Basics of your health plan benefits · time you see a provider or fill a prescription. ... $30 plus...

transcript

2016 HMO Plans

Basics of your health plan benefits

Member NameDENTALVISIONCMPCARE

MEDICAL DRUG

Subscriber Name

Subscriber IDXLHR001234567890

RXBINRXPCNRXGRP

004336ADVRX3990

E040CKC08X-A

DR JOHN MAHALOPACIFIC HEALTH CARE

KEIKI K ALOHA

KIMO K ALOHA

Show your membership card Think of your membership card as your passport to care. Show it every time you see a provider or fill a prescription.

Welcome!

Thank you for choosing HMSA. We deeply appreciate your trust and promise that we’ll always be here for you.

Your good health is our top priority. We’ll work with your doctor to keep you healthy and do all we can to get you compassionate care when you need it.

There’s a lot to think about as you get started with your new plan. And we know you’re busy. We’ll get you the information you need in plain-and-simple language the way you want it, whether it’s on paper, over the phone, or online. This booklet will help you get started.

Establish a relationship with your PCP Having an HMO is like having your own health care team. Leading your team is your primary care provider (PCP). From arranging your lab tests, X-rays, and hospital care to writing prescriptions and recommending specialists if necessary, your PCP makes sure you get the care you need. Whenever possible, your PCP will refer you to a doctor from HMSA’s HMO provider network.

Note: You don’t need to receive care from or arranged by your PCP for emergency services, HMSA’s Online Care, flu vaccines administered or purchased from a pharmacy, vision exams, gynecological exams, mental health and substance abuse services, and from clinics in Hawaii pharmacies approved by HMSA.

Subscriber information

Group information

Access to BCBS provider network out-of-state

Health Plan Hawaii sample

Dependent information

Plan type & coverage information

Get preventive wellness services at no cost to you Your plan provides coverage at no cost to you for preventive care such as annual exams, screenings, immunizations, and well-baby care.

Get specialty care when you need it When you need a specialist, your PCP will arrange care for you with a provider affiliated with your designated health center. You can use HMSA’s Find a Doctor tool online at hmsa.com. The online directory has current information about providers in HMSA’s HMO network, including PCPs, specialists, hospitals, urgent care centers, and other care facilities. Or, if you prefer, call us. We’re happy to help.

Save money with mail-order drugs Purchase prescription drugs from our participating mail-order providers at the best prices possible and have medications delivered right to your doorstep. Your plan also offers benefits for prescriptions purchased from retail pharmacies.

Have peace of mind when you travel HMSA is a part of the Blue Cross and Blue Shield Association (BCBSA). This means you don’t need to worry about your health when you’re away from home. With the BlueCard program, you’ll have access to Blue Cross and Blue Shield doctors across the U.S. Mainland and in more than 200 countries and territories around the world. See your Guide to Benefits for more information.

Get help fast from a doctor with Online Care No appointment, no waiting, no hassle. HMSA’s Online Care makes it easy to talk to a doctor immediately, wherever you are in Hawaii. Go to hmsaonlinecare.com to learn more.

Understand what your plan covers You have comprehensive coverage with your plan, but don’t assume everything is covered. This booklet provides an overview, but it’s only a summary. It isn’t a complete explanation of benefits. Coverage decisions are based on the terms and conditions of your plan, including specific exclusions and limitations, not all of which are described in this booklet.

For a complete description of benefits, see your Guide to Benefits. The Guide to Benefits is a written description of your plan and any riders or certificates and amendments. It includes important information about your plan benefits, limitations, and exclusions.

Other important notesEligible charge vs. actual charge HMSA is always looking for ways to help slow rising health care costs for everyone in Hawaii. Setting an eligible charge for services is one way we do that. Eligible charge is a cap on the total amount we pay for covered services. It’s often less than the actual charge or the amount a provider would bill patients for medical services and supplies. Your PCP, providers in your designated health center, and contracting vision, pharmacy, and dental (assuming you purchased the pediatric dental benefit) providers agree to accept the eligible charge as the most they’ll collect for covered services.

