2019 Summary of BenefitsAnnual Medicare Enrollment Period Your plan will start: 2018 2018 2019 GET...

Your Guide to Choosing a Medicare Advantage Plan

Dual Care Special Needs Plan (PPO SNP)

H3832_1099_2025_12318_M

This is a summary of health services and drug benefits for HMSA Akamai Advantage Dual Care (PPO SNP) effective January 1, 2019.

2019 Summaryof Benefits

1

WHAT’S INSIDE

Everything You Need in One Plan ...........................2

Eligibility and Important Dates ...............................3

Get More with HMSA Akamai Advantage

Dual Care ...................................................................4

Medications ..............................................................6

Need Help Paying For Your Medications? ..............7

Summary of Benefits ...............................................8

Enrollment ..............................................................15

Case Management .................................................16

Pre-enrollment Checklist ........................................17

Multi-language Interpreter Services.....................18

Enrollment Form .................................................... 19

HMSA Centers and Offices ......................Back cover

2

With HMSA Akamai Advantage Dual Care (PPO SNP), we’ll coordinate your Medicare and Medicaid benefits so you can focus on your health and well-being.

Whether you want to make changes to improve your health or if you’re looking for new ways to maintain your lifestyle, you can count on us to be there with you.

EVERYTHING YOU NEED IN ONE PLAN

Personalized care A case manager or registered nurse will help you create a personalized action plan with health goals and help you get the care and support you need to reach those goals.

Choices Choose primary care providers, specialists, and more from a large provider network. You’ll have access to urgent and emergency care services.

Convenient access Whether you need a checkup, specialized care, or urgent care services, you’ll get the care you need at a location near you.

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It’s our privilege to serve you. To enroll in HMSA Akamai Advantage Dual Care, you must meet all of these Medicare requirements:

• Live in Hawaii.

• Have Medicare Part A (hospital insurance), Part B (medical insurance), and a Medicaid plan.

• Pay your Part B premium if Medicaid or another source doesn’t already pay for it.

• Must not have end-stage renal disease (ESRD). There are some exceptions. Contact us for more information.

We make enrolling in HMSA as easy as possible, so you don’t have to worry. We’ll help you find out if you’re eligible.

Call us:

• Oahu: 948-6235

• Neighbor Islands: 1 (800) 693-4672 toll-free

October 1–March 31 Call seven days a week, 8 a.m. to 8 p.m.

April 1–September 30 Call Monday–Friday, 8 a.m. to 8 p.m.

Have your Medicaid and Medicare cards available when you call so we can better serve you.

If you miss the annual Medicare enrollment period, don’t worry. You can enroll throughout the year, up to once per quarter, as long as you’re eligible for Medicare Part A, Part B, and Medicaid.

ELIGIBILITY

IMPORTANT DATES TO REMEMBER

Your plan will start:Annual Medicare Enrollment Period

2018 2018 2019

GET MORE WITH HMSA AKAMAI ADVANTAGE DUAL CARE

Choose your doctors You have access to one of the largest provider networks in the state. With primary care providers (PCPs), nurse practitioners, specialists, and other providers, you’re sure to find the care you need. To find a provider who accepts both Medicare and Medicaid, go to hmsa.com and click Find a Doctor. You can also call us at a number on the back cover.

Care team on your side You’ll work with a case manager or registered nurse to create a personalized care plan to help you achieve your health goals. See page 16 to learn more.

Quick access to care Speak to doctors 24/7 online or by phone without an appointment with HMSA’s Online Care®. You can also see a nurse or other health care provider at your nearest walk-in CVS/minuteclinic® at selected Longs Drugs stores.

American Well® is an independent company providing hosting and software services for HMSA’s Online Care platform on behalf of HMSA.

The path to better well-being is yours to take. And with HMSA Akamai Advantage Dual Care, we’ll be with you on the journey so you won’t have to go it alone.

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http://hmsa.com

Dental care Because oral care is part of overall good health and well-being, you’ll receive benefits for dental exams, cleanings, X-rays, fillings, and more.

Preventive care Your health is important to us. That’s why we make sure that you have access to preventive services to keep you at your healthy best. With HMSA, annual wellness visit and many preventive care services are available at no cost.

Health workshops Attend a variety of health education workshops at no additional cost to learn how to sleep better, make healthier food choices, stay active, and more. Check hmsa.com/well-being/workshops for a schedule.

Health coaching Get guidance, support, and resources to help you manage chronic health conditions, stop smoking, relieve stress, and more.

5

http://hmsa.com/well-being/workshops

6

Get affordable prescription drugs at convenient locations. We coordinate your prescription costs with Medicare and Medicaid.

