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Benefits for AlohaCare Members

AlohaCare QUEST


QUEST Keiki
The QUEST Keiki plan is for keiki under 21 years old. This plan provides medical and behavioral health coverage. QUEST Keiki members also receive free Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services. These well-child check-ups are important to keep your keiki healthy.  

QUEST Adult
The QUEST Adult plan is for adults 21 years old and older. This plan provides medical and behavioral health coverage.
 
Your Benefits
As a member of AlohaCare, some of your QUEST benefits include:
  • Behavioral health services
  • Doctor visits
  • Family planning services
  • Hospital services
  • Pregnancy services
  • Prescription drugs
  • Preventive care services
  • Tests and lab services
 
For a complete listing of your benefits, see your QUEST Member Handbook.
 
Your Primary Care Provider (PCP)
You will choose a Primary Care Provider (PCP) for your care. Your PCP is your personal doctor who you will see first for most of your health care needs. Your PCP will coordinate the rest of your services. This helps your PCP provide you with the best care by knowing your health care needs and services your receive.
 
Nurse Advice Line
The Nurse Advice Line is available when you have a health concern and your PCP is not available. When you call our Nurse Advice Line, you will talk to staff that can help answer your health questions. They can give you advice on the type of care you need if you are sick or don’t know what to do.
 
Language Assistance
We can help if you do not speak or understand English. We can also help you if you have trouble hearing or seeing. You may ask for information in another language, such as Ilocano, Vietnamese, Chinese or Korean, or in another way. TTY assistance is available by calling 1-877-447-5990. These translation services are free. For more information, see our Language Assistance flyer.
 
Contact Us
Oahu: 973-0712
Neighbor Island/Oahu (toll-free): 1-877-973-0712
TTY: 1-877-447-5990


 

AlohaCare Advantage (HMO)


AlohaCare Advantage is a Medicare Advantage Prescription Drug plan. Our plan is available to Medicare beneficiaries who live in our service area. Our service area includes the islands of: Oahu, Maui, Hawaii, Kauai, Molokai and Lanai.

Your Benefits
AlohaCare Advantage offers you Medicare Parts A, B and D coverage with affordable cost sharing. Some of our benefits include:
  • $0 plan premium
  • $0 to $10 copayment for each office visit to your Primary Care Provider (PCP)
  • $35 copayment for each office visit to your specialist (PCP referral required)
  • $0 deductible for Part D prescription drugs
  • $0 copayment for preventive health services
  • 24-hour Nurse Advice Line
  • Medication Therapy Management
 
Limitations, copayments and restrictions may apply. For a complete listing of benefits, see your Summary of Benefits.

Network Providers and Your Primary Care Provider (PCP)
A “network provider” is a provider that participates in our plan. As a member of AlohaCare Advantage, you must use our plan providers except in an emergent or urgent care situations. If you obtain routine care from out-of-network providers neither Medicare nor AlohaCare Advantage will be responsible for the costs.
 
As our member, you have a Primary Care Provider (PCP) within our network of providers. You must get your routine or basic care from your PCP. Your PCP will coordinate the rest of the covered services you receive as a member. For example, in order for you to see a specialist, you usually need to get you PCP's approval first; this is called getting a referral to a specialist.

Prior Authorizations
For certain medical services and medication, you must first receive approval from AlohaCare Advantage before the medical services and medications are covered under your plan. You, your representative or your doctor can initiate the authorization request to AlohaCare Advantage. We will notify you and your doctor of our decision. In some cases, your medical services and medications are covered with a prior authorization.

Low Income Subsidy or “Extra Help”
If you have limited income and resources, you may be able to get Extra Help. If you qualify for Extra Help, you get help paying for your monthly premium, yearly deductible, prescription coinsurance and copayments and experience no gap in coverage. Premiums include coverage for both medical services and prescription drug coverage. This does not include any Medicare Part B premium you may have to pay.

To see how much your premium would be if you qualified for Extra Help, look at the 2014 Low Income Premium Table
 
To see if you qualify for Extra Help, call: 
 
  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
  • The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
  • Your State Medicaid Office.
     
Transition of Care
Under certain circumstances, AlohaCare Advantage can offer a temporary supply of a drug to our members who have a level of care change. For more information about our transition process, see page 90 of your Evidence of Coverage.  
 
Rights upon Disenrollment
Ending your membership with AlohaCare Advantage may be voluntary (your own choice) or involuntary (not your own choice). You might leave our plan because you have decided that you want to leave. There are also limited situations where we are required to end your membership. For example, if you move permanently out of the geographic service area we cover. We cannot ask you to leave our plan because of your health.

If you leave our plan, it may take some time for your membership to end. While you are waiting for your membership to end, you are still a member and must continue to get your care and/or prescription drugs as usual through our plan.

You have the right to make a complaint if we end your membership in our plan. If we end your membership in our plan we will tell you our reasons in writing and explain how you may file a complaint against us if you want to.


