ohana membership manual

8/14/2019 Ohana Membership Manual

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Hawai`iMember Handbook

Caring for you and your

family

Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc.


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Customer Service: 1-888-846-4262 (TTY/TDD: 1-877-247-6272)

WELCOME TO OHANA!We are glad you joined our family! It is a smart move. Ohana is a managed care plan for Medicaidmembers who are aged, blind or disabled. You may have seen or heard about the changes inhealth care. Many people now get their health bene ts through managed care. Managed careplans like Ohana are contracted by the Department of Human Services to help provide quality,cost effective health care. We work with doctors, specialists, hospitals, labs and other health carefacilities that are a part of our provider network to provide the bene ts offered by Medicaid andto coordinate your health care needs. As a member, you will select a primary care provider (PCP).Your PCP will be your personal doctor. They will treat you for most of your health care needs andwill work with you to direct your health care (for more information on PCPs, see pages 8-10).

As you work with everyone at Ohana, you will see that we put you and your family rst, so youget better health care. Our members are our priority. We make every effort to make sure you getthe care you need to stay healthy.

This handbook will tell you more about your bene ts and how your health plan works. Please readit and keep it in a safe place. We hope it will answer most of your questions. For additional help,please call Customer Service at 1-888-846-4262 (TTY/TDD: 1-877-247-6272). We have friendly staff trained to answer all your questions. You can also visit the Web at www.ohanahealthplan.com.

Again, welcome to Ohana. We wish you good health!


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TABLE OF CONTENTSWELCOME TO OHANA!

GETTING HELP FROM THE PLAN 1

Help From Your Service Coordinator 1Help From Ohana Customer Service 2Other Important Phone Numbers 3

KEY WORDS FOR YOU TO KNOW 4

GETTING STARTED 81. Check your ID card and put it in a safe place 82. Getting to know your primary care provider (PCP) 83. Choosing your primary care provider (PCP) 94. Changing your PCP 95. How to get services before choosing or being assigned a PCP 106. Learn how to use your bene ts 107. Get to know your Personal Health Advisor 108. In an emergency 119. Ohana members have certain rights and responsibilities 1110. Call Ohana Customer Service for help 11

HOW TO GET YOUR COvERED SERvICES 12Cost-Sharing 12Covered Bene ts and Services 12

HOW TO GET APPROvED SERvICES 37Services that Require a Referral 37Services Available Without a Referral (Self-Referral Services) 37Services that Require Prior Authorization 38

Second Medical Opinion 39Pregnancy and Newborn Care 39Out-of-State and Off-Island Coverage 39


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Women, Infants and Children (WIC) Program 40Other Ohana Bene ts 40

Personal Health Advisor (24-Hour Nurse Hotline) 40Health Connections 41

Disease Management 42

EMERGENCY SERvICES 43What to Do in an Emergency 43Out-of-Area Emergency Care 44How to Get After-Hours Medical Care 44What to Do if You Need Urgent Care 44

HOW TO GET OTHER OHANA SERvICES 45

Prescription Drug Services 45Prescriptions and Pharmacy Access 45Preferred Drug List 45Over-the-Counter (OTC) Drugs 46

Dental 47Vision 47Transportation 48

ACCESS TO BEHAvIORAL HEALTH SERvICES 49What to Do if You Are Having a Problem 49What to Do in an Emergency or if You Are Out of the Ohana Service Area 49Obtaining Behavioral Health Services 50Behavioral Health Limitations and Exclusions 50

ACCESS TO MEDICAL SERvICES 51

IMPORTANT INFORMATION YOU SHOULD KNOW ABOUT OHANA 52

Enrollment 5290-Day Grace Period 52Annual Change 53


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Reinstatement 53Moving Out of the Ohana Service Area 54Involuntary Disenrollment 54Appeals and Grievance Coordinators and Assistance 55

QExA Ombudsman Program 55Quality and Member Satisfaction Information 56Plan Structure and Operations 56How Doctors Are Paid 56Grievance Information 56Fraud and Abuse 56What to Do When Your Family Size Changes 56Other Programs 57

WELL-CHILD CARE AND EPSDT (EARLY AND PERIODIC SCREENING,DIAGNOSIS AND TREATMENT) SERvICES 58What is a well-child checkup? 58Why is the well-child checkup important? 58When should a well-child checkup occur? 58How much does a well-child checkup cost me? 59What if I need help getting a doctor visit? 59What if I need help getting to the doctor visit? 59

PREvENTIvE HEALTH GUIDELINES 60Pediatric Preventive Health GuidelinesNewborn Up to 21 Years Old 6 1Adult Preventive Health Guidelines 64

ADvANCE DIRECTIvES 67Your Care Is Your Decision 67Advance Directives Help You Make Your Wishes Known 67Where can I get an advance directives form? 67


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MEMBER GRIEvANCE AND APPEAL PROCEDURES 68What is a grievance? 68How do I make a grievance? 68State Grievance Review 69

What is an appeal? 69How do I make an appeal? 69What if I need a fast (expedited) appeal? 70What if I do not like an appeal decision? 70Other Rights 71

OHANA MEMBER RIGHTS AND RESPONSIBILITIES 72

NOTICE OF PRIvACY PRACTICES 76


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2 Customer Service: 1-888-846-4262 (TTY/TDD: 1-877-247-6272)

Once your service coordinator has contacted you, you will get a reminder letter in the mail. It willhave the contact information for your service coordinator, as well as the details about your face-to-face visit. You can also write down this information here:

My Ser ice Coordinators Name: ___________________________________________________

Phone Number: ________________________________________________________________

Help From Ohana Customer Ser iceYou can call Customer Service Monday through Friday from 7:45am to 5:30pm HST. Call withquestions about:

Bene ts

Replacing a lost ID card

Filing a complaint

Changing your doctorGetting a list of doctors in the Plan

Getting a list of drug stores in the Plan

Getting materials in a different language or format

Customer Service Toll-Free Phone Number: 1-888-846-4262 (TTY/TDD: 1-877-247-6272)

You can also contact Customer Service by writing to:Customer Service

P.O. Box 31370Tampa, FL 33631-3370

If you do not speak English, we can help. We want you to know how to use your health care planno matter what language you speak. Just call us and we will nd a way to talk to you in your ownlanguage. We have translation services available. We also have information in large print, Brailleand audible media. All of these services are available at no cost. Our TTY/TDD phone number is1-877-247-6272.


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3Customer Service: 1-888-846-4262 (TTY/TDD: 1-877-247-6272)

Other Important Phone Numbers

Contact Name Phone Number

24-Hour Health Advisor Line 1-800-919-8807

TTY/TDD 1-877-247-6272Service Coordination 1-888-846-4262 (TTY/TDD: 1-877-247-6272)

Transportation 1-888-846-4262 (TTY/TDD: 1-877-247-6272)

Behavioral Health 1-888-846-4262 (TTY/TDD: 1-877-247-6272)

Dental 1-888-846-4262 (TTY/TDD: 1-877-247-6272)

Vision (Block Vision) 1-800-879-6901

Hearing 1-888-846-4262 (TTY/TDD: 1-877-247-6272)

Pharmacy 1-888-846-4262 (TTY/TDD: 1-877-247-6272)

Hawaii Med-QUEST Division 1-808-586-5390


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KEY WORDS FOR YOU TO KNOWAd ance Directi eA legal paper that tells your doctor and family how you wish to be cared for when you are illand might need life-prolonging care. It goes into effect when you are so ill that you cannot make

decisions for yourself.

AppealRequests you make when you do not agree with our decision to deny, cut back or end a service.Someone who represents you can also ask for an appeal.

Bene tsHealth care that is covered by Ohana.

Complaint (same as Grie ance)When you let us know that you are not satis ed. You can do this in writing or tell us verbally. Acomplaint can be led with or without justi cation.

Cost-SharingHow much you must pay when getting care from Ohana providers.

DisenrollmentWhen you no longer wish to be a part of our plan, and the steps to follow to leave Ohana.

Durable Medical EquipmentMedical items such as wheelchairs and oxygen tanks.

EmergencyA very serious medical condition. It must be treated right away.

En ironmental Accessibility AdaptationsPhysical changes to the home that are needed to ensure your health, welfare and safety. Alsohelps you function on your own in the home.


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EPSDT (Early and Periodic Screening, Diagnosis and Treatment) Well-Child visitsRegular health exams for children. They are used to nd and treat medical problems.

Generic DrugA drug that has the same basic ingredients as a brand-name drug.

