Any practices, processes or actions by the health plan or provider that are not consistent with sound fiscal, business, or medical practice resulting in unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or State and Federal requirements. This includes any actions or decisions by a member that may result in unnecessary cost to the Medicaid program.
Acute care
Short-term medical treatment provided under the direction of a physician, usually in an acute care hospital for members having an acute illness or injury.
Adult
QUEST members age twenty-one (21) years or older for coverage benefit purposes only.
Adverse Benefit Determination
A decision your health plan can make to deny, restrict, reduce, limit, suspend or terminate services previously authorized. This includes a denial of a member’s request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, co-insurance, and other member financial liabilities.
Aged, Blind, or Disabled (ABD)
A category of eligibility under the State Plan for persons who are aged (sixty-five (65) years of age or older), legally blind, and/or disabled.
Annual Plan Change Period
A period when an eligible individual is allowed to change from one participating health plan to another participating health plan.
Appeal
A review by the health plan and State Administrative Appeal of an adverse benefit determination.
Authorized representative
An individual or organization designated by the member, in writing, with the designee’s signature or by legal documentation or authority to act on behalf of a member in compliance with federal and state laws or regulations. Member may choose an authorized representative at any time.
B
Beneficiary
Any person determined eligible for Medicaid benefits by the Department of Human Services (DHS).
Benefit year
A continuous twelve (12) month period generally following an open enrollment period. In the event that the current benefit period is not in effect for the full benefit year, any benefit limits will be pro-rated.
Benefits
The health services you can get under the QUEST program.
C
Care Team
A team of health care professionals from different professional disciplines who work together to manage the physical, behavioral health, and social needs of the member.
Centers for Medicare & Medicaid Services (CMS)
The United States federal agency which administers the Medicare program and, working jointly with the state governments, the Medicaid program, and the State Children’s Health Insurance Program (SCHIP).
Child
QUEST members under the age of twenty-one (21) for coverage benefit purposes only.
Children’s Health Insurance Program (CHIP) or State Children’s Health Insurance program (SCHIP)
A joint federal-state health care program for uninsured, targeted, low-income children that is part of the Medicaid expansion program in Hawaii.
Claim
A document which is submitted by a provider to the health plan for payment of health-related services rendered to a member.
Clean claim
A claim that can be processed without requiring additional information from the provider. It does not include a claim from a provider who is under investigation for fraud or abuse, or a claim under review for medical necessity.
Copayment
A specific dollar amount or percentage of the charge you pay at the time of service to a health care plan, physician, hospital or other provider of care for covered services.
Cost-sharing, share of cost or cost share
An amount that you pay to your health care provider or the health plan as part of your share in the cost of your health care eligibility. This amount is determined by your Department of Human Services Case Worker.
Cultural Competency
A set of interpersonal skills that allow individuals to increase their understanding, appreciation, acceptance, and respect for cultural differences and similarities within, among, and between groups and sensitivity to know how these differences influence relationships with members. This requires a willingness and ability to draw on community based values, traditions and customs to come up with strategies to better understand and meet member needs.
D
Department of Human Services (DHS)
The agency that is responsible for providing public assistance programs to the population it serves.
Dual Eligible
A member that is eligible for both Medicare and Medicaid.
Durable Medical Equipment (DME)
Equipment that is primarily and customarily used for a medical purpose. Examples of DMEs are oxygen tanks and concentrators, ventilators, wheelchairs, hospital beds, and orthotic devices.
E
Emergency Medical Condition
One with sudden, severe symptoms that without immediate care could result in placing one’s health in serious jeopardy, serious impairment to bodily functions, serious dysfunction of any bodily organ or part, serious harm to self or bodily harm to others due to an alcohol or drug abuse emergency, or injury to self or bodily harm to others. In the case of a pregnant woman, serious jeopardy to the woman or her unborn child.
Emergency Medical Transportation
Transportation that is provided due to an emergency condition. Service includes ground and air transportation.
Emergency Room Care
: Care that is available in an emergency room 24 hours a day, 7 days week and without a prior authorization to treat a life-threatening or very severe illness.
