HMSA Gold PPO I - 18350HI0880007 Health Insurance Plan
Hawaii Medical Service Association health insurance plan with the Plan ID 18350HI0880007. The plan is called HMSA Gold PPO I.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.96% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.04% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 18350HI0880007 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Hawaii | ||||||||||||||||||
| Health Insurance Issuer | Hawaii Medical Service Association | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 18350HI0880007-00 | ||||||||||||||||||
| Provider Network(s) | VISION-PPO PREFERRED-PROVIDER-PLAN | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 18350HI0880007-00 Standard On Exchange Plan - 18350HI0880007-01 |
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| Last Plan Update Date | Wed, 29 Nov 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of HMSA Gold PPO I Health Insurance Plan, 18350HI0880007-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Accidental Dental
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Applied Behavior Analysis Based Therapies
Precertification is required |
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Autism Spectrum Disorders
|
YES | $30.00 |
40.00% Coinsurance after deductible |
| Bariatric Surgery
|
YES | 20.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Chiropractic Care
|
NO | ||
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Eye Glasses for Children
Lenses limited to one par per calendar year. Frames limited to one frame every 24 months. Member owes all charges over $85 when seeing a nonpar provider |
YES | No Charge |
$85.00 |
| Gender Affirming Care
Precertification is required |
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Generic Drugs
|
YES | $15.00 |
$15.00 Copay after deductible, 20.00% Coinsurance after deductible |
| Habilitation Services
Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Hearing Aids
1 hearing aid per ear every 60 months. |
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Home Health Care Services
Limit: 150.0 Visit(s) per Year |
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Hospice Services
|
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Precertification is required. |
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Infertility Treatment
Infertility treatment is covered. Refer to the plan brochure for covered services, criteria, and limitations. |
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Infusion Therapy
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 20.00% |
40.00% Coinsurance after deductible |
| Mental/Behavioral Health Outpatient Services
|
YES | $30.00 |
40.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
|
YES | $50.00 |
$50.00 Copay after deductible, 20.00% Coinsurance after deductible |
| Nutritional Counseling
Counseling for diagnosed eating disorder by a licensed dietician |
YES | No Charge |
40.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Orthodontic Services to Treat Orofacial Anomalies
Benefits are limited to a maximum of $5,500 per treatment phase |
YES | No Charge |
No Charge |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
40.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
|
YES | $30.00 |
40.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Preferred Brand Drugs
|
YES | $30.00 |
$30.00 Copay after deductible, 20.00% Coinsurance after deductible |
| Prenatal and Postnatal Care
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
Quantitative limit units apply, see EHB |
YES | No Charge |
40.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
40.00% Coinsurance after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Radiation
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Reconstructive Surgery
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
The therapy is short-term, generally not longer than 90 days. |
YES | $30.00 |
40.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
|
YES | $30.00 |
40.00% Coinsurance after deductible |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year Plan will pay up to $40 for out-of-network providers |
YES | $10.00 |
$35.00 |
| Routine Eye Exam for Children
Member owes all charges over $35 when seeing a nonpar provider |
YES | No Charge |
$35.00 |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 120.0 Days per Year |
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Specialist Visit
|
YES | $60.00 |
40.00% Coinsurance after deductible |
| Specialty Drugs
Costshare for preferred specialty drugs. ??Refer to plan brochure for non-preferred specialty drug costshare information. |
YES | $200.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
40.00% Coinsurance after deductible |
| Telehealth
|
YES | $30.00 |
40.00% Coinsurance after deductible |
| Transplant
|
YES | No Charge |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | $45.00 |
40.00% Coinsurance after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Quantitative limit units apply, see EHB |
YES | No Charge |
40.00% |
| X-rays and Diagnostic Imaging
|
YES | 20.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
HMSA Gold PPO I Health Insurance Plan Variant 18350HI0880007-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.819592986346129 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 0.9868 |
| First Tier Utilization | 100% |
| Formulary ID | HIF005 |
| Formulary URL | URL |
| HIOS Product ID | 18350HI088 |
| Import Date | 2023-11-29 20:03:17 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 18350 |
| Issuer Marketplace Marketing Name | HMSA |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | HIN003 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Covered |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Covered |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan ID (Standard Component ID with Variant) | 18350HI0880007-00 |
| Plan Marketing Name | HMSA Gold PPO I |
| Plan Type | PPO |
| Plan Variant Marketing Name | HMSA Gold PPO I |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,100 |
| SBC Scenario, Having a Baby, Copayment | $70 |
| SBC Scenario, Having a Baby, Deductible | $500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $80 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $500 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | HIS001 |
| Source Name | SERFF |
| Plan ID | 18350HI0880007 |
| State Code | HI |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $8,700 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $1000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $500 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $500 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $500 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $1000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $500 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $8,700 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of HMSA Gold PPO I Health Insurance Plan, 18350HI0880007
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about HMSA Gold PPO I, 18350HI0880007 Health Insurance Plan, 18350HI0880007
-
Does HMSA Gold PPO I Health Insurance Plan, 18350HI0880007 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (18350HI0880007) Health Insurance Plan, Variant (18350HI0880007-00) offer Disease Management Programs?
Does (18350HI0880007) Health Insurance Plan, Variant (18350HI0880007-00) have Out Of Country Coverage?
Does (18350HI0880007) Health Insurance Plan, Variant (18350HI0880007-00) have Out of Service Area Coverage?
Does (18350HI0880007) Health Insurance Plan, Variant (18350HI0880007-00) offer Disease Management Programs?
Does HMSA Gold PPO I Health Insurance Plan, Variant (18350HI0880007-00) offer Disease Management Programs for Asthma?
Does HMSA Gold PPO I Health Insurance Plan, Variant (18350HI0880007-00) offer Disease Management Programs for Heart disease?
Does HMSA Gold PPO I Health Insurance Plan, Variant (18350HI0880007-00) offer Disease Management Programs for Depression?
Does HMSA Gold PPO I Health Insurance Plan, Variant (18350HI0880007-00) offer Disease Management Programs for Diabetes?
Does HMSA Gold PPO I Health Insurance Plan, Variant (18350HI0880007-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does HMSA Gold PPO I Health Insurance Plan, Variant (18350HI0880007-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API