Grie ancesWhen you let us know you are not satis ed with a provider, the Plan or a bene t. You can do thisin writing or tell us verbally.

Home Health AgencyA company that provides health care services in your home. These services are things such asnursing visits or therapy treatments.

Health Maintenance Organization (HMO)A company that works with a group of doctors, pharmacies, labs and hospitals. They do this togive quality health care to their members (see also Managed Care Plan).

ImmunizationsShots that keep a child safe from many serious diseases. There are some shots your child has toget before they can start day care or school in Hawai`i.

InpatientA person who stays in a hospital for a period of time. This is usually longer than 24 hours.

Long-Term CareCare and help for elderly or disabled people. It may take place at home, in the community or itmay take place in an institution.

Managed Care PlanA plan that you can choose to help you with all your health care needs. Managed care planslike Ohana work with you, your PCP and other health providers to coordinate your health care.Providers include clinics, doctors, hospitals, pharmacies and others.

Medically Necessary Ser icesMedical services that are needed for you to get well and stay healthy.


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Med-QUEST Di ision (MQD)A division of the State Department of Human Services. It administers the Medicaid programs,including QExA.

MemberA person who has joined Ohana.

Ohana ID CardAn ID card that shows you are a member of Ohana.

OutpatientA person who gets medical treatment, usually at a hospital, but does not need to stay overnight.

O er-the-Counter Drugs

Drugs you can buy that are not behind the drug store counter and may not require a doctorsorder.

Pharmacy NetworkA group of drug stores that members can use.

Post StabilizationServices related to an emergency medical condition that are provided after you are stabilized inorder to maintain or improve your condition.

Preferred Drug List (PDL)Medicines approved by Ohana doctors and pharmacists. These drugs work best, are safe and costless. The Plan also has medicines it does not approve. The PDL shows doctors which drugs arebest to use.

Prescription MedicineA drug for which your doctor writes an order.

Primary Care Pro ider (PCP)Your personal doctor. He or she manages all your health care needs.

Prior AuthorizationWhen Ohana has to okay treatment or medicines ahead of time.


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Pro idersThose who work with the Plan to give medical care. This includes doctors, hospitals, pharmacies,labs and others.

QUEST Expanded Access (QExA)A managed care program. It offers all acute and long-term care services to those eligible as aged,blind or disabled (ABD) under the Medicaid State Plan.

ReferralWhen your PCP or service coordinator sends you to see another health care provider.

SpecialistA doctor who works in a speci c eld of medicine.

TreatmentThe care you get from doctors and facilities.

WIC (Women, Infants and Children)A program that works with women, babies and children. It helps them with nutrition.


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GETTING STARTEDIts easy to get started. Follow these steps. You will be on your way to getting the care you need.

1. Check your ID card and put it in a safe place

You should have received your Ohana member ID card in the mail. Keep this card and yourMedicaid card with you at all times.

You will need your ID card each time you get medical services. This means that you need yourcard when you:

See your primary care provider (PCP)

See a specialist or other provider

Go to an emergency room

Go to an urgent care facility

Go to a hospital for any reason

Get medical supplies

Get a prescription

Have medical tests

Call Ohana Customer Service as soon as possible at 1-888-846-4262 (TTY/TDD: 1-877-247-6272) if:You have not received your card(s) yet.

Any of the information on the card(s) is wrong.

You lose your card(s).

Someone can help you weekdays, 7:45am to 5:30pm HST.

2. Getting to know your primary care pro ider (PCP)Your PCP is your personal doctor. Call your PCP as soon as possible to schedule a physical. YourPCP will treat you for most of your health care needs. Your PCP will work with you to direct yourhealth care. Your PCP will do your checkups and shots and treat you for most of your health careneeds. You can reach your PCP by calling their of ce. Your PCPs name and telephone number are

printed on your ID card.

PC P Name : [ Dr. F irs t Las t Name ]

PC P Group Name : [ Group N

ame ]

[ PC P S tree t Address 1 ] [ PC P S tree t Address 2 ]

[ C i t y, S T Z ip ] PC PP hone : [ X X X- X X X-

X X X X ]

T P L : [ Mu tua l o f Oma ha ]

Mem ber Name : [ F irs t MI Las t Name ]

Mem ber I D : 000000000000

Med ica id I D : 000000000000

E f fec t i ve Da te : [ X X / X X / X X X X ] E PS D T : [ Y ES / NO ]


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Our PCPs are trained in different specialties. They include:Family medicine

General practice

Geriatrician

Internal medicine

Pediatrics

OB/GYN (obstetrics/gynecology)

Advanced Practiced Registered Nurse

Pregnant? You can choose an OB/GYN (obstetrics/gynecology) as your PCP.

There are also times when a specialist can be your PCP, provided:

You have a chronic condition and have a historical relationship with the PCP; andThe specialist agrees in writing to assume the responsibilities of the PCP.

3. Choosing your primary care pro ider (PCP)Ohana members must choose a primary care provider (PCP). You may have done this already.If not, you will need to ll out the Member Data Change form. This form came with your newmember welcome letter. You have 15 days from the date the letter was received to return theform (not including mail time). You can also call Customer Service at 1-888-846-4262(TTY/TDD: 1-877-247-6272) Monday through Friday, 7:45am to 5:30pm HST. Or visit the Web atwww.ohanahealthplan.com to select a PCP.

A PCP will be assigned to you unless you pick one within 15 days of getting your new memberwelcome letter. The assignment will be based on the following:

Where you may have received services before

Where you live

Your language preference

Availability of the PCP (if the PCP is accepting new patients)

Gender (in the case of an OB/GYN, as the available PCP)

4. Changing your PCPIf you would like to change your PCP, you can visit our Web site at www.ohanahealthplan.com orcomplete the PCP change form that was included with your new member welcome letter. Youcan also call Customer Service at 1-888-846-4262 (TTY/TDD: 1-877-247-6272). Customer Servicecan be reached Monday through Friday from 7:45am to 5:30pm HST.


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You can change your PCP at any time. If the change is made between the 1st and 10th of themonth, it will immediately become effective. Changes made after the 10th of the month willbecome effective the 1st of the following month.

Once your change is received, we will send you a new ID card. We will also send a letter to let you

know your PCP has been changed. The letter will tell you the date you can start seeing the newPCP. Please continue to use your old card to receive services until your new card arrives in themail.

For a list of our PCPs:Look in your provider directory

Visit our Web site at www.ohanahealthplan.com

Call Customer Service at 1-888-846-4262 (TTY/TDD: 1-877-247-6272)

5. How to get ser ices before choosing or being assigned a PCPYou can get services after joining Ohana but before you have a PCP. Just look in the providerdirectory that came with this packet. Then select a provider that is a part of the Plans network.You can also view a list of providers on the Web at www.ohanahealthplan.com.

Call to set up an appointment and tell them you are an Ohana member. Show them yourwelcome letter when you arrive for your visit. Your welcome letter will include your member IDnumber and will provide proof of your membership with Ohana.

You can also call Customer Service at 1-888-846-4262 (TTY/TDD: 1-877-247-6272). They will helpyou get the services you need until your ID card arrives with the PCP you have chosen or wereassigned.

6. Learn how to use your bene tsIts easy to use your bene ts. Please read the How to Get Your Covered Services section of thishandbook. It will tell you about your covered services. It will tell you how to access care. You willalso nd information on extra bene ts you receive as a member.

7. Get to know your Personal Health Ad isorOhana has Personal Health Advisors. They can answer your health care questions. Call them when

you are not sure what kind of care you need. It is a free service. Call 24 hours a day, 7 days a week.Call 1-800-919-8807. Learn more about how your Personal Health Advisor can help you on page 40.


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8. In an emergencyFor a MEDICAL EMERGENCY, go to the hospital or call 911. Please read theEmergency Services section of this book. It tells you how you get care. It also gives examples of emergencies.

9. Ohana members ha e certain rights and responsibilitiesYou have certain rights as a plan member. You also have some responsibilities. This booklet tellsyou what they are (see page 72). Please make sure to read them.

10. Call Ohana Customer Ser ice for helpQuestions? Call us. We can get translators for all languages. We have materials available in Ilocano,Tagalog, Mandarin Chinese, Korean, large print, audio tapes and Braille. Sign language services arealso available for visually or hearing-impaired members. All of these services are available at nocost. Call 1-888-846-4262 (TTY/TDD: 1-877-247-6272) weekdays from 7:45am to 5:30pm HST.You can:

Ask for ID cardsChange your doctor

Ask questions about your bene ts

Get a list of doctors in the Plan

Get a list of drug stores in the Plan

You can also contact Customer Service by writing to:

Customer ServiceP.O. Box 31370

Tampa, FL 33631-3370

You are now ready to begin using all of the bene ts you get with Ohana. We look forward toserving you.


