Plan Certificate

Complementary Care Rider

Federal law requires HMSA to provide • Mail: U.S. Department of Health and Marshallese: LALE: Ñe kwōj kōnono you with this notice. Human Services, 200 Independence Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ HMSA complies with applicable Federal Ave. S.W., Room 509F, HHH Building, ilo kajin ṇe aṃ ejjeḷọk wōṇāān. Kaalọk civil rights laws and does not discriminate Washington, DC 20201 1 (800) 776-4672 tollfree, enaj ejjelok wonaan. TTY 711. on the basis of race, , national origin, For complaint forms, please go to age, disability, or sex. HMSA does not hhs.gov/ocr/office/file/index.html. Pohnpeian: Ma ke kin lokaian Pohnpei, exclude people or treat them differently ke kak ale sawas in sohte pweine. Kahlda Hawaiian: E NĀNĀ MAI: Inā hoʻopuka because of things like race, color, nempe wet 1 (800) 776-4672. Me sohte ʻoe i ka ʻŌlelo Hawaiʻi, loaʻa ke kōkua national origin, age, disability, or sex. kak rong call TTY 711. manuahi iā ʻoe. E kelepona iā Services that HMSA provides 1 (800) 776-4672. TTY 711. Samoan: MO LOU SILAFIA: Afai e te tautala Gagana fa'a Sāmoa, o loo iai Provides aids and services to people with Bisaya: ATENSYON: Kung nagsulti ka auaunaga fesoasoan, e fai fua e leai se disabilities to communicate effectively og Cebuano, aduna kay magamit nga totogi, mo oe, Telefoni mai: with us, such as: mga serbisyo sa tabang sa lengguwahe, 1 (800) 776-4672 e leai se totogi o lenei • Qualified sign language interpreters nga walay bayad. Tawag sa ‘au’aunaga. TTY 711. • Written information in other formats 1 (800) 776-4672 nga walay toll. (large print, audio, accessible TTY 711. Spanish: ATENCIÓN: si habla español, electronic formats, other formats) tiene a su disposición servicios gratuitos Chinese: 注意：如果您使用繁體 de asistencia lingüística. Llame al Provides language services to people 中文，您可以免費獲得語言援助 1 (800) 776-4672. TTY 711. whose primary language is not English, 服務。請致電 1 (800) 776-4672。 such as: TTY 711. Tagalog: PAUNAWA: Kung nagsasalita • Qualified interpreters ka ng Tagalog, maaari kang gumamit ng • Information written in other languages Ilocano: PAKDAAR: Nu saritaem ti mga serbisyo ng tulong sa wika nang • If you need these services, please call Ilocano, ti serbisyo para ti baddang ti walang bayad. Tumawag sa 1 (800) 776-4672 toll-free; TTY 711 lengguahe nga awanan bayadna, ket 1 (800) 776-4672 toll-free. TTY 711. sidadaan para kenyam. Awagan ti How to file a discrimination-related 1 (800) 776-4672 toll-free. TTY 711. Tongan: FAKATOKANGA’I: Kapau ‘oku grievance or complaint ke Lea-Fakatonga, ko e kau tokoni Japanese: 注意事項：日本語を話 fakatonu lea ‘oku nau fai atu ha tokoni If you believe that we’ve failed to provide される場合、無料の言語支援を ta’etotongi, pea teke lava ‘o ma’u ia. these services or discriminated against ご利用いただけます。 Telefoni mai 1 (800) 776-4672. TTY 711. you in some way, you can file a grievance in any of the following ways: 1 (800) 776-4672 をご利用くださ Trukese: MEI AUCHEA: Ika iei foosun • Phone: 1 (800) 776-4672 toll-free い。TTY 711.まで、お電話にて fonuomw: Foosun Chuuk, iwe en mei • TTY: 711 ご連絡ください. tongeni omw kopwe angei aninisin • Email: chiakku, ese kamo. Kori 주의 한국어를 사용하시는 [email protected] Korean: : 1 (800) 776-4672, ese kamo. TTY 711. 경우, 언어 지원 서비스를 무료로 • Fax: (808) 948-6414 on Oahu Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng 이용하실 수 있습니다. • Mail: 818 Keeaumoku St., Honolulu, Việt, có các dịch vụ hỗ trợ ngôn ngữ 번으로 연락해 HI 96814 1 (800) 776-4672 miễn phí dành cho bạn. Gọi số 주시기 바랍 니다 번으로 You can also file a civil rights complaint . TTY 711 1 (800) 776-4672. TTY 711. with the U.S. Department of Health and 전화해 주십시오. Human Services, Office for Civil Rights, Laotian: ກະລຸ ນາສງເກດ: in any of the following ways: ັ ້ • Online: ຖ້ າທ່ ານເວົ າພາສາລາວ, ocrportal.hhs.gov/ocr/portal/lobby.jsf ການຊ່ ວຍເຫືຼ ອດ້ ານພາສາ, • Phone: 1 (800) 368-1019 toll-free; ໍ່ບີມຄ່ າໃຊ້ ຈ່ າຍ, ແມ່ ນມີ ໃຫ້ ທ່ ານ. ໂທ TDD users, call 1 (800) 537-7697 1 (800) 776-4672 ຟຣີ . TTY 711. toll-free

