Forms and Information: Members
Below is a list of printable forms and information for your convenience.
Enrollment & Personal Information
Enrollment Application - Please confirm eligibility with your Employer before enrolling yourself or a dependent for medical coverage.Out-of-Pocket Expenses
Information Change Form - Please inform your Employer before requesting a change to your address or other contact information.
Authorization for Release of Personal Health Information - Complete and submit this form to authorize the disclosure of your personal health information to another person and/or entity.
Non-Participating Provider Eligible Charge Request Form - HMAA strongly urges you to see a participating provider to reduce your out-of-pocket expense. However, if you decide to see a non-participating provider, you may complete and submit this form before your appointment to receive an estimate of what your out-of-pocket expense might be.Claim Forms
Participating vs. Non-Participating Provider Visual Illustration - Using a non-participating provider or facility will result in substantially higher out-of-pocket expenses. This document illustrates what your out-of-pocket expense might be when you visit a participating versus a non-participating provider.
Out-of-State and Out-of-Country Information - HMAA’s geographic service area is the State of Hawaii. Please read these instructions if you are planning to travel to the Mainland or outside the United States.
Third-Party Liability Questionnaire Form - Please complete and submit this form to provide us with additional information about services that may be the responsibility of a third-party.Plan Benefits and Information
Non-Participating Providers – When you visit a non-participating provider, you may need to file the claim with HMAA. HMAA will always make payment to you, and not to the non-participating provider.
Pre-Certification Program - HMAA’s health plans require pre-certification of various services and procedures. This list specifies the services that require pre-certification and is subject to change at any time. Failure to obtain pre-certification may result in a reduction of benefits.COBRA
Summary of Material Modifications - This document summarizes important updates that have recently been made to your health plan.
Important Updates (November 2012) - Effective January 1, 2013, Restat will replace Express Scripts as our pharmacy benefit manager, resulting in cost savings to HMAA members and employers' prescription benefits. And later this year, changes will be applied to the HMAA member ID cards.
DOL Guide to Health Benefits Under COBRA - Provides information on employee rights under COBRA to a temporary extension of employer-provided group health coverage.Health Plan Management
HMAA Online for Members Account - HMAA automatically provides free online access to members to help manage their benefits and claims information. Our online service also enables you to request duplicate ID cards and verify claim and payment status. Click on the link for more information or to log in to your account.Appeals
Prescription Drug Online Account - Our pharmacy benefit manager, Restat, provides free online access to members to help manage your prescription plan, and their website includes features such as helping you understand your prescription benefits and obtaining maintenance medications through free home delivery. Click on the link for more information or to register online.
Vision Care Online Account - Vision Service Plan (VSP) provides free online access to members to help manage your vision plan and includes various features from understanding your vison benefits to finding the right doctor. Click on the link for more information or to register online.
Appeals Procedure - If you wish to dispute a determination made by HMAA related to reimbursement, coverage, or any other matter related to your health plan, you may request an appeal. Upon receipt of your request, we will review our initial decision along with all available and newly submitted information, and will notify you of the outcome.Compliance Notice
HMAA is required by law to provide members with certain compliance notices and to abide by the statements made in these notices.
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