HMSA Platinum PPO - 18350HI0880001 Health Insurance Plan

Hawaii Medical Service Association health insurance plan with the Plan ID 18350HI0880001. The plan is called HMSA Platinum PPO.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 88.00% (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 12.00% 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 18350HI0880001
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 18350HI0880001-00
Provider Network(s) ['HIN002']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Hawaii All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 18350HI0880001-00

Standard On Exchange Plan - 18350HI0880001-01

Open to Indians below 300% FPL - 18350HI0880001-02

Open to Indians above 300% FPL - 18350HI0880001-03

Last Plan Update Date Tue, 20 Dec 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of HMSA Platinum PPO Health Insurance Plan, 18350HI0880001-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

10.00%

30.00%
Accidental Dental
YES

$150.00

30.00%
Acupuncture

Limit: 12.0 Visit(s) per Year

YES

$10.00

30.00%
Allergy Testing
YES

10.00%

30.00%
Applied Behavior Analysis Based Therapies

Precertification is required.

YES

$10.00

30.00%
Autism Spectrum Disorders
YES

$10.00

30.00%
Bariatric Surgery
YES

$150.00

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

10.00%

30.00%
Chiropractic Care

Limit: 12.0 Visit(s) per Year

YES

$10.00

30.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

$350.00

30.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

No Charge

100.00%
Dialysis
YES

10.00%

30.00%
Durable Medical Equipment
YES

10.00%

30.00%
Emergency Room Services
YES

$100.00

$100.00
Emergency Transportation/Ambulance
YES

10.00%

30.00%
Eye Glasses for Children

Lenses limited to one pair per calendar year.

YES

$25.00

50.00%
Gender Affirming Care

Precertification is required.

YES

10.00%

30.00%
Generic Drugs
YES

$5.00

$5.00, 20.00%
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

$10.00

30.00%
Hearing Aids

1 hearing aid per ear every 60 months.

YES

10.00%

30.00%
Home Health Care Services

Limit: 150.0 Visit(s) per Year

YES

10.00%

30.00%
Hospice Services
YES

No Charge

100.00%
Imaging (CT/PET Scans, MRIs)

Precertification is required.

YES

$100.00

30.00%
Infertility Treatment

Infertility treatment is covered. Refer to the plan brochure for covered services, criteria, and limitations.

YES

$150.00

30.00%
Infusion Therapy
YES

10.00%

30.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

$350.00 Copay per Stay

30.00%
Inpatient Physician and Surgical Services
YES

$150.00

30.00%
Laboratory Outpatient and Professional Services
YES

$30.00

30.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

$350.00 Copay per Stay

30.00%
Mental/Behavioral Health Outpatient Services
YES

$10.00

30.00%
Non-Preferred Brand Drugs
YES

$50.00

$50.00, 20.00%
Nutritional Counseling

Counseling for diagnosed eating disorder by a recognized licensed dietician

YES

No Charge

30.00%
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

$10.00

30.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

$150.00

30.00%
Outpatient Rehabilitation Services
YES

$10.00

30.00%
Outpatient Surgery Physician/Surgical Services
YES

$150.00

30.00%
Preferred Brand Drugs
YES

$10.00

$10.00, 20.00%
Prenatal and Postnatal Care
YES

10.00%

30.00%
Preventive Care/Screening/Immunization

Quantitative limit units apply, see EHB

YES

No Charge

30.00%
Primary Care Visit to Treat an Injury or Illness
YES

$10.00

30.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

10.00%

30.00%
Radiation
YES

10.00%

30.00%
Reconstructive Surgery
YES

$150.00

30.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

The therapy is short-term, generally not longer than 90 days.

YES

$10.00

30.00%
Rehabilitative Speech Therapy
YES

$10.00

30.00%
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

$150.00 Copay per Stay

30.00%
Specialist Visit
YES

$20.00

30.00%
Specialty Drugs
YES

$150.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

$350.00 Copay per Stay

30.00%
Substance Abuse Disorder Outpatient Services
YES

$10.00

30.00%
Telehealth
YES

$10.00

30.00%
Transplant
YES

No Charge

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$15.00

30.00%
Weight Loss Programs
NO
Well Baby Visits and Care

Quantitative limit units apply, see EHB

YES

No Charge

30.00%
X-rays and Diagnostic Imaging
YES

$30.00

30.00%

HMSA Platinum PPO Health Insurance Plan Variant 18350HI0880001-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.880035748
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 Platinum Off Exchange Plan
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
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 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 Platinum
Multiple In Network Tiers No
National Network Yes
Network ID HIN002
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) 18350HI0880001-00
Plan Marketing Name HMSA Platinum PPO
Plan Type PPO
Plan Variant Marketing Name HMSA Platinum PPO
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $300
SBC Scenario, Having a Baby, Copayment $800
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $80
SBC Scenario, Having Diabetes, Copayment $400
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $100
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID HIS001
Source Name SERFF
Plan ID 18350HI0880001
State Code HI
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $6000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $3000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $3,000
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $0
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 10.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $0
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $6000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $3000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $3,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $6000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $3000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $3,000
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of HMSA Platinum PPO Health Insurance Plan, 18350HI0880001

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about HMSA Platinum PPO, 18350HI0880001 Health Insurance Plan, 18350HI0880001

  • Does HMSA Platinum PPO Health Insurance Plan, 18350HI0880001 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (18350HI0880001) Health Insurance Plan, Variant (18350HI0880001-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does (18350HI0880001) Health Insurance Plan, Variant (18350HI0880001-00) have Out Of Country Coverage?

    Yes. Details: Covered

    Does (18350HI0880001) Health Insurance Plan, Variant (18350HI0880001-00) have Out of Service Area Coverage?

    Yes. Details: Covered

    Does (18350HI0880001) Health Insurance Plan, Variant (18350HI0880001-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does HMSA Platinum PPO Health Insurance Plan, Variant (18350HI0880001-00) offer Disease Management Programs for Asthma?

    Yes, the HMSA Platinum PPO Health Insurance Plan Variant 18350HI0880001-00 offers Disease Management Program for Asthma.

    Does HMSA Platinum PPO Health Insurance Plan, Variant (18350HI0880001-00) offer Disease Management Programs for Heart disease?

    Yes, the HMSA Platinum PPO Health Insurance Plan Variant 18350HI0880001-00 offers Disease Management Program for Heart disease.

    Does HMSA Platinum PPO Health Insurance Plan, Variant (18350HI0880001-00) offer Disease Management Programs for Depression?

    Yes, the HMSA Platinum PPO Health Insurance Plan Variant 18350HI0880001-00 offers Disease Management Program for Depression.

    Does HMSA Platinum PPO Health Insurance Plan, Variant (18350HI0880001-00) offer Disease Management Programs for Diabetes?

    Yes, the HMSA Platinum PPO Health Insurance Plan Variant 18350HI0880001-00 offers Disease Management Program for Diabetes.

    Does HMSA Platinum PPO Health Insurance Plan, Variant (18350HI0880001-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the HMSA Platinum PPO Health Insurance Plan Variant 18350HI0880001-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does HMSA Platinum PPO Health Insurance Plan, Variant (18350HI0880001-00) offer Disease Management Programs for Pregnancy?

    Yes, the HMSA Platinum PPO Health Insurance Plan Variant 18350HI0880001-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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