The actual charge for providers who don’t contract with HMSA is often higher than HMSA’s eligible charge. If you receive vision, retail prescription drugs, or pediatric dental services (assuming you purchased the pediatric dental benefit) from a nonparticipating provider and the actual charge is more than the eligible charge, you owe the difference. The difference, in some cases, can be a lot.

Precertification Some care requires advance approval from HMSA. When services are provided or arranged by your PCP or received from a provider who contracts with HMSA, they take care of precertification for you. If you choose retail prescription drugs, vision services, or pediatric dental services (assuming you purchased the pediatric dental benefit) from a nonparticipating provider, you are responsible for getting precertification approval. For a complete list of care that requires precertification, see Chapter 5: Precertification in your Guide to Benefits.

Subsidy Information The Affordable Care Act (ACA) requires us to let you know that a portion of your invoice includes the amount necessary to cover services required to be segregated under Section 1303 of the ACA. This applies to your 2015 plan and may apply to your 2016 plan if you qualify for a subsidy. Visit this link for more information: law.cornell.edu/cfr/text/45/156.280.

Until you meet the deductible each calendar year, you pay 100 percent of your medical expenses.

Covered before you reach the deductible:

• Most retail generic drugs.• Mail-order generic drugs.• Most wellness care. • Preventive dental services (applies only if you purchased the dental plan).• HMSA’s Online Care.• Disease management programs.• Vision services (adult and child).

Once you meet the out-of-pocket maximum, we pay all covered expenses for the rest of the calendar year.

Other amounts you may owe:

• If you go to a nonparticipating vision, retail prescription drug, or dental provider, you take on more financial responsibility.

See Eligible charge vs. actual charge on page 4.

For Bronze Plan members only, skip step 2 for all services.

All amounts you pay and we pay are based on eligible charge.

Eligible charge is often less than the provider’s actual charge.

Once you meet the deductible, you pay a portion and we pay the rest.

Covered before you reach the deductible:

• Mail-order generic drugs.• Most wellness care. • Preventive dental services (applies only if you purchased the dental plan).• Oral chemotherapy.• Spacers and peak flow meters.• U.S. Preventive Services Task Force (USPSTF) recommended drugs.• Preferred diabetic supplies.• Polycarbonate lenses.• HMSA’s Online Care.• Disease management programs.

3We pay

of eligible charges after you meet the

out-of-pocketmaximum

100%21

You pay

of your deductible100%

We pay the rest

You pay a portion ofthe cost

What you pay and what we pay

What you pay What you pay (after you meet the deductible)

Annual deductible – the fixed dollar amount you pay each calendar year before your health plan pays for certain services.

Plans Single Family

Platinum $0 $0

Gold $1,000 $2,000

Silver $2,500 $5,000

Bronze $5,000 $10,000

Annual out-of-pocket maximum – the most in deductible and copayment amounts you pay for most covered services in one calendar year.

Plans Single Family

Platinum $6,850 $13,700

Gold $6,850 $13,700

Silver $6,850 $13,700

Bronze $6,850 $13,700

Copayments for medical care

Plans Wellness & preventive care

Visits to a provider’s office/specialist/ physician visits to ER

Emergency room services

Most other services

Platinum None $10/$20/None $250 10%

Gold None $15/$30/None $250 20%

Silver None $20/$40/None $250 30%

Bronze (high deductible plan)

None $30/$60/None $250 40%

All percentages shown in this table are based on eligible charge.

* You receive a 30-day supply when you purchase from a retail pharmacy. ** Participating mail order is the most cost-effective option because you receive a 90-day supply.

