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Chapter 6: Benefits-Covered, Excluded and Value-Added

Benefit Information

Benefit: Ambulance

  • Description: Emergency transport
  • Frequency, Limitation and Exclusions: None
  • Description: Non-emergent medical transport.
  • Frequency, Limitation and Exclusions: NA

Benefit: Emergency Services

  • Description: Covered seven days a week at any emergency room. Emergency and post- stabilization services (including observation services).
  • Frequency, Limitation and Exclusions: Limitation: Covered only in the USA

Benefit: Urgent Care Services

  • Description: Covered seven days a week at any emergency room. Emergency and post- stabilization services (including observation services).
  • Frequency, Limitation and Exclusions: Limitation: Covered only in the USA

 

Inpatient hospital and inpatient behavioral health; observation care for behavioral health and residential substance abuse treatment; hospice, long term care and transplants.

Benefit: Inpatient Hospital (Medical)

  • Description: Inpatient care needed for medical, surgical, maternity (including newborn care), intensive care or other acute inpatient services. Also includes post- stabilization services and rehabilitative services.
  • Frequency, Limitation and Exclusions: None

Benefit: Inpatient Hospital (Behavioral Health)

  • Description: Inpatient Behavioral health Care includes: psychiatric / mental health or substance abuse treatment inpatient stays in a facility.
  • Frequency, Limitation and Exclusions: None

Benefit: Observation – Behavioral Health

  • Description: Partial hospitalization for mental health or substance abuse.
  • Frequency, Limitation and Exclusions: None

Benefit: Residential Treatment Facility

  • Description: Alcohol and Chemical Dependency Services – substance abuse services in a treatment setting accredited according to the standards established by the State of Hawaii Department of Health Alcohol and Drug Abuse Division (ADAD). Substance abuse counselors shall be certified by ADAD. Includes detoxification.
  • Frequency, Limitation and Exclusions: None

Benefit: Hospice

  • Description: End of life care – Care for the terminally ill and are expected to live less than six months. Hospice care maybe done in a hospital, other facility or in the member’s home. Children under the age of 21 years can receive treatment to manage or cure their disease while concurrently receiving hospice services.
  • Frequency, Limitation and Exclusions: None

Benefit: Long Term Services and Support and Facility Stays

  • Description: Long term care includes skilled nursing care, intermediate care, sub-acute, and custodial care in a facility or alternative setting such as at home. Facility can be a nursing facility, hospital or other facility licensed for long term care. These services are for members who need assistance with almost all activities of daily living, required skilled monitoring and support.
  • Frequency, Limitation and Exclusions: Limitation: Services are based on member's service plan.

Benefit: Transplants by us

  • Description: Cornea transplants and bone grafts. Bone grafts are covered as an orthopedic procedure.
  • Frequency, Limitation and Exclusions: Exclusions - Experimental and investigational transplants and those covered by SHOTT

Benefit: Transplants by the State of Hawaii Organ and Transplant (SHOTT) Program

  • Description: Refer the member to the SHOTT who covers the following transplants: Liver, heart, heart-lung, lung, kidney, kidney-pancreas and allogenic and autologous bone marrow transplants. Children under 21 years of age: small bowel with or without liver is covered.
  • Frequency, Limitation and Exclusions: See benefit description section to the left

Benefit: Inpatient Professional / Medical Services

  • Description: Hospital, skilled nursing facility or alternate facility – Covered during an authorized facility stay including emergent admissions.
  • Frequency, Limitation and Exclusions: None

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.

Benefit: Outpatient Behavioral Health

  • Description: Includes professional services for evaluation, testing and treatment of mental illnesses and/or substance abuse including therapy and medication management; individual and group therapy sessions. See specific services listed below for additional information.
  • Frequency, Limitation and Exclusions: None
  • Description: Standard outpatient behavioral health services such as visits to a psychiatrist, psychologist, or behavioral health advance practice nurse practitionery (APRN)
  • Frequency, Limitation and Exclusions: None
  • Description: Mental health individual therapy sessions / medication management.
  • Frequency, Limitation and Exclusions: None

Benefit: Outpatient Detoxification

  • Description: Outpatient medically managed detoxification treatment.
  • Frequency, Limitation and Exclusions: None

