CurrentHawaii Medical Service Association (HMSA)Policy QI-2004

Coverage for Our Care, Our Choice Act (OCOCA) medications and visits

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).

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyCoverage for Our Care, Our Choice Act (OCOCA) medications and visits

Policy CodePolicy QI-2004

Change TypeNo material change

Effective DateJan 1, 2019

Next Review Date

Key ActionSubmit prior authorization using DHS Form 1144B with a matching CMS 1500 (including NDC and required pharmacy fields) faxed to MQD/Clinical Standards Office for OCOCA medication reimbursement.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5maximum OCOCA visits per patient

3attending physician visits

1consulting physician visit

1counseling provider visit

T1023 SErequired procedure code/modifier

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Coverage criteria for OCOCA medications and visits

Covered when ALL of the following are met:

Eligible patient and statutory requirements: Patient is a Hawaii resident with a terminal illness and a prognosis of six months or less, and has voluntarily requested OCOCA (Our Care, Our Choice Act) medication.

Source: State statute and MQD memo

Provider visit requirements: Patient completes up to five Medicaid-covered OCOCA visits consisting of: three (3) attending physician visits; one (1) consulting physician visit to confirm the attending physician's diagnosis and prognosis and that the patient is capable of making an informed decision; and one (1) counseling provider visit (psychiatrist, psychologist, licensed clinical social worker in mental health, or mental health APN) to assess decision-making capacity and rule out untreated depression or other conditions affecting capacity.Maximum 5 visits (3 attending, 1 consulting, 1 counseling)

All visits must be billed with procedure code T1023 and modifier SE; additional visits require prior authorization

Drug and dispensing requirements: Only FDA‑approved drugs will be reimbursed. Prescribing provider must submit DHS Form 1144B (prior authorization) and the dispensing pharmacy must submit a matching hard‑copy CMS 1500 that identifies the same drug(s) and quantities, using NDC numbers and NCPDP units; discrepancies or Point‑of‑Service (POS) claims will be denied or delayed.FDA‑approved drugs only

BOTH the completed DHS Form 1144B and CMS 1500 should be submitted together to MQD/Clinical Standards Office for processing

Provider and pharmacy enrollment: Prescribing provider and dispensing pharmacy must be active Hawaii Medicaid providers (fee‑for‑service and managed care as applicable).

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

Prior authorization and submission process: Prior authorization using DHS Form 1144B is required and must be faxed to the MQD/Clinical Standards Office along with the completed CMS 1500; prior authorization review turnaround is two business days.

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

Required visit billing code/modifierCPT | ModifierCovered

T1023	Procedure code for OCOCA visits
SE	Modifier required with T1023

Pharmacy NDC reportingHCPCS

N4	Product ID qualifier for NDC

Maximum covered OCOCA visits

Maximum covered OCOCA visits per patient5 total visits (3 attending physician + 1 consulting physician + 1 counseling provider)

Attending physician visits included3 visits

Consulting physician visit included1 visit

Counseling provider visit included1 visit

Provider responsibilities, documentation, and prior authorization

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

Note

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.

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

Qualified patient

DefinitionA Hawaii resident with a terminal illness and a prognosis of six months or less to live who voluntarily requests medical aid-in-dying medication.

Residency requirementMust be a Hawaii resident as defined by the Act.

Prognosis requirementPhysician-documented prognosis of six (6) months or less to live.

Voluntary requestPatient must voluntarily request the OCOCA medication; retains right to rescind at any time.

Counseling provider

DefinitionA psychiatrist, psychologist, licensed clinical social worker in mental health, or mental health advanced practice registered nurse practitioner who determines the patient has decision-making capacity and is not suffering from untreated depression affecting capacity.

Policy revision history

2019-01-01policy_effective

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.

2020-02-26policy_updateLatest

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.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyCoverage for Our Care, Our Choice Act (OCOCA) medications and visits

Policy CodePolicy QI-2004

Change TypeNo material change

Effective DateJan 1, 2019

Next Review Date

SourceLink

On This Page

Ensure prescribed medication is FDA‑approved before submitting for reimbursement

Documentation Required

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)

Billing Rule

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

Denial Risk

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

RoleAssess patient capacity to make medical decisions and evaluate for untreated depression or other conditions that may impair decision-making.

Accepted provider typesPsychiatrist; Psychologist; Licensed clinical social worker in mental health; Mental health APRN (advanced practice registered nurse practitioner)