NMM_1000_24715_1557_R

HAWAI‘I MEDICAL SERVICE ASSOCIATION Complementary Care Rider

I. ELIGIBILITY provider of the same specialty who belongs to the same group practice, within the past three years. This Rider describes the benefits included in the Guide to (8) “Massage Therapy Services” are services provided by Benefits. Your coverage under this Rider starts and ends on the same a Provider for treatment of Myofascial/Musculoskeletal Disorders, dates as your medical plan coverage. Musculoskeletal Functional Disorders, Pain Syndromes, and/or For eligibility, benefit, or claim questions, call Customer Service lymphedema through physical actions, primarily by hand, at 1-888-981-2746 Monday through Friday between the hours of 3 performed on the body. This may include techniques such as a.m. and 6 p.m., and Saturday, between 10 a.m. to 6 p.m. Hawaii compression, stroking, joint movement, friction, vibration, and Standard Time. Hours adjusted during Daylight Savings Time: percussion. Monday through Friday 2 a.m. to 5 p.m. and Saturday 9 a.m. to 5 (9) “Member Payments” means charges (such as p.m. Hawaii Standard Time. copayments) that are the direct financial responsibility of the Member and are payable directly to the provider for the provision of II. PROVISIONS OF THE MEDICAL PLAN APPLICABLE certain Covered Services as set forth in Section IV. Schedule of Benefits of this Rider. Member Payments may be collected by a All definitions, provisions, limitations, exclusions, and conditions provider (Participating or Nonparticipating) at the time services are of HMSA’s Guide to Benefits shall apply to this Rider, except as provided or subsequently billed to the Member. specifically modified in this Rider. (10) “Musculoskeletal and Related Disorders” means conditions with signs and symptoms related to the nervous, III. DEFINITIONS muscular, and/or skeletal systems. Musculoskeletal and Related Disorders are conditions typically categorized as: structural, When used in this Rider: degenerative, or inflammatory disorders; or biomechanical (1) “ASH Group” means American Specialty Health Group, dysfunction of the joints of the body and/or related components of Inc. which has been contracted by HMSA to administer the benefits the muscle or skeletal systems (muscles, tendons, fascia, nerves, under this Rider. ligaments/capsules, discs, and synovial structures) and related (2) “ Services” are services provided or made manifestations or conditions. Musculoskeletal and Related available to a Member by a Provider for the treatment or diagnosis Disorders include Myofascial/Musculoskeletal Disorders, of Musculoskeletal and Related Disorders, Nausea and Pain. Musculoskeletal Functional Disorders, and subluxation. Acupuncture is the stimulation of a certain point on or near the (11) “Musculoskeletal Functional Disorders” means surface of the body by the insertion and removal of single-use, disorders that are abnormal functions and/or activities-of-daily-living sterilized, disposable needles and/or electrical stimulation (electro- limitations of the body resulting from muscle stiffness, muscle Acupuncture) to normalize physiological functions, to prevent or restriction, and/or range of motion limitations. modify the perception of Pain, or to treat Musculoskeletal and (12) “Myofascial Disorders” means conditions with Related Disorders, Nausea, or conditions that include Pain as a associated signs and symptoms related to the muscular and primary symptom. In addition, it may include such services as surrounding connective tissues. Myofascial Disorders are adjunctive physiotherapy modalities and procedures provided conditions typically categorized as structural, spasms, or during the same Course of Treatment and in support of inflammatory disorders or dysfunction of the muscles of the body. Acupuncture Services. (13) “Myofascial/Musculoskeletal Disorders” means (3) “ Services” are services provided or made conditions with signs and symptoms that relate to the muscular and available to a Member by a Chiropractor for treatment or diagnosis related systems. Myofascial/Musculoskeletal Disorders are of Musculoskeletal and Related Disorders and Pain Syndromes. conditions that are typically categorized as structural, spasms, or Chiropractic Services are limited to the management of inflammatory disorders or dysfunction of the muscles of the body, Musculoskeletal and Related Disorders and Pain Syndromes and/or related components of the motor unit (muscles, tendons, primarily through chiropractic manipulation of the spine, joints, fascia, ligaments/capsules, discs, and synovial structures), and and/or musculoskeletal soft tissue. This includes: (1) differential related manifestations or conditions. diagnostic examinations and related diagnostic x-rays and (14) “Nausea” means an unpleasant sensation in the radiological consultations when used to determine the abdominal region associated with the desire to vomit that may be appropriateness of Chiropractic Services; and (2) the follow-up appropriately treated by a Provider of Acupuncture Services in office visits that must include during the Course of Treatment the accordance with professionally recognized, valid, evidence-based provision of chiropractic manipulation of the spine, joints, and/or standards of practice and includes adult post-operative nausea and musculoskeletal soft tissue. In addition, it may include such vomiting, chemotherapy nausea and vomiting, and nausea of services as adjunctive physiotherapy modalities and procedures pregnancy. provided during the Course of Treatment and in support of (15) “New Patient” means that a patient has not received chiropractic manipulation of the spine, joints, and/or any professional services from the provider, or another provider of musculoskeletal soft tissue. the same specialty who belongs to the same group practice, within (4) “Chiropractor” means a chiropractor who is duly the past three years. licensed to practice chiropractic services in the state or jurisdictions (16) “Nonparticipating Provider” means a provider who has in which Chiropractic Services are provided. not entered into an agreement with ASH Group to provide Covered (5) “Continuity of Care” means that if you are in the course Services to Members. of treatment with a Participating Provider, should that provider end (17) “Pain” means the sensation of hurting or strong his or her participation in this plan, you may continue seeing that discomfort in some part of the body caused by an injury, illness, provider and receive participating benefits for a period of time until disease, functional disorder, or condition that may be appropriately your documented treatment plan is concluded or you may be safely treated in accordance with professionally recognized, valid, transferred to another Participating Provider. At such time, if you evidence-based standards of practice. choose to continue receiving covered services from the provider, (18) “Pain Syndrome” means acute or chronic participating coverage is available only when the provider agrees to Musculoskeletal and Related Disorders including abide by the ASH Group requirements and fee schedule. Myofascial/Musculoskeletal Disorder, or Musculoskeletal Functional (6) “Course of Treatment” means a sequence or series of Disorder, in which the primary symptom consists of sensations of office visits directly related to a diagnosed disease state, illness, or hurting or strong discomfort in some part of the body caused by an injury and provided in conjunction with a defined clinical outcome. injury, illness, disease, functional disorder, or condition that may be (7) “Established Patient” means someone who has appropriately treated by a Chiropractor. received professional services from the provider, or another

