About The HMSA Medical Plans

Overview

If you are a Hawaii employee, you may enroll in one of the HMSA Plans...

  • Preferred Provider (PPO) Plan, or

  • Health Plan Hawaii Plus (HMO) Plan.

You may also be eligible to enroll in the Kaiser Permanente HMO, depending on where you live.

This section provides a summary of the key provisions of the HMSA Plans and outlines many of the services covered under those Plans. HMSA, as the Claims Administrator, pays benefits based on the specific provisions outlined in its Guide to Benefits booklets or certificates. Copies of these booklets are available for your review from your local Human Resources representative. You are also encouraged to call HMSA directly if you have any questions regarding plan provisions or the benefits available to you.

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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.

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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).

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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.

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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.

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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).

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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

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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.

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What The HMSA Plans Cover

The following is a summary of covered services, and the benefits that are paid for these services, under the HMSA Medical Plans.

Note that the benefit descriptions provided under this section are summaries; they do not reflect all limitations or restrictions. For complete details, refer to the official plan document or booklet (available from your local Human Resources representative), or contact HMSA directly at the number indicated on your ID card.

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At The Doctor's Office

Office Visits

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100% after a $15 copayment.

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Preventive Care

  • PPO Plan:

    • Participating Providers—Plan pays 100% for a health assessment when services are provided by a HealthPass program provider. Immunizations are covered at 100% at a participating provider's office.

    • Non-Participating Providers—Not covered.

    For information regarding additional preventive care services, see HealthPass—A Special Benefit for PPO Plan Participants.

  • Health Plan Hawaii Plus—Plan pays 100% for physical exams and immunizations; a $15 copayment applies for immunizations when provided outside a normal office visit.

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Well Child Care

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 70%.

Benefits limited to six visits per year for children under age one, two visits per year for children through one year, and one visit per year for children ages two through five; benefits include all standard childhood immunizations for which Plan pays 100%.

  • Health Plan Hawaii Plus—Plan pays 100% for care provided to children through age five; benefits also include all standard childhood immunizations.

Benefits provided to children through age 5; benefits also include all standard childhood immunizations for which Plan pays 100%.

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HealthPass—A Special Benefit for HMSA Plan Participants

With HealthPass, you (and your covered dependents age 14 or older) may receive one health assessment from a HealthPass provider each calendar year. This assessment is provided at no cost to you when you obtain the assessment through a HealthPass provider.

In addition, the HealthPass program pays 100% of the eligible charges made by a HealthPass provider for diagnostic screening tests; HealthPass also makes available special rates for wellness counseling and health education programs. All of these services are available through HealthPass program providers only.

To obtain a health assessment, contact your nearest HMSA HealthPass office anytime during the year. The HealthPass office will make an appointment for you and your covered dependents.

When the assessment is completed, a HealthPass counselor may arrange for additional tests, exams, or educational or other programs, if such services are deemed needed based on the results of the assessment.

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RSVP—A Special Benefit for Health Plan Hawaii Plus Members

RSVP (Reminder for Screening & Vaccination) helps you keep track of important health screenings for you and your dependents. To help you take advantage of the wellness and preventive benefits the plan provides, HMSA will send you reminders for such things as your child's periodic well child exams, pap tests, mammograms, and prostate cancer screenings.

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At The Hospital

Emergency Room

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 90%.

  • Health Plan Hawaii Plus—Plan pays 100% after a $75 copayment when services are obtained in Hawaii or from BlueCard providers outside of Hawaii; Plan pays 80% for emergency care obtained outside Hawaii from non-BlueCard providers.

Note that no benefits are paid for non-emergency care obtained in an emergency room.

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Semi-Private Room And Board

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100% after $75 inpatient copayment per day.

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Inpatient X-ray And Lab Services

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 90%.

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Surgery

Note: Before you (or a covered dependent) undergo certain surgical procedures, you or your physician must notify HMSA and request a Surgical Review. For details, see Precertification.

