Hawaii Medicaid (Med-QUEST) QUEST Integration (QI) Program

Last updated: February 23, 2024

 

Overview of Hawaii’s QUEST Integration Program

Hawaii’s QUEST Integration Program, or QI Program, is a Medicaid managed care program for state residents of all ages. Via this program, persons receive all of their Medicaid benefits. In addition to medical care and behavioral health services, persons who are at risk of institutionalization (nursing home admission) can receive long-term services and supports (LTSS). While nursing facility care is an available benefit, so are home and community based services (HCBS) to prevent and delay the need for such care. This includes adult day care, home delivered meals, personal emergency response systems, respite care, and in-home personal care assistance.

Program participants can reside in a variety of home and community based settings. These include one’s home, the home of a loved one, an assisted living residence (including a memory care unit for persons with Alzheimer’s disease or a related dementia), an expanded adult residential care home, or a community care foster family home.

All of one’s benefits are received via a single Medicaid plan provided by a managed care organization (MCO). An MCO is essentially a private healthcare company. The MCO has a network of care providers and program participants receive services via these providers. While the state currently offers five healthcare plans, not all plans are available in all areas of the state.

There is some flexibility of providers for persons receiving care services via QUEST Integration. Some long-term care benefits, such as personal assistance services, can be participant-directed. This means that rather than receive services by the MCO’s network of licensed care providers, a program participant can hire their own caregiver. Relatives, including spouses and adult children, can be hired. A financial management services agency handles the financial aspects of employment responsibilities such as tax withholding and caregiver payments.

The Medicaid program in Hawaii is called Med-QUEST. QUEST Integration is a Medicaid program authorized under an 1115 Demonstration Waiver. QUEST stands for Quality care, Universal access, Efficient utilization, Stabilizing costs, and Transforming the way health care is provided to QUEST members. QUEST Integration combined two former programs: QUEST (for children and families) and QUEST Expanded Access (QExA – for aged, blind and disabled persons). The home and community based services offered via QUEST Integration are not necessarily an entitlement; meeting the eligibility criteria does not mean one will immediately receive program benefits. Instead, the number of participant slots may be limited, and when these slots are full, a waiting list forms.

 What is Medicaid Managed Care? Medicaid pays doctors, hospitals, and other providers in one of two ways, either “Fee-For-Service” or “Managed Care”. Under Fee-For-Service, Medicaid pays providers directly for each service they provide. Beneficiaries can receive services from any Medicaid-certified provider. Under Managed Care, Medicaid contracts with a Managed Care Organization (MCO). Medicaid pays the MCO a set amount for each beneficiary, rather than for each service provided. The MCO has a network of doctors, hospitals, and other providers and the MCO pays them. Beneficiaries must use providers within the network.

 

Benefits of Hawaii’s QUEST Integration Program

In addition to inpatient and outpatient hospital services, physician services, diagnostic services, prescription drugs, rehabilitation services, durable medical equipment, vision services, hearing services, behavioral health services, nursing facility care, and cognitive rehabilitation services, long-term home and community based services are available via the QI Program. While all of the benefits below are available to persons who require a Nursing Facility Level of Care (NFLOC), persons who are “at risk” of a NFLOC have fewer benefits available to them. The benefits marked with an asterisk are available to persons “at risk”.

– Adult Day Care / Adult Day Health Care*
– Assisted Living Services
– Chore Services
– Counseling / Training
– Home Delivered Meals*
– Home Maintenance
– Home Modifications – for safety and accessibility
– Moving Assistance
– Personal Care Services* – includes companion services and homemaker services
– Personal Emergency Response Systems*
– Private Duty Nursing / Skilled Nursing*
– Residential Care Services – Community Care Foster Family Home (CCFFH) / Expanded Adult Residential Care Home (E-ARCH)
– Respite Care
– Specialized Case Management
– Specialized Medical Equipment / Supplies
– Transportation Assistance (non-medical)

While services and supports can be provided in assisted living residences, expanded adult residential care homes, and community care foster family homes, the cost of room and board is not covered by QUEST Integration.

 

Eligibility Requirements for Hawaii’s QUEST Integration Program

The QI Program is for Hawaii residents of all ages. Additional eligibility criteria follows and is relevant for aged and disabled adults seeking home and community based services.

 The American Council on Aging provides a quick and easy Hawaii Medicaid Eligibility Test for seniors that require long-term care. 

 

Financial Criteria: Income, Assets & Home Ownership

Income
The applicant income limit is equivalent to 100% of HI’s Federal Poverty Level (FPL), which increases annually in January. However, specific to Med-QUEST, the program income limits increase each March. Effective 2/4/24, an applicant, regardless of marital status can have a monthly income up to $1,443. When both spouses are applicants, each spouse is considered individually, with each spouse allowed income up to $1,443 / month. When only one spouse is an applicant, the income of the non-applicant spouse is not counted towards the income eligibility of their spouse. However, in some cases, income can be allocated to the non-applicant spouse from the applicant spouse as a Spousal Income Allowance, also called a Minimum Monthly Maintenance Needs Allowance (MMMNA), to prevent spousal impoverishment.