Additional Information
AlohaCare Advantage is a health plan with a Medicare contract. The benefit information provided herein is a brief summary, not a complete description of benefits. For more information, contact the plan. Benefits, formulary, pharmacy, network premium and/or copayments/co-insurance may change on January 1 of each year. You must continue to pay you Part B premium.

Contact Us
If you have any questions or for more information on your benefits, call Customer Service at 973-6395 or toll-free at 1-866-973-6395, 8 a.m. to 8 p.m., 7 days a week. TTY users should call 1-877-447-5990.


Click on this link for information regarding your AlohaCare Advantage Part D Prescription Drug Benefit.

H5969_400614_1 CMS Approved 02122014

AlohaCare Advantage Plus (HMO SNP)


AlohaCare Advantage Plus is a Medicare Advantage Prescription Drug plan. Our plan is available to Medicare beneficiaries who live in our service area. Our service area includes the islands of: Oahu, Maui, Hawaii, Kauai, Molokai and Lanai.

Your Benefits
AlohaCare Advantage Plus is a plan that is specifically designed to meet the special needs of individuals who are currently enrolled in Medicare and have full benefit Medicaid coverage. Some of your benefits include:
  • $0 plan premium   
  • $0 Primary Care Provider (PCP) and Specialist visits
  • $0 deductible for Part D prescription drugs
  • $0 copayment for preventive health services
  • 24-hour Nurse Advice Line
  • Member Service Navigators for personal care coordination
  • Medication Therapy Management
 
Limitations, copayments and restrictions may apply. For a complete listing of benefits, see your Summary of Benefits.

Network Providers and Your Primary Care Provider (PCP)
A “network provider” is a provider that participates in our plan. As a member of AlohaCare Advantage Plus, you must use our plan providers except in emergent or urgent care situations. If you obtain routine care from out-of-network providers neither Medicare nor AlohaCare Advantage Plus will be responsible for the costs.
 
As our member, you have a Primary Care Provider (PCP) within our network of providers. You must get your routine or basic care from your PCP. Your PCP will coordinate the rest of the covered services you receive as a member. For example, in order for you to see a specialist, you usually need to get you PCP's approval first; this is called getting a referral to a specialist.

Prior Authorizations
For certain medical services and medications, you must first receive approval from AlohaCare Advantage Plus before the medical services and medications are covered under your plan. You, your representative or your doctor can initiate the authorization request to AlohaCare Advantage Plus. We will notify you and your doctor of our decision. In some cases, your medications and medical services are covered with a prior authorization.

Member Service Navigators
As an AlohaCare Advantage Plus member, you receive personal care coordination from one of our Member Service Navigators. Our Member Service Navigators make sure you get the health care you need, such as:
 
  • Helping you choose your PCP
  • Setting up doctor’s appointments
  • Making sure you get the prescriptions you need
  • Coordinating services under Medicare and Medicaid
  • Answering questions about our plan and how you maintain your Medicaid coverage

Low Income Subsidy or “Extra Help”

If you have limited income and resources, you may be able to get Extra Help. If you qualify for Extra Help, you get help paying for your monthly premium, yearly deductible, prescription coinsurance and copayments and experience no gap in coverage. Premiums include coverage for both medical services and prescription drug coverage. This does not include any Medicare Part B premium you may have to pay.
 
To see how much your premium would be if you qualified for Extra Help, look at the 2014 Low Income Premium Table. 

To see if you qualify for Extra Help, call:
 
  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
  • The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
  • Your State Medicaid Office.
     
Transition of Care
Under certain circumstances, AlohaCare Advantage Plus can offer a temporary supply of a drug to our members who have a level of care change. For more information about our transition process, see page 88 of your Evidence of Coverage.  

Rights upon Disenrollment
Ending your membership with AlohaCare Advantage Plus may be voluntary (your own choice) or involuntary (not your own choice). You might leave our plan because you have decided that you want to leave. There are also limited situations where we are required to end your membership. For example, if you move permanently out of the geographic service area we cover. We cannot ask you to leave our plan because of your health.

If you leave our plan, it may take some time for your membership to end. While you are waiting for your membership to end, you are still a member and must continue to get your care and/or prescription drugs as usual through our plan.

You have the right to make a complaint if we end your membership in our plan. If we end your membership in our plan we will tell you our reasons in writing and explain how you may file a complaint against us if you want to.


Additional Information
AlohaCare Advantage Plus is a health plan with a Medicare contract and a contract with the Hawaii Medicaid program. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or copayments/ coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The State pays the Part B premium for full-dual members who are eligible for AlohaCare Advantage Plus. This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, copayments, coinsurance and deductibles may vary based on the level of Extra Help that you receive. Please contact the plan for further details.
 
Contact Us
If you have any questions or for more information on your benefits, call Customer Service at 973-6395 or toll-free at 1-866-973-6395, 8 a.m. to 8 p.m., 7 days a week. TTY users should call 1-877-447-5990.


Click on this link for information regarding your AlohaCare Advantage Plus Part D Prescription Drug Benefit.
H5969_400614_1 CMS Approved 02122014