HMSA Plan 2000 An Independent Licensee of the Blue Cross and Blue Shield Association
A Health Maintenance Organization HMO
with a Point of Service Product
Serving All of Hawaii
Enrollment in this Plan is limited see page 4 for requirements
Enrollment code
871 Self Only
872 Self and Family
Visit the OPM website at http www opm gov insure and
this Plan's website at http www hmsa com
Authorized for distribution by the
United States Office of Personnel Management
Retirement And Insurance Service
HMSA Plan 2000
Table of Contents
Introduction 1
Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 4
Section 4 What to do if we deny your claim or request for service 7
Section 5 Benefits 9
Section 6 General exclusions Things we don't cover 21
Section 7 Limitations Rules that affect your benefits 21
Section 8 FEHB facts 22
Inspector General Advisory Stop Healthcare Fraud 26
Summary of benefits Inside Back Cover
Premiums Back Cover
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HMSA Plan 2000
Introduction
Hawaii Medical Service Association 818 Keeaumoku Street
Honolulu HI 96814
This brochure describes the benefits you can receive from Hawaii Medical Service Association HMSA an independent licensee of the Blue Cross and Blue Shield Association under its contract CS1058 with the Office of Personnel Management OPM as authorized
by the Federal Employees Health Benefits FEHB law This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled for Self and Family coverage each
eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page 3 Premiums are listed at the end of this brochure
Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have
worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical terms you and other personal pronouns active voice and short sentences
We refer to HMSA Plan as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
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HMSA Plan 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO with a Point of Service Product Turn to this section for a brief description of HMOs and how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
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HMSA Plan 2000
Section 1 Health Maintenance Organizations with a Point of Service Product
This Plan is a health maintenance organization HMO that offers a point of service or POS product When services are needed you may choose to obtain them from your primary care physician within this Plan's provider network or go outside the network for
treatment
When you receive services from your primary care physician within the Plan's provider network you will not have to submit any claim forms However you will need to pay a minimal amount for services received If you receive services from non Plan doctors or
other non Plan providers you pay a substantial portion of the charges and less benefits may be available to you
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available
and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment
Section 2 How we change for 2000
Program wide This year you have a right to more information about this Plan care management our networks changes facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in the
second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the FEHB program See Section 3
How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician amend a record
that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer
Changes to this Your share of the premium will increase by 5.7 for Self Only or 1.2 for Self and Family Plan
You may now receive services from Optometrists allowed under the expanded scope of their license
Your copayments for drug benefits have been changed The copayments from Plan pharmacies for Generic Formulary Drugs have been changed from 2 to 5 for Preferred Name Brand Drugs from 7 to
10 and for Non Preferred Name Brand Drugs from a 20 copayment to a 50 copayment of eligible charges but not less than a 10 copayment for Non Preferred Name Brand Drugs The copayments for
drugs from non Plan pharmacies and the Mail Order Drug Program can be found on pages 15 16 under the Prescription Drug Benefits section
Disposable needles and syringes are now available to you from Plan and non Plan pharmacies A 20 coinsurance is no longer required for disposable needles and syringes needed to inject covered
prescriptions if purchased at a Plan pharmacy If you go to a Plan pharmacy you pay nothing if a nonPlan pharmacy is used you pay the difference between the Plan's payment and the actual charge
Copayments can be found on page16 under the Prescription Drug Benefits section
The telephone number for the Plan's Benefit Manager for mental conditions and substance abuse services is not listed If you use a Plan provider he or she will obtain approval from the Plan's Benefit Manager
on your behalf before you receive services If you use a non Plan provider he or she will not necessarily submit a treatment plan to the Plan's Benefit Manager you are responsible for ensuring that the provider
sends the treatment plan to the Plan's Benefit Manager
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HMSA Plan 2000
Section 3 How to get benefits
What is this To enroll with us you must live in our service area This is where our providers practice Our service Plan's service area is the islands of Hawaii Kauai Maui Oahu Molokai and Lanai
area Ordinarily you must get your care from providers who contract with us If you receive care outside our
service area we will pay only for emergency care or point of service benefits We will not pay for any other health care services
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child goes to college in another state you
should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family member move you do not have to wait until Open Season to change plans
Contact your employing or retirement office
How much do You must share the cost of some services This is called either a copayment a set dollar amount or I pay for coinsurance a set percentage of charges
services When you receive services from a non Plan provider you are also responsible for any difference between
the Plan's payment and the actual charges
This plan provides you with additional benefits described on pages 18 19 Major Medical Benefits There is a 2,500 copayment maximum per member per calendar year The 250 deductible described
below counts toward this copayment maximum After the 2,500 maximum is reached you are no longer responsible for major medical copayments for the rest of that calendar year
The deductible is the amount of covered expenses you must incur each calendar year before the Plan pays benefits For a new enrollee the calendar year begins on the effective date of enrollment in this Plan
and ends on December 31 of that same year The deductible is 250 per person for major medical benefits and is not reimbursable by the Plan
The Plan calculates the Plan's payment and your copayment based on Eligible Charge The Eligible Charge is the lower of either the provider's actual charge or the amount we establish as the maximum
allowable fee
Do I have to submit All Plan and most non Plan providers in the State of Hawaii file claims for you If your non Plan claims provider does not file the claim for you you must submit an itemized bill and receipt for the services
you received within 90 days of the last day on which services were received Payment will be sent to you No payment will be made on claims filed with us more than a year after the service date File a
separate claim for each covered family member and each provider For more information please call the Plan at 808 948 6499 Either OPM or the Plan can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time
Who provides my The Plan has over 3,500 Plan doctors dentists and other health care providers in Hawaii who agree to health care keep their charges for covered services below the Plan's eligible charge guidelines When you go to a
Plan provider you are assured that your copayments will not be more than the amount shown in the brochure
You may go to a non Plan provider however the Plan pays a reduced benefit for certain services from non Plan providers In addition because non Plan providers are not under contract to limit their charges
you are responsible for any charges in excess of eligible charges
