Group Leader

Transcription

Group Leader

HMSA
Group
Leader
G
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Table of Contents
Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
HMSA’s Health Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Dental, Prescription Drugs, and Vision. . . . . . . . . . . . . . . . . . . . . . . . 4
HMSA Senior Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
HMSA Individual Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Group Sponsored Benefits and Services
Benefit Services of Hawaii/USAble Life . . . . . . . . . . . . . . . . . . . . 7
HMSA Well-Being Connection . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Group Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Important Health Care Laws. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Eligibility – General Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Enrollment
General Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
When Can Your Employees and Their Dependents Enroll. . . . . . 16
How to Enroll Your Employees and Dependents. . . . . . . . . . . . . 20
How to Add New Employees. . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
How to Add New Dependents. . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Cancellations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
How to Cancel Your Employees. . . . . . . . . . . . . . . . . . . . . . . . . . 28
How to Cancel Your Dependents. . . . . . . . . . . . . . . . . . . . . . . . . 30
Billing
How to Read Your Bill. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
How to Pay Your Bill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
General Information – Terms and Definitions. . . . . . . . . . . . . . . . . 37
Aloha!
Mahalo for choosing HMSA! As a group leader, you are
an important link between your employer group and HMSA.
Our Group Leader Guide is a valuable tool to help you
administer your program. It outlines the policies and
procedures you’ll need for enrolling and maintaining
members of your group.
MY HMSA ACCOUNT REPRESENTATIVE is:
____________________________________________________
Phone: ____________________________________________
ACCOUNT MANAGEMENT & SALES:
Oahu
Groups with 20 or more employees. . . . . . . . . . . . Contact your account representative
Groups with less than 20 employees. . . . . . . . . . . . . . . . . . . . . . . . . 948-5555
Individual Plans (eligibility, enrollment, and brochures). . . . . . . . . . . 948-5555
Neighbor Islands (toll-free). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (800) 620-4672
Fax. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 948-6343
Hilo Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 935-6993
Kona Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326-1940
Kauai Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245-4299
Maui Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 871-2466
CUSTOMER SERVICE—Plan benefits and claim inquiries
Oahu
Group and Individual Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 948-6111
Federal, State, and County Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . 948-6499
Medicare and HMSA Coverage (including Senior Plan members). . . 948-6000
Dental Plans (including Dental Network) . . . . . . . . . . . . . . . . . . . . . . 948-6440
HMO Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 948-6372
Hilo Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 935-5441
Kona Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 329-5291
Kauai Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 245-3393
Maui Office . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 871-6295
MEMBERSHIP SERVICE
Group Billing Information
Oahu
. . . . . . . . . . . . . . . . . . . . . . . . . . . Contact your Billing Reconciliation Representative
Neighbor Islands (toll-free) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 (800) 446-4440
Individual Plan Billing & Other Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 948-6140
Group Member Eligibility & Other Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 948-6376
HMSA Mailing Address:
HAWAI‘I MEDICAL SERVICE ASSOCIATION
6-AMS
P.O. BOX 860
HONOLULU, HI 96808-0860
For more information about HMSA, visit hmsa.com.
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HMSA’s Health Plans
care. Health Plan Hawaii Plus emphasizes preventive care,
such as physical exams, well-baby visits, standard immunizations, and prenatal care.
Small Group Plus: HMSA’s comprehensive plan for groups
with one to 19 employees. This plan gives members
access to benefits for medical, drug, vision, dental, and
group term life insurance. Small Group Plus is offered with
our Choice Medical and Choice Dental programs. This
allows the member to choose a plan based on their own
personal health care needs and finances.
Small Group Preferred: HMSA’s comprehensive plan for
groups with two to 50 employees. This plan gives members access to benefits for medical, drug, vision, dental,
employee term life insurance, dependent term life,
accidental death and dismemberment (AD&D), and LongTerm Disability. Small Group Preferred is offered with our
Small Group Plus, Choice Medical, and Choice Dental
programs. This allows the member to choose a plan based
on their own personal health care needs and finances.
HMSA offers a variety of comprehensive health plans
designed to meet the changing needs of our members.
Choice Medical: HMSA’s Choice Medical is an innovative
health plan package developed specifically to help keep
your employees healthy and reduce your costs.
Riders: In addition to basic medical plan options, HMSA
also offers extra protection with a dental plan, prescription
drug, and vision programs. Minimum subscriber count is
required for riders.
This unique package combines the Preferred Provider
Plan, CompMED, and Health Plan Hawaii Plus to give your
employees unparalleled choice in health care coverage.
All of these outstanding plans feature extensive provider
networks, away from home coverage, preventive care, and
all of the high standards in service you’ve come to expect
from HMSA.
Retiree Plans: HMSA offers a selection of health and drug
plans for retirees. Employer groups can sponsor a plan for
their retirees or retirees may qualify for individual coverage
on their own.
Among the selection is HMSA’s Medicare Advantage
Prescription Drug plan, designed especially for people in
Hawaii with Medicare who want coverage beyond what
Medicare provides.
Preferred Provider Plan: HMSA members have the
freedom to choose their own physicians. When members
use participating providers, most services are covered at
90 percent of the eligible charge. This free-choice plan
gives members access to the largest network of health
care providers in the state. It also offers members access
to over 750,000 Blue Cross and Blue Shield providers
nationwide. This plan includes a managed-care program to
ensure your employees receive the maximum plan benefits
when using HMSA participating providers.
Retirement can bring up many questions about health
insurance. Please contact your account representative and
ask about HMSA’s free Pre-Retirement Health Care
Planning Seminars.
Individual Plans: For employees leaving your company
who are not eligible for COBRA coverage, we offer
several individual health plan options. Please refer to
page 6 in this guide or call HMSA’s Account Management
& Sales – Individual Plans at 948-5555 on Oahu or
1 (800) 620-4672 toll-free on the Neighbor Islands.
CompMED: A lower-priced plan for employers with
comprehensive benefits for employees. Plan benefits
include coverage for physician office visits, inpatient and
outpatient facility services, and other provider services.
Like the Preferred Provider Plan, this free-choice plan gives
members access to the largest network of health care
providers in the state. It also offers members access
to over 750,000 Blue Cross and Blue Shield providers
nationwide.
Affordable Care Act (ACA). Small businesses with up to
50 full-time employees can choose new ACA plans that
include health benefits required by health care reform.
Premiums for these plans are based on the age of
employees; health plans for older employees may cost
more than plans for younger employees. Small businesses
with an equivalent of up to 25 full-time employees with
average wages of less than $50,000 may qualify for a tax
credit when they buy ACA plans on the Hawai‘i Health
Connector, the state’s online health insurance marketplace.
Health Plan Hawaii Plus: An enhanced version of our
popular health maintenance organization, Health Plan
Hawaii. Members pay only a low copayment for each
health center visit. This means less out-of-pocket
expenses and easier budgeting. This plan requires the
employee to select a primary care provider for coordinated
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Dental, Prescription Drugs, and Vision
Drug/Vision Riders
The following provisions are applicable when enrolling in
HMSA’s drug/vision rider:
•A group must maintain a minimum of five
subscribers to be eligible, with the exception of
Small Group Plus and Small Group Preferred.
•If a group offers the drug/vision rider, all eligible
employees enrolling in the medical plan must also
enroll in the rider.
•Members must take the same level of coverage
in the rider that they have in the medical plan. For
example, an employee may enroll in single medical/
single rider coverage, but may not enroll in single
medical/family rider coverage.
•Members must enroll in the drug/vision rider at the
same time they enroll in the medical plan.
Choice Dental Plan
The following provisions are applicable when enrolling in
HMSA’s Choice Dental Plan:
•Groups that voluntarily cancel their drug/vision rider
may not re-enroll until 12 months after their
cancellation date.
•A group must maintain a minimum of two
subscribers to be eligible, with the exception of
Small Group Plus.
Riders Only
•A group may allow an employee to enroll in rider
coverage only when the rider is accompanied by the
medical or dental plans. This situation may occur
when an employee has an additional medical plan
through a spouse.
•If a group offers the dental plan, all eligible
employees must be enrolled in this plan.
•Members enrolled in the dental plan must enroll in
the single coverage if they have the single basic
medical plan or family dental coverage if they have
the family basic coverage.
•If an employer offers medical and dental coverage, the employee may enroll themselves and their
eligible dependents under the dental coverage. If
the employer offers medical, dental and drug/vision
coverage, the employee may enroll under the dental
and drug/vision coverage. The employee must enroll
in all riders available in the group. Drug/vision rideronly coverage is not allowed.
•Enrollment for medical and dental coverage must be
done at the same time.
•Employer groups that voluntarily terminate their
dental plan will not be permitted to re-enroll until
12 months after the cancellation date.
Members have a choice of the following:
•Riders-only coverage is subject to the same
administrative guidelines as regular coverage, such
as open enrollment, dependent eligibility, and
contribution requirements.
•Participating Provider Program: This program
allows members to receive services from any
licensed dentist. Members may choose from over
700 participating dentists and will receive the
maximum benefits from this option.
•Dental Network Program: Each member can
choose a dental center to receive all of their
services—close to work, home, or school. Offices
are conveniently located on Oahu, Kauai, Hawaii
Island, and Maui. HMSA has contracted with these
dentists to provide members with personal, quality
service with an emphasis on preventive care. They
offer the most modern facilities and treatment
methods for members’ ultimate comfort.
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HMSA Senior Plans
Akamai Advantage
Notification of Creditable Coverage for HMSA
Employer-Sponsored Prescription Drug Plans
HMSA offers health plan and prescription drug options,
with a Medicare contract that is designed especially for
people in Hawaii with Medicare Part A and B who want
benefits beyond what Medicare provides. Groups may
sponsor the health plan and prescription drug coverage as
a retiree plan. Individuals may also qualify for coverage on
their own.
