2019 HMSA Medicare Advantage Disenrollment Request Form

Do you want to disenroll from your HMSA Medicare Advantage plan? Please print out this form, complete it, and mail it to HMSA at the address on the bottom of this page.

PPO plans

  • Complete
  • Complete Plus
  • Standard
  • Standard Plus
  • Dual Care (PPO SNP)

HMO plan

  • Essential Advantage

In general, enrollment or changes are allowed only during the annual election period, October 15 – December 7, 2018. Your plan will start January 1, 2019.

In certain situations, changes are also allowed at other times of the year. For example, people with Medicaid, those who get “Extra Help” paying for their drugs, those who have or are leaving employer coverage, and those who move out of the service area may be allowed to make a change at other times of the year.

If you enrolled in a Medicare Advantage plan for January 1, 2019, and don’t like your plan choice, you can switch to another Medicare health plan (either with or without Medicare prescription drug coverage) or switch to Original Medicare (either with or without Medicare prescription drug coverage) between January 1 and March 31, 2019.

If you don't qualify for a special election period and if you miss the annual election period, you must wait until October 15 – December 7, 2019. Your plan would start January 1, 2020. The Centers for Medicare & Medicaid Services (CMS) must approve your enrollment. Contact our representatives at the phone numbers listed in Contact Information for more information.

Note: If you have a group-sponsored health plan, please contact your benefits administrator before making any changes.

Please complete the entire form so we can process it for you without any delays.

  • Write your:
    • Name
    • HMSA subscriber number
    • Telephone number
    • Birth date
    • Gender
  • Sign and date the form
  • Fill out the second page and check the box next to the statement that applies to you.

Mail disenrollment requests to:

HMSA – Membership Services
P.O. Box 860
Honolulu, HI 96808

If you have other health plan benefits, such as a retiree plan, Medicare Supplement Insurance (Medigap) policy, or an Affordable Care Act (ACA) plan, you may have to contact the plan directly to cancel it. Call us so we can help you determine if you need to cancel your other plan.