When you need covered services outside the state of Hawaii you are encouraged to contact out of state Blue Cross and or Blue Shield Plans for information regarding specific Plan providers in their area
Benefit payments for covered services received out of state are based on contracts negotiated between the out of state Blue Cross and or Blue Shield Plans and their Plan providers
When out of state Blue Cross and or Blue Shield Plan providers participate in the BlueCard Program the amount you pay for covered services rendered by these Plan providers is usually calculated on the
lower of 1 the actual billed charges for your covered services or 2 the negotiated price that the on site Blue Cross and or Blue Shield Plan passes on to the Plan
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HMSA Plan 2000
Section 3 How to get benefits continued
Who provides my In some cases this negotiated price is a simple discount In other cases the negotiated price may be health care an estimate that factors in expected settlements or other non claims transactions with your Plan provider
continued or with a specified group of Plan providers or it may reflect an average expected savings Estimated or average prices may be prospectively adjusted to correct for over or underestimation of past prices
A few states do not allow Blue Cross and or Blue Shield Plans to calculate your payment based on the methods outlined above When you receive covered health care services in one of these states your
payment will be calculated according to the laws of that state
In order to receive Plan Provider benefits for covered out of state services under this plan the services you receive must be rendered by a BlueCard PPO provider Non Plan provider benefits are applied for
covered services rendered by non PPO providers even if they participate in other Blue Cross and or Blue Shield programs
What do I do if my Call us We will help you select a new one primary care
physician leaves the Plan
What do I do if Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist I need to go will make the necessary hospital arrangements and supervise your care
into the hospital
What do I do if First call our customer service department at 808 948 6499 If you are new to the FEHB Program we I'm in the will arrange for you to receive care If you are currently in the FEHB Program and are switching to us
hospital when I your former plan will pay for the hospital stay until join this Plan You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get You have direct access to Plan specialists when needed However you may wish to coordinate your specialty care specialty care with your primary care physician who can help you arrange for the specialty care services
you will need
What do I do if You are encouraged to coordinate your specialty care with your primary care physician If he or she I am seeing a decides to refer you to a specialist you may ask to see your current specialist If your current specialist
specialist when I is not a Plan provider you will pay a copayment plus the difference between the eligible charge and the enroll specialist's billed charge
What do I do if Call your primary care physician who may refer you to another specialist You may receive services my specialist from your current specialist until we can make arrangements for you to see someone else
leaves the Plan
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue have a serious seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
illness and my provider unless the termination is for cause If you are in the second or third trimester of pregnancy provider leaves the you may continue to see your OB GYN until the end of your postpartum care
Plan or this Plan You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and leaves the you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic
Program condition or are in your second or third trimester Your new plan will pay for or provide your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in
your second or third trimester your new plan will pay for the OB GYN care you receive from your current provider until the end of your postpartum care
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HMSA Plan 2000
Section 3 How to get benefits continued
How do you Your physician must get our approval before providing you with certain medical treatments procedures authorize medical or devices Before giving approval we consider if the service is medically necessary and if it follows
services generally accepted medical practice
How do you decide You are not covered for medical treatment procedures drugs devices or care and all related services or if a service is supplies that are experimental or investigational A medical treatment procedure drug device or care
experimental or is experimental or investigative if investigational The drug or device cannot be lawfully marketed without approval of the U S Food and Drug
Administration and approval for marketing has not been given at the time the drug or device is furnished or
The drug device medical treatment or procedure or the patient informed consent document utilized with the drug device treatment or procedure was reviewed and approved by the treating
facility's Institutional Review Board or other body serving a similar function or if federal law requires such review and approval or
Reliable evidence shows that the drug device medical treatment or procedure is the subject of ongoing phase I or phase II clinical trials is for the research experimental study or investigational
arm of ongoing phase III clinical trials or is otherwise under study to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy as compared with a standard means of
treatment or diagnosis or
Reliable evidence shows that the prevailing opinion among experts regarding the drug device medical treatment or procedure is that further studies or clinical trials are necessary to determine its
maximum tolerated dose toxicity safety efficacy or its efficacy compared with a standard means of treatment or diagnosis
Reliable Evidence shall mean only
published reports and articles in authoritative medical and scientific literature
the written protocol or protocols used by the treating facility or the protocol s of another facility studying substantially the same drug device medical treatment or procedure or
the written informed consent used by the treating facility or by another facility studying substantially the same drug device medical treatment or procedure
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HMSA Plan 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
Be in writing
Refer to specific brochure wording explaining why you believe our decision is wrong and
Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your
control
We have 30 days from the date we receive your reconsideration request to
Maintain our denial in writing
Pay the claim
Arrange for a health care provider to give you the service or
Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not receive the
requested information within 60 days we will make our decision based on the information we already have
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM OPM to review a will determine if we correctly applied the terms of our contract when we denied your claim or request for
denial service
What if I have a Call us 808 948 6499 and we will expedite our review serious or life
threatening condition and you
haven't responded to my request for
services
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform OPM denied my request so that they can give your claim expedited treatment too Alternatively you can call OPM's health
for care and my benefits Contract Division II at 202 606 3818 between 8 a m and 5 p m Serious or life threatening condition is serious conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as
or life threatening soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial time limits denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you for additional
information
What do I send Your request must be complete or OPM will return it to you You must send the following to OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim 4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
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Section 4 What to do if we deny your claim or request for service continued
