Inpatient hospital and inpatient behavioral health; observation care for behavioral health and residential substance abuse treatment; hospice, long term care and transplants.
Outpatient surgery, outpatient lab, imaging services and diagnostic tests; outpatient radiation therapy; blood and blood administration; outpatient therapy, cancer treatment and dialysis; outpatient behavioral health and specialized behavioral health programs.
Primary and specialty care provider services; physical exams and preventive services; home health, hearing, chiropractic, podiatry, vision and dental services.
Includes, for example, well-visits, immunizations, and screening visits. Preventive services are usually done by the PCP and include the services listed below and the specified frequency to the right. The frequency can be exceeded based on PCP recommendation.
See below for frequency per specified benefit.
Includes DME/Medical equipment and supplies; diabetic equipment, services and supplies.
Includes disease management programs; translation and interpreter services; 24x7 NurseLine and Nurse Chat services; smoking cessation services, care management services, pain management services; transportation (non-ambulance) and related services.
Note: Care providers who do not provide family planning services on the basis of religious beliefs must refer the member to a care provider who will provide such services.
Additional information on these services is in Chapter 4: Medical Management.
Members whose behavioral diagnostic, treatment or rehabilitative services that we determine not be medically necessary or are not covered.
The Department of Health covers eligible mental health services which include care management, housing, shelter, crisis services, and more. Services are available on all islands. The 24-hour Crisis/Help ACCESS Line is available at 808-832-3100.
Members who have been determined eligible for these services may be referred by the member’s Service Coordinator to the Community Care Services (CCS), which is part of the Department of Human Services. CCS is managed by Ohana Health Plan.
Members who are determined eligible for these services are referred to the Department of Health’s CAMHD. This offers children emotional and behavioral help. CAMHD services are available through their Family Centers.
Contact information is listed below:
Family Guidance Center: Central Oahu
Family Guidance Center: Family Court Liason Branch
Family Guidance Center: Honolulu
Family Guidance Center: Leeward Oahu
Family Guidance Center: Windward Kaneohe
Family Guidance Center: Hawai’i Hilo Waimea Kealakekua
Family Guidance Center: Kauai
Family Guidance Center: Maui
Additional information is available in Chapter 7: Mental Health and Substance Use
We do not provide behavioral health services to those members who have:
We use educational materials and newsletters to remind members to follow positive health actions such as immunizations, wellness, and EPSDT screenings. For those members with chronic conditions, we provide specific information, including recommended routine appointment frequency, necessary testing, monitoring, and self-care through our disease management (DM) program. All materials are based upon evidence-based guidelines or standards. All printed materials are written at a fifth grade reading level. They are available in English as well as other languages. The materials are designed to support members as they begin to take responsibility for their health. They provide information necessary to successfully manage their condition and live a healthy lifestyle.
Members at highest risk with conditions such as asthma, CHF, diabetes, COPD and CAD receive more intense health coaching. Resources and tools are available to support members and caregivers with conditions common to children with special health care needs and help them manage their illness.
Identification – We use claims data (e.g. hospital admissions, ER visits, and pharmacy claims) to identify members with gaps in care and/or chronic conditions.
Referral – PCPs may make referrals to support practice- based interventions by contacting the Health Services team at 866-270-5785.
These are services provided to cognitively impaired persons. They assess and treat communication skills, cognitive and behavioral ability and cognitive skills related to daily living. Reassessments are completed at regular intervals, determined by the care provider and according to the member’s assessed needs, treatment goals and objectives.
Some dental services may be covered by the state, especially for members under the age of 21. Community Case Management Corporation (CCMC) can help find a dentist and assist with transportation and translators. Contact CCMC at 888-792-1070.
For more details, go to UHCprovider.com.
To find a dental provider, go to UHCprovider.com > Find Dr > Dental Providers by state.
