We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at
www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits. The 60% standard is an actuarial value; your specific out-of-pocket costs are determined as explained in this brochure.

See www.opm.gov/healthcare-insurance for enrollment information as well as:

• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, give you other plans' brochures and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

• 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
• What happens when your enrollment ends
• When the next Open Season for enrollment begins

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, disability leave, pensions, etc., you must also contact your employing or retirement office.

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member. Self and Family coverage is for the enrollee and one or more eligible family members. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or 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 that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

Contact your employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits.  Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26^th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage.  For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described below.

Natural children, adopted children, and stepchildren
Coverage: Natural children, adopted children, and stepchildren are covered until their 26th birthday.

Foster children
Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support
Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children
Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance
Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother’s maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

• If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM;
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2024 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2023 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid.  You may be billed for services received directly from your provider.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled 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 (TCC).

You will receive an additional 31 days of coverage, for no additional premium, when:

• Your enrollment ends, unless you cancel your enrollment; or
• You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31^st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60^th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy).

If you are an enrollee and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof.  In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse’s enrollment.  This is the case even when the court has ordered your former spouse to provide health coverage for you.  However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC).  If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices.  You can also visit OPM’s website,
https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

If you leave Federal service, Tribal employment or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, or if you lose your Federal or Tribal job, or if you are a covered child and you turn 26.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health plan (such as your spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHB Program coverage.

Finding Replacement Coverage

We will provide you with assistance in finding a non-group contract available outside the Marketplace if:

• Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
• 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.

You must contact us in writing within 31 days after you are no longer eligible for coverage. For assistance in finding coverage, please contact us at 808-948-5555, Option 2, or visit our website at www.hmsa.com.

Benefits and rates under the replacement coverage will differ from benefits and rates 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.

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.Healthcare.gov.  This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance, if you use our point-of-service program, you can also get care from non-Plan providers but it will cost you more. If you use our Open Access program you can receive covered services from a participating provider without a required referral from your primary care provider or by another participating provider in the network.

To determine if a provider is recognized, we look at many factors including licensure, professional history, and type of practice. All Plan providers and some non-Plan providers are recognized.  To find out if your physician is a participating provider, refer to your HMSA Directory of Participating Providers. If you need a copy, call us and we will send one to you or visit www.hmsa.com/federalplan.

FEHB Carriers must have clauses in their in-network (participating) provider agreements.  These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the in-network provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount.  If an in-network provider bills you for covered services over your normal cost share (deductible, copay, co-insurance) contact your Carrier to enforce the terms of its provider contract.

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law. We credential Plan providers according to national standards. 

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.

We list Plan providers in the provider directory, which we update periodically. The list is also on our website www.hmsa.com/federalplan.

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health.

Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

This plan provides Care Coordinators for complex conditions and can be reached at 808-440-7190 for Oahu and 855-329-5461 for neighbor islands for assistance.

You can receive Plan dental benefits when you see a dental provider for covered services outside of Hawaii. To find a participating dentist, please visit our website at
www.hmsa.com/federalplan.

Non-Plan providers are physicians and other healthcare professionals who are not under contract with this Plan.

For out-of-state services under this Plan, non-Plan provider benefits are applied for covered services rendered by non-BlueCard® PPO providers, even if they participate in other Blue Cross and/or Blue Shield programs.

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these in the provider directory, which we update periodically. The list is also on our website at www.hmsa.com/federalplan.

You are encouraged to coordinate your care with a primary care provider who will provide or arrange most of your healthcare.

Your primary care provider can be a family practitioner, internist, obstetrician/gynecologist or pediatrician. Your primary care provider will provide most of your healthcare, or can refer you to see a specialist.

You have direct access to Plan specialists when needed.  However, you may wish to coordinate your specialty care with your primary care provider, who can help you arrange for the specialty care service you will need.

Here are some other things you should know about specialty care:

• Your primary care provider or specialist may create your treatment plan. The physician may have to get an authorization or approval from us beforehand. If you are seeing a specialist when you enroll in our Plan, you are encouraged to coordinate your specialty care with your primary care provider.  If they decide to refer you to a specialist, ask if you can see your current specialist.
• If you are seeing a specialist and your specialist leaves the Plan, talk to your primary care provider, who will arrange for you to see another specialist. If you decide to continue seeing your specialist, you will pay a copayment/coinsurance plus the difference between the eligible charge and the specialist's billed charge.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause;
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan; or
  • reduce our service area and you enroll in another FEHB plan;  

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Your Plan primary care provider or specialist will make necessary hospital arrangements and supervise your care.  This includes admission to an extended care or other type of facility.

We pay for covered services from the effective date of your enrollment.  However, if you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92^nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person.  If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply.  In such cases, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

You do not need to obtain prior approval for your vaginal delivery and precertification for extended stays for you or your baby. You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery.  Your physician will extend your inpatient stay if medically necessary.

Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

Since we do not have a primary care provider requirement and we allow you to use non-Plan providers, you or your physician will need to obtain our prior approval before you receive certain services. The pre-service claim approval process for services is detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care or services. In other words, a pre-service claim for benefits (1) requires precertification or prior approval and (2) will result in a denial or reduction of benefits if you do not obtain precertification or prior approval.

Your primary care provider has authority to refer you for most services.  For certain services, however, your physician must obtain prior approval from us.  Before giving approval, we check if the service is covered and medically necessary for your condition. A few common examples of things you must obtain prior authorization for:

Lab, X-ray and Other Diagnostic Tests such as genetic testing, polysomnography and sleep studies, computed tomography (CT), and functional MRI.

Surgeries such as organ and tissue transplants, bariatric surgery, and varicose veins treatment.

Treatment Therapies such as applied behavior analysis, physical, occupational and speech therapies, chiropractic services, in vitro fertilization, growth hormone therapy, home IV therapy, habilitative services and devices, drugs such as oral chemotherapy agents, infusibles and injectables, new drug to market (specialty medical drugs), and off-label drug use.

Durable Medical Equipment and Orthotics and Prosthetic Devices such as wheelchairs and external insulin pumps.

This list of services requiring prior approval may change periodically. To ensure your treatment or procedure is covered, call us at 808-948-6499 or visit our website at
www.hmsa.com/federalplan.

If you are under the care of:

• An HMSA participating physician or contracting physician, they will:
  • Obtain prior approval for you; and
  • Accept any penalties for failure to obtain prior approval.
• You are responsible for obtaining prior approval when receiving services from a BlueCard® PPO, BlueCard® Plan provider or a non-Plan provider.  Please contact our Medical Management Department at 808-948-6464 on Oahu, or (1-800-344-6122) toll free from the Neighbor Islands. You may also contact our Medical Management Department by fax at 808-944-5611.

You will need to provide the following information:

• enrollee’s name and Plan identification number;
• patient’s name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• name and phone number of admitting physician;
• name of hospital or facility;
• number of days requested for hospital stay; and
• clinical information.

If you do not receive prior approval and receive any of the services described in Section 3 You need prior Plan approval for certain services - Other services, benefits may be denied.

We will make our decision within 15 days of receipt of the pre-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours.  If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim.  You will then have up to 48 hours to provide the required information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at (1-800-344-6122) for neighbor island, and 808-948-6464 for Oahu.  You may also call OPM’s FEHB 2 at (1-202-606-3818) between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at (1-800-344-6122) for neighbor island, and 808-948-6464 for Oahu. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

A concurrent care claim involves care provided over a period of time or over a number of treatments.  We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends.  If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect. 

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

If you have a pre-service claim and you do not agree with our decision regarding prior approval of a transplant or other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call Customer service at 1-800-776-4672 for neighbor islands, and 808-948-6499 for Oahu.

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to

1. Arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply; or
   
2. Ask you or your provider for more information.
   
   You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.
   
   If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision.
   
3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision.  Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure. 

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.  We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them per calendar year.

The difference between the actual charge and the eligible charge that you pay when you receive service from a non-Plan provider does not apply to your deductible.

We do not have a deductible under the High Option.

The calendar year deductible is $150 per person under the Standard Option. Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $150 under Standard Option. Under Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $300 under Standard Option. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $300 under Standard Option.

Note: If you change plans during Open Season, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

For most medical services, we calculate our payment and your copayment/coinsurance based on eligible charges. The eligible charge is the lower of either the provider’s actual charge or the amount we established as the maximum allowable fee.

For participating facilities, we calculate our payment based on the maximum allowable fee. Your coinsurance is based on the lower of the facility’s actual charge or the maximum allowable fee. Your coinsurance and our payment will equal the maximum allowable fee.

Non-Plan providers are not under contract to limit their charges to our eligible charges. You are responsible for any charges in excess of eligible charges.

Exception: For certain services that may be subject to the No Surprises Act of 2021, your cost-share may be different based on the requirements of the law.

Coinsurance is the percentage of our allowance that you must pay for your care.

Example: When you receive an X-ray, you pay a coinsurance of 20% for Plan providers.

You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

High Option:
After your copayments and coinsurance total $3,000 for Self Only or $6,000 for Self Plus One, or $9,000 for Self and Family enrollment in any calendar year, you are no longer responsible for any coinsurance/copayment amounts for covered services. If you are enrolled in Self Plus One or Self and Family, each family member must individually meet the $3,000 Self Only out-of-pocket maximum but not to exceed the $9,000 Self and Family out-of-pocket maximum for a family of 3 or more.

Coinsurance/copayments for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay coinsurance/copayments for these services even after you have met the out-of-pocket maximum:

• Adult Dental Care (19 years of age and older)
• Adult Vision Care (19 years of age and older)

Standard Option:
After your copayments and coinsurance total $5,000 for Self Only or $10,000 for Self Plus One, or $10,000 for Self and Family enrollment in any calendar year, you are no longer responsible for any coinsurance/copayment amounts for covered services. If you are enrolled in Self Plus One or Self and Family, each family member must individually meet the $5,000 Self Only out-of-pocket maximum but not to exceed the $10,000 Self and Family out-of-pocket maximum for a family of 3 or more.

Coinsurance for Adult Vision Care do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay coinsurance even after you have met the out-of-pocket maximum.

The following amounts do not count toward meeting your catastrophic protection out-of-pocket maximum and you must continue to be responsible for the amounts below even after you have met the out-of-pocket maximum under the high and standard options.

• Payment for services subject to a maximum once you reach the maximum.
• The difference between the actual charge and the eligible charge that you pay when you receive service from a non-Plan provider.
• Payments for non-covered services.
• Any amounts you owe in addition to your coinsurance/copayment for covered services.

Be sure to keep accurate records of your coinsurance/copayments. We will also keep records of your coinsurance/copayments and track your catastrophic protection out-of-pocket maximum.

If you changed to this Plan during open season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note:  If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services.

A surprise bill is an unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

Balance billing happens when you receive a bill from the nonparticipating provider, facility, or air ambulance service for the difference between the nonparticipating provider's charge and the amount payable by your health plan.

Your health plan must comply with the NSA protections that hold you harmless from surprise bills.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to hmsa.com/federalplan or contact the health plan at 808-948-6499.

