2021 CATASTROPHIC PLAN. Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services. HMSA: Catastrophic Plan.
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1 of 8 20 CATASTROPHIC PLANSummary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services HMSA: Catastrophic Plan Coverage Period: 01/01/20 12/31/20Coverage for: Individual | Plan Type: PPO The Summary of Benefits and Covera ge (SBC) document will help you choose a health plan . The SBC shows you how you and the plan would share the cost for covered heal th care services. NOTE: Information about the cost of this plan (called the premium ) will be provided separately. This is onl y a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit www.hmsa.com . For general definitions of common terms, such as allowed amount , balance billing , coinsurance , copayment , deductible , provider , or other underlined terms see the Glossary. You can view the Glossary at http://www.healthcare.gov/sbc -glossary/ or call 1 -800-776-4672 to request a copy. Important Questions Answers Why This Matters: What is the overall deductible ? $,0 individualGenerally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan , each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible . Are there services covered before you meet your deductible ? Yes. Certain preventive care and well -child care services will be covered before you meet your deductible . This plan covers some items deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost -sharing and before you meet your deductible . See a list of covered preventive services at https://www. healthcare.gov/coverage/preventive -care -benefits/ . Are there other deductibles for specific services? No. deductibles for specific services. What is the out-of-pocket limit for this plan ? $,0 individual.The out -of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan , they have to meet their own out -of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit ? Premiums , balance -billed charges , payments for services subject to a maximum once you reach the maximum, any amounts you owe in addition to your copay ment for covered services, and health care this plan out -of-pocket limit . Will you pay less if you use a network provider ? Yes. See http://www.hmsa.com/search/pro viders or call 1 -800-776 -4672 for a list of network providers .This plan uses a provider network . You will pay less if you use a provider in the plan network . You will pay the most if you use an out -of-network provide r, and you might receive a bill from a provider for the difference between the charge and what your plan pays ( balance billing ). Be aware, your network pro vider might use an out -of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to see a specialist ? No. You can see the specialist you choose without a referral .
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2 of 8 20 CATASTROPHIC PLANAll copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) If you visit a healt h care office or clinic Primary care visit to treat an injury or illness First 3 primary care provider office visits : $ copay/visit; deductible does not apply All remaining physician visits : No charge No charge —none— Specialist visit No charge No charge —none— Other practitioner office visit: Physical and Occupational Therapist No charge No charge Services may require preauthorization . Benefits may be denied if preauthorization is not obtained. Psychologist First 3 behavioral health physician se rvices : No charge; deductible does not apply All remaining outpatient behavioral health physician services : No charge No charge —none— Nurse Practitioner First 3 primary care provider office visits : $ copay/visit; deductible does not apply All remaining visits : No charge No charge —none— Preventive care (Well Child Physician Visit) No charge; deductible does not apply No charge; deductible does not apply Age and frequency limitations may apply. You may have to pay for services that aren’t preventive . Ask your provider if the services needed are preventive . Then check what your plan will pay for. Screening No charge; deductible does not apply No charge —none—