HMSA tests all group-sponsored prescription drug plans
every year to ensure they meet or exceed the requirements
necessary to be considered creditable coverage under the
Medicare Modernization Act (MMA).
Creditable coverage means that an employer’s drug plan
benefits are at least equal to Medicare Part D. Employers
offering a group-sponsored drug plan to Medicare-eligible
individuals are required under the Medicare Modernization
Act (MMA) to provide a notice to all of the Medicare-eligible
individuals. A model letter from the Centers for Medicare &
Medicaid Services (CMS) is available on hmsa.com.
Here are some reasons why people in Hawaii
choose HMSA:
Established reputation. A trusted, reputable name for
health care in Hawaii.
Experience. A local company serving Hawaii since 1938.
More than 48 years of Medicare experience.
Employers must provide the creditability of coverage
notice to their Medicare-eligible individuals:
Easily accessible customer relations. Speak to local,
friendly, and knowledgeable customer relations representatives who are eager to help you in person or on the phone.
•Once a year before the Medicare annual
election period (October 15 - December 7).
•Within the 12 months before an individual’s initial
enrollment period for Medicare.
Financial strength. Your health plan is protected by
HMSA’s solid financial foundation. About 93 cents of every
dollar we receive goes to pay for your care. HMSA has one
of the lowest administrative expenses for health plans in
the nation. Our focus is on you.
•Before the start date for a Medicare-eligible
individual beginning participation in the
employer-sponsored group drug plan.
Part of Hawaii’s communities. Generations of Hawaii
families put their trust in us.
•When the plan’s prescription drug benefit ends or
is no longer creditable.
Akamai Advantage offers:
•Upon a beneficiary’s request.
• Affordable plans. Premiums as low as $0.
If you have questions regarding creditable coverage and
the requirement notifications, please contact your HMSA
Account Management & Sales representative or visit
hmsa.com.
•Comprehensive benefits. Medical, drug,
and vision benefits, as well as dental discounts.
•Choice of doctors. Choose from more than
2,700 participating physicians statewide.
HMSA offers complimentary Pre-Retirement Health
Care Planning Seminars. HMSA’s Pre-Retirement Health
Care Planning Seminars are a valuable resource to help
you and your employees as each individual navigates
through health care planning prior to retirement.
• Prescription drugs. Medications are available at
neighborhood pharmacies and conveniently through
the mail.
•Drug discounts in the Coverage Gap. All drug
plans feature discounts in the Coverage Gap
ranging from 28 percent to 52.5 percent on generic
and brand-name drugs to save you money during
this period.
Generally, each seminar takes about an hour and covers
Medicare basics and HMSA plan choices (for eligible
retirees who have Medicare Part A and Part B).
Whether your group sponsors an HMSA retiree health plan
or elects to endorse an HMSA Senior Plan for your retirees
to fund on an individual basis, if you have 10 or more
interested attendees, we will come to your place of
business to host a seminar. For more information, please
call your account representative.
•Financial protection. There’s a limit on how much
you pay every year for medical services.
•Predictable costs. Set charges for most health care
services, including doctor visits, to help you manage
your health care budget.
•Special HMSA member discounts. Save money
on many health and wellness products and services,
including dental and vision.
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HMSA Individual Plans
Dental Plans
HMSA dental plans pay for a variety of dental services with
regular screenings and cleanings. We help pay for basic
services, such as cavity fillings and spacers, and for major
care such as dentures, crowns, or bridges. Our plans
include:
•Dental Plus. For seniors 65 years and older.
•PPO Dental. PPO members have the freedom to
choose their own dentist from one of the largest
network of providers in the state.
•HMO Dental. Our HMO dental plan has the most
value for members who want great care for the least
amount of money. Services must be provided by
Hawaii Family Dental Centers.
Employees leaving your company may be eligible for
COBRA. However, members who are ineligible for COBRA
or choose not to enroll in COBRA, may apply for an HMSA
Individual Plan.
•Children’s dental benefits. You can enroll in an
Affordable Care Act health plan that includes
children’s dental benefits as required by health
care reform:
Conversion Membership. Members must apply within
60 days of their HMSA group plan cancellation date.
However, if they apply within 31 days of their group
cancellation than they will not have a break in coverage.
–Preventive services such as oral exams,
teeth cleaning, and X-rays at no copayment.
–Basic services such as fillings, extraction, and
root canals. Members pay 30 percent of the cost.
ffordable Care Act (ACA). People who buy health
A
insurance on their own can buy an ACA individual PPO or
HMO plan that includes health benefits required by health
care reform. This includes part-time employees and your
employees’ spouse or children. Premiums for these plans
are based on age; the older you are, the more your
premiums will be. People who buy health insurance on the
Hawai‘i Health Connector, the state’s online health insurance marketplace, could qualify for a subsidy depending
on their income.
–Major services such as crowns and dentures.
Members pay 50 percent of the cost.
Where to buy an HMSA Individual Plan. People who
don’t have health insurance, including part-time
employees or your employees’ spouse and children,
have various ways to buy an HMSA individual plan:
•On the phone. Call us at 948-5555 on Oahu or
1 (800) 620-4672 toll-free on the Neighbor Islands.
•Online. Visit hmsa.com and go to Health Plans
and Individuals and Family.
Student Plan 19: A PPO medical plan for students attending an accredited college or university on a full-time basis.
Applicants must be age 19 through 24. Once students
graduate or reach the maximum age of 25, they must
disenroll from this plan. Student Plan 19 also provides
access to medical care to students attending school
outside the state of Hawaii. This plan is specially priced
for students (single plan) and features medical, surgical,
hospital coverage, and a $15,000 group term life insurance
policy. Waiting periods for maternity benefits help to keep
monthly dues affordable.
•In person. Go to an HMSA center or
Neighbor Island office. (Locations and hours of
operation on hmsa.com.)
People can also buy an ACA plan on the Hawai‘i
Health Connector, the state’s online health insurance
marketplace. Depending on their income, they could
receive financial help for health insurance when they
buy it on the Hawai‘i Health Connector.
Children’s Plan: An HMO medical plan that provides
limited basic health care benefits needed to help keep
children age 31 days through 18 years in good health.
The HMSA Children’s Plan covers certain preventive
services, immunizations, doctor visits, diagnostic tests,
emergency care, and mental health benefits. This plan also
provides some prescription drugs and preventive dental
care benefits.
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Group-Sponsored Benefits and Services
and ambulance. In addition, it pays for a routine
physical exam after each anniversary of the policy
effective date.
•CancerCare: Because there are many non-medical
expenses associated with the diagnosis and
treatment of cancer, many people need supplemental coverage. CancerCare plans include benefits
such as hospital stay, surgery, chemotherapy, and
transportation.
•CriticalCare (Critical Illness): This benefit offers
lump-sum payments paid directly to the policyholder or beneficiary upon first positive diagnosis
of a covered critical illness. Critical illnesses include
cancer, heart attack, stroke, end-stage renal failure,
major organ transplant, quadriplegia, coronary artery
bypass surgery, balloon angioplasty, stent or laser
relief obstruction surgery, and carcinoma in situ.
Benefit Services of Hawaii/USAble Life
•Group Term Life and Accidental Death and
Dismemberment: HMSA has made arrangements
through Benefit Services of Hawaii, Inc., to offer life
insurance benefits at competitive rates. We offer
Group Term Life and Accidental Death and Dismemberment plans designed for Hawaii businesses.
Voluntary Group Term Life Insurance, Dependent
Life, and Supplemental Life programs may be
included for your employees to purchase at their
own expense.
•Hospital Confinement Plan: The Hospital Plan
provides coverage from the first day of a hospital
stay as a result of an accident or sickness. Benefits
include coronary care/intensive care, accidental
death and dismemberment, surgical procedures, and
ambulance.
• Voluntary Long-Term Disability: If an employee
becomes disabled due to an accident or illness,
TDI will be exhausted in six months. Voluntary
Long-Term Disability provides extended coverage if
the employee is unable to return to work for a period
of time.
• Temporary Disability Insurance (TDI) [Long-Term
Disability Insurance (LTD)]: Our TDI plan can help
you meet the requirements of the state law while
reducing your administrative burden of dealing with
several carriers for all your insurance needs. LTD
provides protection for one’s most valuable assets –
the ability to earn their paycheck. It helps employees
maintain their standard of living while disabled.
• Voluntary Life and Accidental Death &
Dismemberment (AD&D): Employees may select a
term life insurance for themselves and their spouse
at competitive group rates on a convenient payroll
deduction basis. There are also options available
for their children. Voluntary AD&D provides 24-hour
coverage for accidental loss of limbs, sight, speech,
or hearing.
Worksite Benefits: These voluntary benefits are made
available to provide added peace of mind for your
employees in the event of an unexpected crisis in their
lives. These plans do not require employer contributions
and many of the premiums can be payroll deducted on a
pretax basis. In most cases, the benefits are paid directly
to the insured regardless of any other coverage they may
already have, and those benefits may be used to cover
out-of-pocket expenses such as copayments, and living
and travel expenses.
TASC (Total Administrative Services
Corporation)
• The Flexible Spending Plan allows your employees
to use pretax income to pay for eligible health plan
dues, dependent care expenses, and out-of-pocket
medical expenses not covered by the health plan.
Employees will save 25 percent to 35 percent on
taxes while employers will save about 8 percent in
matching FICA/Medicare taxes.
• Accident Plan: Accidents may happen at anytime,
at work or at home, and are the leading cause of
death and injuries among people from birth to age
44. Unlike a standard AD&D plan, Accident Plan
provides comprehensive benefits that pay for
services such as hospital confinement, burns,
surgery for tendon/ligament repair, emergency room,
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Group-Sponsored Benefits and Services (continued)
HMSA Well-Being Connection
•Well-Being Connection Workshops. Health and
wellness education are key to a healthy lifestyle.
