Additional Information

Request For Arbitration

If you select arbitration, you must submit a written request for arbitration to:

HMSA, Legal Services
P.O. Box 860, Honolulu
Hawaii 96808-0860.

Your request for arbitration will not affect your rights to any other benefits under this plan. You must have fully complied with HMSA’s appeals procedures described above and HMSA must receive your request for arbitration within one year of the decision of your appeal. In arbitration, one person (the arbitrator) reviews the positions of both parties and makes the final decision to resolve the disagreement. The arbitration is binding and the parties waive their right to a court trial and jury.

Before arbitration actually starts, both parties (you and HMSA) must agree on the person to be the arbitrator. If both parties cannot agree within 30 days of your request for arbitration, either party may ask the United States District Court for the District of Hawaii to appoint an arbitrator.

The arbitration hearing shall be in Hawaii. The questions for the arbitrator shall be whether HMSA was in violation of the law, or acted arbitrarily, capriciously, or in abuse of their discretion. The arbitration shall be conducted in accordance with the Federal Arbitration Act, 9 U.S.C. §1 et seq., and such other arbitration rules as both parties agree upon.

HMSA will pay the arbitrator’s fee. You must pay your attorney’s or witness’s fees, if you have any, and HMSA will pay theirs. The arbitrator will decide who will pay all other costs of the arbitration.

HMSA waives any right to assert that you have failed to exhaust administrative remedies because you did not select arbitration.

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Request For Review By Insurance Commissioner

If you are not in an employer sponsored group plan subject to ERISA, you may request review by a panel selected by the Hawaii Insurance Commissioner by submitting a request for review within 60 days of the date of HMSA’s decision to the Insurance Commissioner at:

Hawaii Insurance Division
ATTN: Health Insurance Branch – External Appeals
250 South King Street
Fifth Floor Honolulu, Hawaii 96813
Telephone: 808-586-2804

If your request for review is accepted by the Commissioner, the Commissioner will appoint a three member panel composed of a representative from another health plan, a provider not involved in your care, and a representative from the Commissioner’s office. A hearing will be conducted within 60 days and the panel will issue a decision within 30 days of the hearing.

You may request expedited review by the Insurance Commissioner if application of the above timeframes may…

• Seriously jeopardize your life or health,

• Seriously jeopardize your ability to gain maximum functioning, or

• Subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the appeal.

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What You Should Do

When you receive services, you need to let HMSA know if you have other coverage. Other coverage includes…

• Group insurance

• Other group benefit plans

• Medicare or other governmental benefits

• The medical benefits coverage in your automobile insurance (whether issued on a fault or no fault basis)

You should also let HMSA know if your other coverage ends or changes.

If HMSA needs additional information regarding your other coverage, they will contact you in writing. Your benefit payment may be delayed or denied if you do not provide the information HMSA needs to coordinate your benefits.

To help HMSA coordinate your benefits, you should…

• Inform your provider by giving him or her information about the other coverage at the time services are rendered, and

• Indicate that you have other coverage when you fill out a claim form by completing the appropriate boxes on the form.

What HMSA Will Do

Once HMSA has the information about your other coverage, they will coordinate benefits for you. There are certain rules HMSA follows to help them determine which plan pays first when there is other insurance or coverage that provides the same or similar benefits as this plan.

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Both Plans Are Group Sponsored

The coverage without coordination of benefits rules pays first when both coverages are through a group sponsor such as an employer, and one coverage has coordination of benefits but the other does not.

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Member Coverage

The coverage you have as an employee pays before the coverage you have as a spouse/domestic partner or dependent child.

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Active Employee Coverage

The coverage you have as the result of your active employment pays before coverage you hold as a retiree or under which you are not actively employed.

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Earliest Effective Date

When none of the general coordination rules apply (including those not described above), the coverage with the earliest continuous effective date pays first.

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Birthday Rule

For a child who is covered by both parents who are not separated or divorced and have joint custody, the coverage of the parent whose birthday occurs first in a calendar year pays first.

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Court Decree Stipulates

For a child who is covered by separated or divorced parents and a court decree says which parent has health insurance responsibility, that parent’s coverage pays first.

