Form Instructions
HMSA’s 65C Plus Change Form
This form is for current 65C Plus members who want to switch health plan options
or switch/add Prescription Drug Coverage. 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 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, 2008, will have a proposed effective date of Feb. 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, 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 numbers (65C Plus health plan and, if applicable, 65C Plus
Prescription Drug Coverage).
Section 1
- Write your name and your current HMSA member numbers (65C Plus health plan and,
if applicable, 65C Plus Prescription Drug Coverage). 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, or no if you don’t.
Section 2
- Indicate the payment option you want.
Section 3
- Read the agreement in section 4 before you or your legal guardian signs and dates
the form.
Section 4
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. If you indicated on the change form that you
want your premium withheld from your Social Security, Railroad Retirement Board
(RRB), or Office of Personnel Management (OPM) check, our billing statement will
only show the health plan premium. You must pay your monthly premium 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.