Your employees can take a variety of workshops at
no charge:
Your employees are the most important part of your business. Healthy employees can lead to a more productive
workplace and can help contain your health care costs.
That’s why we continually look at new ways that will help
your employees achieve their health goals and reduce their
risk of chronic diseases.
–Disease Awareness: Review common, life-altering conditions such as heart disease, high-blood
pressure, diabetes, osteoporosis, and cancer.
–General Health: Increase your well-being in these
workshops that focus on virus treatment and prevention, the importance of quality sleep, positive
attitude, and goal-setting.
HMSA Well-Being Connection is a comprehensive,
integrated approach to health and well-being. Well-Being
Connection will help your employees evaluate their current
health, set health goals, and achieve those goals through
support, online tools, and coaching:
–Healthy Aging: Discover ways to keep your body
and mind functioning at high levels in these
engaging sessions.
•Well-Being Connect. This convenient, powerful
website offers your employees a variety of tools and
resources to improve and maintain their health and
well-being. Employees can track their progress in
personal focus areas like managing stress, exercising, weight loss, and calorie intake. Well-Being
Connect is available on My Account on hmsa.com.
We encourage your employees to share their
Well-Being Report and goals from Well-Being
Connect with their primary care provider (PCP).
–Injury Prevention & Safety: Practice healthy
posture, proper lifting techniques, and back
stretches in this interactive workshop. Learn about
the contributing factors for recurring back pain and
reduce your risk.
–Nutrition: Explore our relationship with food, how
to make smart choices on the go, review dietary
guidelines, and choose healthier local foods.
• The Healthways Well-Being Assessment™. This
easy, interactive assessment asks simple questions
about your employees’ health, lab results, physical
and emotional well-being, work environment, health
behaviors, and more. It then analyzes health risks
and suggests areas to work on. Metrics are based
on the Gallup-Healthways Well-Being Index.®
–Physical Activity & Exercise: Tackle a handson approach in these interactive workshops that
focus on cardiovascular exercise, strength training,
outdoor fitness, and family-based activities.
–Stress Management: Relaxing and “finding the
calm” in life are important for your home and work
environment. Learn and practice techniques that
will help you lower your stress levels.
• Well-Being Plan. The plan, created through
Well-Being Connect, recommends steps to improve
behaviors based on each employee’s Well-Being
Assessment. It’s a tailored action plan that changes
with the employee’s progress and includes tools to
help them reach their goals.
–Weight Awareness: Gain an understanding of
calories, lifestyle behaviors, and societal influences
in relationship with weight management in this
interactive workshop.
•Trackers and Resources. Your employees can stay
on track with their Well-Being Plan with these
personalized tools:
Workshops are held at various HMSA Centers and
community locations statewide for members ages 18 and
older. To enroll, call HMSA Well-Being Connection at
1 (855) 329-5461 toll-free. Find more information
on hmsa.com.
– Recipe Centers.
– Meal plans.
Healthways Well-Being Assessment is a trademark of Healthways, Inc.
All rights reserved.
– Articles and videos.
–Trackers for exercise, medication, weight,
and healthy eating.
8
Group Services
HMSA offers many services to enhance your member
experience.
• COBRA – ASSIST
Companies with 20 or more employees are
required to offer continued health care coverage to
employees and their covered dependents under the
Consolidated Omnibus Budget Reconciliation Act
(COBRA). HMSA offers an administrative service to
help you meet your mandated responsibilities.
This service is offered to you at no additional charge
by assisting you with monthly billings, collection,
tracking, bookkeeping, claims processing, and
customer service. For more information, contact
your account representative.
Qualified Guidelines - A “qualified” order must:
•State the name and current addresses of the
employee and each dependent mentioned in the
order.
•Provide, create, or recognize the right, or assigns to
each dependent covered under the order the right to
enroll in the employee’s group health plan.
•Describe the health plan, including the type of
coverage to be provided.
• Specify the period to which the order applies.
• State each health plan affected by the order.
Restrictions of a Qualified Medical Child Support
Order:
• Qualified Medical Child Support Orders
All companies are required to honor Qualified
Medical Child Support Orders by providing group
health plan benefits to children whose parents are
divorced or separated. HMSA will assist you by
providing samples of the administrative procedures
that companies must follow. HMSA will also handle
claims processing and customer servicing for these
dependents.
•Cannot require the employee’s group health plan
coverage to provide any type or form of benefit or
any option that is not otherwise provided to the
employee, except as otherwise required by the law.
2)Second Written Notification — Send written
notification within 10 days of the first notification to:
Sample Administrative Procedures for Qualified
Medical Child Support Orders Required Employer
Action
•The employee affected by the court order.
•Any custodial parent/legal guardian and/or
dependent mentioned in the court order.
This written notification must:
•State whether the order has been determined to be
a “qualified” medical child support order.
Employer Action to Add Dependents – If the medical child support order is determined to be “qualified,” the
employer must:
The Omnibus Budget Reconciliation Act of 1993
(OBRA ‘93) amended ERISA by adding Section 609.
The Act requires all employers to honor Qualified Medical
Child Support Orders (QMCSO) by providing group health
plan benefits for children whose parents are divorced or
separated. All employers must honor QMCSOs received
on or after August 10, 1993.
•Acknowledge in writing that the dependent is eligible
to receive the same group health plan coverage as
the employee.
•Verify in writing who will receive (custodial parent,
legal guardian, etc.) any communications for the
dependent’s health plan coverage. This includes:
Upon receipt of a medical child support order:
1)First Written Notification — Send written notification
within 10 days to:
– Receipt of health plan brochure.
• The employee affected by the court order.
– Separate Summary Plan Description(s).
•Any custodial parent/legal guardian and/or
dependent mentioned in the court order.
–Direction of payment or reimbursements for
covered out-of-pocket medical expenses paid by
the dependent or custodial parent/legal guardian.
This written notification must:
• Acknowledge receipt of the court order.
•Mention employer’s procedure for determining if the
order is a “qualified” one.
9
Group-Sponsored Benefits and Services (continued)
•Enroll each dependent under the employee’s group
health plan using HMSA’s Membership Report form.
•Attach with the enrollment form copies of the letters
to the dependents and a copy of the Qualified
Medical Child Support Order.
•Treat the dependent as an “employee” for purposes
of any reporting and disclosure requirements under
ERISA.
HMSA’s Responsibilities
When the enrollment forms, copies of the letters to the
dependents, and a copy of the QMCSO are received,
HMSA will:
•Enroll the dependent under the employee’s group
health plan.
•Mail benefit checks to the dependents or designated
parent or guardian.
•Answer inquiries from the dependents or
designated guardians.
10
Important Health Care Laws
An HMSA COBRA administrative service is available to
help your company meet your COBRA responsibilities.
Please note that HMSA doesn’t issue mandated COBRA
notices to your employees. For more information, please
contact your account representative or the U.S. Department of Labor Employee Benefits Security Administration
at (626) 229-1000.
ERISA: The Employee Retirement Income Security Act of
1974 as amended requires all employers who have 100 or
more employees to file an annual plan report with the U.S.
Department of Labor and to provide to participants a
summary of the annual report. This annual summary is
in addition to the formal summary plan description (SPD)
each participant receives after becoming a participant.
All ERISA plans, regardless of size, must prepare and
distribute an SPD to participants. For more information,
call the U.S. Department of Labor at (626) 229-1000.
The following is intended to summarize key health care
laws affecting employers. For more detailed information,
please contact the appropriate office listed.
Hawaii Prepaid Health Care Act: This state law requires
employers to offer health care benefits to their employees
who work a minimum of four consecutive weeks at 20 or
more hours a week. For an “A” status plan, the employer
must pay at least half of the premiums for the employee
and the employee is responsible for the balance. The
employee’s portion, however, can’t exceed 1.5 percent
of their gross monthly wage. For a “B” status plan, the
employer’s contribution toward the family premiums must
equal the required single rate contribution plus half the
difference between the single rate and family rate. The
employer also has the option of paying more or all of the
health plan premiums.
COBRA: The Consolidated Omnibus Budget
Reconciliation Act was signed into law on April 7, 1986.
This provision applies to employer groups who had 20 or
more employees for at least 50 percent of the previous
calendar year. Employees are counted on a full-time
equivalent basis, which means that part-time employees
are counted as a fraction of a full-time employee based
on the number of hours worked. Employers must offer
continued group health plan benefits, which may be at the
employee’s expense. Coverage must be made available
for 18 months to employees who have a reduction in work
hours, voluntarily leave employment, are laid off because
of economic conditions, or are discharged other than for
gross misconduct.
If the employee chooses to waive medical coverage, the
employee must complete and submit an HC-5 waiver form
to the employer. The employer must then file the document
with the Hawaii Department of Labor and Industrial
Relations. This exemption is binding for one year and must
be renewed every December 31.
To receive 29 months of COBRA coverage, the qualified
beneficiary must be deemed disabled by SSA within the
first 60 days of COBRA coverage. The qualified beneficiary can be charged up to 150 percent of the cost of
coverage during the 11 month disability extension. The
total maximum period of 29 months of COBRA coverage,
includes the 18 months of COBRA coverage period and
the 11-month extension.
If an employee is hospitalized or otherwise prevented
by sickness from working, the employer shall enable the
employee to continue the employee’s coverage by
contributing to the premiums the amounts paid by the
employer toward such premiums before the employee’s
sickness for the period that the employee is hospitalized or
prevented by sickness from working. This obligation shall
not exceed three months after the month during which the
employee became hospitalized or disabled from working,
or the period for which the employer has undertaken the
payment of the employee’s regular wage in such case,
whichever is longer.
