QUEST (Medicaid) Benefits. Form

808-973-0712 Toll-free: 1-877-973-0712 Effective July 1 2021 GUIDE to your Medicaid Be s Look inside for a complete listing of the medical services and benefits we cover for our QUEST Integration members. AlohaCare QUEST Integration 1357 Kapiolani Blvd., Ste G101 Honolulu, HI 96814

Plan and Benefit Overview and Comparison AlohaCare QUEST Integration Revision Date: July 2021 1 AlohaCare QUEST Integration Benefit Grid Primary and Acute Medical Services NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Ambulance Services  Medically necessary emergent ground and air ambulance transport services.  Air (fixed wing and air) ambulance  Ground ambulance No limit Basic Adult Dental Care  Annual exam  Cleanings  Bitewing x-rays  Periapical x-rays  Fluoride treatment  Filling or non-emergent extraction One (1) regular annual exam or comprehensive exam per year One (1) limited exam per year Two (2) cleanings per year Two (2) periapical x-rays per year Two (2) sets of bitewing x-rays per year One (1) set of full-mouth x-rays every 5 years Two (2) fluoride treatments per year One (1) filling or one (1) non-emergent extraction per year Chemotherapy  Outpatient hospital services for radiation therapy and related services, supplies and drugs. No limit Cognitive Rehabilitation  Education and training to help you with daily activities after a brain injury No limit Diagnostic Tests – Office and Outpatient  Diagnostic and therapeutic radiology and imaging  Pathology/laboratory services  Other diagnostic services/tests No limit Diabetic Supplies  Lancets  Syringes  Test strips No limit

Plan and Benefit Overview and Comparison AlohaCare QUEST Integration Revision Date: July 2021 2 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Dialysis  Dialysis in a hospital, renal dialysis facility or home setting No limit Durable Medical Equipment and Medical Supplies Equipment and supplies for medical purpose such as:  Incontinence supplies  Crutches and canes  Orthotic devices  Oxygen tanks and concentrators  Pacemakers  Prosthetics devices  Surgical dressings  Ventilators  Wheelchairs No limit Emergency Medical and Post Stabilization services For medical emergency care and care after an emergency to keep you stable. May include:  Emergency eye and hearing exams  Emergency room services  Pathology/lab services, diagnostic tests, radiology services, medical supplies and drugs within the ER visit  Physician services provided during the ER visit  Surgery and anesthesiology services provided during the ER visit No limit Family Planning Services  Education and counseling  Family planning drugs and supplies (birth control)  Office visits  Pregnancy testing  Testing for sexually transmitted diseases (STDs) No limit

Plan and Benefit Overview and Comparison AlohaCare QUEST Integration Revision Date: July 2021 3 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Foster Care/Child Welfare Services (CWS) Children  Comprehensive examinations  Development and Behavioral Assessment Services in addition to EPSDT  Medication  Pre-placement physicals No limit Habilitative Services Medically necessary services and devices to develop, improve or maintain your skills such as:  Audiology services  Occupational therapy  Physical therapy  Speech therapy  Vision services (such as augmentative communications devices, reading or visual aids) No limit Hearing Services – Hearing Aids  Hearing aids Limited to one (1) per ear every twenty-four (24) month period Hearing Services – Fitting/Orientation  Fitting/orientation Limited to two (2) every three (3) years for children Limited to one (1) every three (3) years for adults Hearing Services – Hearing Aid check  Hearing aid check Limited to four (4) per year for children 0-3 years old
Hearing Services – Routine Hearing Exams  Hearing exam Limited to one (1) exam per year Home Health Care  Audiology and speech pathology  Home health aide  Home health visits  Medical supplies and durable medical equipment  Skilled nursing  Therapeutic rehab services such as physical and occupational therapy No limit for children Some limitations apply for adults

Plan and Benefit Overview and Comparison AlohaCare QUEST Integration Revision Date: July 2021 4 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Hospice Care  Hospice provides care to terminally ill patients who are not expected to live more than six (6) months No limit Children under the age of twenty-one (21) can receive treatment to manage or cure diseases while in hospice care Immunizations  Diptheria and tetanus  Influenza  Pneumococcal  Other medically necessary vaccines No limit Inpatient Hospital Care – Medical and Surgical Services  Diagnostic tests, lab and radiology  Maternity and newborn care  Medical supplies, equipment and drugs  Nursing care  Physical therapy, occupational therapy, audiology and speech- language pathology services  Physician visits and services  Post stabilization services  Room and board  Surgery and anesthesiology services  Other medically necessary services No limit Interpretation/Translation Services  Services to help you talk to use or your doctor/caregiver  Services that we provide so you can have information in a language that you understand No limit