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3 of 8 20 CATASTROPHIC PLANCommon Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Immunization (Standard and Travel) No charge; deductible does not apply No charge —none— If you have a test Diagnostic test Inpatient No charge No charge Services may require preauthorization . Benefits may be denied if preauthorization is not obtained. Outpatient No charge No charge X-ray Inpatient No charge No charge Services may require preauthorization . Benefits may be denied if preauthorization is not obtained. Outpatient No charge No charge Blood Work Inpatient No charge No charge Servi ces may require preauthorization . Benefits may be denied if preauthorization is not obtained. Outpatient No charge No charge Imaging (CT/PET scans, MRIs) Inpatient No charge No charge Services may require preauthorization . Benefits may be denied if preauthorization is not obtained. Outpatient No charge No charge If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.hmsa.com . Tier 1 mostly Generic drugs (retail) No charge No charge One retail cop ay for 1 -30 day supply, two retail copays for 31 -60 day supply, and three retail copays for 61 -90 day supply. Tier 1 mostly Generic drugs (mail order) No charge Not covered One mail order copay for a 84 -90 day supply at a 90 day at retail network or contracted mail order provider. Tier 2 mostly Pre ferred drugs (retail) No charge No charge One retail copay for 1 -30 day supply, two retail copays for 31 -60 day supply, and three retail copays for 61 -90 day supply. Tier 2 mostly Preferred drugs (mail order) No charge Not covered One mail order copay for a 84 -90 day supply at a 90 day at retail network or contracted mail order provider. Tier 3 mostly Other Brand Name drugs (retail) No charge No charge Cost to you for retail Tier 3 drugs: One copay plus one Tier 3 Cost Share for 1 -30 day supply, two
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4 of 8 20 CATASTROPHIC PLANCommon Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) copays plus two Tier 3 Cost Shares for 31 -60 day supply, and three copays plus three Tier 3 Cost Shares for 61 -90 day supply. Tier 3 mostly Other Brand Name drugs (mail order) No charge Not covered Cost to you for mail order Tier 3 drugs: One mail order copay plus one mail order Tier 3 Cost Share for an 84 -90 day supply at a 90 day at retail network or contracted mail order provider. Tier 4 mostly Preferred Specialty drugs (retail) No charge Not covered Retail benefits for Tier 4 and Tier 5 drugs are limited to a 30 -day supply. Available in participating Specialty Pharmacies only. Tier 5 mostly Other Brand Name Specialty drugs (retail) No charge Not covered Tier 4 & 5 (mail order) Not covered Not covered If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) No charge No charge —none— Phy sician Visits First 3 primary care provider office visits : $ copay/visit; deductible does not apply All remaining physician visits : No charge No charge —none— Surgeon fees No charge (cutting) No charge (cutting) —none— —none— No charge (non -cutting) No charge (non -cutting) If you need immediate medical attention Emergency room care Physician Visit No charge No charge —none— Emergency room No charge No charge —none— Emergency medical transportation (air) No charge No charge Limited to air tra nsport to the nearest adequate hospital within the State of Hawaii. Emergency medical transportation (ground) No charge No charge Ground transportation to the near est, adequate hospital to treat your illness or injury. Urgent care No charge No charge —none— If you have a Facility fee (e.g., hospital room) No charge No charge —none—
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5 of 8 20 CATASTROPHIC PLANCommon Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) hospital stay Physician Visits No charge No charge —none— Surgeon fee No charge (cutting) No charge (cutting) —none— No charge (non -cutting) No charge (non -cutting) —none— If you have mental health, behavioral health, or substance abuse needs Outpatient services Physician services First 3 behavioral health physician services : No charge; deductible does not apply All remaining outpatient behavioral health physician ser vices: No charge No charge —none— Hospital and facility services No charge No charge —none— Inpatient services Physician services No charge No charge —none— Hospital and facility services No charge No charge —none— If you are pregnant Office visit (Prenatal and postnatal care) No charge No charge Cost sharing does not apply to certain pre ventive services . Depending on the type of services, coinsurance or copay may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Childbirth/delivery professional services No charge No charge Childbirth/delivery facility services No charge No charge If you need help recovering or have other special health needs Home health care No charge No charge 150 Visits per Calendar Year Rehabilitation services No charge No charge Services may require preauthorization . Benefits may be denied if preauthorization is not obtain ed. Excludes cardiac rehabilitation. Habilitation services No charge (DME) No charge (PT/OT outpatient) No ch arge (Speech Therapy outpatient) No charge (DME) No charge (PT /OT outpatient) No charge (Speech Therapy outpatient) Services may require preauthorization . Benefits may be denied if preauthorization is not obtained.