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HOW TO GET YOUR COvERED SERvICESMembers get care from PCPs, hospitals and others who contract with the Plan. Ohana coversprimary, acute, behavioral health and long-term care services that are covered by Medicaid.

Cost-SharingMembers may have to share in the cost of health care services. This happens when certainnancial eligibility requirements are not met. A Hawai`i eligibility worker will nd out your cost-sharing portion and let the Plan know. We will let you know how much you have to pay yourdoctors and other providers or the Plan for health care services. The part you owe will be listedon your Explanation of Bene ts. It will tell you how much you have to pay and whom you have topay it to.

For covered services, your provider can only bill you for your cost-sharing portion, as listed on theExplanation of Bene ts you will get from Ohana.

Providers may bill a member other fees or charges: When a member goes to a specialist without a referral or other provider within the networkwithout following plan procedures

When the member and provider have an agreement about self-referrals or services that are notcovered

Providers may not bill a member when they do not follow the Plan procedures and as a result donot get paid.

Not paying for services that are not covered will not result in a loss of Medicaid bene ts.

Co ered Bene ts and Ser icesAs an Ohana member, you will continue to get all medically necessary Medicaid covered services.A list of covered services can be found in the following table:


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Bene ts Coverage and Limits

Beha ioral HealthOutpatient Mental Covered services include all medically necessaryHealth and Substance Abuse behavioral health services for QExA adult and

child members. These services include: 24-hour-a-day care for acute psychiatric

illnesses, including:- Room and board- Nursing care- Medical supplies and equipment- Diagnostic services- Physician services- Other practitioner services, as

needed

- Other medically necessary services Ambulatory services, including

24-hours-a-day, 7-days-a-week crisisservices

Acute day hospital/partialhospitalization, including:

- Medication management- Prescribed drugs- Medical supplies- Diagnostic tests- Therapeutic services, including

individual, family and group therapyand aftercare

- Other medically necessary services Methadone treatment services, which

include the provision of methadoneor a suitable alternative (e.g. LAAM), aswell as outpatient counseling services

Prescribed drugs (excluding Clozarilor Clozapine), including medicationmanagement and patient counseling


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Bene ts Coverage and Limits Diagnostic/laboratory services,

including:- Psychological testing- Screening for drug and alcohol

problems- Other medically necessary

diagnostic services Psychiatric or psychological evaluation Physician services Rehabilitation services Occupational therapy Other medically necessary therapeutic

services

*There are no limits on isits ormedication for children and adults.

Outpatient Hospital Services This service includes 24-hour-a-day,7-days-per-week care for:

Emergency services Ambulatory center services Urgent care services Medical supplies

Equipment and drugs Diagnostic services Therapeutic services

Inpatient Hospital Services 30-day limit for members over 21 years old. No limit for membersunder 21.


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Physical Health Acute Inpatient Hospital Care Includes the cost of room and board for

inpatient stays for: Nursing care Medical supplies Equipment Drugs Diagnostic services Physical and occupational therapy Audiology Speech-language pathology services

Outpatient Hospital Care This service includes 24-hour-a-day,

7-days-per-week care for: Emergency services Ambulatory center services Urgent care services Medical supplies Equipment and drugs Diagnostic services Therapeutic services (including

chemotherapy and radiation therapy)

Cognitive Rehabilitation Services Services provided to cognitively-impairedpersons that assess and treat the following:

Communication skills Cognitive and behavioral ability Cognitive skills related to performing

ADLS

Covered services include assessments completedat regular times (determined by the provider andaccording to the members needs).

Cornea Transplants and Cornea transplants (keraplasty)Bone Graft Services

(Bone graft is an orthopedic procedure and isnot part of the transplant program.)


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Bene ts Coverage and Limits Brief and comprehensive visits Pregnancy testing Contraceptive supplies and follow-up

care Diagnosis and treatment of sexually

transmitted diseases Infertility assessment

Health Education and Counseling Substance use, including: Alcohol Diet and exercise Injury prevention Sexual behavior

Dental health Family violence and depression

Home Health Services Some home health services included are: Skilled nursing Home health aides Medical supplies Physical and occupational therapy Audiology and speech-language

pathology

Hospice Services Provides care to terminally ill patients who have 6 months or less to live.

Medicaid services provided to membersreceiving Medicare hospice services that areduplicative of Medicare hospice bene ts are notcovered. Examples would include personal careand homemaker services. This is only coveredwhen the service need is not related to the

hospice diagnosis.


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Maternity Services Covers: Prenatal care Prenatal laboratory screening tests Diagnostic tests Treatment of missed, threatened and

incomplete abortions Delivery of infant Postpartum care Prenatal vitamins

Cesarean Delivery 4-day stay after delivery

Vaginal Delivery 2-day stay after vaginal delivery

Physician Services Services must be medically necessary andprovided at locations including but not limited to:

Physicians of ces Clinics Private homes Licensed hospitals Licensed skilled nursing facility Intermediate care facility Licensed or certi ed residential setting

Other Practitioner Services Covered services include but are not limited to: Certi ed nurse midwife services Licensed advanced practice registered

nurse services (including family,pediatric, geriatric, psychiatric healthspecialists)

Other medically necessary practitionerservices provided by a licensed orcerti ed health care provider



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Bene ts Coverage and LimitsPrescription Drugs Covers all drugs listed on the Plans

Prescription Drug List (PDL).

Preventive Services Services include:

Initial and interval histories Comprehensive physical examinations

(including developmental services) Immunizations Family planning Diagnostic and screening laboratory X-ray services (including screening for

tuberculosis) Personal Assistance ServicesLevel 1 Covered for members that need help with

key daily activities who do not meet aninstitutional LOC.

Services include companions and homemakers.

Companions are de ned as those who may helpor supervise the member with such tasks as:

Meal preparation Laundry Shopping

Errands Light housekeeping tasks

Homemakers may perform the following dutiesfor members, but not others in their household:

Routine housecleaning such assweeping, mopping, dusting, makingbeds, cleaning the toilet and shower orbathtub, taking out rubbish


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Bene ts Coverage and Limits Care of clothing and linen by washing,

drying, ironing, mending Marketing and shopping for household

supplies and personal essentials (notincluding cost of supplies)

Light yard work such as mowing thelawn

Simple home repairs such as replacinglight bulbs

Preparing meals Running errands such as paying bills,

picking up medication Escort to clinics, physician of ce visits

or other trips for the purpose of obtaining treatment or meeting needsestablished in the service plan, when noother resource is available

Standby/minimal assistance orsupervision of activities of daily livingsuch as bathing, dressing, grooming,eating, ambulation/mobility andtransfer

Reporting and/or documentingobservations and services provided,

including observation of memberself-administered medications andtreatments, as appropriate

Reporting to the assigned provider,supervisor or designee observationsabout changes in the membersbehavior, functioning, condition or self-care/home management abilities thatnecessitate more or less service


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Radiology/Laboratory/ Covered services include:Other Diagnostic Services Diagnostic

Therapeutic radiology and imaging Screening and diagnostic laboratory

tests

Radiology exclusions: Radiologyultrasounds for gender

determination

Laboratory and diagnostic exclusions: Experimental In estigational or generally unpro en Chromosomal e aluations IgG4 testing Procedures related to storing,

preparation and transfer of oocytes forin itro fertilization

Rehabilitation Services Covered services include: Physical and occupational therapy Audiology and speech-language

pathology

Sterilizations and Hysterectomies Covered for members 21 and older only

Sterilizations Covered for both men and women if you are: At least 21 years of age at the time

consent is obtained Mentally competent Voluntarily gives informed consent by

completing the Informed Consent forSterilization

Provider completes the SterilizationRequired Consent Form


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Hysterectomies Covered under the following requirements: Voluntarily by the member (must

complete the HysterectomyAcknowledgement Form)

The member has been told orally andin writing that the hysterectomy willrender the individual permanentlyincapable of reproducing

The member has signed and dated aPatients Acknowledgement of PriorReceipt of Hysterectomy InformationForm before the hysterectomy

Transportation Services The Plan provides both emergency and non-

emergency ground and air services to and frommedically necessary medical appointments formembers who:

Have no means of transportation Reside in areas not served by public

transportation Cannot access public transportation

due to their disability

Out-of-State and Off-Island Coverage The Plan provides any medically necessary

covered services that are required. This includes: Referrals to an out-of-state or off-island specialist or facility

Transportation to and from the referraldestination

Lodging Meals Member attendant (if needed)

Urgent Care Services Covered as medically necessary. No prior

authorization is required.


