HMSA User's Manual by EricCopywriter

HMSA Userâ&#x20AC;&#x2122;s Manual A how-to guide for your health plan

Contents Quick start tips

Basic health plan terms

Your HMSA membership card

How to get answers

How to use My Account

Choosing or changing your PCP

Using HMSAâ&#x20AC;&#x2122;s Online Care

How to update your address

Other health plan benefits

Appealing an HMSA decision

Additional member benefits

Contact HMSA

Congratulations! By joining a health plan, you’ve made an investment in your health. And by choosing HMSA, you’ve got a plan that’s working day and night to make that investment pay off. Because HMSA isn’t just another health plan – we’re an extended ohana that’s working together to improve the health of our entire state. Hawaii is our home, its people are our family, and caring for you is why we’re here. Welcome to the HMSA family. Thank you for choosing us!

How can we help you be as healthy as you can be? There are lots of answers, and most of them lead to one conclusion: We’re in this together. You, your doctors, and your health plan have to work together to make a difference in your life. To do that, we have to know and trust each other. This user’s manual is full of the most important information you need to know about your health plan. It’s a good place to start your journey to healthy-as-can-be.

Being healthy is a lifelong pursuit, but you won’t have to do it alone. We’re here to help you. This brochure gives you an overview of HMSA’s most common plans and answers basic health plan questions. It doesn’t replace your Guide to Benefits brochure, which has all the details about your plan. If you have questions, we want to help. Just call us – our phone numbers are on page 13.

Trust is something we’ll have to earn from you along the way by making sure you have everything you need to address your health issues and take advantage of opportunities to improve, and by always giving you our best whenever you need us.

Quick start tips There’s no right or wrong way to use your health plan, but we do have a few tips to help you get the most out of it. Be yourself. Make sure the information on your membership card is correct and up to date. If it’s not, please let us know. There’s more about your card on page 4. Be accountable. Sign up for My Account on hmsa.com so you can take advantage of all our online features (check out page 6 to learn about them). Represent. If you want somebody like a parent or spouse to be able to see your eligibility, billing, payments, claims, and medical information and make appeals on your behalf, send us an Authorized Representative Form. You can find it on hmsa.com.

Say “hello, doctor!” Having a trusting relationship with a primary care provider (PCP) is your ticket to optimal health, so you should get on that right away. You can use hmsa.com’s Find a Doctor tool to find a PCP – see instructions on page 9. Parlez vous medicalaise? At times, we use industry terms. Sorry! We try to be as plain and simple as possible, but sometimes jargon is unavoidable. So we put together a section that explains different types of health plans and basic health care terms on the next page. Know where to turn for help. There’s a list of our most commonly used contact information on pages 12-13, including listings for our HMSA Centers if you’d like help in person. Check out the How to get answers section on page 5 for more options.

Basic Health Plan Terms Claims: Forms to ask for payment from your health plan for a covered service. Usually claims are submitted by the provider, but some nonparticipating providers might bill you directly and you’ll have to send a claim to HMSA. Covered services: Health care services your plan pays for based on your plan benefits. Even if a service is covered by your plan, you may have to pay a copayment or deductible. Provider: Someone who provides health care. We often say provider because doctor isn’t always technically accurate. You might see a nurse, physical therapist, physician’s assistant, lab technician, or many other health care providers who aren’t doctors. Participating provider: Providers in our network who agree to charge plan members a lower rate than nonmembers; in exchange, the provider gets more business from members of that plan. It’s kind of like a wholesale rate – see a participating provider and you’ll pay less. Nonparticipating providers don’t have an agreement with a plan and may charge as much as they want, which can be more than what your plan will cover (also known as the eligible charge, explained below).

Eligible charge: The amount participating providers agree to charge for covered services. Nonparticipating providers can charge as much as they want – so even if services you get from them are covered, your plan will only pay the eligible charge and you’ll have to pay the rest. Deductible: The amount you pay each year before your plan starts paying for covered services. If you have a $500 deductible and your hospital bill is $700, you’d pay $500 and your health plan would pay $200. After meeting the deductible, you’ll only have to pay your plan’s copayment when you get covered services for the rest of the plan year. Some plans put services in front of the deductible, which means your plan will pay for them even before you’ve met the annual deductible. Copayment: The amount you pay participating providers for covered medical services and products, like a doctor’s visit or prescription drugs, after you meet your plan’s deductible, if your plan has one. A copayment is a percentage of the eligible charge (also called coinsurance) or a fixed dollar amount. If your plan has a $20 copayment for doctor’s visits and your doctor charges $100, you pay $20 and your plan pays $80.