The DD/ID program, through contracted providers, serves people with mental or developmental disabilities including housing, living skills, home chores, alarm system, behavioral help nursing and personal care that is not covered by UnitedHealthcare Community Plan QUEST Integration.
Non-medical transport is also available.
The DD/ID Case Manager is the primary Case Manager and works with the UnitedHealthcare Community Plan QUEST Integration Service Coordinator.
Contact DD/ID at 808-733-9303 (Oahu), 808-241-3406 (Kauai), 808-243-4625 (Maui, Lanai, and Molokai), 808-974-4280 (East Hawai’i) or 808-877-8114 (North Hawai’i).
Early Intervention promotes the development of infants and toddlers with developmental challenges and delays. It also covers certain disabling conditions. The program provides services to eligible children from birth to three years old and their families.
These services and devices develop, improve or maintain skills and functioning for daily living that were never learned. Habilitative services and devices include:
We cover these services and devices only when medically necessary and if not otherwise covered in the benefits package.
Habilitative services do not include routine vision services.
Long Term Support Services (LTSS) is an alternative to out-of-home care (such as nursing homes). It helps pay for services provided to members so they can remain safely in their own home. The types of services authorized through LTSS are:
LTSS allows members to self-direct care through selection, hiring, supervising, training and terminating caregivers(s).
Eligibility – Members must be older than 65 years of age, or disabled, or blind. In some cases, disabled children are also eligible for LTSS. Additional eligibility requirements:
Referral – Anyone may initiate an LTSS application on behalf of a member. Adult members are encouraged to self-refer.
Contact information for referrals-
Member Services: 888-980-8728. Available 7:45 a.m. – 4:30 p.m. HST.
Obtain the Service Coordination Referral Form online at UHCprovider.com.
Assessment and Approval – The County Social Worker schedules a face-to-face assessment with the member to determine need. They authorize the service hours. The member is notified by the county if services are approved or denied. If denied, they are told the reason for denial. We pay for eligible LTSS hours approved by the county agency.
Tese are long-term services and supports provided to members who meet nursing facility level of care to allow those individuals to remain in their home or community.
When not meeting institutional level of care, we provide these HCBS services:
Adult Day Care. This is a regular supportive care provided to four or more disabled adult participants. Services include observation and supervision by center staff; coordination of behavioral, medical, and social plans and implementation of the instructions as listed in the participant’s care plan. Therapeutic, social, educational, recreational, and other activities are also provided. Adult day care staff may not perform health care related services such as medication administration, tube feedings, and other activities which require health care related training. All health care related activities must be performed by qualified and/or trained individuals only, including family members and professionals, such as an RN or LPN, from an authorized agency.
Adult Day Health. This is an organized day program of therapeutic, social, and health services provided to adults with physical or mental impairments, or both, which require nursing oversight or care. The purpose is to restore or maintain, to the fullest extent possible, an individual’s capacity for remaining in the community. Each program must have nursing staff sufficient in number and qualifications to meet the needs of participants. Nursing services are provided under the supervision of a registered nurse. In addition to nursing services, adult day health may also include: 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, and transportation services.
Assisted Living Services. This is personal care and supportive care services (homemaker, chore, attendant services, and meal preparation) given to members who reside in an assisted living facility. An assisted living facility is licensed by the Department of Health. It allows residents to maintain an independent assisted living lifestyle. Payment for room and board is prohibited.
Community Care Management Agency (CCMA). These services are provided to members living in Community Care Foster Family Homes (CCFFH) and other approved community settings. CCMAs:
Community Care Foster Family Home (CCFFH). Care providers give personal care and supportive services, homemaker, chore, attendant care, companion services, and medication oversight in a certified private home by a principal care provider who lives in the home. CCFFH services are currently furnished for up to three adults who receive these services in conjunction with residing in the home. All care providers must give individuals with their own bedroom unless the member consents to sharing a room with another resident. Both occupants must consent to the arrangement. The total number of individuals living in the home, who are unrelated to the principal care provider, cannot exceed four members. Members receiving CCFFH services must be receiving ongoing CCMA services.