What do I send If you want OPM to review different claims you must clearly identify which documents apply to which to OPM claim
continued
Who can make Those who have a legal right to file a disputed claim with OPM are the request
Anyone enrolled in the Plan
The estate of a person once enrolled in the Plan and
Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a copy of the person's specific written consent with the review
request
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision upholds the your only recourse is to sue
Plan's denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third
year after the year in which you received the disputed services or supplies
What laws apply Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its if I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may
recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us the Privacy Act to determine if our denial of your claim is correct The information OPM collects during the review
process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information to support the
disputed claim decision If you file a lawsuit this information will become part of the court record
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HMSA Plan 2000
Section 5 Benefits
Medical and Surgical Benefits
What is covered Basic benefits The following medical and surgical services required as a result of illness or injury are covered as basic
benefits
If you use Plan providers You pay nothing for surgery cutting and well child care immunizations a 20 copay of eligible charges for non cutting surgical procedures anesthesiologist services and most
medical services
If you use non Plan providers You pay any difference between the Plan's payment and the actual charges plus a 30 copay of eligible charges for surgery cutting and non cutting anesthesiologist
services and medical services after the first visit per condition for illness or injury and 100 of the cost of the first visit per condition for medical services for illness or injury you pay any difference between
the Plan's payment and the actual charges for well child care immunizations
Surgery cutting
Non cutting surgery diagnostic endoscopic procedures diagnostic and therapeutic injections including catheters orthopedic castings acne treatment and destruction of localized lesions by
chemotherapy cryotherapy or electrosurgery
Podiatric services
Immunizations and boosters
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two years for women
age 50 through 64 one mammogram every year and for women age 65 and above one mammogram every two years In addition to routine screening mammograms are covered when
prescribed by the doctor as medically necessary to diagnose or treat your illness
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a doctor or a certified nurse midwife The eligible charge for delivery includes
prenatal and postnatal care If payments for prenatal care are made separately prior to delivery these payments will be considered an advance of payment and will be deducted from the maximum
allowance for delivery The mother at her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if
medically necessary If enrollment in the Plan is terminated during pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn child during
the covered portion of the mother's hospital confinement for maternity will be covered under either a Self Only or Self and Family enrollment other care of an infant who requires definitive treatment
will be covered only if the infant is covered under a Self and Family enrollment
Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye diagnostic tests covered under Outpatient X ray and laboratory benefits section see page 10
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney single double lung pancreas kidney and liver transplants allogeneic donor bone marrow transplants autologous bone marrow transplants autologous stem
cell and peripheral stem cell support for the following conditions acute lymphocytic or nonlymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma
advanced neuroblastoma testicular mediastinal retroperitoneal and ovarian germ cell tumors breast cancer multiple myeloma and epithelial ovarian cancer Transplant coverage for breast
cancer multiple myeloma and epithelial ovarian cancer is subject to approval by the Plan based on protocols established by the National Cancer Institute NCI Related medical and hospital expenses
of the donor are covered
You must obtain the approval from the Plan in advance for all transplant evaluations except for cornea and kidney transplant evaluations The Plan will not pay benefits for transplant evaluations if prior
authorization by the Plan is not first obtained Transplant evaluation means those procedures including laboratory and diagnostic tests consultations and psychological evaluations which a hospital or facility
uses in evaluating a potential transplant candidate
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HMSA Plan 2000
Section 5 Benefits continued
Basic benefits The Plan will not pay any transplant benefits other than cornea and kidney transplants unless each of continued the following conditions are met the specific organ to be transplanted must be medically necessary and
appropriate for the treatment of your illness or injury you must obtain written approval from the Plan in advance for all transplants the transplant must be performed at a transplant facility that is under contract
with the Plan for that type of transplant and the contracted transplant facility has accepted you as a transplant candidate
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Surgical treatment of morbid obesity
Home health services including intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness and need
Up to 150 visits per calendar year for home health services of nurses and health aides from a Plan approved home health care agency when medically necessary and prescribed by your doctor who
must certify that you are homebound due to illness or injury and periodically review the program for continuing appropriateness and need
Limited benefits Well child care is limited to six visits from birth up to age one year two visits for children age one year one visit each calendar year for children age 2 through age 12 and appropriate immunizations and
laboratory tests in accordance with prevailing medical standards
Members may select from one of the following options for obtaining routine physical exams
One annual check up from a physician including routine laboratory and X rays related to the exam Lab tests and X rays are paid at 50 of eligible charges women may receive an annual routine
gynecological examination and pap smear or
Free health risk assessment and lifestyle counseling services from HealthPass Members age 18 and older are eligible to receive an annual screening at a HealthPass Office which includes a
comprehensive health questionnaire physical measurements blood cholesterol glucose tests and health counseling Members age 14 to 18 years of age may participate in an innovative interactive
computer program at a HealthPass Office which assesses specific adolescent health risks Additional screening tests when indicated by HealthPass criteria and performed by a provider selected by
HealthPass are provided at 50 of the eligible charge
For more information on HealthPass Program contact the Customer Service Department at 808 948 6499
Doctor visits in a hospital or skilled nursing facility are limited to one per day a second opinion on the necessity of surgery is covered
Allergy testing including agents is limited to one series of tests per calendar year which is paid at 50 of eligible charges in addition 50 of the eligible charges for allergy treatment materials such as
allergy serum are covered
Services of an assistant surgeon are limited to cases when the assistance is medically necessary based on the complexity of the surgery and the hospital does not have a resident or intern on its staff who
could have assisted the surgeon
Outpatient X rays laboratory tests radiation therapy and routine screening by low dose mammography are covered at 50 of eligible charges with the following exceptions X rays ordered
