How The HMSA Plans Work

The HMSA Plans provide comprehensive medical coverage. Both the Preferred Provider (PPO) Plan and the Health Plan Hawaii Plus (HMO) Plan provide benefits for your covered medical expenses when you are diagnosed and treated for a non-occupational illness or accidental injury. However, the Plans differ in several significant areas, as described in the following sections.

If you are injured or become ill as a result of a work-related incident, you may be eligible for Worker's Compensation benefits, including medical benefits. If you suffer a work-related illness or injury, you should contact your manager. He or she will arrange medical care for you and report the incident. For information regarding A&B's Worker's Compensation program, refer to Survivor and Disability.

Back to Top

Choice Of Doctor Or Provider

PPO — Individuals enrolled in this Plan may visit any qualified health care provider as defined in the Definitions section. However, the PPO Plan pays higher benefits when you use a participating provider.

Health Plan Hawaii Plus—Individuals enrolled in this Plan must obtain all of their care from, or have it coordinated by, their designated Primary Care Physician (PCP). No benefits are paid for out-of-network care (unless it is approved in certain circumstances, such as a medical emergency).

Back to Top

Pre-Existing Condition Limitations

Some medical plans may limit the benefits you may receive during your initial months of coverage, based on your medical condition. But under the HMSA Medical Plans, no such "pre-existing condition" limitations apply. Once your coverage takes effect (as explained under When Coverage Begins), the Plans will begin paying benefits for any eligible charges.

If you leave A&B, you will be entitled to receive a certificate of prior coverage, which can be used to offset any pre-existing condition limitations that may apply under your new coverage. For details, see When Coverage Ends.

Back to Top

Payment Provisions

To determine what benefits you may be eligible to receive, it's important you understand the following payment provisions that apply to the administration of the Plans. These provisions include...

  • Deductibles

  • Copayments

  • Coinsurance

  • Out-of-Pocket Maximums

  • Lifetime Maximum Benefits

These payment provisions are explained in the sections below. The table below summarizes all of these payment provisions.

Note : If you or a dependent enroll in a FlexSolutions HMSA Plan after having been a member of another HMSA Plan, any and all benefits that were provided under the previous HMSA plan will be carried forward and applied to reduce the maximum benefits available for such benefits under your FlexSolutions HMSA Plan.

The HMSA Medical Plans... At a Glance
Payment Provisions PPO Plan Health Plan Hawaii Plus

Deductible

$100/individual, $300/family*

None

Copayment Amount

None; coinsurance amounts apply

A $15 copayment applies for many routine services

Coinsurance Amount (for most services)

PPO providers: 90% Non-PPO providers: 70%

100%

Out-of-Pocket Maximum

$2,500/individual, $7,500/family

$2,500/individual, $7,500/family

Lifetime Maximum

Unlimited

Unlimited

* Deductible does not apply for most services received from a participating provider.

Deductibles

The annual deductible is the amount of eligible charges you (or you and your dependents) pay each calendar year for covered services before the Plan begins to pay benefits. You do not have to meet a deductible under Health Plan Hawaii Plus. In all other cases, the following deductibles apply under the HMSA Plans...

PPO Plan, Participating and Non-Participating Providers

The deductible is the amount you pay each calendar year before the HMSA Plan starts to pay benefits. The deductible is $100 per individual. Once you have satisfied your deductible, the coinsurance amounts (as described below) will apply, unless otherwise noted.

Maximum Family Deductible Feature—For families of four or more, once your family members combined satisfy the first $300 in eligible expenses, the plan will treat all family members as if they had satisfied the individual deductible. No single family member can apply more than $100 in eligible expenses to the family deductible.

Back to Top

Hospital Deductible

Under the PPO Plan, a separate $200 hospital deductible applies when a covered individual receives covered services in a non-participating hospital. This $200 deductible applies for each admission to a non-participating hospital. This deductible is separate from, and does not apply toward, the annual deductible or annual out-of-pocket maximum (as described below).

Back to Top

Copayments

"Copayments" are flat dollar amounts you pay for certain covered services. After you pay the required copayment, the Plan will generally pay the remainder of all eligible charges. In general, copayments apply for certain services under the Health Plan Hawaii Plus. Information regarding the copayments that apply is provided under What The HMSA Plans Cover.