Network: The collective term for all of the providers who participate with a health plan.

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

Preferred provider organization (PPO): A type of health plan that lets you see any provider you prefer in HMSA’s network of participating providers. With this plan, you have a wider range of doctors and health centers to choose from than someone with an HMO plan. You can also see nonparticipating providers, but they may charge more than the amount your plan will cover (also known as the eligible charge, explained below).

Those are the basics. You can find an even bigger list if you search for “glossary” on hmsa.com.

Health maintenance organization (HMO): A type of health plan where you pick one health center and a PCP within that health center to provide all of your care. HMO plans work best for people who would rather get all their care from the same health center than have their choice of any doctor in the entire statewide network. You can still see a provider outside of the health center with your PCP’s referral, but if you don’t get a referral, it’ll cost you more.

Your HMSA membership card Your HMSA membership card is your ticket to health care, telling providers what type of plan you have and how to file your claims. While most providers in Hawaii can look up your information quickly without your card as long as you have a valid ID, it’s a good idea to carry your card with you, especially when you leave Hawaii. On the back of your card, there are phone numbers you can call if you have questions about your plan. You can print a copy of your card or ask for a replacement through My Account on hmsa.com. If your plan information changes, we’ll send you a new card and you can throw away your old one. We’ll also send new cards for your covered spouse and dependents.

How to get answers You get more value out of products you understand, and your health plan is no different. So we make it easy to get the information you need to make the most of your health plan. In person We’d love the chance to meet you and help you in person. That’s why we’ve set up HMSA Centers where you can walk in and talk to an HMSA health plan specialist who knows all about coverage, billing, benefits, and anything else you could want to learn about your plan. The centers are listed on page 12. On the phone Our Customer Relations phone reps are eager to help you Monday through Friday, 8 a.m. to 5 p.m. Phone numbers are on page 13.

Online Nothing beats the speed and convenience of going online to find information. We’ve loaded hmsa.com with all the latest on health care reform, plans, benefits, health and wellness discounts, and everything else you might want to learn about your plan. Here are just a few things you can do on hmsa.com: • Find a doctor or health center using the Find a Doctor tool. See page 9 for instructions. • Sign up for and log in to My Account. Check out the next section for an introduction. • Use HMSA’s Online Care to visit a doctor online or over the phone. Page 9 has the details. • See your Guide to Benefits, the ultimate source for all the details about your plan. • And more!

How to use My Account My Account on hmsa.com is your home base for personalized information about your health plan. Use it to: • Ask for a copy of your HMSA membership card. • Change your email preferences or password. • Use HMSA’s Online Care to visit a doctor online or by phone – see page 9 for more. • Search for special discounts for HMSA members with the HMSA365 discount program. • See your claims information – we’ll explain more on that below. People with QUEST or Akamai Advantage plans don’t have this feature on My Account, but you can always call our Customer Relations team for help. • If you have a drug plan, there are prescription tools to make life easier, like ordering refills online that will be delivered to your home in the mail.

To log in or register for My Account, visit the hmsa.com home page. • To log in, click on the Member Login button at the top of the screen, then enter your information, and click Login. • To register, scroll down to the existing members section, and click register next to the Login button. Fill out the required information and we’ll send you an email to validate your email address. After validating your address, you’re all set to log in. To view claims information, log in to My Account and click View Claims on the right side of the home page. On the Claims page, you’ll see a summary of your medical and vision claims. A section with all of your Reports to Member statements (RTMs) will also appear on the lower right of the page. They show how much we paid for a claim and how much you paid or owe, if anything. RTMs can be tricky to interpret – terminology combined with math can add up to confusion – so don’t hesitate to call us at the numbers listed on page 13, because we’d love to help clear it up. We’ll send you an email whenever a new RTM is posted to your My Account. Please note that QUEST and Akamai Advantage members can’t view their claims information on My Account, so if you need information, just call us. If you don’t see a link to view your dental or drug claims, check your HMSA membership card to see if you have dental or drug coverage with HMSA. If you don’t see the word Dental or Drug with a code next to it, check with your employer or employee organization to see if you have coverage under another insurer. If your HMSA membership card shows that you have dental or drug coverage with HMSA and you don’t see a link to view those claims, call the Customer Relations number on page 13. To print a copy of your HMSA membership card, click on Online Services on the left side of the page. You can see the membership cards for any dependents under age 18 if you click on their name. You can also click Request ID Card on the right side of the page to have a new membership card mailed to you.

