CMS AUDIT QUESTIONS AND ANSWERS Part C – 2023 Plan Year

Revised 01.09.23

1. Can you answer a question I have about Medicare Part C and D?

Yes. How can I help you?

2. Do you have a <language> interpreter?

Yes. Please hold on the line while I get an interpreter for you.

3. Can you answer questions about your HMSA Medicare Advantage plans?

Yes. How can I help you?

4. Does HMSA have a plan for people with Medicare and Medicaid?

Yes, we do.
(Optional: HMSA’s Akamai Advantage Dual Care Plan (PPO SNP) is for people with Medicare and
Medicaid.)

5. Does HMSA Medicare Advantage have an HMO Plan?

No, we don’t.
(Optional: All of our Medicare Advantage plans are Preferred Provider Organization (PPO) plans.)

6. How much will I have to pay for a wheelchair or walker?

Your cost share for covered durable medical equipment would be:
• In-network: 20% of the cost. (For Dual Care: In-network: $0)
• Out-of-network: 40% of the cost.

7. Do HMSA Medicare Advantage plans help pay for routine eye exams as either a standard or
optional supplemental benefit?

For All plans: Yes, we do. (Optional: We pay for one routine eye exam per calendar year as a
standard benefit.)

[Rep to quote specific plan’s copayment/co-insurance as requested]

Plan Routine eye exam Routine eye exam
copayment coinsurance
(In-network) (Out-of-network)
Complete (Oahu) $10 40% of the cost
Complete Plus (Oahu) $0 40% of the cost
Standard (Neighbor Island) $10 40% of the cost
Standard Plus (Neighbor Island) $0 40% of the cost
Dual Care (Statewide) $0 30% of the cost
8. Do HMSA Medicare Advantage plans help pay for preventive dental cleaning as either a standard
or optional supplemental benefit?

For Complete, Complete Plus, Standard, & Standard Plus: YES, preventive dental cleanings are a
standard benefit under our Medicare Advantage plans.

For Dual Care: NO, preventive dental cleanings are not a benefit, but may be covered under Quest
Integration.

9. What are the monthly premiums for HMSA Medicare Advantage Plan for people who are not on
Medicaid or who don’t get Extra Help?

[Rep to quote specific plan premium as requested]

Plan Premium
Complete $0
Complete Plus $104
Standard $0
Standard Plus $124
Dual Care $0

10. Does your plan pay for routine flu shots?

Yes.
(Optional: You can get a routine annual flu shot at no charge.)

11. If I have Medicare Part D do I need to enroll in Part B to join a Medicare Advantage plan?

Yes, you’ll need to be enrolled in both Parts A & B and continue to pay your Part B premium.

12. Can I use Medigap (supplemental Medicare plan) to pay for a Medicare Advantage plan's out of
pocket costs, like copayments?

No, you cannot be enrolled in both plans at the same time.

13. Do HMSA Medicare Advantage plans include Part D to help pay for prescription drugs?
Yes.
(Optional: All HMSA Medicare Advantage Plans include Part D prescription drug coverage to help
pay for prescription drugs.)

14. I’ll turn 65 on June 10th of this year. How soon can I be enrolled in a Medicare Advantage plan?

You can start receiving Medicare Advantage benefits on June 1st if you apply up to 3 months prior
to your entitlement date.

15. Can monthly premiums for Medicare Advantage plans be taken out of my Social Security check?

Yes.
16. Do I need a referral for outpatient blood transfusion / diagnostic lab services?

No.
(Optional: You don’t need a referral since our plans are PPO, but it should be ordered by your
doctor.)

17. Do HMSA Medicare Advantage plans help pay for some hospital expenses or do they just pay for
doctor's office visits?

Our plans pay for Medicare covered services, like hospital and doctor office visits, plus additional
benefits.

18. Can someone with mental illness still join a Medicare Advantage plan?

Yes.
(Optional: You can’t be denied health insurance for a chronic or pre-existing health condition.)

19. Do HMSA Medicare Advantage Plans pay for emergency room visits on the Mainland?

Yes.
(Optional: HMSA’s Akamai Advantage (PPO) plans help pay for emergency medical care anywhere
in the United States or its territories.)

20. What’s the maximum copayment or co-insurance for ambulance services?

• For Complete & Standard: $250 copayment per trip or ride (in or out-of-network)
• For Complete Plus & Standard Plus: $225 copayment per trip or ride (in or out-of-network)
• Dual Care:
o $0 copayment (in-network)
o 30% of the cost (out-of-network)

21. Can I get information about your plan's exceptions and appeals processes on your website?

Yes.
(Optional: Please visit hmsa.com/advantage.)

22. If I move out of your plan's service area, can I switch to a different Medicare Advantage plan?

Yes, you may be able to join a Medicare Advantage plan if it’s offered in your new service area
based on a special enrollment period.
23. What’s the maximum copayment or coinsurance for a visit to a primary care provider (PCP)?

