If your plan has an annual deductible, you need to meet the annual deductible before HMSA will pay for certain services. Check your Guide to Benefits.
If you receive medical care from a BlueCard participating provider while away from Hawaii, you’ll pay the participating provider copayment specified in your Guide to Benefits.
If you receive medical care from a provider who doesn’t participate with the local Blue Cross or Blue Shield plan:
- You may be required to pay the provider’s actual charge before you leave the provider’s office or facility. Before services are rendered, we encourage you to confirm with the provider when they expect payment.
- You may also need to file a claim with HMSA to be reimbursed for the portion that HMSA owes for the service. Please check with the provider. See Filing medical claims for services from nonparticipating providers if you’ll be submitting a claim for payment. No payment will be made on claims submitted to HMSA more than one year after the last day on which you received services.
Below is an example of how your portion of the costs for covered services may be calculated for a major surgical procedure performed outside of Hawaii. The figures listed are for illustration purposes only. The cost of actual services rendered may vary. Your copayment will be what’s specified in your Guide to Benefits.
| BlueCard Provider | Participating (PPO provider) |
Nonparticipating |
|---|---|---|
| Provider’s Actual Charge | $100,000 | $100,000 |
| Eligible Charge | $40,000 | $40,000 |
| Your Copayment | 10% of eligible charge | 30% of eligible charge |
| Calculation to Determine Your Portion of the Costs | $40,000 x 10% = $4,000 | $40,000 x 30% = $12,000 Difference between eligible charge and actual charge = $60,000 ($100,000 - $40,000) $12,000 + $60,000 = $72,000 |
| Your Portion | $4,000 | $72,000* |
*Note: Because services were received from a nonparticipating provider, you owe the provider the actual charge of $100,000 and you may need to file your own claim.
Your portion of the costs for services is calculated using the local Blue Cross and Blue Shield plan’s eligible charge and your copayment stated in your Guide to Benefits. The eligible charge varies between Blue Cross and Blue Shield plans.