.org/medicare/applicationstatus.
HI – Senior Advantage – Group
Employer Group Use Only
Please provide receipt date of form in this section when submitting on behalf of employee/retiree.
Employer Group #: Employer Receipt Date:
Please contact Kaiser Permanente if you need information in another language or accessible format (Braille).
To Enroll in Kaiser Permanente Senior Advantage, Please Provide the Following Information
Employer or Union Name: Group #:
FIRST Name: Middle Initial: Gender:
Are you a current or former member of any Kaiser Permanente
health plan? Yes No If yes: Current Former
Kaiser Permanente Medical/Health Record Number:
Permanent Residence Street Address (P.O. Box is not allowed):
County: State: ZIP Code:
Home Phone Number: Mobile Phone Number: Birth Date: (mm/dd/yyyy)
– – – – / /
Mailing Address (only if different from your Permanent Residence Address)
City: State: ZIP Code:
Page 1 of 7
HI – Senior Advantage – Group
Last Name First Name
Please Provide Your Medicare Insurance Information
Please take out your red, white and blue Medicare card to
complete this section.
• Fill out this information as it appears on your
– OR –
• Attach a copy of your Medicare card or your letter from
Social Security or the Railroad Retirement Board.
Name (as it appears on your Medicare card):
Is Entitled To: Effective Date:
HOSPITAL (Part A)
MEDICAL (Part B)
You must have Medicare Part B, however most employer groups
require both Parts A and B to join a Medicare Advantage plan.
Please Read and Answer These Important Questions
1. Do you or your spouse work? Yes No
2. Are you the retiree? Yes No
If no, name of retiree:
3. Are you covering a spouse or dependents under this employer or union plan? Yes No
Name(s) of dependent(s):
4. Some individuals may have other drug coverage, including other private insurance, Worker’s Compensation, VA benefits, or
State pharmaceutical assistance programs.
Will you have other prescription drug coverage in addition to Kaiser Permanente? Yes No
If yes, please list your other coverage and your identification (ID) number(s) for that coverage.
Name of other coverage: ID # for other coverage:
HI – Senior Advantage – Group
Last Name First Name
5. Are you a resident in a long-term care facility, such as a nursing home? Yes No
If yes, please provide the following information:
Name of institution:
Address of institution (number and street): Phone Number:
6. Requested effective date (subject to CMS approval): / /
Please check one of the boxes below if you would prefer that we send you information in an accessible format:
Large Print Braille CD
Please contact Kaiser Permanente at 1-800-805-2739 if you need information in an accessible format or language other than what
is listed above. Our office hours are seven days a week, 8 a.m. to 8 p.m. TTY users should call 711.
Please complete the information below
If you currently have Kaiser Permanente coverage through more than one employer or union/trust fund, you must choose ONE
employer or union/trust fund from which to receive your Senior Advantage coverage. Complete the information for that employer
or union/trust fund below.
Employer Group/Union/Trust Fund Name:
Employer Group/Union/Trust Fund ID #: Subgroup: Requested effective date (subject to CMS approval):
Please Read and Sign Below
By completing this enrollment application, I agree to the following:
Kaiser Permanente is a Medicare Advantage plan and has a contract with the Federal government. I will need to keep my
Medicare Part B, however most employer groups require both Parts A and B. I can only be in one Medicare Advantage plan at a time and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan. It is my responsibility to inform you of any prescription drug coverage that I have or may get in the future. I understand that if I don’t have Medicare prescription drug coverage, or creditable prescription drug coverage (as good as Medicare’s), I may have to pay a late enrollment penalty if I enroll in Medicare prescription drug coverage in the future. I may leave this plan at any time by sending a request to Kaiser Permanente or by calling 1-800-MEDICARE (1-800-633-4227 or TTY 1-877-486-2048), 24 hours a day, 7 days a week. However, before I request disenrollment, I will check with my group or union/trust fund to determine if I am able to continue my group membership.
I understand that if I currently have Kaiser Permanente coverage through more than one employer or union/trust fund, I must choose one of these coverage options for my Senior Advantage plan because I can be enrolled in only one Senior Advantage plan at a time. My other employer or union/trust fund may allow me to enroll in one of their non-Medicare plans as well. I will contact the benefit administrators at each of my employers or union/trust funds to understand the coverage that I am entitled to before I make a decision about which employer’s or union/trust fund’s plan to select for my Senior Advantage plan.
HI – Senior Advantage – Group
Last Name First Name
Kaiser Permanente serves a specific service area. If I move out of the area that Kaiser Permanente serves, I need to notify the plan so I can disenroll and find a new plan in my new area. Once I am a member of Kaiser Permanente, I have the right to appeal plan decisions about payment or services if I disagree. I will read the Senior Advantage Evidence of Coverage document from Kaiser Permanente when I receive it in order to know which rules I must follow to get coverage with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited coverage near the U.S. border.
I understand that beginning on the date Senior Advantage coverage begins, I must get all of my health care from
Kaiser Permanente, except for emergency or urgently needed services or out-of-area dialysis services.