Save time with mail order Your medications will be conveniently mailed to your home. And you can order a constant supply without interruption to help manage chronic conditions.

Affordable generic medications Our prescription drug list includes generics to help you get the medicines you need at an affordable price. Generics are just as safe and effective as brand-name drugs, but they cost less because they don’t have the same marketing and research costs. You’ll get the same medication for a lower price.

Local pharmacies Most major retail pharmacy chains and many independent pharmacies in Hawaii participate with HMSA, so you’re sure to find one near you. Find pharmacies at hmsa.com/advantage. Or call us at a number on the back of this brochure so we can help you.

Pharmacy consultations If you have questions about your prescription medications, talk to pharmacists on the phone or in person. They’ll discuss your prescriptions with you, make sure you understand how to take them, and see if they work well with over-the-counter drugs and supplements you may be taking. To learn more, call CVS Caremark® at 1 (855) 479-3659, 24 hours a day, seven days a week. For TTY, call 711.

While traveling If you need a prescription while you’re on the Mainland, just show your HMSA membership card at more than 9,800 CVS pharmacy locations nationwide. You can easily find pharmacies on hmsa.com.

MEDICATIONS

To see a list of prescription medications in your health plan, go to hmsa.com/advantage. Look under Prescription Drugs List (Formulary).CVS Caremark® is HMSA’s pharmacy benefits manager. CVS Caremark is an independent company providing pharmacy benefit management services on behalf of HMSA.

http://hmsa.com/advantage

http://socialsecurity.gov/prescriptionhelp


7

See if you qualify for Extra Help.

Prescription drugs can be mailed to your home from the HMSA Akamai Advantage mail-order pharmacy. Mail-order prescriptions are usually delivered within 14 days after the pharmacy receives the order.

If your drugs don’t arrive within 14 days, please call 1 (855) 479-3659 toll-free, 24 hours a day, seven days a week; TTY users, call 711. Call these numbers if you want to sign up for our optional automatic delivery program.

With Extra Help, you could qualify for Medicare to help with monthly premiums, annual deductibles, and coinsurance. Many people qualify and don’t even know it.

To find out if you qualify:

• Apply for Extra Helpat socialsecurity.gov/medicare/prescriptionhelp.

• Medicare: 1 (800) MEDICARE1 (800) 633-4227 toll-free 24 hours a day, seven days a week.For TTY, call 1 (877) 486-2048 toll-free.

• Social Security Administration:1 (800) 772-1213 toll-free, Monday through Friday, 7 a.m. to 7 p.m.For TTY, call 1 (800) 325-0778 toll-free.

• The state Medicaid office:1 (800) 316-8005 toll-free.

NEED HELP PAYING FOR YOUR MEDICATIONS?

http://socialsecurity.gov/medicare/prescriptionhelp

8

SUMMARY OF BENEFITS HMSA Akamai Advantage Dual Care (PPO SNP)

Benefits HMSA Akamai Advantage Dual Care (PPO SNP)

HMSA QUEST Integration

YOU PAYMonthly premium

You must continue to pay your Part B premium in addition to your HMSA premium.

$0 $0

Annual deductibleWhat you’ll have to pay each year out of pocket before the plan will pay for some services.

$0 (in-network) $1,364 for Medicare Part A covered

services (out-of-network) $185 for Medicare Part B covered

services (out-of-network)

None

Maximum out-of-pocket This financial safety net protects you from a catastrophic illness. It’s the most you’ll pay out of pocket for Medicare-covered services each year.

$6,700 per year (in-network)$10,000 per year (in-network and

out-of-network)

None

Inpatient hospital care* In-network: $0Out-of-network:

Days 1-60: $1,364 deductible Days 61-90: $341/day

Lifetime reserve days (60): $682/day

$0

Outpatient hospital services*Outpatient hospital facility and ambulatory surgical center services.

$0 (in-network) 30% of the cost (out-of-network)

$0

* For some services, your doctor or other network provider must request prior authorization.Please contact us for more information.

Your share of the cost:$ = Copayment. A set dollar amount that you pay. % = Coinsurance. The percentage of the cost that you pay.

Here’s a short description of the 2019 benefits of HMSA Akamai Advantage Dual Care and HMSA QUEST Integration plans and the amount you’ll pay. There may be some exceptions, so check the Evidence of Coverage for details. Your costs may change or be different depending on how much you receive in Extra Help (see page 7) or if you have Medicaid with a health plan other than HMSA. If you have any questions, please contact us so we can help you.



YOU PAYDoctor’s office visits• Primary care provider (PCP)

A physician or other health care professional who treats common illnesses and manages your preventive care.

