hawaiiamend2.htm


    Back to Form 8-K

    Exhibit 10.2


    STATE
OF HAWAII

    
      


      SUPPLEMENTAL CONTRACT NO.
2

    

    
                                           
       TO CONTRACT DHS-08-MQD-5129                                                                             


    

    
                                                                                                                                            
(Insert contract number or other identifying information)

    

    
      


       

      This Supplemental Contract
No.   2                                                                                                                                                                                             ,
executed on the respective dates

    

    
      indicated
below, is effective as of December
15                                                                                                                                    , 2008                                                                              , between
the

    

    
      Department of Human
Services/Med-QUEST
Division                                                                                                                                                                                                        
 , State of Hawaii

    

    
      (Insert name of stale department, agency, hoard or
commission)

    

    
      ("STATE"),
by its Director, Lillian B.
Koller                                                                                                                                                                                                                                                         ,

    

    
      (Insert
title uf stale officer executing contract)

    

    
      (hereafter
also referred to as the HEAD OF THE PURCHASING AGENCY or designee
("HOPA")),

    

    
      whose
address is 1390 Miller
Street, Honolulu, Hawaii
96813                                                                                                                                                                                                                    ,
and

      WellCare Health Insurance of
Arizona, Inc. dba 'Ohana Health
Plan,  Inc.                                                                                                                                                                  ("CONTRACTOR"),

      a Corporation                                                                                                                                                                                                                                                                                                           

                                                                       (Insert
corporation, partnership, joint venture, sole proprietorship, or other legal
form of the CONTRACTOR)

    

    
      under the
laws of the State of Hawaii                                                                                                                                                                                                   ,
whose business address and federal

    

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

              	
                 

              


      

    

    
       

      
        	GET# Wl
      1018973-01   Fed ID#
86-0269558


      

       

      RECITALS

    

    
       

      
        	
                 

              	
                A.

              	
                WHEREAS,
      the STATE and the CONTRACTOR entered into
  Contract

              


      

    

    
       

      
        	
                 
      

              	
                DHS-08-MQD-5129

              


      

    

    
      (Insert
contract number or other identifying information)

    

    
      dated
February 4,
2008 , which
was amended by Supplemental Contract No(s).  1    


    

    
      dated
May
15      , 2008 , which was
amended by Supplemental Contract No(s).  n/a

    

    
      dated
_________, which was amended by Supplemental Contract
No(s).            __
  

    

    
      dated
_________, ____ (hereafter collectively referred to as "Contract") whereby
the

    

    
      CONTRACTOR
agreed to provide the goods or services, or both, described in the Contract;
and

    

    
       

      
        	
                 

              	
                B.

              	
                HEREAS,
      the parties now desire to amend the Contract

              
	 	 	NOW,
      THEREFORE, THE STATE and the CONTRACTOR mutually agree to amend the
      Contract as follows: (Check Applicable
box(es))


      

    

    
       

    

    
      	
              
                x

              

            	
              
                Amend
      the SCOPE OF SERVICES according to the terms set forth in Attachment - S1,
      which is made a part of the Contract.

              

            
	
              
                 ̈

              

            	
              
                Amend
      the COMPENSATION AND PAYMENT SCHEDULE according to the terms set forth in
      Attachment-S2, which is made a part of the
  Contract.

              

            
	
               ̈

            	
              
                Amend
      the TIME OF PERFORMANCE according to the terms set forth in Attachment-S3,
      which is made a part of the Contract.

              

            
	
               ̈

            	
              
                Amend
      the SPECIAL CONDITIONS according to the terms set forth in Attachments
      SUPPLEMENTAL SPECIAL CONDITIONS, which is made a part of the
      contract.

              

            
	
               ̈

            	
              
                Recognize
      the CONTRACTOR'S change of name.

              

            
	 
      	
              FROM:

            	 
      
	 
      	 
      	 
      
	 
      	 
      	 
      
	 
      	 
      	 
      


    

    
       

      AG-005 Rev
04/30/2007

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

       

    

    
      	 
      	
              TO:

            	 
      
	 
      	 
      	 
      
	 
      	 
      	 
      
	 
      	 
      	 
      
	 	
               

              As
      set forth in the documents attached hereto as Exhibit ____ , and
      incorporated herein.

