---
title: "ʻOhana Health Plan ABA coverage (QUEST Integration)."
url: "https://carelu.com/payers/ohana-health-plan"
markdown_url: "https://carelu.com/payers/ohana-health-plan.md"
state: HI (Hawaii)
payer: Ohana Health Plan (WellCare of Hawaii)
kind: Medicaid managed care plan (MCO)
parent_program: Hawaii Medicaid (Med-QUEST / QUEST Integration)
description: "How ʻOhana Health Plan, WellCare’s Hawaii QUEST Integration plan, handles ABA — prior authorization on 97151–97158, the Med-QUEST benefit it delivers, and its exit from QUEST on December 31, 2026, with members moving to a new plan on January 1, 2027."
last_reviewed: September 2026
---

# ʻOhana Health Plan ABA coverage (QUEST Integration).

_Payer Guide · ʻOhana Health Plan · Last updated September 2026 · 10 primary sources_

> QUEST Integration plan run by WellCare (Centene). LEAVES QUEST on Dec 31, 2026 — members move to another plan Jan 1, 2027. PA on 97151–97158.

ʻOhana Health Plan is WellCare’s (Centene’s) QUEST Integration plan in Hawaii, and it is leaving. Med-QUEST’s March 4, 2026 memo QI-2608 says ʻOhana "does not intend to renew its QI contract beginning January 1, 2027," and ʻOhana’s provider FAQ confirms members move to another QUEST plan on January 1, 2027, after a special open enrollment on October 1–20, 2026. Until then ʻOhana delivers the Med-QUEST ABA benefit (memo QI-2431: under 21, ASD) and prior-authorizes every ABA code from 97151 through 97158.

Note the spelling: the plan writes its name with a leading ʻokina. pVerify lists it as "Ohana Health Plan (WellCare of Hawaii)", and the payer name follows that spelling.

This plan administers the **Hawaii Medicaid (Med-QUEST / QUEST Integration)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Hawaii Medicaid (Med-QUEST / QUEST Integration) guide](https://carelu.com/payers/hawaii-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — ʻOhana’s CMS-0057-F prior-authorization list (effective 12/31/2025) names "ABA Services 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158" [2]
- **Prior auth for treatment**: Required — 97153–97158 on the same list; submit through the WellCare provider portal or by fax [2][3]

## At a glance

- **Plan type:** QUEST Integration plan (WellCare / Centene)
- **Status:** Leaves QUEST December 31, 2026; members on a new plan January 1, 2027
- **Benefit source:** Med-QUEST memo QI-2431 / FFS 24-13 (IBT / ABA)
- **Prior auth:** Required on 97151–97158 (list effective 12/31/2025)
- **Claims run-out:** Services through 12/31/2026 must be billed by 12/31/2027

## The exit, and what it means for an ABA case

ʻOhana’s FAQ (approved August 14, 2026): members were to be notified in early September; the special open enrollment runs October 1–20, 2026; members who don’t choose are assigned; enrollment and transition-of-care files move to the new plans from mid-November; new coverage starts January 1, 2027. Providers should keep treating ʻOhana members through December 31, 2026. On prior authorizations, "Existing QUEST transition of care policies will apply," and members "may continue receiving those services through their new health plan without prior authorization and regardless of provider network status, consistent with applicable QUEST transition of care requirements." Claims for services through December 31, 2026 are due by December 31, 2027, and the call center stays open through then. [1][6]

For intake: an ʻOhana family starting ABA this fall should know which plan they are moving to. Get ʻOhana’s authorization for the current period, check your contract with the family’s new plan, and plan the first reauthorization with the new plan in mind. [1][6]

## Authorization while ʻOhana is the plan

ʻOhana’s CMS-0057-F prior-authorization list (effective 12/31/2025) names ABA Services 97151 through 97158, and separately lists neuropsychological and psychological testing (96112–96146). The fastest route is the WellCare provider portal; fax is also accepted, and phone only for urgent requests, which are decided within 72 hours. ʻOhana’s published 2025 QUEST metrics show 97.8% of standard requests approved, with an average of 3 days and a median of 1. The clinical rules come from Med-QUEST’s memo: diagnosis by the memo’s listed providers, a treatment plan with standardized goal measurement, 26-week periods, supervision at 1–2 hours per 10 RBT hours, and concurrent 97153/97155 billing allowed. [2][3][7]

## Intake gates

The questions that decide whether a family can start with Ohana Health Plan (WellCare of Hawaii), and what they have to bring.

