Being a Member
Rights and Responsibilities
It is important that you know your rights and responsibilities as a member of AlohaCare.
- Ask questions and get answers about anything you do not understand. This includes the right to:
- Know the name, background and professional status of your health care providers. You have the right to know which doctor is mainly responsible for your care.
- Work with your doctor to make decisions about your health care
- Know and understand your medical problems, diagnosis and health care conditions and any known possible outcomes. No procedure or treatment will be started unless you understand the treatment, you are told about the chances of success, and you are told the risks along with available alternatives. This includes the right to:
- Work with your doctors and AlohaCare to set up a treatment plan
- Receive services in a coordinated manner
- A free second medical opinion from an AlohaCare provider when deciding on treatment
- An open discussion of appropriate or medically necessary treatment options for your health care conditions, regardless of cost or benefit coverage.
- Know about any experimental, research or educational activities having to do with your care. After you have been given this information, you can choose to participate or not.
- Make comments and suggestions about anything that we do, including making recommendations about our members’ rights and responsibilities, and about our policies and procedures
- Get your medical information. This includes the right to:
- Look at and get copies of your medical records, unless your doctors or AlohaCare think sharing the information with you may be harmful to you or someone else
- Ask AlohaCare or your doctor to correct any medical information you feel is wrong. If your request is denied, you have the right to get the reason for denial in writing.
- Know who sees your medical records, unless the review of your records is for treatment, payment or health care operations (or some other reasons written in the law).
- Make your wishes known when you are not able to make informed choices for yourself.
- Timely access to care that does not have any communication or physical access barriers. This includes the right to:
- Timely access to doctors you need to see, close to where you live.
- Choose a service provider of your choice among those organizations in AlohaCare’s provider network.
- Get women’s routine and preventive health services from a women’s health specialist without the need for a referral.
- Get appointments with specialists if you have special health care needs.
- Get care from a doctor who does not participate with AlohaCare until we can provide a doctor to care for you.
- Have your doctors’ work together with you and AlohaCare.
- Have written materials available in alternative formats or other languages.
- Offer timely responses on prior approvals and referral requests.
- To have the use of an interpreter to help you speak to AlohaCare staff or your doctor, or to be there with you when you see your doctor. Interpreter and translation services are free.
- Ask us to send mail and call you at the address or telephone number of your choice, to protect your privacy. If we cannot do that, we will let you know why.
- Refuse treatment to the extent it is allowed by law. You are responsible for your actions if you refuse medical care or if you do not follow your provider's advice.
- Know the details of any medical treatment for yourself and the minor children in your care.
- Not having to pay for covered services unless spenddown or cost-share is required by Med-QUEST rules. This includes the right to:
- Not having to pay for AlohaCare’s debt if AlohaCare goes out of business
- Not having to pay for covered services you got if the Med-QUEST Program does not pay AlohaCare
- Not having to pay for covered services you got if AlohaCare does not pay your doctor
- Not having to pay extra for covered services you got even if we could have provided the service for less
- Not be forced to stay somewhere or be kept away from others as a way to control, punish or scare you. No one can make you stay somewhere or keep you away from others unless it is necessary for treatment or your safety.
- Get information about AlohaCare, our services, our health care practitioners and providers and your rights and responsibilities.
- Make suggestions about AlohaCare’s Member Rights and Responsibilities statement.
- Use each available grievance and appeal process through AlohaCare and through Med-QUEST. This includes the right to:
- File an appeal or grievance against AlohaCare or a provider.
- File an appeal or grievance against AlohaCare, the care AlohaCare provides, or a doctor.
- Get a timely response to grievances and appeals. Exercise these rights without affecting the way we treat you as a member.
- What are my responsibilities as a member?
As an AlohaCare member, you have the responsibility to:
- Share health status information that AlohaCare and your health care provider need in order to provide care. This includes the responsibility to:
- Tell your doctors everything you know about your current health, past illnesses, hospital stays, medicines and anything else about your health.
- Tell AlohaCare and your doctor if you are taking part in any medical research tests.
