Hawaii Benchmarks Benefits under the Affordable Care Act (ACA)

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1 Hawaii Benchmarks Benefits under the Affordable Care Act (ACA) 10/2012 Coverage for Newborn and Foster Children Coverage Outside the Provider Network Adult Routine Physical Exams Well-Baby and Well-Child Care Immunizations Routine Mammography Screening HPV/Cervical Cancer Screening Newborn Hearing Screening Newborn Screening (Other than Hearing) Pediatric Hearing Screening Prostate Cancer Screening Colorectal cancer screening Depression Screening (Adolescents and Adults) Diagnostic Bone Mass Measurement/Density Testing Screening Colonoscopy Allergy Testing Diabetes Screening Screening for Sexually Transmitted Infections - HIV Screening for Sexually Transmitted Infections - Other Anemia Screening for Pregnant Women Essential Health Benefit Category Service Could Fit Into Chronic Chronic YES (Preventive, Pediatric Services including Oral and Vision YES (Preventive, Pediatric Services including Oral and Vision Benchmark Benefits Package - for ACA required screenings and counseling typically provided during a physician visit - 1 per year starting at age 40 (baseline at age 35); more frequently or at an earlier age for at risk individuals - 1 screening per year - 1 test per year for men over 50

2 Bacteriuria Urinary Tract Screening for Pregnant Women BRCA Screening and Counseling About Genetic Testing Folic Acid Supplements for Women Who May Become Pregnant Hepatitis B Screening for Newly Pregnant Women Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk Allergy Injections Smoking and Tobacco Cessation Counseling Diabetes Education Diabetes Monitoring Breastfeeding/Lactation Counseling Nutritional Counseling HPV Vaccine Flu Vaccines Room & Board Nursing - General Minimum inpatient stays following delivery of a baby (48 hours normal delivery; 96 hours cesarean) Treatment of Maternity as any Other Illness When Maternity is Provided Chronic Chronic Chronic Chronic Chronic Chronic Chronic Chronic YES (Hospitalization, Maternity and Newborn YES (Hospitalization, Maternity and Newborn YES (Maternity and Newborn YES (Maternity and Newborn Semi-private room; private room if medically necessary Complications of pregnancy YES (Hospitalization) Lab YES (Laboratory services) Pathology Services YES (Hospitalization) Radiology YES (Hospitalization) Anesthesia YES (Hospitalization) Medical Supplies YES (Hospitalization) Durable Medical Equipment Prosthetics YES (Hospitalization) Drugs YES (Hospitalization) Blood YES (Hospitalization) Inpatient Rehab Services Mental Illness Alcoholism/Drug Abuse Treatment - according to federal mental health parity law. Transplants YES (Hospitalization) - with prior authorization Reconstructive Breast Surgery Following a Mastectomy YES (Hospitalization)

3 Surgery to Correct Congenital Anomalies YES (Hospitalization) Other Reconstructive Surgery YES (Hospitalization) - for corrective surgery required to restore, reconstruct or correct any bodiliy function that was lost, impaired, or damaged as a result of illness or injury Bariatric Surgery YES (Hospitalization) - with precertification Tubal Ligation YES (Hospitalization) Vasectomy NO Inpatient Hospice YES (Hospitalization) Vision Procedures Anesthesia and Hospital Charges for Dental Procedures for Children Under Age 9 With Serious Mental, Physical or Behavioral Problems Oral and Maxillofacial Surgery or Emergency Procedure YES (Hospitalization) NO May be covered depending on defined services. Emergency Room Services YES (Emergency Services) Surgery: Operating Room, Recovery and Treatment Rooms Anesthesia Laboratory Services YES (Laboratory services) Pathology Radiology - X-rays, Ultrasound, EKG, EEG, CT, MRI, PET, Diagnostic Angiography Chemotherapy Radiation Therapy Diagnostic Colonoscopy Pulmonary Rehab Physical Therapy Oral Surgery - when dentist is performing emergency service or surgical services and these covered services could also be performed by physicians - short term only (generally not longer than 90 days); combined with occupational therapy Occupational Therapy - short term only (generally not longer than 90 days); combined with physical therapy Speech Therapy Habilitative services and devices IV/Infusion Therapy Hyperbaric Oxygen Therapy YES (Rehabilitative and habilitative services and devices) Not now but will be as one of required benefits under ACA. Dialysis Blood and Plasma Medical and Surgical Supplies Oxygen Nuclear Medicine Injectible Drugs YES (Prescription - requires prior authorization

4 Infertility Services - IVF: one-time only benefit with precertification. Infertility services not covered. Genetic Screening and Testing - requires preauthorization Genetic Counseling Inpatient Visits YES (Hospitalization, Maternity and Newborn Inpatient Surgery YES (Hospitalization, Maternity and Newborn Outpatient Surgery Emergency Room Services YES (Emergency Services) Urgent Care Visits Physician Office Visits Laboratory Services YES (Laboratory services) Diagnostic Imaging Treat maternity as any other illness YES (Maternity and Newborn Prenatal care YES (Maternity and Newborn Mental Illness Alcoholism/Substance Abuse Retail and Mail Order Prescription Drugs Prescription Contraceptives if prescription drugs are a covered benefit Smoking and Tobacco Cessation Prescription Drugs YES (Prescription YES (Prescription Chronic - as identified on the U.S. Preventive Services Task Force list of Grade A and B Recommendations - according to federal mental health parity law - with the inclusion of prescription drug Ambulance Services YES (Emergency Services) Durable Medical Equipment and Devices Home Dialysis Equipment and Supplies Oxygen Prosthetic Devices - if medically necessary; repair/replacement covered if not due to abuse Home Health Visit - limit of 150 visits per year; only when ordered by a physician and when skilled nursing care is required Skilled Nursing Facility Care days per year HIV/AIDS Treatment Certain Treatment of Diabetes(Training and educational services, and equipment, supplies, medications, and laboratory procedures used to treat diabetes) YES (Ambulatory Patient Prescription YES (Ambulatory Patient Prescription TMJ Joint Dysfunction (Diagnostic, therapeutic, and surgical coverage same as any other bone or joint) Abortion Home Hospice Care Nurse Midwife Services YES (Hospitalization, Ambulatory Patient Services) Diagnosis of TMJ is covered; treatment is not covered

5 Coverage for Certain Clinical Trials Medical Foods (Food supplements, formulas or special foods) Pediatric Vision Screening Eyeglasses and Contact Lenses - Adults Eyeglasses and Contact Lenses - Pediatric Pediatric Dental Routine Hearing Exams Hearing Aids Speech Generating Devices / Voice Synthesizers Sources of Information YES (Ambulatory Patient Prescription NO YES (Rehabilitative and Habilitative Services and YES (Rehabilitative and Habilitative Services and - in accord with Medicare guidelines - only to treat inborn errors of metabolism - as defined in ACA wellchild visit. - for certain medical conditions and subject to special limits - for certain medical conditions and subject to special limits Not now but will be as one of required benefits under ACA. - as defined in ACA wellchild visit. - Covers one hearing aid per ear every 60 months Benefit Booklet For HMSA's Preferred Provider Plan

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