The benefits of QUEST Integration include:

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1 Ku i Ka Lono Spread the News For AlohaCare Physicians and Providers Winter 2015 Message from CMO 2015 brings many new and exciting changes to AlohaCare. As you may be aware, the State Department of Human Services has rolled out a new Medicaid program called QUEST Integration (QI). QI combines and replaces both QUEST and QUEST Expanded Access (QExA) programs and as of January 1, everyone is a QI member. QI is one program with one set of benefits for most eligible members. Beneficiaries can now remain with their existing health plans upon turning 65 years old or when changes occur in their health condition. Gary Okamoto Chief Medical Officer QUEST Integration The benefits of QUEST Integration include: More health plan choices for the aged, blind or disabled population Ability to remain with the same health plan upon turning 65 or developing a disability Entire households can enroll in the same health plan Program simplification Single managed care program Single annual plan change period Reduced administrative burden for providers Expanded access to home and community-based services All five health plans are participating in QUEST Integration: AlohaCare, Hawaii Medical Service Association (HMSA), Ohana Health Plan and UnitedHealthcare. Kaiser Permanente, however, will serve the islands of Oahu and Maui only. Recap: QUEST Integration Trainings AlohaCare recently offered a series of provider education sessions for the new plan year. We held 17 sessions throughout Oahu, Maui, Kauai and Hawaii Island. We gave an overview of QI, discussed simple claims submissions, and reviewed our plans general guidelines and processes. If you were unable to join us, you can download and view our presentation at Or if you would like to schedule an in-service training for you and your office staff members, please contact Provider Relations at or toll-free at Medical Policies AlohaCare has developed medical policies for breast pump and circumcision. For the coverage of breast pumps, AlohaCare covers the purchase of one standard electronic breast pump for female members per pregnancy without cost share. pumps. For the coverage of circumcision, AlohaCare covers the procedure for either children or adults. A PA is not required for circumcision. A member may request a breast pump at any time during her 3rd trimester (29-40 weeks) of pregnancy or postpartum. A prior authorization (PA) is required when requesting for breast The breast pump and circumcision medical policies will be available soon on AlohaCare s website at

2 AlohaCare Advantage Plan Change FAQ AlohaCare made the difficult decision to discontinue its AlohaCare Advantage (HMO) Medicare health plan effective January 1, We will continue to offer AlohaCare Advantage Plus, our Medicare Special Needs Plan, for those eligible for both Medicare and Medicaid. We also continue to serve our 60,000 QUEST Integration program enrollees. Across the country, health insurers are experiencing declining federal reimbursements and rising healthcare costs. Over the past eight years, AlohaCare has lost over $15 million due to its Medicare Advantage health plan, therefore making the plan unsustainable. Despite the losses, our organizational mission is aligned closely with the population in the Medicare Special Needs plan, so we will continue serving those members. AlohaCare is building capabilities and competencies within our organization to fulfill the Hawaii Medicaid QUEST Integration contract. The state s future direction in serving dually eligible Medicare and Medicaid populations is a good fit for our mission and the strengths we are building. We committed to ensuring a smooth transition of our 1,300 AlohaCare Advantage members to the Medicare health plan of their choice. We notified our members in October 2014 to make them aware that our plan would no longer be available as of January 1, 2015, and we offered our assistance in helping them choose a new plan. AlohaCare will continue to pay for covered services provided to AlohaCare Advantage members, including any member admitted to a healthcare facility, for several months, as necessary and required. As is prescribed by CMS, claims can be submitted up to 365 days after the date of service to be paid. Q: How does this affect AlohaCare Advantage members? A: For 2015, members need to choose another plan, or return to original Medicare. Q: Are all of AlohaCare s Medicare plans going away? A: No. We will continue to offer our Medicare Special Needs Plan, called AlohaCare Advantage Plus. This plan is specifically for beneficiaries who are eligible for Medicare and Medicaid. From the start, this plan has been our priority because it aligns with our mission for providing coverage for the low-income and dual eligible beneficiaries of Hawaii. Q: I am part of the AlohaCare provider network, will my contract be affected? A: No. There will be no changes to your provider contract with AlohaCare. You will still be contracted for our Medicare Advantage Special Needs Plan, called AlohaCare Advantage Plus, and our QUEST and QUEST Integration plan. Q: Where can my patients go for more information? A: Members have received an official notice that provides information they need to make informed decisions about their coverage choices for 2015: AlohaCare members seeking a new health plan may contact the following for assistance: MEDICARE or Hawaii s local Medicare SHIP office, Sage PLUS at or Members may also call AlohaCare at or toll-free at Should you have questions, please call (808) or toll-free at New Disclosure Form 2 A mailing was sent to all QUEST Integration contracted providers in December Per Hawaii Med-QUEST and federal regulations (42 CFR 455 Subpart B), AlohaCare is required to obtain ownership information from all of our participating providers to confirm that no excluded persons are managing employees or have an ownership or controlling interest in an organization or practice. Excluded parties are individuals or entities that are debarred, suspended, or otherwise excluded from participating in state or federally funded programs. Although the deadline to return completed disclosure forms was December 31, 2014, you may still return the form in the enclosed pre-paid envelope or fax it to: AlohaCare Provider Contracts and Credentialing Department Attn: Disclosure Forms Fax: Should you have any questions or concerns, please call our Provider Relations Department at or toll-free at Thank you for your assistance in fulfilling this requirement.

