QUEST Integration: Transition of Care

Effective:

January 2015

Last Reviewed:

May 2021

1. Purpose
   1. HMSA QUEST Integration (QI) has a process in place to ensure that when the Member transitions to and from the health plan, they continue to receive medically necessary covered services in addition to or other than prenatal services. These services will start the day before coverage begins without any form of prior approval and without regard to whether those services are being provided by contract or non-contract providers. This process also ensures that HMSA QI will be responsible for medically necessary services provided during prior period coverage, retroactive enrollment, and if a Member moves to a different service area while remaining with HMSA QI.
2. Definitions
   1. Expanded Health Care Needs (EHCN): A member that has complex, costly health care needs and conditions, or who is at imminent risk of developing these conditions. The Members that meet EHCN criteria are considered to be highly impactable and likely to benefit from health coordination services.
   2. Home and Community Based Services (HCBS): Long-term care services provided to an individual residing in a community setting who is certified by DHS to be at the nursing facility level of care (LOC) and would be eligible for care provided to an individual in a nursing facility or a medical facility receiving nursing facility LOC.
   3. Long-Term Services and Supports (LTSS): Services provided to a Member in an inpatient medical facility receiving NF LOC or to a resident of a NF LOC. These facilities include assisted living facilities, expanded adult care homes, community care foster family homes, nursing facilities, and sub-acute units.
   4. Primary Care Provider (PCP): A practitioner selected by the Member to manage the Member’s utilization of health care services who is licensed in Hawaii and is:
      1. A physician, either a Doctor of Medicine (M.D.) or a Doctor of Osteopathy (D.O.), and shall generally be a family practitioner, general practitioner, general internist, pediatrician or obstetrician/gynecologist (for women, especially pregnant women) or geriatrician;
      2. An advanced practice registered nurse with prescriptive authority (APRN-Rx); or
      3. A physician’s assistant recognized by the State Board of Medical Examiners as a licensed physician assistant. PCPs have the responsibility for supervising, coordinating, and providing initial and primary care to enrolled individuals and for initiating referrals and maintaining the continuity of their care.
   5. Special Health Care Needs (SHCN): A Member that has chronic physical, behavioral, developmental, or emotional conditions that require health-related services of a type or amount that is beyond what is required of someone of their general age.
3. Standard Procedures
   1. Transition of Care to HMSA QUEST Integration
      1. HMSA QUEST Integration ensures that during transitions of care, new Members:
         1. Receive all medically necessary emergency services
         2. Receive all LTSS, including both HCBS and institutional services that had a previous prior authorization
         3. Adhere to a Member’s existing prior authorizations from another QUEST Integration plan for medically necessary services, including prescription drugs, or courses of treatment
         4. Provide for the cost of care associated with a Member transitioning to or from an institutional facility in accordance with the requirements prescribed in Section 9.2(A) of the QI RFP.
      2. The new Member has access to services consistent with the access they previously had and is permitted to retain their current provider for a period of time if that provider is not in the provider network.
         1. Continuation of services is provided for individuals with EHCN, SHCN or who are receiving LTSS for at least ninety (90) days or until the Member has received an assessment
            1. A new Health and Functional Assessment will be conducted for each transferring LTSS Member to verify what services need to be continued
         2. Continuation of other services is provided for all other Members for at least forty-five (45) days or until the Member’s medical needs have been (re)assessed by the primary care provider (PCP) who has authorized the course of treatment. Services rendered by former PCPs are reimbursed during this period even if they are not in the HMSA QI network.
      3. The Member is referred to appropriate providers of service that are in the HMSA QI provider network.
      4. If the Member is entering her second or third trimester of pregnancy and is receiving medically necessary covered prenatal services the day before enrollment, HMSA QI is responsible for providing continued access to the prenatal care provider, regardless of contracting status, through the post-partum period.
   2. Transition of Care from HMSA QUEST Integration
      1. If a Member moves to a different service area in the middle of the month and enrolls in a different health plan, HMSA QI is responsible for the care and cost of inpatient services provided to the Member if she/he is hospitalized at the time of transition, until discharge or the level of care changes (whichever occurs first). Otherwise, the new health plan is responsible for all services to the Member as of the Member’s date of enrollment. HMSA QI will cooperate with the Member and the new QUEST Integration health plan when notified about the Member’s transition of care and will submit transition of care information to the Department of Human Services, Med-QUEST Division (MQD) using their specified format within 5 business days of being notified of the transition. HMSA QI will assure that MQD or the new health plan has access to the Member’s medical records and any other vital information that we have to facilitate transition of care.
   3. Members moving to a different service area and who remain with HMSA QUEST Integration.
      1. HMSA QUEST Integration will remain responsible for the care and the cost of services provided to Members who move to a different service area and continue to be eligible for HMSA QUEST Integration. Staff will do the following:
         1. Inform the Member that he/she will need to notify their DHS worker of the change in service location. Staff will assist the Member with the notification when requested.
         2. Assist the Member in selecting a PCP in the new service area.
         3. Notify the PCP in the old service area of the Member's change in service area and ask the PCP to determine transition of care needs for the Member as care is being established care in the new service area.
   4. Access to Information
      1. The Member’s previous provider(s) shall fully and timely comply with requests for historical utilization data from the Member’s new provider(s) in compliance with Federal and State law.
      2. The Member’s new provider(s) shall be able to obtain copies of the Member’s medical records consistent with Federal and State law, as appropriate.
      3. This policy shall be updated to include any other necessary procedures as specified by the Secretary of DHHS to ensure continued access to services to prevent serious detriment to the Member’s health or reduce the risk of hospitalization or institutionalization.
      4. This policy shall be publicly available and provide instructions to Members on how to access continued services upon transition.
4. References
   1. State of Hawaii, Department of Human Services, Request for Proposal (RFP), QUEST Integration (QI), Managed Care to Cover Medicaid and other Eligible Individuals, RFP-MQD-2021-008, Section 9.3

Revision History