within 48 hours following an injury are covered at 100 of eligible charges and radiation therapy in the treatment of malignant conditions is covered at 100 of eligible charges benefits will only be paid for
routine chest X ray urinalysis complete blood count pap smear and tuberculin skin test when part of annual health appraisals Laboratory tests in connection with well child care visits are limited to the
following tests through age 12 two tuberculin tests tine or skin sensitivity three blood tests hemoglobin or hematocrit and three urinalysis Screening by low dose mammography benefit
guidelines are described in the Basic Benefits section on page 9
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HMSA Plan 2000
Section 5 Benefits continued
Limited benefits Prostate specific antigen tests are limited to one test per calendar year for men ages 50 and above continued
Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring
within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral areas surrounding the
teeth are not covered as oral surgery including any care involved in treatment of temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and her attending physician may decide whether to have breast reconstruction surgery following a mastectomy and whether
surgery on the other breast is needed to produce a symmetrical appearance surgery and treatment services are covered under the Medical and Surgical Benefits section prosthetic devices and supplies
are covered under Other Benefits Major Medical Benefits section
Diagnosis and treatment of infertility is covered the following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination ICI and intrauterine insemination
IUI are covered cost of donor sperm is not covered Fertility drugs are not covered Other assisted reproductive technology ART procedures such as embryo transfer are not covered except one in
vitro fertilization per qualified married couple per lifetime diagnostic procedures are covered under Medical and Surgical Limited benefits Outpatient X rays and laboratory tests treatment services are
covered under Medical and Surgical Basic benefits
What is not Physical examinations that are not necessary for medical reasons such as those required for
covered obtaining or continuing employment or insurance attending school or camp or travel Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Hearing aids covered under Major Medical Benefits
Foot orthotics except for specific diabetic conditions
Chiropractic services
Homemaker services
Radial keratotomy
Treatment of TMJ dysfunction
Educational programs except services provided by HMSA's HealthPass program
Special Notice Many services that are not listed in the Medical and Surgical section or the Hospital Extended Care section are covered as Major medical benefits see pages 18 19 In addition
Major medical benefits will provide additional benefits for many services listed under the Medical and Surgical section or the Hospital Extended Care section
Hospital Extended Care Benefits
What is covered Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are
hospitalized under the care of a Plan doctor You pay nothing for Plan hospital services and a 20 copay of eligible charges for inpatient visits by Plan providers if a non Plan provider is used you pay a
30 copay of eligible charges plus any difference between the Plan's payment and the actual charges for covered services Doctor visits are limited to one per day All necessary services are covered
including
Semiprivate room accommodations when a doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care Private duty nursing care is
paid at 50 of eligible charges and has a lifetime maximum benefit of 2,000
Specialized care units such as intensive care or cardiac care units
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HMSA Plan 2000
Section 5 Benefits continued
Extended Care The Plan provides a comprehensive range of benefits up to 100 days each calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor
You must be admitted upon the authorization of and be attended by a doctor if you are in the facility for more than 30 days the attending doctor must submit an evaluation report to the Plan at the end of the
30 day period You pay nothing for covered Plan skilled nursing facility services and a 20 copay of eligible charges for inpatient visits by Plan providers if a non Plan provider is used you pay a 30
copay of eligible charges plus any difference between the Plan's payment and the actual charges for covered services Doctor visits are limited to one per day All necessary services are covered
including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a doctor
Hospice Care Supportive and palliative care for up to 210 days for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling The hospice and
attending physician must certify in writing that the patient is in the terminal stages of illness with a life expectancy of six months or less
Hospice services must be provided by a hospice currently under contract with the Plan to provide hospice services services rendered by a non Plan provider are not a benefit of this Plan The member
owes no copay for hospice services
Birthing center Benefits will be provided when a Plan approved birthing center is used instead of regular hospital facilities
Ambulance Automobile ambulance service to and between hospitals is paid at 100 of eligible charges see pages service 18 19 Major medical benefits for air ambulance service
Inpatient dental Hospitalization for certain dental procedures is covered when a doctor determines there is a need for procedures hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the
hospitalization but not the cost of the professional dental services unless the services are covered under dental benefits Conditions for which hospitalization would be covered include hemophilia and heart
disease the need for anesthesia by itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the doctor determines that outpatient management is not medically appropriate See page 15 for nonmedical substance abuse benefits
Ambulatory Charges for surgery will only be paid when the surgery cannot be performed safely and effectively in a surgical center doctor's office
or outpatient hospital
What is not Personal comfort items such as telephone and television covered Blood bank service charges
Custodial care rest cures domiciliary or convalescent care
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HMSA Plan 2000
Section 5 Benefits continued
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe emergency endangers your life or could result in serious injury or disability and requires immediate medical or
surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are emergencies because they are
potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe
Emergencies If you are in an emergency situation please call your primary care doctor Your primary care doctor will within the service provide the necessary care refer you to other Plan providers or make arrangements with other providers
area In extreme emergencies if you are unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room If you are hospitalized in
non Plan facilities and Plan doctors believe care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full
Emergency care is covered the same as routine care provided by Plan providers regardless of whether a Plan provider or non Plan provider is used Benefits are the same within or outside of the Plan's Service
Area
Emergencies Emergency care is covered the same as routine care providers regardless of whether a Plan provider or outside the non Plan provider is used Benefits are the same within or outside of the Plan's Service Area
service area
What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service see page 11 Hospital Extended Care Benefits for automobile ambulance and page 18 Major medical benefits for air ambulance
Filing claims for Plan providers will file their claims submitted on the HCFA 1500 claim form with the Plan When non Plan providers services are provided by non Plan providers you must submit itemized bills and your receipts to the
Plan along with an explanation of the services For more information please call the Plan at 808 948 6499 A payment will be sent to you unless the claim is denied If it is denied you will receive
