Benefits & Costs

Families pay a quarterly contribution (every 3 months) for each child enrolled in Healthy Kids in addition to co-pays for services. Their costs depend on family income and family size.

The quarterly family contribution per child is between $0 and $90.
Mail payments to HPSM Finance Department

Co-pay

Some services do not have a co-pay, and for others the co-pay is between $5 and $15

For all children in one family enrolled in Healthy Kids, the maximum total amount in co-pays a family pays in a 12-month benefit period is $250. Ask for co-pay receipts and mail copies or fax to Member Services when you reach the $250 maximum.

Services from a licensed medical professional received during office visits, and home visits, for medically necessary reasons related to treatment and diagnosis of a medical condition are covered.

Cost:

• $5 to $15 co-pay for most services depending on income category
• $0 co-pay for services for babies 2 years and younger.

Not Covered
Services received at a medical office that is not in the HPSM provider network without getting a prior authorization for coverage from HPSM. Services from a specialist without getting a required referral from a primary care doctor, or prior authorization from HPSM.

Dental Services Provided Through Delta Dental

Covers preventive, diagnostic and restorative services. Maximum cost covered for services is $1,500 per member per 12-month period. Orthodontic services are not covered. Contact Delta Dental for questions about coverage and for assistance in choosing a dentist 1-866-527-9564.

Vision Services

Covers one comprehensive examination and one pair of eyeglasses (lenses and frames) in a 12-month period. Contact lenses are covered only as a substitute for eyeglasses, or if they are medically necessary. Frames are covered up to $75, and contacts with related services up to $110. Members are responsible for paying the difference when costs are higher.

Medicines prescribed by a licensed medical practitioner are covered.

• $5 or $10 co-pay for generic prescriptions, brand prescription if generic is not available or if brand name is medically necessary
• $15 co-pay for brand name if not medically necessary
• $0 co-pay for prescriptions received at a hospital, doctor’s office, or outpatient facility

Not Covered
Over-the-counter medicines that do not require a doctor’s prescription, including dietary supplements. Experimental medicines are also not covered.

Co-pay - $0

Routine check-ups, screenings, tests, immunizations for children, and other office visits with a primary care doctor to prevent problems or identify them early are covered. Some examples of preventive services are:

Not Covered:
Additional examinations/tests needed for school, sports, work, or reasons not related to a routine check-up. You will have to pay for the cost of additional preventive services that are not medically necessary.

See page 35 in the Healthy Kids Member Handbook for more information on preventive services.

Inpatient Care

Services received while hospitalized (inpatient care), including nursing care, and related to surgery are covered. These include a shared room and meals, intensive care unit, medications, anesthesia, lab tests, and other diagnostic, therapeutic, and rehabilitative services.

Cost: $0 co-pay for inpatient services.

Not covered:
Cost of a private room in hospital unless medically necessary.

Emergency Services

Covers services for an emergency medical condition received at any medical facility. Includes coverage for emergency services received outside of the HPSM service area and by a non-HPSM network facility.

Cost: $5 or $15 co-pay per emergency visit; $0 co-pay if you are admitted to a hospital

Not covered:
Non-emergency services received in the emergency room.