Below is a list of printable forms and information for our Members’ convenience.
- 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 (including your spouse or child over the age of 14).
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.
- Precertification List – HMAA’s medical plans require precertification, also known as prior authorization, 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.
- Preventive Services Covered Under ACA – Lists the screening and preventive services that are covered under the Affordable Care Act (ACA). This is updated annually or as required.
- Prescription Plan Information – Details on copayments, the formulary drug list, home delivery services, and online prescription account management.
- 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 and appointment. Our Hawaii provider network, HWMG, is pleased to offer this program to HMAA members.
- 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 travel outside Hawaii.
- Coordination of Benefits (COB) Questionnaire – Please complete and submit this form to provide us with additional information about your other insurance coverage, and avoid potential delays in processing your claims.
- 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, and avoid potential delays in processing your claims.
- 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.
- 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, OptumRx, 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.
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
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. Please contact us for assistance.
Spanish (Español): Para obtener asistencia en Español, llame al 1-888-941-4622.
Tagalog (Tagalog): Kung kailangan ninyo ang tulong sa Tagalog tumawag sa 1-888-941-4622.
Chinese (中文): 如果需要中文的帮助，请拨打这个号码 1-888-941-4622.