Benefit: Methadone Management Services

  • Description: Methadone/LAAM services for adult members are covered for acute opiate detoxification as well as maintenance.
  • Frequency, Limitation and Exclusions: None

Benefit: Serious and Persistent Mental Illness (“SPMI”) Members

  • Description: Services with a diagnosis of Serious and Persistent Mental Illness (SPMI), additional outpatient services are available such as behavioral health intensive case management, psychosocial rehabilitation, therapeutic living program, mental health support and crisis management.
  • Frequency, Limitation and Exclusions: Limitation: SPMI members only; if member is in the Community Care Services (CCS) program, the additional services will be provided through CCS.

Benefit: Behavioral Health Intensive Case Management Services

  • Description: Includes case assessment, planning, outreach, ongoing monitoring and service coordination, including disease and self management to promote illness management and recovery.
  • Frequency, Limitation and Exclusions: Limitation: SPMI members only; if member is in the CCS program, the additional services will be provided through CCS.

Benefit: Psychosocial Rehabilitation / Clubhouse Services

  • Description: Therapeutic day rehab social skill building services, such as group skill building activities that focus on development of problem solving skills, medication education, and symptom management, which results in opportunities to improve the qualify of life through meaningful work, positive relationships, and gainful employment.
  • Frequency, Limitation and Exclusions: Limitation: SPMI members only; if member is in the CCS program, the additional services will be provided through CCS.

Benefit: Therapeutic Living Program

  • Description: Services in settings such as group living arrangements or therapeutic foster homes. Therapeutic supports are only available when the identified individual resides in a licensed group living arrangement or licensed therapeutic foster home.
  • Frequency, Limitation and Exclusions: Limitation: SPMI members only; if member is in the CCS program, the additional services will be provided through CCS.

Benefit: Mental Health Support and Crisis Management

  • Description: Includes 24-hour access line, mobile crisis response, crisis stabilization, and crisis management.
  • Frequency, Limitation and Exclusions: Limitation: SPMI members only; if member is in the CCS program, the additional services will be provided through CCS.

Primary and specialty care provider services; physical exams and preventive services; home health, hearing, chiropractic, podiatry, vision and dental services.

Benefit: Primary Care Provider Services

  • Description: Services by a Primary Care Provider (PCP). In addition to medical and related services, the PCP can help refer members to a specialist for specialty care services. A PCP can be a family practice, general practice, internal medicine, pediatrician, OB/GYN, advance practice nurse practitioner with prescriptive authority (APRN-Rx), physician assistant or community clinic provider.
  • Frequency, Limitation and Exclusions: None

Benefit: Physician Services

  • Description: Services provided by physicians other than a PCP (including specialty care). These are services that a PCP cannot provide.
  • Frequency, Limitation and Exclusions: None

Benefit: Physical Examinations

  • Description: Exams to determine the member’s health status (typically provided by the PCP).
  • Frequency, Limitation and Exclusions: None

Benefit: Preventive 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.

  • Description: Total cholesterol measurement
  • Frequency, Limitation and Exclusions: Frequency: For females age 45-65 and males 35-65, one exam every five years.
  • Description: Pap smears and screening pelvic examinations
  • Frequency, Limitation and Exclusions: Frequency: One every one to two year(s)
  • Description: Annual Mammogram (Breast Cancer)
  • Frequency, Limitation and Exclusions: Frequency: Age 31 and older, every one to two years starting at age 40
  • Description: Bone mass measurement (bone density full body)
  • Frequency, Limitation and Exclusions: None
  • Description: Glaucoma screening
  • Frequency, Limitation and Exclusions: None
  • Description: Colorectal cancer screening
  • Frequency, Limitation and Exclusions: 
  • Description: Frequency: Age 50+, one exam per every two years
  • Frequency, Limitation and Exclusions: 
  • Description: Prostate cancer screening
  • Frequency, Limitation and Exclusions: Age 50+, one exam per year
  • Description: Frequency: HIV/AIDS testing
  • Frequency, Limitation and Exclusions: None
  • Description: Immunizations and vaccines
  • Frequency, Limitation and Exclusions: None
  • Description: Blood pressure measurement
  • Frequency, Limitation and Exclusions: Frequency: Every two years if normal
  • Description: Weight/height measurement
  • Frequency, Limitation and Exclusions: Frequency: Every two years if normal
  • Description: Nutrition Counseling — includes diabetes self-management training (DSMT) programs as part of an American Diabetes Association (ADA)/ American Association of Diabetes Educators (AADE) recognized DSMT programs, nutrition counseling for obesity, and when medically necessary for other metabolic conditions.
  • Frequency, Limitation and Exclusions: NA
  • Description: Nutrition Counseling — Requires physician's order and must be part of a treatment program to mitigate the effects of an illness or condition.
  • Frequency, Limitation and Exclusions: NA