Outpatient

  • PPO Plan:

    • Participating Providers—Plan pays 90% for cutting procedures, 80% for non-cutting procedures.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100%; a $15 copayment applies for physician services.

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Inpatient

  • PPO Plan:

    • Participating Providers—Plan pays 90% for cutting procedures, 80% for non-cutting procedures.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100%.

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Maternity Services

For important details regarding these benefits and your rights under federal law, see Maternity Services.

Office Visits

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100%; a $15 copayment applies to initial visit.

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Hospital Services

Note: Benefits are based on semi-private room rate.

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100% after a $75 inpatient copayment per day.

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Mental Health/Substance Abuse Treatment

Inpatient

  • PPO Plan:

    • Participating Providers—Regular hospital benefits apply for hospital facility services; Plan pays 90% for psychiatrist/psychologist services.

    • Non-Participating Providers—Regular hospital benefits apply for hospital facility services; Plan pays 70% after deductible for psychiatrist/psychologist services.

  • Health Plan Hawaii Plus—Plan pays 100% after a $75 inpatient copayment per day for hospital services and 80% for psychiatrist/psychologist services.

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Outpatient

  • PPO Plan:

    • Participating Providers—Plan pays 90%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100% after a $15 copayment per visit.

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Other Frequently Utilized Services

Outpatient X-ray & Lab Services

Note: Fecal occult blood test (FOBT) screenings for ages 50 and older are covered as an outpatient lab service under the PPO plan.

  • PPO Plan:

    • Participating Providers—Plan pays 80%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 90%.

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Skilled Nursing Facility (SNF)

Note: Benefits are based on semi-private room rate and are limited to 60 days per benefit period (Health Plan Hawaii Plus) or 120 days per calendar year (PPO). A benefit period begins on the first day you are admitted to an inpatient hospital or SNF, and ends when you have not been an inpatient at any hospital or SNF for 60 days in a row.

  • PPO Plan:

    • Participating Providers—Plan pays 90% of semi-private room rate.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100% of semi-private room rate.

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Home Health Care

Note: Benefits are limited to 150 visits per calendar year under the PPO Plan. Benefits are limited to 365 days per illness or injury under the Health Plan Hawaii Plus HMO. Services must be received from a qualified home health agency.

  • PPO Plan:

    • Participating Providers—Plan pays 100%.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 100%.

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Hospice Care

  • PPO Plan:

    • Participating Providers—Plan pays 100%.

    • Non-Participating Providers—Not covered.

  • Health Plan Hawaii Plus—Plan pays 100%.

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Hearing Exams/Hearing Aids

Note: Hearing aids are limited to one device per ear every five years.

  • PPO Plan:

    • Participating Providers—Plan pays 80% after deductible for the exam and the device.

    • Non-Participating Providers—Plan pays 70% after deductible for the exam and the device.

  • Health Plan Hawaii Plus—Plan pays 100% after a $15 copayment for the exam. Plan pays 50% for the device.

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Durable Medical Equipment

  • PPO Plan:

    • Participating Providers—Plan pays 80% after deductible.

    • Non-Participating Providers—Plan pays 70% after deductible.

  • Health Plan Hawaii Plus—Plan pays 50% for external devices and 100% for internal devices.

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Special Notes Regarding Covered Services

Certain restrictions apply to covered services under all of the HMSA Medical Plans.

The listing that follows outlines many of the services for which restrictions apply. For details on these restrictions, contact HMSA or request a copy of the applicable Plan booklet from your local Human Resources representative.You should familiarize yourself with any restrictions that may apply to covered services, particularly those services (such as surgical procedures or any inpatient care) for which significant expenses will be incurred.

Restrictions may apply for...