To view your Guide to Benefits, click on Benefits on the left of the page or View Benefits on the right side of the page. On the Benefits page, click on the PDF icons under Guide to Benefits for each coverage type you have (Medical, Drug, Vision, or Dental). Your Guide to Benefits is a legal document that includes all of the important information about your plan benefits, limitations, and exclusions. If you have any questions about it, call the Customer Relations number on page 13 and we’ll be happy to help you. Not all plans have a Guide to Benefits available online. If yours isn’t and you want a hard copy, please call your employment office or HMSA’s Customer Relations number on page 13. To use online prescription tools, click on Prescription Tools on the left side of the page. You’ll see links to lots of useful features from CVS Caremark, the company that handles everything prescription-related for us, including: • My Dashboard: Your CVS Caremark member home page with links to help you save on drugs, start mail service for your prescriptions, print forms, get messages from CVS Caremark, Ask-a-Pharmacist, and more. • Mail-order drugs: Pay your balance, check your order, view your history, refill and transfer prescriptions, and track the status of your orders. • Drug claims and balances: View processed claims and mail-order payment information. • Drug pricing and comparison: Verify your coverage, check the cost of a drug, and view copayments for brand-name and generic drugs. • Pharmacy search engine: Search for participating local and Mainland pharmacies; you can search by ZIP code, city, and state. My Account is a great resource for information, so we hope you’ll register and use it often. If you have questions about My Account, call the Customer Relations number on page 13 and we’ll help you get squared away.

Choosing or changing your PCP Choosing a primary care provider (PCP) is one of the most important things you can do for your health. It’s called primary care because it’s of primary importance – having a doctor who knows you well and can coordinate care to meet your needs leads to better care, better health, and better value for your health care dollar. HMO plan members have to choose a PCP as part of their plan, but even if you don’t have to choose a PCP, getting one is a great way to build a trusting relationship with a doctor and make the most of your plan’s coverage. And finding one is easy with Find a Doctor. Use the Find a Doctor search engine on hmsa.com to locate any participating provider or dentist. You can search for providers by name, location, specialty (including PCP), or ailment, and narrow your results based on gender, languages spoken, and plan.

The number of patients a PCP can have is limited, so call the PCP you want and ask if new patients are accepted. You can also get a hard copy of our directory of participating providers; call the Customer Relations number on page 13 to ask for a copy. When searching for a PCP, here are some things to consider depending on your plan type: • HMO plan members: You must choose a PCP and health center, so make sure the provider and health center you choose participate with your plan. You can select your plan in the box next to the search field at the top of the Find a Doctor search engine. • PPO plan members: You don’t have to choose a PCP and your doctors can be a participating or nonparticipating providers. But choosing participating providers will save you money.

Using HMSA’s Online Care If you’re an HMO member and want to change your PCP, make sure your new PCP is accepting new patients and then call 948-6372 on Oahu or 1 (800) 776-4672 toll-free on the Neighbor Islands. • You can also mail a request to: Health Plan Hawaii Customer Relations Department HMSA P.O. Box 860 Honolulu, HI 96808-0860

When you can’t get in to a doctor’s office, HMSA’s Online Care gives you the option to get care online or by phone. HMSA’s Online Care connects you to HMSA participating physicians and other health care providers so you can: • Have a secure conversation, chat, or video conference via your computer, phone, or mobile device without an appointment. • Get professional advice and recommendations. • Get a referral or prescription. There’s even an HMSA’s Online Care mobile app that makes it easy to get care whenever and wherever you need it. You don’t have to be an HMSA member to use HMSA’s Online Care, but HMSA members get a discount. For more information, please visit hmsa.com/onlinecare, or call 948-6013 on Oahu or 1 (866) 939-6013 toll-free, Monday through Friday, 8 a.m. to 5 p.m. 9

How to update your address If you get your plan through your employer • Some employers don’t let you report address changes to HMSA, so please check with them first. If they don’t, ask them to notify HMSA of your change. • If your employer lets you report address changes to HMSA, you can: o Update your address on My Account. After you log in, click Online Services and then Change Address. o Mail a request to change your address to Membership Services, P.O. Box 860, Honolulu, HI 96808. Include your name, subscriber number from your HMSA membership card, your old and new addresses, and your signature. o Call the Customer Relations number on page 13.