Services authorized by Kaiser Permanente and other services contained in my Senior Advantage Evidence of Coverage
document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER
MEDICARE NOR KAISER PERMANENTE WILL PAY FOR THE SERVICES.
I understand that if I am getting assistance from a sales agent, broker, or other individual employed by or contracted with Kaiser Permanente, he/she may be paid based on my enrollment in Kaiser Permanente.
Release of Information
By joining this Medicare health plan, I acknowledge that the Medicare health plan will release my information to Medicare and other plans as necessary for treatment, payment and health care operations. I also acknowledge that Kaiser Permanente will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable Federal statutes and regulations. 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 my signature (or the signature of the person authorized to act on my behalf under the laws of the State where I live) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (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 from Medicare.
KAISER FOUNDATION HEALTH PLAN, INC., ARBITRATION AGREEMENT FOR THE HAWAII REGION
If you want to pursue a claim that is not resolved by other procedures described in this section, any and all claims, disputes, or causes of action arising out of or related to this Agreement, its performance or alleged breach, or the relationship or conduct of the parties, including but not limited to any and all claims, disputes, or causes of action based on contract, tort, statutory law, or actions in equity, shall be resolved by binding arbitration as set forth in this Agreement. Claims subject to the Medicare appeals process are not subject to binding arbitration.
By enrolling in Kaiser Permanente Senior Advantage, you waive all rights to have these types of claims decided in a court of law. The arbitrator’s decision is binding. This includes, but is not limited to, any claim asserted:
1. By or against you, or a member, the heirs or the personal representative of your estate or the member’s estate, or any other person entitled to bring an action for damages for harm to you or a member as permitted by applicable federal or Hawaii state law existing at the time the claim is filed (“Member Parties”). For purposes of this section, all family members of you or of the member who have derivative claims arising from such harm, shall also be deemed “Member Parties” and bound to these arbitration terms.
2. On account of death, bodily injury, physical ailment, mental disturbance, or economic loss arising out of the rendering or failure to render medical services or the provision or failure to provide benefits under this Agreement, premises liability, or arising out of any other claim of any nature, irrespective of the legal theory upon which the claim is asserted; and
3. By or against one or more of the following entities or their employees, officers or directors (“Kaiser Permanente Parties”):
(i) Kaiser Foundation Health Plan, Inc.
(ii) Kaiser Foundation Hospitals,
(iii) Hawaii Permanente Medical Group, Inc.,
(iv) The Permanente Federation, LLC,
(v) Any individual or organization that contracts with an organization named in (i), (ii), (iii), or (iv) above to provide services to you or a member, when such contract includes a provision requiring arbitration of the claim made.
Last Name First Name
Claims not subject to binding arbitration
Notwithstanding any provisions to the contrary in this Agreement, the following claims shall not be subject to mandatory arbitration:
1. Claims for monetary damages within the jurisdictional limit of the Small Claims Division of the District Courts of the State of Hawaii;
2. Actions for appointment of a legal guardian of a person or property subject to probate laws;
3. Purely injunctive orders reasonably necessary to protect Kaiser Permanente’s ability to safely render medical services under this Agreement (such as temporary restraining orders, and emergency court orders);
4. For members of private employer Groups, claims for benefits under Section 502(a)(1)(B) of the Employee Retirement Income Security Act (ERISA); and/or
5. Claims subject to the Medicare appeals process.
A demand for arbitration shall be initiated by sending a registered or certified letter to each named party against whom the claim is made, with a notice of the existence and nature of the claim, the amount claimed and a demand for arbitration. Any Kaiser Permanente Parties shall be served by registered or certified letter, postage prepaid, addressed to the Kaiser Permanente Parties in care of the Health Plan at the address set forth in Chapter 2 of the Hawaii Kaiser Permanente Senior Advantage Evidence of Coverage. The arbitrators shall have jurisdiction only over persons and entities actually served.
Within 30 days after the service of the demand for arbitration, the parties shall agree on a panel of arbitrators from which to select arbitrators or shall agree on particular arbitrators who shall serve for the case. If the parties cannot agree on any panel of arbitrators or particular arbitrators within the 30 days, then the panel of arbitrators shall be that of Dispute Prevention and Resolution, Inc. (“DPR”). Unless the parties agree to any other arbitration service and rules, DPR shall administer the arbitration and its arbitration rules shall govern the arbitration (including rules for selection of arbitrators from a panel of arbitrators, if the parties have not already agreed upon particular arbitrators to serve). Kaiser Permanente shall notify DPR (or such other arbitration service as may be
chosen by the parties) of the arbitration within 15 days following the expiration of the 30-day period noted above.
Within 30 calendar days after notice to DPR, the parties shall select a panel of three arbitrators from a list submitted to them by the arbitration service. In all claims seeking a total monetary recovery less than $25,000.00, and in any other case where the parties mutually agree, a panel of one arbitrator selected by both parties from a list submitted to them by the arbitration service will be allowed. The arbitrator(s) shall arrange to hold a hearing in Honolulu (or such other location as agreed by the parties) within a reasonable time thereafter.
