2.2 Fundamentación Teórica
2.2.23 Plataforma Virtual Moodle
under Vision and Miscellaneous Exclusions.
Additional vision services for children are covered but only as described in this chapter under Special Benefits for Children – Pediatric Vision Care.
Hearing aids are limited to one hearing aid per ear every 60 months. Fitting, adjustment, repair and batteries are not covered.
Habilitative and Rehabilitative Therapy Habilitative Services and
Devices
Covered, in accord with HMSA’s medical policies, for health care services that assist an individual in partially or fully acquiring skills and functions of daily living. Habilitation is the process of evaluation, treatment and education for the purpose of developing, improving and maintaining skills and functions which the individual has not previously possessed.
Rehabilitative Services and Devices
Covered, in accord with HMSA’s medical policies, for health care services that assist an individual in improving or restoring skills and functions of daily living that have been lost or impaired due to illness or injury. Rehabilitation is the process of evaluation, treatment and education for the purpose of improving or restoring skills and functions lost or impaired due to illness or injury.
Habilitative and rehabilitative services may include, but are not limited to: Physical and occupational therapy. Services must meet the criteria listed
later in this section under Physical and Occupational Therapy.
Speech/swallowing therapy. Services must meet the criteria listed later in this section under Speech Therapy Services.
Medical equipment, orthotics and prosthetics. Services must meet the criteria listed in the section Other Medical Services and Supplies under the Durable Medical Equipment and Supplies and Orthotics and External Prosthetics. Physical and
Occupational Therapy Covered, but only when all of the following are true: The diagnosis is established by a physician, physician’s assistant or advanced practice registered nurse and the medical records document the need for skilled physical and/or occupational therapy.
The therapy is ordered by a physician, physician’s assistant or advanced practice registered nurse under an individual treatment plan.
The therapy is provided by a qualified provider of physical or occupational therapy services. A qualified provider is one who is licensed appropriately, performs within the scope of his/her licensure and is recognized by HMSA.
The therapy is necessary to achieve a specific diagnosis-related goal that will significantly improve physical and functional abilities. (Significant is defined as a measurable and meaningful increase in the level of physical and functional abilities attained through short-term therapy as documented in the medical records). Habilitative services are covered, but only as described under Habilitative Services and Devices.
The therapy is short-term, generally not longer than 90 days.
The therapy does not duplicate services provided by another therapy or available through schools and/or government programs.
The therapy is described as covered in HMSA’s medical policies on physical and occupational therapy and habilitative services. Information on our policies can be found at www.hmsa.com.
Please note: Precertification is required after the first visit for outpatient services
rendered in the State of Hawaii. Precertification is required for inpatient
rehabilitation facility services and residential rehabilitation programs outside the State of Hawaii. See Chapter 5: Precertification.
Group exercise programs and group physical and occupational therapy exercise programs are not covered.
Speech Therapy Services Covered, for the treatment of communication impairments and swallowing disorders but only when all of the following statements are true:
The diagnosis is established by a physician, physician’s assistant or advanced practice registered nurse and the medical records document the need for skilled speech therapy services.
The therapy is ordered by a physician, physician’s assistant or advanced practice registered nurse.
The therapy is necessary to achieve a specific diagnosis-related goal that will significantly improve physical and functional abilities. (Significant is defined as a measurable and meaningful increase in the level of physical and functional abilities attained through short-term therapy as documented in the medical records). Habilitative services are covered, but only as described under Habilitative Services and Devices.
The therapy is rendered by and requires the judgment and skills of a speech language pathologist certified as clinically competent (SLP CCC) by the American Speech Language Hearing Association (ASHA).
The therapy is provided on a one-to-one basis.
The therapy and diagnosis are covered as described in HMSA’s medical policies for speech therapy services and habilitative services. Information on our policies can be found at www.hmsa.com.
The therapy is not for developmental delay/developmental learning disabilities. Habilitative services are covered, but only as described under
Habilitative Services and Devices.
The therapy does not duplicate service provided by another therapy or available through schools and/or government programs.
Speech therapy services include speech/language therapy, swallow/feeding therapy, aural rehabilitation therapy and augmentative/alternative communication therapy.
When patients receive occupational, speech and/or physical therapy, each therapy should provide different treatments and not duplicate treatment provided under another specialty treatment plan. Physical, occupational and speech therapy must be provided under separate treatment plans and goals with treatment provided by the specific therapist in separate treatment sessions and visits. This includes duplicate services available through schools and government programs. Services may be available under a child’s individualized education program (IEP). An IEP should be completed before requesting coverage through
Please note: Certain services must have precertification. See Chapter 5:
Precertification.
