What The HMSA Plans Do Not Cover

The services listed below are not covered under the HMSA Medical Plans (PPO or Health Plan Hawaii Plus). This listing also includes certain limitations that apply to services that were listed elsewhere as covered under the Plans.

  • Abdominoplasty.

  • Acupuncture, including any services or supplies related to acupuncture.

  • Air purifiers, air conditioners or humidifiers.

  • Any treatment or service not prescribed by a physician.

  • Benefits under the mandatory part of any auto insurance policy written to comply with "no fault" insurance law or uninsured motorist insurance law. (See Motor Vehicle Insurance Rules for more details.)

  • Biofeedback and any other forms of self-care or self-help training, and any related diagnostic testing.

  • Bionic services or devices.

  • Blood and blood products, except as described as covered under Blood, Blood Products and Blood Bank Service Charges.

  • Bone marrow transplants, unless specifically stated (see Organ and Tissue Transplants).

  • Breast reduction surgery.

  • Circumcision (routine).

  • Charges for the completion of claim forms or missed appointments.

  • Charges for services that do not meet HMSA's payment determination criteria.

  • Charges that exceed the level deemed as HMSA's eligible charge.

  • Charges related to the treatment of an injury that happens during work at any job for pay or profit (or for any occupational injury or illness); or, charges for the treatment of any injury or illness for which payment is made or available through Worker's Compensation or a similar law (whether or not such coverage is elected), or through any other employer's liability insurance.

  • Charges made by a hospital for room, board or other fees during a confinement in an area of the hospital that is used as a special care area (regardless of its name) including a skilled nursing facility, hospice, treatment center, ambulatory surgical center, birth center, adult or child day care center, half-way house, vocational rehabilitation center, or any other area of a hospital that renders services on an inpatient basis for other than the acute care of a sick, injured or pregnant individual. Benefits are only payable at the coverage level for the applicable facility, not at the hospital coverage level.

  • Chelation therapy, except to treat cardiac dysrhythmia; atrio ventricular blocks; poisoning by cardio tonic glycosides; disorders of calcium, iron or copper metabolism; and thalassemias.

  • Chemical dependency (substance abuse) treatment in excess of the limits described under Mental Health Substance Abuse Treatment

  • Chiropractic care.

  • Contraceptive items that do not require a prescription.

  • Cosmetic or reconstructive surgery or treatment done primarily to change appearance, regardless of whether performed for psychological or emotional reasons; similarly, any treatment performed as a result of complications from a previous cosmetic surgery. Note that reconstructive surgery provided in connection with a mastectomy will be covered in accordance with federal law, as outlined under Reconstructive Breast Surgery.

  • Counseling services; specifically bereavement, marriage or family, or sexual identification counseling, as well as genetic counseling.

  • Custodial care consisting of training or assisting with personal hygiene or other activities of daily living, rather than to provide medical treatment. Also, care that can be safely and adequately provided by individuals who do not have the technical skills of a covered health care professional.

  • Dental services generally performed only by dentists and not by physicians, including orthodontia, dental splints and other dental appliances; dental prostheses; osseointegration and all related services; removal of impacted teeth; and any other dental procedures involving the teeth, gums and structures supporting the teeth. In addition, any services in connection with the diagnosis or treatment of temporomandibular joint problems or malocclusion (misalignment of the teeth or jaws). These exclusions apply regardless of the symptoms or illness being treated. However, certain dental services are covered under the FlexSolutions Dental Plans as described under About The Dental Plans

  • Dietary foods, dietary supplements, liquid diets, diet plans, or any related products.

  • Ecological or environmental medicine, diagnosis and/or treatment.

  • Education, training, and room and board while confined in an institution that is mainly a school or other institution of training, a place of rest, a place for the aged, or a nursing home.

  • Erectile dysfunction treatment; specifically services and supplies (including prosthetic devices) related to erectile dysfunction except if due to an organic cause. This exclusion includes, but is not limited to, penile implants and drug therapies, except certain injectibles approved by HMSA and only to treat a dysfunction due to an organic cause.

  • Examinations or treatment ordered by a court in connection with legal proceedings, unless such examination or treatment would otherwise qualify as an eligible expense.

  • Expenses incurred before the covered individual is covered under this Plan.

  • Experimental or investigative medical treatments, procedures, drugs, devices or care, and all related services or supplies that are experimental or investigational. For a definition of "experimental or investigative" treatments, see Experimental or Investigational Services.

  • Eye examinations, eyeglasses or contact lenses, and refractive eye surgery to correct visual problems. This includes any confinement, treatment, services, or supplies given in connection with or related to the surgery. Note that certain vision services are covered under the FlexSolutions Vision Plan as described under About The Vision Plan.

  • Fertilization by artificial means (except for a one time only benefit for one outpatient in vitro fertilization procedure provided while you are an HMSA member), including all drugs or services related to the diagnosis or treatment of infertility.

  • Foot orthotics, except for specific diabetic conditions.

  • Hearing aids except as specifically stated as covered under Hearing Exams/Hearing Aids.

