federal plan 2021...minit medical urgent care clinic 270 dairy road, suite 239 kahului ph. 667-6161...

For the good times. For the tough times. For lifetimes.

Federal plan 2021

We’re here with you

Things look a little different now, but HMSA is here with you. We know your health is more important than ever and that means understanding your Federal Plan benefits. We’re proud to offer plans that give you:

• The freedom to choose from thousands of high-quality doctors and health care providers.

• Convenient care options that go beyond the doctor’s office and emergency room. See a doctor from the comfort and safety of home with telehealth.

• Care on the Mainland and many locations worldwide if you need to travel.

• A variety of health and fitness discounts from HMSA365. Save on services and products from popular health and fitness brands through the ChooseHealthy® program.

This year, open season is Nov. 9 to Dec. 14, 2020. If you’re happy with your health plan, you don’t need to do anything. Your HMSA health plan will continue in 2021. If you’re not an HMSA member, this is your opportunity to enroll and see why more than 70% of federal employees choose HMSA.

In the following pages, you’ll find information about the benefits and services you’ll have access to as an HMSA member. Please read on to learn more. If you have questions, we’re happy to help. See the back cover for ways to contact us.

Thank you for learning more about HMSA. You can count on us to be with you every step of the way.

Mahalo,

Mark M. Mugiishi, M.D., F.A.C.S. President and Chief Executive Officer

The ChooseHealthy program is provided by ChooseHealthy, Inc., a subsidiary of American Specialty Health, Incorporated (ASH), a national provider of fitness, health education, musculoskeletal provider networks, and health management programs. ChooseHealthy and the ChooseHealthy logo are trademarks of ASH and used with permission herein.

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We’re proud to work with these health care providers to offer you quality care:

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Top-rated hospitals and clinics

With HMSA, you’ll have access to top-rated hospitals that have been recognized for excel-lence in specialty care:

• Adventist Health Castle.

• Kapi‘olani Medical Center for Women & Children.

• The Queen’s Medical Center.

• Straub Medical Center.

HMSA is part of the Blue Cross and Blue Shield Association, which recognizes these Hawaii hospitals for expertise in delivering quality and cost-effective specialty care:

• Adventist Health Castle for bariatric surgery.

• Adventist Health Castle, Pali Momi Medical Center, and Straub Medical Center for knee and hip replacement.

• Kapi‘olani Medical Center for Women & Children and Wilcox Medical Center for maternity care.

• The Queen’s Medical Center for spine surgery.

• Straub Medical Center for cardiac care.

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How to find a provider

Did you know that choosing a primary care provider (PCP) is an investment in your health? It’s one of the best ways to stay healthy, get the care you need, and make the most of your plan. Your PCP is at the center of your care and can help you stay on top of your health. To find one, go to hmsa.com/federalplan to use the Find a Doctor tool. Just remember to choose the plan you have before starting your search.

Get after-hours care

• See your PCP for routine and preventive care that isn’t an emergency.

• Use telehealth to connect with doctors and specialists online. There’s no copayment to use HMSA’s Online Care® to talk to a doctor from anywhere in Hawaii, 24 hours a day, seven days a week.

• See a doctor or nurse practitioner at CVS/minuteclinic®, the medical clinic in selected Longs Drugs stores on Oahu. To find a CVS/minuteclinic, use the Find a Doctor search on hmsa.com/federalplan.

• Go to an urgent care provider if you have a health concern that isn’t an emergency but needs attention sooner than you can see your doctor.

• Go to the emergency room if you need immediate care in a hospital setting or you’re experiencing a life-threatening emergency.

How to use telehealth

Need to see your doctor but rather not leave the house? Try telehealth.

Talk to a doctor 24 hours a day, seven days a week from the comfort and safety of your home. Use telehealth to connect with a therapist or coun-selor. Or see a doctor for common conditions like headaches, colds, or the flu and manage chronic conditions like allergies and diabetes.

Talk to your doctor about what telehealth options are available to you. There may be a copayment for some services. Another option for telehealth is Online Care which is available at no cost. All you need is a computer, smartphone, or tablet connected to the internet to sign up. Search for Online Care in the App Store or Google Play. Or sign up at hmsaonlinecare.com.