Per section 2799A-5(c) of the PHS Act, section 9820(c) of the Internal Revenue Code, section 720(c) of the Employee Retirement Income Security Act -

Visit our website www.hmsa.com/federalplan for information in plain language on:

1. the restrictions on balance billing in certain circumstances,
2. the requirements described under Code section 9816, ERISA section 716, and PHS Act section 2799A-1, and
3. if you believe that a provider or facility has violated the restrictions against balance billing,  please contact the Hawaii State Insurance Commissioner.

Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26).

FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

Professional services of physicians

• In physician's office
• During a hospital stay
• Extended Care Facility
• Medical consultations - inpatient and outpatient
• At home
• In an urgent care center

Plan Provider
$15 copayment per visit

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
$20 copayment per visit
(no deductible)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Advance care planning visit

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Telehealth physician visits

Note:

• Telehealth services are covered in accordance with HMSA’s medical policy for telehealth services.

Plan Provider
$15 copayment

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
$20 copayment
(no deductible)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Screening Services - Grade A and B Recommendations of the U.S. Preventive Services Task Force (USPSTF). For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at
  https://www.uspreventiveservicestaskforce.org.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Online Care

Note: Covered, when provided by HMSA Online Care at www.hmsa.com. You must be at least 18 years old. A member who is a dependent minor is covered when accompanied by an adult member. Care is available for 10 minute sessions which may be extended up to 5 additional minutes. Each session is limited to a total of 15 minutes.

Plan Provider
Nothing

Non-Plan Provider
All charges

Plan Provider
Nothing

Non-Plan Provider
All charges

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine Pap test
• Pathology
• Pre-surgical labs

   

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(no deductible)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• X-ray
• Non-routine mammogram
• CT Scan
• MRI
• Ultrasound
• Electrocardiogram and EEG
• Pre-surgical diagnostic testing

   

   

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Outpatient thoracic electric bioimpedance in an outpatient setting which includes a physician's office.

All charges

• Routine Physical Exam – one per calendar year

The following services are also covered when performed in conjunction with a covered routine physical exam:

• Vision test
• Hearing test

Note:

• For vision and hearing tests not performed in conjunction with a routine physical exam, see Section 5(a) Hearing services (testing, treatment, and supplies) and Vision services (testing, treatment, and supplies).
• Any procedure, injections, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder.
• The following preventive services are covered at the time interval recommended at each of the links below.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing  

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at
  https://www.cdc.gov/vaccines/schedules/

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing  

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at
  https://shorturl.at/hovHM.
  
  

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing  

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Individual counseling on prevention and reducing health risks

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing  

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women please visit the Health and Human Services (HHS) website at 
  https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing  

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Routine screenings include:

• Routine mammogram – covered for age 40 and older, one every calendar year.

Note:  A screening at any age may be received more often if the member has a history of breast cancer or if the member's parent or sibling had a history of breast cancer.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing  

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

• Standard immunizations
• Immunizations for high risk conditions
• Travel immunizations

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing  

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing  

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Colorectal Cancer Screenings are covered in accord with HMSA’s Preventive Services Guidelines for:
  • Fecal occult blood test
  • Sigmoidoscopy screening
  • Colonoscopy screening

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing  

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Urinalysis – one per calendar year
• Chlamydial infection screening
• Gonorrhea infection screening
• TB Test

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing  

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Double contrast barium enema (DCBE) – once every five years, age 50 and above

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing  

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Routine screenings include:

• Routine Prostate Specific Antigen (PSA) test – one annually for men age 50 and older

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing  

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Physical exams, immunizations and any associated screening procedures in connection with third party requests or requirements such as those for: employment (or work-related exposure), participation in employee programs, sports (athletic exams), camp, insurance, disability licensing, or on court order or for parole or probation
• Physical exams obtained for, or related to, the purpose of travel

Note: Physical examinations that are needed by a third party and are coincidentally performed as part of a routine annual physical examination are covered.

All charges

All charges

• Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to 
  https://brightfutures.aap.org
• Immunizations such as DTAP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at 
  https://www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at 
  https://shorturl.at/hovHM.

Note:

• For vision and hearing tests not performed in conjunction with a routine physical exam, see Section 5(a) Hearing services (testing, treatment, and supplies) and Vision services (testing, treatment, and supplies).
• Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.
• To build your personalized list of preventive services go to  https://health.gov/myhealthfinder

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Laboratory tests:

• Three urinalysis through age five
• As recommended by Bright Futures/American Academy of Pediatrics through age 21

Note: Additional tests for children ages six and older, see Section 5(a) Preventive care, adult.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Complete maternity (obstetrical) care, includes physician or certified nurse-midwife services for routine:

• Prenatal and Postpartum care
• Screening for gestational diabetes
• Delivery
• Screening and counseling for prenatal and postpartum depression

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Note: Here are some things to keep in mind:

• We pay hospitalization, surgeon services, anesthesiology, lab, and ultrasound the same as for illness and injury. See Section 5(c) for hospital benefits, Section 5(b) for surgery and anesthesia benefits, and Section 5(a) for lab, X-ray, and other diagnostic tests benefits.
• See page 29, Professional services of physicians, and page 57, hospital benefits, for how we pay benefits for other circumstances, such as complications of pregnancy and extended stays for you or your baby.
• You do not need to obtain prior approval for your vaginal delivery and precertification for extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. Your physician will extend your inpatient stay if medically necessary.

• Newborn child
  • We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay.
  • Gonorrhea prophylactic medication to protect newborns.
  • See Section 5(c) for hospital benefits, Section 5(b) for surgery and anesthesia benefits, and Section 5(a) for lab, X-ray, and other diagnostic test benefits.
  • We cover care to treat a child's congenital defects and birth abnormalities for the first 31 days of birth.
  • We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment.
  • Surgical benefits, not maternity benefits, apply to circumcision.

Breastfeeding support, supplies and counseling for each birth

• Breast pumps - Purchase of one device including attachments are covered when purchased from a provider that provides medical equipment and supplies.
• Rental of a hospital-grade breast pump is covered if an infant is unable to nurse directly on the breast due to a medical condition, such as prematurity, congenital anomaly and/or an infant is hospitalized.

Note: Hospital-grade rental breast pumps require prior approval. See Section 3 You need prior Plan approval for certain services – Other services.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:  Routine sonograms to determine fetal age, size, or sex.

All charges

All charges

Plan Provider
Nothing

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

A range of voluntary family planning services, limited to:

• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo-Provera)
• Intrauterine devices (IUDs)
• Diaphragms
• Tubal ligation

Note:

• We cover oral contraceptives under the prescription drug benefits. See Section 5(f) Prescription Drug Benefits.
• If you are having problems accessing contraceptive coverage, contact contraception@opm.gov. For more information about contraception you can visit the OPM website at 
  https://www.opm.gov/healthcare-insurance/healthcare/consumer-protections/#url=Your-Right-to-Contraception or email contraception@opm.gov.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Voluntary sterilization. See Section 5(b) Surgical Procedures.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Genetic Testing and Genetic Counseling

Note:

• Genetic testing and genetic counseling is covered only when you meet our criteria.
• Genetic testing and genetic counseling require prior approval.  See Section 3 You need prior Plan approval for certain services - Other services.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic counseling, except as identified on the U.S. Preventive Services Task Force list of Grade A and B recommendations and as identified in the Family planning section

All charges

Infertility is the failure to achieve a successful pregnancy after regular, unprotected intercourse or artificial insemination for 12 months or more (6 months for individuals over age 35). Infertility may also be established through an evaluation based on medical history and diagnostic testing.

Diagnosis and treatment of infertility specific to:

• Artificial insemination (AI):
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)

Note: Coverage determination for follicle stimulating hormones and luteinizing hormones are outlined in our Artificial Insemination medical policy on our website: www.hmsa.com/federalplan.

• Assisted Reproductive Technology Procedures:
  • Gamete Intra-Fallopian Transfer (GIFT)
  • Zygote Intra-Fallopian Transfer (ZIFT)
• In Vitro Fertilization (IVF)
  
  Note: Coverage is limited to a one time only benefit per plan option for one outpatient in vitro procedure in accord with our criteria and in compliance with Hawaii law. Go to our website www.hmsa.com/federalplan for the link to our medical policy.
• Injectable fertility drugs
  
  Note:
  • We cover oral fertility drugs under the prescription drug benefit. See Section 5(f) Prescription Drug Benefits.
  • We cover 3 cycles of IVF drugs per year.
• Cryopreservation for Embryos, Oocytes, and Sperm
  • Covered for the cryopreservation and storage of embryos, oocytes, and sperm for members with iatrogenic infertility.
  • Covered for the cryopreservation and storage of embryos, oocytes, and sperm for gender transition members.
  • Cryopreservation is performed before receiving medical and surgical gender transition treatments that may cause infertility.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Services and supplies related to ART procedures except In Vitro Fertilization, GIFT and ZIFT
• Services of a surrogate
• Cost of donor sperm
• Cost of donor egg
• Any donor-related services, including but not limited to collection, storage, and processing of donor eggs and sperm except for iatrogenic infertility or medical and surgical gender transition.
• Cryopreservation of oocytes, semen and embryos for non-iatrogenic infertility or medical and surgical gender transition.

All charges

• Testing and treatment
• Allergy injections
• Treatment materials

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered: Provocative food testing.

All charges

All charges

• Chemotherapy and radiation therapy
  
  Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants starting on page 51.
• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy and Intravenous nutrient solutions for primary diet
• Outpatient injections
• Specialty Injectable Drugs
• Specialty Self-Injectables
  
  Note: For Specialty inhaled drugs and specialty oral drugs, see Section 5(f) Prescription Drug Benefits.
  
  Note: Home IV Therapy and some injections require prior approval. See Section 3 You need prior Plan approval for certain services - Other services.                                                                                      
• Medical foods and low-protein modified food products for the treatment of inborn errors of metabolism in accord with Hawaii Law and Plan guidelines.
• Growth hormone therapy (GHT)
  
  Note: We only cover GHT when we prior approve the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary.  See Section 3 You need prior Plan approval for certain services - Other services.
  
  Note: Drugs must be FDA approved. See Section 3 You need prior Plan approval for certain services - Other services. 
•  Applied Behavior Analysis (ABA) Therapy
  
  Note: Applied Behavior Analysis Therapy requires prior approval, see Section 3 You need prior Plan approval for certain services - Other services.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Medical Nutrition Therapy

Medical Nutrition Therapy for medical conditions such as:

• Chronic Kidney Disease
• Eating Disorders

Note:

• Participants must meet HMSA’s eligibility criteria and guidelines.
• Eating disorders must be diagnosed by a qualified provider.
• Medical Nutrition Therapy must be rendered by a qualified provider. A qualified provider is a recognized provider practicing within the scope of their license.
• For USPSTF nutrition counseling, see section 5 (a) Preventive care, adult, Screening Services.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not Covered

• Biofeedback and other forms of self-care or self-help training and any related diagnostic testing.
• Recreational Therapy not limited to:
  • wilderness therapy,
  • outdoor skills programs and
  • any other services provided in conjunction or related to (or as part of) those programs.