Back to Top

Coinsurance

"Coinsurance" is the percentage of expenses for covered services that you pay and the Plan pays. The Plans' share of covered expenses generally ranges from 70% to 100% of the eligible charges, depending on the Plan you elect and what type of providers (participating or non-participating) you use. Coinsurance payments apply for all services under the PPO Plan (excluding preventive care services obtained from a HealthPass program provider as noted under HealthPass—A Special Benefit for PPO Plan Participants), and certain services under the other plans.

The coinsurance percentages will apply until you reach your annual out-of-pocket maximum, at which point the Plan pays 100% of the eligible charges for the remainder of the calendar year.

Back to Top

Out-Of-Pocket Maximums

The out-of-pocket maximum - also known as the maximum annual copayment - includes your annual deductible, when applicable, and copayments or coinsurance amounts you pay for your share of eligible charges. Once your share of eligible charges for you or a dependent reaches the out-of-pocket maximum, the Plan pays 100% of most eligible charges for the rest of that Plan Year.

Regardless of whether you meet your out-of-pocket maximum, you are always responsible for any non-participating provider charges that exceed the level of eligible charges for the covered service. Such payments will generally only apply when you receive services from non-participating providers.

The following payments you may make do not apply toward your out-of-pocket maximum...

  • Charges in excess of eligible charges,

  • Charges for non-covered services,

  • Any hospital deductibles, and

  • Copayments for medical foods and contraceptive drugs and devices.

Back to Top

Lifetime Maximum Benefits

Some medical plans used to limit the amount of benefits the plans would pay in a covered individual's lifetime. In compliance with federal health care reform legislation, the HMSA medical plans have an unlimited lifetime maximum for most benefits.

Back to Top

Filing Claims

Whenever you receive eligible medical services, you or your provider must file a claim with HMSA for benefits to be paid. In most cases, the provider will file the claim form for you. To help ensure this is handled properly, at the time you receive an eligible health care service...

  • Present your HMSA membership card to the provider

  • Be sure both the provider and HMSA have your correct mailing address

  • Ask the provider to file the claim for you

While most providers will file claims for you, you are ultimately responsible for making sure that the claim is submitted to HMSA.

If you pay the provider directly for services, you should file a claim with HMSA. HMSA will then reimburse you based on the provisions of the plan. Note that any claim submitted to HMSA more than one year after the date the services were received will not be eligible for payment. Claims should be sent to:

Hawaii Medical Service Association
Claims Administration
P.O. Box 860
Honolulu, HI 96808-0860

In general, HMSA will send benefit payments directly to the network or participating provider, unless you visited a non-participating provider and paid the full amount, in which case the payment will be sent to you.

HMSA reserves the right to send benefit payments to you or to a provider. You cannot assign an HMSA payment to a provider or any other individual. If you die, benefit payments will be sent to your spouse/domestic partner, other eligible survivors, the provider, or the individual in charge of your estate.

In the event a claim is denied you can request a review by submitting a written request to HMSA within one year from the date you received notice of the denied claim. For additional information, refer to your HMSA plan booklet, or contact HMSA directly.

Out-Of-State Claims

If you receive health care services outside Hawaii, there are some special steps you need to take, depending on the provider from whom you receive the care, as outlined below.

PPO Plan

If you need health care services when you are away from home, call 800-810-2583 (800-810-BLUE) and a representative will refer you to a participating provider in your area. As an HMSA PPO member, you are eligible for an enhanced level of benefits through HMSA's select provider network. By calling this number, you are assured that you will be connected with an appropriate provider.

If you choose to visit a non-participating provider, the Plan will pay a reduced level of benefits for covered services—you will be responsible for...

  • The full balance of the provider's bill, and

  • Filing claims with HMSA to receive any benefits.

Back to Top

Health Plan Hawaii Plus

If you require urgent care, call 800-446-6872 (800-4HMO-USA). This referral service will provide you with the name, location, service hours, and phone number of the nearest participating HMO, as well as the phone number of an Away From Home Care Coordinator who will help you get an appointment.

If you require emergency care, go to the nearest emergency room facility and present your HMSA membership card. Ask the physician or hospital to send a copy of your medical records to your primary care physician; you should also request that they file the claim for you. Note that all of your follow-up care must be provided or coordinated by your primary care physician.

Back to Top

Precertification

Precertification is a special approval process to ensure that certain medical treatments, procedures, or devices meet payment determination criteria prior to the service being rendered. HMSA requires precertification of various services before the services are given. Your physician is aware of the guidelines to follow and will submit the information and papers that are needed for consideration. When precertification is authorized, you should receive services at your selected health center unless the services are referred.