Get the care you need

Amwell® is an independent company providing hosting and software services for HMSA’s Online Care platform on behalf of HMSA.

Hawaii IslandHilo Urgent Care Center670 Kekuanaoa St.Hilo Ph. 969-3051Monday–Friday: 8:30 a.m.–8:30 p.m.Saturday–Sunday: 8:30 a.m.–4:30 p.m.

Hilo Urgent Care Center16-590 Old Volcano RoadKeaau Ph. 966-7942Monday–Friday: 8:30 a.m.–6:30 p.m.Saturday–Sunday: 8:30 a.m.–4:30 p.m.

Transformation Health Network75-5995 Kuakini Highway, Suite 213Kailua-Kona Ph. 365-2297Monday–Friday: 11:30 a.m.–9 p.m.Saturday–Sunday: 1–9 p.m.

Waimea Urgent Care65-1230 Mamalahoa Highway, Suite A10Kamuela Ph. 885-0660Monday–Friday: 8:30 a.m.–7 p.m.Saturday–Sunday: 8 a.m.–4 p.m.

KauaiKauai Community Health Alliance2460 Oka St., Suite 101AKilauea Ph. 828-2885Monday–Friday: 8 a.m–7 p.m.Saturday–Sunday: 9 a.m.–5 p.m.

Kauai Medical Clinic4484 Pahee St.Lihue Ph. 245-1532Daily: 8 a.m.–7 p.m.

Makana North Shore Urgent Care4488 Hanalei Plantation RoadPrinceville Ph. 320-7300Daily: 7 a.m.–10 p.m.

Urgent Care at Poipu2829 Ala Kalani Kaumaka St. Suite B-201Koloa Ph. 742-0999Monday–Friday: 8:30 a.m.–7 p.m. Saturday–Sunday:8 a.m.–4:30 p.m.

MauiDoctors on Call3350 Lower Honoapiilani Road, Suite 211Lahaina Ph. 667-7676Daily: 8 a.m.–9 p.m.

Doctors on Call3750 Wailea Alanui Dr., Ste B34Wailea Ph. 667-7676Opening Soon

Kihei-Wailea Medical Center221 Piikea Ave., Suite AKihei Ph. 874-8100Monday–Friday: 8 a.m–8 p.m.Saturday–Sunday: 8 a.m.–5 p.m.

Minit Medical Urgent Care Clinic270 Dairy Road, Suite 239Kahului Ph. 667-6161Monday–Friday: 8 a.m.–7 p.m.Saturday: 8 a.m.–6 p.m.Sunday: 8 a.m.–4 p.m.

Minit Medical Urgent Care Clinic1325 S. Kihei Road, Suite 103Kihei Ph. 667-6161Monday–Friday: 8 a.m.–7 p.m.Saturday: 8 a.m.–6 p.m. Sunday: 8 a.m.–4 p.m.

Minit Medical Urgent Care Clinic305 Keawe St., Suite 507Lahaina Ph. 667-6161Monday–Saturday: 8 a.m.–6 p.m.Sunday: 8 a.m.–4 p.m.

The Maui Medical Group Inc.2180 Main St.Wailuku Ph. 242-6464Monday–Friday: 8 a.m.–9 p.m.Saturday–Sunday: 8 a.m.–4 p.m.

The Maui Medical Group Inc.130 Prison St. Lahaina Ph. 249-8080Monday–Friday: 8 a.m.–7 p.m.Saturday–Sunday: 8 a.m.–5 p.m.

OahuAll Access Ortho1401 S. Beretania St., Suite 102Honolulu Ph. 356-5699Monday–Friday: 8 a.m–8 p.m.Saturday–Sunday: 9 a.m.–5 p.m.

All Access Ortho4850 Kapolei Pkwy., Bldg. FKapolei Ph. 356-5699Monday–Friday: 8 a.m–8 p.m.Saturday–Sunday: 9 a.m.–5 p.m.

All Access Ortho95-1830 Meheula Parkway, Suite C10-11Mililani Ph. 356-5699Monday–Friday: 8 a.m–8 p.m.Saturday–Sunday: 9 a.m.–5 p.m.