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Vision Services The Plan provides eye and vision services formembers:

Younger than 21once per year 21 and olderonce every 2 years

More visits are allowed, depending on thesymptoms or medical condition.

Covered services include: Vision examinations Prescription lenses Cataract removal Prosthetic eyes are covered for all

members Ophthalmologic exam with refraction Visual aids (eyeglasses) Contact lenses and miscellaneous vision

supplies (if medically necessary)

This includes the costs for the lens,frames, or other parts of the glasses.Fittings and adjustments are also covered.

New lenses:

Adultsonce every 2 years Less than 21once every year

Replacement glasses and/or new glasses withmajor changes in prescription are covered withinthe bene t periods for both adults and children.


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Long-Term CareHome andCommunity-Based Ser ices

Adult Day Care Adult day care refers to regular supportivecare provided to 4 or more disabled adultparticipants.

Services include: Observation and supervision by center

staff Coordination of behavioral, medical and

social plans and implementation of theinstructions as listed in the participantscare plan

Therapeutic, social, educational,

recreational activitiesExclusions:Adult day care staff members may not performhealth care-related ser ices, such as:

Medication administration Tube feedings and other acti ities

which require health care-relatedtraining

All health care-related activities must be

performed by quali ed and/or trainedindividuals only. This includes:

Family members Professionals (such as an RN or LPN,

from an authorized agency)

Adult Day Health Adult day health services are organized dayprograms for therapeutic, social and healthservices provided to adults with physical ormental impairments (requires nursing oversight

or care). This also includes:Bene ts Cove


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Bene ts Covege Emergency care Dietetic services Occupational therapy

Physical therapy Physician services Pharmaceutical services Psychiatric or psychological services Recreational and social activities Social services Speech-language pathology Transportation services

Assisted Living Services Assisted living services include: Personal care Supportive care services (homemaker,

chore, attendant services and mealpreparation)

Payment for room and board isprohibited

Attendant Care Refers to the hands-on care for medically fragilechildren.

The service includes member supervisionspeci c to the needs of a medically stable,physically disabled child.

Attendant care may include skilled or nursingcare to the extent permitted by law. Attendantcare services may be self-directed.

Community Care Management Covered for members living in Community Agency (CCMA) Services Care Foster Family Homes and other

community settings, as required.

Includes the following activities:Bene ts Coverage and Limits


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Bene ts Coverage and Limits Continuous and ongoing nurse delegation to

the caregiver Initial and ongoing assessments to make

recommendations to health Ongoing face-to-face monitoring and

implementation of the members careplan

Interaction with the caregiver onadverse effects and/or changes incondition of members

Community Care Foster Family Covered services include:Home (CCFFH) Services Personal care

Supportive services Homemaker services Chore services Attendant care Companion services Medication oversight (to the extent

permitted under state law)

All services must be provided in a certi edprivate home by a principal care provider wholives in the home.

CCFFH services are given to up to 3 adults whoget these services while living in the home.

Counseling and Training Counseling and training activities include thefollowing:

Member care training for members Family and caregivers regarding the

nature of the disease and the diseaseprocess

Methods of transmission and infectioncontrol measures


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Bene ts Coverage and Limits Biological, psychological care and

special treatment needs/regimens Employer training for consumer-

directed services and instruction aboutthe treatment regimens

Use of equipment speci ed in theservice plan employer

Skills updates as necessary to safelymaintain the individual at home

Crisis intervention Supportive counseling Family therapy Suicide risk assessments and

intervention Death and dying counseling Substance abuse counseling Nutritional assessment and counseling

Counseling and training is a serviceprovided to:

Members Families/caregivers on behalf of the

member

Professional and paraprofessionalcaregivers on behalf of the member

Environmental Accessibility Adaptations Covered services include: The installation of ramps and grab-bars Widening of doorways Modi cation of bathroom facilities Installation of specialized electric

and plumbing systems (must benecessary to accommodate the

medical equipment and supplies thatare necessary for the welfare of theindividual)


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Bene ts Coverage and LimitsWindow air conditioners may be installed whenneeded for the health and safety of the member.

Exclusions:

Adaptations or impro ements to thehome that are of general utility

Adaptations which add to the totalsquare footage of the home

All services shall comply with state or localbuilding codes.

Home-Delivered Meals Includes nutritious meals delivered toa location where an individual resides (excluding

residential or institutional settings).

The meals will not replace or substitute for a fulldays nutrition (i.e., no more than 2 meals perday).

Meals are provided to: Individuals who cannot prepare

nutritionally sound meals without help Individuals who need the service to

remain independent in the communityand to avoid being placed in aninstitution

Home Maintenance Home maintenance services are those servicesnot included as a part of personal assistance andinclude:

Heavy-duty cleaning to bring a home upto acceptable standards of cleanliness atthe start of service to a member

Minor repairs to essential appliances,

limited to stoves, refrigerators and waterheaters

Fumigation or extermination services


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Bene ts Coverage and LimitsHelp with cleaning and minor repairs will begiven to those who need it.

Medically Fragile Day Care Medically fragile day care is a non-residential

service for children who are medically and/ortechnology dependent.

Covered services include activities focused onmeeting the following needs for children:

Psychological Physical Functional Nutritional Social

Services are furnished 4 or more hours a day ona regular schedule for 1 or more days a week inan outpatient setting.

Moving Assistance Help moving is offered when the servicecoordinator nds that a member needs to moveto a new home. This includes:

Unsafe home due to deterioration The individual is wheelchair bound,

living in a building with no elevator,multi-story building with no elevatoror where the client lives above the rstoor

Member is evicted from his or hercurrent home

Member can no longer afford the homedue to a rent increase

Moving expenses include packing and moving of belongings.


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Non-Medical Transportation This service helps members travel asspeci ed by the member care plan. It helpsmembers get to community services, activitiesand resources.

Whenever possible, those who can offerthis service without cost will be used. Theyinclude family, neighbors, friends or communityagencies.

Exclusion:Members li ing in a residential care setting or aCCFFH are not eligible for this ser ice.

Personal Assistance ServicesLevel 2 Covered for those who need help with daily

activities and keeping up their health.

This level of service is to be provided by a HomeHealth Aide (HHA), Personal Care Aide (PCA),Certi ed Nurse Aide (CNA) or Nurse Aide (NA)with applicable skills.

Some activities include: Personal hygiene and grooming,

including bathing, skin care, oralhygiene, hair care and dressing

Help with bowel and bladder care Help with mobility Help with transfers Help with medications Help with routine or maintenance

health care services by a personal careprovider

Help with feeding, nutrition, mealpreparation and other dietary activities

Help with exercise, positioning andrange of motion


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Bene ts Coverage and Limits Taking and recording vital signs,

including blood pressure Measuring and recording intake and

output, when ordered Collecting and testing specimens as

directed

Personal Emergency Response PERS are devices to help members who are atSystems (PERS) a high risk of having to go the hospital. They can

get help in case of an emergency.

PERS items include: 24-hour answering/paging

Beepers Med-alert bracelets Intercoms Life-lines Fire/safety devices such as re

extinguishers and rope ladders Monitoring services Light xture adaptations

(blinking lights, etc.) Telephone adaptive devices not

available from the telephone company Other electronic devices or services

designed for emergency assistance

PERS services are limited to those individuals: Who live alone Who are alone for signi cant parts of

the day Who have no regular caregiver for

extended periods Who would otherwise need extensive

routine supervision


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Bene ts Coverage and LimitsPERS services will only be offered to a memberliving in a non-licensed setting.

Private-Duty Nursing Covered for those who need ongoing nursing

care.

The service is provided by licensed nurses withinthe scope of state law.

Residential Care Residential care is provided in a licensed privatehome by a principle care provider who lives inthe home. He or she gives the following servicesto members:

Personal care services Homemaker, chore, attendant care and

companion services Medication oversight (to the extent

allowed by law)

Respite Care Respite care is short-term based care. Itprovides relief to caregivers. It may be providedhourly, daily and overnight.