Coverage must also be offered to the employee’s covered
dependents. Extended coverage of 36 months must be
made available to covered dependents who are spouses
of deceased employees, legally separated or divorced
spouses of current employees, Medicare-ineligible
dependents of employees entitled to Medicare, and
children of current employees who lose coverage because
of their age.
For more information, call the Hawaii Department of Labor
and Industrial Relations at 586-9188 on Oahu.
11
Important Health Care Laws (continued)
HIPAA: The Health Insurance Portability and Accountability
Act of 1996 (HIPAA). The HIPAA Privacy Rule set boundaries for the appropriate uses and disclosures of protected
health information. It also requires health care providers,
plans, and clearinghouses to have policies and procedures
in place to protect the privacy of member information.
Refer to your legal counsel for more information. If you
need information about individual plan options, please
contact your account representative or your local HMSA
office.
HIPAA limits HMSA from disclosing protected health
information to an employer or plan administrator if the
HIPAA privacy regulations or HMSA’s privacy policies don’t
expressly permit the disclosure.
Qualified Medical Child Support Order (QMCSO):
The Omnibus Budget Reconciliation Act of 1993
(OBRA ‘93) added Section 609 to ERISA. The act requires
all employers to honor Qualified Medical Child Support
Orders by providing group health plan benefits for children
whose parents are divorced or separated. All employers must honor QMCSOs received on or after August 10,
1993. HMSA will help employers meet their requirements
for QMCSOs. For more information, refer to the section
on Sample Administrative Procedures for QMCSOs in this
guide or contact the U.S. Department of Labor at
(626) 229-1000.
In such cases, we’ll require the authorization of the enrollee
who is the subject of that information before we disclose
the information. HIPAA was also designed to help
employees maintain access to health coverage as they
change employers or when they leave their employer and
seek an individual health plan. Key provisions include
requirements to apply an individual’s prior health
coverage under a group health plan toward meeting
pre-existing exclusion periods under another group or an
individual health plan.
TEFRA: The Tax Equity & Fiscal Responsibility Act of
1982 requires employers of 20 or more employees to offer
working employees and their spouses the same health
coverage as employees under 65 if either the employee or
spouse is 65 or older and eligible for Medicare. The group
plan becomes primary and will pay benefits first, before
Medicare pays. Refer to your legal counsel for more
information.
HIPAA states that employees who enroll in a new group
plan within 63 days of their prior coverage will receive
“credit” for prior plan coverage. Prior creditable coverage includes coverage under their previous employer’s
group plan, an individual plan, and continuing coverage
under government programs such as Medicare, Medicaid,
QUEST, and TRICARE. The law also limits exclusion
periods for pre-existing conditions in group plans by
applying or crediting previous periods of health plan
coverage toward those exclusion periods. It also limits
pre-existing condition exclusion periods to a maximum
of 12 months for certain individuals (18 months for late
enrollees).
USERRA: The Uniformed Services Employment
and Reemployment Rights Act, signed into law on
October 13, 1994, requires employers to offer up to
24 months of continuation coverage to employees who
take military leave and their dependents. If the health plan
coverage would terminate because of an absence due to
uniformed service, the employee and their dependents
may elect to continue the health plan coverage for up to
24 months after the absence begins or the period of
services, whichever is shorter.
Under the new federal law, it’s the employer’s responsibility
to provide certificates of coverage for all former employees
who have been canceled from the group plan after June 1,
1997. But the law also states employers can contract with
an issuer to provide the certificates for them. As a service
to employer groups, HMSA has elected to perform this
service. The certificate will be important to those employees exiting the group health plan who will join a health plan
that imposes exclusion periods for pre-existing conditions.
This could be an individual plan or a group health plan in
another state.
The law is very similar to COBRA except for two important
differences. First, it applies to all employers; COBRA
generally exempts employers that have fewer than 20
employees. Second, if the military leave is longer than
30 days, employers can charge up to 102 percent of the
premiums. If the leave is 30 days or less, employers can
only charge up to the active employee’s share of the
premiums. On return from service, health insurance coverage must be reinstated without any waiting periods or
exclusions for pre-existing conditions, other than waiting
periods or exclusions that would have applied had there
been no absence for uniformed service.
If a former employee seeks coverage under an individual
plan, HIPAA eligibility will affect their access to coverage.
To be considered eligible under HIPAA, an individual must:
1.Have had 18 months of continuous creditable
coverage with their most recent coverage by a
group health plan;
2.Be ineligible for group coverage, Medicare,
Medicaid, QUEST, or other health insurance; and
3.Be ineligible for COBRA or have accepted and
exhausted COBRA coverage.
12
Domestic Partnership: HMSA will offer domestic
partnership and reciprocal beneficiary coverage if
requested by an employer group. The request must be
submitted to HMSA and approved by your account
representative.
c) A requirement that the dependent will no longer
be eligible for coverage upon the issuance of a
marriage license to either party to the reciprocal
beneficiary relationship.
The following documents must be submitted by the
employer to the account representative for domestic
partnership coverage:
Reciprocal beneficiaries are not qualified beneficiaries
under COBRA and, therefore, they are not eligible for
COBRA coverage. When they are terminated from group
coverage, they are eligible to enroll in individual conversion
plans.
1.A copy of the group’s domestic partnership benefit
policy, which must include:
a) Definition of domestic partners.
b) Benefits, both health and non-health, for which
domestic partners and their dependents are
eligible.
Civil Union: The Hawaii law relating to civil unions, Act 1
of the 2011 Legislature (Act), became effective January
1, 2012. The Act provides that a person who meets the
requirements of a civil union partner as set forth in the Act
has all the same rights, benefits, protections, and responsibilities as are granted to a married spouse.
c) A requirement that the employee provide
evidence showing financial interdependency
and joint residency.
2.A copy of the group’s enrollment and termination
guidelines for domestic partners.
3.A letter of confirmation from the employer stating
that all health plan carriers will provide coverage
for domestic partners.
HMSA will add as a dependent anyone who the employer
identifies as an eligible civil union partner, provided the
employer follows all other HMSA requirements of enrollment for that person. Employers must make their own
determination as to whether dependents have met the
requirements of the Act and should be enrolled.
Domestic partners are not qualified beneficiaries under
COBRA and, therefore, are not eligible for COBRA
coverage. When they are terminated from group coverage,
they are eligible to enroll in individual conversion plans.
For more information, please visit hmsa.com.
Reciprocal Beneficiary: The following documents must
be submitted by the employer to your HMSA account
representative for reciprocal beneficiary coverage:
1.A copy of the group’s reciprocal beneficiary benefit
policy, which must include:
a) Definition of reciprocal beneficiary.
b) Benefits, both health and non-health, for which
reciprocal beneficiaries and their dependents
are eligible.
3.A letter of confirmation from the employer stating
that all health plan carriers will provide coverage
for reciprocal beneficiaries.
2.A copy of the group’s enrollment and termination
guidelines for reciprocal beneficiaries, which, in
accordance with Hawaii Revised Statutes § 572C,
must include:
a) A requirement that a valid Certificate of
Reciprocal Beneficiary Relationship be issued
by the Department of Health before enrollment.
b) A requirement that the dependent will no longer
be eligible for coverage upon the issuance of a
Certificate of Termination of Reciprocal
Beneficiary Relationship by the Department
of Health.
13
Eligibility – General Procedures
Guidelines When Administering a Variety of Medical
and Dental Plans
HMSA has developed guidelines to help protect employers
from rising health care costs. Many employers are
providing their employees with health care options, such
as a choice of medical plans and riders. The objective is to
maintain a balanced membership basis in the community
that encourages stability in plan costs. HMSA’s guidelines
serve to support the community and defend HMSA from
situations where plan costs could unnecessarily rise due to
adverse selection.
•More than one HMSA medical plan: HMSA has a
range of medical plans to meet employer needs,
such as our preferred provider organization,
CompMED, and health maintenance organization
plans. Employers may offer more than one
medical plan to provide their employees with a
choice of coverage, as long as the plans are
sufficiently different in plan type. An employer may
not offer the “A” status and “B” status preferred
provider plans side by side. However, an employer
may offer the Preferred Provider Plan, CompMED,
and HMO plans as these plan types provide a
contrasting range of benefits that offer your
employees variety in coverage types.
This section will give you basic eligibility guidelines for
HMSA’s medical plans, dental plans, drug/vision riders,
and supplemental medical benefit riders.
General Eligibility for HMSA Group Medical and
Dental Plans
•Membership is limited to owners (other than sole
proprietors) and eligible active employees of your
organization. Partners, officers, or directors of
corporations are considered employees if they
are directly involved and participate in the
day-to-day operation of the business. Owners,
partners, officers, and directors must receive a
salary from the company to qualify for coverage
under their group plan.
Additionally, when offering these health care plans,
the package benefits should be relatively equitable.
For example, an employer should offer riders with
both medical plan choices and contribute to both
plans equally. This prevents employees from
selecting a plan based solely upon benefit value or
cost. Presently, plan choices that are balanced in
benefits and employee contribution allow employees
to select the plan that best meets their needs.
•Employees may enroll their spouse and eligible
dependents (see Terms and Definitions for eligible
employees and dependents).
•Employees who wish to enroll in an HMSA
group health plan may do so upon their initial
eligibility. Transfers from one HMSA plan to
another are allowed only during the annual open
enrollment period (see Terms and Definitions).
Employees who choose to end their group health
plan membership outside of an open enrollment
period will be eligible to re-enroll at the next annual
open enrollment period.
•Other non-HMSA medical and dental plans:
HMSA will not offer this contract in conjunction with
another non-HMSA free choice or Preferred Provider
Organization medical or dental plan option. At such
time a non-HMSA plan is added to the group plan
options, the HMSA medical or dental plan will be
canceled immediately.