Counseling and Training. This is a service provided to members, families/caregivers, and professional and paraprofessional caregivers on behalf of the member. Counseling and training services are given individually or in groups. This service may be provided at the member’s residence or an alternative site. Activities include member care training for members, family, and caregivers regarding the nature of the disease and the disease process; methods of transmission and infection control measures; biological, psychological care, and special treatment needs/regimens; employer training for consumer directed services; instruction about the treatment regimens; use of equipment specified in the service plan; employer skills updates as necessary to safely maintain the individual at home; crisis intervention; supportive counseling; family therapy; suicide risk assessments and intervention; death and dying counseling; anticipatory grief counseling; substance abuse counseling; and/or nutritional assessment and counseling; and/or nutritional assessment and counseling on coping skills to deal with stress caused by member’s deteriorating functional, medical or mental status.
Environmental Accessibility Adaptations. These are physical adaptations to the home, required by the individual’s service plan, which are necessary to ensure the health, welfare, and safety of the individual. It also enables the individual to function with greater independence in the home, and without which the individual would require institutionalization. Adaptations may include the installation of ramps and grabbars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems which are necessary to accommodate the medical equipment and supplies that are needed for the welfare of the individual. Window air conditioners may be installed when it is necessary for the health and safety of the member.
Excluded are those adaptations or improvements to the home that are not of direct medical or remedial benefit to the individual, such as carpeting, roof repair, and central air conditioning. Adaptations which add to the total square footage of the home are excluded from this benefit. All services are provided following State or local building codes.
Home Delivered Meals. These are nutritionally sound meals delivered to a location where an individual resides (excluding residential or institutional settings). The meals will not replace or substitute a full day’s nutritional regimen (i.e., no more than two meals per day). Home delivered meals are provided to the individuals who cannot prepare nutritional meals without assistance and are determined, through an assessment, to require the service in order to remain independent in the community and prevent institutionalization.
Home Maintenance. These are services necessary to maintain a safe, clean, and sanitary environment. Home maintenance services are those services not included as a part of personal assistance and include: heavy duty cleaning, which is utilized only to bring a home up to acceptable standards of cleanliness at the inception of services to a member; minor repairs to essential appliances limited to stoves, refrigerators, and water heaters; and fumigation or extermination services. Home maintenance is provided to individuals who cannot perform cleaning and minor repairs without assistance and are determined, through an assessment, to require the service in order to prevent institutionalization.
Moving Assistance. This is provided in rare instances when the Service Coordinator determines that an individual needs to relocate to a new home. The following are circumstances under which moving assistance can be provided to a member: unsafe home due to deterioration; the individual is wheelchair bound living in a building with no elevator; multi-story building with no elevator, where the client lives above the first floor; home unable to support the member’s additional needs for equipment; member is evicted from their current living environment; or the member is no longer able to afford the home due to a rent increase. Moving expenses include the packing and moving of belongings. Whenever possible, the member’s family, landlord, community, or third party resources that can provide this service without charge should be utilized.
Non-Medical Transportation. This enables individuals to gain access to community services, activities, and resources, specified by the service plan. Whenever possible, family, neighbors, friends, or community agencies that can provide this service without charge will be utilized. Members living in a residential care setting or a CCFFH are not eligible for this service.
Personal Assistance Services – Level I. This is for individuals who need help with independent activities of daily living but do not meet an institutional level of care. This prevents a decline in health status and maintain individuals safely in their homes and communities.
Personal assistance services Level I may be self-directed and consist of:
These services may be limited to 10 hours per week. There may also be a maximum threshold of members who are not at a nursing facility level of care who may receive Personal Assistance Level I services.