  • Herbal medicine or holistic or homeopathic care, including drugs and ecological or environmental medicine.

  • High-dose chemotherapy.

  • Human growth hormone therapy, except replacement therapy services due to hypothalamic-pituitary axis damage caused by primary brain tumors, trauma, infection, radiation therapy, Turner's syndrome, or growth failure secondary to chronic renal insufficiency awaiting renal transplantation.

  • Injections or shots administered to prevent disease, except immunizations provided in accordance with the guidelines set by the Advisory Committee on Immunization Practices (ACIP).

  • Lab tests in connection with Well-Baby Care visits that exceed two tuberculin tests (tine or skin sensitivity), two blood tests (hemoglobin or hematocrit) and one urinalysis through age five. (Applies under the PPO Plan when non-network providers are used.)

  • Liposuction.

  • Mammography screening that exceeds one mammogram:

    • between the ages 35 through 39 (baseline), and

    • every calendar year for individuals age 40 and above.

    However, mammograms recommended by a physician will be covered at any age if the woman has a history of breast cancer, or has a mother or sister with such history.

  • Medical exams or tests not needed to treat an illness, accidental injury, or pregnancy, except as specifically provided for by name under this Plan.

  • Membership costs for health clubs, weight loss clinics and similar programs.

  • Newborn well baby care services, except as specifically stated as covered under Well Child Care.

  • Nutritional counseling.

  • Oral surgery, unless the surgery is performed by a physician or dentist, and emergency or surgical services are performed, and such services (if performed by a dentist) could also be performed by a physician (an M.D. or D.O.).

  • Organ transplants that have been classified by the Blue Cross and Blue Shield Association as "experimental" or "investigative" in the circumstances presented, or as not proven to be safe and effective; living organ donor services if you are the organ donor; living donor transport; mechanical or non-human organs; organ purchase; and transplant services or supplies.

  • Outpatient prescription drugs; however, prescription drugs are covered on a retail and mail-order basis as outlined under Prescription Drug Benefits.

  • Personal convenience or comfort items, including, but not limited to, such items as TVs, telephones, first-aid kits, exercise equipment, air conditioners, humidifiers, saunas, and hot tubs.

  • Physician's waiting or stand-by time, unless specifically stated as covered elsewhere.

  • Private duty nursing services while confined in a facility, unless specifically stated as covered under Skilled Nursing Facility.

  • Radiation; either nonionizing or high-dose.

  • Reconstructive surgery, except that which has been specifically stated as covered under Reconstructive Breast Surgery.

  • Rest cures.

  • Routine physical exams or health appraisals except as specifically cited as covered under Preventive Care.

  • Screening by low-dose mammography that exceeds one mammogram:

    • between the ages of 35 through 39 (baseline), and

    • every calendar year for individuals age 40 and above.

      However, mammograms recommended by a physician will be covered at any age if the woman has a history of breast cancer, or has a mother or sister with such history.

  • Self help or sensitivity training, educational training therapy or treatment for an education requirement.

  • Services for injury or illness caused by an act of war (whether or not a state of war legally exists) or required during a period of active duty in any armed force that exceeds 30 days.

  • Services for an injury or illness caused by another person or third party from whom you have or may have a right to recover damages. (See Third Party Liability Rules for information regarding the Plan's right of reimbursement.)

  • Services not described as covered in the HMSA certificate or HMSA Guide to Benefits.

  • Services provided by an individual who is a member of your immediate family. (For the purposes of this provision, your immediate family includes your parents, spouse/domestic partner and children.) Also, any services provided by an individual who resides in your home, or services provided by volunteers or individuals who do not normally charge for their services.

  • Services for which no charge or collection would be made if you or your dependent had no health plan coverage; or that were provided without charge by any federal, state, municipal, territorial, or other government agency.

  • Services provided by a surgical assistant when charged separately from the facility fee. To be covered, charges for a surgical assistant must be included with the facility fee.

  • Services provided by a licensed pastoral counselor.

  • Services related to sex transformation and sexual dysfunctions not due to an organic cause.

  • Smoking cessation programs, except for nicotine patches. Note, however, that such programs may be paid for using money contributed to the Health Care Reimbursement Account; see Reimbursement Accounts for details.

  • Sterilization reversal.

  • Substance abuse treatment in excess of the limits described under Mental Health/Substance Abuse Treatment.

  • Telephone consultations.

  • Treatment in a U.S. government or agency hospital. However, the reasonable cost incurred by the U.S. or one of its agencies for inpatient or outpatient medical care and treatment given by a hospital of the uniformed services may be covered if the charges for the care and treatment are otherwise covered under this Plan. This coverage applies only to care and treatment provided to an individual (or family member of an individual) retired from the uniformed services, a family member of an individual active in the uniformed services, or a family member of a deceased member of the uniformed services.

  • Treatment of any complications arising from a previous cosmetic or experimental treatment, or from investigative or other services not covered by this Plan.

  • Treatment of baldness, including hair transplants, hair weaving or any drug if such drug is used in connection with baldness; also, wigs or toupees.

  • Weight loss or weight control programs.

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