Respite care may be provided in the followinglocations:

Members home or place of residence Foster home or expanded-care adult

residential care home Medicaid-certi ed nursing facility Licensed respite day care facility Other community care residential

facility approved by the Plan

Respite care services are authorized by themembers PCP as part of the members care plan.Respite services may be self-directed.


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Specialized Medical Equipment Refers to the purchase, rental, lease,Warranty and Supplies costs, installation, repairs and removal of devices,

controls or appliances speci ed in the care plan.

This also includes: Items necessary for life support Supplies and equipment needed for the

proper functioning of such items Durable and non-durable medical

equipment not available under theMedicaid state plan

Examples include: Specialized infant car seats

Modi cation of parent-owned motorvehicle to accommodate the child, i.e.wheelchair lifts

Intercoms for monitoring the childsroom

Shower seat Portable humidi ers Electric bills speci c to electrical life

support devices (ventilator, oxygenconcentrator)

Medical supplies


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Bene ts Coverage and Limits Long-Term CareInstitutional Ser ices

Nursing Facility Services Covered for members who need 24-hour-a-dayhelp with ADLs and IADLs. These members needregular, long-term care from licensed nurses andparamedical personnel.

The care that is provided in a nursing facilityincludes:

Independent and group activities Meals and snacks Housekeeping and laundry services Nursing and social work services Nutritional monitoring and counseling Pharmaceutical services and

rehabilitative services

Non-Covered Services Exceptions/Limits

Behavioral HealthMembers:

Whose diagnostic, treatment orrehabilitative services are determinednot to be medically necessary by thehealth plan

Who have been determined eligible forand have been transferred to the DOHsAdult Mental Health Division (AMHD)for services

Who have been determined eligiblefor and have been transferred tothe Behavioral Health Managed Care(BHMC) Plan

Who have been determined eligible for

and have been transferred to the DOHsChild and Adolescent Mental HealthDivision (CAMHD) for services


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Non-Covered Services Exceptions/Limits Who have been criminally committed

for evaluation or treatment in aninpatient setting under the provisionsof Chapter 706, HRS

(Members that fall into one of the categories above will be disenrolled from the programs and will become the clinical and nancialresponsibility of the appropriate state agency.)

Cosmetic Procedures Not covered

Home Health Services Medicaid home health services will not becovered when they are already covered byMedicare home health bene ts.

Hysterectomies Not covered when: Performed solely for the purpose of

rendering a member permanentlyincapable of reproducing

There is more than 1 purpose forperforming the hysterectomy (butthe primary purpose is to render themember permanently incapable of reproducing)

It is performed for the purpose of cancer prophylaxis

Investigational and Experimental Not covered Procedures

Medical Care in a Foreign Country for Not coveredChildren or Adults

Pain Management Not covered


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Non-Covered Services Exceptions/Limits

Radiology/Laboratory/ Non-covered services include: Other Diagnostic Services Radiology servicesultrasounds for

gender determination

Laboratory and diagnostic services: Experimental Investigational or generally unproven Chromosomal evaluations IgG4 testing Procedures related to storing,

preparation and transfer of oocytes forin vitro fertilization

Transplant Services May be covered by DHS through the Stateof Hawaii Organ and Transplant (SHOTT)Program. State limits transplant coverage to non-experimental, non-investigational procedures forthe speci c organ/tissue and speci c medicalcondition.

The Plan will assist with a referral to the SHOTTProgram when medically appropriate.

Vision Services Non-covered services include: Orthoptic training Prescription fee, progress exams Radial Keratotomy, visual training and

Lasik procedure Contacts for cosmetic reasons


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HOW TO GET APPROvED SERvICESSer ices that Require a ReferralYour PCP or plan will need to approve for you to get certain services. These include:

Services that your PCP does not perform

Specialist visits at an of ce or free-standing clinic

Mental health and substance abuse assessments (approval needed from the health plan only)

Services referred by your PCP must be in writing before services can be performed.

Ser ices A ailable Without a Referral (Self-Referral Ser ices)You do not need approval from your PCP or your plan for these services:

Emergency and urgent care services

Routine checkups and treatment from your assigned PCP (12 visits per year for adults over 21years old)

Routine diagnostic tests

Lab tests

Basic radiology services

EPSDT and treatment visits for children up until their 21st birthday

Annual wellness visit for women, including a Pap smear

Routine dental

Routine vision

You can go to any Ohana provider to receive the services listed above. Just call the provider of choice and set up an appointment. Tell them that you are an Ohana member and show themyour ID card at your visit.

You can nd a list of providers on the Web at www.ohanahealthplan.com. You can also callCustomer Service at 1-888-846-4262 (TTY/TDD: 1-877-247-6272) and request a hard copy.


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Ser ices that Require Prior AuthorizationThe following services need to be approved by Ohana before you can get them. This is calledprior authorization. Your PCP or specialist will contact us to ask for this approval. If we do notapprove them, we will notify you. We will give you information about the grievance and appealsprocess and your right to a state hearing.

Medical equipment that costs over $ 200

Therapy services (occupational, physical and speech)

Home health services

Most medical tests done by your PCP or specialist

Inpatient hospital admissions

Outpatient observations

Inpatient mental health and alcohol or substance abuseServices performed in an outpatient or ambulatory surgery setting

Cardiac and pulmonary rehabilitation programs

Chemotherapy

Cosmetic procedures

Hospice services

Investigational and experimental procedures and treatments

Outpatient alcohol and substance abuse

Radiology services

Transportation (non-emergent)

Sterilization

If your PCP, service coordinator or plan representative does not arrange for or approve care thatrequires a prior authorization, you will have to pay for it.


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Second Medical OpinionCall your PCP to get a second opinion about your care. He or she will ask you to pick a plandoctor in your service area. If you cant nd another plan doctor in your area, your PCP will askyou to pick a doctor who is not on the Plan. You dont pay for these services. You can also callCustomer Service to help you with getting a second opinion. Call 1-888-846-4262

(TTY/TDD: 1-877-247-6272).

If the second-opinion doctor asks for tests, they must be done by a plan provider.

Your PCP will look at the second opinion. He or she will then decide the best way to treat you. If you see a doctor not on the Plan without your PCP or plan approval, you may have to pay for thedoctor visit.

Pregnancy and Newborn CareIf you have a baby while you are an Ohana member, we will cover you throughout your

pregnancy and for the rst 30 days after birth. DHS will contact you to inform you of the healthplan choices for your baby. You will have 15 days to choose a plan. If your baby is eligible for QExAand you do not choose a plan within 15 days, your baby will be assigned to Ohana. If your baby iseligible for QUEST and you do not choose within the allowed time, your baby will be assigned toa QUEST health plan.

Moms-to-be should set up a visit with an Ohana OB (obstetrics) doctor. Do this within 14 days of signing up for the Plan or nding out you are pregnant. Customer Service can help you set up anappointment. Call 1-888-846-4262 (TTY/TDD: 1-877-247-6272).

There are more reasons you should call us. We can get you information about having and caringfor a baby. We can sign you up for our prenatal programs. You will also need to choose a PCP foryour baby. You should do this by the time the baby is born. If you do not choose, we will assignone.

Out-of-State and Off-Island Co erageOhana covers any medically necessary covered treatment or services that are not available in thestate or island in which you reside. Ohana will provide these services out-of-state or off-island.

This includes:Referrals to an out-of-state or off-island specialist or facility

Transportation to and from the referral destination for an off-island or out-of-state destination

Lodging and meals for you and any needed attendant


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You can get help with problems like:Back pain

Burns

Colds/ u

Coughing

Crying baby

Cuts

Dizziness

Feeling sick

A nurse is there to help. So call the nurse advice line before you call a doctor or go to the hospital.In an emergency, go the hospital or call 911 rst.

Health ConnectionsOhana knows that families and communities are important. We have programs that will help youand your family connect with local community-based groups to get your health care needs met.Some of the programs include the following:

Online toolsCompass- an online, health education program in several languages.

PreventionStaying healthy is important at any stage in life. Members will enjoy programs like Get-Healthy or Stop Smoking to help you and your families live healthier.

Contact your service coordinator or call Customer Service for more information. Call1-888-846-4262 (TTY/TDD: 1-877-247-6272).


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Disease ManagementOhana has case management programs that are designed to assist members with chronic diseases.These include:

Mellitus

Obesity managementCardiovascular disease

Asthma

Diabetes

HIV/AIDs

Our service coordinators will work with you. They help coordinate your health care needs. Youwill be contacted by our Service Coordination Department to schedule a visit to go over yourhealth care needs.

