HMSA Bronze PPO HSA - 18350HI0880035 Health Insurance Plan
Hawaii Medical Service Association health insurance plan with the Plan ID 18350HI0880035. The plan is called HMSA Bronze PPO HSA .
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.88% (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 35.12% 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 | 18350HI0880035 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| 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 | 18350HI0880035-00 | ||||||||||||||||||
| Provider Network(s) | ['HIN003'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Apr 2024 06:19 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 18350HI0880035-00 Standard On Exchange Plan - 18350HI0880035-01 |
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| Last Plan Update Date | Tue, 20 Dec 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Apr 2024 06:19 GMT |
Benefits of HMSA Bronze PPO HSA Health Insurance Plan, 18350HI0880035-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | No Charge after deductible |
No Charge after deductible |
| Accidental Dental
|
YES | No Charge after deductible |
No Charge after deductible |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
No Charge after deductible |
| Applied Behavior Analysis Based Therapies
Precertification Required |
YES | No Charge after deductible |
No Charge after deductible |
| Autism Spectrum Disorders
|
YES | No Charge after deductible |
No Charge after deductible |
| Bariatric Surgery
|
YES | No Charge after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge after deductible |
No Charge after deductible |
| Chiropractic Care
|
NO | ||
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
No Charge after deductible |
| Dental Check-Up for Children
|
YES | 100.00% |
100.00% |
| Diabetes Education
|
YES | No Charge after deductible |
100.00% |
| Dialysis
|
YES | No Charge after deductible |
No Charge after deductible |
| Durable Medical Equipment
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge after deductible |
| Eye Glasses for Children
Lenses limited to one pair per calendar year. Frames limited to one frame every 24 months |
YES | $25.00 |
50.00% |
| Gender Affirming Care
Precertification Required |
YES | No Charge after deductible |
No Charge after deductible |
| Generic Drugs
|
YES | No Charge after deductible |
No Charge 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 | No Charge after deductible |
No Charge after deductible |
| Hearing Aids
1 hearing aid per ear every 60 months. |
YES | No Charge after deductible |
No Charge after deductible |
| Home Health Care Services
Limit: 150.0 Visit(s) per Year |
YES | No Charge after deductible |
No Charge after deductible |
| Hospice Services
|
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Precertification is required. |
YES | No Charge after deductible |
No Charge after deductible |
| Infertility Treatment
Infertility treatment is covered. Refer to the plan brochure for covered services, criteria, and limitations. |
YES | No Charge after deductible |
No Charge after deductible |
| Infusion Therapy
|
YES | No Charge after deductible |
No Charge after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
No Charge after deductible |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible |
No Charge 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 | No Charge after deductible |
No Charge after deductible |
| Mental/Behavioral Health Outpatient Services
Plan deductible applies after the first 3 Behavioral Health Physician Services |
YES | No Charge after deductible |
No Charge after deductible |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
No Charge after deductible |
| Nutritional Counseling
Counseling for diagnosed eating disorder by a recognized licensed dietician |
YES | No Charge after deductible |
No Charge 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 after deductible |
No Charge after deductible |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
No Charge after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
No Charge after deductible |
| Outpatient Rehabilitation Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Preferred Brand Drugs
|
YES | No Charge after deductible |
No Charge after deductible |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
No Charge after deductible |
| Preventive Care/Screening/Immunization
Quantitative limit units apply, see EHB |
YES | No Charge |
No Charge after deductible |
| Primary Care Visit to Treat an Injury or Illness
Plan deductible applies after the first 3 Primary Care Provider Office Visits |
YES | No Charge after deductible |
No Charge after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | No Charge after deductible |
No Charge after deductible |
| Radiation
|
YES | No Charge after deductible |
No Charge after deductible |
| Reconstructive Surgery
|
YES | No Charge after deductible |
No Charge after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
The therapy is short-term, generally not longer than 90 days. |
YES | No Charge |
No Charge after deductible |
| Rehabilitative Speech Therapy
|
YES | No Charge after deductible |
No Charge 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 |
100.00% |
| Routine Eye Exam for Children
|
YES | $10.00 |
50.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 120.0 Days per Year |
YES | No Charge after deductible |
No Charge after deductible |
| Specialist Visit
|
YES | No Charge after deductible |
No Charge after deductible |
| Specialty Drugs
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Substance Abuse Disorder Outpatient Services
Plan deductible applies after the first 3 Behavioral Health Physician Services |
YES | No Charge after deductible |
No Charge after deductible |
| Telehealth
|
YES | No Charge after deductible |
No Charge after deductible |
| Transplant
|
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
NO | ||
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
No Charge after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Quantitative limit units apply, see EHB |
YES | No Charge after deductible |
No Charge after deductible |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
No Charge after deductible |
HMSA Bronze PPO HSA Health Insurance Plan Variant 18350HI0880035-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.648782704 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze 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, Pain Management |
| EHB Percent of Total Premium | 0.9843 |
| First Tier Utilization | 100% |
| Formulary ID | HIF001 |
| Formulary URL | URL |
| HIOS Product ID | 18350HI088 |
| Import Date | 12/20/2022 20:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| 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 | Expanded Bronze |
| 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 | 1/1/2023 |
| Plan ID (Standard Component ID with Variant) | 18350HI0880035-00 |
| Plan Marketing Name | HMSA Bronze PPO HSA |
| Plan Type | PPO |
| Plan Variant Marketing Name | HMSA Bronze PPO HSA |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $6,900 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,400 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | HIS001 |
| Source Name | SERFF |
| Plan ID | 18350HI0880035 |
| State Code | HI |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $13800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $6900 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $6,900 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $13800 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $6900 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $6,900 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $13800 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $6900 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $6,900 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $13800 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $6900 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $6,900 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $13800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6900 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,900 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $13800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $6900 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $6,900 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of HMSA Bronze PPO HSA Health Insurance Plan, 18350HI0880035
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about HMSA Bronze PPO HSA , 18350HI0880035 Health Insurance Plan, 18350HI0880035
-
Does HMSA Bronze PPO HSA Health Insurance Plan, 18350HI0880035 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (18350HI0880035) Health Insurance Plan, Variant (18350HI0880035-00) offer Disease Management Programs?
Does (18350HI0880035) Health Insurance Plan, Variant (18350HI0880035-00) have Out Of Country Coverage?
Does (18350HI0880035) Health Insurance Plan, Variant (18350HI0880035-00) have Out of Service Area Coverage?
Does (18350HI0880035) Health Insurance Plan, Variant (18350HI0880035-00) offer Disease Management Programs?
Does HMSA Bronze PPO HSA Health Insurance Plan, Variant (18350HI0880035-00) offer Disease Management Programs for Asthma?
Does HMSA Bronze PPO HSA Health Insurance Plan, Variant (18350HI0880035-00) offer Disease Management Programs for Heart disease?
Does HMSA Bronze PPO HSA Health Insurance Plan, Variant (18350HI0880035-00) offer Disease Management Programs for Depression?
Does HMSA Bronze PPO HSA Health Insurance Plan, Variant (18350HI0880035-00) offer Disease Management Programs for Diabetes?
Does HMSA Bronze PPO HSA Health Insurance Plan, Variant (18350HI0880035-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Disclaimer: This is based on the import(Date: Tue, 16 Apr 2024 06:19 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