Emergency Services
Covered inpatient and outpatient services that are needed to evaluate or stabilize an emergency medical condition that is found to exist using a prudent layperson standard (an individual who does not have medical training).
Enrollment Fee
The amount a member is responsible to pay that is equal to the spenddown amount for a medically needy individual or cost share amount for an individual receiving long term services and supports. A resident of an intermediate care facility for intellectual/development disability (I/DD) or a participant in the Medicaid waiver program for individuals with developmental disabilities or intellectual disabilities are exempt from the enrollment fee.
Excluded Services
Health care services that are not covered by QUEST.
G
Grievance
An expression of dissatisfaction from a member, member’s representative, or provider on behalf of a member about any matter other than an adverse benefit determination. Examples of something that you might not be happy about are: Issues with quality of service or care, how we or your provider run their office, if we or your provider was rude, wait times during appointment visits or not getting the information you need.
H
Habilitation Services and Devices
Services and devices to develop, improve, or maintain skills and functioning for daily living that were never learned or acquired to an appropriate level.
Health Action Plan (HAP)
A person-centered individualized plan that is developed with the member and/or authorized representative based on the member’s health care needs (i.e., special health care needs, expanded health care needs or long term services and supports needs).
Health Insurance
Any health insurance program for which a person pays for insurance benefits directly to the carrier, participation through an employer or union sponsored program or participation through a federal or state program (such as Medicaid).
Health Plan
A plan offered by an insurance company or other organization, which provides different health care benefit packages. ey all work together to provide the care you need.
Home Health Care
Services provided in a home and includes medical equipment and supplies, therapy or rehabilitative services, skilled nursing care and home health aides.
Hospice Services
Care if you are terminally ill and are expected to live less than six months.
Hospital Outpatient Care
Medical care treatment that does not require overnight stay in a hospital or medical facility. Services include but are not limited to oncology services, respiratory services, cardiology services and other medically necessary services.
Hospitalization
An admission to a hospital for treatment. This includes admission to an acute care hospital, critical acute care hospital or psychiatric hospital.
I
Indian
The term “Indians” or “Indian,” unless otherwise designated, means any person who is a member of an Indian tribe except that, for the purpose of sections 1612 and 1613 of title 25 of the U.S. Code, such terms shall mean any individual who:
Regardless of whether he or she lives on or near a reservation, is a member of a tribe, band, or other organized group of Indians, including those tribes, bands, or groups terminated since 1940 and those recognized now or in the future by the State in which they reside, or who is a descendant, in the first or second degree, of any such member, or
Is an Eskimo or Aleut or other Alaska Native, or
Is considered by the Secretary of the Interior to be an Indian for any purpose, or is determined to be an Indian under regulations specified by the Secretary of Health and Human Services.
Indian Health Care Provider (IHCP)
A health care program operated by the Indian Health Services (IHS) or by an Indian tribe, tribal organization, or urban Indian organization (otherwise known as an I/T/U).
Indian Tribe
The term “Indian Tribe” means any Indian tribe, band, nation, or other organized group or community, including any Alaska Native village or group our regional or village corporation as defined in or established pursuant to the Alaska Native Claims Settlement Act (85 Stat. 688) [43 U.S.C. 1601 et seq.], which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians.
M
Medicaid
Medical assistance provided under a State plan approved under Title XIX of the Social Security Act. This includes the medical care and long-term care services for eligible individuals.
P
PCP
Your regular doctor is also called a PCP (Primary Care Provider). Your PCP takes care of your healthcare needs. You need to choose a PCP who works with your health plan. When you need to see a specialist or use other medical service, your PCP helps you get that care.
Q
QUEST
The QUEST program is a Hawai‘i Medicaid managed care program administered by the State of Hawai‘i, Department of Human Services, Med-QUEST Division. Eligibility for this program is determined by the State of Hawai‘i.
S
Service Coordinator
Some members of QUEST have a Service Coordinator through their health plan. Your Service Coordinator helps you:
Get better access to healthcare services and providers
Take a more active role in your care
Understand and use your QUEST benefits
U
UnitedHealthcare QUEST
A Medicaid health plan for eligible residents of Hawai‘i who qualify for the QUEST program.