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(19) “Participating Provider” means a provider who has (f) Any service or supply that is not permitted by state entered into an agreement with ASH Group to provide Covered law with respect to the practitioner’s scope of practice. Services to Members. Providers who are employees, independent (g) Any services provided for elective or maintenance contractors or owners of Professional Corporations or Group care (e.g., services provided to a Member whose treatment records Practices who have not been accepted and credentialed to indicate he or she has reached maximum therapeutic benefit). participate in ASH Group are not considered to be Participating (h) Hospitalization, surgical procedures, anesthesia, Providers. A directory of participating providers is available at manipulation under anesthesia, proctology, colonic irrigation, hmsa.com. injections and injection services, or other related services. (20) “Supports and Appliances” means support-type (i) , behavior training, sleep therapy, and devices prescribed by a Chiropractor. In order for Supports and weight problems. Appliances to be covered, the Member must be receiving (j) Thermography, magnets used for diagnostic or Chiropractic Services from a Chiropractor for Musculoskeletal and therapeutic use, ion cord devices, manipulation or adjustments of Related Disorders or Pain Syndrome and have the Supports and the joints, physical therapy services, , hormone Appliances prescribed for that condition. See Section VI of this replacements products, acupuncture point or trigger-point injections Rider for details. (including injectable substances), laser/laser biostimulation, colorpuncture, NAET diagnosis and/or treatment, and direct IV. SCHEDULE OF BENEFITS . (k) Education programs, non-medical lifestyle or self- (1) Copayments help, or self-help physical training or any related diagnostic testing. (a) Participating Providers (l) Services or treatments for pre-employment 1. $15 per visit. physicals or vocational rehabilitation. 2. Copayments do not apply for x-rays and (m) Any services or treatments for conditions caused by radiological consultations. or arising out of the course of employment or covered under (b) Nonparticipating Providers Worker’s Compensation or similar laws. 1. Services provided by a nonparticipating (n) Air conditioners /purifiers, therapeutic mattresses, provider are not covered. You owe the entire charge. supplies, or any other similar devices or appliances. (2) Benefit Maximum (o) Auxiliary aids and services, including but not limited (a) Participating Providers to, interpreters, transcription services, written materials, 1. No more than 20 visits per calendar year. telecommunications devices, telephone handset amplifiers, (3) Chiropractic Services. When authorized by ASH Group, television decoders, and telephones compatible with hearing aids. benefits are available for adjunctive therapy at each office visit. If (p) Any services provided by a person who is a Family adjunctive therapy is provided without an adjustment, the Member. Family Member means a person who is related to the adjunctive therapy will count as an office visit toward the Benefit covered person in any of the following ways: spouse, domestic Maximum. If an exam or re-exam is supplied without an partner, brother-in-law, sister-in-law, son-in-law, daughter-in-law, adjustment, it will count as an office visit toward the Benefit mother-in-law, father-in-law, parent (including stepparent), brother Maximum. All Chiropractic Services except for the initial evaluation or sister (including stepbrother or stepsister), or child (including must be approved by ASH Group as medically necessary for legally adopted, step, or foster child). A Family Member also treatment of either Musculoskeletal and Related Disorders or Pain includes individuals who normally live in the covered person’s Syndromes or both. household (q) Dietary and nutritional supplements, including V. COVERED SERVICES vitamins, minerals, herbs, herbals and herbal products, injectable supplements and injection services, or other similar products. (1) CHIROPRACTIC COVERED SERVICES (r) Transportation costs, including local ambulance (a) A New Patient exam or an Established Patient charges. exam for the initial evaluation of a patient with a new condition or (2) CHIROPRACTIC EXCLUSIONS new episode to determine the appropriateness of Chiropractic (a) Chiropractic supports and appliances. Services. (b) Magnetic resonance imaging, CAT scans, bone (b) Established patient exams as needed to assess scans, nuclear radiology, therapeutic radiology and any diagnostic the need to initiate, continue, extend, or change a Course of radiology other than covered plain film studies. Treatment. The Established patient exam is only covered when (c) Adjunctive physiotherapy modalities and procedures used to determine the appropriateness of Chiropractic Services. unless provided during the same Course of Treatment and in support (c) Follow-up office visits include manipulation of the of chiropractic manipulation of the spine, joints, and/or spine, joints, and/or musculoskeletal soft tissue, a reevaluation, musculoskeletal soft tissue. and/or other services, in various combinations. (d) Adjunctive modalities and procedures such as VII. FILING CLAIMS rehabilitative exercise, traction, ultrasound, electrical muscle stimulation, and other therapies covered only when provided during (1) For services you receive from a provider who does the same Course of Treatment and in support of chiropractic not file claims for you, follow these steps to receive manipulation of the spine, joints, and/or musculoskeletal soft tissue. reimbursement for Covered Services: (e) X-rays and radiological consultations (a) Complete a separate claim form for each provider of 1. When provided by or referred by a participating service. provider to another participating provider, services are payable in (b) Provide all of the following information on the claim full. form (your treating provider can help you get this information): 2. Services provided by a nonparticipating 1. Itemized date(s) of service. provider are not covered. You owe the entire charge. 2. Diagnosis code. 3. Procedure code. VI. LIMITATIONS AND EXCLUSIONS 4. Billed charge per service. 5. Provider’s name and credentials. (1) GENERAL EXCLUSIONS 6. Provider’s full address. (a) Services or supplies provided by a nonparticipating 7. Provider’s tax ID, employer identification provider. number or Social Security number. (b) Acupuncture Services. 8. National Provider Identifier (NPI) number. (c) Massage Therapy Services and Supplies. (c) Attach the itemized bill from the provider of service (d) BlueCard program. with a claim form. (e) Services provided in excess of any Benefit Maximum.