  • Appliances and durable medical equipment

  • Automobile and air ambulance services

  • Donor services

  • HealthPass services

  • Home health care services

  • Hospice care services

  • Inpatient hospital services

  • Maternity, nurse-midwife, birthing center, and newborn child services

  • Nicotine patches

  • Oral surgery

  • Organ transplants

  • Outpatient laboratory and x-ray services

  • Outpatient surgical center services

  • Physical, occupational, and speech therapy

  • Prescription drug benefits

  • Psychiatrist/chemical dependency (substance abuse) treatment services

  • Reconstructive surgery

  • Skilled nursing facility services

  • Surgery, including multiple surgical services, services of an assistant surgeon, payment for pre- and post-operative care for major and minor surgical service, and non-cutting surgical services

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Prescription Drug Benefits

All of the HMSA Medical Plans offer prescription drug benefits that have been ordered as a result of an accidental injury or illness, as outlined below...

  • If you obtain your prescription drugs through a participating pharmacy (as defined below), the Plans pay 100% of the eligible charges after you pay a $30 copayment for brand names, or a $10 copayment for generics and insulin, for each 30-day supply (or portion thereof). No copayment for oral chemotherapy drugs.

  • If you choose to obtain a brand name drug instead of the generic equivalent, or the particular generic equivalent was out-of-stock or not available at the pharmacy, you must pay the entire cost of the brand name drug at the time of purchase and file a claim for reimbursement. HMSA will reimburse you the amount that would have been paid for the generic equivalent less the brand name copayment (in other words, you are responsible for the brand name copayment plus the difference between the generic and brand name cost).

  • If you obtain your prescription drugs through a non-participating pharmacy, you must pay the entire cost of the prescription drug at the time of purchase, and you must file a claim for reimbursement. HMSA will reimburse you the amount of the eligible charges minus the applicable copayment for each prescription that is your responsibility ($30 copayment for brand names, or $10 copayment for generics and insulin).

  • Mail-order drugs are available only through an HMSA-contracted company. All of the Plans pay 100% of the eligible charges after a $60 copayment for brand names or a $20 copayment for generics, for each 90-day supply (or portion thereof). No copayment for oral chemotherapy drugs.

  • Diabetic supplies are covered at 100% of the eligible charges. This benefit is limited to syringes, needles, lancets, auto-lancet devices, insulin tubing, calibration solution, test strips, and acetone test tablets.

In order to be considered a participating provider for the purposes of HMSA's prescription drug benefits, the provider must be contracted as an HMSA Participating Pharmacy. A provider who is contracted as an HMSA Participating Physician or Other Health Care Provider is not considered a participating provider for prescription drug benefits.

Note, too, that these prescription drug benefits are provided as a supplement to your other HMSA benefits. As such, all definitions, provisions, limitations, exclusions, and conditions included elsewhere in this Handbook with regard to the HMSA Plans apply to the prescription drug benefits, unless specifically stated otherwise in this section. See also Special Notes Regarding Covered Services for additional information.

Obtaining Your Prescription Drugs

To obtain your prescription drugs from a participating pharmacy, simply present your HMSA membership card and pay the applicable copayment. You generally do not need to file a claim for benefits.

If you obtain your prescription drugs from a non-participating pharmacy, you will need to pay the full amount for the prescription and then submit a claim for reimbursement. Claim forms are available from your pharmacy.

For mail-order drugs, you will need to complete a Patient/Profile Order Form, which is available from your local Human Resources representative or online (for printing) via the Company intranet. You will need to include the prescription order you received, the completed form and your required copayment when you complete your initial mail-order transaction.

As noted above, if you choose to obtain a brand name drug instead of the generic equivalent, or the particular generic equivalent was out-of-stock or not available at the pharmacy, you must pay the entire cost of the brand name drug at the time of purchase, and you must file a claim for reimbursement.

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What The Prescription Drug Benefit Program Does Not Cover

The following are not covered through the HMSA prescription drug benefit program...

  • Agents used in skin tests to determine allergic sensitivity.

  • Appliances and other non-drug items.

  • Charges for a contraceptive device or substance, except oral contraceptives for specific hormonal disorders.

  • Charges for growth hormones; immunization agents; biological sera, blood or blood plasma; levonorgestrel (Norplant); or minoxidil (Rogaine).