            
	 	 
	 	
              
                A
      tax clearance certificate from the State of Hawaii o is x is not required
      to be submitted
      to the STATE prior to commencing any performance under this
      

              

            
	Supplemental
      Contract.


    

    
       

    

    
      
        	 	A tax clearance
      certificate from the Internal Revenue Service Q is x is not required
      to be submitted to the STATE prior to commencing any performance under
      this 
	 Supplemental
      Contract.


      

       

          The entire
Contract, as amended herein, shall remain in full force and
effect.

    

    
      


          IN VIEW OF
THE ABOVE, the parties execute this Contract by their signatures, on the dates
below, to be effective as of the date first above written.

       

    

    
      	 
      	
              STATE

               

              
                /s/ Lillian B.
      Koller                      
            

              

              (Signature)

            
	 
      	
              
                 

                Lillian
      B.
      Koller                                                
      

              

              (Print
      Name)

            
	 
      	
               

              
                Director                                                            
      

              

              (Print
      Title)

            
	 
      	
               

              
                ____________________________

              

              (Date)

            


    

    


    
      	
               

               

              CORPORATE
      SEAL

              (If
      available)

            	
              CONTRACTOR

               

              
                WellCare
      Health Insurance of Arizona, Inc. dba ‘Ohana Health Plan,
      Inc.

              

              (Name
      of Contractor)

            
	 
      	
               

              
                /s/
      Heath
      Schiesser                                        
      

              

              (Signature)

            
	 
      	
               

              
                Heath
      Schiesser                                             
      

              

              (Print
      Name)

            
	 
      	
               

              
                President
      and
      CEO                                         
      

              

              (Print
      Title)

            
	 
      	
               

              
                1-8-09                                                                
      

              

              (Date)

            


    

    
      APPROVED
AS TO FORM:

    

    
      


    

    
      /s/
Name
Illegible                             


    

    
      Deputy
Attorney General

    

    
      


       

      **Evidence
of authority of the CONTRACTOR'S representative to sign this Contract for the
CONTRACTOR must be attached.

    

     

    
      AG-005 Rev
04/30/2007


    

    
      2


        
          
             


          

          
             


            
              

            

          

          
             


          

        



    

    
      CONTRACT
NO.
DHS-08-MDQ-5129

    

    
      


      PROVIDER’S
ACKNOWLEDGMENT

    

    
      


    

    
      	
              STATE
      OF

            	
              FLORIDA

            	
              )

            
	 	 	 	)	 
	 
      	
              COUNTY
      OF

            	
              HILLSBOROUGH

            	
              )
      ss.

            	 
      


    

    
       

    

    
      On this 8th
day of January,
2009, before me
appeared Heath
Schiesser and ______________________, to me known, to be the person(s)
described in and, who, being by me duly sworn, did say that he/she/they is/are
the President
and CEO_________ of Wellcare Health Insurance of
Arizona, Inc. the PROVIDER named in the foregoing instrument, and that
he/she/they is/are authorized to sign said instrument on behalf of the PROVIDER,
and acknowledges that he/she/they executed said instrument as the free act and
deed of the PROVIDER.

    

    
       

    

    
      	
               

               

               

              (Notary
      Seal)

            	
              By /s/ Tolliver L.
      Rowson                 
      

              (Signature)

               

            
	
              Print
      Name Tolliver L.
      Rowson        


               

            
	
              Date
      January 8,
      2009                          
      

               

            
	
              Notary
      Public, State of Florida          
      

               

            
	
              My
      Commission expires 11.30.2012 
      

               

            
	
              Doc.
      Date:

            	 
      	
              #
      Pages: ___________

            	 
      	 
      
	
              Notary
      Name:

            	
              Tolliver L.
      Rowson                     
      

            	 	________	
              Circuit

            	 
      


    

    
      	
              Doc
      Description:

            	 
      	 