Benefit: Home Health Services

  • Description: Services include medical equipment, medial supplies, therapy or rehabilitative services, skilled nursing care, audiology, speech-language pathology and home health aides.
  • Frequency, Limitation and Exclusions: None

Benefit: Hearing Services

  • Description: Services include screening, evaluation, diagnostic, or corrective services, equipment, or supplies provided by, or under the direction of an otorhinolaryngology or an audiologist to whom a patient is referred by a physician.
  • Frequency, Limitation and Exclusions: Frequency/Limitation: Initial Eval/Selection: Every 24 months Electroacoustic Eval: Three years or less is four times per year; greater than four years is two times per year Fitting/Orientation/ Hearing Aid Check: <21 years is two times every three years; >21 years is once every three years
  • Description: Hearing aid device coverage is for both analog and digital models and includes service, loss, damage warranty, a trial or rental period. Hearing Aid Vendor: EPIC Hearing. EPIC Hearing works with the requesting care provider on the prior authorization process. EPIC Hearing has its own hearing aid network.
  • Frequency, Limitation and Exclusions: Limitation: One hearing aid per ear every two years. Limit can be exceeded if medically necessary

Benefit: Chiropractic Services

  • Description: Not a covered benefit.
  • Frequency, Limitation and Exclusions: Exclusion

Benefit: Podiatry Care

  • Description: Includes foot and ankle care related to the treatment of infection or injury provided in the office/outpatient clinic setting, surgical procedures involving the ankle and below, diagnostic radiology procedures limited to the ankle and below, bunionectomies when bunion is present with overlying skin ulceration or neuroma secondary to the bunion. Also includes professional services not involving surgery provided in the office/clinic or related to diabetic foot care in the outpatient/inpatient hospital.
  • Frequency, Limitation and Exclusions: None

Benefit: Vision Services

  • Description: Medically Necessary Eye ExamsEye/Vision exams for medical diagnosis
  • Frequency, Limitation and Exclusions: Limited to exams to diagnose and treat diseases and conditions of the eye (not to correct poor vision/visual acuity).
  • Description: Routine Eye Exams (to correct poor vision/visual acuity, must be provided by a qualified optometrist) 
    • Vision exams
    • Refraction
  • Frequency, Limitation and Exclusions: Adults: Limit to one routine eye exam every 24 months Children under the age of 21: Limit to one eye exam every 12 months
  • Description: Routine Eye Exams (to correct poor vision/visual acuity, must be provided by a qualified optometrist) 
    • Vision exams
    • Refraction
  • Frequency, Limitation and Exclusions: Adults: Limit to one routine eye exam every 24 months Children under the age of 21: Limit to one eye exam every 12 months
  • Description: Visual Aids – must be prescribed by ophthalmologists or optometrists
    • Eye glasses
    • Contact lenses
    • Miscellaneous vision supplies including prosthetic eyes, lens, frames or other parts of the glasses as well as fittings and adjustments
    • Replacement glasses or contact lenses
  • Frequency, Limitation and Exclusions: Adults/Children: Limit to one pair of glasses or contact lenses every 24 months. Individuals under 40 years of age require medical justification for bi-focal.
  • Description: Orthopedic training, prescription fee; progress exams, radial keratotomy, visual training, Lasik procedure, and contact lenses for cosmetic reasons.
  • Frequency, Limitation and Exclusions: Exclusion
  • Description: Cataract removal: covered under the outpatient surgery benefit.
  • Frequency, Limitation and Exclusions: None

