RCUH Policies and Procedures
HMSA Akamai Advantage Prime (MA)
Your Medicare Advantage Plan Guide
This is a summary of health services and drug benefits for HMSA Akamai Advantage® Prime (MA) plan effective Jan. 1, 2022.
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What’s inside
Eligibility 3
Get More with HMSA Medicare Advantage 4
Travel Benefits 6
Summary of Benefits 8
Next Steps 12
Looking for a Doctor? 13
Pre-enrollment Checklist 14
2022 Medicare Star Ratings 15
Contact Us Back Cover
Eligibility
To enroll in HMSA Medicare Advantage, you must:
• Have Medicare Part A (hospital insurance) and Part B
(medical insurance).
• Continue to pay your Part B premium in addition to your
HMSA Medicare Advantage premium.
• Live in the United States or the territory of Puerto Rico.
Still not sure if you’re eligible? Please contact your health plan
administrator for more information.
IMPORTANT:
If you already have a separate federal, state, county, or employer-sponsored retiree plan, talk to your health plan administrator at work before enrolling in HMSA Medicare Advantage. You may not need to enroll in HMSA Medicare Advantage. Also, if you enroll in a Medicare Advantage plan, you may lose your state or county retiree plan and may not be able to re-enroll.
Get more with HMSA Medicare Advantage
All the benefits of Original Medicare
and so much more.
Choose your doctors
You have access to a large provider network.
With primary care providers, nurse practitioners, specialists, and other providers, you’re sure to find the care you need. To find a provider, go
to hmsa.com and click Find a Doctor. See
page 13 to learn more.
Customer service
Local, friendly health plan experts are ready to help you on the phone or in person.
Financial protection
It makes dollars and cents to choose HMSA.
You have a limit on how much you pay for
out-of-pocket health care expenses each
calendar year. If you reach your annual
out-of-pocket maximum, we’ll pay for your Medicare-covered medical expenses for the
rest of the year.
Travel
Have peace of mind knowing you have health plan benefits on the Mainland and worldwide. See page 6 to learn more.
Eye care benefits
You’ll see clearly now with benefits for routine
eye exams, eyeglasses, and contact lenses.
Quick access to care
Get care from the comfort and safety of your home
with telehealth services, including HMSA’s Online
Care®, at no cost. For hours of operation, check with the telehealth provider. You can also see a nurse or other health care provider at your nearest walk-in MinuteClinic® at selected Longs Drugs stores.
Preventive care
One of the best ways to stay healthy is to detect and treat illnesses early to help prevent serious problems. Your annual wellness visit and many preventive care services are available at no cost.
Health education workshops
Attend a variety of health education workshops
at no cost to learn how to sleep better, make healthier food choices, stay active, and more.
Check hmsa.com/well-being/workshops for a schedule and locations.
Health coaching
Get guidance, support, and resources to help you manage chronic health conditions, stop smoking, relieve stress, and more. To learn more, visit hmsa.com/well-being/health-coaching/.
Amwell® is an independent company providing hosting and software services for HMSA’s Online Care platform on behalf of HMSA.
Travel benefits
Your health plan travels with you.
If you need care while traveling, the HMSA Akamai
Advantage Visitor Travel Program has you covered.
You’ll have access to the nationwide Blue Medicare
Advantage PPO network. See a participating network
doctor in one of the 46 states, District of Columbia,
or Puerto Rico highlighted in blue on the map to the
right. You’ll pay the same in-network costs for covered
services as if you were seeing a network doctor in Hawaii.
Find a doctor or hospital in the state you’re
visiting. Call Blue Cross Blue Shield Global Core
at 1 (800) 810-BLUE (2583). That number is also on
your HMSA membership card. You can also visit
bcbsglobalcore.com.
You’ll also receive health care benefi ts for doctor
visits and hospital stays if you have a medical
emergency in another country.
HMSA Akamai Advantage Visitor Travel Program
Alabama
Arizona
Arkansas
California
Colorado
Connecticut
Delaware District of
Columbia (D.C.)
Florida
Georgia
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Wisconsin
West Virginia
This list is current as of September 2021 and may change. For some states, Medicare Advantage PPO
networks are available only in portions of the state. For an updated list of states and to learn more, visit hmsa.com/health-plans/medicare/travel-program/.
Summary of Benefits
HMSA Akamai Advantage Prime (MA)
Your share of the cost:
$ = Copayment. A set dollar amount that you pay.
