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Medical Coverage


 
What are my benefits?
As a member of AlohaCare, some of your QUEST Integration (QI) benefits include:
  • Doctor visits
  • Family planning services
  • Hospital services
  • Prescription drugs
  • Preventive care services
  • Tests and lab services
  • Long-term services and supports
  • Service coordination

For a complete listing of your benefits, see the list of QUEST Integration Benefits.

 
Will I have to pay for covered services or covered drugs?
No. There is no copayment for covered services. There is no copayment for covered drugs, unless you also have Medicare. If you have Medicare, your Medicare Part D plan will cover most of your drugs though you will have a copayment. There are certain drugs and over-the-counter medications not covered by your Medicare Part D plan that AlohaCare may cover without a copayment.
 
 
Will I have to pay for other medical services under QUEST Integration? 
You may have to share in the cost of your health care or support services.  This is based on your Medicaid financial eligibility.  AlohaCare will assist in making sure you are aware of your costs and help you coordinate the payment.
 
 
Will I have to pay if I see a provider not in AlohaCare’s provider network?
You may have to pay.  If you need care from a doctor, social worker, or counselor who is not in our provider network, your Primary Care Provider (PCP) will work with us for prior authorization.  If you are approved to get care from a doctor who is not in our provider network then AlohaCare will pay for your services.
 
 
Can I get care outside of Hawaii?
When you are travelling away from home (e.g., visiting family, on vacation) and you become ill, you can still get medical help.  Take your AlohaCare member ID card with you when you travel to the Mainland, in case you need it.  Emergency care is covered outside of Hawaii.  Non-emergency care is not covered outside of Hawaii.
 
If you need emergency services on the Mainland, go to a hospital emergency room for care. 
  • Adults are covered for emergency care while on the Mainland. 
  • Children are covered for emergency care while on the Mainland.  Children are also covered for all medically necessary EPSDT covered services while on the Mainland.

 
What if I get sick when I am out of the country?
Emergency care and medical services outside of the United States are not covered for children or adults. You will need to pay for these services yourself.

 
What if I need medical care and my doctor’s office is closed?
If it is not an emergency, call your doctor’s office.  Even if your doctor’s office is closed, your doctor’s phone message will tell you how to get a hold of your doctor or someone from the office.
 
 
For example, you may be told to:
  • Go to an after-hours clinic or urgent care center
  • Go to the office in the morning
  • Go to the Emergency Room (ER)
  • Get medication from your pharmacy
 
 
You can also call our Nurse Advice Line toll-free at 1-877-225-8839, 24 hours a day, 7 days a week. 

 
What if I have an emergency?
If it is an emergency, call 911 or go to the nearest emergency room, whether you are in or out of Hawaii.  Emergency services are covered 24 hours a day, seven days a week without prior authorization.  Emergency services are covered in Hawaii and on the Mainland.
 
If you need help getting to the emergency room, call 911.  You are not required to call your doctor before you go to the emergency room.  Do not use the emergency room for routine health care.
 
A medical emergency is when you suddenly become very sick or seriously injured and not getting care right away could result in the following:
  • Placing your life in danger
  • Putting your health, a body function or body part in danger
  • Harming yourself or another person
  • Placing your life or your unborn baby’s life in danger while you are pregnant
 
 
 
What if I get a bill from my doctor?
If you get a bill from your doctor, hospital or other provider, ask them why they are billing you.  You should not be billed for services covered under the QI program. 
 
 
Who do I call if I get a bill?
You can call Member Services at 973-0712 (Oahu) or toll-free at 1-877-973-0712.  TTY users call 1-877-447-5990. Be sure to have the bill and your member ID card in front of you.  You will need to tell us:
  • Your name, member ID number and date of birth
  • Who sent you the bill
  • The date you received the services
  • The cost of the services
 
We will contact your doctor directly to fix the billing problem.
 
 
How do I submit claims for services or prescription drugs that I paid for?
If you already paid for services or prescription drugs covered under the QI program, you can ask AlohaCare to pay you back.  This is called a member reimbursement.  You can submit a claim form and your receipts to AlohaCare.  You have up to one year to request a reimbursement.
 
 
What do I need to include for my reimbursement?
  • A completed, signed Direct Member Reimbursement (DMR) form
  • A detailed receipt (no handwritten receipts) or printout with information about the services you received
    • Member name
    • Provider name
    • List of itemized services received
    • Date of services
    • Amount you paid
  • All of the information must be included. If information is missing, your DMR request will be denied.  You will be able to send in your request again with the missing information.
 
 
Where do I send my request for reimbursement?
AlohaCare
Attention: Claims Department
1357 Kapiolani Blvd, Suite 1250
Honolulu, HI 98614
 
 
Technology Assessment
AlohaCare evaluates the use of new technologies in a timely manner.  AlohaCare has a committee that looks carefully at new procedures, medications, treatments, and devices to determine whether we should update our list of covered benefits.  Providers and members can ask AlohaCare to cover something new by submitting a written request to the Chief Medical Officer.  When AlohaCare receives such a request, the committee investigates the procedure, medication, treatment, or device.  The committee will research current medical literature and medical practice and thoroughly discuss the findings.  The committee will then make a decision about coverage.
 
The AlohaCare technology assessment process assures that coverage will be available when medical necessity criteria are met and evidence of safety and effectiveness exists.
 
 
 
Clinical Practice Guidelines
AlohaCare uses clinical practice guidelines developed by local and national associations. These guidelines are based on evidence and data. Providers are held to these standards. These guidelines are created with the assistance of local physicians. If you would like copies of the guidelines, please call Member Services at 973-0712 (Oahu) or toll-free at 1-877-973-0712. TTY users call 1-877-447-5990.