Special Benefits – Disease Management and Preventive Services Disease Management
Programs
Covered, for programs available through HMSA Well-Being Connection for members with asthma, diabetes, cardiovascular disease, chronic obstructive pulmonary disease (COPD), and behavioral health conditions (mental health and substance abuse). The programs offer services to help you and your physician manage your care and make informed health choices.
You may be automatically enrolled in some of these programs or referred by your physician. HMSA reserves the right to at any time add other programs or to end programs. Call your nearest HMSA office listed on the back cover of this guide for more information.
Preventive Services Programs
Covered, for programs available through HMSA Well-Being Connection such as the prenatal care program which helps expectant couples through normal and at- risk pregnancies with information and support services, and the stop smoking program which offers support for those wanting to quit.
You may be automatically enrolled in some of these programs or referred by your physician. HMSA reserves the right to at any time add other programs or to end programs. Call your nearest HMSA office listed on the back cover of this guide for more information.
Physical Examinations for Adults (routine annual checkup)
Covered for ages 22 and above. Includes a routine vision and hearing tests, and the following recommended screening tests.
Audiogram (optional). Urinalysis.
Blood count.
Chest X-ray – 2 views (not more than once every two years). Also for ages 40 and above:
Biochemistry Panel.
Electrocardiogram (EKG 12 lead).
Please note: Copayments for physical examinations do not apply toward
meeting the Annual Copayment Maximum.
Please note: Physical exams for Members under age 22 are covered in accord
with other sections of this chapter labeled Special Benefits for Children –
Medical Care, Well-Child Care.
Screening Services and
Preventive Counseling Covered, for Grade A and B recommendations of the U.S. Preventive Services Task Force (USPSTF) such as the following: Preventive Counseling Services
Screening Laboratory Services:
Screening for Lipid Disorders in Adults
Screening for Asymptomatic Bacteriuria in Adults
Screening for Gonorrhea
Screening for Hepatitis B Virus Infection
Screening for HIV
Screening for Syphilis Infection
Screening for Type 2 Diabetes Mellitus in Adults
Screening for Iron Deficiency Anemia
Screening for Rh (D) Incompatibility
Screening for Congenital Hypothyroidism
Screening for Phenylketonuria (PKU)– Screening for Sickle Cell Disease in Newborns Screening Radiology Services:
Screening for Abdominal Aortic Aneurysm– Screening for Osteoporosis in Postmenopausal Women
Please note: Certain services must have precertification. See Chapter 5:
Precertification.
Please note: The list of U.S. Preventive Services Task Force (USPSTF)
recommended screenings may change. If you need more information about the USPSTF recommended screenings, including a current list of recommendations, please call us at one of the telephone numbers listed on the back of this guide.
Please Note: Benefits for other U.S. Preventive Services Task Force (USPSTF)
Grade A and B recommended screenings may be found in other sections of this chapter under Surgical Services, Testing, Laboratory, and Radiology, and
Special Benefits for Women.
Covered for recommended preventive services for women developed by the Institute of Medicine (IOM) and supported by the Health Resources and Services Administration (HRSA), such as the following:
Breastfeeding Support and Counseling – but only when received from a trained physician or midwife during pregnancy and/or in the postpartum period.
Contraceptive Counseling. Gestational Diabetes Screening.
Human Papillomavirus (HPV) DNA Testing.
Interpersonal and Domestic Violence Screening and Counseling.
Please Note: Benefits for other IOM recommended preventive services for
women may be found in this section under other sections of this chapter under
Special Benefits for Women and Prescription Drugs and Supplies.
Well-Being Connect Covered, for you and your covered dependents age 18 and older. Well-Being Connect is an online health portal that includes a well-being assessment that evaluates your health and lifestyle. The assessment helps you design a personal well-being plan that fosters healthy behavior.
Special Benefits for Children – Medical Care Newborn Circumcision Covered.
Well-Child Care Covered, from birth through age twenty-one including office visits for history, physical exams, sensory screenings, developmental/behavioral assessments, anticipatory guidance, lab tests, and immunizations. Well Child Care means routine and preventive care for children through age twenty-one. If your child needs medical care as the result of an illness or injury, physician visit benefits apply (and not well-child care benefits). See Physician Services earlier in this chapter.
Well Child Care Immunizations
Covered, in accord with Hawaii law and the guidelines set by the Advisory Committee on Immunization Practices (ACIP).