In 2024, the MMMNA in HI is $3,853.50 / month. If a non-applicant spouse has monthly income under this amount, income can be transferred from the applicant spouse to the non-applicant spouse to bring their monthly income up to this level. A non-applicant spouse who already has a monthly income of $3,853.50 or more is not entitled to a MMMNA / Spousal Income Allowance.

Assets
In 2024, the asset limit is $2,000 for a single applicant. For married couples, with both spouses as applicants, the asset limit is $3,000. When only one spouse is an applicant, the assets of both the applicant and non-applicant spouse are still limited. This is because Medicaid considers the assets of a married couple to be jointly owned. In this case, the applicant spouse can retain up to $2,000 in assets and the non-applicant spouse can keep up to $154,140. This larger allocation of assets to the non-applicant spouse is called a Community Spouse Resource Allowance (CSRA).

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

Assets should not be given away or sold under fair market value within 60-months of long-term care Medicaid application. This is because Medicaid has a Look-Back Rule and violating it results in a Penalty Period of Medicaid ineligibility.

 To determine if you might have assets over Hawaii Medicaid’s countable limit, and if so, receive an estimate of the amount, use our Spend Down Calculator

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. For eligibility purposes, Med-QUEST considers the home exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has Intent to Return, and in 2024, their home equity interest is no greater than $1,071,000. Home equity is the current value of the home minus any outstanding mortgage. Equity interest is the portion of the home’s equity value that is owned by the applicant.
– The applicant has a spouse living in the home.
– The applicant has a minor child living in the home.
– The applicant has a permanently disabled or blind adult child living in the home.

Learn more about the potential of Medicaid taking the home here.

 

Medical Criteria: Functional Need

An applicant must require a Nursing Facility Level of Care (NFLOC) OR be “at risk” of requiring this level of care. A level of care (LOC) assessment (functional assessment) is completed to determine if an applicant meets the criteria. A need for assistance with Activities of Daily Living (i.e., transferring from the bed to a chair, mobility, eating, toileting, bathing, grooming, dressing) and Instrumental Activities of Daily Living (i.e., routine housecleaning, laundry, preparing meals, shopping for essentials) is considered. Cognitive deficits, which are common in persons with Alzheimer’s Disease or a related dementia, are also taken into account. A diagnosis of dementia, such as Alzheimer’s disease, in and of itself does not mean one will automatically meet the level of care need.

 Learn more about long-term care Medicaid in Hawaii.

 

Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for Med-QUEST. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

Persons who have income over the limit, but have high medical bills, can become income-eligible via Hawaii’s Medically Needy Spenddown program. This program permits applicants to spend their “excess” income on medical expenses in order to meet the Medically Needy income limit. The amount that must be paid each month can be thought of as a deductible. Once one’s “deductible” has been met for the month, the QI Program will pay for services and supports. More about the Medically Needy pathway to eligibility.

When persons have assets over the limits, one option is to “spend down” assets. Examples include paying off debt, making home modifications, and purchasing pre-paid funeral and burial expense trusts called Irrevocable Funeral Trusts. Although rarely utilized anymore, a Medicaid Divorce is sometimes feasible when a married couple has a significant amount of excess assets and only one spouse is applying for long term care. There are many other options when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in the state of Hawaii to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, there are additional Medicaid planning strategies that not only help one meet Medicaid’s financial criteria but can also protect assets from Medicaid’s Estate Recovery Program. These strategies often violate Medicaid’s 60-month Look-Back Rule, and therefore, should be implemented well in advance of the need for long-term care. However, there are some workarounds, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid Planner.

 

How to Apply for Hawaii’s QUEST Integration Program

Before You Apply

Prior to applying for the QI Program, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid Eligibility Test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, bank statements up to 60-months prior to application, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are delayed is required documentation is missing or not submitted in a timely manner.

Since home and community based services are not necessarily an entitlement, there may be a waiting list to receive these benefits. In the case of a waiting list, it is thought that a participant slot is based on one’s date of Medicaid application.

 

Application Process

To be eligible for the QUEST Integration Program, one must be eligible for Hawaii Medicaid (Med-QUEST). One can apply online at MyBenefits or by calling Med-QUEST at 877-628-5076. Persons can also print and complete an Application for Health Coverage & Help Paying Costs and submit it to their local Med-QUEST office. Persons who need application assistance can contact a Community Partner in their area.

Eligible persons are given the option to choose their health plan. Health plans include AlohaCare, Hawaii Medical Service Association (HMSA), Kaiser Permanente, “Ohana Health Plan, and UnitedHealthcare Community Plan. Kaiser Permanente is limited to O’ahu and Maui.

For questions, or to choose one’s health plan, Med-QUEST Customer Service can be reached at 800-316-8005, or in O’ahu, 808-524-3370. Alternatively, to choose a plan, one can complete and submit the Choice Form they receive with their enrollment packet. Persons who do not choose a health plan will have one assigned to them.

Learn more about the QUEST Integration Program here. The State of Hawaii Department of Human Services’ (DHS) Med-QUEST Division (MQD) administers the QI Program.

 

Approval Process & Timing

The Hawaii Medicaid / Med-QUEST application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further. Furthermore, as a waiting list may exist, approved applicants may spend many months waiting to receive benefits.

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