Form Instructions

HMSA’s 65C Plus Enrollment Application

Completed applications must be received by the last business day of a month to be approved for the first day of the next month. For example, applications received by January 31, 2008, will have a proposed effective date of February 1, 2008, subject to CMS approval. Note: The 65C Plus health plan is open for enrollment throughout the year. However, enrollment in HMSA's 65C Plus Prescription Drug Coverage is 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, November 15th – December 31st, for an effective date of January 1st of the following year unless you qualify for a special election period. Contact our representatives at the phone numbers listed in Contact Information for more information.

To apply for enrollment in HMSA’s 65C Plus, print and fill out this form. Mail it to HMSA at the address given on the bottom of this page.

All four sections of this application must be completed or your enrollment could be delayed.

You’ll need:

Your Medicare card
Your HMSA member number, if you have one
Your personal care (primary) physician’s name
Your Social Security number (optional)

Section 1

Write your name, address, mailing address (if different), birth date, gender, daytime telephone number, email address, and current HMSA member number, if applicable.
Write the name of your current personal care (primary) physician.
Propose an effective date, the date you’d like your coverage to start.
Select High, Basic or Saver Option for your health plan coverage, and SRx or ERx, if you want to enroll in prescription drug coverage as well, or no, if you don’t.

Section 2

Attach a copy of your Medicare card, or your letter from the Social Security Administration or Railroad Retirement Board, or fill in the blanks to match your Medicare card.
Write your name as it appears on your Medicare card, Medicare claim number, gender, effective date and coverage you are entitled to under Medicare.

Section 3

Carefully read the section to ensure 65C Plus is the right choice for you.
Indicate the premium payment option you want.
Answer yes or no to the questions and fill in all applicable blanks. Remember, an incomplete application can delay your enrollment.

Section 4

Read the agreement.
Sign and date the form or have your legal guardian sign the form.

Mail application forms to:
HMSA/ 6-CSS
P.O. Box 860
Honolulu, HI 96808-0860

Do not send payment with your application. Once your application is approved, we'll send you a billing statement every month showing you the premium you owe and the date by which we must receive it. If you indicated on the application form that you want your premium withheld from your Social Security, Railroad Retirement Board (RRB), or Office of Personnel Management (OPM) check, you will not receive a billing statement. Your monthyly premium must be paid in advance.

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.