[Rep to quote specific plan copayment or co-insurance as requested]

Plan In-network Out-of-network

copayment copay/co-insurance
Complete (Oahu) $0 $40
Complete Plus (Oahu) $0 $30
Standard (Neighbor Island) $0 $40
Standard Plus (Neighbor Island) $0 $30
Dual Care (Statewide) $0 30% of the cost

24. How much is my Part B premium?

The standard Part B monthly premium in 2023 is $164.90.

(Optional: It may be higher depending on your income. To confirm your Part B premium, contact
Social Security.)

25. Do I still have to pay my Medicare Part B premium if I enroll in your Medicare Advantage Plan?

Yes.

26. How much will I have to pay for an emergency room visit?
• Complete, Complete Plus, Standard, & Standard Plus:
o ER visit is $90 copay (in or out-of-network)

• Dual Care:
o ER visit is $0 copay (in or out-of-network)

27. Do HMSA Akamai Advantage PPO plans help pay for services provided by an out-of-network
doctor?

Yes.
(Optional: If you use out-of-network providers for care that isn't emergency care or urgently needed
care, your share of the costs for your covered services may be higher.)

28. What’s the total maximum out of pocket cost?

• Complete Plus and Standard Plus:
o $3,450 per year (in-network)
o $5,150 per year (in and out-of-network services combined)
• Complete, Standard, and Dual Care:
o $6,700 per year (in-network)
o $10,000 per year (in and out-of-network combined)

[For Rep info only – These costs include Medicare-covered Part A and B services. They don’t include
Part D prescription drug costs. Dual Care members generally don’t have any out-of-pocket costs
because Medicaid pays for any remaining costs after HMSA Medicare Advantage benefits are paid.]
29. What’s my cost share for preventive services that are covered at no cost sharing under Original
Medicare?

There is $0 cost share for preventive services under Original Medicare.

(Optional: If you receive additional non-preventive services, then cost sharing standards apply.
Please see your plan’s Evidence of Coverage for a list of preventive services available at no cost to
you.)

30. How much would I pay for Outpatient chemotherapy services?

[Rep to quote specific plan copayment/co-insurance as requested]

Plan Medicare Part B Medicare Part B

chemotherapy drugs (Out-of-
drugs and other network)
Part B drugs
(In-network)
Complete (Oahu) 20% of the cost 40% of the cost
Complete Plus (Oahu) 20% of the cost 40% of the cost
Standard (Neighbor Island) 20% of the cost 40% of the cost
Standard Plus (Neighbor Island) 20% of the cost 40% of the cost
Dual Care (Statewide) $0 copayment 30% of the cost

31. How much will I have to pay for OUTPATIENT renal dialysis services?

[Rep to quote specific plan copayment/co-insurance as requested]

Plan In-network Out-of-network

Complete (Oahu) 20% of the cost 20% of the cost
Complete Plus (Oahu) 20% of the cost 20% of the cost
Standard (Neighbor Island) 20% of the cost 20% of the cost
Standard Plus (Neighbor Island) 20% of the cost 20% of the cost
Dual Care (Statewide) $0 copayment 20% of the cost

32. How many days does your plan cover for Skilled Nursing Facility?

Our plan covers up to 100 days.

33. How much will I have to pay for care at a Skilled Nursing Facility?
[Rep to quote specific plan copayment as requested]

Plan In-network copayment Out-of-network

Complete Days 1-20: $0 per day
(Oahu) Days 21- 60: $185 per day
Days 61-100: $0 per day
Complete Plus Days 1-20: $20 per day
(Oahu) Days 21-40: $175 per day
copayment
Days 1-50: $200 per day
Days 51-100: $0 per day
Days 1-34: $150 per day
Days 35-100: $0 per day
 Days 41-100: $0 per day
Standard Days 1-20: $0 per day
(Neighbor Island) Days 21- 60: $185 per day
Days 61-100: $0 per day
Standard Plus Days 1-20: $20 per day
(Neighbor Island) Days 21-40: $175 per day
Days 41-100: $0 per day
Dual Care Days 1-100: $0 per day
(Statewide) Authorization rules may apply
Days 1-50: $200 per day
Days-51-100: $0 per day
Days 1-34: $150 per day
Days 35-100: $0 per day
Days 1-20: $0 per day
Days 21-100: $200 per day

34. Is the cost of services like cooking and cleaning part of your plan’s home health benefits?

• For Complete, Complete Plus, Standard, and Standard Plus: No, cooking and cleaning are
not benefits of the plan.

• For Dual Care: No, cooking and cleaning are not benefits of the plan.
(Optional: Medicaid may help pay for some of these services. Please check with your
Medicaid plan to find out.)

