- As of July 1, 2011, there were 272,218 beneficiaries enrolled in Hawaii Medicaid. Of these, 268,645 were enrolled in one of four commercial managed care organizations (MCOs) or one Medicaid-only MCO under a managed care program known as Hawaii QUEST. QUEST provides medical and mental health services. Dental services are provided on a fee-for-service basis.
- Child and adult Medicaid beneficiaries with developmental disabilities are eligible to receive services through the state’s home and community-based services waiver program. The program aims to help beneficiaries remain in the community and avoid institutionalization, and offers services including personal assistance/habilitation, skilled nursing, transportation services, and consumer directed services.
As stated in Hawaii’s administrative rules (Hawaii Administrative Rules 1700.1-41), “medical necessity” refers to those procedures and services that:
“are considered to be necessary and for which payment will be made. Medically necessary health interventions (services, procedures, drugs, supplies, and equipment) must be used for a medical condition. There shall be sufficient evidence to draw conclusions about the intervention’s effects on health outcomes. The evidence shall demonstrate that the intervention can be expected to produce its intended effects on health outcomes. The intervention’s beneficial effects on health outcomes shall outweigh its expected harmful effects. The intervention shall be the most cost-effective method available to address the medical condition. Sufficient evidence is provided when evidence is sufficient to draw conclusions, if it is peer-reviewed, is well-controlled, directly or indirectly relates the intervention to health outcomes, and is reproducible both within and outside of research settings.”
|Initiatives to Improve Access
Pay for Performance
Hawaii Medicaid implemented a pay for performance incentive program to encourage improvements in quality and access. Child-specific benchmark measures include childhood immunizations, and getting care needed-child CAHPS.
|Reporting & Data Collection||
Managed care plans are required to submit encounter data at least once per month.
Electronic Data Reporting
Hawaii Medicaid is in the process of implementing an online EPSDT reporting system that allows providers to submit data electronically. The system will capture information on vaccines, screenings, and referrals, and would provide prompts and alerts for services that are due.
|Support to Providers and Families||
Support to Providers
Hawaii Medicaid operates a provider webpage with information on Medicaid and EPSDT, covered services, fee schedules, and other resources. The state also published a provider manual, which includes a chapter on EPSDT that contains a description of the program as well as information on covered services and billing procedures.
Hawaii’s Medicaid Provider Manual contains a detailed description of the dental services available to children eligible for EPSDT, including applicable billing codes, and whether prior approval is needed for each service. The state also operates a dental page for providers, which contains dental fee schedules and contact information for dental coordinators employed by Community Case Management Corporation (CCMC). Hawaii Medicaid contracts with CCMC to help beneficiaries find dentists and other dental providers.