      	 
      
	 
      	 
      	
               

               

               

               

              (Notary
      Stamp or Seal)

            
	 
      	 
      
	 
      	 
      
	
               

              /s/ Tolliver L.
      Rowson                                                

              Notary
      Signature

            	
               

              1.8.2009                                                                   
      

              Date

            
	
               

              NOTARY
      CERTIFICATION

               

            	 
      


    

    
      

        
          
             


          

          
             


            
              

            

          

          
             


          

        

      

    

    
       

      CONTRACT
NO. DHS-08-MQD-5129

    

    
      


    

    
      PROVIDER'S


      STANDARDS
OF CONDUCT DECLAMATION

    

    
      


       

      For the
purposes of this declaration:


    

    
       

      
        	
                 
      

              	
                "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).

              


      

    

    
      


      On behalf
of:

    

    
      WellCare Health Insurance of Arizona, Inc.,
dba 'Ohana Health Plan, Inc.                                                                                                                                                                                                    


    

    
      (Name of
PROVIDER)

    

    
      


    

    
      PROVIDER,
the undersigned does declare as follows:

       

    

    
      
        	
                 
      

              	
                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).

              


      

    

    
      


    

    
      PROVIDER
understands that the Contract to which this document is attached is voidable on
behalf of the STATE if this Contract was entered into in violation of any
provision of chapter 84, Hawai'i Revised Statutes, commonly referred to as the
Code of Ethics, including the provisions which are the source of the
declarations above. Additionally, any fee, compensation, gift, or profit
received by any person as a result of a violation of the Code of Ethics may be
recovered by the STATE.

    

    
      ________________________________

      *Reminder to agency:
If the "is" block is checked and if the Contract involves goods or services of a
value in excess of $10,000, the Contract may not be awarded unless the agency
posts a notice of its intent to award it and files a copy of the notice with the
State Ethics Commission. (Section 84-15(a), HRS).

    

    
      


       

      AG Form
103F (10/08) 

      Standards
of Conduct Declaration

    

    
      Page 1 of
2

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      CONTRACT
NO. DHS-08-MQD-5129

    

    
       

    

    
      	 
      	
              PROVIDER

               

              By
      /s/ Heath
      Schiesser                       
      

                                     (Signature)

            
	 
      	
               

              Print
      Name Heath
      Schiesser              
      

            
	 
      	
               

              Print
      Title President
      and CEO           
      

            
	 
      	
                            
         ___________________

            
	 
      	
               

              Date
      1-8-09                                           
      

            


    

     

    
       

    

    
       

    

    
      AG Form
103F (10/08) 

      Standards
of Conduct Declaration

      Page 2 of 2

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      CONTRACT
NO. DHS-08-MQD-5129

    

    
       

      CERTIFICATE
OF EXEMPTION FROM CIVIL SERVICE

    

    
       

      
        	
                1.

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

              


      

    

    
       

      Pursuant to the delegation of the
authority by the Director of Human Resources Development, I certify that the
services provided under this Contract, and the person(s) providing the services
under this Contract are exempt from the civil service, pursuant to §76-16,
Hawai'i Revised Statutes ("HRS").

    

    
       

    

    
      	
              
                /s/
      Lillian B.
      Koller                       
      

              

              (Signature)

               

            	
              
                01/15/09                     
      

                              (Date)

              

            
	
              
                Lillian
      B.
      Koller                             
      

              

              (Print
      Name)

               

            	 
      
	
              
                Director
      of Human Services       
      

              

              (Print
      Title)

               

            	 
      


    

    
      


    

    
      _______________________________________________

    

    
      1 This
part of the form may be used by all department heads and others to whom the
Director of Human Resources Development (DHRD) has delegated authority to
certify §76-16, HRS, civil service exemptions. The specific paragraph(s) of
§76-16, HRS, upon which an exemption is based should be noted in the contract
file. NOTE: Authority to certify exemptions under §§ 76-16(2), 76-16(12), and
76-16(15), HRS, has not been delegated; only the Director of DHRD may certify
§§76-16(2), 76-16(12), and 76-16(15) exemptions.