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(d) Send the claim form and bill to: American Specialty Health Group, Inc. P.O. Box 509077 San Diego, CA 92150

VIII. UTILIZATION REVIEW

(1) For Covered Services you receive from a Participating Provider, utilization review requirements are the responsibility of your provider, not you. (2) ASH Group will respond within one week of receipt of the completed form. Notification of the clinical decision will be mailed or faxed directly to the provider and will include the name and phone contact information of the peer-clinician who rendered the decision. Services provided during the review period will be reimbursed if they are approved by ASH Group.

IX. EXPLANATION OF BENEFITS (EOB)

ASH Group notifies you of any financial responsibilities you have (other than Copayments) in a document called the Explanation of Benefits (EOB). The EOB is not a bill, but rather, communicates important information about services you receive including the total amount charged, the allowed amount, the amount covered by ASH Group, and the amount that you pay.

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Serving you Meet with knowledgeable, experienced health plan advisers. We’ll answer questions about your health plan, give you general health and well-being information, and more. Visit hmsa.com for directions.

HMSA Center @ Honolulu 818 Keeaumoku St. Monday through 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 through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m.

HMSA Center @ Hilo Waiakea Center | 303A E. Makaala St. Monday through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m.

HMSA Center @ Kahului Puunene Shopping Center | 70 Hookele St. Monday through Friday, 9 a.m.–6 p.m. | Saturday, 9 a.m.–2 p.m.

Customer Relations representatives are also available in person at our Neighbor Island offices, Monday through Friday, 8 a.m. to 4 p.m.: Kailua-Kona, Hawaii Island 75-1029 Henry St., Suite 301 | Phone: 329-5291 Lihue 4366 Kukui Grove St., Suite 103 | Phone: 245-3393

Contact HMSA. We’re here for you. Call 948-6111 on Oahu or 1 (800) 776-4672 toll-free on the Neighbor Islands or Mainland.

hmsa.com myhmsa @askHMSA askhmsa

Together, we improve the lives of our members and the health of Hawaii. Caring for our families, friends, and neighbors is our privilege.

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