notice of the decision including the reasons for the denial and the provisions of the contract on which denial was based You may request reconsideration in accordance with the disputed claims procedure set
forth on page 7
Mental Conditions Substance Abuse Benefits
Mental Conditions
What is covered To the extent shown below the Plan covers the following services by psychiatrists psychologists or qualified clinical social workers and advanced practice registered nurses when necessary for the diagnosis
and treatment of acute psychiatric conditions including the treatment of mental illness or disorders when the Plan deems such care necessary
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care Up to 24 outpatient visits to doctors consultants or other psychiatric personnel each calendar year However benefits for additional visits require that you receive approval from the benefit manager If
you use Plan providers You pay a 20 copay of eligible charges for diagnostic evaluation and psychiatric treatment and a 50 copay of eligible charges for psychological testing
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HMSA Plan 2000
Section 5 Benefits continued
Outpatient care If you use non Plan providers You pay any difference between the Plan's payment and the actual continued charges plus a 30 copay of eligible charges for diagnostic evaluation and psychiatric treatment and a
50 copay of eligible charges for psychological testing
Approval from the Plan's Benefit Manager must be obtained in advance for mental conditions or substance abuse services recommended by Plan and non Plan providers
If your provider is a Plan provider he or she will submit a treatment plan on your behalf to the benefit manager
If your provider is a non Plan provider he or she will not necessarily submit a treatment plan on your behalf You are responsible for ensuring that the provider sends a treatment plan to the benefit manager
Inpatient care Up to 30 days of hospitalization each calendar year additional benefits for inpatient psychiatric care available under Major medical benefits see page 19
If you use Plan providers You pay nothing for up to 30 days of hospitalization In addition services of a Plan psychiatrist psychologist clinical social workers and advanced practice registered
nurses in an inpatient setting are paid at the same benefit rate as outpatient care for up to 30 visits per calendar year
If you use non Plan providers You pay a 30 copay of eligible charges plus balance of actual charges for up to 30 days of hospitalization all charges thereafter In addition professional services of a
non Plan provider in an inpatient setting are paid at the same benefit rate as outpatient care for up to 30 visits per calendar year
Approval from the Plan's Benefit Manager must be obtained in advance for mental conditions or substance abuse services recommended by Plan and non Plan providers
If your provider is a Plan provider he or she will submit a treatment plan on your behalf to the benefit manager
If your provider is a non Plan provider he or she will not necessarily submit treatment plan on your behalf You are responsible for ensuring that the provider sends a treatment plan to the benefit manager
In case of emergency your physician must contact the Benefit Manager within 48 hours or on the first working day thereafter whichever is later The Benefit Manager will be available 24 hours a day
The Benefit Manager will review the medical necessity and appropriateness of treatment including the method and place of treatment and approve the level of treatment eligible for benefits The Plan will pay
benefits only up to the level of treatment approved by the Benefit Manager Any services beyond the level of treatment approved by the Benefit Manager will not be eligible for benefits
Mental conditions substance abuse services recommended by non Plan providers which have not been reviewed by the Benefit Manager will be subject to review of the medical necessity and appropriateness
of treatment by the Plan at the time the claim is made The Plan will not pay benefits for any mental conditions substance abuse services which are determined not to be medically necessary or which would
not have been approved for benefits if the Benefit Manager's review had been obtained
What is not Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless covered determined by the Plan to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a psychiatric condition
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HMSA Plan 2000
Section 5 Benefits continued
Substance abuse
What is covered This Plan provides detoxification services see page 12 for Acute inpatient detoxification and diagnosis and treatment of alcohol and drug dependence or abuse You are eligible for two treatment programs per
lifetime a treatment program is an admission for treatment under a plan designed to produce remission in those who complete treatment A complete program includes assessment and referral initial
rehabilitative care up to 30 days and aftercare up to 30 hours Once you start your first treatment program the entire program must be completed within 12 months
Benefits available under the initial rehabilitative care described above consist of an outpatient program including counseling services educational program nutritional therapy and therapeutic and
recreational activities as well as a residential program including room and board medication counseling services educational program and therapeutic and recreational activities
You pay a 20 copay of eligible charges for covered inpatient and outpatient services if a Plan provider is used if a non Plan provider is used you pay any difference between the Plan's payment and the actual
charges plus a 30 copay of eligible charges for covered services You pay all charges after two authorized treatment programs The Plan has contracted with a limited number of providers to become
program providers of substance abuse services Benefits for a Plan provider shall be paid only for services rendered by such program providers
The substance abuse benefit may be combined with the mental conditions benefits shown on pages 13 14 provided such treatment is necessary as a Mental Conditions Benefit and is approved by the Plan or
the Plan's Benefit Manager to permit additional care for the psychiatric aspects of substance abuse subject to the applicable Mental Conditions Benefit copayments and visit day limitations
Approval from the Plan's Benefit Manager must be obtained in advance for substance abuse services recommended by Plan and non Plan providers No benefits will be provided for substance
abuse services recommended by a non Plan provider which would not have been approved if the Benefit Manager's review had been obtained
If your provider is a Plan provider he or she will submit a treatment plan on your behalf to the benefit manager
If your provider is a non Plan provider he or she will not necessarily submit a treatment plan on your behalf You are responsible for ensuring that the provider sends a treatment plan to the benefit manager
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a doctor and obtained at a pharmacy will be dispensed with a maximum limit of a 30 day supply or fraction thereof and paid upon submission of a claim to the Plan
When certain generic drugs which are recognized by the Plan for extended dispensing limits are prescribed in quantities of 100 units or a 60 day supply or fraction thereof whichever is greater a single
copay charge will apply
If you use a Plan pharmacy You pay a 5 copay per prescription unit or refill for generic drugs a 10 copay for preferred name brand drugs a 50 copay of eligible charges but not less than 10 copay
for non preferred name brand drugs
If you use a non Plan pharmacy You pay 20 of the remaining eligible charges after a 5 copay per prescription unit or refill for generic drugs or a 10 copay for preferred name brand drugs plus any
difference between the Plan's payment and the actual charge for non preferred name brand drugs you pay a 50 copay of eligible charges but not less than 10 copay plus any difference between the Plan's
payment and the actual charge
The Plan requires the substitution of generic drugs listed on the Hawaii Drug Formulary of Equivalent Drug Products for a name brand drug except when substitution is not permissible If you choose not to