Copayments for prescription drugs

Participating retail pharmacy*

Mail-order pharmacy** or 90-day at Retail

Nonparticipating retail pharmacy*

Tier 1 Platinum/Gold: $7

Silver/Bronze: $10

Platinum/Gold: $11

Silver/Bronze: $20

Platinum/Gold: $7 plus 20% of remaining eligible charge

Silver/Bronze: $10 plus 20% of remaining eligible charge

Silver/Bronze: $50

Platinum/Gold: $65

Silver/Bronze: $125

Tier 3 Platinum/Gold: $30 plus $45 Tier 3 cost share

Silver/Bronze: $50 plus $50 Tier 3 cost share

Platinum/Gold: $65 plus $135 Tier 3 cost share

Platinum/Gold: $30 plus $45 Tier 3 cost share; plus 20% of remaining eligible charge

Silver/Bronze: $50 plus $50 Tier 3 cost share; plus 20% of remaining eligible charge

Tier 4 Platinum/Gold: $100 Silver/Bronze: $150

Not covered Not covered

Tier 5 Platinum/Gold: $200 Silver: $300

Not covered Not covered

Copayments for contraceptives

Tier 1 None None Platinum/Gold: $7 plus 20% of remaining eligible charge

Silver/Bronze: $50

Platinum/Gold: $65

Silver/Bronze: $125

Tier 3 Platinum/Gold: $30 plus $45 Tier 3 cost share

Platinum/Gold: $65 plus $135 Tier 3 cost share

Platinum/Gold: $30 plus $45 Tier 3 cost share; plus 20% of remaining eligible charge

Silver/Bronze: $50 plus $50 Tier 3 cost share; plus 20% of remaining eligible charge

Over-the-counter Contra- ceptives for women by prescription only

None None Platinum/Gold: $7 plus 20% of remaining eligible charge

Copayments for vision services for adults

Participating vision provider

Nonparticipating vision provider

Eye exam $10 per exam All charges over $40

Frames (standard)

$15 per standard frame All charges over $12

Lenses for frames

$10 per pair of lenses Single: All charges over $16 Multifocal: All charges over $25

Contact lenses

$25 plus charges over $130 All charges over $50

Contact lens fitting

All charges over $45 All charges over $20

The amounts you pay for adult vision services don’t apply toward reaching the out-of-pocket maximum.

Copayments for vision services for children

Participating vision provider

Nonparticipating vision provider

Eye exam $10 per exam 50% of eligible charge

Frames (standard)

$15 per standard frame 50% of eligible charge

Lenses for frames

$10 per pair of lenses 50% of eligible charge

Contact lenses

50% of actual charge 50% of actual charge

Contact lens fitting

50% of eligible charge 50% of eligible charge

Poly- carbonate lenses

None 50% of eligible charge

* You receive a 30-day supply when you purchase from a retail pharmacy. ** Participating mail order is the most cost effective option because you receive a 90-day supply.

Copayments for contraceptives (continued)

Cervical caps/diaphragms

None None $10 per device

Implants, injectables, & IUDs

None N/A N/A

All percentages shown in this table are based on eligible charge.

Copayments for dental care HMO plans (if you purchased an Individual Dental Plan)

Plan Benefits Basic Plan

Monthly Premiums $21.39 (ages 0-18) $21.39 (ages 19-20) $20.35 (ages 21+)

Coverage Pediatric1 Adult

Deductible $0 $0

Waiting Period(s) 24 Month Medically Necessary Ortho

12 Month Major

Preventive Services

Exams $10 $10

X-rays $10 & up $10 & up

Cleanings $10 $10

Routine/Basic Services2

Fillings $40 & up $40 & up

Periodontal Treatment $20 & up $20 & up

Root Canals $285 $285

Crowns $225 & up $225 & up

Bridges (adults only) Not a benefit $225 & up

Denture (complete/partial) $300/$250 $300/$250

Calendar Year

Calendar year maximum Does not apply None

Out-of-pocket maximum $350 child/ $700 (2+ children) max

Does not apply

Rollover No No

IMPORTANT NOTE: The Affordable Care Act (ACA) requires that all individual health plans include pediatric dental benefits as an essential health benefit. 1 Pediatric benefits apply to members ages 0–18.2 Endodontic and periodontal services are considered major services for members

age 19 and older and are subject to the waiting period for new members.