Braun Urgent Care Kailua130 Kailua Road, Suite 111Kailua Ph. 261-4411Daily: 8 a.m–8 p.m.

Doctors of Waikiki120 Kaiulani Ave., Wing 10 & 11Honolulu Ph. 922-2112Daily: 8 a.m–midnight

Empower Health 91-6390 Kapolei Parkway Ewa Beach Ph. 691-8200 Daily: 8 a.m.–8 p.m.

Kalihi Kai Urgent Care2070 N. King St., Ste A1 Honolulu Ph. 841-2273 Monday–Friday: 9 a.m–6 p.m. Saturday–Sunday: 9 a.m.–1 p.m.

Kunia Urgent Care94-673 Kupuohi St., Suite C201Waipahu Ph. 983-9175Daily: 8:30 a.m.–9 p.m.

Queen’s Island Urgent Care98-199 Kamehameha Hwy., Suite FAiea Ph. 735-0007Monday–Friday: 8 a.m.–8 p.m.Saturday–Sunday: 8 a.m.–5 p.m.

Queen’s Island Urgent Care400 Keawe St.Honolulu Ph. 735-0007Daily: 8 a.m–8 p.m.

Queen’s Island Urgent Care449 Kapahulu Ave., Suite 104Honolulu Ph. 735-0007Daily: 8 a.m.–8 p.m.

Queen’s Island Urgent Care6600 Kalanianaole Hwy., Suite 114AHonolulu Ph. 735-0007Daily: 8 a.m–8 p.m.

Queen’s Island Urgent Care377 Keahole St., Suite E108 E109 Honolulu Ph. 735-0007 Daily: 8 a.m.–8 p.m.

Queen’s Island Urgent Care1215 Hunakai St. Honolulu Ph. 735-0007 Opening soon

Straub Medical Center-Kahala Clinic & Urgent Care4210 Waialae Ave., Ste 501 Honolulu Ph. 462-5300 Daily: 10 a.m.–8 p.m.

Straub Medical Center–Kapolei Clinic & Urgent Care91-5431 Kapolei Pkwy., Suite 1706Kapolei Ph. 426-9300Daily: 10 a.m–8 p.m.

Straub Medical Center– Doctors on Call–Sheraton Waikiki2255 Kalakaua Ave., Manor Wing Shop No. 1Honolulu Ph. 971-6000Daily: 7 a.m–11 p.m.

Straub Medical Center–Ward Village Clinic & Urgent Care1001 Queen St., Suite 102 Honolulu Ph. 462-5200Daily: 10 a.m.–8 p.m.

US Med Urgent Care1860 Ala Moana Blvd., Suite 101Honolulu Ph. 921-2273Monday–Friday: 8 a.m.–2 p.m.Saturday–Sunday: Closed

US Med Urgent Care660 Kailua RoadKailua Ph. 263-2273Monday–Friday: 8 a.m.–7 p.m.Saturday–Sunday: 9 a.m.–5 p.m.

US Med Urgent Care890 Kamokila Blvd., Suite 106Kapolei Ph. 521-2273Monday–Friday: 7 a.m.–7 p.m.Saturday–Sunday: 8 a.m.–6 p.m.

US Med Urgent Care1245 Kuala St., Suite 103Pearl City Ph. 784-2273Monday–Friday: 7 a.m.–8 p.m.Saturday–Sunday: 8 a.m.–6 p.m.

Windward Urgent Care Services46-001 Kamehameha Hwy, Suite 107Kaneohe Ph. 247-7596Daily: 8 a.m.–9 p.m.

For a current list of participating urgent care providers, visit hmsa.com/federalplan.

These options aren’t a substitute for emergency care. If you experience life-threatening conditions such as a stroke or difficulty breathing, call 911 or go to the emergency room immediately. Most urgent care clinics are closed on Thanksgiving Day, Christmas Day, and New Year’s Day. Services vary at locations. Call the clinic to ask about specific services. Current as of August 2020.

Participating Urgent Care Clinics

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Top-rated hospitals and clinics

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If you need to travel, your health plan gives you access to care on the Mainland and in many international locations. If you have eligible dependents on your plan, they can get care from participating Blue Cross and Blue Shield providers on the Mainland.

