QUEST Integration-Net, QUEST Integration-ACE, and Basic Health Hawaii – Benefits

Original Effective Date:

04/01/1996; 07/01/2010 (BHH)

Current Effective Date:

01/01/2015

The benefit year is July 1 to June 30 of each year. Members who exhaust their benefits are financially responsible for the costs of further services.

QUEST Integration-Net and QUEST Integration-ACE Benefits

Inpatient Hospital

• Medical, surgical or behavioral healthcare confinements
• A total of 10 days per benefit year
• Maternity, nursery, rehabilitation and skilled nursing are excluded

Outpatient Hospital Care

• Unlimited ER care for bona fide emergencies
• Non-emergency care in the ER subject to outpatient visit limits
• Patient responsible for facility charges for a non-emergent visit in the ER.

Ambulatory Surgery

• Three surgeries per benefit year
• Services in free-standing or hospital-based ambulatory surgery centers, physician offices or hospital treatment rooms
• Procedure must be six or more surgical units on the Hawaii Relative Value Scale. Lower-level surgeries, including cast removal, suture removal, venipuncture, and removal of impacted cerumen count as outpatient visits
• Termination of pregnancy included unless performed inpatient and counted against hospital inpatient limit

Outpatient/Office Visits

• Twelve visits per benefit year
• Services by physicians and other practitioners
• Visit to confirm pregnancy not applied toward the 12-visit limit
• Family planning services apply toward the 12-visit limit
• Physical exams not applied toward the 12-visit limit but subject to the following schedule:
  • ages 19-35 = 1 every 5 years
  • ages 36-55 = 1 every 2 years
  • older than age 55 = 1 every year
• Immunization are limited to only tetanus, diphtheria, pneumonia, and influenza

Behavioral Health Outpatient Visits

• Six visits per benefit year
• Member may use up to 6 of 12 outpatient/office visits as additional behavioral health visits
• Alcohol and substance abuse treatments apply toward behavioral health outpatient or inpatient visits depending on where services are rendered
• Methadone treatment excluded

Diagnostic Test/Lab/X-ray/Nuclear Medicine

• Services rendered in association with a covered outpatient/office or emergency room visit.

Transportation

• Ground and air ambulance transportation for bona fide emergencies only
• Non-emergent transportation not covered

Family Planning Services

• Generic birth control pills
• Depo-Provera (Medroxyprogesterone acetate)
• Diaphragms
• Visits subject to the 12 outpatient visits limit per benefit year

Prescription Drugs

• Over-the-counter drugs not covered
• The following generics covered (refer to Drug Formulary for complete list of drugs)
  • generic cephalosporin agent
  • generic tetracycline agent
  • generic penicillin agent
  • generic erythromycin agent
  • Trimethoprim with sulfamethoxazole
  • ophthalmic sulfacetamide
  • otic polymyxin/neomycin/hydrocortizone
  • birth control pills: Loestrin, Tri-levlen, Desogen, Micronor
  • Depo-Provera

Basic Health Hawaii Benefits

• Emergency medical services;
• Ten inpatient hospital days. There is no maternity benefit for members. However, Basic Health Hawaii members who become pregnant should be referred to their eligibility worker to determine their eligibility for QUEST Integration.
• Twelve outpatient medical visits (alcohol and substance abuse services are included as part of medical visits);
• Six mental health outpatient visits. If all six are used and the member has not used all twelve outpatient medical visits, up to six of the twelve outpatient medical visits may be allocated to mental health outpatient visits (thereby giving the member a maximum of twelve mental health outpatient visits and six outpatient medical visits;
• Three ambulatory surgeries (include surgeries performed in a free-standing ambulatory surgery center (ASC), physician’s office, outpatient hospital, and hospital ASC);
• Diagnostic tests (laboratory tests, x-ray services, nuclear medicine) associated with the twelve outpatient medical visits;
• Immunizations for diphtheria, tetanus, pneumonia, and influenza;
• No more than four prescriptions per calendar month. They may not exceed a 30 day supply and must be from the HMSA QUEST Integration formulary. Each prescription of insulin will be counted toward the limit of four prescriptions; chemotherapy medication (either oral or intravenous) is counted toward the limit of four total prescriptions per month;
• Family planning services including family planning drugs, supplies and devices which are limited to generic birth control pills, medroxyprogesterone acetate (Depo-Provera) and diaphragms and are not counted toward the limit of four prescriptions;
• Diabetic supplies to include syringes, test strips, and lancets will be covered and will not count toward the four prescription monthly limit; and
• Translation Services/Interpreter Services;
• Ground and air ambulance transportation for bona fide emergencies only.

Revision History