Benefit: Dental Services

  • Description: Routine Dental
    • Exams
    • X-rays
    • Preventative care and treatment
  • Frequency, Limitation and Exclusions: Carved out to the State:
    • Covered only for Children under 21 years old.
    • Call Community Case Management Corporation (CCMC) at 808-792-1070 or 888-792-1070. We can also make a referral to CCMC.
  • Description: Emergency Dental Services
    • Services to relieve dental pain, eliminate infections, and treat acute injuries to teeth and jaw
  • Frequency, Limitation and Exclusions: Carved out to the State:
    • Covered for Adults age 21 years and older
    • Call Community Case Management Corporation (CCMC) at 808-792-1070 or 888-792-1070.
  • Description: Dental Services Covered by us
    • Dental services that are medically necessary to treat a medical condition
    • Dental or medical services resulting from a dental condition provided in a facility (hospital or a ambulatory surgery center) and are the result of a dental or medical condition
    • Dental services performed by a dentist or physician due to a medical emergency (e.g., car accident) where services provided are primarily medical
    • Dental services in relation to oral or facial trauma, oral pathology (including but not limited to infections or oral origin, cyst and tumor management) and craniofacial reconstructive surgery (performed on an inpatient basis in an acute care hospital setting)
  • Frequency, Limitation and Exclusions: Exclusion: Services provided in private dental offices, government sponsored or subsidized dental clinics, and hospital outpatient dental clinics.

 

Includes DME/Medical equipment and supplies; diabetic equipment, services and supplies.

Benefit: Durable Medical Equipment and Medical Supplies

  • Description: Include but are not limited to the following:
    • Oxygen tanks and concentrators
    • Ventilators
    • Wheelchairs
    • Crutches and canes
    • Orthotic devices
    • Prosthetic devices
    • Pacemakers
    • Breast pumps
    • Incontinence
    • Foot appliances (orthoses, prostheses)
    • Orthopedic shoes and casts
    • Orthodigital prostheses and cases
    • Medical supplies as surgical dressings, ostomy, etc.
  • Frequency, Limitation and Exclusions: None

Benefit: Diabetic Equipment

  • Description: Insulin pump and glucose monitoring devices.
  • Frequency, Limitation and Exclusions: None

Benefit: Diabetic Supplies

  • Description: All diabetic supplies, including but not limited to alcohol swabs, syringes, test strips and lancets. Diabetic supplies can be from a participating pharmacy or can be delivered to the Member’s home (from our mail order pharmacy, OptumRx).
  • Frequency, Limitation and Exclusions: Limitation: Glucometers are obtained by calling the manufacturer, not through retail pharmacy.
  • Description: Mail order pharmacy is provided through our pharmacy benefit manager Optum RX; they can be reached at 877-889-6510.
  • Frequency, Limitation and Exclusions: Limitation: Quantity Limits apply. Please see the QUEST Integration formulary at UHCprovider.com/HIcommunityplan > Pharmacy Resources and Physician Administered Drugs

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.

Benefit: Disease Management Programs

  • Description: We use screening and evaluation procedures for the early detection, prevention, and treatment of chronic illnesses under our disease management programs. This helps members to manage their chronic disease or condition. Our disease management programs include diabetes, congestive heart failure, asthma and high-risk pregnancy.
  • Frequency, Limitation and Exclusions: None

Benefit: Translation and Interpreter Services

  • Description: Services for non-English speaking members and for members with visual and hearing impairments. Contact us to access services or for assistance.
  • Frequency, Limitation and Exclusions: None

Benefit: NurseLine & Nurse Chat Services

  • Description: Available for Members, 24-hours, seven days a week. NurseLine can help with minor injuries, common illnesses, self-care tips and treatment options, recent diagnoses and chronic conditions, and much more.
  • Frequency, Limitation and Exclusions: None
  • Description: NurseLine: 877-512-9357
  • Frequency, Limitation and Exclusions: None
  • Description: Access Nurse Chat at myuhc.com
  • Frequency, Limitation and Exclusions: None