Plan and Benefit Overview and Comparison AlohaCare QUEST Integration Revision Date: July 2021 5 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Kapiolani Cleft Palate and Craniofacial Clinic  Audiologist services  Services provided by specialists in dentistry, oral surgery and other specialties that treat defects of the cleft palate, skull and/or face  Speech and feeding specialist services No limit Medical Nutritional Therapy  An initial nutrition and lifestyle assessment  Follow-up sessions to monitor progress Must be ordered by your PCP Up to four (4) visits per year Mosquito Repellent  Environmental Protection Agency (EPA)-registered insect repellent  DEET 25% or picaridin 20% Limited to two (2) bottles every thirty (30) days for women 14-45 years of age Nutrition Counseling  Diabetes self-management training  Nutrition counseling for obesity  Nutrition counseling for other metabolic condition if medically necessary * Limitations apply to diabetes self- management training. Oral Surgery  Medical and surgical services performed by an oral surgeon or physician No limit Outpatient Hospital Services – Outpatient Services and Ambulatory Surgical Center Services at a hospital or care center where you stay less than one day such as:  Diagnostic services  Medical supplies, equipment and drugs  Sleep laboratory services  Surgeries performed in a free- standing or hospital ambulatory surgical center  Therapeutic services  Urgent care services No limit

Plan and Benefit Overview and Comparison AlohaCare QUEST Integration Revision Date: July 2021 6 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Physician Services  Physician office and outpatient facility visit  Physician visits in the home or other residential setting No limit Practitioner Services  Behavior health provider, such as psychologists  Certified nurse midwife services  Certified substance abuse counselors  Licensed advanced practice registered nurse services including family, pediatric and psychiatric health specialists  Marriage and family therapists  Mental health counselors No limit Podiatry Services Services for the foot and ankle such as:  Bunion removal  Diabetic foot care in hospital or outpatient facility  Surgical procedures No limit Pregnancy-Related Services – Services for Pregnant Women and Expectant Parents  Breast pump (rental or purchase)  Delivery of the infant  Diagnostic tests  Inpatient hospital services  Laboratory  Lactation counseling  Outpatient hospital services related to pregnancy  Physician services  Prenatal care  Postpartum care and prenatal vitamins  Radiology  Treatment of missed, threatened and incomplete abortions  Other practitioner services No limit

Plan and Benefit Overview and Comparison AlohaCare QUEST Integration Revision Date: July 2021 7 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Prescription Drugs  Medically necessary medications  Medication management and counseling No limit Preventive Services – Adult (21 years or older)  Blood pressure  Breast cancer screening  Cervical cancer screening  Chemoprophylaxis  Colorectal cancer screening  Health education and counseling  Immunizations  Prostate cancer screening  Rubella serology or vaccine history  Total cholesterol measurements  Tuberculin skin testing  Weight/height measurements No limit Preventive Services – Children (Less than 21 years of age)  Age appropriate dental referral and oral fluoride  Age appropriate health education  EPSDT services  Hospital stay for normal, term and healthy newborn  Immunizations  Newborn screening  Other age appropriate laboratory screening tests  Screening to assess medical health status  Screening to assess developmental/behavioral and mental health status (as needed)  Tuberculin skin testing No limit

Plan and Benefit Overview and Comparison AlohaCare QUEST Integration Revision Date: July 2021 8 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Preventive Services – Pregnant Woman  Diagnostic amniocentesis, diagnostic ultrasound, fetal stress and non-stress  Diagnostic of premature labor  Health education and screening  Hospital stays  Prenatal laboratory screening tests  Prenatal visits  Prenatal vitamins including folic acid No limit Prosthetics and Orthotics  Orthotic devices  Prosthetic devices No limit Radiation Therapy  Outpatient hospital services  Related services, supplies and drugs No limit Rehabilitation Services  Occupational therapy  Physical therapy  Speech therapy No limit Sleep Laboratory Services  Diagnosis and treatment of sleep disorders No limit Smoking Cessation  Counseling  Medication At least four (4) counseling sessions per quit attempt Limited to two (2) quit attempts per year Sterilization and Hysterectomy Services  Surgical services that prevent pregnancy (sterilization) or treat a medical condition which renders the woman unable to become pregnant (hysterectomy) Must be 21 years old at the time of consent Transplants – Corneal Transplants and Bone Grafts  Corneal and bone graft transplant services No limit Transplants – Small Bowel with or without Liver  Small bowl transplant services Not a covered benefit for adults

