MTM Hawaii Medical Plan
At MTM, your health—and the health of your family—comes first. Our medical plans are designed to give you access to quality care, comprehensive coverage, and the wellness support you need to feel your best. From preventive services to everyday care and long‑term well‑being, MTM is here to support your whole health journey with compassion and care.
If you live in the state of Hawaii, you are eligible for the MTM Hawaii Medical Plan administered by UnitedHealthcare (UHC) using the UnitedHealthcare Options PPO Network. This plan includes comprehensive medical, pharmacy, behavioral health, and Hawaii‑mandated benefits. You are not eligible for the Basic, Select, and HDHP medical plans.
What the Plan Offers
- Plan Type: UnitedHealthcare Options PPO
- Network Required: To receive the best coverage, you must use in‑network providers. Out‑of‑network services cost more and may involve higher cost‑sharing.
Eligibility and Waiting Period
Eligibility
As an MTM employee, you are eligible for most benefits if you are scheduled to work at least 40 hours per week (20 hours per week for medical benefits). The exception to that is for the 401(k) Retirement Plan and Employee Assistance Plan, which are both eligible to all employees regardless of the hours you work.
The benefits you select during your new hire enrollment will remain in effect for the remainder of the calendar year. If you experience a Qualified Life Event (QLE), you may make a change in your enrollment(s) consistent with the event. For example, if you have a baby, you may enroll your baby in coverage when they are born. For more information on QLEs and the required enrollment timing, click on the link in the Learn More section.
Waiting Period
The waiting period for benefits varies based on your employee type and benefit plan. Review the chart below for details.
Qualified Dependents
You may enroll your eligible dependents for coverage once you are eligible. Your eligible dependents include:
Your legally married spouse or domestic partner
Your children up to age 26, (biological, adopted, step, those under your legal guardianship)
Disabled children may be covered after age 26 with appropriate documentation
Dependent Verification
If you are enrolling a dependent in a health plan, you must submit dependent proof as follows:
For Legal Spouse or Domestic Partner:
Marriage Certificate
Domestic Partner Affidavit
For Children:
Biological Child: Birth Certificate
Adopted Child: Birth Certificate or Adoption Certificate or Placement Agreement
Stepchild or Domestic Partner Child: Birth Certificate AND the spouse/domestic partner document
Guardianship: Birth Certificate AND court order document of guardianship
Disabled Child: Documentation listed above AND documentation required per the Health Plan.
Documentation must be scanned and uploaded in Workday and submitted with your enrollment election. Failure to provide the required documentation will result in your dependent not being enrolled in coverage.
If you have questions or want help understanding your options, reach out to the Benefits Team anytime by logging in to Workday and submitting a Help Ticket. We are happy to help.
Your Medical Network
UnitedHealthcare Options PPO Network
Your medical coverage uses the UnitedHealthcare Options PPO network. This network offers:
- A wide selection of in‑network doctors and specialists
- Access to major hospitals and care facilities
- No referrals needed to see a specialist
- Lower out‑of‑pocket costs when you stay in‑network
Why It Matters
Using in‑network providers gives you:
- Lower costs and predictable copays
- Full access to preventive services at 100%
- Better coordination of care within the network
Plan Costs at a Glance
You can view your benefit premiums in Workday during the enrollment event. Since costs vary based on the plan, your coverage level, and who you enroll, your premium will be tailored to your specific selections. For general rate information at any time, search “Employee Premiums” in the Workday search bar. Be sure to review your elections to see your exact cost.
Preventive Care – Covered at 100%
Preventive services—including annual physicals, well‑child visits, recommended screenings, and immunizations—are covered at 100% when using in‑network providers. This means no deductible, no copay, and no cost to you.
Costs You Pay
- Deductible: $100 per person / $300 per family annually (combined in‑ and out‑of‑network)
- Out‑of‑Pocket Maximum: $2,500 per person / $7,500 per family annually (includes deductible)
- Cost Sharing: Most services require a copay or coinsurance.
- In‑network: Typically 10% coinsurance
- Out‑of‑network: Typically 30% coinsurance and may include balance billing
Hospital & Emergency Care
- Emergency Room: 10% coinsurance; paid as in‑network for true emergencies.
- Urgent Care: 10% in‑network / 30% out‑of‑network
- Inpatient hospital: 10% in‑network
- Outpatient surgery: 10% in‑network
Mental Health & Substance Use Services
Covered for both inpatient and outpatient care, including:
- Individual, family, and group therapy
- Substance use treatment
- Residential and intensive outpatient programs
- Autism-related behavioral therapies (ABA) as required by Hawaii law
Cost sharing: 10% in‑network / 30% out‑of‑network.
Pharmacy Benefits
- Prescription coverage included through UHC’s Prescription Drug List (PDL).
- Retail (31-day supply):
- Tier 1: $10
- Tier 2: $30
- Tier 3: $50
- Mail order (90-day supply):
- Tier 1: $30
- Tier 2: $90
- Tier 3: $150
- Oral chemotherapy: Covered at 100% (no cost) for mail order.
- Some drugs require prior authorization or step therapy.
Hawaii‑Required Benefits
This plan includes all Hawaii‑mandated medical coverage, including:
- Autism Spectrum Disorder treatment (for dependents under age 14) — behavioral, psychological, and therapeutic services
- Blood and blood products
- In vitro fertilization (IVF) – one covered attempt if strict medical criteria are met
- Medical foods for metabolic disorders
- Orthodontic services for orofacial anomalies (e.g., cleft palate) — up to $5,500 per phase
- Telehealth services – covered the same as in‑person visits
Prior Authorization
Prior authorization is required for many services, especially out‑of‑network.
If not obtained when required, a $400 penalty per incident may apply (max $1,000/year).
Using Out‑of‑Network Providers
If you choose an out‑of‑network provider:
- You pay 30% coinsurance plus any amount billed above the Allowed Amount.
- You may need to submit your own claims.
- Prior authorization is your responsibility.
Need Help?
Members can contact UHC at 866-6333-2446 for benefit questions, provider searches, or clarification on coverage and prior authorization.
