Description of Covered Services

The following is a summary of additional services covered under the HMSA Medical Plans; this section also provides more details on some of the covered services outlined previously. Note that for the services listed below, and unless otherwise noted, the Plans pay benefits as follows...

• PPO Plan:

  • Participating Providers—Plan pays 80% or 90% of the eligible charges, after the deductible (when applicable).

  • Non-Participating Providers—Plan pays 70% of the eligible charges, after the deductible.

• Health Plan Hawaii Plus—Plan pays 100% after a $15 copayment for many services, 100% of the eligible charges for other services; no benefits are paid for non-approved out-of-network care.

Specific payment provisions for the most frequently utilized services were outlined previously under What The HMSA Plans Cover. For additional details, refer to the HMSA plan booklet available from your local Human Resources representative, or contact HMSA directly at the number indicated on your ID card.

Allergy Testing And Treatment Materials

Both testing and treatment are covered. Allergy testing is limited to no more than one testing series per calendar year.

Ambulance

Includes auto or air services within the state of Hawaii, if provided by a properly licensed or certified provider. Air ambulance is limited to intra-island or inter-island transportation to the nearest hospital or skilled nursing facility that can adequately treat your illness or injury.

Anesthesiology Services

Includes services of an anesthesiologist (physician) when such services are required by a physician; hospital anesthesia services (i.e., nurse anesthetist services) are paid in accordance with inpatient hospital services as outlined above.

Appliances and Durable Medical Equipment

Includes hearing aids (one device per ear every five years); cardiac pacemakers; artificial limbs, eyes, hips and similar non-experimental appliances; casts, splints, trusses, braces, and crutches; oxygen and rental of equipment for its administration; rental or purchase of wheelchair and hospital-type bed; and charges for the use of an iron lung, artificial kidney machine, pulmonary resuscitator, and similar special mechanical equipment.

Birthing Center Services

Covered under all of the Plans. (See Maternity Services for an important note regarding maternity and newborn benefits.)

Blood, Blood Products and Blood Bank Service Charges

These items are covered, unless donated. Under the PPO Plan, any additional charges for autologous blood (blood reserved for the individual donating it) are not covered.

Chemical Dependency Treatment

Includes both inpatient and outpatient services. See Mental Health/Substance Abuse Treatment for payment provisions and limitations.

Chemotherapy

Includes chemical agents (other than oral) for treatment of a malignancy.

Consultation Visits

Includes medical or surgical visits.

Dialysis and Supplies

Such services are covered under the Plans; benefits differ based on whether the services are provided on an inpatient or outpatient basis.

Emergency Room Use

Use of an emergency room is covered only if a bona fide medical emergency exists; non-emergency use of an emergency room is not covered. Emergency physician visits are covered under the applicable physician visit (office, hospital or surgery) as outlined elsewhere.

Emergency Services

Covered, including room charges and physician visits, if a prudent layperson could reasonably expect the absence of immediate medical attention to result in:

• Serious jeopardy to the health of the individual (or, with respect to a pregnant woman, the health of the woman and her unborn child);

• Serious impairment to bodily functions; or

• Serious dysfunction of any bodily organ or part.

Examples of an emergency include chest pain or other heart attack signs, poisoning, loss of consciousness, convulsions or seizures, broken back or neck, heavy bleeding, sudden weakness on one side, severe pain, breathing problems, drug overdose, severe allergic reaction, severe burns, and broken bones. Examples of non-emergencies are colds, flu, earaches, sore throats, and using the emergency room for your convenience or during normal physician office hours for medical conditions that are treatable in a physician’s office.

If you require emergency services, call 911 or go to the nearest emergency room for treatment. Pre-authorization is not required.

Please note: if you are admitted to the hospital directly from the emergency room, hospital inpatient benefits will apply to your emergency room services.

You will not receive benefits if you use an emergency room for your convenience or during normal office hours for medical conditions that are treatable in a physician's office.

Hearing Exams

Covered if for the evaluation of hearing aid use. For specific benefit payment provisions and limitations, see Hearing Exams/Hearing Aids.

Home Health Care

Includes part-time skilled medical services. For specific benefit payment provisions and limitations, see Home Health Care.

Hospice Care Services

Limited to care for a terminal illness; benefit payment is made in lieu of any other covered services for the terminal illness. For specific benefit payment provisions and limitations, see Hospice Care.

Hospital Visits By a Physician

Covered as applicable.

Immunizations

Includes immunizations provided in accordance with guidelines set by the Advisory Committee on Immunization Practices (ACIP). If the immunizations are provided as part of eligible Preventive or Well Baby Care, the Health Plans pay 100% of eligible charges (with no deductible) if received as part of a physician office visit.

Inpatient Hospital Services

Includes room and board at the semi-private room rate. Also includes care in an Intermediate Care, Isolation Care, or Intensive Care/Coronary Care Units; ancillary inpatient services (such as operating room, surgical supplies, drugs, dressings, anesthesia services and supplies, oxygen, antibiotics, and blood transfusion services); and lab and X-ray services.

Charges for such services will be based on each Plan's provisions as outlined previously under At The Hospital.

Maternity Services

Includes physician services, surgery for cesarean sections and/or complications of pregnancy, hospital services, and routine visit to newborn child.

Note: Federal law protects the benefit rights of mothers and newborns related to any hospital stay in connection with childbirth. In general, group health programs and health insurance issuers may not:

• Restrict benefits for the length of hospital stay for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable).

• Require that a provider obtain authorization from the program or the insurance issuer for prescribing a length of stay of up to 48 hours (or 96 hours).

