HMSA’s 65C Plus (Cost) Change Form
This form is for current 65C Plus (Cost) members who want to switch health plan
and/or Prescription Drug Coverage options. You must print and fill out this change
form. Mail your completed form to HMSA at the address on the bottom of this page. You may also fax your completed application to (808) 948-6343 (on Oahu).
Completed change forms requesting health plan option changes must be received by
the last business day of a month to be approved for the first day of the next month.
For example, change forms received by Jan. 31, 2012, will have a proposed effective
date of Feb. 1, 2012, subject to Centers for Medicare and Medicaid Services (CMS) approval.
Enrollment changes in HMSA’s 65C Plus Prescription Drug Coverage Cost are
possible only at certain times during the year. In general, enrollment or changes
to HMSA’s 65C Plus Prescription Drug Coverage are allowed only during the
Annual Election Period, Oct. 15 – Dec. 7, 2011, for an effective date of Jan. 1,
2012. If you miss this Annual Election Period, you must wait until Oct. 15 - Dec.
7, 2012, for an effective date of January 2013, to make a change, unless you qualify
for a special election period. Enrollments are subject to approval from CMS. Contact our representatives at the phone numbers
listed in Contact Information for more
Note: If you have coverage through a group-sponsored arrangement, please contact
your benefits administrator before making any changes.
All four sections of this change form must be completed or your enrollment change
could be delayed.
- Your current HMSA member number(s) (65C Plus Cost health plan subscriber number
and, if different from your health plan subscriber number, your 65C Plus Prescription
Drug Coverage Cost subscriber number).
- Your primary care physician's name (optional)
- Write your name, residence address, mailing address (if different from residence
address), and your current HMSA subscriber number(s) (65C Plus health Cost plan
subscriber number and, if different from your health plan subscriber number, your
65C Plus Prescription Drug Coverage Cost subscriber number). Provide a daytime telephone
number where we can contact you if we have any questions to avoid delays in processing
the form. Indicate the change you want to make by checking off your current 65C
Plus option and what 65C Plus option you would like to change to.
- Please read this important information.
- Indicate the payment option you want.
- Please read the important information.
- Read and sign and date the form.
- If the applicant is unable to sign, the applicant's legal representative must sign
and fill in their name, mailing address, telephone number, and indicate their relationship
to the applicant.
Mail change forms to:
HMSA / 6AMS-IP
P.O. Box 860
Honolulu, HI 96808-0860
Do not send payment with your change form. Once your enrollment
change is approved, we’ll send you a billing statement every month showing
you the premium you owe and the due date. You must pay your monthly premium in advance.
If you indicated on the change form that you want your premium withheld from your
Social Security Administration (SSA) or Railroad Retirement Board (RRB) check, we will contact you.
Important: If we do not receive your premiums on a timely basis
and reasonable attempts have been made to collect them, your membership in the 65C
Plus health plan and prescription drug coverage, if applicable, will be terminated.