Plan and Benefit Overview and Comparison AlohaCare QUEST Integration Revision Date: July 2021 9 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Transportation (Non-Emergent)  Meals and lodging for off-island services  Transportation for off-island or out-of service area appointments  Transportation to medically necessary covered medical appointments for members who have no means of transportation and who reside in areas not covered by public transportation or cannot access public transportation  Transportation, meals and lodging for an escort (if medically necessary)  For members under the age of 18, one escort to accompany the member to and from medically necessary visits Daily reimbursement limits apply for both adult and children amounts. Detailed itemized receipts are required. Tips for meals are not reimbursable. Urgent Care Services  Urgent care means you need medical care that is not an emergency, but needs to be taken care of within 24 hours to treat serious symptoms. No limit Vision Services – Cataract Removal  Cataract removal No limit Vision Services – Medically Necessary Eye Exams  Eye exams for medical diagnosis  Vision exams No limit Vision Services – Routine Eye Exams  Vision exams Limited to one (1) exam every twelve (12) months for children Limited to one (1) exam every twenty- four (24) months for adults

Plan and Benefit Overview and Comparison AlohaCare QUEST Integration Revision Date: July 2021 10 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Vision Services – Vision Appliances and Prosthetics  Contact lenses (vision related)*  Frames  Prescriptions lenses  Prosthetic eye Frames lenses, and contacts are limited to one every two (2) years Additional services may be available if needed Standard Behavioral Health Services Behavioral health services are provided to people who have emotional problems, mental illness or addictions to drugs, alcohol or other substances. Your doctor can refer you for behavioral health services. You can also self-refer for behavioral health services. How do I get Behavioral Health Services? You can go to any participating provider who offers behavioral health services. Hawaii law allows minors age 14 and older to consent to outpatient mental health services. A licensed therapist must be consulted and agree that the minor is able to give consent. Some services may need approval from AlohaCare before they can be provided to you. The approval and amount is based on the medical need review by AlohaCare. If you self-refer for services, we will contact you doctor/provider if prior approval is required. If your doctor refers you, we will work with your doctor in these cases. NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Ambulatory Mental Health Services  24-hour access line (CARES)  Crisis Management  Crisis residential services  Crisis stabilization  Mobile crisis response No limit Autism Spectrum Disorder  Applied Behavioral Analysis Treatment (ABA)  Screening and Diagnostic evaluations  Assessments and reassessments  Adaptive behavior treatments  Family support and training No limit Not a covered benefit for adults 21 years or older

Plan and Benefit Overview and Comparison AlohaCare QUEST Integration Revision Date: July 2021 11 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Inpatient Psychiatric Hospitalizations  Ancillary services  Diagnostic services  Medical supplies and equipment  Medications and medication management  Nursing care  Other medically necessary services  Psychiatric and other practitioner services  Room/board  Substance abuse treatment No limit Medically necessary services for substance use disorders  Inpatient substance abuse services  Outpatient substance abuse services No limit Methadone management services  Acute opiate detoxification and maintenance No limit Prescription Drugs  Medically necessary medications No limit Psychiatric or psychological evaluation and treatment  Individual and group counseling and monitoring  Neuropsychological and psychological testing No limit Psychotropic Medications and Medication Management  Counseling and education  Evaluation, prescription and maintenance of psychotropic medications  Medication management No limit

Plan and Benefit Overview and Comparison AlohaCare QUEST Integration Revision Date: July 2021 12 Home and Community Based Services NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Adult day care  Day care center where you go during the day and have supportive care and social programs not health care Based upon assessed needs Adult day health  Day programs where you get supportive care, social and nursing services. Based upon assessed needs Assisted living facility services  Services to help with personal care, homemaker, housekeeping, and meals preparation in an assisted living facility Does not include room and board is an assisted living facility setting – Based upon assessed needs Community Care Management Agency (CCMA) services  Care coordination services you receive if you live in a residential setting such as CCFFH, assisted living or Expanded adult care home. Based upon assessed needs Community Care Foster Family Home (CCFFH) services  Services such as personal care, nursing, homemaker, and housekeeping provided in a foster family home Based upon assessed needs You must be receiving ongoing CCMA services Does not include room and board in a CCFFH setting. Counseling and training  Training to help you and our caregivers with care training Based upon assessed needs Environmental accessibility adaptations  Changes to your home that are needed to keep you healthy and safe Cannot be of general utility, add to the size of your home and are based upon medical need. Based upon assessed needs

