2016 HMSA Individual Plan Application Instructions

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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.

Applications are accepted during the annual Open Enrollment Period or throughout the year if you qualify for a Special Enrollment Period.

When you choose an HMSA individual plan, be sure you also choose one of HMSA’s stand-alone dental plans. If you don’t choose a stand-alone dental plan, you’ll need to attest that you’re enrolled in an exchange-certified dental plan that includes pediatric dental benefits as required by the Affordable Care Act.

Mail the completed application to:

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

If you have questions about filling out your application, please call 808-948-5555, option 2, on Oahu or 1-800-620-4672 toll-free 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

  1. Please read the application form carefully and answer all questions that apply to you. If your application isn’t complete, your benefits may be delayed.
  2. In Section A, fill in your name, mailing & billing address, phone numbers, email address, and responsible party.
  3. In Section B, select one of the boxes about your enrollment. If you’re applying during a special enrollment period (SEP), enter your SEP number from Section G at the bottom of page 3 of the application and fill in the date of the qualifying event.
  4. Select which plan you’d like to enroll in.
  5. To enroll in the Catastrophic Plan (single coverage only), you must either be under 30 years of age or have a hardship exemption from the Federally Facilitated Marketplace. If you qualify due to a hardship exemption, please mark YES and enter the certificate of exemption number.
  6. Select a stand-alone dental and answer the questions about your past HMSA dental coverage.
  7. Important: If you don’t choose a stand-alone dental plan, you’ll need to attest that you’re enrolled in an exchange-certified dental plan that includes pediatric dental benefits as required by the Affordable Care Act. Fill in the name of your dental insurance carrier, name of your dental plan, and policy number.
  8. Check “Yes” or “No” regarding your state of Hawaii residency.
  9. Check “Yes” or “No” if you are an American Indian or Alaska Native.
  10. Answer the questions about your most recent health plan by checking the appropriate boxes and filling in the blanks as needed.
  11. On page 2, check the appropriate box for loss of coverage reason.
  12. If you currently have an HMSA individual plan, check “Yes” or “No” to cancel your current plan if you’re accepted in the new HMSA plan. If you check “Yes,” fill in your medical and/or dental subscriber number.
  13. In Section C, complete all items for all eligible family members who will be covered by your plan.
  14. On page 3, complete Sections D and E
  15. Read and complete Section F by signing and dating the enrollment form. Also, print your name & fill in your relationship (i.e. self)
  16. Mail the completed application to:

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

If you have questions about filling out your application, please call 808-948-5555, option 2, on Oahu or 1-800-620-4672 toll-free on the Neighbor Islands, Monday through Friday, 8 a.m. - 5 p.m.