•HMSA reserves the right to audit the group at
its discretion for compliance with group and
membership eligibility and enrollment requirements.
This includes proof of dependent relationships.
Under circumstances of fraudulent enrollment,
cancellation will be immediate and any premiums
paid for an ineligible employee will be returned by
HMSA. Any benefits paid out by HMSA for ineligible
employees in excess of premiums collected will
become the group’s liability.
14
Dependent Maximum Age Limit:
•Retirees: In most cases, retirees are not eligible
for coverage under an employer group health plan
since they are not considered actively employed.
HMSA has individual and senior plans that retirees
may enroll in for medical coverage. However, on an
exception basis, HMSA may allow the continuation
of group plan coverage to all retirees of the group.
See your account representative for more
information.
There are some conditions where continued coverage is
available for dependents who would otherwise be ineligible
due to maximum age limit of the plan.
•A disabled dependent may be eligible for
continuous coverage if they meet all of the
specified criteria defining a child with special
needs (see Terms and Definitions).
• Independent Contractors: Independent contractors
are not considered employees of a group and are not
eligible for enrollment under the group health plan.
HMSA has plans for sole proprietors and selfemployed individuals that are available for
independent contractors working in the state of
Hawaii on a full-time basis. In special situations,
HMSA may evaluate requests from groups to cover
all independent contractors in an equitable manner
under the group health plan. Please contact your
account representative for more information.
•Canceled dependents may not continue their health
coverage under the employer group plan unless the
employer group is affected by COBRA (see Health
Care Laws). They may, however, be eligible for
conversion coverage to an HMSA Individual Plan.
•For more details, please contact your account
representative.
Members Age 65: HMSA members who reach the age of
65 will be sent a letter concerning their Medicare status.
If they are no longer eligible for a group plan, they may
apply for an HMSA senior plan if they have Medicare Parts
A and B or Part B only. Members should apply at least 60
days prior to the cancellation of their group plan to ensure
continuous coverage.
•Non-Employed Family Members: Relatives who
are not employed by the company are not eligible for
group health plan enrollment except for legal
spouses or eligible children. Family members who
are employees may be enrolled provided their
employee benefits are administered in the same
manner as non-family employees.
Actively employed individuals age 65 or older who are
eligible for Medicare will have benefits paid by their group
plan coverage first, then by Medicare, if the group has 20
or more employees (see Health Care Laws—TEFRA).
Persons Not Eligible for Group Coverage
HMSA group plans are designed to assist employers in
complying with the requirements of the Hawaii Prepaid
Health Care Act. The law mandates employers to provide
health care coverage for active employees who receive
compensation from their employer. The employer is also
responsible for deductions such as FICA and state and
federal taxes.
If an employer has members enrolled under their group
plan who do not meet HMSA’s guidelines defining an
eligible employee, those individuals must be cancelled
from the HMSA group health plan (such as listing an
individual on the group plan that has less than the
minimum number of work hours required, or listing an
out-of-state individual on the group plan who is not
actually working for the group). HMSA will work with the
employer to determine suitable alternate coverage options
for that individual.
15
Enrollment – General Information
•Open Enrollment Period is when your employees
and their eligible dependents who did not join HMSA
when they were first eligible may enroll. During this
period, members may also change their medical and
dental plans.
•New Eligible Dependents such as newborn
children, newly married spouses, and adopted
children, must be added to the HMSA plan within
31 days of the qualifying event. A qualifying event
would be the birth date, marriage date, adoption
date, or date a minor child is placed for adoption and
the member has assumed a legal obligation for total
or partial support. For eligible newborns, HMSA will
enroll the baby effective from the date of birth. For
other dependents, coverage becomes effective the
first of the month following the date of the qualifying
event, provided HMSA receives notice within the
appropriate time frame.
HMSA offers group-sponsored prepaid medical plans.
Monthly dues must be paid on or before the first of the
month for that month’s coverage. If the group becomes
30 days delinquent in payment, it will be canceled.
• Change of Employment Status: For example, an
employee changes from part time to full time. On the
HMSA Membership Report form, you would provide
an explanation in the “Action Request” column such
as “part time to full time on (date),” and list the
effective date for this coverage to begin.
When Can Your Employees and Their Dependents
Enroll?
•When HMSA receives an enrollment form,
membership will be effective on the first of the
month following the receipt of the required
enrollment forms.
•Loss of Coverage Under Spouse’s GroupSponsored Plan occurs when your employee is
covered under their spouse’s group plan and that
spouse loses coverage. Your employee and their
dependents are then eligible for coverage under
your group plan. Submit an enrollment form and
Membership Report form; in the Action Requested
column, include an explanation such as “spouse lost
coverage due to termination on (mm/dd/yy),” and
provide an effective date for this coverage to begin.
Example: HMSA receives an enrollment form on
July 20, so the effective date of coverage for this
employee would be the first of the following month
or August 1.
•If a person does not enroll when they first become
eligible, your company will be liable for any claims
incurred during the period of non-coverage. HMSA
will not accept retroactive enrollment unless there
was an unusual and justifiable cause for late
enrollment.
•Initial Enrollment Period is when new
employees can enroll for the first of the month
following their hire date or the first of the month
following completion of four consecutive weeks of
employment, working 20 or more hours a week.
Employees must also add eligible dependents at
this time.
Example: An employee is hired on June 11. That
employee can be enrolled the first of the following
month or July 1. However, should the company
require the employee to work four consecutive
weeks at 20 hours or more a week, the employee
would become eligible on July 11, and the effective
date of coverage for this employee would be the first
of the following month or August 1.
16
Electronic Enrollment
To learn more about HMSA Enroll, visit
www.hmsaenroll.com/start/.
Employers can administer their employees’ health plan
enrollment process online using HMSA Enroll. This Web
tool’s convenient, easy-to-use features allow you to:
For registered users, visit www.hmsaenroll.com and
enter your user ID and password.
•View new enrollment benefit elections.
•Add new employees.
•Make changes to existing employee records.
•Cancel existing employees.
•View new enrollment benefit elections
•Generate detailed reports on demand to manage
employee eligibility.
17
Enrollment – General Information (continued)
To enroll an employee, you must submit the following
forms to HMSA. To avoid delay in enrollment, please be
sure that all items are completed and signed.
Once all forms are completed, send them electronically
using HMSAenroll or by mail to:
• HMSA Medical/Dental Plan Enrollment Form
•Membership Report form
HMSA
Membership Service Department
P.O. Box 860
Honolulu, HI 96808-0860
75610-1
Group No. ______________________
HMSA MEDICAL/DENTAL PLAN ENROLLMENT FORM
Aloha, Inc.
Employer ______________________
PLEASE PRINT OR TYPE IN BLUE OR BLACK INK. REFER TO THE BACK FOR ENROLLMENT INSTRUCTIONS.
A
EMPLOYEE DATA:
FOR HMSA USE ONLY
Last Name
First (Legal)
Kealoha
M. I. Suffix Gender Birthdate: (mm/dd/yyyy)
M/F
O
K
John
Mailing Address (Number & Street or P.O. Box Number)
City
1997 Mahalo Lane
Social Security No. (See Section A on reverse side for additional
information on submission of SSN)
SELECTING YOUR COVERAGE:
My Present or Former HMSA No.
ENROLLMENT DATA:

pleX
HMO Medical Plan
X

CompMED
m
a
S
Health Plan Hawaii Plus
LEGAL NAME
M. I. Suffix Gender
APP RCV DATE _____________ PROC DATE ___________
TRX ______________ _______________ _______________
______________ _______________ _______________
HMSA’s Choice Dental Plan (Select one)
HMO Dental Plan
Free Choice Dental Plan
Participating Provider Dental Program

Dental Network Program
mm
dd
SOCIAL SECURITY NO. COMPLETE THIS SECTION IF YOU SELECTED AN HMO MEDICAL PLAN
(over age 18) See Sec C on reverse side
yyyy
Health Center
Personal Care Physician
Current
Physician?
X
Yes
Kealoha
Leilani
F
Child
M/F
Y/N
Y/N
M/F
Child
Y/N
M/F
Child
Y/N
M/F
Child
Y/N
M/F
OTHER INSURANCE:
DO YOU OR YOUR DEPENDENTS HAVE OTHER COVERAGE (INCLUDING HMSA)?
Name of Other Policy Holder
Other Policy Holder’s ID No.
Leilani Kealoha
CONDITIONS OF ENROLLMENT:
_
_
_
_
_
_
_
_
_
_
_
_
123-45-7890
01 13 1967
M/F
Child
E

Full Time
Student
BIRTHDATE
First Name
Employee
(Self)
D
CONT __________ PKG __________ DEPT. NO. _________
545-5678
IF YOU SELECTED AN HMO MEDICAL PLAN, ENTER A HEALTH CENTER AND PERSONAL CARE PHYSICIAN FOR YOU AND YOUR DEPENDENTS.
Last Name
Spouse
EFF. DATE _______________ GROUP NO. _____________
If you are currently the subscriber of an HMSA Individual
Plan and wish to cancel that membership, please submit
a separate cancellation request in writing.
**If selecting this plan, indicate desired
Health Center AND Personal Care Physician
in Section C below
C
555-1234
PLEASE CHECK WITH YOUR EMPLOYER REGARDING THE MEDICAL AND DENTAL PLAN OPTIONS.
Free Choice Medical Plan
Preferred Provider Plan
SUB ID NO. ________________________________________
Home Phone No.
96813
HMSA’s Choice Medical Plan (Select one)

Zip Code
HI
987 _ 65 _ 4321 R98765432
B
05-17-1965
State
Honolulu
Work Phone No.