- Tell AlohaCare and your eligibility worker if you have a workers' compensation claim, personal injury or medical malpractice lawsuit, or if you have been in a car accident.
- Tell AlohaCare and your eligibility worker if you have any other medical insurance.
- Inform AlohaCare of any other insurance you had when you enrolled with the QUEST Integration program/AlohaCare or any that you get after you become a member of AlohaCare.
- Tell your child’s PCP about any shots your child already got. This includes immunizations or shots your child got from another clinic or doctor, or when living somewhere else. Always ask your child’s doctor to fill out your child’s immunization record and keep this list with your child’s important papers.
- Work with your doctors to make decisions about your treatment options and develop treatment goals. This includes the responsibility to:
- Call your PCP before seeing other doctors. AlohaCare may not pay if you see a doctor who is not an AlohaCare provider, unless it is an emergency.
- Call your PCP to get an appointment ahead of time. If you cannot make it to your appointment, call your doctor's office as soon as you can to cancel or make another appointment.
- Follow advice, care plans and instructions you agreed to with your doctor.
- Understand your health conditions.
- Ask questions about your care to make sure you understand what you need to do. Tell your doctors or other providers if you do not understand what they are telling you about a medical procedure, word, diagnosis or care plan. Let them know if you do not understand what to do.
- Do the best you can to stay healthy.
- Treat AlohaCare staff, your doctors and their office staff with respect and dignity, and cooperate with them.
- Follow AlohaCare’s policies and procedures. This includes the responsibility to:
- Not lend your AlohaCare member ID card or allow others to use your card. You may lose your benefits if you do.
- Have your AlohaCare member ID card with you when you go to see your doctor or go to the pharmacy.
- Report if you suspect a member or a provider has committed fraud or abuse.
- Report any changes in your status.
- Tell AlohaCare and Med-QUEST of any changes including marriage, divorce, birth of a child, adoption of a child, death of a spouse or child, a new job, getting other health insurance or change in your address or phone number.
- Pay your cost-share for services.
- You may have to share in the cost of your health care or support services. This is based on your Medicaid financial eligibility. If you have a cost-share, you must pay this to one of your providers every month. This is usually a long-term care facility or a home and community based provider.
- Paying for non-covered services
- Pay for services if you receive care from a specialist without a referral from your PCP.
- Pay for services that are not covered under the Medicaid program.
What is the Quality Improvement Program?
AlohaCare’s Quality Assessment and Performance Improvement Program (QAPI) focuses on high quality relationships with members and providers. We are committed to improving care and services for our members.
What is the goal of the QAPI Program?
The goal is to improve the health of members by:
- Improving the quality of care and services
- Promoting safe clinical practices
Who is involved in the QAPI Program?
The QAPI Program involves the Executive Leadership, Managers and staff of AlohaCare. The QAPI program may also involve providers, practitioners, and members within our network for community input.
How does the QAPI Program work?
The QAPI program includes activities to improve outcomes and patient safety. We measure to see if our interventions are effective. We measure preventive health screenings and chronic disease tests and procedures. We want to see if members are receiving services that would help them stay healthy.
For example, we collect data to see whether or not our members have done their pap smears for Cervical Cancer Screening. We collect data to see if members have done mammography tests for Breast Cancer Screening. We collect data to see if members with diabetes have gotten their lab work or their eye exams done.
The goal is to increase the amount of members who are able to self-manage their disease and/or prevent any conditions or diseases.
How does the QAPI Program affect me?
You may receive phone calls from your providers and/or AlohaCare to remind you to have certain preventive services done. You may receive educational materials about well child visits and immunizations (shots) your child should get.
What are the outcomes of the QAPI Program?
We would like to tell you about some of the improvements we have seen in our program.
- Cervical Cancer screening—More members got their pap smears done.
- Immunization for Adolescents—More adolescents received their immunizations.
- Prenatal/Postpartum Care—More members came in for their prenatal and postpartum care.
- Colorectal Cancer Screening—More members had this screening done.
Utilization Management Program
We want to make sure you get the right care, when you need it. We make decisions about the services you receive based upon your need and appropriateness of care. We do not reward our staff or others for denying you any services. We do not provide monetary incentives to other people who make decisions about your care that would limit or deny you from getting the care you need.