use the generic equivalent the Plan will reimburse you the amount that would have been paid for the generic equivalent
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HMSA Plan 2000
Section 5 Benefits continued
What is covered Drug Benefits Management Program the Plan has arranged with Plan pharmacists to assist in continued managing the usage of drugs including drugs listed in the HMSA Drug Formulary Under the
program Plan pharmacists can only dispense certain drugs listed in the HMSA Drug Formulary after receiving the preauthorization of the Plan
You pay the entire cost of the drug if preauthorization is not obtained or if the preauthorization is denied
Plan pharmacists may also dispense a maximum of a 30 day supply or fraction thereof for first time prescriptions of maintenance drugs For subsequent refills the Plan pharmacist may dispense a
maximum 90 day supply or fraction thereof after confirming that you have tolerated the drug without adverse side effects that may cause you to discontinue using the drug and your doctor has determined
that the drug is effective
Nonformulary drugs will be covered when prescribed by a Plan doctor
In addition the Plan offers a Mail Order Drug Program Up to a 90 day supply or fraction thereof of certain maintenance medications may be obtained by mail If you are currently taking prescription
medication on a regular basis the Mail Order Drug Program may help you save money on the cost of your medication
If you use the Mail Order Drug Program You pay a 10 copay per prescription unit or refill for generic drugs and preferred name brand insulin a 20 copay for preferred name brand drugs and nonpreferred
name brand insulin and a 45 copay for non preferred name brand drugs You pay nothing for preferred name brand diabetic supplies and you pay a 20 copay for non preferred name brand diabetic
supplies
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Insulin when obtained by prescription with a copay charge applied to each 30 day supply or fraction thereof If you use a plan pharmacy you pay a 5 copay for preferred name brand insulin or
a 10 copay for non preferred name brand insulin If you used a non Plan pharmacy you pay 5 plus any difference between the Plan's payment and the actual charge for preferred name brand
insulin or a 10 copay plus any difference between the Plan's payment and the actual charge for nonpreferred name brand insulin Also see mail order insulin
Diabetic supplies including insulin syringes needles lancets auto lancet devices glucose test tablets and test tape and acetone test tablets If you used a plan pharmacy you pay nothing for
preferred name brand diabetic supplies or a 10 copay for non preferred name brand diabetic supplies If you use a non Plan pharmacy you pay any difference between the Plan's payment and
the actual charge for preferred name brand diabetic supplies or a 10 copay plus any difference between the Plan's payment and the actual charge for non preferred name brand diabetic supplies
Also see mail order diabetic supplies
Disposable needles and syringes needed to inject covered prescribed medication you pay nothing at a Plan pharmacy and you pay any difference between the Plan's payment and the actual charge at a
non Plan pharmacy
Injectable drugs such as Imitrex epinephrine emergency kit Self administered injectable medication and intravenous fluids and medication for home use see the Major Medical Benefits
section on page 19 other injectable drugs are covered see appropriate sections on pages 9 10
Nicotine patches for the cessation of smoking by prescription only limited to one treatment cycle per calendar year with a limit of two treatment cycles per member per lifetime
FDA approved prescription drugs and devices for birth control
Internally implanted time release contraceptive drugs contraceptive drugs injected periodically and intrauterine devices are covered under the Major Medical Benefits section on page 19
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HMSA Plan 2000
Section 5 Benefits continued
What is covered Oral medication for treatment of impotency such as Viagra Benefits are limited to the following continued Up to 4 pills every 30 days
One month dispensed at a time
Retail pharmacy access only not available through mail order
Covered for males only
Physician must certify in advance that the patient has impotence due to organic causes from vascular or neurological disease
What is not Drugs and devices available without a prescription or for which there is a nonprescription equivalent covered available
Medical supplies such as dressings antiseptics and spacers for inhaled drugs
Vitamins minerals and nutritional substances
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs are not covered except for nicotine patches and Zyban prescription drug
Drugs related to the diagnosis or treatment of infertility
Other Benefits
Dental Care
What is covered The following dental services are covered when you use a Plan dental center Plan provider or non Plan provider
Services If you use Plan If you use non Plan dental center or Plan provider you pay
provider you pay
Preventive Annual exam visit annual cleaning prophylaxis Nothing 30 of eligible charges dental care plus balance of actual
charges
Standard dental For permanent teeth only x rays 2 annual bite 30 of eligible charges 50 of eligible charges services wings and one full mouth series every 5 years plus balance of actual
fillings amalgam silicate you pay surcharge charges for gold extractions root canal treatment
treatment for diseases of the gum space maintainers anesthesia
Dental surgery Incision and drainage of abscess alveolectomy 30 of eligible charges 50 of eligible charges excision of cysts plus balance of actual
charges
Occlusal Splint When pre authorized and determined by the Plan occlusal splint therapy is covered for the treatment of a Therapy temporomandibular disorder involving the muscles of mastication chewing Plan pays 50 of the
eligible charges based on an all inclusive rate not to exceed a maximum Plan payment of 125 You pay 50 of eligible charges plus all costs after the Plan maximum benefit has been paid whether a Plan
or non Plan provider is used
Coverage of occlusal splint therapy is subject to the following limitations a removable acrylic appliance is used in conjunction with the therapy the disorder is present at least one month prior to the start of
the therapy and the therapy does not exceed ten weeks the therapy does not result in any irreversible alteration in the occlusion and is not intended to be for the treatment of bruxism for the prevention of
injuries of the teeth or occlusion or is related to other treatment of the occlusion the benefit is limited to one treatment episode per lifetime and the member must be 15 years of age and above
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HMSA Plan 2000
Section 5 Benefits continued
Accidental Restorative services necessary to repair but not replace natural teeth is covered The need for these injury benefit services must result from an accidental injury You pay nothing if a Plan provider is used a 30 copay
of eligible charges plus balance of actual charges for non Plan providers
What is not All other dental services including topical application of fluoride covered Dental appliances such as false teeth crowns bridges and repair of dental appliances
Dental prostheses dental splints except as covered under occlusal splint therapy dental sealants orthodontia or other dental appliances regardless of the symptoms or illness being treated
Osseointegration dental implants and all related services
Vision Care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye an annual vision exam and eye refraction to provide a written lens prescription for eyeglasses may
be obtained If you use Plan optometrists You pay no more than 7 If you use other Plan providers You pay 20 of eligible charges If you use non Plan providers You pay any difference between
the Plan's payment and the actual charges plus a 30 copay of eligible charges for the eye refraction
What is not Corrective eyeglasses or contact lenses including the fitting of the lenses covered
Cardiac rehabilitation
What is covered Cardiac rehabilitation programs are covered at 50 of eligible charges not to exceed a maximum Plan payment of 300 per program You pay 50 of eligible charges plus all costs after the Plan maximum