Benefit: Smoking Cessation

  • Description: Counseling
    • Practical counseling (problem-solving/skills)
    • Social support
  • Frequency, Limitation and Exclusions: Limitation: At least four in-person sessions per quit attempt
  • Description: Medications
    • Nicotine
    • Non-nicotine
  • Frequency, Limitation and Exclusions: Limitation: Included as part of the Quit Attempts

Benefit: Pain Management

  • Description: Professional management, medication and other services as medically necessary to help manage chronic pain.
  • Frequency, Limitation and Exclusions: None

Benefit: Transportation and Related Services (for emergency transport, see Ambulance Benefit)

  • Description: Ground and/or air transportation to and from covered medically necessary appointments.We provide an attendant if the member requires assistance. All Transportation and Related Services are provided by Logisticare. Members should call Logisticare to schedule all trips at least 48 hours in advance of their health care appointment.
  • Logisticare Contact Information:
    • Reservations 877-564-5909
    • Ride Assistance 877-564-5910
    • Hearing Impaired 866-288-3133
  • Frequency, Limitation and Exclusions: Limitation: Covered only for members who have no means of transportation and who reside in areas not served by public transportation or cannot access public transportation.The following is not covered:
    • Transport services when a Prior Authorization is required but not obtained.
    • Transport related to services that are not medically necessary.
    • Transport to a pharmacy.
    • Transport for personal errands such as shopping or visiting.
    • Transport to a SSI Determination Medical Appointment or Medicaid eligibility.
    • Transport to classes, support groups, community events, etc., unless included as part of the service plan.
    • Transport for any services not covered under QUEST Integration.
    • Transportation for individuals that have Medicare or other insurance coverage that is primary to Medicaid. Medicare or other primary insurance and Medicaid have different benefits and coverage policies. Under the member’s primary insurance coverage, members may be able to seek health care services on a different island from the one that they live on. However, Medicaid requires that members receive care on the island where they live if those services are available. If the member travels to another island or to the mainland and those health care services are available on the island that member resides in, we will not pay for transportation.
  • Description: Lodging and meals/food are covered if needed due to Inter-Island or Out-of- State. Meals/Food limit will be based on the case scenarios specified under limitations to the right. Reimbursement: No member reimbursement will be allowed without a receipt for all food/meal purchases.
  • Frequency, Limitation and Exclusions: Inter-island (same day doctor visit/one day visit): Limit to $15 per member and per authorized companion. Inter-island (multiple doctor visits/days per duration): Limit to $30 per day per member and per authorized companion. Out-of-State (all visits): Limit to $30 per day per member and per authorized companion.

Benefit: Maternity Care

  • Description: Covered throughout pregnancy right up to and after delivery and may be provided by physicians and other practitioners as licensed and in their scope of practice, including certified nurse midwives or licensed midwives. Services include:
    • Prenatal care (which should begin as soon as possible)
    • Radiology, lab and other diagnostic testing
    • Prenatal vitamins
    • Doctor/Practitioner visits
    • Up to three ultrasounds without needing authorization
    • Other necessary services that impact pregnancy outcomes
    • For high risk pregnancies, you can get additional support and help from one of our Plan’s care managers
    • Delivery of your baby
    • Postpartum care (up to 60 days from the date of delivery)
    • Health education and screening
  • Frequency, Limitation and Exclusions: None

Benefit: Newborn Care

  • Description: Includes newborn hearing assessment, laboratory screening, delivery, inpatient hospital related services, outpatient services, EPSDT services, circumcision and other needed newborn care services.
  • Frequency, Limitation and Exclusions: Circumcision: Once in a lifetime.

Benefit: Genetic Testing

  • Description: Tests such as chromosomal analysis to determine potential for genetic conditions that may be passed from parent to child.
  • Frequency, Limitation and Exclusions: None

Benefit: Infertility Testing and Treatments

  • Description: Not Covered
  • Frequency, Limitation and Exclusions: Can be reviewed upon request for medical necessity on a case-by-case basis.

 

Benefit: Family Planning Services

  • Description:Services available on a confidential and voluntary basis to all members by in-network and out-of-network care providers and includes, at a minimum the following:
    • Family planning drugs, supplies and devices to include but not limited to generic birth control pills, medroxyprogesterone acetate (Depo-Provera), intrauterine device (IUD), and diaphragms.
    • Education and counseling necessary to make informed choices and understand-contraceptive methods
    • Emergency contraception
    • Follow-up, brief and comprehensive visits
    • Pregnancy testing
    • Contraceptive supplies and follow-up care; and
    • Diagnosis and treatment of sexually transmitted diseases

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.