• Advanced practice registered nurse, nurse practitioner, or physician’s assistant

$0 (in-network)30% of the cost (out-of-network)

$0 Includes physical exams

and screenings

• SpecialistA physician who treats specific conditions such as allergies, heart disease, or foot disorders.

Preventive care $0 (in-network)30% of the cost (out-of-network)

• Annual wellness visits.• Annual physical exam.• Bone mass measurements.• Diabetes screenings.• Mammograms.• Some vaccines such as flu

shots, hepatitis B shots, and pneumococcal shots.

For a complete list of preventive care services, please see the Evidence of Coverage.

$0 for routine adult care• Blood pressure check.• Cholesterol level blood test.• Colorectal cancer check by

sigmoidoscopy or fecal occult blood test.

• Mammogram with or without a breast exam.

• Pap test and pelvic exam.$0 for routine preventive care for

children younger than age 21. • Early and Periodic Screening,

Diagnostic, and Treatment (EPSDT) services include regular checkups and shots. Referrals to specialists for problems found during an EPSDT exam.

Emergency careYou won’t pay a copayment for emergency care if you’re admitted to the hospital within 24 hours.

$0 (in-network and out-of-network)

$0

Urgent careYou won’t pay a copayment for urgent care if you’re admitted to the hospital within 24 hours.

$0 (in-network and out-of-network)

$0

Hearing services $0 (in-network)30% of the cost (out-of-network)

• Exam to diagnose and treat hearing and balance-related conditions. Doesn’t include routine hearings exams or hearing aids.

$0• Ear molds. • Hearing aid batteries.• Hearing exam.• Unilateral hearing aids with

standard features. 9



YOU PAYDiagnostic services, labs, and imaging*


• Diagnostic tests and procedures, lab services, and outpatient X-rays.

• Diagnostic radiology services including advanced imaging services such as MRI, CT, and PET scans.

• Therapeutic radiology services such as radiation treatment for cancer.

$0• Medically necessary diagnostic

or therapeutic radiology or lab services.

• Sleep lab tests to diagnose sleep-related disorders.

Dental services $0 (in-network)30% of the cost (out-of-network)

• Services by a dentist or oral sur-geon, limited to surgery of the jaw or related structures, setting frac-tures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic disease, or services that would be covered when provided by a doctor.

$0 (in-network)

50% of the cost (out-of-network) Preventive and additional com-

prehensive dental services every calendar year:

• Two oral exams.• Two cleanings.• One set of bitewing X-rays.• One full mouth or panoramic

X-rays every five calendar years.

• Two fluoride treatments.• One filling per tooth surface.• One root canal per tooth.• One periodontal scaling and

root planing procedure per quadrant.

• Two denture adjustments• One simple denture repair per

arch.The plan covers up to $2,500 per calendar year for preventive and additional comprehensive ser-vices.

$0• Dental or medical services in

a hospital or surgery center as a result of a dental or medical condition.

• Emergency services by a dentist or oral surgeon and physicians such as plastic surgeons, otolaryngologists (ear, nose, and throat doctors), and general surgeons due to a traumatic injury such as a car accident.

10

11



YOU PAYVision services $0 (in-network)

30% of the cost (out-of-network)• Eye exam to diagnose and treat

eye diseases and conditions including yearly glaucoma screening.

• Eyeglasses or contact lenses after cataract surgery.

$0• Eye exams to test for refraction.• Eyeglasses to correct vision.

Mental health care• Inpatient visit* In-network: $0

Out-of-network: Days 1-60: $1,364 deductible

Days 61-90: $341/day Lifetime reserve days (60): $682/day

Includes mental health care services that require a hospital stay.

$0Services for inpatient psychiatric hospitalizations include:• Psychiatric services.• Substance abuse treatment.

• Outpatient therapy visits $0 (in-network)30% of the cost (out-of-network)

• Individual and group visits.

$0Outpatient mental health services include:• Ambulatory mental health services.• Crisis management.• Day treatment.• Medications and medication

management.• Methadone management.• Psychiatric or psychological

evaluation and treatment.• Treatment for medically necessary

alcohol and chemical dependency.Skilled nursing facility* In-network: $0

Out-of-network: Days 1-20: $0/day

Days 21-100: $170.50/dayOur plan covers up to 100 days in a skilled nursing facility. No prior

Medicare-covered acute level of care hospital stay is required.

$0


12



YOU PAYOutpatient rehabilitation* $0 (in-network)

30% of the cost (out-of-network)

• Occupational therapy visit.• Physical therapy. • Speech and language therapy

visit.

$0Services include assessment and treatment for problems with:• Communicating.• Doing everyday tasks.• Memory.• Paying attention.• Thinking.

