Mandated Benefits

The state mandates that all employer-sponsored insurance plans provide certain benefits for their members. In addition to these mandated benefits, some HMSA plans may provide additional services, higher age limits and/or higher benefit maximums. Following are descriptions of mandated benefits that are covered under all employer-sponsored HMSA plans. (Government-sponsored plans may exempt themselves from complying with some of the mandates.)

Note: The following information does not apply to Medicare-based plans (e.g., 65C Plus).

Well-baby Care Services (Birth Through Age 5)

• 12 physical exams ( Note: If an infant is discharged within 48 hours of birth, an extra well-baby visit will be allowed during the first year.)
• 2 blood tests (hemoglobin or hematocrit)
• 2 TB skin tests
• 1 urinalysis
• Routine childhood immunizations (See Childhood Immunizations)

These services are not subject to waiting periods or deductibles.

Well-baby Care Immunizations

• Routine childhood immunizations are covered for infants and children through age 5.
• All well-baby immunizations are paid at 100 percent of the eligible charge.

These services are not subject to waiting periods or deductibles.

Mental Health Benefits

HMSA covers a variety of mental health diagnoses and all alcohol and other drug dependence diagnoses at parity with coverage for physical illness.

The state mandates that all employer-sponsored insurance plans provide certain benefits for their beneficiaries. In addition to these mandated benefits, some HMSA plans may provide additional services, higher age limits and/or higher benefit maximums.

The following mandated mental health benefits are covered under all private employer-sponsored HMSA plans:

• 24 outpatient visits (in applying benefits, HMSA equates one visit to one 50-minute session) per calendar year.
• 30 hospital days and 30 inpatient visits (in applying benefits, HMSA equates one visit to one 50-minute session) per calendar year.
• Two-for-one benefit exchange (refer to Two-for-one Benefit Exchange and Case Management and Review)

Screening Mammogram for Women

• Age 35-39 - One during this period
• Age 40+ - One every calendar year
• Any age - One every calendar year if the patient, her mother or her sister has a history of breast cancer

Plan deductibles are applicable before benefits are payable.

Medical Foods

Medical foods and low-protein modified food products are covered for the treatment of an inborn error of metabolism. The foods must be ordered by a physician. To arrange for benefit coverage for patients needing medical foods, please call HMSA at 948-6464 on Oahu.

Contraceptive Benefits

HMSA plans (except individual plans) cover contraceptive services, oral contraceptives and contraceptive devices. As an exception, plans for groups with moral or religious reservations against contraception are not required to cover these services.

In Vitro Fertilization

This benefit is limited to one complete attempt at in vitro fertilization per qualified married couple, whether or not the attempt is successful. Guidelines for coverage of this service are listed in the benefit policies section. (Note: The Federal Employee Plan (Federal Employees Health Benefits (FEHB) Program, (coverage codes 111, 112, 113, 131, 132, and 133) and FEP Postal Service Health Benefits (PSHB) Program (33A, 33B, 33C, 35A, 35B, and 35C) does not cover any assisted reproductive technology including in vitro fertilization.)

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