All charges

All charges

Physical and occupational therapies are covered:

• When the therapy is provided by a qualified provider of physical and occupational therapy services.  A qualified provider is one who is licensed appropriately, performs within the scope of their license and is recognized by HMSA.
• In accord with HMSA’s medical policies for habilitative services and devices and for rehabilitative services and devices.

Note:

• Prior approval is required for physical and occupational therapy subject to HMSA's criteria.  Plan providers obtain approval for you, non-Plan providers do not. See Section 3 You need prior Plan approval for certain services - Other services.
• Rehabilitation is the process of evaluation, treatment and education for the purpose of improving or restoring skills and functions lost or impaired due to illness or injury.
• Rehabilitative services and devices are healthcare services that assist an individual in improving or restoring skills and functions of daily living that have been lost or impaired due to illness or injury.
• Habilitation is the process of evaluation, treatment and education for the purpose of developing, improving and maintaining skills and function which the individual has not previously possessed.
• Habilitative services and devices are healthcare services that assist an individual in partially or fully acquiring skills and functions of daily living. 

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Long-term rehabilitative therapy
• Exercise programs, except as offered through an HMSA program. See Section 5(a) Pulmonary rehabilitation.
• Cardiac Rehabilitation, except as offered through an HMSA program. See Section 5(h) Wellness and Other Special Features.

All charges

All charges

Pulmonary rehabilitation is a multidisciplinary approach to reducing symptoms and improving quality of life in patients with compromised lung function.

• Benefits are not provided for maintenance programs.
• Participants must meet HMSA’s eligibility criteria and guidelines.

Note: These services require prior approval. See Section 3 You need prior Plan approval for certain services - Other services.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Speech therapy services include:

• Speech/language therapy
• Swallow/feeding therapy
• Aural rehabilitation therapy
• Augmentative/alternative communication therapy

We only cover therapy:

• When rendered by and requires the judgment and skills of a speech language pathologist certified as competent (CCC-SLP) by the American Speech-Language Hearing Association (ASHA).

Prior approval is required for speech therapy subject to HMSA’s criteria.  Plan providers obtain approval for you, non-Plan providers do not.  See Section 3 You need prior Plan approval for certain services – Other services.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Hearing testing performed in conjunction with a physical exam for children up to age 22. See Section 5(a) Preventive care, children.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing  

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Hearing aids and Diagnostic hearing tests. See Section 5(a) Orthopedic and prosthetic devices.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Eyeglasses or contact lenses for certain medical conditions limited to one pair of eyeglasses, replacement lenses, or contact lenses (or equivalent supply of disposable contact lenses) per incident.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Annual vision exam and eye refraction

Note:

• For vision tests performed in conjunction with a routine physical exam, see Section 5(a) Preventive care, adult and children.

For information on your out-of-pocket maximum, see Section 4 Your Cost for Covered Services.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Eyeglasses or contact lenses, except as shown above
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery
• Contact lens fitting

All charges

Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges

• Artificial limbs and eyes
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Hearing Aids, limited to:
  • one per ear every 60 months
  • Repair or replacements require prior approval. See Section 3 You need prior Plan approval for certain services – Other services.
• Hearing aid evaluation
  
  Note: For hearing tests performed in conjunction with a routine physical exam, see Section 5(a) Preventive care, adult and children.
  
• Diagnostic hearing test
• Prosthetic devices, such as artificial limbs and lenses following cataract removal
• Orthopedic devices, such as braces
• Spinal orthoses
  
  Note: Spinal orthoses requires prior approval, see Section 3 You need prior Plan approval for services - Other services.
  
• Orthodontic services for the treatment of orofacial anomalies.
  
  Note: Orthodontic services requires prior approval, see Section 3 You need prior Plan approval for certain services - Other services.
  
• Gradient Compression Garments
  • Must be prescribed by a provider and meet HMSA criteria

• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants and batteries, and surgically implanted breast implant following mastectomy
  
  Note: See Section 5(b) for coverage of the surgery to insert the device.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Nonstandard or deluxe hearing aids and hearing aid features
• All other hearing tests
• Fitting and Adjustments of hearing aids
• Hearing aid batteries, except cochlear implant batteries
• Orthopedic and corrective shoes, podiatric shoes, arch supports, heel pads and heel cups
• Orthotics and prosthetics primarily for participation in sports or leisure activities
• Foot orthotics, except under the following conditions:
  • Foot orthotics for persons with specific diabetic conditions per Medicare guidelines;
  • Foot orthotics for persons with partial foot amputations;
  • Foot orthotics that are an integral part of a leg brace and are necessary for the proper functioning of the brace; and
  • Rehabilitative foot orthotics that are prescribed as part of post-surgical or post-traumatic casting care.
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Microprocessor-controlled/computer-controlled and myoelectric components for lower and upper limb prosthetics and orthotic devices
• Services or supplies related to the treatment and or prevention of baldness or hair loss regardless of condition. This includes hair transplants and topical medications.

All charges

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Mobility assistive equipment (wheelchairs, crutches, walkers, power mobility devices)
• Blood glucose monitors
• Insulin pumps

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Durable medical equipment must meet all of the following criteria:

• FDA-approved for the purpose that it is being prescribed.
• Able to withstand repeated use.
• Primarily and customarily used to serve a medical purpose.
• Appropriate for use in the home. Home means the place where you live other than a hospital or extended care or intermediate nursing facility.
• Necessary and reasonable for the treatment of an illness or injury, or to improve the functioning of a malformed body part. It should not be useful to a person in the absence of illness or injury.
• Can be rented or purchased, however, certain items are covered only as rentals.
• Repair and replacement of durable medical equipment is covered subject to certain limitations and exclusions.  Please call for details.
• Supplies and accessories necessary for the effective functioning of the equipment are covered subject to certain limitations and exclusions.  Call us for details.

See Section 3 You need prior Plan approval for certain services - Other services.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Environmental Control Equipment and Supplies such as air conditioners, humidifiers, dehumidifiers, air purifiers or sterilizers, water purifiers, vacuum cleaners, or supplies such as filters, vacuum cleaner bags, and dust mite covers
• Hygienic equipment
• Exercise equipment
• Items primarily for participation in sports or leisure activities
• Educational equipment
• Comfort or convenience items 
• Duplicate durable medical equipment and supplies, orthotics and external prosthetics, and vision and hearing appliances that are intended to be used as a back-up device, for multiple residences, or for traveling, e.g., a second wheeled mobility device specifically for work or school use or a back-up manual wheelchair when a power wheelchair is the primary means of mobility.
• Repairs or replacements of durable medical equipment and supplies, orthotics and external prosthetics, and vision and hearing appliances covered under the manufacturer or supplier warranty or that meet the same medical need as the current item but in a more efficient manner or is more convenient, when there is no change in your medical condition.

All charges

• Home healthcare ordered by a Plan physician and provided by a qualified home health agency for the treatment of an illness or injury when you are homebound. Homebound means that due to an illness or injury, you are unable to leave home or if you leave home, doing so requires a considerable and taxing effort.
• Services provided for up to 150 visits per calendar year.

Note: If you need home healthcare services for more than 30 days, a physician must certify that there is further need for the services and provide a continuing plan of treatment at the end of each 30-day period of care.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family.
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.

All charges

• Chiropractic manipulation
  
  Prior plan approval is required for chiropractic services subject to HMSA’s criteria. Plan providers obtain approval for you, non-Plan providers do not. See Section 3 You need prior Plan approval for certain services - Other services.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

No Benefit

All charges

All educational classes and programs must be received through HMSA. Call 808-948-6499 for more information.

• Disease Management Programs

Programs are available for members with asthma, diabetes, cardiovascular disease, chronic obstructive pulmonary disease (COPD), behavioral health conditions (mental health and substance use disorder), Chronic Kidney Disease (CKD), and normal and at-risk pregnancies.  The programs offer services to help you and your physician manage your care and make informed health choices.

• Tobacco Cessation Program

Tobacco programs are available through the Hawaii Tobacco Quitline® for members who need help to quit tobacco use, including coaching methods through online support, phone consultations, or both.  For more information contact the Hawaii Tobacco Quitline®, toll-free at 800-QUIT-NOW, (1-800-784-8669).

Note: Prescribed Over-the-Counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence, see Section 5(f) Prescription Drug Benefits.

Plan Provider
Nothing

Non-Plan Provider
All Charges

Plan Provider
Nothing

Non-Plan Provider
All Charges

Not covered:

• Weight reduction programs

All Charges

All Charges

Surgery includes preoperative and postoperative care.

Note: Non-Plan providers may bill separately for preoperative care, the surgical procedure, and postoperative care. In such cases, the total charge is often more than the eligible charge. You are responsible for any amount that exceeds the eligible charge.

Surgical procedures, such as:

• Operative procedures
• Treatment of fractures, including casting
• Acne treatment destruction of localized lesions by chemotherapy (excluding silver nitrate)
• Cryotherapy
• Diagnostic injections including catheter injections into joints, muscles, and tendons
• Electrosurgery
• Correction of amblyopia and strabismus
• Diagnostic and Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Insertion of internal prosthetic devices.  See Section 5(a) Orthopedic and prosthetic devices for device coverage information.
• Voluntary sterilization (e.g., Tubal ligation, Vasectomy)
• Treatment of burns
• Newborn circumcision
• Surgical treatment of severe obesity (bariatric surgery) is covered with the following criteria:
  • Patient is severely obese, which is defined as at least 100 pounds over or twice the ideal weight according to current underwriting standards OR patient has a body mass index (BMI) greater than 40 OR patient has a BMI between 35 and 40 with a high-risk comorbidity, such as: severe sleep apnea, Pickwickian syndrome, heart problems, or severe diabetes
  • OR patient has a BMI between 30 and 34.9 with type II diabetes
  • There is documentation of failure to lose weight
  • Only those surgical procedures that have proven long term efficacy and safety in peer reviewed scientific literature will be approved.
    
    Prior approval is required for this surgery. See Section 3 You need prior Plan approval for certain services - Other services.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot; (see Foot care)

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts
  • treatment of any physical complications, such as lymphedemas
  • breast prostheses and surgical bras and replacements. See Section 5(a) Orthopedic and prosthetic devices
    
    Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure. 

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Gender affirming surgery
  • Any procedure or treatment to treat gender dysphoria based on the medical necessity for each individual including but not limited to:
    • areola reconstruction, breast augmentation, clitoroplasty, vaginectomy, hair removal on skin graft prior to genital surgery, hysterectomy/salpingo-oophorectomy, mastectomy, penile or testicular prosthesis implant, perineoplasty, phalloplasty, prostatectomy, removal and/or replacement of penile prosthesis, repair of penile prosthesis, scrotoplasty, urethroplasty, vaginoplasty, and vulvectomy.
  • Contact the Plan for the current medical policy
  • Prior approval is required for this surgery. See Section 3 You need prior Plan approval for certain services - Other services.
  • For benefits for covered services related to the surgery, see Section 5(a) for Professional services of physicians, Section 5(b) for anesthesia benefits, Section 5(c) for hospital benefits, and Section 5(f) for prescription drug benefits.