- **Age limit**: Under 21 — the Med-QUEST benefit ʻOhana delivers (MQD memo). ʻOhana coverage itself ends December 31, 2026. [7][1]
- **Prior-auth decision time**: Expedited requests: "a determination within 72 hours" (ʻOhana). Standard: the federal managed-care limit of 7 calendar days for rating periods from January 1, 2026 (extendable by 14). ʻOhana’s 2025 QUEST standard average was 3 days, median 1. Continuation requests are due at least two weeks before the period ends (MQD memo). [3][9][2][7]
- **Referral required?** _(plan-dependent)_: The MQD memo lets plans require a PCP referral for the diagnostic evaluation. ʻOhana’s behavioral health page lists psychiatric and psychological evaluations as not needing prior authorization; ABA itself is controlled by PA. [7][4][2]
  - Ask the plan: ʻOhana Provider Services 1-888-846-4262 — ask whether a PCP referral is required.
- **Other insurance (who pays first)** _(plan-dependent)_: Medicaid is secondary to all other insurance (MQD memo), so ʻOhana pays after any commercial plan. Whether ʻOhana requires its own PA when secondary is not stated. TRICARE pays after other coverage except Medicaid; CHAMPVA pays last. [7][10][13][14]
  - Ask the plan: ʻOhana Provider Services 1-888-846-4262 — confirm PA requirements when ʻOhana is secondary.
- **Telehealth** _(ask the plan)_: MQD’s telehealth memo QI-2527 applies (audio-video, modifier 95/GT/GQ); ʻOhana is listed there as the contact for plan billing rules. No ʻOhana ABA telehealth rule found. [12]
  - Ask the plan: ʻOhana Provider Services 1-888-846-4262.

## Delivery and billing rules

Coverage decides whether Ohana Health Plan (WellCare of Hawaii) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Concurrent billing (97153 + 97155)** _(ask the plan)_: The MQD memo allows 97153 and 97155 concurrently when both codes’ criteria are met and they carry different modifiers. Med-QUEST’s 2024 rate-study meetings recorded that "one MCO allows billing for RBT + BCBA concurrent services; other MCOs do not" — confirm ʻOhana’s edit. [7][11]
  - Ask the plan: ʻOhana Provider Services 1-888-846-4262 — ask whether its claim edits allow 97153 + 97155 for the same time.
- **Daily limits / MUEs** _(ask the plan)_: No ʻOhana unit cap published; hours are authorized per request. The MQD memo sets no daily cap and approves hours per week for up to 26 weeks. [7][2]
  - Ask the plan: ʻOhana utilization management through the WellCare provider portal or 1-888-846-4262.

## What intake should collect for Ohana Health Plan (WellCare of Hawaii)

- **Which plan the family is moving to:** ʻOhana coverage ends December 31, 2026. Ask which plan they picked in the October 1–20 enrollment, or which one they were assigned.
- **ʻOhana member ID and QUEST enrollment:** Confirm ʻOhana is the assigned plan for the dates you are treating.
- **ASD diagnosis and age:** The Med-QUEST benefit is for members under 21 with ASD, diagnosed by one of the memo’s listed providers.
- **Assessment authorization:** 97151 and 97152 are on ʻOhana’s PA list — get the authorization before the assessment.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### Is ʻOhana Health Plan leaving QUEST?

Yes. ʻOhana leaves the QUEST program on December 31, 2026. Members pick a new plan during the October 1–20, 2026 special open enrollment or are assigned one, and new coverage starts January 1, 2027. QUEST transition-of-care rules let ongoing services continue with the new plan.