Personal Assistance Services–Level II. These are for individuals who require moderate/substantial to total assistance to perform activities of daily living and health maintenance activities. Services are provided by a Home Health Aide (HHA), Personal Care Aide (PCA), Certified Nursing Aide (CNA) or Nurse Aide (NA) with applicable skills competency. They may be self-directed.
The following activities may be included as a part of personal assistance services Level II:
When personal assistance services Level II activities are the primary services, personal assistance services Level I activities identified in the service plan that are incidental to the care furnished or are essential to the health and welfare of the member, rather than the member’s family, may also be provided.
Personal Emergency Response Systems (PERS). This is a 24-hour emergency assistance service that gives the member immediate assistance during an emotional, physical, or environmental emergency. Service is limited to those members who live alone or who are alone for long periods of time. PERS is an electronic device which enables certain individuals at high risk of institutionalization to secure help in an emergency. The individual may also wear a portable “help” button. The system is connected to the member’s phone and programmed to signal a response center once a “help” button is activated. The response center is staffed by trained professionals.
These are allowable types of PERS items:
PERS services will only be provided to a member residing in a non-licensed setting except for an Assisted Living Facility (ALF).
Residential Care Services. These are personal care services, homemaker, chore, attendant care companion services, and medication oversight given in a licensed private home by a principal care provider who lives in the home.
Residential care is furnished:
Respite Care Services. These are provided to individuals unable to care for themselves. They are furnished on a short-term basis because of the absence of or need for relief for those persons normally providing the care. Respite may be provided at three different levels: hourly, daily, and overnight. Respite care may be provided in these locations:
Respite care services are authorized by the member’s PCP and approved through the Service Coordinator. Respite services may be self-directed.
Skilled (or Private Duty) Nursing. This service is for members requiring ongoing nursing care listed in the care plan. It is provided by licensed nurses within the scope of State law. Skilled nursing services may be self directed under Personal Assistance Level II.
Specialized Medical Equipment and Supplies. These supplies let members maintain or increase their daily living activities. This involves the purchase, rental, lease, warranty cost, installation, repairs, and removal of devices, controls or appliances specified in the service plan, that enables individuals to increase and/or maintain their abilities to perform activities of daily living, and/or to control, participate in, or communicate with the environment in which they live.
This service also includes items necessary for life support, ancillary supplies, and equipment necessary to the proper functioning of such items, and durable and non-durable medical equipment not available under the Medicaid State Plan. All items must meet applicable standards of manufacture, design, and installation and may include:
Specialized medical equipment and supplies must be recommended by the member’s PCP.
These are services that provide care to terminally ill patients who are expected to live less than six months. Care providers must meet Medicare requirements. We do not cover hospice services provided to dual eligible members that are covered by Medicare. In these instances, only when the service need is not related to the hospice diagnosis, can the service be covered.
Hospice services provided to dual eligible members that are covered by Medicare (e.g., personal care services, homemaker services) are not covered (i.e., duplicated) by UnitedHealthcare Community Plan QUEST Integration. In these instances, only when the service need is not related to the hospice diagnosis can the service be covered by UnitedHealthcare Community Plan QUEST Integration.
This is part-time or intermittent care for members who do not require hospital care. This service is provided under the direction of a physician to prevent rehospitalization or institutionalization. Care providers must meet Medicare standards. We do not cover home health services provided to members who are covered by Medicare.
Nursing Facility Services. These services are provided to members who require care, including activities of daily living and instrumental activities of daily living, 24 hours a day from medical personnel on a long-term basis. Nursing facility services are provided in a free-standing or a distinct part of a licensed facility. The care that is provided includes:
Acute Waitlisted ICF/SNF. This is either ICF or SNF level of care services provided in an acute care hospital in an acute care hospital bed. We work with the facilities to identify these individuals who are acute waitlisted for discharge to a more appropriate location for treatment.