To learn more about these programs, call Customer Service. Call weekdays from 7:45am to 5:30pm,HST, at 1-888-846-4262 (TTY/TDD: 1-877-247-6272).


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EMERGENCY SERvICESEmergency services help stabilize a medical condition that is very serious and must be treatedright away. They may include inpatient and outpatient services.

What to Do in an EmergencyCall 911 in an emergency. Call an ambulance if you do not have 911 service in your area. Emergencyservices do not require prior authorization, so go to the nearest hospital emergency room rightaway. The choice is yours. Call your PCP or our 24-hour nurse hotline when you are not sure its anemergency. Some examples of emergencies are:

Heavy blood loss

Heart attack

Cuts requiring stitches

Loss of consciousness

Poisoning

Severe chest pains

Loss of breath

Broken bones

An emergency is when the lack of immediate attention results in the following: Placing the physical or mental health of the individual (or with respect to a pregnant woman, thehealth of the woman or her unborn child) in serious jeopardy

Serious impairment to bodily functions

Serious dysfunction of any bodily organ or part

Serious harm to self or others due to an alcohol or drug abuse emergency

Injury to self or bodily harm to others

With respect to a pregnant woman having contractions(1) that there is adequate time toeffect a safe transfer to another hospital before delivery, or (2) that transfer may pose a threatto the health or safety of the woman or her unborn child

When you get to the emergency room (ER), you will need to show your Ohana ID card. Ask theER staff to call Ohana. Let your PCP know as soon as you can when you are in the hospital andlet him or her know if you received care in an ER. Ohana will pay for follow-up care to emergencytreatment (post-stabilization).


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The ER doctor will decide if your visit is an emergency. If it is not, you get the choice to stay. If you stay when it is not an emergency, you must pay for the care.

Prior approval is not needed for emergency services or follow-up care regardless of whether youget this care within or outside the Plans network.

Out-of-Area Emergency CareWhat should you do if you have an emergency while traveling? Go to a hospital. Show your IDcard. Call your PCP as soon as you can. Ask the hospital staff to call Ohana. If you have to pay forcare you get while you are out of the service area, write to our Claims Department. They will needcopies of your medical reports and the bills. They will also need proof of payment.

What should you do if you get sick or hurt while out of the Ohana service area and it is not anemergency? Call Customer Service. Call toll-free 1-888-846-4262 (TTY/TDD: 1-877-247-6272).

How to Get After-Hours Medical CareWhat should you do if you get sick or hurt when your PCPs of ce isnt open and it is not anemergency? You should still call your PCP. The number is on your ID card. All of our PCPs haveanswering services. They will have your PCP call you. If it is not an emergency, do not go to thehospital rst. We will get you care within 24 hours for all urgent care and pediatric sick visits.

What to Do if You Need Urgent CareYou should still call your PCP rst for all urgent care. Urgent care is needed when you requiremedical care within 24 hours but the problem will not cause serious harm to your health. Youmay go to an urgent care center when your PCP cannot see you within 24 hours. Such conditions

include:Injury

Illness

Severe pain

Not sure you need urgent care? Call your PCP. Urgent care center services do not need priorapproval. You will need to show your Ohana and Medicaid ID cards at the urgent care center. Askthe staff to call Ohana.

Let your PCP know if you get care in an urgent care center. That way, he or she can give youfollow-up care.


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HOW TO GET OTHER OHANA SERvICESPRESCRIPTION DRUG SERvICES

Prescriptions and Pharmacy Access

Q. How do I get a prescription?

A. Prescriptions must be written by a plan doctor.

Q. Which drug stores will ll my prescription?

A. Prescriptions must be lled at a drug store in the plan network. A list of these drug stores is inyour provider directory and at www.ohanahealthplan.com.

Q. What is the process for getting a prescription lled?

A. Show your ID card when you give your prescription to the pharmacist. Members get anunlimited number of prescriptions monthly.

Preferred Drug List

Q. What medicines does the Plan pay for?

A. Ohana pays for medicines on our Preferred Drug List (PDL). Doctors, pharmacists and nursesmake the list. Your PCP will use the list when prescribing drugs for you. The list will also havedrugs that may have limits, due to your age or gender. If you would like to see the list, it is onour Web site. Go to www.ohanahealthplan.com.

Q. Are there medicines that the Plan will not pay for?

A. The plan does not pay for these medicines:Those used to help you get pregnant

Those used for erectile dysfunction

Those that are cosmetic or help you grow hair

Those used for cough and cold for members age 21 and older


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Q. Can I get any medicine I want?

A. No. We created our Preferred Drug List to show you the drugs we will pay for. Call CustomerService at 1-888-846-4262 (TTY/TDD: 1-877-247-6272) if you have any questions.

Q. Are generic drugs as good as brand-name drugs?

A. Yes. Generic drugs work the same as brand drugs. They have the same ingredients as branddrugs.

O er-the-Counter (OTC) Drugs

Q. Does the Plan pay for OTC drugs?

A. The Plan pays for some OTC drugs. All OTC drugs require a prescription. The Plan pays for theseitems:

AspirinIbuprofen

Diphenhydramine

Non-sedating antihistamines

Insulin

Insulin syringes

Urine test strips

Antacids

H-2 receptor antagonist

Proton pump inhibitors

Multivitamins/multivitamins with iron

Iron

Topical antifungals

See our Preferred Drug List for a list of all covered OTC drugs. Call Customer Service if you have

any pharmacy-related questions. Call 1-888-846-4262 (TTY/TDD: 1-877-247-6272).


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TRANSPORTATIONThe Plan provides both emergency and non-emergency ground and air services to and frommedically necessary medical appointments for members who:

Have no means of transportation

Reside in areas not served by public transportationCannot access public transportation due to their disability

Please call Customer Service at 1-888-846-4262 (TTY/TDD: 1-877-247-6272) to schedule yourappointment.


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ACCESS TO BEHAvIORAL HEALTH SERvICESIf you or someone in your family has personal problems, Ohana can help you get an outpatientmental health or substance abuse assessment. Call 1-888-846-4262 (TTY/TDD: 1-877-247-6272) if you want to know more. Our staff will be happy to help you. Prior approval is not needed by yourPCP.

What to Do if You Are Ha ing a ProblemIf you are having any of these problems, you should call us. We can get you an assessment from abehavioral health provider.

Always feeling sad

Feeling hopeless and/or helpless

Feelings of guilt

Feelings of worthlessnessDif culty sleeping

Poor appetite

Weight loss

Loss of interest

Dif culty concentrating

Irritability

Constant pain such as headaches, stomach and backaches

You do not need to call your PCP for a referral. You will get an approval for services when you callthe Plan. If you use a provider without getting approval from the Plan, you may have to pay the bill.

What to Do in an Emergency or if You Are Out of the Ohana Ser ice AreaFirst, decide if it is a true behavioral health emergency. Do you think that you are a danger toyourself or others? If you think you are, call 911. Or go the nearest emergency room. Do this even if the emergency room is not in our service area.

If you need emergency behavioral health care outside our service area, please tell us. Just call thenumber on your ID card. You should also call your PCP if you can. Call your PCP again in 24 to 48hours. Once you are stable, plans will be made to transfer you to a Medicaid facility.Obtaining Beha ioral Health Ser ices


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ACCESS TO MEDICAL SERvICESOhana has guidelines to ensure that our members can get to services in a timely manner.

Tra el time to medical ser ices:

Provider Urban* RuralPCPs 30 minute driving time 60 minute driving timeSpecialists 30 minute driving time 60 minute driving timeHospitals 30 minute driving time 60 minute driving timeEmergency service facilities 30 minute driving time 60 minute driving timeMental health providers 30 minute driving time 60 minute driving timePharmacies 15 minute driving time 60 minute driving time24-hour pharmacy 60 minute driving time N/A

*Urban is de ned as the Honolulu metropolitan statistical area (MSA).

Timely care: Immediate care 24 hours a day, 7 days a week. In emergency situations, prior authorizations arenot required.

Urgent care and PCP pediatric sick isits within 24 hours. Urgent care is for a problem that isnot life-threatening but could cause sickness or harm with no care.