Some pediatric services require prior authorization to ensure certain treatments, procedures, or devices meet the payment determination criteria before the service is rendered. Please refer to the Dental Guide to Benefits at hmsa.com/dental for complete information on benefits and provisions.

Your PCP is the one who provided or arranged your care.

(See page 2 of this booklet for services not subject to this rule.)

Services are listed as coveredin your Guide to Benefits and:

• For adult and pediatric vision, prescription drugs, and pediatric dental (assuming you purchased pediatric dental benefits), if services are received from a nonparticipating provider and precertification applies, precertification approval is received.

• The covered service meets all criteria for your condition and diagnosis as well as payment determination criteria and HMSA’s medical policies; and

Your deductible was met for the calendar year.

AND AND ➡THENWePay

Our process for paying a claimTo avoid unexpected fees, please review how we decide if a claim is payable.

The process shown assumes:

• We receive a claim. • Your plan is active at the time you receive services. • Another party or another plan is not responsible for payment. • You haven’t reached a benefit maximum. A benefit maximum is a frequency,

duration, or visit limit that applies to some covered services or supplies. If you reach a benefit maximum during the calendar year, benefits for that service or supply ends until the next calendar year.

• You haven’t met your copayment maximum (also known as out-of-pocket maximum) for the year.

When you don’t agree If you wish to dispute a decision made by HMSA related to coverage, reimbursement, or any other decision or action by HMSA, ask for an appeal in writing (unless you’re asking for an expedited appeal). Send the appeal within one year from the date of the action or decision you’re contesting. In the case of coverage or reimbursement disputes, this is one year from the date we first informed you of the denial or limitation of your claim, or of the denial of coverage for any requested service or supply.

For more information, see Chapter 8 of your Guide to Benefits. We’re also happy to help you over the phone at 948-5090 or 1 (800) 462-2085 toll-free.

Learn more Whether you’re a new member or you’ve been with us for a while, we’re here for you. Call or visit us at an HMSA Center or office near you. Call us. Check out our online tools and resources at hmsa.com. Or find information and tips on Facebook, Twitter, or Instagram.

Services Summary notes Chapter # Chapter name Subsection name

Alcohol or drug dependence Not covered solely because court ordered.

4 Description of Benefits Behavioral Health – Mental Health and Substance Abuse

Allergy testing and treatment Covered. 4 Description of Benefits Testing, Laboratory, and Radiology

Ambulance (air and ground)

Covered, but air ambulance is covered within Hawaii only.

4 Description of Benefits Other Medical Services

Anesthesia Monitored anesthesia when you meet high-risk criteria.

4 Description of Benefits Physician Services

Also see Dental Services (Pediatric) in this booklet

Behavioral health – Mental health

Precertification required for care in a residential rehabilitation facility outside Hawaii.

4 Description of Benefits Behavioral Health – Mental Health and Substance Abuse

Blood, blood products, and administration

Covered, including blood costs, blood bank services, and blood processing.

4 Description of Benefits Other Medical Services and Supplies

Cardiac rehabilitation Not covered. 6 Services Not Covered Miscellaneous Exclusions

Chemotherapy Coverage for high-dose chemotherapy only in conjunction with peripheral stem-cell transplants.

Chemotherapy drugs must be FDA-approved.

Description of Benefits

Services Not Covered

Chemotherapy and Radiation Therapy; Organ and Tissue Transplants

Miscellaneous Exclusions

Circumcision Coverage for newborn circumcision only. 4

Special Benefits for Children

Preventive and Routine

Clinical trials (routine care associated with clinical trials)

Covered when the routine care is associated with a clinical trial.

Continued on the next page

Services at a glanceThis table summarizes covered and not-covered services. It isn’t a complete explanation of coverage. To avoid unexpected fees, call us or consult your Guide to Benefits, which may be accessed through My Account on hmsa.com.

This booklet is a summary only and not a complete description of services, exclusions, or limitations. For complete information, see your Guide to Benefits.

