New Off Exchange Applications (we are only accepting paper applications for this SEP):Anthem Blue Cross applications are available for download on the links below. Mail, scan and e-mail or fax to me for enrollment processing. Be sure to select the appropriate application for your county of residence.
- Not be currently enrolled in a health care plan
- Attest that they did not realize there was a tax penalty (complete this attestation form)
- In addition, individuals applying for coverage during this SEP must write “I Did Not Know About the Tax Penalty” somewhere on the first page of the application, submit a completed and signed attestation form, and submit payment or select auto payment method. Applications submitted between the 1st and 15th of the month will have an effective date of the 1st of the following month. Applications submitted after the 15th, will have an effective date of the 1st of the month after next.
- Applications submitted without “I Did Not Know About the Tax Penalty” written on the first page or no Qualifying Event box checked will be returned. If the application is due to a “Normal” qualifying event - the Qualifying Event box must be checked because standard effective date rules would apply (see the Anthem application for details regarding effective date assignment for qualifying events).
PPO Only - Alameda, Alpine, Amador, Butte, Calaveras, Colusa, Contra Costa, Del Norte, Glenn, Humboldt, Imperial, Inyo, Kern, Lake, Lassen, Marin, Mariposa, Mendocino, Merced, Modoc, Mono, Monterey, Napa, Nevada, Plumas, San Benito, San Joaquin, San Luis Obispo, San Mateo, Santa Barbara, Santa Cruz, Shasta, Sierra, Siskiyou, Solano, Sonoma, Stanislaus, Sutter, Tehama, Trinity, Tulare, Tuolumne, Ventura, and Yuba
EPO & HMO - Los Angeles, Orange and San Diego
PPO & HMO - El Dorado, Fresno, Kings, Madera, Placer, Riverside, Sacramento, San Bernardino, Santa Clara, and Yolo
EPO Only - San Francisco
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