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HMSA’s 65C Plus (Cost) Change Form

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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 January 31, 2013, will have a proposed effective date of Febuary 1, 2013, subject to Centers for Medicare and Medicaid Services (CMS) approval.

Enrollment changes in HMSA’s 65C Plus Prescription Drug Coverage 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, October 15 – December 7, 2012, for an effective date of January 1, 2013, 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 information.

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.

You’ll need:

  • Your current HMSA member number(s) (65C Plus health plan subscriber number and, if different from your health plan subscriber number, your 65C Plus Prescription Drug Coverage subscriber number).
  • Your primary care physician’s name (optional)

Section 1

  • Write your name, residence address, mailing address (if different), birth date, sex (gender), current HMSA member number (or Medicare claim number), daytime telephone number, and email address (optional).
  • Write the name of your primary care provider.
  • 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.
  • Check the box to request infromation in large-print format.

Section 2

  • Please read this important information.
  • Indicate the payment option you want.

Section 3

  • Please this important information 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.