% = Coinsurance. The percentage of the cost that you pay.
Benefits
Prime (MA)
YOU PAY
Monthly premium
You must continue to pay your Part B premium in addition to your HMSA premium.
Contact your plan administrator
Annual deductible
What you’ll have to pay each year out of pocket before the plan will pay for some services.
$0
Maximum out of pocket
This financial safety net protects you from a catastrophic illness. It’s the most you’ll pay out of pocket for
Medicare-covered medical services each year.
$3,450 per year (in-network)
$5,150 per year (in-network and out-of-network)
Inpatient hospital care*
In-network:
Days 1-6: $225/day
Days 7-30: $50/day
Days 31-90: $0/day
Additional days: $0/day
Out-of-network:
Days 1-11: $375/day
Days 12-90: $0/day
Additional days: $0/day
Outpatient hospital services*
20% of the cost (in-network)
40% of the cost (out-of-network)
Ambulatory surgery center services*
20% of the cost (in-network)
40% of the cost (out-of-network)
Doctor’s office visits
Primary care provider
A physician or other health care professional who
treats common illnesses and manages your
preventive care.
$10 (in-network)
$30 (out-of-network)
Advanced practice registered nurse, nurse
practitioner, or physician’s assistant
$10 (in-network)
$30 (out-of-network)
* For some services, your doctor or other network provider must request prior authorization. Please contact us for more information.
Benefits
Prime (MA)
YOU PAY
Doctor’s office visits (continued)
Specialist
A physician who treats specific conditions such as
allergies, heart disease, or foot disorders.
$30 (in-network)
$40 (out-of-network)
Preventive care
Includes annual wellness visits, bone mass measurements, diabetes screenings, mammograms, and some vaccines such as flu shots, hepatitis B shots, and
pneumococcal shots. For a complete list of preventive
care services that our plan pays for, please see the
Evidence of Coverage.
$0 (in-network and out-of-network)
Emergency care
You won’t pay a copayment for emergency care if you’re admitted to the hospital within 24 hours.
$90
(in-network and out-of-network)
Urgent care
You won’t pay a copayment for urgent care if you’re
admitted to the hospital within 24 hours.
$30
(in-network and out-of-network)
Diagnostic services, labs, and imaging*
Diagnostic tests and procedures, lab services, and outpatient X-rays
$30 or 20% of the cost, depending on
the service (in-network)
40% of the cost (out-of-network)
Diagnostic radiology services including advanced imaging services such as MRI, CT, and PET scans
$100 or 20% of the cost, depending on
the service (in-network)
40% of the cost (out-of-network)
Therapeutic radiology services such as radiation treatment for cancer
$30 (in-network)
40% of the cost (out-of-network)
Hearing services
Exam to diagnose and treat hearing and balance-related conditions. Doesn’t include routine hearing exams or hearing aids.
$30 (in-network)
40% of the cost (out-of-network)
Dental services
Limited dental services.
Doesn’t include services related to care, treatment, or filling, removing, or replacing teeth.
$30 (in-network)
40% of the cost (out-of-network)
* For some services, your doctor or other network provider must request prior authorization. Please contact us for more information.
Benefi ts Prime (MA)
YOU PAY
Vision services
Medicare-covered vision services
• Eye exam to diagnose and treat eye
diseases and conditions
$10 (in-network)
40% of the cost (out-of-network)
• Eyeglasses or contact lenses after
Medicare-covered cataract surgery $0 (in-network and out-of-network)
Supplemental vision services
• Routine eye exam (once a calendar year)
$10 (in-network)
40% of the cost (out-of-network)
• Contact lenses and eyeglasses (frames and lenses)
The plan pays up to $100 every two calendar years for
contact lenses and eyeglasses (frames and lenses).
$0 (in-network and out-of-network)
Mental health care
• Inpatient visit*
Mental health care services that require a
hospital stay.
In-network:
Days 1-6: $225/day
Days 7-90: $0/day
Out-of-network:
Days 1-11: $375/day
Days 12-90: $0/day
• Outpatient therapy visits
Individual and group visits
$30 (in-network)
40% of the cost (out-of-network)
Skilled nursing facility*
Our plan covers up to 100 days in a skilled nursing facility.
No prior Medicare-covered acute level of care hospital
stay is required.