  • Compound preparations, except those that contain at least one federally controlled prescription drug that is not a vitamin or mineral. Compound drugs that contain any experimental/investigational drugs are not covered. Compound drugs made with bulk chemicals are not covered.

  • Convenience-packaged drugs.

  • Drugs labeled "Caution—limited by federal law to investigational use," or experimental drugs, even if you or your dependent is charged.

  • Drugs taken or administered while confined to a hospital, skilled nursing facility or similar institution. (These charges are normally covered as inpatient expenses.)

  • Drugs that may be purchased without a prescription.

  • Immunization agents (though immunizations may be covered under the medical benefit portion of your Plan as described elsewhere).

  • Infertility treatment drugs; also, all drugs to treat sexual dysfunction (except suppositories used to treat sexual dysfunction due to an organic cause as determined by HMSA).

  • Injectable drugs (other than insulin and Imitrex).

  • Non-legend (over-the-counter) drugs other than insulin.

  • Refills dispensed more than one year following the date of the prescription order or if not indicated on your original prescription.

  • Therapeutic devices or appliances, including hypodermic needles, syringes, support garments, and other non-medical substances, regardless of their use; however, diabetic supplies (including insulin and syringes) are covered.

  • Unit-dose drugs.

  • Vitamins and minerals, except for folic acid used for the treatment of cancer and sodium fluoride for the prevention of tooth decay.

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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.

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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.

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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.

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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.

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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.

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Birthing Center Services

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

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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.

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Chemical Dependency Treatment

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

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Chemotherapy

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

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Consultation Visits

Includes medical or surgical visits.

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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.

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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.

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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.

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Hearing Exams

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

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Home Health Care

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

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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.

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Hospital Visits By a Physician

Covered as applicable.

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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.

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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.

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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.

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Medical Foods

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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Psychiatric Treatment

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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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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Additional Information

Additional information that applies to all of the HMSA Medical Plans is provided under More About Your Health Care Benefits.

Also, the following provisions apply to your (and your dependents') HMSA coverage.

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Appealing Reduced Or Denied Benefits

If you wish to dispute a determination made by HMSA related to coverage, reimbursement, or any other matter related to this Agreement, you must request an appeal. Your request must be in writing unless you are requesting an expedited appeal. HMSA must receive it within one year from the date HMSA informed you of the denial or limitation of your claim, or within one year of the denial of coverage for any requested service or supply.

Address written requests to:

HMSA
ATTN: Appeals Coordinator
P.O. Box 1958
Honolulu, HI 96805-1958

Or, send HMSA a fax at 808-952-7546.

You must also provide the information described in the section below labeled “What Your Request Must Include.” Requests which do not comply with the HMSA’s requirements will not be recognized or treated as an appeal by HMSA.

If you have any questions regarding appeals, you can call HMSA at 808-948-5090, or toll free at 800-462-2085.

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Appeal Of HMSA’s Decision

If your appeal is for a precertification decision, HMSA will respond to your appeal as soon as possible given the medical circumstances of your case but not later than 30 days after they receive your appeal.

If your appeal is for any other type of decision, HMSA will respond to your appeal within 45 calendar days of there receipt of your appeal.You may request an expedited appeal if application of the time periods for appeal above 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 of treatment that is the subject of the appeal.

You may request an expedited appeal by calling HMSA at 808-948-5090, or toll free at 800-462-2085. HMSA will respond to your request for expedited appeal as soon as possible taking into account your medical condition but not later than 72 hours of their receipt of your request.

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Who Can Request An Appeal

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Either you or your authorized representative may request an appeal. Authorized representatives include...

  • Any person you authorize to act on your behalf provided you follow HMSA’s procedures which include filing a form with HMSA. To obtain a form to authorize a person to act on your behalf, call HMSA at 808-948-5090, or toll free at 800-462-2085. (Requests for an appeal from an authorized representative who is a physician or practitioner must be in writing unless requesting an expedited appeal.)

  • A court-appointed guardian or an agent under a health care proxy.