Not covered:

• Cosmetic surgery that are not medically necessary
• Reversal of gender affirming surgery

All charges

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate
• Removal of stones from salivary ducts
• Excision of leukoplakia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Other surgical procedures that do not involve the teeth or their supporting structures

Plan Provider
Nothing
 

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
• Dental surgeries generally done by dentists and not physicians
• Services, drugs or supplies for nondental treatment of temporomandibular joint (TMJ) syndrome

All charges

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan.  Refer to Other services in Section 3 for prior approval procedures.

• Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
• Cornea
• Heart
• Heart/lung
• Intestinal transplants
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas
• Kidney
• Kidney-pancreas
• Liver
• Lung: single/bilateral/lobar
• Pancreas

Note: HMSA follows the guidance in the American Society for Transplantation and Cellular Therapy (ASTCT) manuscript for hematopoietic stem cell transplantation only.

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
Nothing

Non-Contracted Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
30% of eligible charge
(deductible applies)

Non-Contracted Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior approval procedures.

• Autologous tandem transplants for
  • AL Amyloidosis
  • Multiple myeloma (de novo and treated)
  • Recurrent germ cell tumors (including testicular cancer)

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
Nothing

Non-Contracted Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
30% of eligible charge
(deductible applies)

Non-Contracted Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Blood or marrow stem cell transplants.

The plan extends coverage for the diagnosis as indicated below.

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells can grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant.

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Infantile malignant osteopetrosis
  • Kostmann's syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi's, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia) 
  • Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Adrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e. myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast cancer
  • Epithelial ovarian cancer
  • Ewing's sarcoma
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
Nothing

Non-Contracted Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
30% of eligible charge
(deductible applies)

Non-Contracted Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan. 

Refer to Other services in Section 3 for prior approval procedures:

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi's, PNH, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
Nothing

Non-Contracted Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
30% of eligible charge
(deductible applies)

Non-Contracted Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence if approved by the Plan’s medical director in accordance with the Plan’s protocol.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogeneic transplants for:
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Beta Thalassemia Major
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Sickle Cell anemia
• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Myelodysplasia/Myelodysplastic Syndromes
  • Myeloproliferative disorders (MDDs)
  • Sarcomas
  • Sickle cell anemia
• Autologous Transplants for:
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Aggressive non-Hodgkin's lymphoma
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Epithelial Ovarian Cancer
  • Mantle Cell (Non-Hodgkin's lymphoma)
  • Systemic sclerosis

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
Nothing

Non-Contracted Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Blue Distinction Centers for Transplants (BDCT) Provider and Contracted Provider
30% of eligible charge
(deductible applies)

Non-Contracted Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Organ donor services:

Note:

• We cover related medical and hospital expenses of the donor when we cover the recipient.
• We cover donor screening for up to three potential donors and the actual donor for allogeneic bone marrow/stem cell transplants.
• This coverage is secondary and the living donor’s coverage is primary when:
  • You are the recipient of an organ from a living donor, and
  • The donor’s health coverage provides benefits for organs donated by a living donor

Please refer to the prior approval information shown in Section 3. 

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Transplant evaluation (office consultation)

Note: For those procedures such as laboratory and diagnostic tests, and psychological evaluations used in evaluating a potential transplant candidate, see Section 5(a) Lab, X-ray and other diagnostic tests and Section 5(e) Mental health and substance use disorder benefits.

Plan Provider
$15 per visit

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
$20 per visit
(no deductible)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Donor screening tests and donor search expenses, except those performed for the actual donor and for allogeneic bone marrow/stem cell transplant donors as shown above
• Implants of artificial organs, except for total artificial hearts when used as a bridge to a permanent heart transplant
• Transplants not listed as covered
• Mechanical or non-human organs
• Your transportation for organ or tissue transplant services
• Transportation of organs or tissues
• Organ Donor Services when you are donating an organ to someone else

All charges

All charges

Professional services provided in:

• Hospital (inpatient)
• Hospital outpatient department
• Extended Care facility
• Ambulatory surgical center
• Office

Note: Professional services include general anesthesia; regional anesthesia; and monitored anesthesia when you meet the Plan’s high risk criteria.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Room and board, such as:

• Semiprivate accommodations
• General nursing care
• Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Note: Hospital transfers – If you are transferred directly from one hospital to another, a separate per-admission copayment will not be charged for the admission to the second hospital. Hospital Discharge and Readmission – If you are discharged and then readmitted to a hospital (not transferred) whether or not on the same day, a separate per-admission copayment will be charged for your readmission.

Plan Provider
$200 per admission
(based on semiprivate room rate)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge 
(based on semiprivate room rate)

Plan Provider
30% of eligible charge
(based on semiprivate room rate)
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(based on semiprivate room rate)
(deductible applies)

Special care units, such as:

• Intensive care
• Cardiac care units

Plan Provider
$200 per admission

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Administration of blood and blood products
• Blood or blood plasma cost, blood processing, blood bank services
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Custodial care, rest cures, domiciliary or convalescent care
• Non-covered facilities, such as adult day care, intermediate care facilities, schools
• Personal comfort items, such as phone, television, barber services, guest meals and beds
• Private nursing care
• Additional charges for autologous blood

All charges

Outpatient medical services provided by a hospital or ambulatory surgical center, not related to an outpatient surgery:

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• X-rays
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma cost, blood processing, blood bank services
• Pre-surgical testing (non-laboratory) is covered but only when you meet our criteria
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics
• Anesthesia service (See Section 5(b) Anesthesia)

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures except those services that are described in the Dental Benefits section.

Plan Provider
20% of eligible charges

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Outpatient medical services provided by a hospital or ambulatory surgical center, not related to an outpatient surgery:

• Diagnostic laboratory tests and pathology services
• Pre-surgical laboratory tests are covered but only when you meet our criteria

Note: For immunizations, see Section 5(a) Preventive care, Adults.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Outpatient medical services provided by a hospital or ambulatory surgical center related to a surgery:

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood plasma cost, blood processing, blood bank services
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics
• Anesthesia service (See Section 5(b) Anesthesia)
• Orthopedic and prosthetic devices (See Section 5(a) Orthopedic and prosthetic devices)

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures except those services that are described in the Dental Benefits section.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Extended Care Facility (Skilled Nursing, Sub-acute, and Long-term Acute Care Facilities):

Room and Board is covered, but only for semiprivate rooms when:

• You are admitted by your provider
• Care is ordered and certified by your provider
• Care is for skilled nursing care, sub-acute care, or long-term acute care rendered in an extended care facility
• We approve the confinement
• Confinement is not primarily for comfort, convenience, a rest cure, or domiciliary care
• If days exceed 30, the attending physician must submit a report showing the need for additional days at the end of each 30-day period
• The confinement is not longer than 100 days in any one calendar year

Services and supplies are covered, including routine surgical supplies, drugs, dressings, oxygen, antibiotics, blood transfusion services, and diagnostic and therapy benefits.

Plan Provider
Nothing
(based on semiprivate room)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(based on semiprivate room)

Plan Provider
30% of eligible charge
(based on semiprivate room)
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(based on semiprivate room)
(deductible applies)

Not covered: Custodial care, rest cures, domiciliary or convalescent care

All charges

All charges

A hospice program provides care (generally in a home setting) for patients who are terminally ill and who have a life expectancy of six months or less.

• Inpatient residential room and board
• Referral visits

Plan Provider
Nothing

Non-Plan Provider
All charges

Plan Provider
Nothing after deductible

Non-Plan Provider
All charges

Not covered:

• Independent nursing
• Homemaker services

All charges

Ground professional ambulance service is covered when:

• Medically appropriate
• Services to treat your illness or injury are not available in the hospital or nursing facility where you are an inpatient

Plan Provider
Nothing

Non-Plan Provider
Any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charge
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Professional emergency services of physicians

• In an emergency room

Plan Provider
$15 copayment per visit

Non-Plan Provider
$15 copayment per visit and any difference between our eligible charge and the actual charge

Plan Provider
$20 copayment per visit
(no deductible)

Non-Plan Provider
$20 copayment per visit and any difference between our eligible charge and the actual charge
(deductible applies)

• Emergency diagnostic tests
• Emergency X-rays

Plan Provider
20% of eligible charges

Non-Plan Provider
20% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Emergency laboratory tests
• Emergency surgery

Plan Provider
Nothing

Non-Plan Provider
Any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Emergency room facility

Note:

• Other plan benefits may also apply in addition to the emergency room benefit. However, if you are admitted as an inpatient following a visit to the emergency room, hospital inpatient benefits apply and not emergency room benefits.
• For High Option, plan provider services only:
  • If you receive observation services following a visit to the emergency room, then hospital inpatient benefits apply and not emergency room or outpatient benefits.

Plan Provider
20% of eligible charges 

Non-Plan Provider
20% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered: Elective care or non-emergency care

All charges

All charges

Professional emergency services of physicians

• In an emergency room

Plan Provider
$15 copayment per visit

Non-Plan Provider
$15 copayment per visit and any difference between our eligible charge and the actual charge

Plan Provider
$20 copayment per visit
(no deductible)

Non-Plan Provider
$20 copayment per visit and any difference between our eligible charge and the actual charge
(deductible applies)

• Emergency diagnostic tests
• Emergency X-rays

Plan Provider
20% of eligible charges

Non-Plan Provider
20% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Emergency laboratory tests
• Emergency surgery

Plan Provider
Nothing

Non-Plan Provider
Any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Emergency room facility

Note:

• Other plan benefits may also apply in addition to the emergency room benefit. However, if you are admitted as an inpatient following a visit to the emergency room, hospital inpatient benefits apply and not emergency room benefits.
• For High Option, plan provider services only:
  • If you receive observation services following a visit to the emergency room, then hospital inpatient benefits apply and not emergency room or outpatient benefits.

Plan Provider
20% of eligible charges 

Non-Plan Provider
20% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:  Elective care or non-emergency care

All charges

All charges

Ground professional ambulance service when the following apply:

• Transportation begins at the place where an injury or illness occurred or first required emergency care
• Transportation ends at the nearest facility equipped to furnish emergency treatment
• Transportation is for the purpose of emergency treatment

See Section 5(c) for non-emergency service.

Plan Provider
Nothing

Non-Plan Provider
Any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Air ambulance for intra-island or inter-island transportation within the state of Hawaii.

• Transportation begins at the place where an injury or illness occurred or first required emergency care.
• Transportation ends at the nearest facility equipped to furnish emergency treatment
• Transportation is for the purpose of emergency treatment

Note: Non-Plan provider air ambulance services will be covered the same as Plan provider air ambulance services when our Plan provider is not available to respond to the emergency. To get this benefit, you must first contact the Plan provider. Once we are able to secure the confirmation in writing that they were unable to provide services,
you will only be responsible for the copayment amount you would have paid had you received the service from a Plan provider.