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Court Decree Does Not Stipulate

For a child who is covered by separated or divorced parents and a court decree does not stipulate which parent has health insurance responsibility, then the coverage of the parent with custody pays first. The payment order for this dependent child is as follows…

1. Custodial parent

2. Spouse/domestic partner of custodial parent

3. Non-custodial parent

4. Spouse/domestic partner of non-custodial parent

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Earliest Effective Date

If none of these rules apply, the parent’s coverage with the earliest continuous effective date pays first.

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Medicare As Secondary

Since 1980, congress has passed legislation making Medicare the secondary payer and group health plans the primary payer in a variety of situations. These laws apply only if you have both Medicare and employer group health coverage, and your employer has the minimum required number of employees as described in the following paragraphs. For more information, contact your employer or the Centers for Medicare and Medicaid Services.

If You Are Age 65 Or Older

If your group employs 20 or more employees and if you are age 65 or older and eligible for Medicare only because of your age, the coverage described in this plan will be provided before Medicare benefits as long as your employer or group health plan coverage is based on your status as a current active employee or the status of your spouse/domestic partner as a current active employee.

If You Are Under Age 65 With Disability

If your employer or group employs 100 or more employees and you are under age 65 and eligible for Medicare only because of a disability (and not End-Stage Renal Disease (ESRD)), coverage under this plan will be provided before Medicare benefits as long as your group health plan coverage is based on your status as a current active employee or the status of your spouse/domestic partner as a current active employee or on the current active employment status of an individual for whom you are a dependent.

If You Are Under Age 65 With End-Stage Renal Disease (ESRD)

If you are under age 65 and eligible for Medicare only because of ESRD (permanent kidney failure), coverage under this plan will be provided before Medicare benefits, only during the first 30 months of your ESRD coverage. Then, the coverage described in this plan will be reduced by the amount that Medicare pays for the same covered services.

Dual Medicare Eligibility

If you are eligible for Medicare because of ESRD and a disability, or because of ESRD and you are age 65 or older, the coverage under this plan will be provided before Medicare benefits during the first 30 months of your ESRD Medicare coverage if this plan was primary to Medicare when you became eligible for ESRD benefits.

This Plan Secondary Payer To Medicare

If you are covered under both Medicare and this plan, and Medicare is allowed by law to be the primary payer, coverage under this plan will be reduced by the amount of benefits paid by Medicare for the same covered services. Except as provided below, after applying any deductible you may owe under this plan, HMSA will cover any remaining Medicare copayments and deductibles. Benefits under this plan will be paid up to either the Medicare approved charge for services rendered by a Medicare participating provider, or the lesser of the eligible charge or the limiting charge (as defined by Medicare) for services rendered by a provider that does not participate with Medicare.

Exhaustion Of Medicare Benefits

If you are entitled to Medicare benefits, HMSA will begin paying benefits after all Medicare benefits (including all lifetime reserve days) are exhausted.

If your inpatient hospital stay is extraordinarily long and costly and some or all of the stay is not covered by Medicare because your Medicare inpatient hospital benefits (including lifetime reserve days) are exhausted, HMSA will pay the lesser of…

• The HMSA eligible charge for the entire confinement less Medicare inpatient hospital payments and Medicare Part B payments for inpatient lab, diagnostic and X-ray services on those days; or

• Total hospital charges for inpatient days for which Medicare rules permit the hospital to bill you less Medicare Part B payments for inpatient lab, diagnostic and X-ray services on those days.

Medicare Part B Only

If you have coverage under Medicare Part B only, HMSA will pay inpatient benefits based on the eligible charge less any Medicare Part B benefits for inpatient lab, diagnostic and X-ray services.

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 payer, HMSA 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.

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If You Have Coverage Under Workers' Compensation Or Motor Vehicle Insurance

If you have or may have coverage under workers' compensation or motor vehicle insurance for the illness or injury, please note the following…

• Worker’s Compensation Insurance. If you have or may have coverage under worker’s compensation insurance, such coverage will apply instead of the coverage under HMSA’s Guide to Benefits. Medical expenses arising from injuries or illness covered under worker’s compensation insurance are excluded from coverage under the Guide to Benefits.

• Motor Vehicle Insurance. If you are or may be entitled to medical benefits from your automobile coverage, you must exhaust those benefits first, before receiving benefits from us. Please refer to Motor Vehicle Insurance Rules for a detailed explanation of the rules applicable to your automobile coverage.