Complications of non-covered procedures

Not covered. 6 Services Not Covered Miscellaneous Exclusions

Contraceptives (implants, injectables, IUDs)

One method per period of effectiveness. Also see Prescription Drugs in this booklet.

4 Description of Benefits Special Benefits for Women

Cosmetic services, surgery, supplies Not covered. 6 Services Not Covered Miscellaneous Exclusions

Dental – Services of a dentist

Limited to emergency or surgical services that would otherwise require a physician.

Other Medical Services and Supplies

Dental Care

Developmental delay services Not covered when provided by the government.

6 Services Not Covered Miscellaneous Exclusions

Diagnostic tests Covered. 4 Description of Benefits Testing, Laboratory, and Radiology

Dialysis and supplies Covered. 4 Description of Benefits Other Medical Services and Supplies

Disease management programs Covered. 4 Description of Benefits Disease Management Programs and Preventive Services

Durable medical equipment and supplies

Covered, but limitations apply. 4

Emergency servicescontinued on page 21

Covered when your condition is life-threatening or you need care immediately, such as when there is:

• Serious risk to the health of the individual or to a pregnant woman or her unborn child.

• Serious impairment to bodily functions.

• Serious dysfunction of any body organ or part.

4 Description of Benefits Emergency Services

Emergency services, continued

Emergency conditions include uncontrolled bleeding, difficulty breathing, broken bones and other major injuries, chest pain or pressure, coughing or vomiting blood, fainting, poisoning, sudden facial drooping or weakness in an arm or leg, sudden severe pain.

If you’re admitted as an inpatient after a visit to the emergency room, hospital inpatient benefits apply, not emergency room benefits.

4 Description of Benefits Emergency Services

Genetic testing and counseling Covered when specific criteria for genetic testing and counseling are met.

Testing, Laboratory, and Radiology

Counseling Services; Miscellaneous Exclusions

Growth hormone therapy Covered when specific criteria for growth hormone therapy are met.

Hearing services Evaluation for aids covered only in office of physician or audiologist. One hearing aid per ear every 60 months.

HMSA’s Online Care Covered for members age 18 and older. 4 Description of Benefits Online Care; Special Benefits – Disease Management; Preventive Services

Home IV therapy Covered, but drugs must be FDA-approved.

Hospice services Covered. 4 Description of Benefits Special Benefits for Homebound, Terminal, or Long-term Care

Hospital (and other facility) services Covered. 4 Description of Benefits Hospital and Facility Services

Immunizations and vaccinations Covered. High-risk conditions only as recommended by the Advisory Committee on Immunization Practices (ACIP). Also see Well-Care in this booklet.

Physician Services

Infertility treatment Covered for one in-vitro fertilization per lifetime.

Special Benefits for Member and Covered Spouse

Fertility and Infertility

Labs and pathology Covered. 4 Description of Benefits Testing, Laboratory, and Radiology

Mammography screening One baseline for women ages 35-39, then one per year thereafter.

Maternity care Reminder: Call us to add baby to your plan within 31 days of birth.

Newborn Care Reminder: Call us to add baby to your plan within 60 days of birth

10 General Provisions Children Who are Newborns or Adopted

Outpatient health care Covered up to 150 visits per calendar year. 4 Description of Benefits Special Benefits for Homebound, Terminal, or Long-term Care

Physician visits Covered. 4 Description of Benefits Physician Services

Pregnancy/maternity Inpatient stays after delivery for up to 48 hours from time of delivery for normal labor and delivery or 96 hours from time of delivery for a Caesarean birth.

Prescription drugs (outpatient)

Covered when purchased from participating and nonparticipating retail pharmacies or participating mail-order pharmacy. A maximum 42-day supply (or fraction thereof) for Omeprazole OTC when purchased in a store (no benefits for mail order). Also see Contraceptives in this booklet.

Prescription Drugs and Supplies

Radiation therapy Covered. High-dose radiation only when related to a peripheral stem-cell transplant. Non-ionizing radiation not covered.