### Does ʻOhana require prior authorization for ABA?

Yes — its prior-authorization list names 97151 through 97158, including the 97151 assessment.

### Is ʻOhana Health Plan the same as WellCare?

Yes — it is WellCare’s Hawaii plan, part of Centene. Payer directories list it as "Ohana Health Plan (WellCare of Hawaii)".

## Primary sources

1. [ʻOhana Health Plan — QUEST program transition FAQ for providers (approved 8/14/2026)](https://www.ohanahealthplan.com/content/dam/centene/wellcare/hi/pdfs/provider/HI_Caid_Provider_Information_Letter_2026_R.pdf)
2. [ʻOhana Health Plan — CMS-0057-F Prior Authorization Requirements, CCS & QI (list effective 12/31/2025)](https://www.ohanahealthplan.com/content/dam/centene/wellcare/hi/pdfs/provider/HI_OhanaHP_Medicaid_CCS_QI_PriorAuthReq_R.pdf)
3. [ʻOhana Health Plan — Medicaid authorizations page](https://www.ohanahealthplan.com/providers/medicaid/authorizations.html)
4. [ʻOhana Health Plan — Medicaid behavioral health provider page (BH prior-authorization list)](https://www.ohanahealthplan.com/providers/medicaid/behavioral-health.html)
5. [ʻOhana Health Plan — QUEST Provider Quick Reference Guide (2026)](https://www.ohanahealthplan.com/content/dam/centene/wellcare/hi/pdfs/provider/HI_Caid_Quest_Provider_Quick_Reference_Guide_2026_R.pdf)
6. [Med-QUEST memo QI-2608 — Auto-assignment algorithm for QI members, March 1, 2026 to Dec 31, 2028 (ʻOhana not renewing from Jan 1, 2027)](https://medquest.hawaii.gov/content/dam/formsanddocuments/provider-memos/qi-memos/qi-memos-2026/QI-2608%20Auto%20Assignment%20draft%20memo%20update.pt_jf_RS%20lp%20ad%20m%20(part%201)%20-%20signed.pdf)
7. [Med-QUEST memo QI-2431 / FFS 24-13 (Dec 31, 2024) — Coverage of IBT for children under 21 with ASD: Guidelines for ABA (Attachments A–C)](https://medquest.hawaii.gov/content/dam/formsanddocuments/provider-memos/qi-memos/qi-memos-2024/QI-2431,%20FFS%2024-13%20Replaces%20QI-2301,%20FFS%2023-01%20Coverage%20of%20IBT%20for%20treatment%20of%20children%20under%2021%20years%20of%20age%20with%20ASD_Guidelines%20for%20ABA._FINAL%20(part%201)%20-%20signed.pdf)
8. [Med-QUEST — provider memo index (QI-2431 still the current ABA memo, checked 9/23/2026)](https://medquest.hawaii.gov/en/plans-providers/provider-memo.html)
9. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
10. [42 CFR 433.139 — Medicaid payment of claims involving third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
11. [Med-QUEST / Milliman — ABA policy and rates updates presentation (Oct 30, 2024)](https://medquest.hawaii.gov/content/dam/formsanddocuments/plans-and-providers/fee-for-service/20241030%20-%20ABA%20Policy%20and%20Rates%20Updates%20Presentation.pdf)
12. [Med-QUEST memo QI-2527 / FFS 25-12 / CCS-2509 — Telehealth Implementation (Dec 8, 2025)](https://medquest.hawaii.gov/content/dam/formsanddocuments/provider-memos/qi-memos/qi-memos-2025/QI-2527%20FFS%2025-12%20CCS-2509%20%20Telehealth%20Implementation%20-%20signed.pdf)
13. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage except Medicaid](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)
14. [38 CFR 17.270 — CHAMPVA is the last payer](https://www.ecfr.gov/current/title-38/section-17.270)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.