In-network:
Days 1-20: $20/day
Days 21-40: $165/day
Days 41-100: $0/day
Out-of-network:
Days 1-10: $150/day
Days 11-44: $175/day
Days 45-100: $0/day
Outpatient rehabilitation*
• Occupational therapy, physical therapy,
and speech and language therapy visits.
$30 (in-network)
40% of the cost (out-of-network)
* For some services, your doctor or other network provider must request prior authorization. Please contact us for more information.
Benefits Prime (MA)
YOU PAY
Ambulance
Ground and air ambulance $225 (in-network and out-of-network)
Transportation Not covered
Medicare Part B drugs*
Chemotherapy and other Part B drugs. 20% of the cost (in-network)
40% of the cost (out-of-network)
Medical equipment and supplies*
Includes oxygen tanks, walkers, and wheelchairs. 20% of the cost (in-network)
40% of the cost (out-of-network)
Telehealth Services
HMSA’s Online Care and other telehealth services. $0 (in-network and out-of-network)
HMSA Akamai Advantage® is a PPO plan with a Medicare contract. Enrollment in HMSA Akamai Advantage depends on contract renewal. To learn more about the health plan benefi ts and costs of Original Medicare, see the Medicare & You 2022 handbook at medicare.gov. To request a copy, call 1 (800) MEDICARE [1 (800) 633-4227] toll-free, 24 hours
a day, seven days a week. For TTY, call 1 (877) 486-2048.
Out-of-network/non-contracted providers are under no obligation to treat HMSA Akamai Advantage
members except in emergency situations. Please call our customer service number or see your Evidence of
Coverage for more information, including the cost-sharing that applies to out-of-network services.
* For some services, your doctor or other network provider must request prior authorization. Please contact us for more information.
Next steps
We’ll make your transition to HMSA Medicare Advantage as smooth and
easy as possible. Here’s what you can expect from us:
Enrollment verification letter
If we helped you enroll in HMSA Medicare Advantage for the first time, we’ll send you
a verification letter after your enrollment.
Welcome packet
You’ll receive an HMSA Medicare Advantage welcome packet and enrollment confirmation letter in the mail. Please read the information about your plan benefits. It can help you get
high-quality care and save money.
HMSA membership card
You’ll receive your new card in the mail. Show this card when you see your doctor or go to a hospital. Secure it like a credit card. To prevent identity theft, don’t share your card with anyone, keep it in a safe place, and call us if you lose your card. Cut up old or out-of-date cards.
Choose a PCP
When you enroll, it’s important that you choose a primary care provider as your
partner in health. Please let us know the
name of your PCP so we can put it on your HMSA membership card. See page 13 for
ways to find a participating provider or to check if your provider participates with HMSA.
Getting care
To get the most savings from your health plan, go to doctors, hospitals, pharmacies, and other providers in the HMSA Medicare Advantage network. They have an agreement with HMSA to charge you a lower amount than providers outside the network. You can go to providers outside the network, but you may pay more.
HMSA Akamai Advantage (PPO)
Looking for a Doctor?
The 2022 Provider Directory will be available Oct. 1.
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HMSA Akamai Advantage (PPO)
Visit hmsa.com/advantage.
1. Click Find a Doctor.
2. Under Medicare, select your plan.
3. Click Remember my plans then the Search button.
You can search by provider name, location, specialty, or ailment.
Get our Provider Directory. You have three options:
• View online. Go to hmsa.com/advantage. Under Members, click View resources. Under Plan Documents, click your plan then Provider Directory.
• Go online to request a printed copy. Go to hmsa.com/advantage.
Under Members, click View resources. Under Plan Documents, click your plan. Click Request hard copy. Follow the instructions and click Submit.
• Call us to request a printed copy. Call (808) 948-6000 or
1 (800) 660-4672 daily, 8 a.m. to 8 p.m. For TTY, call 711.
We can mail you a provider directory for:
• HMSA Akamai Advantage® (PPO)
• HMSA Akamai Advantage Dual Care Dental
• HMSA Akamai Advantage Routine Vision
You also can request a copy of HMSA’s Silver&Fit® Healthy Aging &
Exercise program directory. Call us at a number above and ask for the
Silver&Fit directory. We’ll be happy to mail you one.
The providers listed in our directories participate with HMSA. However, check to make sure your provider is in your plan’s network to get the most savings.
Questions? If you need help finding a provider, call a number above and
we’ll be happy to help you.
HMSA Akamai Advantage is a PPO plan with a Medicare contract.