Plan Provider
20% of eligible charges

Non-Plan Provider
20% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Air Ambulance to the Continental United States

• Covered in certain situations when treatment for critical care is not available in Hawaii and air ambulance transportation to the continental US with life supporting equipment and/or a medical support team is needed.

Note: Air ambulance services to the continental US requires prior approval. See Section 3 You need prior Plan approval for certain services.

Plan Provider
20% of eligible charges

Non-Plan Provider
20% of eligible charges

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
30% of eligible charges
(deductible applies)

Not covered:

• Transportation from the continental US to Hawaii.
• Transportation within the continental US.
• Transportation for patients whose condition allows for transportation via commercial airline.
• Transportation on a commercial airline.

All charges

All charges

When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as licensed physicians, psychiatrists, psychologists, or clinical social workers, marriage and family therapists, advanced practice registered nurses (APRN), dieticians, or mental health counselors.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders. Services include:

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of substance use disorders including detoxification, treatment and counseling
• Electroconvulsive therapy

Plan Provider
$15 copayment per visit

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
$20 copayment per visit
(no deductible)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Telehealth Services

• Telehealth physician visits

Note:

• Telehealth services are covered in accordance with HMSA’s medical policy for telehealth services.

Plan Provider $15 copayment

Non-Plan Provider 30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
$20 copayment
(no deductible)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Screening Services – Grade A and B Recommendations of the U.S. Preventive Services Task Force (USPSTF). For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
Nothing  

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

• Online Care

Note: Covered, when provided by HMSA Online Care at www.hmsa.com. You must be at least 18 years old. A member who is a dependent minor is covered when accompanied by an adult member. Care is available for 10 minute sessions which may be extended up to 5 additional minutes. Each session is limited to a total of 15 minutes.

Plan Provider
Nothing

Non-Plan Provider
All charges

Plan Provider
Nothing  

Non-Plan Provider
All charges

• Diagnostic tests
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Laboratory tests

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
• Inpatient services in approved alternative care settings such as residential treatment, full-day hospitalization

Plan Provider
$200 per admission

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Outpatient services provided and billed by a hospital or other covered facility

• Services in approved treatment programs, such as partial hospitalization

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(deductible applies)

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Other training services
• Services we have not approved
• Hypnotherapy

Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges

We cover the following drugs and supplies prescribed by a recognized provider practicing within the scope of their license and obtained from a Plan or non-Plan Pharmacy, or through our mail order program:

• Drugs that, by Federal law of the United States, require a physician’s prescription for their purchase, except those listed as Not covered.
• Injectable drugs limited to those designated as covered in the HMSA formulary on our website at www.hmsa.com or call us at 808-948-6499 for the most current list of covered injectable drugs.
  
  Note: Specialty injectable drugs and intravenous fluids and drugs for home use may be covered under your medical coverage. See Section 5(a) Treatment therapies.
• Drugs for sexual dysfunction
  
  Benefits are limited to the following:
  • Quantity limits may apply
  • Up to four doses every 30 days for erectile dysfunction drugs
  • Up to three months dispensed at a time (Multiple copayments will apply)
  • Covered for gender approved by FDA
  • Physician must certify in advance that the patient has impotence due to organic causes from vascular or neurological disease
• Oral fertility drugs 
• Vitamins and minerals limited to:
  • The treatment of an illness that in the absence of such vitamins and minerals could result in a serious threat to the member's life
  • Sodium fluoride if dispensed as a single drug to treat tooth decay 
• Non-FDA approved drugs included in our formulary.
• Compound Drugs made with non-specialty, non-bulk chemicals are subject to a Tier 3 copayment. Compound Drugs made with specialty, non-bulk chemicals are subject to a Tier 5 copayment. Tier exceptions are not applicable for compound drugs.
• Drugs to treat gender dysphoria
  • Hormonal therapy to treat gender dysphoria to include but not limited to:
    • Progestins, estrogen derivatives, aldosterone antagonists, androgens, gonadotropin-releasing hormone agonists
• Weight Management Drugs. See Section 3 You need prior Plan approval for certain services - Other services.
  • Includes Weight Loss Injectable drugs
• Specialty Drugs
  • Benefits are not available through HMSA's Prescription Drug Mail Order Program
  • You must purchase these drugs from a Plan Provider
  • Limited distribution drugs dispensed by a Non-Plan provider will be covered the same as a Plan provider
  • Limited to up to a 30-day supply dispensed at a time
  • Copayments may be prorated when a reduced supply of specialty medications is dispensed for the first time.
  • Includes specialty inhaled drugs and specialty oral drugs

Please refer to the prior approval information shown in Section 3.

Tier 1 (Preferred Generic):
Plan Pharmacy
$7 copayment

Non-Plan Pharmacy
$7 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge 

Tier 2 (Non-Preferred Generic and Preferred Brand):
Plan Pharmacy
$35 copayment

Non-Plan Pharmacy
$35 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge 

Tier 3 (Other Brand):
Plan Pharmacy
$70 copayment 

Non-Plan Pharmacy
$70 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge

Tier 4 (Preferred Specialty):
Plan Provider
$80 copayment

Non-Plan Provider
All charges

Tier 5 (Non-Preferred Specialty):
Plan Provider
$200 copayment

Non-Plan Provider
All charges

Tier 1 (Preferred Generic):
Plan Pharmacy
$7 copayment (no deductible)

Non-Plan Pharmacy
$7 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Tier 2 (Non-Preferred Generic and Preferred Brand):
Plan Pharmacy
40% of eligible charge (up to $100) (deductible applies)

Non-Plan Pharmacy
60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Tier 3 (Other Brand):
Plan Pharmacy
40% of eligible charge (up to $600) (deductible applies)

Non-Plan Pharmacy
60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Tier 4 (Preferred Specialty):
Plan Provider
$200 copayment (deductible applies)

Non-Plan Provider
All charges

Tier 5 (Non-Preferred Specialty):
Plan Provider
40% of eligible charge (up to $1,200) (deductible applies)

Non-Plan Provider
All charges

• Tobacco Cessation Drugs
  • Includes prescribed over-the-counter Tobacco Cessation Drugs
  • You must receive a written prescription from a recognized provider practicing within the scope of their license for Tobacco Cessation Drugs

Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge

Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge (deductible applies)

• Spacers for inhaled drugs and peak flow meters are limited to those designated as covered in the HMSA formulary on our website at www.hmsa.com or call us at 808-948-6499 for the most current list of covered spacers for inhaled drugs and peak flow meters.

Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge

Plan Pharmacy
Nothing after deductible

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge (deductible applies)

• Insulin

Note: When obtained by prescription.

Preferred Brand Insulin:

Plan Pharmacy
$7 copayment 

Non-Plan Pharmacy
$7 copayment plus 20% of eligible charges and any difference between our eligible charge and the actual charge 

Other Brand Insulin:

Plan Pharmacy
$35 copayment

Non-Plan Pharmacy
$35 copayment plus 20% of eligible charges and any difference between our eligible charge and the actual charge 

Preferred Brand Insulin:
Plan Pharmacy
$7 copayment (no deductible)

Non-Plan Pharmacy
$7 copayment plus 20% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Other Brand Insulin:
Plan Pharmacy
40% of eligible charges (up to $600) (deductible applies)

Non-Plan Pharmacy
60% of eligible charges and any difference between our eligible charge and actual charge (deductible applies)

Diabetic supplies include:

• Insulin syringes
• Needles
• Lancets
• Lancet devices
• Test Strips
• Glucose test tablets and test tapes
• Acetone test tablets

Preferred Brand Diabetic Supplies:
Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge 

Other Brand Diabetic Supplies:
Plan Pharmacy
$35 copayment

Non-Plan Pharmacy
$35 copayment and any difference between our eligible charge and the actual charge

Preferred Brand Diabetic Supplies:
Plan Pharmacy
40% per covered brand name formulary drug up to a $100 maximum (deductible applies)

Non-Plan Pharmacy
60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Other Brand Diabetic Supplies:
Plan Pharmacy
40% per other brand diabetic supplies up to a $600 maximum (deductible applies)

Non-Plan Pharmacy
60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

• Contraceptive drugs and devices as listed in the ACA/HRSA site. Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care).
  
  • Oral Contraceptives
  • Contraceptive Rings and Patches
• Over-the-counter contraceptive drugs and devices

Note:

• Over-the-counter contraceptive drugs and devices for men and women approved by the FDA require a written prescription by a recognized provider practicing within the scope of their license.
• To submit a claim for OTC contraceptives, see Section 7 Filing a Claim for Covered Services.
• If you are having problems accessing contraceptive coverage, contact contraception@opm.gov. For more information about contraception you can visit the OPM website at 
  https://www.opm.gov/healthcare-insurance/healthcare/consumer-protections/#url=Your-Right-to-Contraception.

Tier 1 (Preferred Generic):
Plan Pharmacy
Nothing

Non-Plan Pharmacy
$7 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge

Tier 2 (Non-Preferred Generic and Preferred Brand):
Plan Pharmacy
Nothing

Non-Plan Pharmacy
$35 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge

Tier 3 (Other Brand):
Plan Pharmacy
Nothing

Non-Plan Pharmacy
$70 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge 

Tier 1 (Preferred Generic):
Plan Pharmacy
Nothing

Non-Plan Pharmacy
$7 copayment plus 20% of remaining eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Tier 2 (Non-Preferred Generic and Preferred Brand):
Plan Pharmacy
Nothing

Non-Plan Pharmacy
60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

Tier 3 (Other Brand):
Plan Pharmacy
Nothing

Non-Plan Pharmacy
60% of eligible charges and any difference between our eligible charge and the actual charge (deductible applies)

• Internally implanted time-release contraceptive drugs
• Contraceptive drugs injected periodically and intrauterine devices

Plan Provider
Nothing 

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge  

Plan Provider
Nothing

Non-Plan Provider
40% of eligible charges and any difference between our eligible charge and the actual charge
(deductible applies)

•  Diaphragms and Cervical Caps

Plan Pharmacy 
Nothing 

Non-Plan Pharmacy
$10 copayment and any difference between our eligible charge and the actual charge  

Plan Pharmacy
Nothing

Non-Plan Pharmacy
$10 copayment and any difference between our eligible charge and the actual charge
(deductible applies)

Mail Order Drug Program: Preferred Generic Drugs

Nothing

Nothing

Mail Order Drug Program: Non-Preferred Generic Drugs

Nothing

Nothing

Mail Order Drug Program: Preferred Brand Name Drugs

$75 Copayment

40% Coinsurance (up to $200) (deductible applies)

Mail Order Drug Program: Other Brand Name Drugs

$185 Copayment

40% Coinsurance (up to $1200) (deductible applies)

Mail Order Drug Program: Preferred Brand Name Insulin

$11 Copayment

$11 Copayment (deductible applies)