    

    
      


       

      2.           By
the Director of Human Resources Development, State of
Hawai'i.

    

    
      


                    I
certify that the services to be provided under this Contract, and the person(s)
providing the services under this Contract are exempt from the civil service,
pursuant to §76-16, HRS.

    

    


    
      	
              
                 

                ____________________________________

              

              (Signature)

            	
              
                 

                ________________

              

                           
      (Date)

            
	
              
                 

                ____________________________________

              

              (Print
      Name)

            
	
              
                 

                ____________________________________

              

              (Print
      Title, if designee of the Director of
DHRD)

            


    

    
      


       

    

    
      
        AG Form
103F (9/08) 

        Competitive

        Page 1


        
          
            
               


            

            
               


              
                

              

            

            
               


            

          

        

        AG Form
103F (9/08) Competitive

      

    

    
       

      STATE
OF HAWAII

       

      SCOPE
OF SERVICES

    

    
      
Revisions
to specific provisions in the Request for Proposals, RFP~MQD-2008~006 issued
October 10, 2007, as amended, are set forth below. Except for the revised
definition of "Medical Necessity," and the amendment to section 40.750.2, all of
the following revisions are necessary to comply with conditions imposed by the
Centers of Medicare and Medicaid Services (CMS).

    

    
      


       

      20.100                      RFP Timeline

    

    
                                      
Replace the last row on the table with:

    

     

    
      	
              
                Commencement
      of Services to Members

              

            	
               February
      1, 2009

            	
              
                 

              

            


    

    
       

      30.200                      Definition/Acronyms

    

    
       

      Action
(may also be referred to as an adverse action)

       

    

    
      Replace the 4th bullet
point with:

       

    

    
      The failure to provide services in a
timely manner, as defined in Section 40.230;

       

    

    
      Healthcare
Professional

       

    

    
      Add the following sentence to the end
of definition of Healthcare Professional:

       

    

    
      See Appendix O.

       

    

    
      Medical
Necessity

       

    

    
      Replace this definition with the
following:

       

    

    
      As defined in HRS
§432E-1.4.

    

    
      


       

      30.550                     90-Day Grace Period

    

    
      Replace the first two paragraphs with
the following:

    

    
       

      
        	
                 
      

              	
                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.

              


      

       

      AG-011 Rev
07/28/2005


    

    
      1


        
          
             


          

          
             


            
              

            

          

          
             


          

        
Attachment – S1  


    

    
      STATE OF
HAWAII

    

    
      


      SCOPE
OF SERVICES

    

    
       

       

      
        	
                30.820.4

              	
                Behavioral Health Services for
      Children/Support for Emotional and Behavioral Development (SEBD)
      Program

              


      

    

    
       

      Replace this section with the
following:

    

    
       

      
        	
                 
      

              	
                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.

              


      

    

    
      


       

      40.400                     Provider Credentialing,
Recredentialing and Other Certification

    

    
                                      Add
the following sentence to the end of the first sentence in the second
paragraph:

    

    
       

      See Appendix O.

    

    
       

      40.750.1.v              Vision
Services

    

    
      Replace the first sentence of the third
paragraph with the following:

    

    
       

      
        	
                 
      

              	
                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                  Primary and Acute Care Services -
Behavioral Health

    

    
       

      Replace this section in its entirety
with the following:

    

    
       

    

    
      
        	
                40.750.2

              	
                Primary and Acute Care Services
      - Behavioral Health

              


      

    

    
      


    

    
      
        	
                 
      

              	
                a.