3 Quality Improvement Program AlohaCare s Quality Improvement Program is built on a foundation of dedication to high quality collaborative relationships with all stakeholders, and commitment to continuous improvement in care and service. AlohaCare shares responsibility with its practitioners, providers, community stakeholders and client organizations to provide effective, efficient and timely care and services. AlohaCare s commitment to continuous improvement in care and services is the underpinning for the quality improvement program. Purpose The purpose of AlohaCare s quality improvement program is to create a continuous quality improvement structure and environment that improves processes and systems, resulting in improved health outcomes for health plan members while exceeding customer expectations. Scope The scope of AlohaCare s quality improvement program is comprehensive and encompasses all clinical care and service aspects of the organization. The quality improvement program includes an array of indicators to measure critical clinical and service processes and outcomes. The quality improvement work plan delineates the critical performance measures that define the scope and range of the quality improvement program. Components addressed include: Accessibility of services Availability of services Clinical quality improvement Goals The AlohaCare s primary quality improvement goal is to improve members health status through a variety of activities implemented across all care settings and aimed at improving quality of care delivered and quality of services provided while promoting safe clinical practices. AlohaCare provides services to a diverse population of different cultures, races, ethnic backgrounds and religions in a manner that recognizes values, affirms and respects the worth of the individual member and protects and preserves the dignity of each member. Service quality improvement Member experience Practitioner experience Clinical practice guidelines Preventive health guidelines Continuity and coordination of care Patient safety Practitioner performance Effectiveness of the quality improvement program Should there be any questions or feedback, please contact Senior Director of Quality Improvement Jonathan Cascino at jcascino@alohacare.org. Increased EPSDT Rates AlohaCare has increased its EPSDT rates effective February 1, EPSDT 2014 EPSDT 2015 EPSDT catch-up/ 2014 EPSDT catch-up/ Island comprehensive comprehensive follow-up immunization follow-up immunization payment payment and screening payment and screening payment Oahu $120 $ $30 $14.83 Kauai $120 $ $30 $14.83 Maui $120 $ $30 $15.53 Lanai $120 $ $30 $15.53 Molokai $120 $ $30 $15.53 Hawaii $120 $ $30 $15.53 By increasing the EPSDT rates, AlohaCare hopes to encourage providers to get more members in for care. AlohaCare wants to make sure all its members, especially children, get the best health care possible. 3

4 Clinical Guidelines The clinical practice guidelines developed will be relevant to AlohaCare s QUEST and Medicare populations, based on (but not limited to) the following: age, disease categories, and special risk status. Practice guidelines are from recognized sources and/or a consensus of health care professionals in a relevant field. The Chief Medical Director, with the assistance of the Quality Improvement Department (QI), oversees the annual review and updating of the Clinical Practice Guidelines. The AlohaCare Physicians Advisory Committee (PAC), which includes participating providers from AlohaCare s provider network, reviews the existing guidelines to ensure they remain current and in alignment with national and community standards of medical practice. The PAC and the QI Department also makes recommendations on additional guidelines to be adopted. Sources of information for supportive decisionmaking include, but are not limited to, the findings, guidelines and recommendations set forth in peer-reviewed medical journals; those advised by recognized authoritative agencies, such as the Centers for Disease Control, or professional societies, such as the American Academy of Pediatrics; and known community standards of care. AlohaCare adopts evidence-based preventive health guidelines for: Perinatal Care Care for children up to 24 months old Care of children 2-19 years old Care for Adults years old, and Care for adults 65 years and older These guidelines are updated every two years or sooner if national guidelines addressing the same or similar content changes or are published. The following guidelines can be found on AlohaCare s website: Adult Preventive Health American Optometric Association US Preventive Services Task Force American Speech-Language-Hearing Association The American Cancer Society American College of Obstetricians and Gynecologists Centers for Disease Control and Prevention Chronic Heart Failure American Heart Association Chlamydia US Preventive Services Task Force Coronary Artery Disease (CAD) U.S. Preventive Services Task Force Adult Immunizations Centers for Disease control and Prevention Child/Adolescent Immunizations Centers for Disease control and Prevention Diabetes Mellitus American Diabetes Association Diagnosis and Treatment Management of Attention Deficit/Hyperactivity Disorder (ADHD) in School-Aged Children American Academy of Pediatrics Management of Asthma National Heart, Lung, and Blood Institute Routine Prenatal and Postpartum Care American College of Obstetrics and Gynecology Treatment for Patients with Major Depressive Disorder American Psychiatric Association Should you have any questions, recommendations or suggestions, please contact Gary Okamoto, AlohaCare s Chief Medical Officer at gokamoto@alohacare.org. Primary Source Verification Effective January 1, 2015, AlohaCare will no longer use Aperture Inc. for the primary source verification function. This function will now be performed by AlohaCare s Contracts and Credentialing Department. You will receive a notification letter by mail with details. 4