How it works

HMSA is part of the Blue Cross and Blue Shield network, which includes 95% of doctors and 96% of hospitals on the Mainland. Your HMSA plan will also protect you in nearly 190 countries and territories around the world.

Looking for a doctor or hospital on the Mainland? Go to bcbs.com.

Traveling internationally? Download the Blue Cross Blue Shield Global Core mobile app for Apple and Android devices. Use the app to search for providers when you travel. To learn more, go to bcbsglobalcore.com.

Be prepared• Before you go, make sure you have

your current HMSA membership card with you. Your card will help providers file your claims.

• You can also call 1 (800) 810-BLUE (2583) for the names of participating doctors and hospitals in the area you’ll be visiting.

Get care around the world

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Prescription drugs

† The 20% discount is restricted to items purchased for the health care of the cardholder, spouse, or dependents. The discount excludes prescriptions, alcohol, tobacco, lottery, postage stamps, gift cards, money orders, prepaid cards, and photo finishing, and aren’t valid on other items reimbursed by a government program.

CVS Caremark® is an independent company providing pharmacy benefit management services on behalf of HMSA.

$0 copayment with Maintenance Choice With the CVS Caremark® Maintenance Choice program, Federal Plan members can get 90-day supplies of generic drugs in the mail or from a Longs Drugs (CVS/pharmacy) with a $0 copay-ment. That’s a savings that can’t be beat. To learn more how you can save money on your medications, call 1 (855) 298-2491 toll-free.

Save money with generic drugs Here’s a simple way to keep your medication costs down: Choose generic drugs whenever possible. Ask your doctor or pharmacist if it’s OK for you to take generic drugs. These drugs have the same active ingredients as brand-name drugs, are just as effective, and cost much less.

Shopping discounts Save money with the ExtraCare® Health Card when you shop at Longs Drugs. You’ll get a 20%† discount on thousands of CVS/pharmacy Brand health-related items that are regularly priced at $1 or more. And you’ll get the same savings when you shop online at cvs.com.

ExtraCare Health

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As an HMSA member, you can buy supplemental plans such as dental and accidental care plans.

Dental Plans*

HMSA offers comprehensive dental plans that include cleanings, exams, and major services like crowns, dentures, and bridges. Choose our HMSA Dental PPO plan, which is a PPO plan, or our HMSA Dental HMO plan, which is an HMO plan. With the Oral Health for Total Health program, eligible members can receive addi-tional dental services at no added cost.

Visit hmsa.com/federalplan to learn more.

Additional HMSA benefits

* These dental products are separate and distinct from FEDVIP and therefore pre-miums for these products cannot be deducted on a pre-tax basis. These benefits are neither offered nor guaranteed under contract with the FEHB Program, but are available to all enrollees and family members who become members of HMSA.

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PPO dental HMO dentalNetwork access (local) Choice of dental providers Hawaii Family Dental and

participating HMO providers

Network (U.S. Mainland) United Concordia No

Annual deductible Yes, for basic plans only No

Calendar year maximum Yes, for adult care only No

Preventive care Yes, coinsurance varies Yes, copayment varies

Basic services Yes, coinsurance varies Yes, copayment varies

Major services Yes, coinsurance varies; certain exclusions apply

Yes, copayment varies; certain exclusions apply

Rollover benefit No No

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*These products are separate and distinct from FEDVIP and therefore premiums for these products cannot be deducted on a pre-tax basis. These benefits are neither offered nor guaranteed under contract with the FEHB Program, but are available to all enrollees and family members who become members of HMSA.

USAble Life is an independent company that does not provide HMSA products or services. USAble Life is solely responsible for providing ancillary insurance products.

USAble Life’s Accident Elite Plan*

Life can change in an instant. Be sure you’re protected if the unexpected happens. USAble Life’s Accident Elite plan pays cash directly to you in the event of an accident or injury.

Highlights of the plan

• This plan provides benefits 24 hours a day no matter where the accident occurs.

• There’s no deductible, annual maximum, or limit on the number of covered accidents.

• This plan is portable, which means you can take it with you if you leave your place of employment.

