Eligibility - Frequently Asked Questions

Medicaid Fee-For-Service QUEST QUEST-NET Transitional Medical Assistance (TMA)
Pregnant Women Long Term Care Basic Health HawaiiLien

Medicaid Fee-For-Service

Q: Can I get help if my income is over the Medicaid standard?
A: Maybe. You may qualify for partial coverage in a month where you have high medical expenses. Your out-of-pocket medical expenses must exceed the difference between your income and the Medically Needy Income Standard. Coverage may be provided for the portion of your expenses that are above the difference.

EXAMPLE:
Mr. A meets the eligibility requirements for the Medicaid FFS program except his income is $600 over the Medically Needy Standard. His monthly out-of-pocket medical expenses exceed $1,000. Coverage can be provided for monthly expenses that exceed $600.

Q: Can I get coverage for medical bills I already have?
A: Yes. The Medicaid FFS program can provide coverage for unpaid medical bills up to three months before you applied for assistance. You must meet all program requirements during the month the bill was incurred.

Q: Can I go to any medical provider?
A: You must go to any provider who is a registered Medicaid provider. If you receive services from a non-Medicaid provider, Medicaid will not pay the bill.

QUEST

Q: Can I get services right away?
A: Individuals under age 21 can get services right away. All other individuals may have to wait one month for some services, but including urgent or emergency services.

Q: Does QUEST cover medical bills I already have?
A: Services received in an emergency room or hospital may be covered if the Department receives your application within 5 calendar days of getting those services, and you are found to be eligible for medial assistance.

Q: Will I have to pay for coverage under QUEST?
A: Only members who are self-employed and their spouse must pay a premium share. A premium share is an amount that must be paid every month to be covered by QUEST. The Med-QUEST Division will let you know if you have a premium share and the amount you must pay.

If you have a premium share, you must pay every month, even if you do not use any medical service. If you do not pay, you will lose coverage under QUEST. If you want to end your coverage under QUEST, you must send your eligibility worker a letter to stop your coverage. Until the Med-QUEST Division gets your letter, you will be responsible for the premium share. Any premiums you owe when you leave the QUEST program must be paid to the Med-QUEST Finance Office.

Q: Are the QUEST benefits the same for everyone in the program?
A: The basic medical benefits are the same for everyone, but persons under age 21 receive some extra services through the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. The ESPT health services provide coverage for:

• Complete medical and dental exams;
• Hearing and vision tests, laboratory tests;
• Immunizations and skin tests for tuberculosis (TB);
• Assistance with necessary scheduling and transportation upon request.
• There are limited mental health benefits for adults under QUEST. Some members who need special mental health care will be evaluated by the Division to see if they qualify for a separate "wraparound" mental health program. There are no limits for individuals under age 21.
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Q: Will I have to pay for QUEST-Net?
A: If household income is over 100% of the FPL, enrollees who are age 19 and older must pay the full QUEST-Net monthly premium. Self-employed enrollees and their spouses with income that does not exceed 100% of the FPL must pay 50% of the QUEST-Net monthly premium.

Individuals under age 19 with household income exceeding 250% of the FPL must pay part or all of a QUEST-Net monthly premium.  QUEST-Net enrollees who receive financial assistance do not have to pay a premium share.

Premium shares must be paid every month, even if benefits are not used. QUEST-Net coverage will be terminated if premium shares are not paid. Enrollees who want to end QUEST-Net coverage must inform their eligibility worker.  Otherwise, the enrollee will continue to be responsible for the premium share. Any premiums owed must be paid to the Med-QUEST Finance Office.

Q: Does QUEST-Net cover maternity benefits?
A: No, it is not included for individuals age 21 or older. But, a pregnant may be eligible for QUEST coverage if the family's income does not exceed 185% of the FPL for a family size, which includes the unborn child(ren).  If not eligible for QUEST, the woman may also be eligible for coverage in the QUEST-Spenddown program by paying a monthly spenddown amount.

Q: Will QUEST-Net recipients be enrolled in a medical plan under QUEST-Net?
A: QUEST-Net eligible adults and children under age 19 who are not blind or disabled shall be enrolled in a QUEST-Net health plan that will provide coverage of medical services.  Enrollees who were QUEST recipients will be enrolled in the QUEST-Net Plan of the health organization that provided QUEST benefits.  Enrollees who were Medicaid FFS recipients will have to choose a QUEST-Net plan.  Children who are blind or disabled receive coverage on a fee-for-service basis.

Traditional Medical Assistance

Q: How do I apply for Transitional Medical Assistance?
A: Your medical assistance worker will determine your eligibility for Transitional Medical Assistance when you and your child are no longer eligible for medical coverage for families with children as described in section 1931 of the Social Security Act.

Q: Do I enroll in a medical plan?
A: If eligible, you will continue to be enrolled in the Hawaii QUEST plan that covered you as a recipient of families with children as described in section 1931 of the Social Security Act. Similarly, dental coverage will be provided on a fee-for-service basis.

Q: Am I able to change my medical plan during the annual open enrollment period for Hawaii QUEST?
A: No. You may change your medical plan ONLY IF you move to a new residence, which is not serviced by the plan in which you are enrolled.

Q: Will I have to pay for Transitional Medical Assistance?
A: Transitional Medical Assistance will be provided at no cost.

Q: What does Transitional Medical Assistance Cover?
A: You and your family will continue to receive the same medical and dental coverage you received previously.