35. Is there any information on your website about your plans out-of-network coverage rules?

Yes.
(Optional: this information can be found in the plan’s Evidence of Coverage Chapter 3, Section 2.4:
“How to get care from out-of-network providers.” This document is available online at
hmsa.com/advantage.)

36. What’s HMSA Akamai Advantage’s Star Rating?

All HMSA Medicare Advantage plans have an overall star rating of 3.5 for 2023.

37. Will you advise me if my doctor leaves the HMSA Medicare Advantage’s provider network?

Yes, we will notify you.

38. How often do you update your provider directory?

We update our provider directory every month.

(Optional: For the most current information, go to hmsa.com/advantage.)

39. Do I need to choose a primary care doctor (PCP)?

No, you do not, however, we do encourage it.

40. How much will I have to pay for a hospital bed?

For medically necessary hospital bed, your cost share would be:
 • In-network: 20% of the cost. (For Dual Care: In-network: $0)
• Out-of-network: 40% of the cost. (For Dual Care: Out-of-network: 30% of the cost.)

41. If my mom is taken to the emergency room, will they waive the share of cost (copay) if she is
admitted in the hospital for a particular length of time?

Yes, if she’s admitted to the hospital within 24 hours for the same condition there would be $0
copay for the emergency room visit.

42. Will my mom need a referral to see a specialist?

No, a referral is not needed to see a specialist.

43. Will my mom be able to get a member handbook/Evidence of Coverage and provider directory in
large print?

Yes.

44. My mom lives in <Hawaii/Maui/Kauai/Kalawao/Honolulu county>, can she enroll in your

Medicare Advantage plan?

Yes.

45. Does your plan have an annual deductible for Part C services?

• Complete Plus and Standard Plus: There is no annual deductible.

• Complete and Standard: There’s a $120 annual deductible for some services (in and out-of-
network).
• Dual Care: There is no annual deductible for in-network. For out-of-network, $1,600 for Part
A covered services and $226 for Part B covered services.

[For Rep info only: The deductible does not apply to some services, including certain in-network
preventive services. This means that we will pay our share of the costs for these services even if you
haven’t paid your deductible yet. The deductible does not apply to the following services:

• All covered in-network services, except:

o Outpatient hospital services and
o Outpatient surgery, including services provided at hospital outpatient facilities and
ambulatory surgical centers
• Emergency care
• Urgently needed services
• Ambulance services
• Hospice care
• Medicare-covered preventive services]
46. How much will I have to pay for Medicare-covered INPATIENT renal dialysis services?

[Rep to quote specific plan copayment/co-insurance as requested]

Plan In-network Out-of-network

Complete (Oahu) $0 copayment $0 copayment
Complete Plus (Oahu) $0 copayment $0 copayment
Standard (Neighbor Island) $0 copayment $0 copayment
Standard Plus (Neighbor $0 copayment $0 copayment
Island)
Dual Care (Statewide) $0 copayment 30% of the cost

[For Rep info only – Member will have cost sharing for inpatient hospital stay.]

47. My mom is blind, can she get a braille version of the Summary of Benefits/Provider list/Formulary?
Yes she can. [For Rep info only - Audio, large print, and other formats are also available.]

48. Does your plan provide hearing aids as a supplemental benefit under Part C?
No, hearing aids are not a benefit.

49. If my mom joins your Medicare Plan (Part C), can she go back to original Medicare during next
year’s open enrollment period?
Yes.

50. My mom is trying to quit smoking cigarettes. Does your plan provide consultation services to help
my mom quit smoking?

Yes, our plan provides Medicare-covered smoking and tobacco use cessation counseling.

51. If my mom enrolls in your Medicare Advantage (Standard, Standard Plus, Complete, or Complete
Plus) PPO plan, will she be covered if she goes to an out-of-network doctor for routine care (non-
emergency)?

Yes.
(Optional: if she uses an out-of-network provider for care that isn’t emergency or urgently needed
care, her share of the costs for covered services may be higher.)

52. My mom is visually impaired, can she get the plan benefits in audio?
Yes, she can.

53. Can my mom enroll in your health plan even though she doesn’t have her Medicare card yet?
Yes, we’ll just need her Medicare Beneficiary Identifier number.

54. Will joining affect how much my mom pays for her Part B premium?
No, joining our plan will not affect her Part B premium.
55. Is the Annual Notice of Change on your website?
Yes.
(Optional: it is posted on the website between October and December of each plan year.)

56. Is the Provider Directory on your website?

Yes.

57. Is the Summary of Benefits of the plan on your website?

Yes.

58. Where can I find the Notice of Privacy?

It can be found on our website at hmsa.com.

59. Is the Privacy Notice on your website?

Yes.

60. Will your plan cover for my mom’s annual wellness visit if she sees a doctor that is out-of-network?

Yes, there is no coinsurance or copayment.