APPLICATIONS & FORMS

The following is a list of our online forms and applications. Sales Literature can now be found under Sales Assistance To order a supply, use the Broker Supply Order Form. All Letter of Record forms can be found under Reports & Commissions.

online-fillable form Online-fillable form

Individual

2018 QHP

New applicants use the Idaho Individual Application & Cover Sheet for their region. To choose the correct application, please refer to the region by county list below. The QHP Change Form is used to change an existing member's off-exchange QHP plan. To choose the correct form, please refer to the region by county list below.

North Region - For residents of the following counties: Benewah, Bonner, Boundary, Clearwater, Idaho, Kootenai, Latah, Lewis, Nez Perce and Shoshone counties

Idaho Individual Application & Cover Sheet – North Region online-fillable form 3-1179
Qualified Health Plan Products Change Form – North Region online-fillable form 3-1182

Southwest Region - For residents of the following counties: Ada, Adams, Blaine, Boise, Camas, Canyon, Cassia, (for CarePoint St. Luke’s Health Partners plan applicants), Elmore, Gem, Gooding, Jerome, Lincoln, Minidoka, Owyhee, Payette, Twin Falls, Valley and Washington counties

Idaho Individual Application & Cover Sheet – SW Region online-fillable form 3-1180
Qualified Health Plan Products Change Form – SW Region online-fillable form 3-1183

East/Southeast Idaho Region - For residents of the following counties: Bannock, Bear Lake, Bingham, Bonneville, Butte, Caribou, Cassia (for Hometown East plan applicants), Clark, Custer, Franklin, Fremont, Jefferson, Lemhi, Madison, Minidoka, Oneida, Power and Teton counties

Idaho Individual Application & Cover Sheet – East/ SE Region online-fillable form 3-1178
Qualified Health Plan Products Change Form – East/ SE Region online-fillable form 3-1181

2017 QHP

New applicants use the Idaho Individual Application & Cover Sheet for their region. To choose the correct application, please refer to the region by county list below. The QHP Change Form is used to change an existing member's off-exchange QHP plan. To choose the correct form, please refer to the region by county list below.

North Region - For residents of the following counties: Benewah, Bonner, Boundary, Clearwater, Idaho, Kootenai, Latah, Lewis, Nez Perce and Shoshone counties

Idaho Individual Application & Cover Sheet – North Region online-fillable form 3-1179
Qualified Health Plan Products Change Form – North Region online-fillable form 3-1182

Southwest Region - For residents of the following counties: Ada, Adams, Blaine, Boise, Camas, Canyon, Cassia, (for CarePoint St. Luke’s Health Partners plan applicants), Elmore, Gem, Gooding, Jerome, Lincoln, Minidoka, Owyhee, Payette, Twin Falls, Valley and Washington counties

Idaho Individual Application & Cover Sheet – SW Region online-fillable form 3-1180
Qualified Health Plan Products Change Form – SW Region online-fillable form 3-1183

East/Southeast Idaho Region - For residents of the following counties: Bannock, Bear Lake, Bingham, Bonneville, Butte, Caribou, Cassia (for Hometown East plan applicants), Clark, Custer, Franklin, Fremont, Jefferson, Lemhi, Madison, Minidoka, Oneida, Power and Teton counties

Idaho Individual Application & Cover Sheet – East/ SE Region online-fillable form 3-1178
Qualified Health Plan Products Change Form – East/ SE Region online-fillable form 3-1181

Grandfathered and Grandmothered

General Maintenance Forms

New applicants can apply using the Idaho Individual Application & Cover Sheet for their region. To choose the correct application please refer to to the region by county list below.
The QHP Change Form is used to change an existing member's off-exchange QHP plan. To choose the correct form, please refer to the region by county list below.

Group

Enrollment Applications

We've combined our coversheet and application into one PDF that can be used for all group sizes and both pre-ACA and post-ACA plans. We hope this makes the application process easier for you and your groups.

Idaho Universal Group Application width Cover Sheet online-fillable form

  • For all groups excluding the below
3-1231

Idaho Universal Group Application with Cover Sheet and Health Statement online-fillable form

  • For all new medium groups
  • For all new large groups not using claims experience
  • For existing small grandfathered/ grandmothered groups if enrollment addition exceeds 20% threshold
3-1230

Idaho Universal Group Application Cover Sheet online-fillable form

3-1157C
Group Standalone Dental Enrollment Application online-fillable form 3-395
Group Voluntary Vision Enrollment Application 3-412
Statewide School Retiree Application online-fillable form 4-150
Statewide Schools ASC Health/Dental/Vision Enrollment Application online-fillable form 3-307SWS