Supplemental Contract No. 2 to Contract DHS-08-MQD-5129 between the Department of Human Services/Med-QUEST Division, State of Hawaii and WellCare Health Insurance of Arizona, Inc. (dba Ohana Health Plan, Inc.)

and state taxpayer identification numbers are as follows: 8735 Henderson Rd., Tampa, FL 33634

 

 

A.

WHEREAS, the STATE and the CONTRACTOR entered into Contract

 

DHS-08-MQD-5129

 

B.

HEREAS, the parties now desire to amend the Contract

 

"Agency" means and includes the State, the legislature and its committees, all executive departments, boards, commissions, committees, bureaus, offices; and all independent commissions and other establishments of the state government but excluding the courts.

 

"Controlling interest" means an interest in a business or other undertaking which is sufficient in fact to control, whether the interest is greater or less than fifty per cent (50%).

 

"Employee" means any nominated, appointed, or elected officer or employee of the State, including members of boards, commissions, and committees, and employees under contract to the State or of the constitutional convention, but excluding legislators, delegates to the constitutional convention, justices, and judges. (Section 84-3, HRS).

 

1.

PROVIDER    ¨ is* xis not a legislator or an employee or a business in which a legislator or an employee has a controlling interest. (Section 84-15(a), HRS).

 

2.

PROVIDER has not been represented or assisted personally in the matter by an individual who has been an employee of the agency awarding this Contract within the preceding two years and who participated while so employed in the matter with which the Contract is directly concerned. (Section 84-15(b), HRS).

 

3.

PROVIDER has not been assisted or represented by a legislator or employee for a fee or other compensation to obtain this Contract and will not be assisted or represented by a legislator or employee for a fee or other compensation in the performance of this Contract, if the legislator or employee had been involved in the development or award of the Contract. (Section 84-14 (d), HRS).

 

4.

PROVIDER has not been represented on matters related to this Contract, for a fee or other consideration by an individual who, within the past twelve (12) months, has been an agency employee, or in the case of the Legislature, a legislator, and participated while an employee or legislator on matters related to this Contract. (Sections 84-18(b) and (c), HRS).

1.

By Heads of Departments or Agencies as Delegated by tSie Director of Human Resources Development1.

 

Provided the health plan into which the member wants to enroll is not capped, the DHS will allow members to change health plans without cause for the first ninety (90) days from the effective date of enrollment in that health plan. If the member does not change health plans during the ninety (90) days following the date of initial enrollment in a health plan, the member will be allowed to change health plans only during the annual plan change period, as described in Section 30.560, or as outlined in Section 30.600.

 

The DOH, through its Child and Adolescent Mental Health Division (CAMHD), will provide acute inpatient psychiatric and outpatient behavioral health services, community crisis management and crisis residential services, intensive family intervention, therapeutic living and therapeutic foster care supports, hospital-based residential treatment, partial hospitalization, and biopsychosocial rehabilitation to children and adolescents age three (3) through age twenty (20) who the DOH determines are in need of intensive mental health services and are determined eligible for the SEBD Program. Additional information on the SEBD program is available in Appendix D.

 

Visual aids prescribed by ophthalmologists or optometrists (eyeglasses, contact lenses and miscellaneous vision supplies) are covered by the health plan, if medically necessary.

40.750.2

 

a.

Overview

 

o

Room and board

 

o

Nursing care

                                     •

Ambulatory services including twenty-four (24) hours, seven (7) days per week crisis services;

                                     •

Acute day hospital/partial hospitalization including:

                                                 o     

Therapeutic services including individual, family and group therapy and aftercare

                                     •

Methadone treatment services which include the provision of methadone or a suitable alternative (e.g. LAAM), as well as outpatient counseling services;

                                     •

Prescribed drugs including medication management and patient counseling;

 

                                    •

Diagnostic/laboratory services including:

 

                                    •

Physician services;

 

                                    •

Rehabilitation services;

 

Individuals age twenty-one (21) and older are limited to thirty (30) days of hospitalization per benefit year. No limits exist for outpatient behavioral health services for individuals. A benefit year is defined as the period between July 1 through June 30. The health plan may, at its option, exceed the limits on inpatient behavioral health services. Individuals under age twenty-one (21) are not subject to the inpatient behavioral health limits.

 

The health plan may utilize a full array of effective interventions and qualified professionals such as psychiatrists, psychologists, counselors, social workers, registered nurses and others. Substance abuse counselors shall comply with the State Department of Health Alcohol and Drug Abuse Division (ADAD) certification requirements.

 

The health plan is encouraged to utilize currently existing publicly funded community-based substance abuse treatment programs, which have received ADAD oversight, through accreditation and monitoring. Methadone/LAAM services are covered for acute opiate detoxification as well as maintenance. The health plan may develop its own payment methodologies for Methadone/LAAM services.

 

The health plan shall be responsible for providing behavioral health services to persons who have been involuntarily committed for evaluation and treatment under the provisions of Chapter 334, HRS to the extent that these services are deemed medically necessary by the health plan's utilization review procedures and are within the established limits.

 

The health plans are responsible for training residential care facilities on how to care for members who require behavioral health services.

 

The health plan is not obligated to provide behavioral health services to those members:

 

•

Whose diagnostic, treatment or rehabilitative services are determined not to be medically necessary by the health plan; or

 

•

Who have been determined eligible for and have been transferred to the behavioral health managed care (BHMC) plan, as described below; or

 

•

Who have been determined eligible for and have been transferred to the DOH's Child and Adolescent Mental Health Division (CAMHD) for services, as described in below; or

 

•

Who have been criminally committed for evaluation or treatment in an inpatient setting under the provisions of Chapter 706, HRS. These individuals will be disenrolled from the programs and will become the clinical and financial responsibility of the appropriate State agency. The psychiatric evaluation and treatment of members who have been criminally committed to ambulatory mental healthcare settings will be the clinical and financial responsibility of the appropriate State agency. The health plan shall remain responsible for providing medical services to these members.

 

Room and board in special treatment facilities for adolescents is not covered but therapy/treatment provided in the facility for this population is the responsibility of the health plan.

                •

Crisis Management

                              o

24-hour crisis telephone consultation

                              o

Mobile outreach services

                              o

Crisis intervention/stabilization services

                              o

Community-based Specialized Residential

                              o

Mental Health Respite Home

                              o

Therapeutic Group Home

 

If a member's SMI designation is denied by the DHS, the DHS or its designee must provide written denial and notification of appeal rights. The health plan may, with approval of the affected member, appeal any denial of SMI determination to the DHS on behalf of the member.

 

•

A provider directory that includes the names, location, telephone numbers of, and non-English languages spoken by contracted providers in the member's service area including identification of providers that are not accepting new patients.

 

The bullets from "Have direct access to a women's health specialist within the network" to "Receive a description of cost sharing responsibilities, if any" are moved out one level to below the bullet "Freely exercise his or her rights..."

2

HAR Title 11: http://gen.doh.hawaii.gov/sites/har/admrules/default.aspx

HAR Title 16: http://hawaii.gov/dcca/main/har