benefit has been paid whether a Plan or non Plan provider is used Members must be referred by their doctor for cardiac rehabilitation within three months after coronary bypass surgery or diagnosis of acute
myocardial infarction angina pectoris or coronary disease There is a lifetime maximum of two complete programs
Each program must consist of planned exercise to rehabilitate and strengthen the heart and education to provide information and motivation for behavior lifestyle changes Each treatment program must be
completed within 180 days no benefits are paid if the program is not completed
Major medical benefits
In addition to benefits described elsewhere in this brochure Major medical benefits are paid for the services and supplies listed below Each person must meet the 250 deductible before he she can receive
reimbursement under Major medical benefits Only eligible charges for services and supplies that are listed below and not covered by other Plan benefits count toward the deductible Once the deductible is
met the Plan will add the Major medical benefit payment to benefits otherwise payable to cover the major portion of most allowable expenses See page 4 for additional information If you use Plan
providers You pay a 20 copay of eligible charges under Major medical benefits after the 250 deductible is met If you use non Plan providers You pay any difference between the Plan's
payment and the actual charges plus a 30 copay of eligible charges under Major medical benefits after the 250 deductible is met After you have paid 2,500 in Major medical eligible charges during a
calendar year you pay nothing for Major medical copayments for the rest of that calendar year
What is covered Doctor's visits surgery and anesthesiology Hospital expenses
Laboratory tests audiograms X rays allergy testing radiotherapy and chemotherapy
Blood and blood products including cost of administration and blood bank service charges Any additional charges for autologous blood reserved for a beneficiary who donated the blood are
excluded as a benefit
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HMSA Plan 2000
Section 5 Benefits continued
What is covered Short term physical and speech therapy when rendered by a registered certified physical or speech continued therapist and ordered by a doctor in an individualized treatment plan for restoration of a function
impaired by illness or injury Services of an occupational therapist are covered as physical therapy if the service is also performed by a physical therapist Long term maintenance therapy programs are
not covered
Outpatient services and supplies for the injection or intravenous administration of either medication or nutrient solutions required for primary diet
Prosthetic devices such as artificial limbs and lenses following cataract removal orthopedic devices such as braces breast prostheses surgical bras and replacements rental or purchase of
durable medical equipment such as wheelchairs and hospital beds
Air ambulance service limited to inter island or intra island transportation within the state of Hawaii from place where injury occurred or illness first required care to nearest facility equipped to
render proper care
Hospitalization for dental surgery as a result of accidental injury or because of medical condition that makes hospitalization necessary
Inpatient psychiatric care to a lifetime non renewable maximum of 10,000 as a Major medical benefit in addition to the benefits shown on pages 13 14
Hearing aids one device per ear every 5 years
Internally implanted time release contraceptive drugs one every five calendar years contraceptive drugs injected periodically 4 injections per calendar year intrauterine devices one per calendar
year For other related services such as laboratory test and family planning services see appropriate sections under Basic Benefits For oral contraceptives and diaphragms see the Prescription
Drug Benefits section
What is not No payment will be made under this Major Medical Section for immunizations surgical services covered skilled nursing facility services home health care out of hospital psychiatric care an illness or
injury resulting from a major disaster or routine or preventive services except for screening mammograms
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HMSA Plan 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available to all enrollees and family members who are members of this Plan The cost of the benefits
described on this page is not included in the FEHB premium any charges for these services do not count toward any FEHB deductibles out of pocket maximum copay charges etc These benefits are not subject to the FEHB
disputed claims procedures
Cancer Care Plan
Benefit Services of Hawaii a subsidiary of Blue Cross and Blue Shield of Hawaii is pleased to make available a supplemental plan called CancerCare a cancer and specifi ed di sease prot ecti on pl an
CancerCare provides inpatient and outpatient benefits for cancer and 34 specified diseases The plan pays cash benefits directly to you regardless of any other coverage you may already have The extra funds can help pay for any out ofpocket
medical expenses and many non medical expenses such as rent or mortgage utility bills etc
Plan Features Hospit al confi nement Surgery Experimental treatment Radiation Chemotherapy
Blood Plasma Transportation cost
Two CancerCare Plans are available which vary in benefits and rates You may also choose two optional riders the Cancer Diagnosis Benefit Rider and the Intensive Care Coronary Care Rider
If you are a Hawaii resident under the age 65 you can apply for coverage for yourself and your eligible family members Please call us at 948 6373 for more information
Long term care
Can you imagine being faced with bills of 40,000 50,000 or 80,000 a year for long term care That's why BSH Life a subsidiary of HMSA is pleased to introduce a long term care protection plan designed specifically for
Hawaii residents Now you can have coverage that puts you in control of your future and protects you and your loved ones from the unexpected
Our plan offers a variety of long term care services to meet your diverse needs including
Personal Care Assisted Living Facility Care
Home Health Care Adult Residential Care Homes ARCH
Adult Day Care Nursing Home Care
BSH Life's Long Term Care Plan is available to all Hawaii residents between the ages of 20 to 84
Please Call 1 888 820 4672 for more information
Expanded Prescription Drug Benefit
Special Notice Spacers for inhaled drugs are not a benefit of this Plan However HMSA has arranged with specific drug manufacturers to provide these items to members at special member rates when they are purchased
from a Plan pharmacy Any charges for these services do not count toward your deductibles out of pocket maximum copay charges etc
Benefits on this page are not part of the FEHB contract
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HMSA Plan 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you may
need to file a Medicare claim form
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on suspending your FEHB
enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833
Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance coverage You must tell us if you or a family member has double coverage You must also send us documents
about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever is
less We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide beyond our control them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for another person caused you must reimburse us for whatever services we paid for We will cover the cost
injuries of treatment that exceeds the amount you received in the settlement If you need more information contact us for our third party liability procedures
HMSA Plan 2000
Section 7 Limitations Rules that affect your benefits continued
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage
Workers We do not cover services that compensation
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or Agencies indirectly pays for
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right information about to information about your health plan its networks providers and facilities You can also find out about