Changes To The List Of Services And Supplies Which Require Precertification

From time to time, it is necessary to change the list of services and supplies that require precertification. Changes are necessary so that your plan benefits remain current with changes to the way therapies are delivered and may occur at any time during your plan year. If you would like to know if a treatment, procedure or device has been added or deleted from the list, call your nearest Customer Service office.

If you would like to check on the status of the precertification, also call your nearest Customer Service office.

Back to Top

HMSA’s Response To Your Request For Precertification Of Non-urgent Care

If your request for precertification is not urgent, HMSA will respond to your request within a reasonable time appropriate to the medical circumstances of your case but not later than 15 days after receipt of your request. HMSA may extend the time once for 15 days if they cannot respond to your request within the initial 15 days and it is due to circumstances beyond their control. If this happens, HMSA will let you know before the end of the initial 15 days why they are extending the time and the date they expect to render their decision. If HMSA needs additional information from you, they will let you know and provide you with at least 45 days to provide the information.

Back to Top

HMSA’s Response To Your Request For Precertification Of Urgent Care

Your care is urgent if application of the time periods applicable to non-urgent care…

  • Could seriously jeopardize your life or health or your ability to regain maximum function, or

  • In the opinion of your treating physician, would subject you to severe pain that cannot be adequately managed without the care that is the subject of the request for precertification.

HMSA will respond to your request for precertification for urgent care as soon as possible given the medical circumstances of your case but not later than 72 hours after their receipt of the request.

If you do not provide sufficient information for HMSA to determine whether or to what extent the care you request is covered, they will notify you within 24 hours of their receipt of your request. HMSA will let you know what information they need to respond to your request and provide you a reasonable time but not less than 48 hours to provide the information.

Back to Top

Appeal Of HMSA’s Precertification Decision

If you disagree with HMSA’s precertification decision, you may appeal their decision.

types Of Care Requiring Approval

The following types of care require approval by HMSA…

  • Autologous chondrocyte implants

  • Bone Density Test

  • Durable medical equipment

  • Genetic testing if predictive in asymptomatic individuals with the following:

    • Family history of breast cancer

    • Family history of ovarian cancer

    • Familial adenomatous polyposis

    • Hereditary nonpolyposis colorectal cancer

  • Growth hormone therapy

  • Home IV Therapy:

    • Albumin Therapy

    • Inotropic Therapy

    • Intravenous Immune Gamma Globulin (IVIG) Therapy

    • Pain Management Infusion Therapy

    • Parenteral Nutrition Therapy

  • In Vitro fertilization

  • Injectable drugs

    • Amevive

    • Forteo

    • Synagis

    • Velcade

    • Xolair

    • Zevalin

  • Positron Emission Tomography (PET)

  • Routine care associated with clinical trials

  • Stereotactic radiosurgery utilizing particle beams

  • Surgery for hyperhydrosis

  • Surgery to correct morbid obesity

  • Surgeries, therapies or procedures employing new technology

In addition, HMSA’s approval is required for organ and tissue transplants, including:

  • Transplant Evaluation

  • Allogeneic Bone Marrow Transplant

  • Autologous Bone Marrow Transplant

  • Heart Transplant

  • Heart/Lung Transplant

  • Liver Transplant

  • Lung Transplant

  • Simultaneous Kidney/Pancreas Transplant

Back to Top

Integrated Case Management Services

Integrated Case Management is a special program to assist members with certain medical conditions that require costly, long-term care and when a hospital may not be the most appropriate setting for your treatment. If you meet HMSA’s criteria, your coverage provides you with alternative benefits to help meet health care needs resulting from extreme illness or injury (providing costs do not exceed inpatient facility costs). You, your physician, and the hospital can work with HMSA’s case managers to identify and arrange alternative treatment plans to meet your special needs and to assist in preserving your health care benefits.

Conditions and treatments for which benefits management might be appropriate are: AIDS, coma, traumatic brain injury, respirator dependency, spinal cord injury, and long-term intravenous therapy.

Before benefits are available for alternative treatment plans, approval must be received. Without approval, no benefits for alternative treatment plans are available. The physician will usually contact HMSA on your behalf to identify and arrange alternative treatment plans. If you are not sure if your provider has contacted HMSA, you should talk with you physician or call HMSA at 808-948-5711 or neighbor islands call 808-365-7665.

Back to Top