- Enrollment Application – Please confirm eligibility with your Employer before enrolling yourself or a dependent for medical coverage.
- Information Change Form – Please inform your Employer before submitting 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.
Forms and Information: Members
Enrollment & Personal Information
Plan Documents and Information
Please confirm your plan coverage with your Employer or refer to your member ID card.
- Summary of Benefits and Coverage (SBC) – Summarizes information on certain health benefits and costs.
- Summary of Material Modifications – Summarizes important updates that have recently been made to your health plan.
- Precertification List – HMAA’s medical plans require precertification of certain services and procedures. This list specifies the services that require precertification and are subject to change at any time. Failure to obtain precertification may result in a reduction of benefits.
- Screening and Preventive Services – Lists the screening and preventive services with a grade of A or B from the U.S. Preventive Services Task Forms (USPSTF) that are covered under the Affordable Care Act (ACA). This list is updated annually.
- Prescription Plan Formulary – HMAA’s current drug formulary developed by our pharmacy benefit manager, Express Scripts. You may also search online for a particular drug by name.
- Interisland Access to Care Program’s Travel Request Form – If you decide to see a provider on another island because that care is not available on your home island, please complete and submit this form to request airfare reimbursement prior to booking your flight or the scheduled appointment. Our Hawaii provider network, HWMG, is pleased to offer this program to HMAA members.
- Non-Participating Provider Eligible Charge Request Form – If you decide to see a non-participating provider, complete and submit this form before your appointment to receive an estimate of what your out-of-pocket expense might be. In addition, you may need to file a Claim Form with HMAA. We strongly urge you to visit participating providers to reduce your out-of-pocket expense.
- 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.
- Services Outside Hawaii – Please read these instructions if you are planning to receive services outside Hawaii.
- Coordination of Benefits (COB) Questionnaire – Please complete and submit this form to provide us with additional information about other insurance coverage.
- 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.
- 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.
- Employee’s 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 members with free online access to benefits and claims information. Our secure online service also enables you to view plan documents, request duplicate ID cards, and verify status of a claim or payment.
- Prescription Drug Online Account – Our pharmacy benefit manager, Express Scripts, provides members with free online access 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. You may also view our Prescription Plan Information.
- Vision Care Online Account – Vision Service Plan (VSP) provides members with free online access to help manage your vision plan and includes various features from understanding your vision benefits to finding the right doctor.
Complaints & Appeals
If you are enrolled in a group health plan and would like to appeal HMAA’s decision, you must do one of the following:
- For appealing an issue of medical necessity, appropriateness, health care setting, level of care, or effectiveness, or a determination by HMAA that the service or treatment is experimental or investigational and you meet the requirements of Hawaii Revised Statutes Chapter 432E: Request review by an independent review organization (IRO) selected by the Hawaii Insurance Commissioner. You must ask for review by an IRO within 130 days of the decision. The following forms must be submitted to request external review by an IRO.
- For appealing all other issues: File a lawsuit against HMAA under 29 USC 1132(a) unless your plan is one of the three bulleted types below in which case you must request arbitration before a mutually selected arbitrator:
- A church plan as defined in 29 USC 2002(33) and no selection has been made in accord with 26 USC 410(d), or
- A governmental plan as defined in 29 USC 1002(32).
- A sole proprietor
Language Translation Service
- We provide language translation services as an added communication support for assistance to our non-English speaking customers while on the phone or face-to-face with one of our employees or participating providers. Written translation services for a particular plan document are available upon request.
- Member Satisfaction Survey – This survey is for our Members to provide feedback to HMAA. The information collected from this survey will enable us to make improvements to our health plans and services, and will be kept strictly confidential.