Enrollment in HMSA Akamai Advantage depends on contract renewal.
American Specialty Health (ASH) is an independent company providing chiropractic,
acupuncture, fitness programs, and/or massage therapy services on behalf of HMSA.
The Silver&Fit program is provided by American Specialty Health Fitness, Inc. (ASH Fitness),
a subsidiary of American Specialty Health Incorporated (ASH). All programs and services
are not available in all areas. Silver&Fit is a federally registered trademark of ASH and used
with permission herein.
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Pre-enrollment checklist
Before making an enrollment decision, it is important that you fully understand our benefits and rules.
If you have any questions, you can call and speak to a customer service representative at (808) 948-6235 or 1 (800) 693-4672. For TTY, call 711.
Understanding the Benefits
Review the full list of benefits found in the Evidence of Coverage, especially for those services for which you routinely see a doctor. Visit hmsa.com/advantage or call us at the numbers listed above to view a copy of the EOC.
Review the Provider Directory
(or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will have to select a new doctor.
Review the Provider Directory to make sure the pharmacy you use for any prescription medicine is in the network. If the pharmacy is not listed, you will have to select a new pharmacy for your prescriptions.
Understanding Important Rules
In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month. Benefits, premiums and/or copayments/coinsurance may change Jan. 1, 2023. Our plan allows you to see providers outside of our network (noncontracted providers).
However, while we will pay for covered services provided by a noncontracted provider, the provider must agree to treat
you. Except in an emergency or urgent situations, noncontracted providers may deny care. In addition, you will pay a higher copayment for services you receive from noncontracted providers.
IMPORTANT INFORMATION:
2022 Medicare Star Ratings
HMSA Akamai Advantage – H3832
F or 2022, HMSA Akamai Advantage – H3832 received the following Star Ratings from
Medicare: Overall Star Rating:
Health Services Rating:
Drug Services Rating:
E very year, Medicare evaluates plans based on a 5-star rating system.
The number of stars show how well a plan performs.
EXCELLENT
ABOVE AVERAGE
AVERAGE
BELOW AVERAGE
POOR
Why Star Ratings Are Important
Medicare rates plans on their health and drug services.
This lets you easily compare plans based on quality and
performance. Star Ratings are based on factors that include:
Feedback from members about the plan’s service and care
The number of members who left or stayed with the plan
The number of complaints Medicare got about the plan
Data from doctors and hospitals that work with the plan
More stars mean a better plan – for example, members may
get better care and better, faster customer service.
Get More Information on Star Ratings Online
Compare Star Ratings for this and other plans online at medicare.gov/plan-compare compare.
Questions about this plan?
Contact HMSA Akamai Advantage 7 days a week from 8:00 a.m. to 8:00 p.m. Hawaii time at 800-693-4672 (toll-free)
or 711 (TTY), from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through
Friday from 8:00 a.m. to 8:00 p.m. Hawaii time. Current members please call 800-660-4672 (toll-free) or 711 (TTY).
HMSA Akamai Advantage® is a PPO plan with a Medicare
contract. Enrollment in HMSA Akamai Advantage depends
on contract renewal.
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NOTES
HAWAI‘I MEDICAL
SERVICE ASSOCIATION
hmsa.com/advantage
We’re here with you.
Call (808) 948-6235 or 1 (800) 693-4672
TTY: 711
8 a.m.–8 p.m.
Oct. 1–March 31: Seven days a week
April 1–Sept. 30: Monday–Friday
Visit us
HMSA Center @ Honolulu
818 Keeaumoku St.
Monday–Friday, 8 a.m.–5 p.m.
Saturday, 9 a.m.–2 p.m.
HMSA Center @ Pearl City
Pearl City Gateway
1132 Kuala St., Suite 400
Monday–Friday, 9 a.m.–6 p.m.
Saturday, 9 a.m.–2 p.m.
HMSA Center @ Kahului
Puunene Shopping Center
70 Hookele St., Suite 1220
Monday–Friday, 9 a.m.–6 p.m. Saturday, 9 a.m.–2 p.m. HMSA Center @ Hilo
Waiakea Center 303A E. Makaala St.
Monday–Friday, 9 a.m.–6 p.m. Saturday, 9 a.m.–2 p.m. Kauai Offi ce
4366 Kukui Grove St., Suite 103 Monday–Friday, 8 a.m.–4 p.m.
hmsa.com
2025-423753 10.21 JR