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What You Need To Do

Your cooperation is necessary for HMSA to determine its liability for coverage and to protect its rights to recover their payments. HMSA will provide benefits in connection with the injury or illness in accordance with the terms of the Guide to Benefits only if you cooperate with HMSA by doing all of the following…

• Give HMSA Timely Notice. You must give HMSA timely notice in writing of each of the following: (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. To give timely notice, your notice must be no later than 30 calendar days after the occurrence of each of the events stated above.

• Sign Requested Documents. You must promptly sign and deliver to HMSA all liens, assignments, and other documents they deem necessary to secure their rights to recover payments, and you hereby authorize and direct any person or entity making or receiving any payment on account of such injury or illness to pay to HMSA so much of such payment as necessary to discharge your reimbursement obligations described above.

• Provide HMSA Information. You must promptly provide HMSA any and all information reasonably related to HMSA’s investigation of their liability for coverage and HMSA determination of their rights to recover payments. HMSA may ask you to complete an Injury/Illness report form, and provide them medical records and other relevant information.

• Do Not Release Claims Without HMSA’s Consent. You must not release, extinguish, or otherwise impair HMSA’s rights to recover their payments, without their express written consent.

• Cooperate With HMSA. You must cooperate in protecting HMSA’s rights under these rules. This includes giving notice of their lien as part of any written claim or demand made against any third party or other source of recovery in connection with the illness or injury.

Any written notice required by these rules must be sent to…

If you do not cooperate with HMSA as described above, your claims may be delayed or denied, and HMSA shall be entitled to reimbursement of payments made on your behalf to the extent that your failure to cooperate has resulted in erroneous payments of benefits or has prejudiced HMSA’s rights to recover payments.

Payment Of Benefits Subject To HMSA’s Right To Recover Their Payments

If you have complied with the rules above, HMSA will pay benefits in connection with the injury or illness to the extent that the medical treatment would otherwise be a covered benefit payable under HMSA’s Guide to Benefits. However, HMSA shall have a right to be reimbursed for any benefits they provide, from any recovery received from or on behalf of any third party or other source of recovery in connection with the injury or illness, including, but not limited to, proceeds from any…

• Settlement, judgment, or award;

• Motor vehicle insurance including liability insurance or your underinsured or uninsured motorist coverage;

• Workplace liability insurance;

• Property and casualty insurance;

• Medical malpractice coverage; or

• Other insurance.

HMSA shall have a first lien on such recovery proceeds, up to the amount of total benefits they pay or have paid related to the injury or illness. You must reimburse HMSA for any benefits paid, even if the recovery proceeds obtained (by settlement, judgment, award, insurance proceeds, or other payment)…

• Do not specifically include medical expenses

• Are stated to be for general damages only

• Are for less than the actual loss or alleged loss suffered by you due to the injury or illness

• Are obtained on your behalf by any person or entity, including your estate, legal representative, parent, or attorney

• Are without any admission of liability, fault, or causation by the third party or payer

HMSA’s lien will attach to and follow such recovery proceeds even if you distribute or allow the proceeds to be distributed to another person or entity. HMSA’s lien may be filed with the court, any third party or other source of recovery money, or any entity or person receiving payment regarding the illness or injury.

If HMSA is entitled to reimbursement of payments made on your behalf under these rules, and they do not promptly receive full reimbursement pursuant to their request, HMSA shall have a right of set-off from any future payments payable on your behalf under the Guide to Benefits.

To the extent that HMSA is not reimbursed for the total benefits they pay or have paid related to your illness or injury, HMSA has a right of subrogation (substituting HMSA to your rights of recovery) for all causes of action and all rights of recovery you have against any third party or other source of recovery in connection with the illness or injury.

HMSA’s rights of reimbursement, lien, and subrogation described above, are in addition to all other rights of equitable subrogation, constructive trust, equitable lien and/or statutory lien they may have for reimbursement of these payments, all of which rights are preserved and may be pursued at HMSA’s option against you or any other appropriate person or entity.

For any payment made by HMSA under these rules, you are still responsible for your copayments, deductibles, timeliness in submission of claims, and other obligations under the Guide to Benefits.

Nothing in these Third Party Liability Rules shall limit HMSA’s ability to coordinate benefits as described earlier.

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