• This plan pays you in the event of an accident regardless of what your health plan may pay.

• You can enroll yourself, your spouse, and eligible children. You must be under age 65 to enroll.

• A wellness benefit of $75 is included when you receive covered health screenings during the year such as an annual physical exam.

How does it work?

If you’re injured, the Accident Elite Ultra plan will pay you the cost of:

• Wellness benefits.

• Ambulance service.

• Emergency room treatments.

• Injury.

• Two follow-up physician visits.

• Six physical therapy sessions.

Other plans are also available. To find out more, please visit USAbleLife.com/FederalPlan.

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HMSA’s Plan for

Federal Employees

*Deductible doesn’t apply.

If you’re a retired HMSA Federal Plan member and have Original Medicare, your HMSA plan will coordinate with Medicare. This means Medicare becomes your primary coverage and pays first. Your HMSA plan will pay for services not covered by Medicare based on your plan benefits.

This is a summary of the features of the HMSA Plan. Before making a final decision, please read the Plan’s Federal brochure (RI 73-010). All benefits subject to the definitions, limitations, and exclusions in the brochure.

Here are some of your plan’s benefits and your share of the costs.Benefits High Option

You PayStandard Option

You Pay

Annual deductible None $150 per person

Annual out-of-pocket maximum Protection against catastrophic costs

$3,000 per person per year $9,000 per family per year (Some costs can’t be applied to your maximum.)

$5,000 per person per year$10,000 per family per year

Physician servicesPhysician visits Laboratory and pathology X-rays

$15 $0 20%

$20*30%* of eligible charges30% of eligible charges

Hospital servicesInpatient Outpatient

$200 copayment per admission 20% of eligible charges

30% of eligible charges30% of eligible charges

Emergency benefits (In area and out of area)Laboratory tests Physician visitsEmergency room facility and other emergency services

$0 $15 copayment per visit 20% of eligible charges

30% of eligible charges$20 copayment per visit*30% of eligible charges

Mental health and substance abuse treatmentDiagnostic, psychological, and laboratory tests Professional services and medication management Inpatient admission Partial hospitalization and outpatient facility

$0 $15 $200 $0

30% of eligible charges

$20*

30% of eligible charges30% of eligible charges

Prescription drugs Tier 1 (preferred generic)Tier 2 (non-preferred generic and preferred brand)Tier 3 (other brand) Tier 4 (preferred specialty) Tier 5 (non-preferred specialty)

$7 $35

$70 $80 $200

$7* 40% of eligible charge up to $100 40% of eligible charge up to $600 $200 40% of eligible charge up to $1,200

Dental care Preventive services

$0 Not a benefit

Annual vision exam 20% of the eligible charges 30% of the eligible charges

Point-of-service benefits Yes Yes

Non-postal Premium Postal PremiumBiweekly Monthly Biweekly

Type of Enrollment

Enrollment Code

Government Share

Your Share

Government Share

Your Share

Category 1 Your Share

Category 2 Your Share

High Option Self Only

871 $218.51 $72.83 $473.43 $157.81 $69.92 $60.45

High Option Self Plus One

873 $478.76 $159.58 $1,037.30 $345.77 $153.20 $132.46

High Option Self and Family

872 $491.20 $163.73 $1,064.27 $354.75 $157.18 $135.90

Standard Option Self Only

874 $157.10 $52.36 $340.37 $113.46 $50.27 $43.46

Standard Option Self Plus One

876 $344.18 $114.72 $745.71 $248.57 $110.14 $95.22

Standard Option Self and Family

875 $353.14 $117.71 $765.14 $255.04 $113.00 $97.70

These rates don’t apply to all enrollees. If you’re in a special enrollment category, please contact the agency or tribal employer that maintains your health benefits enrollment.

2021 Rates

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RetirementMedicare is a health insurance program for people age 65 or older. Medicare has different parts that cover specific services.

Medicare Part A (Hospital Insurance)

Part A helps cover inpatient care in hospitals, including critical access hospitals and skilled nursing facilities (not custodial or long-term care). It also helps cover hospice care and some home health care. Beneficiaries must meet certain conditions to get these benefits. Most people don’t pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working.