Mail Order Drug Program: Other Brand Insulin

$75 Copayment

40% Coinsurance (up to $600) (deductible applies)

Mail Order Drug Program: Preferred Brand Name Diabetic Supplies

Nothing

40% Coinsurance (up to $200) (deductible applies)

Mail Order Drug Program: Other Brand Name Diabetic Supplies

$75 Copayment

40% Coinsurance (up to $1200)
(deductible applies)

Mail Order Drug Program: Tobacco Cessation Drugs

Nothing

Nothing

Mail Order Drug Program: Spacers for inhaled drugs and peak flow meters

Nothing

Nothing after deductible

Mail Order Drug Program: Preventive Care Medications

Nothing

Nothing

Mail Order Drug Program: Oral Contraceptives

Nothing

Nothing

Mail Order Drug Program: Contraceptive Rings and Patches

Nothing

Nothing

Mail Order Drug Program: Diaphragms and Cervical Caps

Nothing

Nothing

Mail Order Drug Program: Over-the-counter contraceptive drugs and devices

Nothing

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Vitamins, nutrients, and food supplements not listed as a covered benefit, even if a physician prescribes or administers them
• Over-the-Counter drugs, other than:
  • Those designated as covered in the HMSA Fed 87 Drug Formulary on our website at
    www.hmsa.com or call us at 808-948-6499 for the most current list of covered nonprescription medications.
  • Those defined previously in Section 5(f) as covered when prescribed and dispensed by a healthcare professional practicing within the scope of their license and filled by a network pharmacy.
• Medical supplies such as dressings and antiseptics
• Compound drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration
• Compound drugs that are available as a similar commercially available prescription drug product
• Bulk chemicals
• Compounds made with bulk chemicals
• Replacement for lost, stolen or destroyed prescriptions
• Non-FDA approved drugs except those included in our drug formulary
• Nonprescription medications unless specifically indicated elsewhere

Note: Prescribed over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation benefit. (See page 74)

All charges

Medications to promote better health as recommended by ACA as recommended by the U.S. Preventative Services Task Force (USPSTF).

• Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over-the counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to
  www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations.
• You must receive a written prescription from a recognized provider practicing within the scope of their license.
• These drugs are limited to those listed as covered in the HMSA formulary on our website at
  www.hmsa.com or call us at 808-948-6499 for the most current list.

Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge

Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge
(deductible applies)

Rescue Based Agents

• Naloxone Nasal Spray

Note:

• Initial fill limited to one carton per fill per calendar year.
• Subsequent refills to follow copay on page 72.
• Benefits are not available through HMSA’s Prescription Drug Mail Order Program

Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge

Plan Pharmacy
Nothing

Non-Plan Pharmacy
Any difference between our eligible charge and the actual charge
(deductible applies)

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Vitamins, nutrients, and food supplements not listed as a covered benefit even if a physician prescribes or administers them
• Over-the-Counter drugs, other than:
  • Those designated as covered in the HMSA Fed 87 Drug Formulary on our website at
    www.hmsa.com or call us at 808-948-6499 for the most current list of covered nonprescription medications.
  • Those defined previously in Section 5(f) as covered when prescribed and dispensed by a healthcare professional practicing within the scope of their license and filled by a network pharmacy.
• Medical supplies such as dressings and antiseptics
• Compound drugs that do not contain at least one ingredient that has been approved by the U.S. Food and Drug Administration
• Compound drugs that are available as a similar commercially available prescription drug product
• Bulk chemicals
• Compounds made with bulk chemicals
• Replacement for lost, stolen or destroyed prescriptions
• Non-FDA approved drugs, except those included in our drug formulary.

Note: Prescribed over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation benefit. (See page 74)

All charges

All charges

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

Accidental injury is defined as bodily injury sustained solely through violent, external and accidental means.

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

Plan Provider
30% of eligible charges
(no deductible)

Non-Plan Provider
50% of eligible charges and any difference between our eligible charge and the actual charge
(no deductible)

Preventive dental care

• Annual exam/visit
• Annual cleaning (prophylaxis)

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

All charges

• X-rays [One set of bitewings (1-4 films) per calendar year]
• One full mouth series or panoramic X-ray every 5 years
• Periapical X-rays

Note:

• For Bitewing X-rays taken prior to the Full mouth X-ray and within 12 months, both procedures will be covered.
• Additional panoramic X-rays may be allowed if taken by an oral surgeon and the previous X-ray is over 12 months old.

Plan Provider
30% of eligible charges

Non-Plan Provider
50% of eligible charges and any difference between our eligible charge and the actual charge

All charges

• Teledentistry visit

Plan Provider
Nothing

Non-Plan Provider
30% of eligible charges and any difference between our eligible charge and the actual charge

All charges

Standard dental service for permanent teeth only

• Fillings (composite resin for anterior teeth and single, stand-alone facial surfaces of bicuspids only; amalgam; and silicate)
• Extractions
• Root canal treatment
• Treatment for diseases of the gum
• Space maintainers
• Anesthesia

Plan Provider
30% of eligible charges

Non-Plan Provider
50% of eligible charges and any difference between our eligible charge and the actual charge

All charges

Dental Surgery

• Incision and drainage of abscess
• Alveoplasty
• Excision of cysts

Plan Provider
30% of eligible charges

Non-Plan Provider
50% of eligible charges and any difference between our eligible charge and the actual charge

All charges

Occlusal Splint

When precertified and determined by the Plan, occlusal splint therapy is covered for the treatment of temporomandibular disorder involving the muscles of mastication (chewing). 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
• It is not intended to be for the treatment of bruxism
• It is not for the prevention of injuries of the teeth or occlusion
• The benefit is limited to one treatment episode per lifetime

Plan Provider or Non-Plan Provider

50% of eligible charges and any difference between our eligible charge and the actual charge

All charges

Not covered:

• All other dental services, including topical application of fluoride
• Major dental services including: 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
• Dental implants, osseointegration and all related services
• Vertical bitewings
• Bitewing taken after the full mouth X-ray and within 12 months

If you have questions or need more information, please call 808-948-6440 on Oahu or (1-800-792-4672) on the mainland or neighbor islands Monday through Friday, 8 a.m. to 5 p.m., or visit our website at
www.hmsa.com/federalplan.

All charges

Flexible Benefits Option

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

We have arranged with Plan Pharmacies to assist in managing the usage of certain kinds of drugs, including drugs listed in the HMSA Fed 87 Drug Formulary.

We have identified certain kinds of drugs listed in the HMSA Fed 87 Drug Formulary that require prior approval. The criteria for prior approval are that:

• The drug is being used as part of a treatment plan;
• There are no equally effective drug substitutes; and
• The drug meets the “medical necessity” criteria and other criteria as established by us.

Step Therapy is another type of prior approval. Before we cover selected medications, you may be required to try one or more specific drugs to treat a particular condition.

Quantity Limitation. Certain medications may be covered up to a certain quantity. This quantity is not to exceed the FDA maximum recommended dose. Doses that exceed the quantity limits are subject to prior approval.

A list of these drugs in the HMSA Fed 87 Drug Formulary has been distributed to all participating providers.

Plan Pharmacists will 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.

Routine care associated with clinical trials is covered in accord with criteria established by us.

These services require prior approval. Please refer to the prior approval information shown in Section 3.

The program will offer members with advanced life limiting diseases, who have not elected hospice, access to comprehensive symptom management and care coordination services in addition to life prolonging therapies for a 90-day period.  These services are aimed at providing relief of symptoms, spiritual, social and psychological support and access to interdisciplinary care to support the life prolonging therapy.

• Participants must meet supportive care eligibility criteria and guidelines.
• Participants must be referred by their physician or specialist.
• Participants must obtain necessary specialty referrals if needed for symptom management.
• Services will be limited to a 90-day period per 12 months.

• Participants must meet HMSA’s eligibility criteria and guidelines. You are eligible for this program if you meet one or more of the criteria below:
  • An acute myocardial infarction within the preceding 12 months;
  • A coronary artery bypass surgery;
  • Current stable angina pectoris;
  • Heart valve repair or replacement;
  • Percutaneous transluminal coronary angioplasty (PTCA) or coronary stenting;
  • A heart or heart-lung transplant;
  • Stable, chronic heart failure.
• Program services are provided by practitioners who contract with HMSA to provide program services, and
• Services are received in the State of Hawaii at an accredited Ornish Reversal Program.
• Dr. Ornish’s Program for Reversing Heart Disease™ is a comprehensive approach to cardiovascular disease management and overall well-being improvement that addresses modifiable risk factors under the supervision of a multidisciplinary team. It helps members with heart disease and related health issues to assess, track and manage their condition; and, improve key factors such as eating habits, stress management and physical activity. The program consists of eighteen 4 hour sessions which include:
  • Supervised exercise
  • Yoga and meditation
  • Support group
  • Experiential education session with group meal

Note: Coverage is limited to one program per lifetime. If you receive benefits for this program under an HMSA plan, you will not be eligible for benefits for the program under any other HMSA plan.

Medication Therapy Management Program

Medication Therapy Management Program

The program aims to improve your health by helping you:

• Consolidate your prescriptions to one pharmacy location
• Use more cost-effective medications
• Increase your knowledge of your medications and condition
• Improve your medication adherence
• Reduce the risk of adverse drug interactions

To enroll in this program, please visit
https://hmsa.com/employer/federalplan_memberresources/.

Diabetes Prevention Program

The Diabetes Prevention Program is a structured health behavior change intervention that provides practical training in long-term dietary change, increased physical activity, and problem-solving strategies for overcoming challenges to sustaining weight loss and a healthy lifestyle.

You may be eligible for the program if you:

• Are 18 or older.
• Have a body mass index of at least 25 (or at least 23 if you identify as Asian).
• Have had at least one of the three following results within the first 12 months of the program:

1. A hemoglobin A1c test between 5.7 and 6.4 percent.
2. Fasting plasma glucose between 100 and 125 mg/dL.
3. Two-hour plasma glucose between 140 and 199 mg/dL.

• Haven’t been diagnosed with type 1 or type 2 diabetes (other than gestational diabetes).
• Don’t have end-stage renal disease.
• Haven’t enrolled in the program before.

For more information on the program and how to find a provider, please visit our Diabetes Prevention Program page at
https://hmsa.com/well-being/diabetes-prevention/.

HMSA Pregnancy and Postpartum Support Program

The HMSA Pregnancy and Postpartum Support Program offers specialty nursing care management and education to pregnant members across all lines of business at no cost. Members may self-enroll in this voluntary program or may be identified as high risk by their health care providers.

Program goals include member education and satisfaction, breastfeeding for six months or more, appointment adherence, reducing preterm labor and delivery, addressing and assisting with social determinants of health, and reducing preventable admissions to the neonatal intensive care unit.

Accident Elite provides supplemental coverage for costs associated with accidental injury and death occurring on and off-the-job.

CriticalCare Elite provides supplemental coverage for costs associated with the first positive diagnosis of a covered critical illness.