Subacute Facility Services. These are provided in either a licensed nursing facility or a licensed and certified hospital in accordance with Hawaii Administrative Rules. Subacute facility services provides the patient with services that meet a level of care that is needed by the patient not requiring acute care, but who needs more intensive skilled nursing care than is provided to the majority of the patients at a skilled nursing facility level of care. The Subacute level of care is designated either as Level I or II.
These services are not covered by UnitedHealthcare Community Plan. This a carved-out service. ITOPs are covered by the DHS in compliance with federal regulations through Xerox.
You may contact Xerox for additional information at 808-952-5570 (Oahu) or toll free at 800-235-4378 (Neighbor Islands).
For transportation related to ITOP services providers may contact Community Case Management (CCMC) at 792-1070 (Oahu) or toll free at 888-792-1707 (Neighbor Islands) for assistance.
All claims for ITOP procedures, medications, transportation, meals, and lodging associated with ITOPs must be submitted directly to Xerox at:
P.O. Box 1220
Honolulu, Hawaii 96807-1220
The KidsHealth website offers health and wellness resources to encourage healthy behaviors among children, young adults and their parents. These health care education resources include assistance for high-risk members managing such conditions as diabetes, asthma and stress. Links on the member website, myuhc.com, reveal videos and articles accessible through a computer, tablet or smartphone. KidsHealth is for members 20 years and younger.
Apps are available at no charge to our members.
NurseLine is available at no cost to our members 24 hours a day, seven days a week. Members may call NurseLine to ask if they need to go to the urgent care center, the emergency room or to schedule an appointment with their PCP. Our nurses also help educate members about staying healthy. Call 888-980-8728 to reach a nurse.
These include 24 hours a day, seven days a week, emergency services, ambulatory center services, urgent care services, medical supplies, equipment and drugs, diagnostic services, and therapeutic services including chemotherapy and radiation therapy.
This is only available as an additional service for behavioral health members. Our peer support services works with members to develop coping skills. Skills include encouragement, safety and a sense of responsibility for their own recovery. This benefit also emphasizes support to those with a behavioral health diagnosis while working through substance use disorder (SUD) treatment and recovery.
Eligible members are identified through predictive modeling and claims data, a health risk assessment (HRA) or your referral. The program has no age limitation.
We cover prescription drugs when medically necessary to optimize the member’s medical condition. Behavioral health prescription drugs are covered for children receiving services from the Children and Adolescent Mental Health Division. Medication management and patient counseling are also included. More pharmacy resources and information is available at UHCprovider.com/ HIcommunityplan > Pharmacy Resources and Physician Administered Drugs.
The Department of Education provides some services to students. It promotes caring relationships among students, teachers, families, and agencies and seeks to ensure timely intervention to provide optimum classroom climate, family involvement, and specialized help. Contact them at 808-735-6225 or fax 808-733-9890.
This is a carved-out service. The Department of Human Services provides transplants which are not experimental or investigational and not covered by UnitedHealthcare Community Plan QUEST Integration. The SHOTT program
covers adults and children for liver, heart, heart-lung, lung and bone marrow transplants. In addition, children are covered for transplants of the small bowel with or without liver. Children and adults must meet medical criteria as determined by the State and the SHOTT program contractor.
For information, contact our Member Services at 888-980-8728 or TTY: 711.
This program provides free:
Oahu #: 808-586-8175
Neighbor Islands #: 888-820-6425
The Zero to Three Program helps children with conditions that may result in developmental delay. Members with children who may qualify can call the Hawai’i Keiki Information Service System (H-KISS) at 800-235-5477 or 808-594-0066 (Oahu).
H-K ISS is the central point for referrals. Referrals may be from any source. This includes hospitals, doctors, parents, day care, education or public agencies, or other providers. The Department of Health coordinates services with local agencies.
Certain services and service categories are excluded from coverage under the UnitedHealthcare Community Plan QUEST Integration Program. Certain Medicaid covered services may also be carved out and are provided by the state and/or other local agencies.
For a complete list of exclusions, contact Provider Services at 888-980-8728.