Rehabilitation services include:• Corrective surgery.• Durable medical equipment (DME).• Medical supplies.• Occupational therapy.• Physical therapy.• Prostheses and orthoses.• Respiratory services.• Speech therapy.

Habilitation services that develop, improve, or maintain skills for daily living include:• Audiology services.• Devices to help communicate, read,

and see.• Occupational therapy.• Physical therapy.• Speech therapy.• Vision care.

Ambulance Ground and air ambulance.


$0

SUMMARY OF BENEFITS (continued)


13



YOU PAYTransportation Not covered $0

Non-emergency transportation services when your medical condition requires treatment that isn’t available in your area.• Air transport.• Ground transportation.• Lodging.• Meals.• Taxi service.

Medicare Part B drugs*Chemotherapy and other Part B drugs.


$0Drugs on the Medicaid formulary.

Medical equipment and supplies*


Includes oxygen tanks, walkers, and wheelchairs.

$0Durable medical equipment that helps alleviate a medical disability or restore

or improve bodily function.

PRESCRIPTION DRUGSPrescription drugs Deductible:

If you qualify for a low-income subsidy, you pay $0. If you don’t

qualify for a low-income subsidy, you pay a $415 deductible for your drugs.

$0Drugs on the Medicaid formulary.

For drugs in the Medicare and HMSA QUEST Integration formularies:

The drug will be processed under the Medicare formulary and the

copayment may be paid by HMSA QUEST Integration.


14



YOU PAYPRESCRIPTION DRUGS (continued)

Initial coverage stageGeneric drugs, including brand drugs

treated as generic:• $0• $1.25• $3.40• 15%

All other drugs:• $0• $3.80• $8.50• 15%

Until your yearly out-of-pocket drug costs reach $5,100

Catastrophic coverage$0

After your yearly out-of-pocket drug costs reach $5,100

HMSA Akamai Advantage Dual Care is a PPO SNP plan with a Medicare contract. Enrollment in HMSA Akamai Advantage Dual Care depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information or refer to the Evidence of Coverage at hmsa.com/advantage.

To be enrolled in a Dual Care Special Needs Plan, you must be eligible for your state’s Medicaid program. If you have questions about your Medicaid eligibility and the benefits you’re entitled to, call MedQUEST at 524-3370 on Oahu or 1 (800) 316-8005 toll-free on the Neighbor Islands.

To learn more about the health plan benefits and costs of Original Medicare, see the Medicare & You handbook at medicare.gov. To request a copy, call 1 (800) MEDICARE [1 (800) 633-4227]. For TTY, call 1 (877) 486-2048. Contact us if you’d like to receive a copy in Braille, large print, audio, or other formats.

HMSA works closely with CVS Caremark (Longs Drugs) to help you get the medications you need. However, other pharmacies are available in our network.

This plan helps you pay for Part D drugs and Part B drugs, such as chemotherapy and some drugs administered by your provider. See the complete list of Part D prescription drugs and any restrictions at hmsa.com/advantage. Cost sharing may differ for long-term care pharmacies.

Out-of-network/non-contracted providers are under no obligation to treat HMSA Akamai Advantage Dual Care members except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.


http://medicare.gov


15

Choose one of five easy ways to enroll.

Online Enroll 24/7 at hmsa.com/advantage. Follow the instructions to complete the online application. Once you submit your request, you’ll receive an application receipt number.

Phone Call an HMSA sales representative, 8 a.m. to 8 p.m.

• Oahu: 948-6235• Neighbor Islands: 1 (800) 693-4672 toll-free• TTY: 711

October 1–March 31: Seven days a week.April 1–September 30: Monday–Friday.

In person We’ll be happy to see you and help you enroll.Visit your nearest HMSA Center or office.(See back page for locations and hours.)

If you’re enrolling in HMSA Akamai Advantage for the first time, we can come to your home or the location of your choice. To make an appointment, call 948-5535 on Oahu, Monday through Friday, 8 a.m. to 4 p.m.

Mail Fill out the HMSA Akamai Advantage application and mail it to:

HMSA Akamai Advantage SalesP.O. Box 3500Honolulu, HI 96811-3500

Through Medicare Visit medicare.gov.

ENROLLMENTSign up today!


http://medicare.gov

16

CASE MANAGEMENT

Step 1. You’ll get a case manager.One of the unique features of this plan is the personalized attention you get beyond the doctor’s office. We’ll assign a case manager to you who’ll evaluate your health and help you identify and overcome health issues.

Step 2. Take a health questionnaire. To better serve your health care needs, we need a complete picture of your health and well-being. So before we can start your health plan, we’ll need to ask you some simple questions.

Choose a way to take the questionnaire that’s convenient for you:

• Over the phone.• In person with your case manager.• By mail.

