Form Instructions
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.
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. 29, 2010, will have a proposed effective date of Feb. 1, 2010, subject to
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 (Cost) are allowed
only during the Annual Election Period, Nov. 15 – Dec. 31, for an effective date
of Jan. 1 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.
All four sections of this change form must be completed or your enrollment change
could be delayed.
You’ll need:
- 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).
Section 1
- Write your name 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 any delays in
processing the form. Indicate the change you want to make by checking off both the
health plan and (if applicable) Prescription Drug Coverage you want to be enrolled
in.
Section 2
- Please read this important information.
Section 3
- Indicate the payment option you want.
Section 4
- Read the agreement in section 5 before you or your legal guardian signs and dates
the form.
Section 5
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 date by which we must receive it. 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), Railroad Retirement
Board (RRB), or Office of Personnel Management (OPM) check, we will contact you
about having your premium deducted from your SSA, RRB or OPM payment.
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.
This page is current as of Oct. 1, 2009. (H1251_4006_10_Web_Pages – CMS 1/8/2010)