X
YES
43-015761320
NO
Oahu Physician Group
Dr. Richard Oh
Yes
Yes
Yes
Yes
Yes
Yes
IF YES, COMPLETE THE FOLLOWING:
Name of Other Health Plan
Other Health Plan’s Phone Number
Aetna
645-8774
READ, SIGN AND DATE BELOW.
If I am accepted for coverage under a medical plan that requires selection of a personal care physician, all benefits must be provided or arranged by my personal care physician. I further understand that as an HMSA member, I agree: (a) to
abide by the HMSA’s constitution and by-laws, and terms and conditions of the health/dental plan; (b) to provide information to HMSA about my current or future medical treatment or condition; and (c) to appoint my employer or group as
my agent for dues payment and for sending and receiving all notices to and from HMSA concerning the health/dental plan.
John Kealoha
Signature _______________________________________________________________________
Form No. 4000-114 (02/09)
01 04 10
Date _____/_____/_____
SEE REVERSE SIDE
18
White - HMSA
Yellow - HMSA/OPL
Pink - GROUP
January 20, 2010
ABC Inc.
65432
955-2468
100 King Street Suite #333 Honolulu, HI 96814
Brandon Pratt
12
R10362317
Mark Young
12
R10531047
Angie Turner
1
1
ple
m
a
S
M 02-01-10 New employee hired on 12-29-09
M 02-01-10 Part-time to Full-time 01-12-010
F 02-01-10 Spouse losing coverage 01-31-10
Doug Young
Doug Young
19
Enrollment (continued)
How to Enroll Your Employees & Dependents
ENROLLMENT INSTRUCTIONS
Complete all applicable fields to minimize delay in processing. You may not be entitled to all of the plans shown on this enrollment form. Only
select plans that your employer states are available. See your employer if you have any questions.
SECTION A - EMPLOYEE DATA: complete your legal name (last name, first name, middle initial, generational suffix such as Jr, III), gender (M or
F), birth date, work phone number, mailing address, home phone number, and social security number. Important Note: Section 111 of the
Medicare, Medicaid and SCHIP Extension Act (MMSEA) of 2007 (P.L. 110-173) and 42 U.S.C. 1395y(b)(7), requires HMSA to report social
security numbers for anyone on this Plan age 55 and over or for anyone on this Plan who is otherwise eligible to receive Medicare benefits
regardless of age. Effective January 1, 2011, HMSA is required to include anyone on this Plan age 45 and over.
Enter your present or former HMSA number, if any. If you are currently enrolled in an HMSA Individual Plan (PPO Conversion Plan, Individual
Business Plan, Individual Care Plan, Plan 6, Student Plan 19, HPH Conversion Plan or 65C Plus), and would like that coverage canceled, please
submit a signed letter (include your Subscriber Number) stating you wish to cancel your individual plan coverage to: Hawaii Medical Service
Association; P.O. Box 3500; Honolulu, HI 96811-3500. The cancellation will be effective on the first of the month following the receipt of the letter.
SECTION B - SELECTING YOUR COVERAGE: select one of the medical plan options from HMSA’s Choice Medical Plan. If you select an
HMO Medical Plan, enter a Health Center and a Personal Care Physician in Section C.
If your employer offers a dental plan, select one of the dental plan options from HMSA’s Choice Dental Plan.
SECTION C - ENROLLMENT DATA: list the legal name (last name, first name, middle initial, generational suffix such as Jr, III), gender (M or F),
birth date, and social security number for your spouse and each dependent child who you wish to cover under your selected plan. If a dependent
child is a full-time student over the age of 18, circle “Y”; if not, circle “N”. Important Note: Section 111 of MMSEA (P.L. 110-173) and 42 U.S.C.
1395y(b)(7), requires HMSA to report a social security number for anyone on this Plan age 55 and over or for anyone on the Plan who is eligible
to receive Medicare benefits. Effective January 1, 2011, HMSA is required to include anyone on this Plan age 45 and over or anyone on this Plan
who is otherwise eligible to receive Medicare benefits regardless of age.
If you selected an HMO Medical Plan in Section B, such as Health Plan Hawaii Plus, you must enter a Health Center and the full name of a
Personal Care Physician for yourself, your spouse, and each dependent child. In the Current Physician box, check “Yes” for you, your spouse,
and each dependent child if the physician you selected is the current physician. Note: some Personal Care Physicians are not accepting new
patients. For a current list, reference the current Directory of Health Centers and Providers or on the Internet at www.HMSA.com and click on
“Find a Doctor”.
SECTION D - OTHER INSURANCE: Check “Yes” to indicate if you, your spouse, or any of your dependents are also covered by any other group
health plan (including HMSA or Medicare). If you check “Yes”, enter the other policy holder’s name, the other policy holder’s ID number, the name
of the other health plan, and a phone number for the other health plan.
SECTION E - CONDITIONS FOR ENROLLMENT: sign and date the enrollment form.
20
75610-1
Group No. ______________________
HMSA MEDICAL/DENTAL PLAN ENROLLMENT FORM
Aloha, Inc.
Employer ______________________
PLEASE PRINT OR TYPE IN BLUE OR BLACK INK. REFER TO THE BACK FOR ENROLLMENT INSTRUCTIONS.
A
EMPLOYEE DATA:
FOR HMSA USE ONLY
Last Name
First (Legal)
Kealoha
M. I. Suffix Gender Birthdate: (mm/dd/yyyy)
M/F
O
K
John
Mailing Address (Number & Street or P.O. Box Number)
City
1997 Mahalo Lane
Social Security No. (See Section A on reverse side for additional
information on submission of SSN)
SELECTING YOUR COVERAGE:
Zip Code
HI
My Present or Former HMSA No.
555-1234
ENROLLMENT DATA:

X
CompMED
______________ _______________ _______________

X
Full Time
Student
BIRTHDATE
First Name
M. I. Suffix Gender
mm
dd
Participating Provider Dental Program

Dental Network Program
SOCIAL SECURITY NO. COMPLETE THIS SECTION IF YOU SELECTED AN HMO MEDICAL PLAN
(over age 18) See Sec C on reverse side
yyyy
Employee
(Self)
Health Center
Personal Care Physician
Current
Physician?
X
Yes
Kealoha
Leilani
F
Child
M/F
Y/N
Y/N
M/F
Child
Y/N
M/F
Child
Y/N
M/F
Child
Y/N
M/F
OTHER INSURANCE:
DO YOU OR YOUR DEPENDENTS HAVE OTHER COVERAGE (INCLUDING HMSA)?
Name of Other Policy Holder
Other Policy Holder’s ID No.
Leilani Kealoha
CONDITIONS OF ENROLLMENT:
_
_
_
_
_
_
_
_
_
_
_
_
123-45-7890
01 13 1967
M/F
Child
E
HMO Dental Plan
Free Choice Dental Plan
Health Plan Hawaii Plus
LEGAL NAME
D
TRX ______________ _______________ _______________
IF YOU SELECTED AN HMO MEDICAL PLAN, ENTER A HEALTH CENTER AND PERSONAL CARE PHYSICIAN FOR YOU AND YOUR DEPENDENTS.
Last Name
Spouse
APP RCV DATE _____________ PROC DATE ___________
HMSA’s Choice Dental Plan (Select one)
HMO Medical Plan
**If selecting this plan, indicate desired
Health Center AND Personal Care Physician
in Section C below
C
CONT __________ PKG __________ DEPT. NO. _________
545-5678
96813
HMSA’s Choice Medical Plan (Select one)
Preferred Provider Plan
EFF. DATE _______________ GROUP NO. _____________
Home Phone No.
PLEASE CHECK WITH YOUR EMPLOYER REGARDING THE MEDICAL AND DENTAL PLAN OPTIONS.
Free Choice Medical Plan

SUB ID NO. ________________________________________
If you are currently the subscriber of an HMSA Individual
Plan and wish to cancel that membership, please submit
a separate cancellation request in writing.
987 _ 65 _ 4321 R98765432
B
05-17-1965
State
Honolulu
Work Phone No.
X
YES
43-015761320
NO
Oahu Physician Group
Dr. Richard Oh
Yes
Yes
Yes
Yes
Yes
Yes
IF YES, COMPLETE THE FOLLOWING:
Name of Other Health Plan
Other Health Plan’s Phone Number
Aetna
645-8774
READ, SIGN AND DATE BELOW.
If I am accepted for coverage under a medical plan that requires selection of a personal care physician, all benefits must be provided or arranged by my personal care physician. I further understand that as an HMSA member, I agree: (a) to
abide by the HMSA’s constitution and by-laws, and terms and conditions of the health/dental plan; (b) to provide information to HMSA about my current or future medical treatment or condition; and (c) to appoint my employer or group as
my agent for dues payment and for sending and receiving all notices to and from HMSA concerning the health/dental plan.
John Kealoha
Signature _______________________________________________________________________
Form No. 4000-114 (02/09)
01 04 10
Date _____/_____/_____
SEE REVERSE SIDE
21
White - HMSA
Yellow - HMSA/OPL
Pink - GROUP
How to Add a New Employee –
Membership Report Form Instructions:
1. DATE: Print today’s date.
14.SIGNED: Be sure the Membership Report form is
signed by the group leader or authorized person.
The signature is necessary before HMSA can accept
the request. Also, print the name of that authorized
person.
2. FROM: Print name of company or group.
3.GROUP NUMBER: Group number can be found in the
upper right-hand corner on the first page of the billing
statement (use only one group number per form).
Submit changes as soon as they occur – daily if you
choose, as this will help us keep your records updated on
a timely basis.
4. ADDRESS: Print your company’s mailing address.
5.PHONE NUMBER: Include your company’s phone
number.
6.HMSA NUMBER: Information is not necessary when
adding new employees.
7.NAME OF EMPLOYEE: Include the full legal name of
the employee.