your HMO care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov lists
the specific types of information that we must make available to you
If you want specific information about us call 808 948 6499 or write to 818 Keeaumoku Street Honolulu HI 96814 You may also contact us by fax at 808 948 5567 or visit our website at
http www hmsa com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make an
enrolling in the informed decision about FEHB Program When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
premiums effective premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled when I retire in the FEHB Program for the last five years of your Federal service If you do not meet this requirement
you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section
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HMSA Plan 2000
Section 8 FEHB FACTS continued
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are unmarried dependent children under age 22 including any foster or step children your employing or
available for my retirement office authorizes coverage for Under certain circumstances you may also get coverage for a family and me disabled child 22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before to 60 days after
you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is born or becomes an eligible
family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or remove family
members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan
Are my medical We will keep your medical and claims information confidential Only the following will have access to and claims records it
confidential OPM this Plan and subcontractors when they administer this contract
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF2809 cards or the OPM annuitant confirmation letter until you receive your ID card You can also use an
Employee Express confirmation letter
What if I paid Your old plan's deductible continues until our coverage begins a deductible
under my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you conditions enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens You will receive an additional 31 days of coverage for no additional premium when if my enrollment
Your enrollment ends unless you cancel your enrollment or in this Plan ends
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under spouse coverage your former spouse's enrollment But you may be eligible for your own FEHB coverage under the
spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information about your coverage choices
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HMSA Plan 2000
Section 8 FEHB FACTS continued
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you can
receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under TCC in TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling in TCC You
must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies them for coverage
or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline
How can I You may convert to an individual policy if convert to
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not individual pay your premium you cannot convert
coverage You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to us within 31 days after you receive this notice However if you are a
family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or limit your coverage due
to pre existing conditions
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HMSA Plan 2000
Section 8 FEHB FACTS continued
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Certificate of indicates how long you have been enrolled with us You can use this certificate when getting health
Group Health insurance or other health care coverage You must arrange for the other coverage within 63 days of Plan Coverage leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions
for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well
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HMSA Plan 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 808 948 5166 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE 202 418 3300
U S Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400 Washington D C 20415
Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may
investigate anyone who uses an ID card if they
Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you
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HMSA Plan 2000
Summary of Benefits for HMSA Plan 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes inhospital Care doctor care room and board general nursing care private room if medically necessary
diagnostic tests drugs and medical supplies use of operating room intensive care and complete maternity care You pay nothing for Plan hospital services and a 20 copay of eligible charges
for inpatient visits by Plan providers 11 12
Extended All necessary services up to 100 days per year You pay nothing for services of Plan providers 12 care
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year conditions You pay nothing for Plan hospital services and a 20 copay of eligible charges for
inpatient visits by Plan providers 14
Substance Medical complications and acute detoxification covered under hospital benefits Lifetime maximum abuse of two 30 day substance abuse rehabilitation programs includes inpatient residential and outpatient
care you pay a 20 copay of eligible charges for services of Plan providers 15
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury including care specialist's care preventive care including well child care periodic check ups and routine
immunizations laboratory tests and X rays complete maternity care You pay nothing for surgery cutting and well child care immunizations a 20 copay of eligible charges for
non cutting surgery medical services and anesthesiology a 50 copay for laboratory tests and X rays 9 11
Home Up to 150 visits per calendar year by nurses and health aides You pay a 20 copay of eligible health care charges for services of Plan approved providers 10
Mental Up to 24 outpatient visits per year you pay a 20 copay of eligible charges for diagnosis and conditions treatment and a 50 copay of eligible charges for psychological testing for services of Plan
providers 13 14
Substance Lifetime maximum of two substance abuse rehabilitation programs includes inpatient residential abuse and outpatient care up to 30 days initial rehabilitative care and up to 30 hours after care per
program you pay a 20 copay of eligible charges for services of Plan providers 15
Emergency care Eligible charges for services and supplies required because of a medical emergency to the extent these services would have been covered if received from Plan providers You pay
applicable copays as if routine services were rendered by Plan providers regardless of whether a Plan or non Plan provider is used and any charges for services that are not covered benefits
of this Plan 13
Prescription drugs Drugs prescribed by a doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill for generic drugs a 10 copay for preferred name brand drugs a 50 copay of
eligible charges but not less than 10 copay for non preferred name brand drugs 15 17
Dental care Accidental injury benefit preventive dental care and other services You pay copayments for most services 17 18
Vision care One refraction annually You pay 20 copay of eligible charges for Plan providers per refraction if you use Plan optometrists you pay no more than 7 per refraction 18
Out of pocket Copayments are required for some benefits however the Plan has set a maximum of 2,500 maximum per member per calendar year for total Major medical copayments you must pay for services covered
by the Plan This copayment maximum only applies to services covered under Major medical benefits 18 19
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HMSA Plan 2000
2000 Rate Information for
Hawaii Medical Service Association Plan
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but not a member
of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal
Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your Enrollment Share
Share Share Share Share Share Share Share
All of Hawaii
Self Only 871 68.44 22.81 148.28 49.43 80.98 10.27 80.98 10.27
Self and Family 872 152.33 50.77 330.04 110.01 180.25 22.85 180.25 22.85
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