Hawaii HI

Hawaii Medicaid = Med-QUEST Division (DHS). 100%-MCO state via QUEST Integration (5 MCOs: AlohaCare, HMSA, Kaiser, Ohana/WellCare-CVS, UnitedHealthcare) covering integrated PH+BH+LTSS since 2015; FFS is residual. DESPITE being MCO-dominated, HI publishes a REAL centralized PA criteria layer on medquest.hawaii.gov (AEM /content/medquest/en/ paths): (1) FFS Pharmacy PA Criteria as a single inline HTML page (drug-by-drug clinical criteria, ~82KB, page live & maintained); (2) PA Item & Service Codes master PDF (CY Q1-Q3 2025) listing FFS PA-required procedure codes; (3) FFS Provider Manual (21 chapters) stating service-level PA policy; (4) Provider Memos (QI-series, ongoing); (5) Health Plan Manual Part I-IV governing MCO operational guidance incl PA delegation. Authority = Med-QUEST Division (DHS) for FFS criteria + standard QI MCO contract terms; per-member medical PA routes to enrollee QI plan; pharmacy is per-MCO PBM. No login/portal wall on criteria pages (invisible recaptcha on forms only). URL DECAY: the four primary_source_urls pinned in state_meta (prior-authorization.html, medquest-resources.html, quest-integration.html under /en/plans-providers/) now 404 — site migrated to /content/medquest/en/ AEM paths. Live replacements in data.repin_candidates. state_meta NOT patched.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

Last award: 2015-07-01_for_QI_launch (the 2020 award was rescinded on 2020-08). Next due: TBD_pending_re-procurement. Contracts extended through: open-ended_incumbent_extension_until_new_RFP_awarded.

## 1. How HI requires PA Hawaii's Medicaid program, known as Hawaii QUEST Integration (HI QI), requires prior authorization (PA) for a variety of services and drugs to ensure medical necessity and appropriate utilization. The state operates under a managed care model with five Managed Care Organizations (MCOs): AlohaCare, HMSA, Kaiser, Ohana/WellCare-CVS, and UnitedHealthcare. Despite being primarily MCO-driven, Hawaii maintains a centralized layer for PA criteria, which is published on the Med-QUEST Division website of the Department of Human Services (DHS). For example, specific drugs like Actiq, Abraxane, Acne Drugs, Actonel, and Altace have detailed PA criteria. These criteria are outlined in HTML documents available online, specifying conditions under which these medications can be authorized. Similarly, behavioral assessments and treatments for autism-related conditions require documentation such as face-to-face interactions with patients/caregivers, standardized tests, and detailed histories. ## 2. How HI publishes and reports PA Hawaii publishes its PA criteria through a centralized portal on the Med-QUEST Division website. The specific documents include HTML pages detailing PA requirements for various drugs and services, as well as PDFs listing prior-authorization codes and criteria. For instance, the document titled "HI_FFS_Pharmacy_PA_Criteria.html" provides detailed PA criteria for medications like Actiq and Abraxane. The state also maintains a list of prior-authorization codes in documents such as "Prior Auth PC Codes CY 2025.pdf," which includes CPT codes for services like behavioral assessments (e.g., 0359T, 0364T/0365T) and psychological testing (e.g., 96101-96121). These documents are updated periodically to reflect changes in criteria or new services. ## 3. HI's CMS-0057-F and PA-reform compliance posture Hawaii has a specific legislative act, Act 151, Session Laws of Hawaii 2025 (HB250 CD1), which pertains to the gold-card law but does not explicitly detail its compliance with CMS-0057-F or other PA reforms. The state's Medicaid program is structured under an 1115 waiver known as Hawaii QUEST Integration, which includes carve-ins for Long-Term Services and Supports (LTSS) delivered through QUEST Integration MCOs. The state has not explicitly mentioned its compliance with CMS-0057-F in the provided documents. However, given the centralized PA criteria layer and the detailed documentation available on the Med-QUEST Division website, it is likely that Hawaii adheres to federal guidelines for PA processes. The state's focus on detailed PA criteria and documentation suggests a strong commitment to ensuring medical necessity and appropriate utilization of services. ## 4. How HI runs its own program Hawaii's Medicaid program is managed through QUEST Integration (HI QI), which includes five MCOs covering primary health, behavioral health, and long-term services and supports (LTSS). The state maintains a centralized PA criteria layer despite being primarily MCO-driven, ensuring consistency across the network. The fiscal agent for Hawaii's fee-for-service (FFS) program has transitioned from ACS-Inc to Conduent/Gainwell over time. This transition is tracked to ensure that URLs and subdomains remain current and functional. The last award for QUEST Integration MCOs was in 2015, with contracts extended through an open-ended incumbent extension until a new Request for Proposal (RFP) is awarded. The state's PA process involves detailed criteria and documentation requirements for various services and drugs. For example, insulin requires medical necessity criteria and specific documentation, while hysterectomy procedures require authorization but not step therapy. The provider manual includes sections dedicated to different types of services, such as pharmacy services in Chapter 19, which outlines the need for prior authorization for specific drugs. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Centralized PA Criteria Layer**: Despite being primarily MCO-driven, Hawaii maintains a centralized layer for PA criteria, ensuring consistency across the network. - **Detailed Documentation Requirements**: The state emphasizes detailed documentation requirements for various services and drugs, such as face-to-face interactions and standardized tests for behavioral assessments. - **Regular Updates**: PA criteria documents are updated periodically to reflect changes in criteria or new services. ### What's Missing/Uncertain: - **Specific Compliance with CMS-0057-F**: There is no explicit mention of Hawaii's compliance with CMS-0057-F or other PA reforms in the provided documents. - **Foster Care Program Details**: The foster-care MCO program details are unspecified, leaving uncertainty about how these services are managed and authorized. - **Next MCO Procurement Cycle**: The next MCO procurement cycle is unknown as there is no published RFP visible as of 2026-Q1. This lack of information makes it difficult to predict future changes in the Medicaid program structure. Overall, while Hawaii has a robust PA system with detailed criteria and documentation requirements, there are gaps in information regarding specific compliance measures and future procurement cycles.