Hospital Confinement Plan provides coverage in the form of a fixed daily benefit during periods of hospitalization.

In most cases, providers, facilities and pharmacies file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form; facilities must file on the UB-04 form; dental services must be on the American Dental Association (ADA) form; and pharmacies must file on the Universal Drug form. For claims questions and assistance, contact us at 808-948-6499.

When you must file a claim – such as for services you receive outside the Plan’s service area – submit it on one of the forms indicated above or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number and ID number
• Name and address of the provider or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payor – such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:

For Physician claims
HMSA-CMS 1500 claims
P.O. Box 44500
Honolulu, Hawaii 96804-4500
808-948-6499

For Facility claims
HMSA-UB04 claims
P.O. Box 32700
Honolulu, Hawaii 96803-2700
808-948-6499

Submit your claims to:

For Prescription drug claims
CVS Health
P.O. Box 52066
Phoenix, AZ  85072-2066

Submit your claims to:

For Dental claims
HMSA-Dental claims
P.O. Box 1187
Elk Grove Village, IL  60009-1187
808-948-6440 or toll free at (1-800-792-4672)

For Vision claims
First American Administrators, Inc.
Attn: OON Claims
P.O. Box 8504
Mason, OH  45040-7111

All Plan and most non-Plan providers in the State of Hawaii file claims for you. If your non-Plan provider does not file the claim for you, you must submit an itemized bill and receipt for the services you received by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible. File a separate claim for each covered family member and each provider. For more information, please call us at 808-948-6499.

We will notify you of our decision within 30 days after we receive your post-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

Ask us in writing to reconsider our initial decision. You must:

a)  Write to us within 6 months from the date of our decision; and

b)  Send your request to us at: Hawai‘i Medical Service Association, Attn: Member Advocacy and Appeals, P.O. Box 1958, Honolulu, Hawaii  96805-1958 (for Dental, send your request to HMSA-Dental P.O. Box 69437, Harrisburg PA 17106-9437); and

c)  Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d)  Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

e)  Include your email address, if you would like to receive our decision via email. Please note that by giving us your email address, we may be able to provide our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision.  We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date.  However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration.  You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information.

You or your provider must send the information so that we receive it within 60 days of our request.  We will then decide within 30 more days.

If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due.  We will base our decision on the information we already have.  We will write to you with our decision. 

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us – if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 2, 1900 E Street, NW, Washington, DC 20415-3620.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email address, you may receive OPM’s decision more quickly.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, 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, drugs, or supplies or from the year in which you were denied prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault. This is called “double coverage”.

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines.  For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.hmsa.com/federalplan.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will pay after the primary plan pays.  Payment will not exceed the amount this plan would have paid if it had been your only coverage. Additionally, when this plan is secondary, benefits will be paid only for those services or supplies covered under this plan.

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military.  TRICARE includes the CHAMPUS program.  CHAMPVA provides health coverage to disabled Veterans and their eligible dependents.  If TRICARE or CHAMPVA and this Plan cover you, we pay first.  See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium.  (OPM does not contribute to any applicable plan premiums.)  For information on suspending your FEHB enrollment, 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 unless you involuntarily lose coverage under TRICARE or CHAMPVA.

Every job-related injury or illness should be reported as soon as possible to your supervisor. Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices. If you are a federal or postal employee, ask your supervisor to authorize medical treatment by use of form CA-16 before you obtain treatment. If your medical treatment is accepted by the Dept. of Labor Office of Workers’ Compensation (OWCP), the provider will be compensated by OWCP. If your treatment is determined not job-related, we will process your benefit according to the terms of this plan, including use of in-network providers. Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send it to your provider as soon as possible after treatment, to avoid complications about whether your treatment is covered by this plan or by OWCP.

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• 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.

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium.  For information on suspending your FEHB enrollment, contact your retirement or employing office.  If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

The “When others are responsible for injuries” provision outlines our rights to pursue reimbursement and subrogation recoveries. These rights are defined below and throughout this recovery provision.

Reimbursement means a carrier’s pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers’ compensation program or insurance policy, and the terms of the carrier’s health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

Subrogation means a carrier’s pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers’ compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier’s health benefits plan. 

Many states have laws that do not allow health insurers to reimburse or subrogate against recoveries the insured receives from a negligent third party or other party responsible for payment in the event of an accident. This health plan for federal employees, however, is not subject to those state laws or any regulation issued thereunder, which relates to health insurance or plans.

Our rights to recover in these situations are based on the terms of this health plan contract, as well as the provisions of the Federal statutes governing the FEHB Program. The rights set forth in this section of the health benefit contract are a condition of, and a limitation on, your eligibility for benefits.

The provisions of this section apply to all current or former plan participants and also to the parents, guardian, or other representative of a dependent child who incurs claims and is or has been covered by this plan. Our right to recover (whether by subrogation or reimbursement) shall apply to the personal representative of your estate, your heirs or beneficiaries, administrators, legal representatives, successors, assignees, minors, and incompetent or disabled persons. “You” or “your” includes anyone on whose behalf we pay benefits. No adult covered person hereunder may assign any rights that it may have to recover medical expenses from any tortfeasor or other person or entity to any minor child or children of said adult covered person without our prior express written consent.  Benefits are extended to you on the condition that we may pursue and receive reimbursement and subrogation recoveries pursuant to the contract. 

Our rights to pursue reimbursement and subrogation recoveries arise upon the occurrence of the following:

• You have received benefits or benefit payments as a result of an illness or injury; and
• You have accrued a right of action against a third party for causing that illness or injury; or you have received a judgment, settlement or other recovery on the basis of that illness or injury; or you are entitled to receive compensation or recovery on the basis of the illness or injury, including from insurers of individual (non-group) policies of liability insurance that are issued to and in the name of the enrollee or a covered family member. 

Your coverage is always secondary to any payment made or reasonably expected to be made by any party that may be liable for an illness or injury.  In addition, our rights of reimbursement and subrogation extend to all amounts available to or received by you or on your behalf by judgment, settlement, or other recovery, to the extent of the amount of benefits that have been paid or provided by us. Our sources of recovery include, but are not limited to:

• A workers compensation program or insurance policy,
• Any non-fault based insurance, including automobile and non-automobile no-fault and medical payments insurance,
• Any liability insurance policy or plan (including a self-insured plan) issued under an automobile or other type of policy or coverage,
• Personal umbrella coverage,
• You, and
• Any automobile insurance policy or plan (including a self-insured plan), including, but not limited to, uninsured and underinsured motorist, and umbrella coverages.

Since we are always secondary to any automobile no-fault (Personal Injury Protection) or medical payments coverage, you should review your automobile insurance policies to ensure that appropriate policy provisions have been selected to make your automobile coverage primary for your medical treatment arising from an automobile accident.

As outlined herein, in these situations, we may make payments on your behalf for this medical care, subject to the conditions set forth in this provision for us to recover these payments from you or from other parties. Immediately upon making any conditional payment, we shall be subrogated to (stand in the place of) all rights of recovery you have against any person, entity or insurer responsible for causing your injury, illness or condition or against any person, entity or insurer listed as a primary payer above.

In addition, if you receive payment from any person, entity or insurer responsible for causing your injury, illness or condition or you receive payment from any person, entity or insurer listed as a primary payer above, we have the right to recover from, and be reimbursed by you for all conditional payments we have made or will make as a result of that injury, illness or condition. You and your legal representative agree to hold any such funds in trust until you have confirmed the amount that we are owed and make arrangements to repay us.

We will automatically have a lien, to the extent of benefits we paid for the treatment of the injury, illness or condition, upon any recovery whether by settlement, judgment or otherwise. The lien may be enforced against any party who possesses funds or proceeds representing the amount of benefits paid by us including, but not limited to, you, your representatives or agents, any person, entity or insurer responsible for causing your injury, illness or condition or any person, entity or insurer listed as a primary payer above.

By accepting benefits (whether the payment of such benefits is made to you or made on your behalf to any healthcare provider) from us, you acknowledge that our recovery rights are a first priority claim and are to be paid to us before any other claim for your damages. We shall be entitled to full reimbursement on a first-dollar basis from any payments, even if such payment to us will result in a recovery to you which is insufficient to make you whole or to compensate you in part or in whole for the damages you sustained. We are not required to participate in or pay court costs or attorney fees to any attorney hired by you to pursue your damage claims.

We are entitled to full recovery regardless of whether any liability for payment is admitted by any person, entity or insurer responsible for causing your injury, illness or condition or by any person, entity or insurer listed as a primary payer above. We are entitled to full recovery regardless of whether the settlement or judgment received by you identifies the medical benefits we provided or purports to allocate any portion of such settlement or judgment to payment of expenses other than medical expenses. We are entitled to recover from any and all settlements, judgments or other recoveries and are not impacted by how the recovery is characterized, designated or apportioned (including those designated as for pain and suffering, non-economic damages and/or general damages only).

You, and your legal representatives, shall fully cooperate with our efforts to recover our benefits paid. It is your duty to notify us within 30 days of the date of (1) your knowledge of any potential claim against any third party or other source of recovery in connection with the injury or illness; (2) any written claim or demand (including legal proceeding) against any third party or against other source of recovery in connection with the injury or illness; and (3) any recovery of damages (including any settlement, judgment, award, insurance proceeds, or other payment) against any third party or other source of recovery in connection with the injury or illness.  Such notice must be sent to HMSA, Attn:  7 CA/Third Party Liability, P.O. Box 860, Honolulu, Hawaii 96808-0860.

You and your agents or representatives shall provide all information requested by us or our representatives. You shall do nothing to prejudice our subrogation or recovery interest or to prejudice our ability to enforce the terms of this provision. This includes, but is not limited to, refraining from making any settlement or recovery that attempts to reduce or exclude the full cost of all benefits provided by us.

Failure to provide requested information or failure to assist us in pursuit of our subrogation or recovery rights may result in you being personally responsible for reimbursing us for benefits paid relating to the injury, illness or condition as well as for our reasonable attorney fees and costs incurred in obtaining reimbursement from you.

Some FEHB plans already cover some dental and vision services.  When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage.  FEDVIP coverage pays secondary to that coverage.  When you enroll in a dental and/or vision plan on www.BENEFEDS.com or by phone at (1-877-888-3337), (TTY: 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits.  Providing your FEHB information may reduce your out-of-pocket cost.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy.
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. This plan does not cover these costs.
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.

For more detailed information on “What is Medicare?” and “Should I Enroll in Medicare?” please contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Original Medicare)  is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care. Your care must continue to be prior approved as required.

We will not waive any of our copayment/coinsurance for services or supplies that are not covered by Original Medicare (for example, hearing aids).  Your regular Plan benefits will be applied to your claim and you are responsible for any applicable copayments or costs.