Benefit: Intentional Termination of Pregnancy (ITOP) (Abortions)

  • Description: Services we do not cover
    • The State of Hawaii (DHS) covers all procedures, medications, transportation, meals, and lodging associated with ITOPs (abortions). Providers must bill the State of Hawaii DHS’ fiscal agent directly for services related to ITOPs.
  • Frequency, Limitation and Exclusions: Carved out to the State: Contact DHS' Fiscal Agent at 808-952-5570 (Oahu) or 800-235-4378 (Neighbor Islands).
  • Description:Services we cover
    • We cover treatment of medical complications resulting from ITOPs (abortions). We cover treatments for spontaneous, incomplete or threatened terminations for ectopic pregnancies.
  • Frequency, Limitation and Exclusions: Limitation: Only related services for treatment of medical complications resulting from an ITOP.

Benefit: Sterilizations and Hysterectomies

  • Description: Sterilization is any medical procedure or treatment for the purpose of rendering a man or woman incapable of reproducing.
  • Sterilization is only covered when:
  1. Member has given informed consent (DHS Form 1146)
  2. Member is at least 21 years old at the time of consent
  3. Consent is at least 30 days but not more then 180 days before the procedure
  4. The provider signs the informed consent form (DHS Form 1146)
  5. In the case of emergency abdominal pain, at least 72 hours have passed since informed consent was given
  6. In the case of premature birth, informed consent was given at least 30 days in advance of the expected delivery dat
  7. Interpreter services have been given to non-English speaking members or other assistance to communicate with members with hearing or vision impairments or other disability.
  • Frequency, Limitation and Exclusions: Exclusions: If member is institutionalized in a correctional facility, mental hospital or other rehabilitative facility.
  • Description: Hysterectomy is a medical procedure to remove a women’s reproductive system (all or part of the uterus). A hysterectomy is only covered when:
  1. Member has given informed consent (DHS Form 1145)
  2. The member has been informed verbally and in writing that a hysterectomy will render her permanently incapable of reproducing. This not needed if member is already sterilized or in the case of an emergency hysterectomy.
  3. The member has signed and dated the consent form (DHS Form 1145) in advance of the hysterectomy
  4. Interpreter services have been given to non-English speaking members or other assistance to communicate with members with hearing or vision impairments or other disability
  • Frequency, Limitation and Exclusions: Exclusions: If member is institutionalized in a correctional facility, mental hospital or other rehabilitative facility. A hysterectomy is NOT covered:
    • For the sole or primary purpose of rendering a member permanently incapable of reproducing.
    • There is more than one purpose for performing hysterectomy but the primary purpose is to render the member permanently incapable of reproducing.
    • If performed for the purpose of cancer prophylaxis (prevention).

Benefit: Pharmacy Benefit Manager (Includes home delivery)

  • Description: The pharmacy benefit manager is Optum Rx (a UnitedHealth Group company). Home Delivery (Mail Service-Dual Members Only): 877-889-6358 Pharmacies Only: 877-889-6510
  • Frequency, Limitation and Exclusions: Contact Optum RX

Benefit: Prescription Drugs

  • Description: Drugs prescribed by a physician. This includes education about how to take the drugs.
  • Frequency, Limitation and Exclusions: Limitation See our QUEST Integration drug formulary at: UHCprovider.com/HIcommunityplan > Pharmacy Resources and Physician Administered Drugs

Ambulance and Transportation 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.

For Adults With Serious Mental Illness

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.