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6 of 8 20 CATASTROPHIC PLANCommon Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Network Provider (You will pay the least) Out-of-Network Provider (You will pay the most) Skilled nursing care No charge No charge 120 Days per Calendar Year. Durable medical equipment No charge No charge Services may require preauthorization . Benefits may be denied if preauthorization is not obtained. Hospice services No charge Not covered —none— If your child needs dental or eye care Children’s eye exam No charge No charge Limited to one routine vision exam per calendar year. Benefits available through age 18. Children’s glasses (single vision lenses and frames selected within designated group) No charge No charge Limited to one pai r of glasses per calend ar year. Benefits available through age 18. Children’s dental check -up Not covered Not covered Excluded service Excluded Services & Other Covered Services: Services Y our Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services .) Acupuncture Cardiac rehabilitation Cosmetic surgery Dental care (Adult) Dental care (Child) Long -term care Private -duty nursing Routine foot care Weight loss programs Ot plan document.) Abortion Bariatric surgery (requires precertification) Chiropractic care (e.g., office visits, x -ray films limited to services co vered by this medical plan and within the scope of a chiropractor’s license) Hearing aids (limited to one hearing aid per ear every 60 months) Non-emergency care when traveling outside the U.S. For more information, see www.hmsa.com Routine eye care (Adult) (limited to services covered under a rider) Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: 1) 1-800-776-4672 for HMSA; 2) (808) 586-2790 for the State of Hawaii, Dept. of Commerce and Consumer Affairs Insurance Division; 3) 1- 866-444-3272 or http://www.dol.gov/ebsa/healthreform for the U.S. Department of Labor, Employee Benefits Security Administration; or 4) 1-877-267-2323 x61565 or http://www.cciio.cms.gov for the U.S. Department of Health and Human Services. Church plans are not covered by the Federal COBRA continuation coverage rules. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace . For more information about the Marketplace , visit www.HealthCare.gov or call 1- 800-318-2596.
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8 of 8 20 CATASTROPHIC PLANAbout these Coverage Examples: This is not a cost estimator. Treatmen ts sho wn ar e just examp les of how th is plan might cover medical care . Your actual co sts will be different depending on the actual care you receive, the prices you r providers charge , and many other factors. Focus on th e co st sharing amoun ts (deductibles , copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of in -network pre -natal care and a hospital delivery) The plan’s overall deductible $,0 Specialist coinsurance 0% Hospital (facility) coinsurance 0% Other coinsurance 0% This EXAMPLE event includes services like: Specialist office visits ( prenatal care ) Childbirth/Delivery Professional Services Childbirth/Delivery Facility S ervices Diagnostic tests ( ultrasounds and blood work ) Specialist visit ( anesthesia ) Total Example Cost $12,800 In this example, Peg would pay: Cost Sharing Deductibles $,0Copayments $0 Coinsurance $0 Limits or exclusions $60 The total Peg would pay is $,0 (a year of routine in -network care of a well -controlled condition) The plan’s overall deductible $,0 Specialist coinsurance 0% Hospital (facility) coinsurance 0% Other coinsurance 0% This EXAMPLE event includes services like: Primary care physician office visits ( including disease education ) Diagnostic tests ( blood work ) Prescription drugs Durable medical equipment ( glucose meter ) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles $6,400 Copayments $400 Coinsurance $0 What is Limits or exclusions $60 The total Joe would pay is $6,8 60 (in -network emergency room visit and follow up care) The plan’s overall deductible $,0 Specialist coinsurance 0% Hospital (facility ) coinsurance 0% Other coinsurance 0% This EXAMPLE event includes services like: Emergency room care ( including medical supplies ) Diagnostic test ( x-ray) Durable medical equipment ( crutches ) Rehabilitation services ( physical therapy ) Total Example Cost $1,900 In this example, Mia would pay: Cost Sharing Deductibles $,00Copayments $0 Coinsurance $0 Wha Limits or exclusions $0 The total Mia would pay is $,00