Medicare Part B (Medical Insurance)

Part B helps cover doctors’ services and outpatient care. It also covers other medical services that Part A doesn’t cover, such as some physical and occupational therapy services and some home health care. Part B helps pay for these services and supplies when they are medically necessary. Most people pay a monthly premium for Part B.

If you’re a retired HMSA Federal Plan member and have Original Medicare, your HMSA plan will coordinate with Medicare. Medicare becomes your primary plan. This means Medi-care pays for your services first, then your HMSA plan will pay for services not covered by Medi-care based on your plan benefits.

Two cards for more benefits

When you receive care, show your providers both your HMSA membership card and your Medicare member ID card. This ensures your claims are processed correctly.

Finding a provider

Medicare has its own network of participating providers who accept Medicare’s allowance. If you visit a provider outside of their network, we’ll pay the difference between what Medicare pays and what you owe the provider. You can find out which providers are in the Medicare partici-pating provider network at medicare.gov. Go to medicare.gov, hover over forms, and click find doctors, hospitals, and other providers.

Keep in mind that you may be required to see a participating provider based on your plan type. To find a doctor, use the Find a Doctor tool on hmsa.com/federalplan.

For more information about Medicare, visit medicare.gov.

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Lifestyle resources

• Health and fitness discounts

– The Active&Fit DirectTM program provides access to more than 1,500 online workout videos, discounted fitness memberships, and more. The enrollment fee is waived until Dec. 31, 2020. Log in to My Account to access.

– The ChooseHealthy program gives members discounts on health and fitness products such as apparel, home exercise and gym equip-ment, smartwatches, services from specialty health care practitioners, and more.

– HMSA365 is a member-savings program for fitness, healthy living, and well-being products and services.

Go to hmsa.com/federalplan and click Member Resources to learn more.

• Island Scene is a health and well-being magazine for members. Read it at home or online at islandscene.com.

Health Resources

• Caregiver resources are offered to members who are caring for a loved one.

• Hawai‘i Tobacco Quitline provides support for members who want to quit tobacco for good. Talk to your PCP and call 1 (800) QUIT-NOW (784-8669) toll-free to get started. Or visit hawaiiquitline.org. Find more information about the risk of vaping and resources to help you quit on islandscene.com.

• Health coaching is available to help members reach their health goals at no cost. Call 1 (855) 329-5461 toll-free to connect with an HMSA health coach.

Well-being programsWith HMSA, there are many ways to take care of your health and well-being. Here are some of the benefits and programs available to you at little or no cost. Go to hmsa.com/federalplan to learn more. This is an overview of HMSA’s well-being programs and services. Check your Guide to Benefits to confirm your plan’s specific benefits.**Some programs may only be available online during the COVID-19 pandemic. Visit hmsa.com/federalplan for updates.

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Active&Fit Direct is a trademark of ASH. The Active&Fit Direct program is provided by American Specialty Health Fitness, Inc., a subsidiary of ASH. American Specialty Health (ASH) is an independent company providing chiropractic, acupuncture, fitness programs, and/or massage therapy services on behalf of HMSA.

GET STARTED

Interested in health management programs or advance care planning? Talk to your PCP. For health and well-being discounts, go to hmsa.com/federalplan and log in to your account.

Questions? Call us at 948-6499 on Oahu or 1 (800) 776-4672 toll-free or visit us at an HMSA Center or office.

Preventive Care

• Online health education workshops are fun, interactive ways for members to learn about health and well-being topics.

• HMSA Diabetes Prevention Program helps eligible members prevent the onset of type 2 diabetes through lifestyle and diet changes, exercise, and group support. Check with the participating program site for hours of operation.

Medical Resources

• Advance care planning is a process that documents your health care wishes so that your doctors know how you want to be cared for if you can’t communicate your wishes.

• Diabetes education provides information and resources for members living with diabetes.

• Health and well-being support provides outreach and coaching for members with chronic health conditions.

• HMSA Behavioral Health Program provides referrals to providers who can help members with their emotional health.

• HMSA Pregnancy and Postpartum Support Program provides eligible members with personalized counseling from a maternity nurse.