Department of Health's Child and Adolescent Mental Health Division (CAMHD) for Children Ages Three Through 20

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

  • Location: Pearl City
  • Telephone: 808-453-5900

Family Guidance Center: Family Court Liason Branch

  • Location: Kailua
  • Telephone: 808-266-9922

Family Guidance Center: Honolulu

  • Location: Honolulu
  • Telephone: 808-733-9393

Family Guidance Center: Leeward Oahu

  • Location: Kapolei
  • Telephone: 808-692-7000

Family Guidance Center: Windward Kaneohe

  • Location: Kaneohe
  • Telephone: 808-233-3770

Family Guidance Center: Hawai’i Hilo Waimea Kealakekua

  • Location: Hilo Kamuela Kealakekua
  • Telephone: 
    • 808-933-0610
    • 808-887-8100
    • 808-322-1541

Family Guidance Center: Kauai

  • Location: Lihue
  • Telephone: 808-274-3883

Family Guidance Center: Maui

  • Location: Wailuku
  • Telephone: 808-243-1252

Additional information is available in Chapter 7: Mental Health and Substance Use

EXCLUSION

We do not provide behavioral health services to those members who have:

  • Requested services that were determined to be not medically necessary
  • Transferred to the Department of Human Services (DHS) Community Care Services (CCS) Program (currently managed by “Ohana CCS Program”).
  • Transferred to the DOH Child and Adolescent Mental Health Division
  • Criminally committed in an inpatient setting under the provisions of Chapter 706, HRS

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.

We cover these transplants in accordance with HAR 17-1737-92.

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:

  • Audiology services
  • Occupational therapy
  • Physical therapy
  • Speech-language therapy
  • Vision services
  • Devices associated with these services including augmentative communication devices, reading devices, and visual aids but exclude those devices used specifically for activities at school.

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:

  • Housecleaning
  • Meal preparation
  • Laundry
  • Grocery shopping
  • Personal care services (such as bowel and bladder care, bathing, grooming and paramedical services)
  • Accompaniment to medical appointments
  • Protective supervision for the mentally impaired

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:

  • Hawaii resident physically residing in the United States
  • Meet Medicaid recipient eligibility criteria
  • Reside in own home (acute care hospital, long-term care facilities, and licensed community care facilities are not considered “own home”)
  • Submit a completed Health Care Certification form completed by a licensed health care professional indicating the member is: Unable to perform more than one activity of daily living independently, and is at risk of out-of-home care placement without ILTSS.

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:

  1. Communicate with a member’s physician(s) regarding the member’s needs including changes in medication and treatment orders;
  2. Work with families regarding service needs of members and serve as an advocate for their members; and
  3. Be accessible to the member’s caregiver 24 hours a day, seven days a week.

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:

  • Companion Services. Companion services are preauthorized by the Service Coordinator in the member’s service plan and include non-medical care, supervision, and socialization provided to a member who is assessed to need these services. Companions may assist or supervise the individual with such tasks as meal preparation, laundry, and shopping/errands, but do not perform these activities as discrete services. Providers may also perform light housekeeping tasks that are incidental to the care and supervision of the individual.
  • Homemaker Services. Homemaker services are covered when the individual regularly responsible for these activities is temporarily absent or unable to manage the home and care for the member. Homemaker services, pre-authorized by the Service Coordinator in the member’s service plan, do not require specialized training or professional skills such as those possessed by a nurse or home health aide. The scope of homemaker services covers only those activities that need to be provided for the member and not for other members of the household:
  • Routine housecleaning
  • Care of clothing and linen
  • Shopping for household supplies and personal essentials (not including the cost of supplies)
  • Light yard work
  • Simple home repairs, such as replacing light bulbs
  • Preparing meals
  • Running errands, such as paying bills and picking up medication
  • Escort to clinics, physician office visits, or other trips for the purpose of obtaining treatment or meeting needs established in the service plan, when no other resource is available
  • Standby/minimal assistance or supervision of activities of daily living
  • Reporting and/or documenting observations and services provided, including observation of member self-administered medications and treatments
  • Reporting to assigned provider, supervisor, or designee, observations about changes in the member’s behavior, functioning, condition, or self- care/home management abilities that necessitate more or less service

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:

  • Personal hygiene and grooming, including bathing, skin care, oral hygiene, hair care, and dressing
  • Assistance with bowel and bladder care
  • Assistance with ambulation and mobility
  • Assistance with transfers
  • Assistance with medications, which are ordinarily self-administered when ordered by the member’s physician
  • Assistance with routine or maintenance health care services by a personal care provider with specific training, satisfactorily documented performance, Service Coordinator consent and when ordered by the member’s physician
  • Assistance with feeding, nutrition, meal preparation, and other dietary activities
  • Assistance with exercise, positioning, and range of motion
  • Taking and recording of vital signs, including blood pressure
  • Measuring and recording intake and output, when ordered
  • Collecting and testing specimens, as directed
  • Special tasks of nursing care when delegated by a registered nurse, for members who have a medically stable condition and who require indirect nursing supervision
  • Proper utilization and maintenance of member’s medical and adaptive equipment and supplies
  • Checking and reporting any equipment or supplies that need to be repaired or replenished
  • Reporting changes in the member’s behavior, functioning, condition, or self-care abilities which necessitate more or less service
  • Maintaining documentation of observations and services provided

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:

  • 24-hour answering/paging
  • Beepers
  • Med-alert bracelets
  • Medication reminder services
  • Intercoms
  • Life-lines
  • Fire/safety devices, such as fire extinguishers and rope ladders
  • Monitoring services
  • Light fixture adaptations (e.g., blinking lights)
  • Telephone adaptive devices not available from the telephone company
  • Other electronic devices/services designed for emergency assistance

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:

  1. in a Type I Expanded Adult Residential Care Home (E-Arch) to a maximum of six individuals, no more than three of whom may be a nursing facility level of care; or
  2.  in a Type II E-Arch, for seven or more individuals; no more than 20% of the home’s licensed capacity may be individuals meeting a nursing facility level of care who receive these services in conjunction with residing in the home.

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:

  • Home or place of residence
  • Foster home/expanded-care adult residential care home
  • Medicaid certified nursing facility
  • Licensed respite day care facility
  • Other community care residential facility approved by the State.

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 infant car seats
  • Modifications of a parent-owned motor vehicle to accommodate the child (e.g., wheelchair lift)
  • Intercoms for monitoring the member’s room
  •  Shower seat
  • Portable humidifiers
  • Electric bills specific to electrical life support devices (e.g., ventilator, oxygen concentrator)
  • Medical supplies
  • Heavy duty items including but not limited to patient lifts or beds that exceed $1,000 per month
  • Rental of equipment that exceeds $1,000 per month, such as ventilators
  • Miscellaneous equipment such as customized wheelchairs, specialty orthotics, and bath equipment that exceeds $1,000 per month

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:

  • Independent and group activities
  • Meals and snacks
  • Housekeeping and laundry services
  • Nursing and social work services
  • Nutritional monitoring and counseling
  • Pharmaceutical services
  • Rehabilitative services.

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.

  • Level I – Patients who require continuous ventilation for at least 50% of each day and are medically stable.
  • Level II – Patients who do not require continuous mechanical ventilation for at least 50% of each day, are medically stable, and require the following services:
    • Tracheostomy care with suctioning at least once per hour
    • Any combination of mechanical ventilation, tracheostomy care with suctioning, and inhalation treatment at least once every eight hours
    • Total prenatal nutrition (TPN)
    • Continuous intravenous therapy or intermittent intravenous therapy at least once every eight hours
    • Stable newborns/premature infants under age one year who are inpatients in an acute care hospital for at least one week and require manual stimulation for bradycardia/apnea or nasogastric or gastrostomy feedings
    • Stable patients who are admitted to an acute hospital for an infection for training of intravenous antibiotic administration or for close monitoring of oral antibiotics OR two or more of the following services:
    • Stable newborns/premature infants under age one year who are inpatients in an acute care hospital for at least one week and require manual stimulation for bradycardia/apnea or nasogastric or gastrostomy feedings
    • Stable patients who are admitted to an acute hospital for an infection for training of intravenous antibiotic administration or for close monitoring of oral antibiotics OR two or more of the following services:

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:

Xerox State Healthcare

Attention: Claims

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.

  • Health4Me enables users to review health benefits, access claims information and locate in-network providers.

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:

  • Nutritious food such as milk, eggs, cereal, etc.
  • Education on nutrition best for your family.
  • Support for mothers related to breastfeeding.
  • Health care referrals.

Contact Information:

Oahu #: 808-586-8175

Neighbor Islands #: 888-820-6425

http://health.hawaii.gov/wic/program_ details/#qualify

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.