Whatever method you choose, the questionnaire will take about 20 to 30 minutes to complete.

Step 3. Meet your case manager.You’ll meet your case manager to go over the results of the questionnaire and develop an action plan for areas in your life that you need to improve or maintain. Your case manager will work with you and your health care team to get you the care you need.

Step 4. Follow-up care.Your case manager will work with you throughout the year either on the phone or in person to make sure you’re following your action plan and staying on track toward your goals. You can contact your case manager any time if you have questions. It’s like having a friend to help you focus on your health.

We’re with you every step of the way

Here are some things you’ll need to know when you enroll in HMSA Akamai Advantage Dual Care.

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PRE-ENROLLMENT CHECKLIST

Before making an enrollment decision, it is important that you fully understand our benefits and rules.

If you have any questions, you can call and speak to a licensed sales representative at 948-6235 on Oahu or 1 (800) 693-4672 toll-free. For TTY, call 711.

Understanding Important Rules

In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.

Benefits, premiums, and/or copayments and coinsurance may change on January 1.

Our plan allows you to see providers outside of our network (non-contracted providers). However, while we’ll pay for covered services provided by a noncontracted provider, the provider must agree to treat you. Except in an emergency or urgent situations, noncontracted providers may deny care. In addition, you may pay a higher copayment for services received by noncontracted providers.

This plan is a dual eligible special needs plan (D-SNP). To enroll in this plan, you must be eligible for Medicare and Medicaid.

Understanding the Benefits

Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely see a doctor. Visit hmsa.com/advantage or call us at the numbers listed above.

Review the Provider Directory (or ask your doctor) to make sure the doctors you see now are in the network and accept Medicaid. If they’re not listed, you’ll likely have to select a new doctor.

Review the Provider Directory to make sure the pharmacy you use for prescription medicines is in the network. If the pharmacy isn’t listed, you’ll likely have to select a new pharmacy for your prescriptions.


Federal law requires HMSA to provide you with this notice. HMSA complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. HMSA does not exclude people or treat them differently because of things like race, color, national origin, age, disability, or sex. Services that HMSA provides Provides aids and services to people with disabilities to communicate effectively with us, such as: • Qualified sign language interpreters • Written information in other formats

(large print, audio, accessible electronic formats, other formats)

Provides language services to people whose primary language is not English, such as: • Qualified interpreters • Information written in other languages • If you need these services, please call

1 (800) 776-4672 toll-free; TTY 711 How to file a discrimination-related grievance or complaint If you believe that we’ve failed to provide these services or discriminated against you in some way, you can file a grievance in any of the following ways: • Phone: 1 (800) 776-4672 toll-free • TTY: 711 • Email:

[email protected] • Fax: (808) 948-6414 on Oahu • Mail: 818 Keeaumoku St., Honolulu,

HI 96814 You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, in any of the following ways: • Online:

ocrportal.hhs.gov/ocr/portal/lobby.jsf • Phone: 1 (800) 368-1019 toll-free;

TDD users, call 1 (800) 537-7697 toll-free

• Mail: U.S. Department of Health and Human Services, 200 Independence Ave. S.W., Room 509F, HHH Building, Washington, DC 20201

For complaint forms, please go to hhs.gov/ocr/office/file/index.html. Hawaiian: E NĀNĀ MAI: Inā hoʻopuka ʻoe i ka ʻŌlelo Hawaiʻi, loaʻa ke kōkua manuahi iā ʻoe. E kelepona iā 1 (800) 776-4672. TTY 711. Bisaya: ATENSYON: Kung nagsulti ka og Cebuano, aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe, nga walay bayad. Tawag sa 1 (800) 776-4672 nga walay toll. TTY 711. Chinese: 注意：如果您使用繁體

中文，您可以免費獲得語言援助

服務。請致電 1 (800) 776-4672。TTY 711. Ilocano: PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Awagan ti 1 (800) 776-4672 toll-free. TTY 711. Japanese: 注意事項：日本語を話

される場合、無料の言語支援を

ご利用いただけます。 1 (800) 776-4672 をご利用くださ

い。TTY 711.まで、お電話にて

ご連絡ください.

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1 (800) 776-4672번으로 연락해 주시기 바랍 니다. TTY 711 번으로 전화해 주십시오.

Laotian: ກະລຸນາສັງເກດ: ຖ້າທ່ານເວົ ້ າພາສາລາວ, ການຊ່ວຍເຫຼື ອດ້ານພາສາ, ບໍ່ ມີ ຄ່າໃຊ້ຈ່າຍ, ແມ່ນມີ ໃຫ້ທ່ານ. ໂທ 1 (800) 776-4672 ຟຣີ . TTY 711.