• HMSA Supportive Care helps members manage the symptoms and stresses of serious illnesses.

• Ornish Lifestyle Medicine™ is a nine-week program that helps eligible members reverse the effects of heart disease and reduce risk factors for health conditions like hypertension, predia-betes, diabetes, and early-stage prostate cancer.

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hmsa.com/federalplanView your health plan information and member benefits online on My Account at hmsa.com/federalplan.

Visit hmsa.com for: • Your plan brochure.• Summary of Benefits and Coverage.• A directory of participating doctors and other

health care providers.• A list of prescription drugs your plan pays for.• Open enrollment brochure and videos.• Customer service contact information.• A link to Member Login on hmsa.com.

Please mail a printed Federal Plan brochure to me at the address below:

NAME

ADDRESS

CITY STATE ZIP CODE

Mail your request to:

HMSA Federal Plan AMS/8th Floor P.O. Box 860 Honolulu, HI 96808

Log in to My Account to:• Request or print a copy of your HMSA

membership card.• View your claims history and Report

to Member. • View your Guide to Benefits.

• Use an annual maximum out-of-pocket calculator.

Go to hmsa.com/federalplan and click Member Login to register.

CUT HERE

Notice of Summary of Benefits and Coverage: Availability of Summary Health Information

FEHB Program offers numerous health plan benefits and coverage options. Choosing a health plan and coverage option are important decisions. To help you make an informed choice, each FEHB plan makes available a Summary of Benefits and Coverage (SBC) about each of its health coverage options online and on paper. The SBC summarizes important information in a standard format to help you compare plans and options.

To see the High Option plan SBC, visit https://hmsa.com/2021FederalPlanSBC. To see the Standard Option plan SBC, visit https://hmsa.com/2021FederalStandardPlanSBC. If you want us to send you a copy at no charge, call 1 (800) 776-4672 toll-free.

For more information about plans available under the FEHB Program, including SBCs for other FEHB plans, visit opm.gov/healthcare-insurance.

Can’t access the portal? We can send you a copy of the Federal Plan brochure. Just fill out and mail this form or email your request to [email protected].

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Claim An invoice that includes information about the health care services you’ve received.

Coinsurance Your share of the cost for health care services. It’s usually a percentage of the amount charged for services. You start paying coinsurance after you’ve paid the deductible.

Copayment The fixed dollar amount you pay to receive a service. The amount can vary by type of service.

Covered services These are health care services that HMSA pays for based on your plan benefits. Sometimes, if your HMSA plan covers a service, you may have to pay a copayment or deductible.

Deductible The amount you pay for certain services each calendar year before your health plan pays.

Drug formulary A list of generic and brand-name prescription drugs that your drug plan pays for.

Eligible charge The amount that participating providers can charge as part of their agreement with HMSA. This is the amount that your copayment or coinsurance is based on.

Network The group of providers that participates in a health plan. As an HMSA member, you have access to the providers in the HMSA network of providers.

Nonparticipating provider A doctor, hospital, pharmacy, lab, health center, or other health care provider who doesn’t contract with HMSA to charge set fees to members. Using these providers almost always costs more than using participating providers.

Out-of-pocket maximum The most you’ll have to pay per calendar year for covered health care services. Once you reach the out-of-pocket maximum, your plan pays 100% of the allowed amount for covered services excluding taxes.

Participating provider Providers in our network who agree to charge members a set amount for covered services.

Primary care provider (PCP) Your main doctor who coordinates your care.

Provider A health care professional such as a physician, nurse, physical therapist, physician’s assistant, or lab technician.

Health care plain and simpleCheck out this glossary of common health care terms.

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PLEASE PRINT

Section 1 – HMSA Subscriber Information

HMSA subscriber’s name: _____________________________________________ Birth date: ______________________

Employment status: Active Retired

Retirement date (if applicable): ______________________________

HMSA subscriber ID: _____________________________________ Social Security number: __ __ __-__ __-__ __ __ __

Phone number: ( ______ ) _________________________________

I certify that the information I’ve provided on this form is true and correct. I agree to inform HMSA of any changes.

