I. Description

1. As it applies to its health plans, HMSA defines deductible as a set dollar amount of healthcare expense for which the member is responsible per calendar year before benefits become payable under his or her plan.
2. Some HMSA plans (e.g., Health Plan Hawaii) do not include deductibles. Other HMSA plans (e.g., most Preferred Provider Plans) may include a small deductible for certain services and items. Examples are services such as physical therapy or DME items. Yet other plans (e.g., Federal Plan 87) may include deductibles for services performed by providers who are not contracted with HMSA. Some of HMSA's individual plans (e.g., the Catastrophic Care Plan) already include high plan  deductibles.
3. Participating Providers shall collect any applicable Deductibles required for Covered Services directly from Members and shall not waive, discount or rebate any such Deductibles.

II. Claims Filing Information

1. When a claim is filed for a service for which the member has a plan deductible, the claim is processed and an eligible charge is determined. If the plan deductible has not been met, the amount of that eligible charge is applied to the member's deductible and no payment will be made to the provider. However, a Report to Provider (RTP) will be issued indicating how much of the eligible charge was applied to the deductible.

Example:

For example, Marvin Mahalo may have a plan deductible of $250 for certain services. He receives physical therapy. The participating physical therapist bills HMSA for the service performed in the amount of $140. HMSA's eligible charge for the service is $100, which is applied toward the member's deductible. Payment is not made to the provider, but an RTP is issued indicating the amount of the eligible charge that was applied to the deductible. The member has a remaining deductible of $150 that must be met before the plan will make payment for similar services.

Participating providers have agreed to accept HMSA's eligible charge as payment in full for their services. In the example above, the provider may bill the member $100, plus any applicable tax on this amount. The member is not responsible for paying the difference between the billed charge and the $100 eligible charge. This difference is taken as an adjustment by the provider. The  MEMBER OWES  column on your RTP will show exactly how much the member owes for the service.

III. Benefit Information

1. Information about plan deductibles can be viewed by practitioners who log in to the Hawaii Healthcare Information Network (HHIN+). The physician can look at the benefits information section for the member's coverage code.

   1. The plan's annual deductible amount is listed under the PROVISIONS section heading.

       

      

       

   2. If the annual deductible must be met before any benefits are paid, this will be indicated in the applicable benefit language as in the examples noted below.
      
      
      
       

IV. Deductible Accumulation

1. Information about deductible accumulation will be included in a future enhancement to HHIN+. You can also ask the member whether he or she has met the plan deductible. Members receive updated status of their deductible amount for the calendar year in their HMSA's Report to Member (RTM).
2. After the deductible is met, subsequent claims will be paid based on plan benefits for the services. The member will owe only his or her plan copayment and any applicable tax.
3. Contact a Provider Teleservice Representative at 948-6330 on Oahu or 1 (800) 790-4672 from the Neighbor Islands with questions on deductible accumulation.