Office Visit/Physician Services

The information below applies to the HPH/HMO Commercial Copay Table.

General Provisions Applicable to Coverage Codes Listed

Benefit coverage for office visits and outpatient physician services include: diagnosis and treatment for illness and injury; consultations; specialist care; physical and inhalation therapy; allergy testing and treatment; injectable drugs; anesthesia; office surgery; specific oral surgery as it relates to a medical condition; chemotherapy for malignancy; dressings; splints and casts; family planning counseling; sterilization and interrupted pregnancies; and referred specialty care outside of the member's health center or network.

Footnotes

1. This copayment applies only when network participating providers render services such as a physician office visit, office surgery, oral surgery, urgent care services away from beneficiary?s home island, and allergy testing and treatment (copayment per visit). The member?s copayment for a physician home visit is $10. This plan also has benefit coverage of 100 percent of eligible charges for anesthesia services, maternity physician's office visits, and physical examination (physical exams, checkups, or related services only for the purpose of employment or insurance are not covered). Services received from non-network participating providers or non-network, nonparticipating providers have higher copayments.
2. This copayment also applies to additional outpatient physician services, including vision exams (one per calendar year) and skilled nursing facility physician visits. Allergy testing and treatment requires a copayment of 50 percent of eligible charges.
3. This plan has benefit coverage for skilled nursing facility physician visits and procedure for miscarriages at 100 percent of eligible charges.
4. This copayment also applies to additional outpatient physician services, including laboratory tests, X-rays, hearing tests and skilled nursing facility physician visits. This plan requires a member copayment of 20 percent of eligible charges for office surgery, oral surgery (as it relates to a medical condition) and anesthesia services.
5. This plan does not provide benefit coverage for family planning counseling. Dressings, splints and casts are not covered in a physician office visit.
6. This copayment also applies to additional outpatient physician services, including vision examinations (one per calendar year), hearing tests, and skilled nursing facility physician visits. Oral surgery as it relates to a medical condition listed in the plan is covered 100 percent of eligible charge.
7. This copayment also applies to additional outpatient physician services, including hearing tests, vision exams (one per calendar year) and skilled nursing facility physician visits. This plan requires members to pay 20 percent of eligible charges for office surgery, oral surgery and anesthesia services. A copayment of 10 percent of the eligible charges applies to physician maternity services. This plan covers 100 percent of eligible charges for laboratory tests, diagnostic tests and X-rays.
8. This copayment also applies to additional outpatient physician services, including hearing tests, vision exams (one per calendar year) and skilled nursing facility physician visits. This plan requires a member to pay 30 percent of eligible charges for oral surgery, surgery-related physician services, assistant surgeon services, anesthesiologist services, and office anesthesia services. There is a copayment of 10 percent of the eligible charges for physician maternity services. A $25 copayment is required for inpatient physician services and specialist care, and allergy testing and treatment (per visit). This plan has a benefit covering 100 percent of eligible charges for laboratory tests, diagnostic tests and X-rays.
9. This plan is limited to 12 outpatient physician visits per calendar year. This copayment also applies to physician visits limited to the diagnosis and treatment for illness and injury, consultations, specialist care, and referred specialty care outside The Children?s Plan network. Outpatient physician visits involving surgery are limited to three surgical visits per calendar year for office surgery, oral surgery (as it relates to a medical condition), and anesthesia services.
10. This plan has benefit coverage for skilled nursing facility physician visits at 100 percent of eligible charges.
11. This copayment also applies to vision examinations (one per calendar year). This plan also has benefit coverage for skilled nursing facility physician visits at 100 percent of eligible charges.
12. This plan has a 12-month waiting period for any preexisting illness or condition, including conditions resulting from an injury. The waiting period also applies to a complication resulting from a preexisting illness or condition.
13. This plan has a 12-month waiting period for any preexisting illness or condition, including conditions resulting from an injury. The waiting period also applies to a complication resulting from a preexisting illness or condition. This plan has a 12-month waiting period for maternity care, pregnancy, childbirth and related conditions.
14. This plan has a nine-month waiting period for maternity care, pregnancy, childbirth and related conditions. Routine care visits count against the maximum of 12 outpatient physician visits per calendar year. Well-child care benefits are covered through age 18. Physical examinations and health appraisals and related services are excluded, except for well-child care visits. A routine gynecological exam can be performed without a referral from the member?s Personal Care Physician (PCP). This benefit is limited to one exam per calendar year and must be performed by a network physician.
15. This copayment also applies to vision examinations (one per calendar year). This plan also has benefit coverage for skilled nursing facility physician visits and procedure for miscarriage at 100 percent of eligible charges.
16. This copayment applies only when network participating providers render services such as a physician office visit, office surgery, oral surgery, urgent care services away from beneficiary?s home island, and allergy testing and treatment (copayment per visit). The member?s copayment for a physician home visit is $14. This plan also has benefit coverage of 100 percent of eligible charges for anesthesia services, maternity physician's office visits, and physical examination (physical exams, checkups, or related services only for the purpose of employment or insurance are not covered). Services received from non-network participating providers or non-network, nonparticipating providers have higher copayments.

Revision History