Services to Family Members

HMSA plans do not provide benefit payment or cover services rendered by medical practitioners to themselves, their immediate family, or to members of their household. Coverage exclusion applies to services, supplies or prescriptions provided, ordered or prescribed for themselves or members of their immediate family or shared household.

HMSA defines immediate family members as:

• Husband and 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

Medical services, durable medical equipment (DME), medical supplies, or prescriptions provided or prescribed by any individual meeting the definition of immediate family member are HMSA benefit exclusions and do not meet payment criteria. Any claims for such services rendered or ordered / prescribed by an immediate family member will be ineligible for payment under this policy.

As an extension of this long-standing policy, primary care providers participating in HMSA’s primary care payment model program may not add themselves or their immediate family members to the PCP’s own patient panel, or accept patient attribution for themselves or immediate family members. That is because HMSA makes benefit payment in the form of a per member per month (PMPM) global payment for each attributed patient. Accepting a PMPM payment for yourself or immediate family members is a violation of this policy.

Please do not bill HMSA for treating immediate family members. Also, do not add yourself or your immediate family members to HMSA’s population management tools or select yourself as a PCP or allow immediate family members to select you as their PCP when enrolling in HMSA plans.

This policy is consistent with the Centers for Medicare and Medicaid Services’ General Exclusions from Coverage, which state that no payment can be made for charges by immediate relatives or members of household. It is also consistent with the American Medical Association’s Code of Medical Ethics, which states that physicians should not treat themselves or members of their family unless in an emergency setting or for short-term minor problems and that there should be no fee for such treatment.

Revision History