Claims process when you have the Original Medicare Plan – You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. We will coordinate benefits under this Plan up to the Medicare approved charge not to exceed the amount this Plan would have paid if it had been your only coverage. If you are entitled to Medicare benefits, we will begin paying benefits after all Medicare benefits (including lifetime reserve days) are exhausted. If you receive inpatient services and have coverage under Medicare Part B only, or have exhausted your Medicare Part A benefits, we will pay inpatient benefits based on our eligible charge less any payments made by Medicare for Part B benefits (i.e., for inpatient lab, diagnostic, and X-ray services). To find out if you need to do something to file your claim, call us at 808-948-6499 or see our website at www.hmsa.com/federalplan.

We do not waive any costs if the Original Medicare Plan is your primary payor. 

Please review the following examples which illustrates your cost share if you are enrolled in Medicare Part B.

Benefit Description: Deductible
High Option You pay without Medicare: $0
High Option You pay with Medicare Part B: $0
Standard Option You pay without Medicare: $150
Standard Option You pay with Medicare: $150

Benefit Description: Out-of-Pocket Maximum
High Option You pay without Medicare: $3,000 per person/$9,000 family
High Option You pay with Medicare Part B: $3,000 per person/$9,000 family
Standard Option You pay without Medicare: $5,000 self only / $10,000 family
Standard Option You pay with Medicare: $5,000 self only / $10,000 family

Benefit Description: Part B Premium Reimbursement Offered
High Option You pay without Medicare: NA
High Option You pay with Medicare Part B: NA
Standard Option You pay without Medicare: NA
Standard Option You pay with Medicare: NA

Benefit Description: Primary Care Provider
High Option You pay without Medicare: $15 Copayment
High Option You pay with Medicare Part B: $15 Copayment
Standard Option You pay without Medicare: $20 Copayment
Standard Option You pay with Medicare: $20 Copayment

Benefit Description: Specialist
High Option You pay without Medicare: $15 Copayment
High Option You pay with Medicare Part B: $15 Copayment
Standard Option You pay without Medicare: $20 Copayment
Standard Option You pay with Medicare: $20 Copayment

Benefit Description: Inpatient Hospital
High Option You pay without Medicare: $200 Copayment per admission
High Option You pay with Medicare Part B: $200 Copayment per admission
Standard Option You pay without Medicare: 30% of eligible charges
Standard Option You pay with Medicare: 30% of eligible charges

Benefit Description: Outpatient Hospital
High Option You pay without Medicare: 20% of eligible charges
High Option You pay with Medicare Part B: 20% of eligible charges
Standard Option You pay without Medicare: 30% of eligible charges
Standard Option You pay with Medicare: 30% of eligible charges

Benefit Description: Incentives Offered
High Option You pay without Medicare: NA
High Option You pay with Medicare Part B: NA
Standard Option You pay without Medicare: NA
Standard Option You pay with Medicare: NA

Facilities or Providers Not Eligible or Entitled to Medicare Payment - When services are rendered at a facility or by a provider that is not eligible or entitled to receive reimbursement from Medicare, and Medicare is allowed by law to be the primary payor, we will limit payment to an amount that supplements the benefits that would have been payable by Medicare had the facility or provider been eligible or entitled to receive such payments, regardless of whether or not Medicare benefits are paid.

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan.  These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. 

To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (1-800-633-4227), (TTY: 877-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and our Medicare Advantage plan:  You may enroll in our Medicare Advantage Plan called Akamai Advantage and also remain enrolled in our FEHB Plan.  If you have Medicare Parts A and B, you can enroll in our Akamai Advantage Plans.  For more information, please call us at 808-948-5555 on Oahu or (1-800-620-4672) toll-free on the Neighbor Islands. Our phone representatives are available 8 a.m. to 8 p.m.  TTY: users should call 948-6222 on Oahu or (1-877-298-4672) toll-free on the Neighbor Islands.  You may also visit our website at www.hmsa.com/advantage.

This Plan and another plan’s Medicare Advantage plan:   You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan.  We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area, and for services paid by a Medicare Advantage plan we will not waive, for example, our Plan physician visit and emergency room copayments.  If you enroll in a Medicare Advantage plan, tell us.  We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium.  (OPM does not contribute to your Medicare Advantage plan premium.)  For information on suspending your FEHB enrollment, contact your retirement or employing office.  If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

An authorization by you (the enrollee or covered family member) that is approved by us (the Carrier), for us to issue payment of benefits directly to the provider.

• We reserve the right to pay you directly for all covered services. Benefits payable under the contract are not assignable by you to any person without express written approval from us, and in the absence of such approval, any assignment shall be void.
• Your specific written consent for a designated authorized representative to act on your behalf to request reconsideration of a claim decision (or, for an urgent care claim, for a representative to act on your behalf without designation) does not constitute an Assignment.

OPM’s contract with us, based on federal statute and regulation, gives you a right to seek judicial review of OPM's final action on the denial of a health benefits claim but it does not provide you with authority to assign your right to file such a lawsuit to any other person or entity. Any agreement you enter into with another person or entity (such as a provider, or other individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf, does not constitute an Assignment, is not a valid authorization under this contract, and is void.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

• Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy
• Extra care costs - costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient's routine care
• Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.

See Section 4, page 24.

See Section 4, page 24.

See Section 4, page 24.

See Section 4, page 24.

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

All care you receive must meet all of the following Payment Determination Criteria:

• For the purpose of treating a medical condition.
• The most appropriate delivery or level of service, considering potential benefits and harms to the patient.
• Known to be effective in improving health outcomes, provided that:
  • Effectiveness is determined first by scientific evidence;
  • If no scientific evidence exists, then by professional standards of care; and
  • If no professional standards of care exists or if they exist but are outdated or contradictory, then by expert opinion.
• Cost-effective for the medical condition being treated compared to alternative health interventions, including no intervention. For purposes of this paragraph, cost-effective shall not necessarily mean the lowest price.

Services which are experimental or investigational and which are not known to be effective in improving health outcomes do not meet Payment Determination Criteria.

Definitions of terms and additional information regarding application of this Payment Determination Criteria are contained in the Patient’s Bill of Rights and Responsibilities, Hawaii Revised Statutes § 432E-1.4. The current language of this statutory provision will be provided upon request. Requests should be submitted to HMSA’s Customer Service Department.

The fact that a physician may prescribe, order, recommend, or approve a service, drug, or supply does not in itself mean that the service, drug, or supply is medically necessary, even if it is listed as a covered service.

Except for BlueCard® participating and BlueCard® PPO providers, participating providers may not bill or collect charges for services or supplies that do not meet HMSA’s Payment Determination Criteria unless a written acknowledgement of financial responsibility, specific to the service, is obtained from you or your legal representative prior to the time services are rendered.

Participating providers may, however, bill you for services or supplies which are excluded from coverage without obtaining a written acknowledgement of financial responsibility from you or your representative.

You may ask your physician to contact us to determine whether the services you need meet our Payment Determination Criteria or are excluded from coverage before you receive the care.

Observation services are clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital. Observation services are appropriate for patients who require a significant period of treatment or monitoring before a decision is made concerning their admission or discharge.

The eligible charge for most medical services, is the amount we use to determine our payment and your coinsurance for covered services. We determine our eligible charge as the lower of either the provider’s actual charge or the amount we establish as the maximum allowable fee.

The maximum allowable fee is the maximum dollar amount paid for a covered service, supply, or treatment. We use the following method to determine the maximum allowable fee:

• For most services, supplies, or procedures, we consider:
  • increases in the cost of medical and non-medical services in Hawaii over the previous year;
  • the relative difficulty of the services compared to other services;
  • changes in technology; and
  • payment for the service under federal, state, and other private insurance programs.
• For some facility-billed services (not to include practitioner-billed facility services), we use a per case, per treatment, or per day fee (per diem) rather than an itemized amount (fee for service). For Non-Plan hospitals, our maximum allowable fee for all-inclusive daily rates established by the hospital will never exceed more than if the hospital had charged separately for services.

For participating facilities, we calculate our payment based on the maximum allowable fee. Your coinsurance is based on the lower of the facility’s actual charge or the maximum allowable fee. Your coinsurance and our payment will equal the maximum allowable fee.

Plan providers agree to accept the eligible charge for covered services. Non-Plan providers generally do not. Therefore, if you received services from a non-Plan provider you are responsible for any difference between the actual charge and the eligible charge.

You should also see Important Notice About Surprise Billing - Know Your Rights in Section 4 that describes your protection against surprise billing under the No Surprise Act.

An unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by nonparticipating providers with respect to patient visits to participating health care facilities, or for
• air ambulance services furnished by nonparticipating providers of air ambulance services.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Medical Management Department at 808-948-6464 on Oahu or (1-800-344-6122) toll-free from the Neighbor Islands.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

$15 copayment

29

Nothing for laboratory and pathology services; 20% of eligible charges for X-rays

30

$200 copayment per admission

57

20% of eligible charges

58

$15 copayment for physician visit; 20% of eligible charges for emergency room facility copay; Nothing for laboratory tests; and 20% of eligible charges for other emergency services

62

$15 copayment for physician visit; 20% of eligible charges for emergency room facility copay; Nothing for laboratory tests; and 20% of eligible charges for other emergency services

63

$15 copayment for professional services and medication management; Nothing for diagnostic tests, psychological testing, and laboratory tests; $200 per inpatient admission; and Nothing for partial hospitalization and outpatient facility

66

$7 copayment for Tier 1 (preferred generic drugs); $35 copayment for Tier 2 (non-preferred generic and preferred brand drugs); $70 copayment for Tier 3 (other brand drugs); $80 copayment for Tier 4 (specialty drugs); $200 copayment for Tier 5 (non-preferred specialty drugs)

72

Nothing for preventive dental care

80

20% of eligible charges for an annual vision exam

42

Yes

86

Nothing after $3,000 per person or $9,000 per Family enrollment per year

Some costs do not count toward this protection

25

$20 copayment

29

30% of eligible charges for laboratory and pathology services; 30% of eligible charges for X-rays*

30

30% of eligible charges*

57

30% of eligible charges*

58

$20 copayment for physician visit; 30% of eligible charges for emergency room facility copay*; 30% of eligible charges for laboratory tests*; and 30% of eligible charges for other emergency services*

62

$20 copayment for physician visit; 30% of eligible charges for emergency room facility copay*; 30% of eligible charges for laboratory tests*; and 30% of eligible charges for other emergency services*

63

$20 copayment for professional services and medication management; 30% of eligible charges for diagnostic tests, psychological testing, and laboratory tests*; 30% eligible charges for inpatient services*; and 30% of eligible charges for partial hospitalization and outpatient facility*

66

$7 copayment for Tier 1 (preferred generic drugs)

40% of eligible charges (up to $100) for Tier 2 (non-preferred generic and preferred brand drugs)*

40% of eligible charges (up to $600) for Tier 3 (other brand drugs)*

$200 copayment for Tier 4 (preferred specialty drugs)*

40% of eligible charges (up to $1,200) for Tier 5 (non-preferred specialty drugs)*

72

30% of eligible charges for Accidental Injury Benefits only

80

30% of eligible charges for an annual vision exam*

42

Yes

87

Nothing after $5,000 per person or $10,000 per Family enrollment per year

Some costs do not count toward this protection

25