HMSA subscriber’s signature: __________________________________________ Date: __________________________

Section 2 – Other Coverage Information

Policyholder’s name: _________________________________________________________________________________

Sex: Male Female

Birth date: ______________________________________________ Social Security number: __ __ __-__ __-__ __ __ __

Relationship to you: __________________________________________________________________________________

Other health plan’s name: _____________________________________________________________________________

Policyholder identification number: ______________________________________________________________________

Other health plan’s address: ___________________________________________________________________________

Phone number: ( ______ ) _________________________________

Employment status: Active Retired

Employer’s name: ____________________________________________________________________________________

Retirement date (If applicable): _____________________________

Type of coverage Medical Drug Dental VisionEffective dateCancellation date

If you and your dependents are covered under multiple health plans, this form will help us process your claims quickly and accurately. (You can also fill this form out by logging into members.hmsa.com)

If you, your spouse, and your dependents are only covered by your HMSA plan, complete section 1.

If you, your spouse, or any of your dependents are covered by your HMSA plan and: Complete sections:

Another health insurance plan ............................................................................ 1 and 2

Medicare ................................................................................................................. 1 and 3

Another health insurance plan and Medicare ................................................. 1, 2, and 3

Coordination of Benefits FormCU

T HE

RE

✁✁

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Please list any other dependents who are on this other plan.

1. First and last names: _______________________________________________________________________________

Relationship to you: _______________________________________________________________________________















Section 3 – Medicare Coverage Information

Medicare beneficiary’s name:

_________________________________________

Social Security number: __ __ __-__ __-__ __ __ __

Medicare number: __________________________

Type of coverage Effective datePart A (Hospital)Part B (Medical)Part D (Drug)

Medicare eligibility due to:

Age

Disability

End-stage renal disease

- Initial dialysis

date: ________________________________

Please return your completed Coordination of Benefits Form to:

Hawaii Medical Service AssociationP.O. Box 860Honolulu, HI 96808-9988ATTN: 7th Floor CA Dept./Coordination of Benefits

Medicare beneficiary’s name:

_________________________________________

Social Security number: __ __ __-__ __-__ __ __ __

Medicare number: __________________________

Type of coverage Effective datePart A (Hospital)Part B (Medical)Part D (Drug)

Medicare eligibility due to:

Age

Disability

End-stage renal disease

- Initial dialysis

date: ________________________________

Federal law requires HMSA to provide you with this notice.

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(08) 4000-251055 9.20 fn

Serving youMeet with knowledgeable, experienced health plan advisers. We’ll answer questions about your health plan, give you general health and well-being information, and more. Due to COVID-19, hours of operation may change. Please go to hmsa.com/contact before your visit.

HMSA Center @ Honolulu818 Keeaumoku St.Monday through Friday, 8 a.m.–5 p.m. | Saturday, 9 a.m.–2 p.m.

HMSA Center @ Pearl CityPearl City Gateway | 1132 Kuala St., Suite 400 Monday through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m.

HMSA Center @ HiloWaiakea Center | 303A E. Makaala St. Monday through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m.

HMSA Center @ KahuluiPuunene Shopping Center | 70 Hookele St., Suite 1220Monday through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m.

Customer Relations representatives are also available in person at our Neighbor Island offices, Monday through Friday, 8 a.m. to 4 p.m.:

Kailua-Kona, Hawaii Island 75-1029 Henry St., Suite 301 | Phone: 329-5291

Lihue 4366 Kukui Grove St., Suite 103 | Phone: 245-3393

Contact HMSA. We’re here for you.

Call 948-6499 on Oahu or 1 (800) 776-4672 toll-free on the Neighbor Islands or Mainland.

Monday through Friday, 8 a.m.–5 p.m.

Together, we improve the lives of our members and the health of Hawaii. Caring for our families, friends, and neighbors is our privilege.

This is a summary of the features of the HMSA Plan. Before making a final decision, please read the Plan’s Federal brochure (RI 73-010). All benefits subject to the definitions, limitations, and exclusions in the brochure.

hmsa.com/federalplan myhmsa @askHMSA askhmsa

federal plan 2021...minit medical urgent care clinic 270 dairy road, suite 239 kahului ph. 667-6161...

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