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Federal law requires HMSA to provide you with this notice. HMSA complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. HMSA does not exclude people or treat them differently because of things like race, color, national origin, age, disability, or sex. Services that HMSA provides Provides aids and services to people with disabilities to communicate effectively with us, such a s: ŁQualified sign language interpreters ŁWritten information in other formats (large print, audio, accessible electronic formats, other formats) Provides language services to people whose primary language is not English, such as: ŁQualified interpreters ŁInf ormation written in other languages ŁIf you need these services, please call 1 (800) 776 -4672 toll -free ; TTY 711 -related grievance or complaint If you believe that we™ve failed to provide these services or discriminated against you in some way, you can file a grievance in any of the following ways: ŁPhone: 1 (800) 776 -4672 toll -free ŁTTY: 711 ŁEmail: Compliance_Ethics@hmsa.com ŁFax: (808) 948 -6414 on Oahu ŁMail: 818 Keeaumoku St., Honolulu, HI 96814 You can also file a civil rights complaint with the U.S. Department of Health and Human Services, O ce for Civil Rights, in any of the following ways: Online: ocrportal.hhs.gov/ocr/portal/lobby.jsf ŁPhone: 1 (800) 368 -1019 toll -free; TDD users, call 1 (800) 537 -7697 toll -free ŁMail: U.S. Department of Health and Human Services, 200 Independence Ave. S.W., Room 509F, HHH Building, Washington, DC 20201 For complaint forms, please go to hhs.gov/ocr/office/file/index.html . Hawaiian : opuka oe i ka lelo Hawai i, loa a ke k kua manuahi i oe. E kelepona i 1 (800) 776 -4672. TTY 711. Bisaya : ATENSYON: Kung nagsulti ka og Cebuano, aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe, nga walay bayad. Tawag sa 1 (800) 776 -4672 nga walay toll. TTY 711 . Chinese : 1 (800) 776 -4672 TTY 711. Ilocano : PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Awagan ti 1 (800) 776 -4672 toll -free. TTY 711 . Japanese : 1 (800) 776 -4672 TTY 711. . Korean : :08„: F’˚¡6è*° ˛ñ7ä, 6ì6è 2P/x3Ø*° 8¨7ÝF„4˘ 3L 8¼3é#ü$˘. 1 (800) 776 -4672 -¼8p)’ 7$(±F¨ -H(Á #ü$˘. TTY 711 -¼8p)’ 98G‹F¨ . Laotian: : , , , . 1 (800) 776 -4672 . TTY 711. Marshallese : , e a ejje k k 1 (800) 776 -4672 tollfree, enaj ejjelok wonaan. TTY 711 . Pohnpeian: Ma ke kin lokaian Pohnpei, ke kak ale sawas in sohte pweine. Kahlda nempe wet 1 (800) 776 -4672. Me sohte kak rong call TTY 711. Samoan : MO LOU SILAFIA: Afai e te tautala Gagana leai se totogi, mo oe, Telefoni mai: 1 (800) 776 -4672 e leai se totogi o lenei ‚au™aunaga. TTY 711 . Spanish : ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1 (800) 776 -4672. TTY 711 . Tagalog : PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1 (800) 776 -4672 toll -free. TTY 711 . Tongan : FAKATOKANGA™I: Kapau ‚oku ke Lea -Fakatonga, ko e kau tokoni fakatonu lea ‚oku nau fai atu ha tokoni ta™etotongi, pea teke lava ‚o ma™u ia. Telefoni mai 1 (800) 776 -4672. TTY 711 . Trukese: MEI AUCHEA: Ika iei foosun fonuomw: Foosun Chuuk, iwe en mei tongeni omw kopwe angei aninisin chiakku, ese kamo. Kori 1 (800) 776 -4672, ese kamo. TTY 711 . Vietnamese : CHÚ Ý: N u bn nói Ti ng Vi t, có các dch v h tr ngôn ng min phí dành cho b n. G i s 1 (800) 776 -4672. TTY 711 . NMM_1000_24715_1557_ R
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