You may use this form to apply for a Sutter Health Plus individual and family plan or make changes to an existing policy. This form is not used to notify us of a termination.

Please note:

• If you are selecting the same plan for yourself, spouse/domestic partner, or dependent(s), please complete one application
• If your spouse/domestic partner or dependent(s) want a different plan they must complete a separate application
• You and your dependents* (other than a dependent child) must live or reside in the Sutter Health Plus licensed service area to be eligible for coverage
• If you or any dependent you’re applying for are entitled to Medicare Part A or are enrolled in Medicare Part B, that applicant is not eligible to apply for new Sutter Health Plus coverage; visit Medicare.gov to learn more about Medicare plan options The Health Insurance Counseling & Advocacy Program (HICAP) offers free, one-on-one Medicare counseling by calling 1-800-434-0222. You may also contact your local HICAP for more information about Medicare rights and benefits.

The Health Insurance Counseling & Advocacy Program (HICAP) provides health insurance counseling to senior California residents free of charge by calling 1-800-434-0222. You may also contact your local HICAP for more information about Medicare rights and benefits.

HICAP Contact Information by County

Important Note

The Affordable Care Act (ACA) requires Sutter Health Plus to collect the Social Security numbers (SSNs) for all enrolled members. Sutter Health Plus is required to provide IRS Form 1095-B to the IRS with a copy to you. Form 1095-B includes information you will need to report on your income tax return showing that you and your covered family members had qualifying health coverage (referred to as “minimum essential coverage”) for some or all months during the year. Sutter Health Plus will not use or share your SSN other than as required by law. Please be sure to include all SSNs where requested.

Language Assistance

If you have questions about completing this application, please contact Sutter Health Plus Member Services at 1-855-315-5800 (TTY 1-855-830-3500), Monday through Friday from 8 a.m. to 7 p.m. Sutter Health Plus provides translation services and other language assistance services to you free of charge. If you are working with a broker, you may also call them for assistance. If a broker helped you read and complete this application, they must sign the application (see Section H).

* A dependent may be:

• Your spouse
• Child of a subscriber or spouse
• Parent or stepparent of a subscriber who meets the definition of a qualifying relative under section 152(d) of Title 26 of the United States Code