5 New Provider Portal Features Neighbor Island Offices The AlohaCare Provider Portal (AC Online) has some new and exciting features. AC Online now allows providers to refer members to our Disease Management Program. When a provider checks eligibility for a member, there is a new section below the eligibility information that will allow the provider to refer the member to our Asthma, Diabetes and Coronary Artery Disease programs. When a member is referred, they will receive a call from an AlohaCare representative to discuss the program and the member responsibilities within the program. AlohaCare has also added the capability for providers to view a member s prescription history. This allows the provider to see the previous two years of medication prescribed to the member while in the AlohaCare network. These pharmacy details, in addition to the medical claim submission history that AlohaCare already provides, will give providers better medical history information for their members. Don t have an AC Online account? Sign up today! Go to: click on the Provider tab, click on Forms, and then download the AC Online Registration Form. Enroll in AC Online so you and your staff can access member eligibility, check on claim status, submit electronic referrals, request prior authorizations, and more. Fax your completed form to the Provider Relations Department at In order to meet the needs of our members statewide, AlohaCare has recently opened offices on Maui and Kauai. These offices are currently open to the public and are staffed with customer service representatives, service coordinators, and provider relations representatives. Be on the lookout for an invitation to these offices grand openings soon. Maui: 210 Imi Kala St., Suite 206 Wailuku, HI Kauai: 4473 Pahe e St., Suite N Lihue, HI AlohaCare has also added staff to its Hawaii Island office. The office recently had its grand opening by collaborating with community partners to host a health fair. The health fair featured fitness demonstrations, hula performances, giveaways, and more. Hilo: 1221 Kilauea Ave., Suite 50 Hilo, Hi Oahu: 1357 Kapiolani Blvd., Suite 1250 Honolulu, HI Contact Us: Frequently Used Phone and Fax Numbers AlohaCare wants to make sure you have the most current contact numbers for our departments. Whether inquiring about member eligibility or submitting a change form, the following phone and fax numbers are listed for your convenience. Use these phone numbers to contact our Neighbor Island offices as well. Department Member Services Phone Numbers QUEST Integration Toll-free: Medicare Toll-free: Provider Relations and Contracts/Credentialing Pharmacy Management Clinical Operations Referral/Pre-Authorization Behavioral Health Toll-free: Fax: Toll-free: Fax: Toll-free fax: Toll-free: Fax: Toll-free fax: Toll-free: Fax: Toll-free fax:

6 PRSRT STD U.S. POSTAGE PAID HONOLULU, HI PERMIT NO Kapiolani Blvd., Suite 1250 Honolulu, HI Follow Us! Follow AlohaCare to see what is happening in your community. Get information on upcoming events and learn how AlohaCare can help you stay healthy! Facebook: AlohaCareHawaii Instagram: AlohaCareHawaii YouTube: AlohaCareHawaii AlohaCare Ohana Ku i Ka Lono Spread the News Maui Team (L to R): Mindy Baker, RN; Kristine Omura, RN; Marie Sabado; Sarah Hambek; and Melissa Arnold. Hilo Team (L to R): Jennie Tabuyo-Caban; Pamela Tugwell, RN; Regina K. Soller; Tanya Anynessazian; Christian Olsen; and Marada Terry. Kauai Team (L to R): Paula Chong; Iris Erickson; Brennan Carroll; and Robyn Okamura.