PCP adult sick care within 72 hours

Specialist/non-emergent hospital stays within 4 weeks

Routine and well isits within 21 days

Waiting times no more than 45 minutes for scheduled appointments

Follow-up care as needed


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IMPORTANT INFORMATION YOU SHOULD KNOW ABOUT OHANAEnrollmentIndividuals covered under QUEST Expanded Access (QExA) are eligible to enroll in Ohana. QExAprovides acute, behavioral health and long-term care services to persons who are aged, blind or

disabled (ABD). Covered groups include:ABD individuals living in the community

ABD individuals residing in long-term care institutions

ABD individuals enrolled in an existing Home and Community Based Services program

Other relatively small, specialized ABD populations

There are certain eligibility requirements that you have to meet to be covered under QExA. TheMed-QUEST Division (MQD) oversees the process for eligibility and will determine eligibilitystatus.

Once you are determined eligible for QExA, you are noti ed by MQD within 10 days and providedinformation on the process for selecting a health plan. You will also receive information that willaddress the basics of managed care and the health plans available to provide care. To learn moreabout the selection process and how to join a plan, please call the QExA Enrollment Counselors.Their number is 1-866-928-1959 (TTY: 1-866-928-1958).

90-Day Grace PeriodYou have 90 days to try the Plan after enrolling. If you want to, you can change plans during thistime. This is called your Open Enrollment period. At the end of 90 days, you must stay in the Plan

until the next Annual Change period (see page 53).

You may also change plans at any time if you have a good cause to do so. A good cause tochange plans could involve the following:

An administrative appeal decision

Provisions in administrative rules or statutes

A legal decision

Relocation to a service area where the health plan does not provide service

An administrative decision for foster children which is the result of an agreement between the DHS, the child welfare service worker and the health plan involved


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The plans refusal, because of moral or religious objections, to cover the service you may want

The need for related services (for example, a cesarean section and a tubal ligation) to beperformed at the same time and not all related services are available within the network andyour PCP or another provider determines that receiving the services separately would subjectthe member to unnecessary risk

Other reasons, including but not limited to:Poor quality of care

Lack of access to services covered under the contract

Lack of access to providers experienced in dealing with your health care needs

Lack of direct access to certi ed nurse midwives, pediatric nurse practitioners, family nursepractitioners, if available in the geographic area in which the member resides

Lack of direct access to womens health care specialists for breast cancer screenings, Pap smearsand pelvic exams

Annual ChangeEvery year, the State will have a health plan change period to allow you to change plans withoutcause. You will be noti ed 60 days prior to the effective date of the change. If you do not choosea health plan, the State will choose one for you. Before they do, they will try to contact you. If you do not reply within 15 days, a plan will be chosen for you. For more information, call the QExAEnrollment Counselors at 1-866-928-1959 (TTY: 1-866-928-1958).

If you have any questions, call the QExA Enrollment Counselors. Their number is1-866-928-1959 (TTY: 1-866-928-1958). You can also call Ohana Customer Service at1-888-846-4262 (TTY/TDD: 1-877-247-6272).

ReinstatementIf you lose your Medicaid eligibility but get it back within 60 days, the State will reinstate you as amember of Ohana.

We will send you a letter within 10 days after you are reinstated. You can choose the same PCPyou had previously or you can pick a new PCP.


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Mo ing Out of the Ohana Ser ice AreaOhana serves the following islands:

Kauai

Oahu

Molakai

Maui

Lanai

Hawai i

If you move, call Customer Service. You will want to pick a PCP near your new home. If you moveout of the Plans service area, you must call MQD. Their number is [Phone/TTY]. They will be ableto help you with your health care needs.

In oluntary DisenrollmentYou may lose your Ohana membership if you:

No longer qualify based on the medical assistance eligibility criteria

Voluntarily leave the program

Die

Become incarcerated

Enter the Hawaii State Hospital

Become a PACE or Pre-P ACE participantEnter the State of Hawaii Organ and Transplant (SHOTT) Program

Are in foster care and have moved out of state by the DHS

Become a Medicare Special Savings Program recipient bene ciary

Provide false information with the intent of enrolling in the program under false pretenses

Choose another health plan during the annual plan change period and that health plan is notcapped

Enter a long-term care residential facility that is not in the Plans provider network and is in theprovider network of a different health plan (so long as that health plan is not capped)

Select a PCP who is not in the health plans provider network and is in the provider network of adifferent health plan (so long as that health plan is not capped)


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To learn more, contact:Med-QUEST DivisionHealth Care Services BranchP.O. Box 700190Kapolei, HI 96709-0190

[Phone]

You can also call Customer Service at 1-888-846-4262 (TTY/TDD: 1-877-247-6272).

Quality and Member Satisfaction InformationYou can ask about how this plan has performed. You can also ask if our members are satis ed orprovide ideas for how the Plan can improve. To do this, call Customer Service. Call 1-888-846-4262(TTY/TDD: 1-877-247-6272).

Plan Structure and Operations

To learn more about the structure and operations of the Plan, call Customer Service. Call1-888-846-4262 (TTY/TDD: 1-877-247-6272).

How Doctors Are PaidOhana works hard to give you the care you need. We work with many providers. You may askhow they are paid. And if how they are paid will affect how they use referrals. You may also askif it will affect other services you may need. Call Customer Service for more information. Call1-888-846-4262 (TTY/TDD: 1-877-247-6272).

Grie ance InformationYou can nd out about grievances led with the Plan in the past 3 years. Call Customer Service at1-888-846-4262 (TTY/TDD: 1-877-247-6272).

Fraud and AbuseFraud happens when the Plan gets billed for a service that costs more than the service received.It also happens when the Plan pays for a service that someone never used. If you know that fraudhappened, tell us. Call our 24-hour hotline at 1-866-678-8355. To learn more, call Customer Service.Call 1-888-846-4262 (TTY/TDD: 1-877-247-6272).

What to Do When Your Family Size ChangesSometimes your familys structure or size will change. If this happens, call your eligibility workerand report the changes.

QExA OmbudsmanContact Information[ ]


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Other ProgramsOhana also offers the services listed below in your area. To learn more, call your PCP. Or, callCustomer Service at 1-888-846-4262 (TTY/TDD: 1-877-247-6272).

Programs to stop smoking

Drug and alcohol programsDomestic abuse support

Programs for moms-to-be and their babies

Programs for kids


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WELL-CHILD CARE AND EPSDT (EARLY and PERIODIC SCREENING,DIAGNOSIS and TREATMENT) SERvICESOhana covers well-child checkups for all members from age 0 to 21. We want to make sure kidsvisit their PCPs at an early age. This is important for a childs health later in life.

What is a well-child checkup?A well-child checkup is when your childs PCP will make sure that your child is growing up healthy.The PCP will:

Do an unclothed head-to-toe physical and mental health exam

Give any needed shots

Do any needed blood and urine tests

Look into your childs mouth and check teeth

Test your child for tuberculosis and leadGive you health tips and education according to your childs age

Talk to you about your childs growth, development and eating habits

Measure height, weight, blood pressure and how well your child sees and hears

There are certain services that your child should get at each age. These can be found in thePreventive Health Guidelines section of this book.

Why is the well-child checkup important?

Checkups help nd health concerns before they become bigger problems. Also, your child can getthe shots he or she needs during these visits.

When should a well-child checkup occur?Your children should visit their PCP for checkups. They should go even when they are well. Theyshould go at these times, as recommended by the American Academy of Pediatrics:

At birth, in the hospital

3-5 days

1 month old2 months old


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4 months old

6 months old

9 months old

12 months old

15 months old

18 months old

24 months old

30 months old

Every year from ages 321

How much does a well-child checkup cost me?

Nothing. Checkups are done by your childs PCP at no cost to you.

What if I need help getting a doctor isit?We can help you get an appointment. Just call Customer Service. Call 1-888-846-4262 (TTY/TDD:1-877-247-6272).

What if I need help getting to the doctor isit?We can help you get a ride to the doctor. Just call Customer Service. Call 1-888-846-4262(TTY/TDD: 1-877-247-6272).


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PREvENTIvE HEALTH GUIDELINESOn the next few pages of this book, you will nd guidelines. These tell you when you and yourfamily should get checkups, tests and shots.

You can use these to help you know when it is time to visit your PCP. They also tell youwhat services you should get from your PCP. Please look at these guidelines. If you see thatyou or anyone in your family is missing a checkup or test, you should call your doctor for anappointment.

We will help you remember to get these services. We will send each family member a reminderevery year on their birthday. It will tell them about the tests and shots they may need.

These guidelines do not replace your PCPs advice. When you see your PCP, he or she may tell youthat other services are needed. This would be based on your speci c health care needs. Alwaystalk with your PCP. Be sure to tell him or her about your health concerns. This will help you and

your family get the right care.

Rememberif you just joined the Plan, you should see your PCP within 90 days.