Chemotherapy and Radiation Therapy

Radiology Covered. Also see Mammography Screenings and Well-Care in this booklet.

4 Description of Benefits Testing, Laboratory, and Radiology

Reconstructive surgery Reconstructive surgery related to complications of a non-covered procedure aren’t covered.

Surgical Services

Rehabilitation and habilitative programs

Covered, including occupational, speech, and physical therapies. Group programs aren’t covered.

4 Description of Benefits Habilitative and Rehabilitative Therapy

Screenings and preventive counseling

Covered. Grade A and B, and frequency based on recommendations of the U.S. Preventive Services Task Force (USPSTF).

4 Description of Benefits Special Benefits for Women; Testing, Laboratory, and Radiology; Surgical Services, Special Benefits for Disease Management

Skilled nursing facility Covered up to 120 days maximum per calendar year, when certain criteria are met.

4 Description of Benefits Hospital and Facility Services

Surgery Covered. 4 Description of Benefits Surgical Services

Transplants – Organ and tissue

Covered when specific criteria are met, including that major organ transplants and transplant evaluations take place in a contracting transplant facility located in Hawaii or an approved Blue Distinction Center for Transplants.

Organ and Tissue Transplants

Transplants

Tubal ligation Covered. Reversals aren’t covered. 4

Special Benefits for Women

Fertility/Infertility

Vasectomy Covered. Reversals aren’t covered. 4

Special Benefits for Men

Fertility/Infertility

Vision services (age 19 and older)

Covered. Benefit maximums apply:

• One eye exam per calendar year. • One frame every 24 months. • One pair of lenses per calendar

year (one pair of prescription lenses or one pair of disposable or nondisposable contact lenses).

Vision Care Services for Adults

Vision Care

Vision services (children through age 18)

• One eye exam per calendar year. • One frame every calendar year. • One pair of prescription lenses

or one pair of contact lenses per calendar year.

4 Description of Benefits Special Benefits for Children – Pediatric Vision Care

Well-Care for adults (22 and older)

• Men: One PSA screening per calendar year for men 50 or over; one physical exam per calendar year.

• Women: One ob-gyn exam, including pap smear; one physical exam per calendar year.

Special Benefits, Disease Management and Preventive Programs

Well-Care for children (through age 21)

Covered. Benefit maximums apply in accord with guidelines set by Advisory Committee on Immunization Practices (ACIP) and other criteria. Well-child care includes care from a child’s birth through age 21, including office visits for medical history, physical exams, sensory screenings, development/behavioral assessments, anticipatory guidance, lab tests, and immunizations.

4 Description of Benefits Special Benefits for Children – Medical Care

We’re here to helpPhone 948-6111 on Oahu If you’re calling from the U.S. Mainland, please call 1 (800) 776-4672. If you need to call a local Hawaii telephone number from the Mainland, the area code is 808.

HMSA Centers Visit one of our HMSA Centers with extended evening and Saturday hours:

HMSA Center @ Honolulu 818 Keeaumoku St. Monday – Friday, 8 a.m. – 6 p.m. Saturday, 9 a.m. – 2 p.m.

HMSA Center @ Pearl City Pearl City Gateway 1132 Kuala St., Suite 400 Monday – Friday, 9 a.m. – 7 p.m. Saturday, 9 a.m. – 2 p.m.

HMSA Center @ Hilo Waiakea Center 303A E. Makaala St. Monday – Friday, 9 a.m. – 7 p.m. Saturday, 9 a.m. – 2 p.m.

Offices Visit your nearest HMSA office Monday through Friday, 8 a.m. – 4 p.m.

Kahului 33 Lono Ave., Suite 350

Kailua-Kona 75-1029 Henry St., Suite 301

Lihue 4366 Kukui Grove St., Suite 103

Visit hmsa.com/contact for our holiday schedule.

Online hmsa.com Facebook: facebook.com/myhmsa Twitter: @AskHMSA Instagram: @AskHMSA

Basics of your health plan benefits · time you see a provider or fill a prescription. ... $30 plus...

Documents