Medical Coverage

AlohaCare covers a variety of medical services and benefits for our QUEST (Medicaid) members.

What are my benefits?

As a member of AlohaCare, some of your QUEST (Medicaid) 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 (Medicaid) 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 (Medicaid)?

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
- Click here for a list of urgent care centers and after-hours clinics.
Go to the office in the morning
Go to the Emergency Room (ER)
Get medication from the 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

Emergency Facilities

Kaua`i
Kapa`a	Samuel Mahelona Memorial Hospital	808-822-4961	4800 Kawaihau Road Kapa`a, HI 96746
Līhue	Wilcox Memorial Hospital	808-245-1100	3-3420 Kuhio Highway Līhue, HI 96766
Waimea	West Kaua`i Medical Center	808 338-9431	4643 Waimea Canyon Drive Waimea, HI 96796
O`ahu
`Aiea	Pali Momi Medical Center	808-486-6000	98-1079 Moanalua Rd. `Aiea, HI 96701
`Ewa Beach	The Queen's Medical Center West	808-691-3000	91-2141 Fort Weaver Rd. `Ewa Beach, HI 96706
Honolulu	Kaiser Permanente	808-432-0000	3288 Moanalua Rd. Honolulu, HI 96819
Honolulu	Kapi`olani Medical Center	808-983-6000	1319 Punahou Street Honolulu, HI 96826
Honolulu	Kuakini Medical Center	808-531-3511	226 N. Kuakini Street Honolulu, HI 96817
Honolulu	Straub Clinic & Hospital	808-522-4000	888 South King Street Honolulu, HI 96813
Honolulu	The Queen's Medical Center	808-691-1000	1301 Punchbowl St. Honolulu, HI 96813
Honolulu	Tripler Emergency Room	808-433-6661	1 Jarrett White Road Tripler Army Medical Center, HI 96859
Wahiawa	Wahiawa General Hospital	808-621-8411	128 Lehua Street Wahiawa, HI 96786
Wai`anae	Wai`anae Coast Comprehensive Health Center	808-697-3300	86-260 Farrington Hwy. Wai`anae, HI 96792
Moloka`i
Kaunakakai	Moloka`i General Hospital	808-553-5331	280 Home Olu Place Kaunakakai, HI 96748
Maui
Kula	Kula Hospital	808-878-1221	100 Keokea Place Kula, HI 96790
Wailuku	Maui Memorial Hospital	808-244-9056	221 Mahalani Street Wailuku, HI 96793
Lana`i
Lana`i City	Lana`i Community Hospital	808-565-8450	628 7th Street Lana`i City, HI 96793
Hawai`i Island
Honoka`a	Hale Ho`ola Hamakua	808-932-4100	45-547 Plumeria Street Honoka`a, HI 96727
Hilo	Hilo Medical Center	808-932-3000	1190 Waianuenue Avenue Hilo, HI 96720
Kapa`au	Kohala Hospital	808-889-6211	54-383 Hospital Road Kapa`au, HI 96755
Kamuela	North Hawai`i Community Hospital	808-885-4444	67-1125 Mamalahoa Highway Kamuela, HI 96743
Kealakekua	Kona Community Hospital	808-322-9311	79-1019 Haukapila Street Kealakekua, HI 96750
Pahala	Ka`u Hospital	808-932-4200	1 Kamani Street Pahala, HI 96777

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 808-973-0712 (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

Please call AlohaCare Customer Service at the first notification of a bill from a provider. The issue is usually simple to resolve as the service provider may not have accurately obtained your insurance information. Facilities, like hospitals or other ambulance carriers, may send invoices that have not yet been handed out for collection. AlohaCare Customer Service will reach out to the provider, biller or collection agency to assist in resolving the matter.

How do I submit claims for services or prescription drugs that I paid for?

Please see the "How Can I Request Reimbursement for My Drugs?" section of http://www.alohacare.org/QUEST/PrescriptionDrugs for more information.

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?

Reimbursement for Medical Services

AlohaCare

Attn: Reimbursement Coordinator

1357 Kapi`olani Blvd, Suite G101

Honolulu, HI 96814

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 808-973-0712 (O`ahu) or toll-free at 1-877-973-0712. TTY users call 1-877-447-5990.