Exclusions

HMSA medical plans exclude benefits for the following services. Please refer to the member’s Guide to Benefits for more details.

Autologous blood donations (excluded: additional charges for related services).

Airline oxygen is a covered benefit under the Federal Plan (coverage code 87), HMSA Plan for Postal Service Employees (coverage codes 452 and 454), and the carpenters union plan (coverage codes 455, 532 and 533) as long as service is not a duplication of oxygen services billed by other providers.

Bereavement counseling or services of volunteers or clergy

Biofeedback and any other form of self-care or self-help training and any related diagnostic testing. Lamaze classes and other self-help classes are not a benefit of HMSA plans. Classes or education for diabetes, asthma, behavioral health, or smoking cessation are available to members identified through HMSA’s various services (e.g., HMSA’s behavioral health services, HMSA’s disease management services).

Cardiac rehabilitation services

Carcinoembryonic antigen (CEA) when CEA is used as a screening test.

Contraceptives that do not require a prescription, including condoms, foams, and creams.

Cosmetic services that may improve physical appearance but do not restore or materially improve a bodily function, or any complication or revision required to repair, revise, or treat a condition resulting from the cosmetic surgery.

Ductal lavage

Enzyme-potentiated desensitization for asthma

Extracorporeal shock wave therapy, except for the treatment of kidney disease.

Fertilization by artificial means and drugs or services related to the diagnosis and treatment of infertility. In compliance with the state mandate, all HMSA plans include benefits for in-vitro fertilization. Artificial insemination is also covered by HMO plans and some PPO plans.⁽²⁾

Foot orthotics – As an exception, HMSA will cover orthopedic shoes and supportive devices for members with specific diabetic conditions.

Genetic counseling

Intradiscal electrothermal therapy (IDET)

Lodging

Marriage and family counseling or other training services – Mental health services billed with diagnosis ‘Z63.0 – Problems in relationship with spouse or partner’ alone or with other non-mental health diagnoses are considered as marriage and family counseling services.

Personal convenience items (e.g., air conditioners, dehumidifiers, ramps, home remodeling, hot tubs, or swimming pools)

Physician waiting or stand-by time – Preferred Provider Plans do not cover standby services. HMO commercial plans cover standby services in certain limited instances.

Private duty nursing – A few plans may cover these services as an exception.

Provider is an immediate family member such as Husband or wife; Natural or adoptive parent, child, and sibling; Stepparent, stepchild, stepbrother, and stepsister; Father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, and sister-in law; Grandparent and grandchild; and Spouse of grandparent and grandchild; or self (when a provider is providing professional services to themself).

Purchase or rental of motor vehicles, such as cars and vans or the conversion of a motor vehicle to accommodate a disability.

Refractive eye surgery to correct visual acuity problems.

Rest cures, custodial care, and sanatorium care

Reversal of sterilization

Routine physical examinations and screening procedures – HMSA’s HMO commercial plans, the Federal Plan (coverage code 87), HMSA Plan for Postal Service Employees (coverage codes 452 and 454), and the Hawaii State Teachers Association (HSTA) Plan (coverage codes 596, 641, and 668) include benefits for an annual physical examination. A few other plans may cover this service as an exception. HMO commercial plans generally cover screening prescribed by the member's PCP.

Self-help and self-cure programs or equipment

Services or supplies related to routine foot care – These services are covered by the Federal Plan (coverage code 87) and HMSA Plan for Postal Service Employees (coverage codes 452 and 454).

Services provided by a medical professional to a member of their immediate family or household – See Services to Family Members.

Services Related to Employment – refer to member’s Guide to Benefits, a few benefit plans did not take this exclusion

Supplies not covered are take-home supplies or supplies billed separately by the provider when the supplies are necessary to the services they perform.

Thoracic electric bioimpedance (outpatient)

Topical hyperbaric oxygen therapy

Treatment for weight loss or weight control programs – HMSA plans include benefits for surgical treatment of morbid obesity (refer to Bariatric Surgery). Other services performed for weight loss or weight control are generally not a benefit of any HMSA plan. If you are treating an obese patient for heart disease, thyroid disease, or other medical conditions, be sure to indicate the appropriate medical diagnosis on the claim.

Treatment of TMJ dysfunction – Services to diagnose the condition causing the member’s problem are covered by HMSA’s Private business plans except for coverage codes 522 and 523 which do not cover services related to the diagnosis of TMJ disorder, and coverage codes 455, 532, and 533 which only cover services in connection with the initial visit to diagnose TMJ disorder. Subsequent services rendered to treat the condition are not a benefit.⁽¹⁾

Treatment of baldness, including hair transplants and topical medications – An initial visit to diagnose the cause of the member’s hair loss, laboratory services if needed, and a follow-up visit to discuss laboratory results, if applicable, are covered. Subsequent treatment is not covered. (See Hair Loss – Alopecia)

Treatment of complications resulting from previous cosmetic, experimental, or investigative services, or other services not covered by HMSA plans.

Treatment with nonionizing radiation

Vertebral axial decompression (VAX-D)

Vitamins, minerals, and food supplements

Wigs and artificial hairpieces

Footnotes:

⁽¹⁾ TMJ diagnostic evaluation is limited to:

• No more than three E/M visits;
• One X-ray, tomogram, or arthrogram;
• One CT or MRI scan;
• One cephalogram; and
• One pantogram.

⁽²⁾ PPO plans that do not cover Artificial Insemination:

• EUTF (449, 562, 563, 667, 668, 690, 693, 823, 852, 855)
• Hawaiian Airlines (510, 673, 716, 744, 758)
• ILWU (522, 523)
• PAMCAH (450, 651)
• Carpenters (532, 533)
• HI SIC (486, 683)
• HECO (825)
• KIUC (521)

Revision History