Individual plan members

Additional member benefits

Please let us know if your address changes. You can:

Your health plan has a lot to offer beyond doctor’s visits. Check out these added benefits that can help you live a healthy lifestyle and stay in touch with your doctors.

• Update your address on My Account. After you log in, click Online Services and then Change Address. • Mail a request to change your address to Membership Services, P.O. Box 860, Honolulu, HI 96808. Include your name, subscriber number from your HMSA membership card, your old and new addresses, and your signature. • Call the Customer Relations number on page 13. • If you bought your plan through the Hawai‘i Health Connector, please contact the Hawai‘i Health Connector to change your address.

Other health plan benefits This brochure includes general information about HMSA plans. For details, see your Guide to Benefits brochure or visit hmsa.com. Your plan provides many benefits in specific situations such as coverage when you’re away from Hawaii, managing more than one insurance plan, and coverage for your family. And you can always call our Customer Relations department at the number on page 13.

Appealing an HMSA decision If you disagree with a decision HMSA has made about your plan coverage, reimbursements to you or your doctor, or other decisions, you can file an appeal with HMSA to review the decision. When you file an appeal, we review all the available information and make sure that the rules of your plan were followed. After the review is done, your appeal will either be approved or denied, and both you and your provider will be notified of the decision. If your appeal is denied, you’ll receive a letter explaining why the appeal wasn’t approved.

HMSA365 • Everybody loves to save! HMSA365 gives you discounts on health and wellness products and services like LASIK surgery, massage therapy, and exercise classes. • Go to hmsa.com/hmsa365 for a full list of discounts or call 1 (866) 520-6362 toll-free for more information. Island Scene Magazine • Every quarter, we’ll mail you our member magazine, Island Scene, which is packed with articles on health, fitness, family, and member news. You could even be in the magazine if you have an interesting story to tell or recipe to share! • You can read past articles on islandscene.com. If you’ve got an idea for a story, a recipe to share, or questions about the magazine, go to islandscene. com, click About, then Contact Us, and fill out the feedback form. Cozeva • Better communication means better health care. Cozeva makes that happen by putting you in touch with your doctors. With Cozeva, you can: o Request appointments online. o Send messages to your doctor after office hours. o Get preventive care reminders. o Request prescription renewals online. o Manage your family’s health through Cozeva Circle. • Check Cozeva’s Doctor Directory at www.cozeva.com or call your doctor to see if they’re participating in Cozeva.

You can find detailed instructions on how to file an appeal in your Guide to Benefits. If you have questions about appeals, call the Customer Relations number on page 13.

Contact HMSA HMSA Centers: Our neighborhood centers are conveniently located and have extended evening and Saturday hours to help you. You can ask questions about HMSA plans or health care reform, talk to a representative about your benefits or claims, pay your HMSA bill, and more. HMSA Center @ Honolulu 818 Keeaumoku St. • Monday through Saturday, 8 a.m.- 6 p.m. HMSA Center @ Pearl City Pearl City Gateway Center, 1132 Kuala St., Suite 400 • Monday through Saturday, 9 a.m.- 7 p.m. Opening in October HMSA Center @ Hilo Waiakea Center, 325 E. Makaala St., Suite 303A • Monday through Saturday, 9 a.m.- 7 p.m. Opening in December Neighbor Island Offices: Our Customer Relations representatives are available in person from 8 a.m. to 4 p.m., Monday through Friday. Hawaii Island, Hilo (closing in December to reopen at Waiakea Center) 670 Ponahawai St., Suite 121 • Hilo, HI • 96720 935-5441 Hawaii Island, Kona 75-1029 Henry St., Suite 301• Kailua-Kona, HI • 96740 329-5291 Kauai 4366 Kukui Grove St., Suite 103 • Lihue, HI • 96766 245-3393 Maui 33 Lono Ave., Suite 350 • Kahului, HI • 96732 871-6295