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PEDIATRIC PREvENTIvE HEALTH GUIDELINESNEWBORN UP TO 21 YEARS OLD

These guidelines for pediatric preventive health are recommendations only. Additional servicesmay be considered necessary based on individual circumstances.

Age Well-Baby Checkups and Shot Guide

NewbornWell-baby checkup 1 at birthHearing testNewborn screening blood tests and Hepatitis B (HepB) shot

35 daysWell-baby checkup 1 if discharged less than 48 hours after deliveryNewborn screening blood testsImmunizations 2: HepB if not done at birth

1 month

Well-baby checkup 1

Newborn screening blood test if not already completedImmunizations 2: HepB

2 months Well-baby checkup1

Immunizations 2: Rota, DTaP, Hib, PCV, IPV


Immunizations 2: Rota, DTaP, Hib, PCV, IPV

6 monthsWell-baby checkup 1Immunizations 2: Rota, DTaP, Hib, PCV, IPV, HepB (HepB and IPV Age Range6to 18 months), annual In uenza


Lab testing: lead screening, hemoglobin or hematocrit

12 months

Well-baby checkup 1Lab testing (if not done at 9 months of age): lead screening, hemoglobin orhematocritImmunizations 2: Hib, MMR, HepA, Varicella, PCVDental visit as need identi ed

15 monthsWell-baby checkup 1 Lab testing: urine test and blood lead if not done at 9 months or 12 monthsImmunizations 2: DTaP, Hib


Immunizations 2: second HepA (6 months after the rst dose)


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Lab testing: blood lead test

30 months Well-baby checkup1,

Immunization catch-up, vision, hearing screening

Age Well-Child Checkups and Shot Guide

Flu shots Each year for kids age 6 months or older who have certain high-risk diseaseslike asthma and diabetes

3 yearsWell-child checkup 1 Eye screeningAnnual dental visit 3

45 years

Well-child checkup 1 each yearEye screeningLab testing: urine test at age 5 yearsImmunizations 2: MMR, DTaP, IPV sometime between ages 4 and 6 andsecond VaricellaAnnual dental visit

610 yearsWell-child checkup 1 every yearLab testing: urine test at age 6 years if not done at age 5 yearsAnnual dental visit

11 to 12 years

Well-child checkup 1 every year

Immunizations2

: MCV4, Tdap, HPV4

Annual dental visit

13 to 21 years

Well-adolescent checkup 1 each yearFemales should have a pelvic exam and Pap smear between 18 and 21 yearsLab testing: hemoglobin or hematocrit by age 14, urine test by age 16Annual dental visit


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NOTES:1 Well-baby, -child and -adolescent checkups/physical exam with infant totally undressedor older child undressed and suitably covered, health history, developmental and

behavioral assessment, health education (sleep position counseling from 0-6 months,injury/violence prevention and nutrition counseling), height, weight, test for obesity (BMI),vision and hearing screening, head circumference at 024 months and blood pressure atleast every year beginning at age 3.

2 Consult your primary care provider for speci c immunization recommendations.3 Dental visits may be recommended beginning at 1 year of age.4 Subject to speci c state coverage.

The following services are provided as needed:

Hemoglobin or hematocrit between ages 15 months through 6 years and between ages 11 years through 21 years old

Urine testing from age 11 years to 21 years old

Lead risk assessments and/or testing from 3 to 6 years old

Tuberculosis risk assessments and/or testing from age 12 months through 21 years old

Cardiovascular disease risk assessments and cholesterol screening from age 2 yearsthrough 21 years old

Sexually transmitted disease testing from age 11 years through 21 years old

Catch up on any shots that have been missed at an earlier age

References:

Recommendations for Preventive Pediatric Health Care, American Academy of Pediatrics. 2008.

Recommended Immunization Schedule for Persons Aged 06 yearsUnited States. 2008. CDC.

Catch-up Immunization Schedule for Persons Aged 4 Months18 Years Who Start Late or Who Are More Than 1 Month Behind. 2008. CDC.

Recommended Immunization Schedule for Persons Aged 718 YearsUnited States. 2008. CDC.

Revised 2/26/08


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ADULT PREvENTIvE HEALTH GUIDELINESFrequency of Physical ExaminationAll new members should get a baseline physical exam in the rst 90 days of enrollment. Pregnantmembers should be seen in the rst 30 days. The Cleveland Clinics recommendations for periodic

health exam visits for asymptomatic adults are: Age 19 to 39 every 1 to 3 years. (Women should get an annual Pap smear. If 3 normal smears ina row, then 1 every 3 years.)

Age 40 to 64 every 1 to 2 years based on risk factors.

Age 65 and older every year.

Age: Screening: Frequency:

18 years of age and older

Blood pressure, height,

body mass index (BMI),alcohol use

Each year from age 18 to 21.

Then, every 1 to 2 years or atPCPs recommendation.

Men 35 to 65 years of age

Women 45 to 65 years of age

Cholesterol(non-fasting TC/HDL)Cholesterol(non-fasting TC/HDL)

Every 5 years (more often if elevated)Every 5 years (more often if elevated)

High-risk men and women 20years of age and older

Cholesterol(non-fasting TC/HDL)

Every 5 years (more often if elevated)

Women 18 to 25 years of age who

are sexually active (consider at age12 if sexually active)

ChlamydiaEach year and at PCPsrecommendation

Women 18 to 65 years of age(or 3 years after onset of sexualactivity, whichever comes rst)

Pap smear Every 1 to 3 years

Women 40 years of ageand older Mammography Every 1 to 2 years

50 years of age and older Colorectal Periodically dependingupon test

Women 65 years of age andolder (60 and older if at risk forfractures)

Osteoporosis Routinely

65 years of age and older Vision, hearing Periodically


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Immunization

Tetanus-Diphtheria and acellular pertussis(Td/Tdap)

Tdevery 10 years, 18 years and olderTdapsubstitute 1 dose of Tdap for Td(one-time administration)

Varicella (VZV)Susceptible adults only, 18 years of age andolder2 doses

Measles, Mumps, Rubella (MMR) Adults 19-49 years of age who do not showevidence of immunity1-2 doses

Pneumococcal 65 years of age and older1 dose

In uenza Every year, 50 years of age and older

Hepatitis B vaccine Adults at risk, 18 years of age and older3

doses

Meningococcal conjugate vaccineCollege freshmen living in dormitories andothers at risk, 18 years of age and older1dose

Human-papillomavirus (HPV) All previously unvaccinated women through26 years of age3 doses

Prevention

Aspirin to prevent cardiovascular events Men40 years of age and olderWomen50 years of age and older

Breast cancer (for women at high risk)

Prostate speci c antigen (PSA) test and rectal exam (for men after 40 years of age per PCPsdiscretion)


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Counseling

Calcium1,000mg a day for women 18 to 50 years of age; 1,200 to 1,500mg a day for women50 years of age and older

Folic acid0.4mg a day for women of childbearing age; 4mg a day for women who have hadchildren with Neural Tube Defects (NTDs)

Breast feedingwomen after giving birth

Quitting tobacco; drug and alcohol use; STDs and HIV; nutrition; physical activity; sunexposure; oral health; injury prevention; polypharmacy

References: Guide to Clin ical Preventive Services, 2005: Recommendations of the U.S. Preventive Services Task Force, June 2005.

Press Release CDCs Advisory Committee Recommends Human Papillomavirus Virus Vaccination June 29, 2006.

Recommended Adult Immunization ScheduleUnited States, October 2006-September 2007. MMWR October 13, 2006, Vol. 55, No. 40.

Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) May2001.

Bone Health and Osteoporosis: A Report of the Surgeon General (2004).

Cleveland Clinic www.cchs.net/health/health-info Periodic Health Exams and Cancer Screening.


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MEMBER GRIEvANCE AND APPEAL PROCEDURESWe want you to let us know right away if you have any questions, concerns or problems aboutyour covered services or the care you receive.

This section will explain how you can express your concerns/complaints.

There are 2 types of complaints you can make. They are called grievances and appeals. Statelaw allows you to make a complaint if you have any problems with the Plan. The State has alsohelped to set the rules for making a complaint and helped to make the rules for what the Planmust do when a complaint is received. If you le a grievance or an appeal, we must be fair. Wecannot remove you from the Plan or treat you differently because you made a complaint.

What is a grie ance?A grievance is when you call or write to complain about a provider, the Plan and/or service. Issuesmay include:

Quality-of-care issues

Wait times during provider visits

The way your providers or others act

Un

ohana membership manual

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