8.PACKAGE#: Package number can be found on
Section 2 of the billing statement.
9.DEPENDENT’S NAME: If the employee is enrolling
dependents, it is not necessary to include their names
on the Membership Report form. This information will
be taken from the enrollment form.
10.DEPENDENT’S BIRTH DATE: If the employee is
enrolling dependents, it is not necessary to list the
dependent’s birth dates on the Membership Report
form. This information will be taken from the enrollment
form.
11.SEX: Indicate whether the employee is male or female.
12.EFFECTIVE DATE: Indicate the tentative effective date
of the employee’s HMSA membership.
13.ACTION REQUESTED: Use this section for
explanations and reasons for requesting action to:
•Add New Employee when Initially Eligible: Write
“New employee hired on (date).”
• Add Employee after Initial Eligibility:
If adding employee due to change in status,
write “Part-time to full-time on (date).”
Note: Dues Payment
Do not submit dues payment with the Membership
Report form; these changes will be reflected on the
following month’s bill.
If adding employee due to losing other coverage,
write “Spouse losing coverage due to termination
on (date).”
22
Adding Employees
& Dependents
January 20, 2010
ABC Inc.
65432
1
955-2468
Brandon Pratt
12
M 02-01-10 New employee hired on 12-29-09
R10362317
Mark Young
12
M 02-01-10 Part-time to Full-time 01-12-010
R10531047
Angie Turner
1
F 02-01-10 Spouse losing coverage 01-31-10
Doug Young
Doug Young
23
How to Add New Dependents – Membership Report
form instructions:
If adding child(ren) due to Legal Guardianship:
write “Adding dependent, Legal Guardianship date
(mm/dd/yy). Include date of birth under Dependent’s
Birthday column. A copy of the court document must
be attached to the Membership Report Form.
number.
Note: Court Document should include:
– Subscriber’s name
– Member’s HMSA Identification Number
– Date of Birth (if applicable, expected date of birth)
– Name of child(ren)
– Gender
6.HMSA NUMBER: Include the employee’s HMSA
number.
Note: Eligible for coverage only if reported within
31 days of the marriage, birth, or adoption.
7.NAME OF EMPLOYEE: Include the full legal name of
the employee.
signed by the group leader or authorized person. The
signature is necessary before HMSA can accept the
request. Also, print the name of that authorized person.
8.PACKAGE#: Package number can be found on
Section 2 of the billing statement.
9. DEPENDENT’S NAME: List the dependent’s name.
Once all forms are completed, send them to:
HMSA
P.O. Box 860
10.DEPENDENT’S BIRTH DATE: Include the dependent’s
birth date.
11.SEX: Indicate whether the dependent is male or
female.
Submit changes as soon as they occur— daily if you
choose, as this will help us keep your records updated on
a timely basis.
12.EFFECTIVE DATE: Indicate the tentative effective date
of the dependent’s HMSA membership.
If adding a spouse due to marriage, write “Adding
spouse - marriage date (mm/dd/yy)” and include date
of birth under Dependent’s Birthday column.
If adding child(ren), write “Adding dependent” and
include date of birth under Dependent’s Birthday
column. Note: Newborn dues for the first month will be
prorated according to the date of birth.
If adding adopted child(ren), write “Adding
dependent, adoption date (mm/dd/yy).” This date
may also be the date a minor child is placed for
adoption and the member has assumed legal
obligation for total or partial support. Include date of
birth under Dependent’s Birthday column. A copy of
the court documents must be attached to the
Membership Report Form.
Note: Dues Payment
Do not submit dues payment with the Membership
Report form; these changes will be reflected on the
following month’s bill.
24
Adding Employees
& Dependents
January 20, 2010
ABC Inc.
65432
955-2468
R10471326
John Gates
12
1
Maile Doo
06-30-70 F
02-01-10 Adding spouse - marriage 01-16-10
Doug Young
Doug Young
25
Cancellations – General Information
HMSA does not accept retroactive cancellations for
monthly dues credit or refund.
Membership cancellations are effective on the first day of
the month following the receipt of the request.
• Report cancellations as soon as possible.
•Termination: Members who terminate employment
may not continue their health coverage under their
employer group plan unless the employer group is
affected by COBRA (see Health Care Laws). They
may be eligible for conversion benefits under an
HMSA Individual Plan.
Membership will end when:
– The group contract ends,
– The group contract is terminated due to
non-payment,
– The employee chooses to end their coverage,
– Employees and dependents no longer meet
eligibility requirements,
– Consecutive non-payment for employee and
dependents, or
– Employees do not exercise their continuation
option under COBRA.
Employer Group Cancellation Procedures
Upon Request: Groups requesting cancellation of their
contract with HMSA must submit written notification.
This notification is requested 30 days in advance to
accurately process your request.
HMSA reserves the right not to renew the Group Plan
Agreement if the group has been cancelled more than
once within any 12-month period. In this case, if HMSA
renews the agreement with the group, the effective date of
coverage will be no earlier than six months from the date
of cancellation.
If a Group Plan Agreement is cancelled for non-compliance
with HMSA’s underwriting policies, HMSA may re-enroll the
Group Plan Agreement upon the group providing evidence
of compliance that is satisfactory to HMSA.
26
Name or Address Changes and Cancellations –
General Information
Group or Member Address Changes: You or your
employee can report an address change. There are
several ways to report the change — in person, online at
hmsa.com, or by mailing a completed Membership Report
form. When reporting the change, make sure you include
the full name of the employee, the membership number,
and the complete new address. Address changes should
be submitted as soon as possible to ensure prompt
claims payment.
Name Changes: Surname changes must be submitted
on the Membership Report form by indicating the former
name in the “Name of Employee” column and the new
legal name in the “Action Requested” column. If a name
change coincides with a contract-type change to add
a spouse, make the change on the Membership Report
form.
January 20, 2010
65432
ABC Inc.
1
955-2468
New group address
200 King Street
Suite 777
Honolulu, HI 96814
Doug Young
Doug Young
27
Cancellations – How to Cancel your Employees
How to Cancel Your Employees
To cancel employees, complete the Membership Report
form (see Example C - page 21) by following these
instructions:
number.
number.
7.NAME OF EMPLOYEE: Note the employee’s full legal
name as it was listed on the HMSA statement.
8.DEPENDENT’S NAME: Not necessary to fill out when
canceling employee; dependents will be
cancelled automatically.
9.DEPENDENT’S BIRTH DATE: Not necessary to fill out
when canceling employee; dependents will be
cancelled automatically.
10.SEX: Not necessary to fill out when canceling
employee.
11.EFFECTIVE DATE: List the requested effective date of
the cancellation.
Cancel Employee. Write “Cancel employee –
left employment/deceased/request (date).” This
request will cancel the employee and all dependents
covered with the employee.
Also print the name of that authorized person.
Once the form is completed, send it to:
HMSA
P.O. Box 860
28
Cancellng Employees
January 20, 2010
65432
ABC Inc.
R10362317
1
955-2468
Michael Jones
M 02-01-10 Cancel employee-left employment 01-12-10
Doug Young
Doug Young
29
Cancellations – How to Cancel your Dependents
How to Cancel Your Dependents
To cancel dependents, complete the Membership Report
form (see Example C - page 23) by following these
instructions:
number.
number.
7.NAME OF EMPLOYEE: Note the employee’s full name
as it was listed on the HMSA statement.
8.DEPENDENT’S NAME: List the dependent(s) to be
canceled.
9.DEPENDENT’S BIRTH DATE: Include the dependent’s
birth date.
10.SEX: Not necessary to fill out when canceling
dependents.
11.EFFECTIVE DATE: List the requested effective date of
the cancellation.
Cancel Spouse and/or Child(ren). Write
“Cancel dependent.”
Also print the name of that authorized person.
Once the form is completed, send it to:
HMSA
P.O. Box 860
30
Cancelling Dependents
January 20, 2010
65432
ABC Inc.
R10531047
Lani Kealoha
1
955-2468
Karl Kealoha
04-19-60
02-01-10 Cancel dependent
Doug Young
Doug Young
31
Billing – How to Read Your Bill
Your billing statement is divided into three sections
Section 1: Summary of the Current Billing Period
Section 2:Detailed Summary Sheet of Your Rates
& Benefits
Section 3: List of Your Covered Employees
Section 1 – Summary of the Current Billing Period
1.GROUP NUMBER: The unique number that identifies
your group. Following the group number is the
subgroup number and check digit, which further
identifies your group. Please be sure to use all of
these numbers when your group number is requested.
5.GRAND TOTAL DUE: This is the sum of your current
dues, arrears (retroactive additions, cancellations or
changes to your account), and payments past due
(amounts from previous bills if applicable).
6.PAYMENT COUPON: To avoid a delay in processing
your payment, detach and remit bottom portion of the
bill with your payment.
2.CURRENT BILLING PERIOD: “From” identifies the
start date covered by the bill. “To” identifies the date
the group was billed up to. This is one day after the
last day of coverage.
7.AMOUNT PAID: This is the amount of the total bill you
are paying.
3.BILLING ASSISTANCE: This is where the phone
number is located if you need to contact your billing
reconciliation representative who is assigned to help
you with any billing questions you may have.
4.BASIC COVERAGE: The sum of the group’s individual
subscriber billed amounts—current dues within the
group’s “bill from date” to the “bill to date.”
8.CHECK NUMBER: This is the number on the check
you are enclosing with your bill payment.
32
Section 2 – Detailed Summary of Your Rates & Benefits
1.COVERAGE: A brief description of your benefit
coverage by line of business.
Contracts
Current
Retro Amount
Two-Party
$625.19
$$$
Single$$$ credit
2.CONTRACTS: Indicates the type of subscribers
covered within each package (e.g., single, two-party,
family).