              	
                Overview

              


      

    

    
      


                                    
The health plan shall provide all medically necessary behavioral health services
to QExA adults and child members. These services include:

    

    
      


                                          
•           Twenty-four
(24) hour care for acute psychiatric illnesses including:

    

    
      
        	
                 
      

              	
                o

              	
                Room and
    board

              


      

    

    
      
        	
                 
      

              	
                o

              	
                Nursing
    care

              


      

    

    
      


       

    

    
      AG-011 Rev
07/28/2005

      2

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    Attachment – S1 


    


    
      STATE OF
HAWAII

    

    
      


      SCOPE
OF SERVICES

    

    
       

    

    
                  
o          Medical
supplies and equipment

    

    
                  
o          Diagnostic
services

    

    
                  
o          Physician
services

    

    
                  
o          Other
practitioner services as needed

    

    
                   o          Other
medically necessary services;

    

    
      
        	
                                                    
      •

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

              


      

    

    
      
        	
                                                    
      •

              	
                Acute
      day hospital/partial hospitalization
including:

              


      

    

    
                   o          Medication
management

    

    
                  
o          Prescribed
drugs

    

    
                  
o          Medical
supplies

    

    
                  
o          Diagnostic
tests

    

    
      
        	
                                                                
      o      

              	
                Therapeutic
      services including individual, family and group therapy and
      aftercare

              


      

    

    
                  
o          Other
medically necessary services;

    

    
      
        	
                                                     •

              	
                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:

              


      

    

    
                   o          Psychological
testing

    

    
                  
o          Screening
for drug and alcohol problems

    

    
                  
o          Other
medically necessary diagnostic services;

    

    
                                          
•           Psychiatric or
psychological evaluation;

    

    
      
        	
                 
      

              	
                                                   
      •

              	
                Physician
      services;

              


      

    

    
      
        	
                 
      

              	
                                                   
      •

              	
                Rehabilitation
      services;

              
	 	                                   
      •      	Occupational
      therapy; and
	 	                                    •    	Other
      medically necessary therapeutic
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.

              


      

    

    


    
      AG-01I Rev
07/28/2005

    

    
      3



    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    


    
      Attachment –S1 


      STATE
OF HAWAII

    

    
      


      SCOPE
OF SERVICES

    

    
       

      
        	
                 
      

              	
                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.

              


      

       

      AG-011 Rev
07/28/2005

      4


    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    
      Attachment
– S1

    

    
      STATE
OF HAWAII

    

    
       

      SCOPE
OF SERVICES

    

    
       

      b.       
    Health Plan Responsibilities for SMI
Adults

    

    
       

      Certain
specialized mental health services for adults diagnosed with SMI will be carved
out of QExA as provided in this subsection. The health plan shall continue to be
responsible for all other Medicaid services (primary, acute and long-term care
services) for the member who is receiving behavioral health services through
another entity. Adult members with SMI may receive services through the Adult
Mental Health Division (AMHD) or the BHMC program.

    

    
       

      Health
plans will coordinate with the AMHD regarding behavioral health services for
adult members with SMI who are receiving services through AMHD. The cost of AMHD
services will not be included in the capitation rate paid to the health plans.
The AMHD will continue to bill the DHS on a FFS basis for the services it
provides to these members. All other behavioral health services will be provided
by the health plans.

    

    
       

      The
health plan is responsible for making the initial determination of whether or
not an adult member has SMI (using the definition in Appendix D). Once the
health plan has made this determination, the health plan shall refer the adult
member to the DOH AMHD for an evaluation to confirm the initial diagnosis and
coverage AMHD services. During the referral process, the health plan shall
continue to coordinate the member's care and provide any medically necessary
services. AMHD services shall include:

    

    
      
        	
                               
      •

              	
                Crisis
      Management

              


      

    

    
      
        	
                                              o

              	
                24-hour crisis telephone
      consultation

              


      

    

    
      
        	
                                             
      o

              	
                Mobile outreach
      services

              


      

    

    
      
        	
                                              o

              	
                Crisis intervention/stabilization
      services

              


      

      
        	               
      •	Crisis
      Residential Services
	               
      •	Intensive
      Outpatient Hospital Services
	               
      •   	Therapeutic
      Living Supports


      

    

    
      
        	
                                             
      o

              	
                Community-based
      Specialized Residential

              


      

    

    
      
        	
                                             
      o

              	
                Mental
      Health Respite Home

              


      

    

    
      
        	
                                             
      o

              	
                Therapeutic
      Group Home

              


      

    

    
                     
•          
  Biopsychosocial Rehabilitative Services

    

    
                     
•            
Intensive Case Management/Community Based Case Management

    

    
       

      If AMHD
denies the SMI designation the health plan shall refer the member to the DHS for
determination as to whether he or she is eligible for the BHMC program.
Appendices D.2 and D.3 provide additional information on this
process.

