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https://www.geoaccess.com/uhcwest/Commercial/begin.asp?statusID=&stateofresidence=CA&netcode
=&CompanyID=CO&MarketID=CA&cmdContinue.x=67&cmdContinue.y=12&CLR=MPCM&Mode=QS&Pla
nID=&RET=https%3A%2F%2Fwww%2Emypacificare%2Ephs%2Ecom%2Fmembers%2Fdoctor%2Fpcpconf
irm%2Easp

1 Address: Type city and zip code
2. Select Plan or Service Type: United Healthcare Signature Value Advantage (HMO Value
Network)
3. Select Provider type: Primary Care Physician
4. Select the Primary Care Physician and Medical group under the United Healthcare
Signature Value Advantage
(HMO Value Network)
If you don’t provide the PCP information on the application, we will assign a PCP nearby your
residence. You may change your PCP
after receiving the insurance ID card for change of PCP beginning in September.

4. ACI Benefit Coverage
Based on HMO 30 premium
Employee (only) 20% and ACI 80%

5. Health Benefit Declination
Fill out: “ (HEALTH) Decline Form“

6. Age Banded Rates Change under the Affordable Care Act
- Ages 0 20 are one rate band. But ages 21 through 64 have rate bands for each year in this range.
After that, there is a rate for ages 64 and over.
- Children aged 0 20 are each charged the 0 20 rate, for up to three children in this age group.
(There is no charge for additional children aged 0 20.) Because children can be covered up to age 26,
once a child reaches 21, they will have a rate for their specific age through age 26.
- The age represented by each member will be their age at their enrollment date.
That age rate will remain until the contract renews. The ages will then be adjusted to the current
ages of
members at the contract renewal.

Thank you,

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