Call us if you have questions about how we manage your care and services or if you have an issue with a utilization management decision. Call Member Services at 973-0712 (Oahu) or toll-free at 1-877-973-0712. TTY users call 1-877-447-5990. Staff is available from 7:45 a.m. to 5:00 p.m., Monday through Friday.
What is Protected Health Information?
When you see your doctor, there is a record of your visit. This record may have details about your treatment, condition, test results, and more. Your doctor sends claims to AlohaCare to pay for the services you receive. The claims may include some information from your records. We call this information about you and the services that you received your protected health information, or PHI.
What is routine use?
Routine use means using your PHI in the following ways:
- For your treatment with your doctor or other health care providers.
- To pay doctors, hospitals and other health care providers for the care you receive.
- To make sure you receive proper health care.
Is AlohaCare authorized to use information not covered in routine use?
Yes, there are some cases where we must share your PHI without your consent for non-routine use. We may use or share your PHI in any of the following situations:
- We may share your PHI with public health or legal agencies that work to prevent or control disease, injury or disability in Hawaii.
- As required by law, we may need to share PHI if we suspect abuse, neglect or domestic violence.
- We may share PHI with agencies that work to help prevent fraud and abuse and for other government activities that watch over health care.
- We may share your PHI with law enforcement officials because of a court order, warrant, subpoena or other law process.
- We may use or share PHI as required by the federal privacy law.
- We may share PHI with the medical examiner or a funeral director so they can do their job.
- We may share PHI with researchers who are approved to do research projects.
- We may share PHI to protect the health of another person or for the public.
- We may share your PHI with federal officials for national security activities.
- We may share PHI to comply with laws on workers’ compensation or other programs.
- During a medical emergency or disaster, we may share PHI to make sure you get the care or services you need.
Unless for one of the reasons listed here, we have to get your written permission to share your PHI. You do not have to agree and authorize additional use of your PHI. If you do agree and later change your mind, you may cancel your authorization.
How do I request restrictions on use or disclosure of PHI?
Call or write us to request restrictions on use of your PHI. There may be reasons why we cannot agree to this request. Even if we agree, we may still share records with a health care provider if needed for your treatment in an emergency.
How do I amend my PHI?
Call or write us to change or add to your PHI. In some cases, we may not be able to comply with your request, such as if we did not create the PHI. If we cannot comply with your request, we will explain why in writing.
How do I request an accounting of disclosures of PHI?
Call or write us to ask for and receive a list of people or organizations outside of AlohaCare that we share your PHI with. We share your PHI only for the reasons described above.
How do I access my PHI?
If you would like a copy of your PHI or need to request access to the PHI that AlohaCare has, please call Member Services at 973-0712 (Oahu) or toll-free at 1-877-973-0712 (Neighbor Islands/Oahu). AlohaCare does not keep copies of your medical records. To get copies of your medical records, please call your provider’s office and request a copy of your medical record.
You may also make your request in writing by sending a letter to:
Attention: Compliance Department
1357 Kapiolani Blvd, Suite 1250
Honolulu, HI 96814
AlohaCare has the right to not provide copies of your PHI in certain cases. To understand your rights, and the rights of AlohaCare, please see Notice of Privacy Practices or look at your AlohaCare QUEST Integration Member Handbook. You can also request a copy of the Notice of Privacy Practices by calling us.
How does AlohaCare protect my PHI?
AlohaCare is committed to protecting your sensitive and confidential information. We have privacy policies and procedures that tell staff about how to keep your health information secure. We provide ongoing training to our staff about confidentiality. We make sure staff only see and use the information that is required for them to do their job. Staff are very careful not to talk about confidential information where others may hear or in inappropriate places. We keep paper documents in a secure locked space when not in use. They are never visible when not in use. We have systems in place to protect electronic information throughout the organization. Our building is secure and visitors are not permitted in without authorization. AlohaCare reviews these protections on an annual basis, and looks for ways of improving protections for your PHI.