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HMSA Individual Plan Application Instructions

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HMSA Individual Plan Application Instructions

Please read the application form carefully and answer all questions that apply to you. If your application isn’t complete, your coverage may be delayed.

When you choose an HMSA individual plan, you have to choose a plan with pediatric dental coverage or one of HMSA’s stand-alone dental plans, or you need to attest that you’re enrolled in a dental plan certified by the Hawai‘i Health Connector, which is the state’s health insurance marketplace. This is a requirement under health care reform.

Mail the completed application to:

HMSA/6-AMS
P.O. Box 860
Honolulu, HI 96808-0860

If you have questions about filling out your application, please call 808-948-5555 on Oahu or 1-800-620-4672 on the Neighbor Islands, Monday through Friday, 8 a.m. - 5 p.m.

If you need detailed instructions on how to fill out the application please see below.

How to fill out an HMSA Individual Plan Application

Please read the application form carefully and answer all questions that apply to you. If your application isn’t complete, your coverage may be delayed.

  1. In Section A, fill in your name, street address, phone numbers, email address, and current or former HMSA subscriber number.

  2. In Section B, select one of the boxes about your enrollment. If you’re applying during a special enrollment period, enter your SEP number from Section H at the bottom of page 3 of the application and fill in the event date.

  3. Select which plan you’d like to enroll in.

    Important: When you choose an HMSA individual plan, you have to choose a plan with pediatric dental coverage or one of HMSA’s stand-alone dental plans, or you need to attest that you’re enrolled in a dental plan certified by the Hawai‘i Health Connector, which is the state’s health insurance marketplace. This is a requirement under health care reform.

  4. If you’d like to enroll in a stand-alone dental plan, choose PPO Dental High, PPO Dental Basic, or HMO Dental Network Basic, and answer the question about your past HMSA dental coverage.

  5. If you don’t want an HMSA plan with pediatric dental coverage, you have to attest that you have other dental coverage that includes pediatric dental benefits as certified by the Hawai‘i Health Connector. Fill in the name of your dental insurance carrier and the name of the dental plan.

  6. To enroll in the Young Adults Plan with Pediatric Dental, check the box. You must be under age 30 to apply for this plan, which provides single coverage for yourself only.

  7. To enroll in the Catastrophic Plan with Pediatric Dental, check the box. To apply for this plan, you must have a hardship exemption or statutory unaffordability exemption from the Hawai‘i Health Connector. Answer the yes/no question and fill in your certificate of exemption number.

  8. Check “Yes” or “No” regarding your state of Hawaii residency.

  9. Answer the two questions about your most recent health insurance coverage by checking the appropriate box, then filling in the blanks as needed.

  10. On page 2, answer questions about COBRA coverage.

  11. If you currently have an HMSA individual plan, check “Yes” or “No” to cancel your current coverage if you’re accepted in the new HMSA plan. If you check “Yes,” fill in your medical and/or dental subscriber number.

  12. In Section C, complete all items for all eligible family members who will be covered by your plan.

  13. On page 3, complete Sections D, E, and F.

  14. Read Section G, then sign and date your application form.

  15. Mail the completed application to:

    HMSA/6-AMS
    P.O. Box 860
    Honolulu, HI 96808-0860

If you have questions about filling out your application, please call 808-948-5555 on Oahu or 1-800-620-4672 on the Neighbor Islands, Monday through Friday, 8 a.m. - 5 p.m.