Recently, an HMSA member came home to find a big bill from an out-of-network hospital
on the outskirts of Las Vegas. The member had been feeling ill, so he checked with
the hospital and was told he would be accepted as a patient.
The total charge for the four-day inpatient stay was $22,898. The chart below shows
his expense for this out-of-network hospital, and how much it would have been if
he had chosen a network provider.
|
|
Out-of-network Nonparticipating Hospital |
Network Preferred Hospital |
|
Total Charge |
$22,898 |
$22,898 |
|
Eligible Charge |
$6,839 |
$7,632 |
|
Negotiated Discount |
$0 |
$15,266 |
|
Member Out-of-pocket Expense |
$18,180* |
$763** |
|
|
|
| * |
Member out-of-pocket expense is 30 percent of the eligible charge after applying
the $100 annual deductible, plus the difference between the total charge and eligible
charge. |
| ** |
Member out-of-pocket expense is 10 percent of the eligible charge. |
|
To clarify, a network provider is an HMSA participating provider in Hawai‘i
or a preferred or participating provider with the Blue Cross and Blue Shield Association’s
BlueCard program on the Mainland. On the Mainland, a participating provider may
not also be a preferred provider. When choosing a provider, always confirm that
they are participating with HMSA or are preferred or participating with BlueCard
on the Mainland.
PPO Members: Going out of network means there’s no HMSA agreement with the
provider. Without this protection, here are just two of the challenges you’ll
face:
- You’ll be required to pay upfront in full for the services you receive, especially
for out-of-network services on the Mainland. Participating providers in Hawai‘i
and BlueCard preferred providers on the Mainland will generally bill you for your
copayment after HMSA’s payment has been made.
- You will usually have a large amount to pay out of pocket because our reimbursement
to you is based on eligible charges for preferred or participating providers. In
addition, many of our plans pay lower percentages (and often have a deductible)
for nonparticipating provider services.
HMO Members: Generally, our HMO plans covered out-of-network services
if you had a referral from your primary care provider (PCP). However, beginning
in November 2007, out-of-network services must be reviewed before you receive care.
Your PCP must send HMSA a precertification request if they are referring you to
nonparticipating providers in Hawai‘i or for any out-of-state services. (Exceptions:
Emergency or urgent care, and mental health or substance abuse services from an
HMSA provider or a BlueCard preferred or participating provider.)
HMO plans are based on coordinated care from a member’s PCP. This enhanced
precertification process will help your PCP manage your care better.
To Find a Network Provider
- In Hawai‘i: Use the
provider search on hmsa.com. Be sure to confirm with the provider that they
participate with HMSA. You can also call your local
HMSA office for help.
- In another state: Call 1 (800) 810-BLUE (2583) to locate a BlueCard preferred or
participating provider (this phone number is printed on your HMSA card). You can
also use the BlueCard Doctor and Hospital Finder at www.BCBS.com. (Travel tip: Use the Finder to print a personalized
directory of BlueCard providers in the city you’ll be visiting before you
leave home.
Important note for PPO members while on the Mainland: Choosing a preferred provider
assures you the best benefits. Services from nonpreferred providers, including BlueCard
participating providers, are reimbursed at the lower nonpreferred benefit level.
Although benefits are paid at the lower level, you’ll still have the protection
of the negotiated discount.