Determining PPO Cost for Care Outside of Hawaii

If your plan has an annual deductible, you need to meet the annual deductible according to your Guide to Benefits before HMSA will pay for certain services.

If you receive medical care from a BlueCard preferred provider while away from Hawaii, you’ll pay the participating provider copayment listed in your Guide to Benefits.

If you receive medical care from a BlueCard participating provider who is not preferred, you’ll pay the nonparticipating provider copayment listed 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:

  • Your portion of the costs for services may be substantially higher than if you choose a preferred provider. Your portion of the charge usually includes all of the following: your copayment, your deductible, the difference between the eligible charge and the provider’s actual charge, and the customary applicable taxes.
  • 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 about when you are expected to pay for the services.
  • 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 received by 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 is listed in your Guide to Benefits.

BlueCard Provider Provider’s Actual Charge Eligible Charge Your Copayment Calculation to Determine Your Portion of the Costs Your Portion
Preferred
(PPO provider)
$100,000 $40,000 10% of eligible charge $40,000 x 10% = $4,000 $4,000
Participating but not preferred $100,000 $40,000 30% of eligible charge $40,000 x 30% = $12,000 $12,000
Nonparticipating $100,000 $40,000 30% of eligible charge $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
$72,000*

*Note: Because services were provided by 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 by 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.