For a hospital delivery, the hospital length of stay begins at the time of delivery (or at the time of the last delivery in the case of multiple births). For a delivery outside the hospital, the hospital length of stay begins at the time the mother or newborn is admitted as a hospital patient in connection with childbirth by the attending physician.

Medical Foods

Covered for the treatment of inborn errors of metabolism in accordance with Hawaii law and HMSA guidelines.

Nurse-Midwife Services

Payment for these services may be made when provided in lieu of physician services in conjunction with a normal pregnancy and delivery. Covered under the PPO Plan only.

Organ and Tissue Transplants

The following may be covered: transplant evaluations, bone marrow, heart, heart and lung, liver, lung, simultaneous kidney/pancreas, and corneal and kidney transplants. Precertification is required to ensure that payment determination criteria has been met; benefits will be denied if prior approval for the specified transplants is not obtained.

Outpatient Injections

Covered, for outpatient services and supplies for the injection or intravenous administration of medication or nutrient solutions required for primary diet, and travel immunizations in accord with the guidelines set by the Advisory Committee on Immunization Practices (ACIP).

Please note: certain services require Precertification.

Outpatient Lab and X-Ray Services

Such services are covered if ordered by a physician for the diagnosis or treatment of an injury or illness, and include lab services and diagnostic tests, X-ray films and radiotherapy, and screenings by low-dose mammography. Certain exclusions and limitations may apply as outlined under What The HMSA Plans Do Not Cover.

Outpatient Surgical Centers

Includes operating room, surgical supplies, oxygen, antibiotics, blood transfusion services, and routine lab and X-ray services normally associated with the surgery. Charges for such services will be based on each Plan's provisions as outlined previously under At The Hospital.

Physical And Occupational Therapy

Covered, but only when all of the following are true:

• The therapy is ordered by a physician under an individual treatment plan.

• The therapy is received from a licensed physical or occupational therapist.

• The therapy is necessary to restore neurological or musculoskeletal function that was lost or impaired due to an illness or injury.

• The therapy and diagnosis are described as covered in HMSA’s medical policies on physical and occupational therapy.

Visits are covered up to the number of visits necessary to restore sufficient neurological or musculoskeletal function but not more than the maximum number of visits defined in HMSA’s medical policies on physical and occupational therapy. The maximum number of visits allowed is combined for both physical and occupational therapy. Neurological or musculoskeletal function is sufficient when one of the following first occurs:

• Neurological or musculoskeletal function is the level of the average healthy person of the same age, or

• When further significant functional gain is unlikely.

Group exercise programs are not covered. Physical therapy evaluations are not covered when provided by an occupational therapist.

Physician's Visits

Includes home visits, office visits, standard immunizations, office consultations, Away from Home Care, allergy testing, physical and occupational therapy, outpatient mental health and substance abuse physician visits, outpatient hospital visits, and outpatient surgery, up to plan limits. Benefits will also be paid for second opinions regarding the necessity of surgery.

Psychiatric Treatment

Covered as outlined previously under Mental Health/Substance Abuse Treatment.

Psychological Testing

Such testing is covered; however, each testing session will apply toward the applicable calendar year maximums for inpatient stays or outpatient visits as outlined previously under Mental Health/Substance Abuse Treatment.

Reconstructive Breast Surgery

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

• All stages of reconstruction of the breast on which the mastectomy was performed,

• Surgery and reconstruction of the other breast to produce a symmetrical appearance,

• Prostheses, and

• Treatment of physical complications of all stages of the mastectomy, including lymphedemas.

These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and surgical benefits provided under this program.

Reconstructive Surgery

Limited to corrective surgery required to restore, reconstruct or correct any bodily function that was lost, impaired or damaged as a result of an illness or injury. Benefits will be paid only if the surgery is for congenital anomalies (defects present from birth) when the defect severely impairs or impedes normal, essential bodily functions (unless it is for reconstructive breast surgery as described above). Reconstructive surgery intended to improve appearance when it is unrelated to an injury, illness, or physical or birth defect, as well as complications arising from a non-covered cosmetic reconstructive surgery, is not covered.

Routine Physical Exams

Covered only when network providers are used or, under the PPO Plan when HealthPass providers are used as described under Preventive Care.

Skilled Nursing Facility

Covered for skilled nursing facility room and board charges based on the minimum semi-private room rate. To be eligible for benefits, the following statements must be true:

• You are admitted by your physician.

• Care is ordered and certified by your physician.

• Confinement is not primarily for comfort, convenience, a rest cure, or domiciliary care.

• If confinement days exceed 30 days, the attending physician must submit a report showing the need for additional days at the end of each 30-day period.

• Confinement is not longer than 120 days in any one calendar year (100 days under the Health Plan Hawaii Plus Plan).

• Confinement is not for custodial care.

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

Speech Therapy

Covered, when the following statements are true:

• The therapy is ordered by a physician under an individual treatment plan.

• The therapy is received from a speech therapist holding a Certificate of Clinical Competence from the American Speech and Hearing Associations.

• The therapy is necessary to restore speech function that was lost or impaired by illness or injury.

• The therapy is short term (long-term maintenance and group speech therapy programs are not covered).

• The therapy is not for developmental learning disabilities, or developmental delay.

Surgery

Includes inpatient or outpatient surgery as outlined under Surgery. Note that benefits may be limited for multiple surgeries and surgical services that do not require cutting, as explained under Special Notes Regarding Covered Services.

Well Baby/Child Care Visits

No deductibles apply for such services, as outlined under Well Child Care. Note that routine lab tests are covered under Outpatient Lab and X-ray Services as described elsewhere.