Laboratory Tests Covered, in conjunction with office visits, from birth through age twenty-one. Laboratory tests are covered during the well-child care period as identified on the American Academy of Pediatrics Periodicity Schedule of the Bright Futures Recommendations for Preventive Pediatric Health Care, in addition to one urinalysis through age five.
Well Child Care Physician
Office Visits Covered, including routine sensory screening, and developmental/behavioral assessments according to the American Academy of Pediatrics Periodicity Schedule of the Bright Futures Recommendations for Preventive Pediatric Health Care:
Birth to one year: seven visits Age one year: three visits Age two years: two visits
Age three years through twenty-one years: one visit per year
Special Benefits for Children – Pediatric Dental Care Pediatric Dental Care
Benefits Dental care benefits are available to children through age 18. Dental Care – Diagnostic
& Preventive Services Cleaning and
Polishing Covered, but limited to 2 per calendar year.
Please note: You may be eligible for additional services under the Enhanced
Dental Benefit program. See later in this section under Dental Care - Enhanced
Dental Benefits for more information.
Diagnostic Casts Covered for a cast impression of the teeth and jaw. Precertification is required. See Chapter 5: Precertification.
Exam Covered for clinical oral exams, but limited to 2 per calendar year.
Fluoride Covered for topical fluoride treatments (including fluoride varnish, but limited to 2 per calendar year).
Please note: You may be eligible for additional services under the Enhanced
Dental Benefit program. See later in this section under Dental Care - Enhanced Dental Benefits for more information
Sealants Covered for sealants applications for 1st and 2nd permanent molars, but limited to one every five years for ages 5 through 18 years.
Spacers Covered for fixed unilateral and bilateral spacers, but limited to 2 per day, up to 4 every 2 years. Recementation is limited to once per year.
X-rays Covered for radiographs and other diagnostic imaging, but limited to: 2 set of bitewings per calendar year
1 full-mouth x-ray with bitewings every 5 years
1 panoramic x-ray every 2 years which cannot be taken in conjunction with a full mouth x-ray
Cephalometric X-ray Covered for radiographic exam of the head, including mandible, in full lateral view used for making cranial measurements, but limited to 1 per day.
Precertification is required. See Chapter 5: Precertification. Intraoral Occlusal X-
Ray Covered, but limited to 1 per day.
Skull and Facial Bone
X-Ray Covered for posterior-anterior or lateral skull and facial bone survey radiographic images, but limited to 1 per day. Precertification is required. See Chapter 5:
Precertification.
Dental Care – Restorative Services (Fillings & Crowns)
Core Buildup Covered, including pins, but limited to permanent teeth only, excluding 3rd molar.
Fillings Covered for primary or permanent teeth. Includes amalgam and resin-based composite restorations and polishing. Coverage is limited to:
1 restoration per surface per tooth every 2 calendar years.
Precertification is required for posterior composite fillings of 3 surfaces or more. See Chapter 5: Precertification.
Metal Crowns Covered for crowns made of high noble metal, noble metal, predominantly base metal and titanium, but limited to:
1 per tooth every 5 years for permanent teeth excluding 3rd
molar.
Endodontic treatment, loss of one major cusp (posterior), or loss of not less than 40% of clinical crown (anterior).
Precertification is required. See Chapter 5: Precertification. Pin Retention Covered in addition to restoration, excluding 3rd molars. Porcelain Crowns Covered for porcelain fused to metal crowns, but limited to:
1 per tooth every 5 years for permanent teeth, excluding 3rd
molar. Endodontic treatment, loss of one major cusp (posterior), or loss of not less
than 40% of clinical crown (anterior).
Precertification is required. See Chapter 5: Precertification. Post and Core Covered for permanent teeth, excluding 3rd molar.
Prefabricated Crowns – Primary
Covered, but limited to primary teeth only – 1 per tooth per year. Prefabricated Resin
Crowns – Permanent Teeth
Covered, but limited to permanent teeth excluding 3rd molar – 1 per tooth per year. Limited to endodontic treatment, loss of one major cusp (posterior), or loss of not less than 40% of clinical crown (anterior). Precertification is required. See
Chapter 5: Precertification.
Prefabricated Stainless Steel Crowns – Permanent Teeth
Covered but limited to permanent teeth excluding 3rd molar – 1 per tooth per year. Precertification is required. See Chapter 5: Precertification.
Recementation of Inlay/Onlay & Crown
Covered for primary and permanent teeth, including 3rd molars, but limited to 1 per tooth per day.
Temporary Crowns Covered, but limited to fractured tooth emergencies in cases involving endodontic treatment, loss of at least one major cusp (posterior), or loss of no less than 40% of the clinical crown (anterior) and for permanent teeth, excluding 3rd molar.