7.TOTAL AMOUNT: The sum of the current amount plus
the retro amount.
3.BILLED: Indicates the number of subscribers billed per
contract type.
8.TOTAL PACKAGE: These are the subtotals for the
number of subscribers, Current Amount column, Retro
Amount column, Total Amount column for a particular
package.
4.MONTHLY RATE: Indicates the package rate per
contract type.
9.TOTAL CURRENT PERIOD: The sum of the group’s
package subtotals. This field should correspond to the
basic coverage amount on the summary page (page 1)
of the current billing period.
5.CURRENT AMOUNT: This is the amount equal to the
number of subscribers in each contract type multiplied
by their corresponding monthly rate.
6.RETRO AMOUNT: This column should have a zero
balance except for those occasions when a change
to a subscriber’s status (e.g., changing contract types
– single to two-party) is submitted requesting coverage for the same billing period and the bill has already
been generated. In this case, the following month’s bill
will show a “retro amount” to be paid for the difference
between the single and two-party rate for which the
subscriber was covered but not yet billed.
10.TOTAL PRIOR UNPAID BILLS: The sum of the group’s
past due amounts. This field should correspond to the
payment past due indicated on the summary page
(page 1) of the current billing period.
NOTE: If there is no past due amount, there will be no
payment past due field on the summary sheet.
TOTAL AMOUNT DUE: The sum of the total current
period plus the sum of the total prior unpaid bills. This field
should correspond to the grand total due indicated on the
summary page (page 1) of the current billing period.
For example, this billing has already been generated
and HMSA receives a change in contract type from
single to two-party. Next month’s bill will reflect the
following:
33
Billing – How to Read Your Bill (continued)
Section 3 – Detail of Subscribers for Current Billing Period
1.SUBSCRIBER IDENTIFICATION NO.:
A unique number assigned to the subscriber.
8.RETRO AMOUNT: This column should have a zero
balance except for those occasions when a change
to a subscriber’s status (e.g., changing contract types
– single to two-party) is submitted requesting coverage for the same billing period that the bill has already
been prepared for. In this case, the following month’s
bill will show a “retro amount” to be paid for the
difference between the single and two-party rate for
which the subscriber was covered but not yet billed.
2.SUBSCRIBER NAME: Identifies the name of the
subscriber.
3.FROM: Identifies the start date covered by the bill.
4.TO: Identifies the date the group was billed up to for
the subscriber’s coverage.
9.TOTAL AMOUNT: The sum of the current amount plus
the retro amount.
5.CONT TYPE (CONTRACT TYPE): Indicates the type
of contract that covers this subscriber (e.g., single,
two-party, family).
10.PACKAGE NUMBER: Identifies the package the
subscriber is enrolled under.
6.TYP CHG (TYPE CHANGE): Indicates a code for any
maintenance performed during the current billing
period. The codes are as follows:
11.SUBTOTAL PACKAGE: The subtotal figures for your
group’s current amount, retro amount, and total
amount for a particular package.
A = Add
B = Benefit Changes
C = Cancellation
7.CURRENT AMOUNT: Indicates the subscriber’s dues
payment (package rate).
12.TOTAL CURRENT BILLING PERIOD: The sum of your
group’s package subtotals. This field should
correspond to the basic coverage amount on the
summary page (page 1) of the current billing period.
34
Billing – How to Pay Your Bill
HMSA’s billing service makes it simple, because you just
pay as billed.
4. Retain the rest of the bill for your records.
To verify the GRAND TOTAL DUE, compare the list of
covered employees (in Section 3 of your bill) with our
records. Changes not received by HMSA by the first
of the prior month may not be reflected on your current
statement.
1.The GRAND TOTAL DUE is located in the middle of
page 1. Simply pay the amount shown.
2.Fill in the amount paid and your check number in the
space provided (lower left-hand corner of the bill).
3. Detach the bottom portion from the rest of the bill and
mail it with your payment in the r eturn envelope
provided to:
Example: Changes received after 05-01-10 may not
reflect on your [06-01-10 to 07-01-10] billing statement.
HMSA
P.O. Box 29330
If you have any questions concerning your bill, call the
Billing Reconciliation Representative who has been
assigned to your group and have your group number
available. Your Billing Reconciliation Representative’s
phone number can be found on page 1, Section 1,
of your bill.
Note: Monthly dues must be paid with a bankimprinted company check, unless other arrangements
for payment have been made in advance with your
account representative.
Note: Group payments not received by the due date
are considered late and may be subject to delinquency
notices and late fees.
Please do not enclose enrollment forms and
membership report forms with dues payments.
35
Billing – How to Pay Your Bill (continued)
Non-Payment
In the event the group fails to pay monthly dues on or
before the due date, HMSA may terminate the Group Plan
Agreement for failure to pay dues, unless all dues are
brought current within 10 days of HMSA’s providing
written notice of default to the group. HMSA will not be
liable to pay any benefits for services rendered after the
date of termination.
•If the group plan is canceled for reason of
non-payment of dues, HMSA may re-enroll the
group under another Group Plan Agreement if all
dues are brought current and all other membership
requirements are met. Initial dues must be paid in
the form of a cashier’s check or money order, and
must be received prior to the new effective date of
coverage, which will be the first day of the month for
which dues are paid.
•HMSA reserves the right not to renew the Group
Plan Agreement if the group has been canceled more
than once within any 12-month period. In this case,
if HMSA renews the agreement with the group, the
effective date of coverage will be no earlier than six
months from the date of cancellation.
•If a Group Plan Agreement is canceled for reason of
non-compliance with HMSA’s underwriting policies,
HMSA may re-enroll the Group Plan Agreement upon
the group providing evidence satisfactory to HMSA
of compliance.
Policy on Checks Returned for Insufficient Funds
Returned checks require additional time and administrative
expense to properly reflect the payment status of the
individuals or groups. HMSA will assess a service fee for
each returned check to help defray the costs incurred.
Mail payments to:
HMSA
P.O. Box 29330
Mail Enrollment Forms and Membership Reports to:
HMSA
P.O. Box 860
Please do not enclose enrollment forms or
membership report forms with dues payments.
36
General Information – Terms and Definitions
Disabled Dependent: Your child may be eligible if they
are disabled and you provide us with written documentation acceptable to us demonstrating that:
Health Center: A health center is a group of private
providers who have joined together to provide health
care services to the members of an HMO plan. Enrolled
members and dependents receive all of their routine and
specialty care from providers within their chosen health
center. A health center can sometimes be a single building,
where all of the providers practice, such as Straub Clinic.
Other health centers, such as Pacific Health Care, include
providers who are not in the same physical location and
practice from their own private offices located throughout
the island.
•Your child is incapable of self-sustaining support
because of a physical or mental disability.
•Your child’s disability existed before the child
reached your plan’s dependent age maximum limit.
•Your child relies primarily on you for support and
maintenance as a result of their disability.
Health Maintenance Organization (HMO): A health
maintenance organization provides a broad range of health
care services, including preventive care for its members.
All health care (or that care which the HMO states it will
provide) is received from one health center that has been
pre-selected by the member. Employees enrolling in HMO
plans must select a primary care provider (PCP) and
corresponding health center.
–Your child is enrolled and has had continuous
health care coverage with us since before the
plan’s dependent age maximum limit. (Please refer
to your current plan’s Guide to Benefit for details
regarding the dependent maximum age limit).
Eligible Dependent: Your child may be eligible if they
meet all of these requirements:
Medicare Advantage Prescription Drug (MAPD) Plan:
A plan with a Medicare contract that offers Local PPO
and Regional PPO plans. To be eligible for an MAPD plan,
members must have Medicare Part A and Part B, pay
Medicare premiums, and live within the service area.
•The child is your son, daughter, stepson or
stepdaughter, your legally adopted child, or a child
placed with you for adoption, a child for whom you
are the court-appointed guardian, or eligible foster
child (defined as in individual who is placed with you
by an authorized placement agency or by judgement, decree, or other court order.
Participating Provider: Physicians, dentists, and other
health care providers who have agreed to accept HMSA’s
benefit payment along with the patient’s copayment as
payment in full.
•The child is under your plan’s dependent maximum
age limit. (Please refer to your current plan’s
Guide to Benefit for details regarding the dependent
maximum age limit).
Primary Care Provider (PCP): Your personal doctor who
will coordinate all of your health care needs. A PCP is an
internist, general practice doctor, family practice doctor, or
pediatrician. Some obstetricians/gynecologists (ob-gyns)
may be willing to be your personal care provider.
A PCP is required for all HMO plans; a member must
select one to be enrolled.
Eligible Employee: A person employed for at least 20
hours a week for four consecutive weeks, where employee
benefits (including wages or salary) and taxes (i.e., FICA,
Unemployment Insurance, etc.) are paid for the employee
by the employer.
Spouse: The member’s legally married spouse. The state
of Hawaii does not recognize common-law marriages.
Employer Group: A person or organization who hires the
services of a person in exchange for employee wages,
benefits and taxes (i.e., FICA, Unemployment Insurance,
etc.), which are paid for the employee by the employer.
The employer must meet all state and federal employer
requirements, have a General Excise Tax License,
Department of Labor Number, Unemployment Insurance,
and Federal ID numbers. The employer must be doing
business activity or commerce in Hawaii with employees
residing in the state. HMSA may give special consideration
to employees who reside out of state. The group must
submit a detailed description and evidence of the nature of
its business to HMSA.
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Notes:
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Notes:
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HMSA is a Hawaii-based health care services organization dedicated, for over 70 years,
to improving the health and wellness of individuals and our community. We provide our
customers real value and security by creating a broad range of products that gives them
choices of health care plans, provider networks, prices, and other health care services,
with a commitment to superior customer service. For more information, visit hmsa.com.
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(00) 4000-2307 6.14 fn