Q: What happens when the Transitional Medical Assistance ends?
A: You will be contacted before the end of the four, six, or twelve month period to determine your continued eligibility. When you respond, the medical assistance worker will determine your eligibility for QUEST or another medical assistance program.

Q: Can pregnant minors or teens apply?
A: Yes. Parental income may be counted, but it depends on the specific living arrangements.

Q: Can a certified nurse-midwife be used instead of a doctor?
A: Yes. Certified nurse midwives may provide primary care, prenatal care, labor and delivery services, family planning and gynecological services. QUEST members interested in using a certified nurse midwife should contact their health plan for more information.

Q: If I go into a nursing facility will the home be an exempt asset?
A: If the home is not in a trust, the Department may exempt the property if the individual claims an intent to return the home if released from the nursing facility. If the home property is in a trust is not exempt unless the spouse, minor child, an adult child who is blind or disabled is residing on the property.

Q: Whose resources will be used to determine eligibility?
A: All assets owned by an individual or married couple will be counted. In the case of a married couple, the spouse that is not institutionalized is allowed to keep some of the couple’s resources. This is called the community spouse resource allowance, and the amount is updated each year. For 2006, the community spouse resource allowance was $99,540. The institutionalized spouse will not be eligible for assistance if the remaining assets exceed $2,000.

EXAMPLE:
Mr. and Mrs. A apply for long term care assistance for Mr. A. They have $100,540 in countable assets (joint savings and checking accounts, and some stocks owned by Mr. A).

Q: Can assets be transferred to gain Medicaid eligibility?
A: No. Persons who transfer an asset for less than its fair market price may be subject to a penalty period. During the penalty period, Medicaid will not pay for long term care services. The penalty may be applied to assets that were transferred in the period prior to the application for long term care or when a Medicaid recipient begins receiving long term care services. The length of the penalty period is based on the value of the transferred asset divided by the average monthly cost of care in a Hawaii long term facility.

EXAMPLE:
Mrs. A, applied for assistance in 12/06 due to her admission to a nursing facility. In 08/06, she transferred $70,000 in bonds to her daughter. Calculation of a penalty period: $70,000 ÷ $7,000 (monthly long term care cost) = 10 month penalty period. Mrs. A is ineligible for long term care assistance for a period of 10 months.

Q: What would be a recipient’s share of the medical bills?
A: Only the income of the person who needs long term care services will be used to determine Medicaid eligibility, even if the person is married. Once determined eligible, a Personal Needs Allowance (currently $30) is deduced, then the cost of any medical insurance premium or other medical bills. The rest of the person’s income will be his/her share of the medical bills.

EXAMPLE:
Mr. A has been admitted to a nursing facility. He receives $1,030 from Social Security. He does not have any medical insurance or other medical expenses.

Q: Can the community spouse receive income from the institutionalized spouse?
A: Yes , the community spouse may receive an “income allowance" from the institutionalized spouse. The amount of the income allowance is determined by Federal regulations and is updated yearly. For the year 2006, the maximum income allowance is $2,489. The community spouse cannot receive more than the difference between the monthly income allowance and the community spouse’s gross monthly income.

EXAMPLE:
Mr. A is the institutionalized spouse and Mrs. Aloha is the community spouse. Mr. A receives $1830 monthly from Social Security and a pension. Mrs. A receives $989 from Social Security.

Mr. A can contribute up to $1,800 of his income to Mrs. A. However, based on her income, Mrs. A can only receive $1,500 from Mr. A. Mr. A’s remaining income is his cost share.

Q: What is the benefit year for Basic Health Hawai�i benefits?
A: The benefit year begins July 1 and ends June 30.

Q: Am I required to get a referral from a primary care physician?
A: No, referrals are not required for outpatient services.

Q: Will all my prescriptions be covered?
A: There is a maximum of 4 medication prescriptions per month. Each prescription cannot be more than a one-month supply. Only medications included in the health plan�s list of prescriptions will be covered. Plans are not required to cover a brand name medication if a generic medication is available, some exceptions may apply.

Q: Will my chemotherapy or dialysis treatment be covered by Basic Health Hawai�i?
A: Chemotherapy is included in the four medication prescriptions per month. Dialysis is covered under the Emergency Medical Assistance program for immigrants legally residing in the United States for less than five years and non-immigrants.

Q: What if I use all of the outpatient mental health visits and need more?
A: After using all outpatient mental health visits your health plan will allow the use of 6 available outpatient physician visits.

Q: Is maternity care a covered benefit?
A: A visit to confirm the pregnancy will count toward the 12 outpatient visit. Report the pregnancy to your DHS Eligibility Worker for possible change to another program for maternity care.

Q: Can I get coverage if I travel outside Hawai�i?
A: Basic Health Hawai�i will not provide coverage for out-of-state emergency and non-emergency services.

Q: Is transportation a covered service?
A: No. Air and ground transportation are not covered services.

Q: What happens if a recipient is discharged from the medical institution and returns home?
A: Any lien imposed shall be dissolved upon the recipient’s discharge from the medical institution and return home.

Q: Does the placement of a lien affect a recipient's eligibility or benefits?
A: No. The placement of a lien does not affect eligibility or the medical benefits that are available to a Medicaid recipient.

Q: Does the placement of a lien affect property ownership?
A: No. A lien on the home property does not change the ownership of the property. The lien secures the asset for future reimbursement to the State for the cost of medical care when the property is sold or transferred.

Q: Does the program require recipients to sell their homes?
A: No. Recipients are not required to sell their home as a condition to qualify for Medicaid.