Dental Care – Endodontic Services (Tooth Roots)
Apexification/Re- calcification
Covered for permanent teeth excluding 3rd molars. Includes initial, interim and final visit, but limited to 1 per tooth per lifetime.
lifetime. Includes complete root canal therapy including all appointments necessary to complete the treatment, clinical procedures and follow-up care for anterior, bicuspid, or molar teeth.
Endodontic
Retreatment Covered for retreatment of previous root canal therapy, in accord with our dental policies. Precertification is required. See Chapter 5: Precertification. Partial Pulpotomy Covered for permanent tooth with incomplete root development. Services are
limited to 1 per tooth per day per lifetime. Pulpotomy
(Therapeutic) Covered for primary and permanent teeth, excluding 3
rd
molar. Includes therapeutic pulpotomy, but not the final restoration. Services are limited to 1 per tooth per day per lifetime.
Dental Care – Periodontic Services (Gums & Jaw)
Full Mouth
Debridement Covered for the removal of heavy plaque and calculus to enable a comprehensive evaluation. Precertification is required. See Chapter 5: Precertification. Periodontal
Maintenance Covered for periodic maintenance following periodontal therapy to maintain periodontal health. Precertification is required. See Chapter 5: Precertification. Please note: You may be eligible for additional services under the Enhanced Dental Benefit program. See later in this section under Dental Care - Enhanced Dental Benefits for more information.
Scaling and Root
Planning Covered. Precertification is required. See Chapter 5: Precertification. Please note: You may be eligible for additional services under the Enhanced Dental Benefit program. See later in this section under Dental Care - Enhanced Dental Benefits for more information
Dental Care – Dentures (Artificial Teeth)
Adjustments Covered for full and partial dentures, but limited to once per day. Denture – Complete Covered for complete and immediate maxillary and mandibular dentures
(including routine post-delivery care), but limited to 1 per arch every 5 years. Precertification is required. See Chapter 5: Precertification.
Denture – Partial Covered for maxillary or mandibular partial denture resin base and cast metal frame, but limited to 1 per arch every 5 years. Precertification is required. See
Chapter 5: Precertification.
Denture Rebase Covered for complete and partial replacement of resin base material. Denture Repair Covered for complete repairs, partial denture base, partial denture cast
framework, repair or replace broken clasp, and adding tooth to partial denture, but limited to 1 per day.
Reline Procedure Covered for denture reline of a complete maxillary/mandibular denture after 1 year following the initial fitting of a new denture. Services are limited to once every 2 years. Precertification is required. See Chapter 5: Precertification. Replacement Covered for denture teeth replacement for broken or missing teeth on complete
or partial dentures, but limited to 3 teeth per day. Dental Care –
Maxillofacial Prosthetics Covered for prosthetic devices related to or affecting the upper jaw bone and face. Precertification is required. See Chapter 5: Precertification. Dental Care – Surgical
Services (Mouth, Face, Neck)
Alveoloplasty Covered for surgical preparation of ridge for dentures with or without extractions. Precertification is required. See Chapter 5: Precertification.
Tissue
Biopsy of Soft Tissue Covered for removal of soft tissue to prepare for pathological evaluation. Device to Aid
Eruption of an Impacted Tooth
Covered for an orthodontic device to guide eruption of an unerupted tooth after surgical procedure, but limited to permanent teeth only, excluding 3rd molars. Precertification is required. See Chapter 5: Precertification.
Excision of Bone
Tissue Covered.
Extractions Covered for simple extraction, surgical removal of erupted tooth, removal of soft tissue, partial bony and complete boney impactions, removal of complete bony impactions with complications, and surgical removal of residual roots, but limited to 1 per tooth for all primary and permanent teeth. Extractions related to orthodontic services are not covered.
Incisions Covered for surgical incision and drainage of abscess of intraoral soft tissue for all primary and permanent teeth.
Oral Surgery – Repair Covered for the excision of hyperplastic tissue or pericoronal gingival, but limited to frenectomy, frenotomy, or frenuloplasty.
Oral Antral Fistula
Closure Covered for closure of an opening between the maxillary sinus and oral cavity. Radical Excision Covered for removal of cyst, tumor or lesion up to 1.25 cm.
Removal of Cyst or
Tumor Covered.
Surgical Access of an
Unerupted Tooth Covered for surgical exposure of an impacted tooth not intended for extraction, but limited to permanent teeth only, excluding 3rd molar. Precertification is required. See Chapter 5: Precertification.