Marshallese: LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk wōṇāān. Kaalọk 1 (800) 776-4672 tollfree, enaj ejjelok wonaan. TTY 711. Pohnpeian: Ma ke kin lokaian Pohnpei, ke kak ale sawas in sohte pweine. Kahlda nempe wet 1 (800) 776-4672. Me sohte kak rong call TTY 711. Samoan: MO LOU SILAFIA: Afai e te tautala Gagana fa'a Sāmoa, o loo iai auaunaga fesoasoan, e fai fua e leai se totogi, mo oe, Telefoni mai: 1 (800) 776-4672 e leai se totogi o lenei ‘au’aunaga. TTY 711. Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1 (800) 776-4672. TTY 711. Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1 (800) 776-4672 toll-free. TTY 711. Tongan: FAKATOKANGA’I: Kapau ‘oku ke Lea-Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai atu ha tokoni ta’etotongi, pea teke lava ‘o ma’u ia. Telefoni mai 1 (800) 776-4672. TTY 711. Trukese: MEI AUCHEA: Ika iei foosun fonuomw: Foosun Chuuk, iwe en mei tongeni omw kopwe angei aninisin chiakku, ese kamo. Kori 1 (800) 776-4672, ese kamo. TTY 711. Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1 (800) 776-4672. TTY 711.

NMM_1000_24715_1557_R

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf

http://www.hhs.gov/ocr/office/file/index.html

(continued)H3832_1070_2050_30017_19_M

SECTION 1: PROVIDE INFORMATION ABOUT YOU

First Name MI

Last Name

Permanent Residence Street Address (Include apartment number. P. O. Box isn’t allowed.)

H I

Residence City State ZIP Code

/ / Sex ( ) —Birth Date (MM/DD/YYYY) M or F Primary Phone Number

( ) —

Secondary Phone Number

Mailing Address (only if different from your Permanent Residence Address):

Mailing Street Address (Include apartment number)

Mailing City State ZIP Code

Current HMSA Member Number (if applicable)

Email Address (By providing your email address, you're allowing us to email you important health information.)

HMSA Use Only

App Rec Date: / / MBI: - - SBM Item #: ______________

Sub ID#: A - Group Sponsored Individual

HMSA Akamai Advantage Group#: - Effective Date: / /Election Period: ICEP IEP-D AEP (Oct 15-Dec 7) SEP (type): _____________________________________

Not Eligible:____________________ OEP (Jan 1-Mar 31) ESRD Group Waiver Authorization Form

Sales Agent ID:___________________________________ Agent Assisted: No Yes ___________________________________(Agent Assist ID & Name)

SOA # ________________________________________________________________

0 0 0 0

0 1 2 0 1 9

HMSA Akamai Advantage Dual Care (PPO SNP) Enrollment Form for CY 2019

(continued)

Primary Care Provider. No titles required. (Example: John Smith)

First Name Last Name

I‘d like HMSA Akamai Advantage Dual Care to begin on the first day of the month of

I understand that this is my HMSA Akamai Advantage Dual Care proposed start date.

Please check the box below: Monthly Premium

I’m enrolling in HMSA Akamai Advantage Dual Care (PPO SNP). . . . . . . . . . . . . . . . . . . . . . . $0 (Available to residents of the State of Hawaii.) This plan is available to most individuals who have both Medical Assistance from the state and Medicare.

Alternate Person’s Contact Information:

First Name Last Name

Relationship to Enrollee

( ) — ( ) —Primary Phone Number Secondary Phone Number

Email Address

SECTION 2: PROVIDE YOUR MEDICARE INSURANCE INFORMATIONPlease take out your red, white and blue Medicare card to complete this section:

Yes No Are you enrolled in QUEST Integration (Medicaid)? If “yes,” please provide your Medicaid number:

(M M / Y Y Y Y)

/ 2 0 1 9

• Please fill in theseblanks so they matchyour red, white, andblue Medicare card.

You must haveMedicare Part Aand Part B to join aMedicare Advantageplan.--------- OR ---------

• Attach a copy ofyour Medicare cardor your letter fromSocial Security or theRailroad RetirementBoard.

Medicare Card First Name (as it appears on your Medicare card) MI

Medicare Card Last Name (as it appears on your Medicare card)

- -

Medicare Number

Is entitled to: Effective Date (MM/DD/YYYY)

HOSPITAL (Part A) / /

MEDICAL (Part B) / /

HMSA Use Only: Card information verified by

(continued)

SECTION 3: SELECT YOUR PLAN PREMIUM PAYMENT OPTION

If we determine that you owe a late enrollment penalty (or if you currently have a late enroll-ment penalty assessed), we need to know how you would prefer to pay it. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month.