Plan and Benefit Overview and Comparison AlohaCare QUEST Integration Revision Date: July 2021 13 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Expanded-Adult Residential Care Home  Services such as personal care, nursing, homemaker, and housekeeping provided in an Expanded-Adult Residential Care Home by a care provider who lives in the home No limit You must be receiving ongoing CCMA services Home delivered meals  Healthy meals delivered directly to your home when you cannot prepare a nutritious meal without help from others. Up to two (2) meals per day based upon assessed needs Home maintenance  Services to keep your home safe and clean when you cannot clean or keep home safe without help from others. Services not part of personal assistance. Based upon assessed needs Moving assistance  Services to help you move to a new home when home is unsafe or when member can no longer stay in home. Based upon assessed needs. Non-medical transportation  Transportation to get to certain non-medical services and community activities Based up assessed needs. Members living in a CCFFH or residential care setting are not eligible for this service Personal assistance services – Level I and Level II  Services to help you with chores like light housekeeping, shopping for household items, running errands such as picking up medications, light yard work, and meal preparation along with help with bathing, dressing, walking, eating toileting and other activities to help you in your home. Based upon assessed needs Personal Emergency Response Systems (PERS)  A 24-hour service that helps you get help right away if you have an emergency. Based upon assessed needs

Plan and Benefit Overview and Comparison AlohaCare QUEST Integration Revision Date: July 2021 14 NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Expanded-Adult Residential Care Home (E-ARCH)  Services such as personal care, nursing, homemaker, and housekeeping provided in an Expanded-Adult Residential Care Home by a care provider who lives in the home Based upon assessed needs You must be receiving ongoing CCMA services Does not included room and board in an E-ARCH setting Respite care  Care services provided on a short-term basis then the person who normally provides your care cannot do so or needs a break Based upon assessed needs Skilled (or private duty) nursing  Ongoing Nursing care from a licensed nurse Based upon assessed needs Specialized medical equipment and supplies  Items that help you perform activities of daily living or are needed for life-support. These items must be of direct medical benefit as recommended by PCP. Based upon assessed needs Institutional Services NAME OF SERVICE DESCRIPTION/COVERAGE COVERAGE LIMITS Acute Waitlisted ICF/SNF  Services when you are in a hospital waiting to be moved to a skilled nursing facility Based upon meeting level of care criteria Nursing Facility (NF) Services  Daily living services when you need help from registered nursing staff 24 hours a day or for a long period of time. Based upon meeting level of care criteria Sub-acute facility services  Level of care that does not require hospital acute care, but requires more intensive skilled nursing care Based upon meeting level of care criteria Community Integration Services  Pre-tenancy and housing stabilization services for members who are 18 years of age or older. Based upon meeting eligibility criteria

We are here to help you! Call or visit us on O'ahu, Maui, Kaua'i and Hawai'i Island. Hawaii Island AlohaCare complies with applicable Federal civil rights laws and does not discriminate on the basis of: • Race • Color • National Origin • Age • Disability • Sex (English) Do you need help in another language? We will get you a free interpreter. Call 1-808-973-0712 to tell us which language you speak. (TTY: 1-877-447-5990). (Ilocano) Masapulyo kadi ti tulong iti sabali a pagsasao? Ikkandakayo iti libre nga paraipatarus. Awaganyo ti 1-808-973-0712 tapno ibagayo kadakami no ania ti pagsasao nga ar-aramatenyo. (TTY: 1-877-447-5990). (Traditional Chinese) 您需要其它語言嗎？如有需要, 請致電1-808-973-0712, 我們會提供免費翻譯服務 (TTY: 1-877-447-5990). (Korean) 다른언어로 도움이 필요하십니까? 저희가 무료로 통역을 제공합니다. 1-808-973-0712로 전화해서 사용하는 언어를 알려주십시요 (TTY: 1-877-447-5990). (Vietnamese) Bạn có cần giúp đỡ bằng ngôn ngữ khác không ? Chúng tôi sẽ yêu cầu một người thông dịch viên miễn phí cho bạn. Gọi 1-808-973-0712 nói cho chúng tôi biết bạn dùng ngôn ngữ nào. (TTY: 1-877-447-5990).