Through Social Media:

myhmsa https://www.facebook.com/myhmsa https://www.facebook.com/islandscene

askhmsa @AskHMSA @HMSAislandscene

instagram http://instagram.com/askhmsa By Mail: General HMSA P.O. Box 860 Honolulu, HI 96808-0860 Claims Medical and Physician Claims (HCFA 1500) P.O. Box 44500 Honolulu HI 96804-4500 Dental Claims P.O. Box 1320 Honolulu, HI 96807-1320 Hospital Claims (UB-92) P.O. Box 32700 Honolulu, HI 96803-2700 Out of State Claims P.O. Box 2970 Honolulu, HI 96802-2970 Drug Claims Go to hmsa.com and login to My Account. Once you’re logged in, go to Prescription Drug Tools and follow the instructions to file your drug claim. Appeals HMSA Attn: Appeals Coordinator P.O. Box 1958 Honolulu, HI 96805-1958

By Phone: HMSA representatives help you on the phone from 8 a.m. to 5 p.m., Monday through Friday (unless otherwise noted). Oahu Member Inquiries 948-6079 Group/Individual PPO 948-6111 HMO/Health Plan Hawaii 948-6372 Dental Services 948-6440 Individual Plan Billing 948-6140 Fraud Hotline (Confidential) 948-5166 HMSA’s Online Care Support (Available 24 hours a day, seven days a week.) 948-6013 Molokai Member Inquiries 1 (800) 776-4672 Group/Individual PPO 1 (800) 776-4672 HMO/Health Plan Hawaii 1 (800) 776-4672 Dental Services 1 (800) 792-4672 Individual Plan Billing 1 (800) 782-4672 Fraud Hotline (Confidential) 1 (888) 398-6445 HMSA’s Online Care Support (Available 24 hours a day, seven days a week.) 1 (866) 939-6013 Maui Member Inquiries 871-6295 Group/Individual PPO 1 (800) 776-4672 HMO/Health Plan Hawaii 1 (800) 776-4672 Dental Services 1 (800) 792-4672 Individual Plan Billing 1 (800) 782-4672 Fraud Hotline (Confidential) 1 (888) 398-6445 HMSA’s Online Care Support (Available 24 hours a day, seven days a week.) 1 (866) 939-6013 Lanai Member Inquiries 1 (800) 776-4672 Group/Individual PPO 1 (800) 776-4672 HMO/Health Plan Hawaii 1 (800) 776-4672 Dental Services 1 (800) 792-4672 Individual Plan Billing 1 (800) 782-4672 Fraud Hotline (Confidential) 1 (888) 398-6445 HMSA’s Online Care Support (Available 24 hours a day, seven days a week.) 1 (866) 939-6013

Kauai Member Inquiries 245-3393 Group/Individual PPO 1 (800) 776-4672 HMO/Health Plan Hawaii 1 (800) 776-4672 Dental Services 1 (800) 792-4672 Individual Plan Billing 1 (800) 782-4672 Fraud Hotline (Confidential) 1 (888) 398-6445 HMSA’s Online Care Support (Available 24 hours a day, seven days a week.) 1 (866) 939-6013 Kailua-Kona, Hawaii Member Inquiries 329-5291 Group/Individual PPO 1 (800) 776-4672 HMO/Health Plan Hawaii 1 (800) 776-4672 Dental Services 1 (800) 792-4672 Individual Plan Billing 1 (800) 782-4672 Fraud Hotline (Confidential) 1 (888) 398-6445 HMSA’s Online Care Support (Available 24 hours a day, seven days a week.) 1 (866) 939-6013 Hilo, Hawaii Member Inquiries 935-5441 Group/Individual PPO 1 (800) 776-4672 HMO/Health Plan Hawaii 1 (800) 776-4672 Dental Services 1 (800) 792-4672 Individual Plan Billing 1 (800) 782-4672 Fraud Hotline (Confidential) 1 (888) 398-6445 HMSA’s Online Care Support (Available 24 hours a day, seven days a week.) 1 (866) 939-6013 Additional customer services numbers: Compliance & Ethics, Privacy & Security Incident Hotline (Confidential) 1 (800) 749-4672 HMSA Well-Being Connect Support 1 (855) 329-5461 Corporate Telephone Operator 948-5110 on Oahu Employment Office 948-5588 on Oahu TTY 711

(00) 1000-3019 10.13 AM

We hope this brochure helps you understand how your health plan works. Thanks again for choosing HMSA.