If you don’t select a payment option, you’ll receive a bill each month.

Please select a premium payment option:

HMSA will mail you a bill each month.

Electronic funds transfer (EFT) from your checking or savings account each month.

New (Please complete the enclosed HMSA Dues Payment Authorization Form.)

Existing HMSA Akamai Advantage member with EFT – authorize HMSA to retainsame EFT.

Automatic deduction from your monthly Social Security or Railroad Retirement Board (RRB) benefit check. I get monthly benefits from:

Social Security

Railroad Retirement Board

(The Social Security/RRB deduction may take two or more months to begin after Social Security or RRB approves the deduction. In most cases, if Social Security or RRB accepts your request for automatic deduction, the first deduction from your Social Security or RRB benefit check will include all premiums due from the point withholding begins, which could correspond to your enrollment start date. If Social Security or RRB doesn't approve your request or approves it for a later date, we'll send you a paper bill for your monthly premiums.)

If you must pay a Part D-Income Related Monthly Adjustment Amount, the Social Security Administration will notify you. You must pay this extra amount in addition to your plan premium. You’ll either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay HMSA the Part D-Income Related Monthly Adjustment Amount.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for 75 percent or more of your drug costs, including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify won’t be subject to the coverage gap or late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about Extra Help, contact your local Social Security office or call Social Security at 1 (800) 772-1213 toll-free. TTY users should call 1 (800) 325-0778 toll-free. You can also apply for Extra Help online at socialsecurity.gov/prescriptionhelp. Premiums, copayments, coinsurance and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

If you qualify for Extra Help with your Medicare prescription drug costs, Medicare will pay all or part of your plan premium. If Medicare pays only a portion of this premium, we’ll bill you for the amount that Medicare doesn’t cover.

(continued)

Please read and answer these important questions:

1. Yes No Do you have end-stage renal disease (ESRD)?

If you have had a successful kidney transplant and/or you don’t need regular dialysis any more, please attach a note or records from your doctor showing you have had a successful kidney transplant or you don’t need dialysis. Otherwise, we may need to contact you for more information.

2. Some individuals may have other drug benefits, including other private insurance,TRICARE, federal employee health benefits, VA benefits, or state pharmaceuticalassistance programs.

Will you have other prescription drug benefits in addition to HMSA Akamai Advantage DualCare as of the proposed start date?

Yes. Continue the questions below. No. If “no,” skip to question 3.

If "yes," when did these benefits begin? Month/Year: /

Are you getting these benefits through: Yourself Spouse

Is the person checked above getting these benefits because they’re actively employed or is it a retiree plan?

Actively employed Retiree plan Other

If actively employed, does the employer have 20 or more employees (full and part time)?

Yes No

Insurance Company Name

Insurance Company Member ID No. Insurance Company Plan/Group No.

3. Yes No Are you a resident in a long-term care facility, such as a nursing home? If “yes”, please provide the following information.

Name of Institution

( ) - /

Institution Phone Number Admission Date

Institution Mailing Address

Institution City State ZIP Code

4. Do you or your spouse work? No Yes

(continued)

5. What language do you speak most of the time at home? (Choose one.)

English Hawaiian Korean Vietnamese

Cambodian Ilocano Mandarin Other (any language not listed above.)

Cantonese Japanese Tagalog

6. Please check this box if you prefer that we send you information in large-print format.

Please contact HMSA Akamai Advantage at 948-6235 on Oahu or 1 (800) 693-4672 toll-free on the Neighbor Islands and U.S. Mainland if you need information in large-print format. Tele-phone hours are 8 a.m. to 8 p.m., seven days a week. TTY users, call 711.

SECTION 4: PLEASE READ THIS IMPORTANT INFORMATION• If you currently have another health plan (employer or union group or ACA), joining

HMSA Akamai Advantage could affect your employer or union health benefits; pleasecontact your health insurance carrier. You could lose your employer or union healthbenefits if you join HMSA Akamai Advantage. Read the information your employer orunion sends you. If you have questions, visit their website or contact them. If there isn'tany contact information, your benefits administrator or the office that answers questionsabout your benefits can help.

SECTION 5: PLEASE READ AND SIGN ON FOLLOWING PAGE

By completing this enrollment application, I agree to the following:

HMSA Akamai Advantage Dual Care (HMSA Akamai Advantage) is a Medicare Advantage plan that has a contract with the federal government. I'll need to keep my Medicare Parts A and B. I can be in only one Medicare Advantage plan at a time and I understand that my enrollment in this plan will automatically end my enrollment in another Medicare health plan or prescription drug plan. I'm responsible for letting HMSA Akamai Advantage know about any prescription drug benefits that I have or may get in the future.