    

    
      


      AG-011 Rev
07/28/2005

      5


    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    Attachment
S1

    
      STATE
OF HAWAII

    

    
       

      SCOPE
OF SERVICES

    

    
       

      
        	
                 
      

              	
                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.

              


      

    

    
       

      40.750.3.g               Counseling
and Training

    

    
      Add the following sentence to the end
of the last paragraph:

    

    
       

      Training should occur by qualified
health professionals as defined in Appendix 0.

    

    
      50.100                     Health
Plan Enrollment Responsibilities

    

    
       

      50.110                     General
Overview

       

    

    
      Add as the final bullet point to the
bulleted list in the section:

    

    
      
        	
                 
      

              	
                •

              	
                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.

              


      

    

    
      


      50.350                     Member
Rights

    

    
       

      
        	
                 
      

              	
                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..."

              


      

       

      AG-0II Rev
07/28/2005

    

    
      6


    

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    Attachment
– S1 

    STATE OF HAWAII

     

    
      SCOPE
OF SERVICES 

       

      Appendix
O

    

    
      State
Requirements for Health Care Professionals, including Mental Health
Providers


    

     

    
      	
              
                Specialty

              

            	
              
                Hawaii
      Revised Statutes (HRS)1

              

            	
              
                Hawaii
      Administrative Rules (HAR)2

              

            
	
              
                Advanced
      Practice Registered Nurse

              

            	
              
                457-8.5

              

            	
              
                Title
      16-89C

              

            
	
              
                Audiologist

              

            	
              
                468E

              

            	
              
                Title
      16-100

              

            
	
              
                Chiropractor

              

            	
              
                442

              

            	
              
                Title
      16-76

              

            
	
              
                Community
      Mental Health Center

              

            	 
      	
              
                Title
      11-179

              

            
	
              
                Dentist

              

            	
              
                448

              

            	
              
                Title
      16-79

              

            
	
              
                Licensed
      Practical Nurse

              

            	
              
                457-8

              

            	
              
                Title
      16-89

              

            
	
              
                Marriage
      and Family Therapist

              

            	
              
                451J

              

            	 
      
	
              
                Mental
      Health and Substance Abuse Systems

              

            	 
      	
              
                Title
      11-175

              

            
	
              
                Mental
      Health Counselor

              

            	
              
                453D

              

            	 
      
	
              
                Occupational
      Therapist

              

            	
              
                457G

              

            	 
      
	
              
                Optometrist

              

            	
              
                459

              

            	
              
                Title
      16-92

              

            
	
              
                Physician/Psychiatrist

              

            	
              
                453

              

            	 
      
	
              
                Physical
      Therapist

              

            	
              
                461J

              

            	
              
                Title
      16-110

              

            
	
              
                Physician
      Assistant

              

            	
              
                453-5.3

              

            	 
      
	
              
                Podiatrist

              

            	
              
                463E

              

            
	
              
                Psychologist

              

            	
              
                465

              

            
	
              
                Registered
      Dietitian

              

            	
              
                448-B

              

            	
              
                Title
      11-79

              

            
	
              
                Registered
      Nurse

              

            	
              
                457-7

              

            	
              
                Title
      16-89

              

            
	
              
                Speech-Language
      Pathologist

              

            	
              
                468E

              

            	
              
                Title
      16-100

              

            
	
              
                Social
      Worker

              

            	
              
                467E

              

            	 
      
	
              
                Special
      Treatment Facility

              

            	 
      	
              
                Title
      11-98

              

            


    

    
       

      ___________________________
1      http://hawaii.gov/dcca/main/hrs/

    

    
      


       

      
        	
                2

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

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

              


      

       

      AG-OII Rev
07/28/2005

    

    
      7