Limited civil discovery shall be permitted only for:
1. Production of documents that are relevant and material,
2. Taking of brief depositions of treating physicians, expert witnesses and parties (a corporate party shall designate the person to be deposed on behalf of the corporation), and a maximum of three other critical witnesses for each side (i.e., respondents or claimants), and
3. Independent medical evaluations. HI – Senior Advantage – Group Page 5 of 7
The arbitrator(s) will resolve any discovery disputes submitted by any party, including entry of protective orders or other discovery orders as appropriate to protect the parties’ rights under this paragraph.
Any payment for the fees and expenses of the arbitration service and the arbitrator(s) shall be borne one-third by the Member Parties and two-thirds by the Kaiser Permanente Parties.
Each party shall bear their own attorney’s fees, witness fees, and discovery costs.
The arbitrator(s) may decide a request for summary disposition of a claim or particular issue, upon request of one party to the proceeding with notice to all other parties and a reasonable opportunity for the other parties to respond. The standards applicable to such request shall be those applicable to analogous motions for summary judgment or dismissal under the Federal Rules of Civil Procedure.
In claims involving benefits and coverage due under this Agreement or disputes involving operation of the Plan, Health Plan’s determinations and interpretations, and its decisions on these matters are subject to de novo review.
The arbitration award shall be final and binding. You, the Member Parties and Kaiser Permanente Parties waive your/their rights to jury or court trial.
With respect to any matter not expressly provided for herein, the arbitration will be governed by the Federal Arbitration Act, 9 U.S.C. Chapter 1.
All claims based upon the same incident, transaction or related circumstances regarding you or the same member shall be
arbitrated in one proceeding (for example, all Member Parties asserting claims arising from an injury to the same Health Plan Member, shall be arbitrated in one proceeding). A claim for arbitration shall be waived and forever barred if on the date notice thereof is received, the claim, if it were then asserted in a civil action, would be barred by the applicable Hawaii statute of limitations. All notices or other papers required to be served or convenient in the conduct of arbitration proceedings following the initial service shall be mailed, postage prepaid, to such address as each party gives for this purpose. If the Federal Arbitration Act or other law applicable to these arbitration terms is deemed to prohibit any term in this Agreement in any particular case, then such term(s) shall be severable in that case and the remainder of this Agreement shall not be affected thereby. Class actions and consolidation of parties asserting claims regarding multiple Members or members are prohibited. The arbitration provisions in this Agreement shall supersede those in any prior Agreement.
This Agreement concerns personal medical information whose confidentiality is protected by law. Neither party nor the
arbitrator(s) may disclose the substance of the arbitration proceedings or award, except as required by law or as necessary to file a motion regarding the award pursuant to the Federal Arbitration Act, in any federal or state court of appropriate jurisdiction within Hawaii, and in that event, the parties shall take all appropriate action to request that the records of the arbitration be submitted to the court under seal.
1. Medical Malpractice Claims. Prior to initiating any arbitration proceedings alleging medical malpractice, you shall first submit the claim to a Medical Inquiry and Conciliation Panel pursuant to Chapter 671, Hawaii Revised Statutes, Sections 11-19. Following the termination of proceeding by the Medical Inquiry and Conciliation Panel, if the claim has not been withdrawn or settled, you shall serve a demand for arbitration on Kaiser Permanente Parties as specified above.
2. E RISA Claims. If your plan is governed by ERISA, and you have a claim for benefits that is denied or ignored (in whole or in part), you may file suit in federal court under Section 502(a)(1)(B) of ERISA. If a suit is filed, the court will decide who should pay court costs and legal fees. If you are successful, the court may order the person or entity you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. If you have any questions about your plan, you should contact the plan administrator, i.e., your employer or group sponsor.
Although benefit-related claims subject to ERISA are not required to be resolved by binding arbitration pursuant to this section, you may still make a voluntary election to use binding arbitration to resolve these claims, instead of court trial, by filing a demand for arbitration upon Kaiser Permanente Parties pursuant to the provisions of Section 8-B of the Hawaii Kaiser Permanente Senior Advantage Evidence of Coverage. If a voluntary election to use binding arbitration is made by you, the arbitration shall be conducted pursuant to this Section 8-B of the Hawaii Kaiser Permanente Senior Advantage Evidence of Coverage.
3. Senior Advantage Member Claims. Complaints and appeals procedures are described in the Hawaii Kaiser Permanente
Senior Advantage Evidence of Coverage chapter titled, “What to do if you have a problem or complaint (coverage decisions, appeals, and complaints)”. The arbitration provisions of this Agreement apply only to Senior Advantage Member claims asserted on account of medical malpractice or a violation of a legal duty arising out of this Agreement, irrespective of the legal theory upon which the claim is asserted.
Last Name First Name
I acknowledge that I have read and understood the information in the Arbitration Agreement above and agree that I, on behalf of myself, all applicants, and all family members, hereby (i) acknowledge that I have read and understood the provisions of the KFHP Arbitration Agreement, (ii) agree to binding arbitration, and (iii) give up my constitutional right to a jury trial.
Today’s Date: / /
If you are the authorized representative, you must sign above and provide the following information:
Phone Number: – – Relationship to Enrollee:
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:
2021 HI Group Plan Enrollment Form