Enrollment in this plan is generally for the entire year. Once I enroll, I may leave this plan or make changes only at certain times of the year when an enrollment period is available (example: October 15 – December 7 of every year), or under certain special circumstances.

HMSA Akamai Advantage serves a specific service area. If I move out of the area that HMSA Akamai Advantage serves, I need to notify HMSA so I can disenroll and find a new plan in my new area. Once I'm a member of HMSA Akamai Advantage, I have the right to appeal plan decisions about payment or services if I disagree. I'll read the Evidence of Coverage from HMSA Akamai Advantage when I get it to know which rules I must follow to get benefits with this Medicare Advantage plan. I understand that people with Medicare aren’t usually covered under Medicare while out of the country except for limited benefits near the U.S. border.

I understand that beginning on the date HMSA Akamai Advantage coverage begins, using services in-network can cost less than using services out-of-network, except for emergency or urgently needed services or out-of-area dialysis services. If medically necessary, HMSA Akamai Advantage provides refunds for all covered benefits, even if I get services out of network. Services authorized by HMSA Akamai Advantage and other services contained in my HMSA Akamai Advantage Evidence of Coverage document (also known as a member contract or subscriber agreement) will be covered. Without authorization, NEITHER MEDICARE NOR HMSA AKAMAI ADVANTAGE WILL PAY FOR THE SERVICES.

I understand that a sales agent, broker, or other individual employed by or contracted with HMSA Akamai Advantage who's helping me may be paid based on my enrollment in HMSA Akamai Advantage.

RELEASE OF INFORMATION

By joining this Medicare health plan, I acknowledge that HMSA Akamai Advantage will release my information to Medicare and other plans as is necessary for treatment, payment, and health care operations. I also acknowledge that HMSA Akamai Advantage will release my information including my prescription drug event data to Medicare, who may release it for research and other purposes which follow all applicable federal statutes and regulations. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.

I understand that my signature (or signature of the person authorized to act on my behalf under the state of Hawaii laws) on this application means that I have read and understand the contents of this application. If signed by an authorized individual (as described above), this signature certifies that 1) this person is authorized under state law to complete this enrollment and 2) documentation of this authority is available upon request from HMSA Akamai Advantage or from Medicare. This would include a court-appointed legal guardian or a person with general durable power of attorney.

/ /

Applicant’s signature or, if applicant is unable to sign, Date (MM/DD/YYYY) applicant’s legal representative’s signature. If applicant’s legal representative signs, please complete legal representative’s information below:

Name of Legal Representative (please print)

Legal Representative’s Mailing Address

Legal Representative’s City State ZIP Code

( ) -

Legal Representative’s Telephone Number Legal Representative’s Relationship to Applicant

For more information, please call 948-6235 on Oahu or 1 (800) 693-4672 toll-free on the Neighbor Islands and U.S. Mainland. Telephone hours are 8 a.m. to 8 p.m., seven days a week. TTY users, call 711. Or visit HMSA’s website at hmsa.com/advantage. Return HMSA Akamai Advantage application forms to HMSA at P.O. Box 3500, Honolulu, HI 96811-9983.

To be enrolled in a Dual Special Needs Plan, you must be eligible for your state’s Medicaid program. Premiums may vary based on the level of Extra Help you receive. Please contact the plan for further details.

(00) 2025-30017 8.18 cs

HAWAI‘I MEDICALSERVICE ASSOCIATION

hmsa.com/advantage

HMSA CENTERSVisit one of our HMSA Centers

with convenient evening and Saturday hours.

Honolulu, Oahu818 Keeaumoku St.

Monday through Friday, 8 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m.

Pearl City, OahuPearl City Gateway | 1132 Kuala St., Suite 400


Hilo, Hawaii Island Waiakea Center | 303A E. Makaala St.


Opening in 2019 HMSA Center @ Kahului

Puunene Shopping Center | 70 Hookele St.

OFFICESVisit your nearest HMSA office Monday through Friday, 8 a.m.–4 p.m.:

Kailua-Kona, Hawaii Island | 75-1029 Henry St., Suite 301

Kahului, Maui | 33 Lono Ave., Suite 350

Lihue, Kauai | 4366 Kukui Grove St., Suite 103

PHONE 948-6235 on Oahu

1 (800) 693-4672 toll-free on the Neighbor Islands TTY users, call 711

October 1 – March 31

Call seven days a week, 8 a.m. to 8 p.m.

April 1 – September 30Call Monday–Friday, 8 a.m. to 8 p.m.

(00) 2025-12318 1.19 LG



2019 Summary of BenefitsAnnual Medicare Enrollment Period Your plan will start: 2018 2018 2019 GET...

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