What Your Request Must Include

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To be recognized as an appeal, your request must include all of the following information…

  • The date of your request

  • Your name

  • The date HMSA denied the service (or in the case of precertification for a service or supply, the date coverage for such service or supply was denied)

  • The subscriber number from your member card

  • The provider name

  • A description of facts related to your request and why you believe HMSA’s decision was in error

  • Any other information relating to the claim for benefits including written comments, documents, and records you would like HMSA to review

You should keep a copy of the request for your records. It will not be returned to you.

Information Available From HMSA

If your appeal relates to a claim for benefits or request for precertification, HMSA will provide upon your request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim as defined by the Employee Retirement Income Security Act.

If You Disagree With HMSA’s Appeal Decision

If you disagree with HMSA’s decision, you must either request arbitration before a mutually selected arbitrator, or file a lawsuit against HMSA. If you are not enrolled in an employer sponsored group plan subject to ERISA, you have the additional option of requesting a review by a panel appointed by the Hawaii State Insurance Commissioner.

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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Coordination Of Benefits

Some individuals have health coverage in addition to coverage under this plan. When this is the case, the benefits from "other plans" will be taken into account.

Coverage That Provides Same Or Similar Coverage

You may have other insurance coverage that provides benefits which are the same or similar to this plan. If so, the benefits payable under this plan, when combined with benefits paid under your other coverage, will not exceed the lesser of…

  • 100 percent of HMSA eligible charge, or

  • The amount payable by your other coverage plus any deductible and copayment you would owe if the other coverage were your only coverage.

The method HMSA uses to calculate the eligible charge may be different from the methods of other plans. For a description of how HMSA determines their eligible charge refer to HMSA’s Guide to Benefits, Chapter 2: Payment Information.

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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General Coordination Rules

This section lists four common coordination rules. The complete text of your coordination of benefits rules is available upon request.

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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Dependent Children Coordination Rules

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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Motor Vehicle Insurance Rules

If your injuries or illness are due to a motor vehicle accident or other event for which HMSA believes motor vehicle insurance coverage reasonably appears available under Hawaii Revised Statures Chapter 431, Article 10C, then that motor vehicle coverage will pay before this coverage.

You are responsible for any cost sharing payments required under any motor vehicle insurance coverage; HMSA does not cover cost sharing payments.

Before HMSA pays benefits under this coverage for an injury covered by motor vehicle insurance, you must provide HMSA a list of medical expenses paid by the motor vehicle insurance. The list must show the date expenses were incurred, the provider of service, and the amount paid by motor vehicle insurance.

HMSA will review the list of expenses to verify that the motor vehicle insurance coverage available under Hawaii Revised Statutes Chapter 431, Article 10C is exhausted. Upon verification of exhaustion, you are eligible for covered services in accord with the Guide to Benefits.

Please note that in the following two situations, you are also subject to the Third Party Liability Rules: (1) if your injury of illness is caused or alleged to have been caused by someone else and you have or may have a right to recover damages or receive payment in connection with the illness or injury, or (2) if you have or may have a right to recover damages or receive payment without regard to fault (other than coverage available under Hawaii Revised Statures Chapter 431, Article 10C).

Any benefits paid by HMSA in accordance with this section or the Third Party Liability Rules, are subject to the provisions described later under Third Party Liability Rules.

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Medicare Coordination Rules

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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Third Party Liability Rules

Third party liability is when you are injured or become ill and…

  • The illness or injury is caused or alleged to have been caused by someone else and you have or may have a right to recover damages or receive payment in connection with the illness or injury; or

  • You have or may have a right to recover damages or receive payment without regard to fault.

In such situations, any payment made by HMSA on your behalf in connection with such injury or illness will only be in accordance with the following rules.

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…

HMSA
Attn: 8 CA/Other party Liability
P.O. Box 860 Honolulu
Hawaii 96808-0860

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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The information in this handbook is for summary purposes only. If any discrepancy exists between the information in this Benefits Handbook and the official plan documents, the official plan documents will govern. For additional details, please see Important Information. Updated: 03/07/2011
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