Coverage for Our Care, Our Choice Act (OCOCA) medications and visits
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Governance of Medicaid coverage, billing, and prior authorization processes for medical aid-in-dying medications and required visits under Hawaii's Our Care Our Choice Act (applies to QUEST Integration plans and Fee-For-Service Medicaid providers).
No material clinical or coverage changes in this revision.
Coverage criteria for OCOCA medications and visits
Coverage criteria for OCOCA medications and visits
Covered when ALL of the following are met:
Source: State statute and MQD memo
All visits must be billed with procedure code T1023 and modifier SE; additional visits require prior authorization
BOTH the completed DHS Form 1144B and CMS 1500 should be submitted together to MQD/Clinical Standards Office for processing
Prescribing provider must be an active Hawaii Medicaid managed care provider; dispensing pharmacy must be an active Hawaii Medicaid fee‑for‑service and managed care provider
Follow DHS Form 1144B instructions and submit both forms together to expedite processing
Only FDA-approved drugs will be reimbursed. Unapproved drugs, including foreign-made versions of FDA‑approved drugs that were not manufactured pursuant to FDA approval, will not be reimbursed.
Billing, codes, and pharmacy reporting
| T1023 | Procedure code for OCOCA visits |
| SE | Modifier required with T1023 |
| N4 | Product ID qualifier for NDC |
Provider responsibilities, documentation, and prior authorization
Prior Authorization Required (DHS Form 1144B)
Prior Authorization Required: The DHS Form 1144B must be completed and faxed to the MQD/Clinical Standards Office (MQD/CSO) along with a completed hard‑copy CMS 1500 for review and approval. Turnaround time is two (2) business days. Do NOT fax the 1144B or CMS 1500 to the Medicaid Fiscal Agent — sending to the fiscal agent will result in a delay or denial. Upon MQD/CSO approval, the approved PA and CMS 1500 will be forwarded to the fiscal agent for processing.
- Submit DHS Form 1144B (mark top: "Medications for Our Care Our Choice")
- Include completed hard‑copy CMS 1500 that matches the 1144B (drug(s), strengths, quantities)
- Fax both forms together to MQD/Clinical Standards Office for PA review
Provider action
Only FDA‑approved drugs will be reimbursed by MQD. Unapproved drugs, including foreign‑made versions of FDA‑approved drugs that were not manufactured pursuant to FDA approval, will not be reimbursed.
- Ensure prescribed medication is FDA‑approved before submitting for reimbursement
Required documentation and submission
Required documentation must be submitted together and must be complete and consistent. Incomplete forms or discrepancies between the DHS Form 1144B and the CMS 1500 will delay processing or result in denial.
- Completed DHS Form 1144B with prescribing provider sections, diagnosis, prognosis, justification, supplier section, and prescriber signature
- Completed hard‑copy CMS 1500 indicating on top: "Medications for Our Care Our Choice"
- If patient has commercial insurance, include the EOB showing denial with the CMS 1500
- Both the completed 1144B and CMS 1500 must identify and match the same drug(s), strength(s), and exact quantity(ies)
Pharmacy NDC and claim entry requirements
Pharmacy billing requirements: the dispensing pharmacy must be an active Hawaii Medicaid fee‑for‑service and managed care provider and must enter specific NDC and quantity details on the CMS 1500. Point‑of‑Service (POS) claims will be denied.
- Enter product ID qualifier N4 and the National Drug Code (NDC) in Box 24A‑E
- Provide drug name, strength, two‑character unit of measure qualifier (e.g., F2, GR, ML) and the numeric quantity dispensed to three (3) decimal places
- Use NDC numbers and NCPDP units to identify medications on the claim
- Complete Boxes 24A, 24B, 24E (add "21A" in 24E to reference diagnosis code in field 21A), 24F, 24G (days = 1) and 24J; pharmacy must sign Box 31 and complete Box 33 provider info and phone number
- Point of Service (POS) claims will be denied
OCOCA visit billing rule
Claims for OCOCA visits must use the specified procedure code and modifier. Using any other procedure code or modifier will result in denial and delay payment.
- Use Procedure Code/Modifier: T1023 SE for physician, consult, and counseling visits
- Total covered OCOCA visits are limited to five (5): three attending physician visits, one consulting physician visit, and one counseling visit
- If additional visits are needed, submit a prior authorization request to the Fiscal Agent
Policy background and scope
The Our Care Our Choice Act (OCOCA) allows terminally ill Hawaii residents with a prognosis of six months or less to voluntarily request medical aid‑in‑dying medication. Medicaid coverage and billing for OCOCA services require plans to notify in‑network providers of OCOCA requirements and the process to request and bill MQD for the required physician, consult, and counseling visits and for the self‑administered medications used by a qualified Medicaid patient.
Key definitions
Policy revision history
Hawaii law (Our Care, Our Choice Act) coverage for OCOCA became effective and Hawaii Medicaid began covering statutorily required visits and medications under Fee‑For‑Service effective January 1, 2019.
Med-QUEST Division clarified coverage and reimbursement rules: only FDA‑approved drugs will be reimbursed and unapproved/foreign‑made versions will not be reimbursed; QI plans must notify providers of OCOCA requirements and billing process.
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