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Documents for Employees

Documents below are available to be downloaded, you may click on the link to do so:

HMSA documents

• Application
• Well-Being Guide
• Premiums Rates for plan year 2022
• We're Here For You Brochure
• Benefits At-a-Glance 2022
• Guide to Benefits HPHa-Jan2022
• Summary of Benefits HPH HMO Dental 2022
• Summary of Benefits HPH PPO Dental 2022
• Prescription Drug Rider 2022
• Vision Care Rider 2022 
• HPH Provider Directory 2021
• PPP Provider Directory 2021
• My Account Tutorial Rack Card
• Online Care Rack Card
• Travel with HMSA flyer

ACA required documents for ELIGIBLE employees (even if they decline coverage)

• Healthcare Compliance Notices 2022
• No Surprises Act Notice
• Nondiscrimination Notice 
• ACA Model Cover Letter to Employees (ask your church for a copy)
• ACA Model Notice Health Plan (ask your church for a copy)
  
  

ONLY IF the employee is eligible, but declines health insurance

• HC-5 Form for 2022 

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Documents for Employers to complete and then give to Employee(s)

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• ACA Model Cover Letter to employee
  • Copy and paste the ACA Model Cover Letter to Employees to your church's letterhead, make appropriate changes, sign, and give to the employee.
• ACA Model Notice Health Plan
  • Complete Part B: (pages 2 & 3)