HMSA Gold HMO

Individual Health Insurance (Obamacare)

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Benefits & Coverage

Plan Name
HMSA Gold HMO
Plan ID
18350HI0890007
Plan Year
2014
Insurance Type
Individual Health Insurance (Obamacare)
Insurance Provider
Metal Level
Gold
Plan Type
HMO
Deductible
$1,000
Out-of-Pocket Maximum
$4,000
Plan Highlights

Cost & Coverage

Estimated Monthly Base Rate
Estimated monthly premium starts at $487.20
Deductible
Individual: $1000
Family: $2000
In-Network Out-of-Pocket Limit
Individual: $4000
Family: $8000
What is included in the in-network out-of-pocket limit?
Deductible + Coinsurance + Co-pay
Is this plan Health Savings Account (HSA) eligible?
No
How can I find a doctor in this plan's network?
Plan Type
HMO

Health Services Options

Service
In Network
Out of Network
Primary care physician office visit
$25 Copay after deductible
Not Covered
Specialist
$25 Copay after deductible
Not Covered
Diagnostic Test (X-ray, blood work)
10% Coinsurance after deductible
Not Covered
Outpatient Facility Fee
10% Coinsurance after deductible
Not Covered
Outpatient Physician/Surgeon Fee
10% Coinsurance after deductible
Not Covered
Hospital facility fee
10% Coinsurance after deductible
Not Covered
Hospital physician/surgeon fee
10% Coinsurance after deductible
Not Covered
Emergency Room
20% Coinsurance after deductible
20% Coinsurance after deductible

Drug Services

Generic Drugs
Coverage: $7 Copay before deductible
Preferred Brand Drugs
Coverage: $30 Copay after deductible
Specialty Drugs
Coverage: $100 Copay after deductible

Mental Health or Substance Abuse Services

Service
In Network
Out of Network
Mental/behavioral health outpatient services
10% Coinsurance after deductible
Not Covered
Mental/behavioral health inpatient services
10% Coinsurance after deductible
Not Covered
Substance use disorder inpatient services
10% Coinsurance after deductible
Not Covered
Substance use disorder outpatient services
10% Coinsurance after deductible
Not Covered

Maternity Services

Service
In Network
Out of Network
Prenatal/postnatal care
$25 Copay after deductible
Not Covered
Delivery and all inpatient services for maternity care
10% Coinsurance after deductible
Not Covered

Coverage Options Summary

Included Benefits
  • Bariatric surgery
  • Dental care adult
  • Durable medical equipment
  • Emergency Transportation
  • Eye glasses children
  • Habilitation
  • Home health care
  • Hospice
  • Imaging (CT/PET scans, MRIs)
  • Inpatient rehabilitation
  • Non-preferred brand drugs
  • Skilled nursing care
  • Other practitioner office visit
  • Outpatient rehabilitation
  • Preventive care, screening, immunization
  • Routine eye exam children
  • Routine hearing tests
  • Urgent Care
Excluded Benefits
  • Acupuncture
  • Chiropractic
  • Cosmetic surgery
  • Dental check up children
  • Long Term Care
  • Non-emergency care outside U.S.
  • Private duty nursing
  • Routine foot care
  • Weight loss program
Limited Benefits
  • Eye exam adult
  • Hearing Aid
  • Infertility treatment

What To Know

  • This is an ACA (Obamacare) compliant health plan.
  • This plan is not eligible for a tax credit subsidy

Physician Directory

List of doctors that accepts HMSA Gold HMO Obamacare Plan in Hawaii

/
AYON, DENNIS
5333 LIKINI ST
HONOLULU, HI 96818
KURIHARA, REYN
1425 ALA KOPIKO ST
HONOLULU, HI 96818
LAWSON, MARVA
750 SIGNER BLVD
HONOLULU, HI 96818
COLE, JASMIN
755 SCOTT CIR
HICKAM AFB, HI 96853
HICKS, CINDY
99-128 AIEA HEIGHTS DR
AIEA, HI 96701
CHUNG, RYAN
98-1079 MOANALUA ROAD
AIEA, HI 96701
IWAMOTO, MIEKO
99-128 AIEA HEIGHTS DR
AIEA, HI 96701
CHEN, HONG-RU
98-1079 MOANALUA RD
AIEA, HI 96701
KOIKE, CATHERINE
99-128 AIEA HEIGHTS DR
AIEA, HI 96701
LIU, YU-CHIN
98-151 PALI MOMI ST
AIEA, HI 96701
CHINEN, SHERI
888 SOUTH KING ST.
AIEA, HI 96701
KOBAYASHI, JOEL
98-1247 KAAHUMANU ST
AIEA, HI 96701
TOM, RUSSELL
98-1079 MOANALUA RD
AIEA, HI 96701
KUROSAWA, MICHAEL
98-151 PALI MOMI ST
AIEA, HI 96701
WU, DANIEL
98-151 PALI MOMI ST
AIEA, HI 96701
FUJITA, WAYNE
99-128 AIEA HEIGHTS DR
AIEA, HI 96701
WONG, ROBERT
98-211 PALI MOMI STREET
AIEA, HI 96701
KIM, JEONG
98-211 PALI MOMI ST STE 312
AIEA, HI 96701
FONG, JENIFER
98-151 PALI MOMI ST
AIEA, HI 96701
NGUYEN, MARISA
98-151 PALI MOMI ST
AIEA, HI 96701
LENCINAS, CLAUDIO
98-151 PALI MOMI ST
AIEA, HI 96701
HINO, RONALD
98-151 PALI MOMI ST
AIEA, HI 96701
LEE, KENNETH
98-151 PALI MOMI ST
AIEA, HI 96701
MARTYAK, ANTHONY
98-151 PALI MOMI ST
AIEA, HI 96701
GRIEF, MARK
98-1079 MOANALUA RD
AIEA, HI 96701
Details
DENNIS AYON, M.D.
Phone Number
(808) 594-7845
Office Locations
5333 LIKINI ST
HONOLULU, HI 96818
5333 LIKINI ST HONOLULU HI, 96818

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