11 rules0 of 36 subsections
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UNOFFICIAL 1700.1-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1700.1
DEFINITIONS
§17-1700.1-1 Purpose §17-1700.1-2 Definitions
Historical Note: This chapter is based substantially upon chapter 17-1700, section 17-1701-2 of chapter 17- 1701; 17-1702-2 of chapter 17-1702; section 17-1703-3 of chapter 17-1703; section 17-1704-2 of chapter 17- 1704; sections 17-1705-2, 17-1705-36, 17-1705-44, 17- 1705-51 and 17-1705-66 of chapter 17-1705; section 17- 1706-2 of chapter 17-1706; section 17-1721-2 of chapter 17-1721; section 17-1721.1-2 of chapter 17- 1721.1; sections 17-1722-34, 17-1722-57, 17-1722-87, 17-1722-117 and 17-1722-146 of chapter 17-1722; section 17-1722.1-2 of chapter 17-1722.1; section 17- 1722.2-2 of chapter 17-1722.2; section 17-1722.3-2 of chapter 17-1722.2; section 17-1726-2 of chapter 17- 1726; section 17-1727-2 of chapter 17-1727; section 17-1728-2 of chapter 17-1728; section 17-1728.1-2 of chapter 17-1728.1; section 17-1732-2 of chapter 17- 1732; sections 17-1736-2, 17-1736-12 and 17-1736-32 of chapter 17-1736; sections 17-1737-2, 17-1737-11, 17- 1737-27, 17-1737-90, 17-1737-100 and 17-1737-116 of chapter 17-1737; section 17-1738-2 of chapter 17-1738; section 17-1739-53 of chapter 17-1739; section 17- 1739.1-2 of chapter 17-1739.1; section 17-1739.2-1 of chapter 17-1739.2; section 17-1740.1-2 of chapter 17-
UNOFFICIAL 1700.1-2 1740.1; section 17-1741-2 of chapter 17-1741; section 17-1744-2 of chapter 17-1744; section 17-1745-2 of chapter 17-1745. [Eff 08/01/94; am 07/20/95; am 11/13/95; am 01/29/96; am 03/30/96; am 11/25/96; am 09/14/98; am 07/06/99; am 06/19/00; am 10/26/01; am 12/03/01; am 02/16/02; am 05/10/03; am 09/01/03; am 11/20/03; am 03/11/04; am 02/07/05; am 04/08/05; am 05/05/05; am 12/26/05; am 12/29/05; am 05/24/07; am 09/17/07; am 02/18/08; am 01/31/09; am 09/10/09; am 10/19/09; am 04/01/10; am 04/30/10; am 08/19/11; am 06/25/12; am 04/12/13; R 09/30/13]
§17-1700.1-1 Purpose. The purpose of this chapter is to provide the definitions for words and terminologies used throughout subtitle 12 of title 17. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §346.14; 42 C.F.R. §431.10)
§17-1700.1-2 Definitions. For the purpose of this subtitle unless the context otherwise indicates: “Abuse” means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program. “Active treatment” means a continuous program for each client as identified in an individualized plan of care: (1) For individuals with mental illness (MI) the plan shall be developed under and supervised by a physician. The prescribed components of the individualized active treatment program shall be provided by a physician or other qualified mental health professionals for the treatment of individuals who are experiencing an acute episode of severe MI which necessitates twenty-four hour
UNOFFICIAL 1700.1-3 supervision by trained mental health personnel to diagnose or reduce the individual’s psychotic or neurotic symptoms which necessitated institutionalization, to improve the individual’s level of functioning and, whenever possible, to achieve the individual’s discharge from inpatient status at the earliest possible time; (2) For individuals with intellectual disability (ID) or with related conditions, the individual program plan shall be developed and supervised by an interdisciplinary team that represents areas that are relevant to identifying the individual’s needs and to designing programs that meet the individual’s needs, and is directed towards: (A) The acquisition of the behaviors necessary for the individual to function with as much self determination and independence as possible; and (B) The prevention or deceleration of regression or loss of current optimal functional status; and (3) It does not include, in the case of a resident of a Nursing Facility (NF), services within the scope of services which the facility shall provide or arrange for its resident. “Actuarially sound” means an annuity, promissory note, or similar financial contract where no payments will be made beyond the life expectancy of the owner of the contract as determined in accordance with actuarial publications of the Office of the Chief Actuary of the Social Security Administration. “Acuity based reimbursement system” means the Medicaid reimbursement system for nursing facility (NF) level of care described in exhibit A of chapter 17-1739.2. The acuity based reimbursement system applies to acuity level A and acuity level C services, excluding services in critical access hospitals.
UNOFFICIAL 1700.1-4 “Acuity level or level of medical care” means one of the following types of inpatient services: NF or ICF-ID. “Acuity level A” means that the department has applied its standards of medical necessity and determined that an individual requires a level of medical care from a nursing facility relatively lower than acuity level C. Prior to October 1, 1990, that level of care was appropriately obtained from an ICF. “Acuity level B” means that the department has applied its standards of medical necessity and determined that an individual requires the level of medical care and special services that are appropriately obtained from an ICF/MR. “Acuity level C” means that the department has applied its standards of medical necessity and determined that an individual requires a level of medical care from a nursing facility relatively higher than acuity level A. Prior to October 1, 1990, that level of care was appropriately obtained from an SNF. “Acuity level D” means that the department has applied its standards of medical necessity and determined that an individual requires a level of medical care that is relatively higher than acuity level C, but less than acute. “Acuity ratio” means the estimated average acuity level A direct nursing costs divided by the estimated average acuity level C direct nursing costs, as determined by the department. For the FY 98 rebasing, the department has determined the ratio to be 1.00:0.8012. “Acute care services” means the short term medical treatment, usually in an acute care hospital, for individuals having an acute illness or injury. “Adequate notice” means a notice sent to an individual no later than the date of the action affecting medical eligibility that includes: (1) A statement of the action the department has taken or intends to take; (2) The reason for the intended action; (3) The specific departmental rule supporting the action;
UNOFFICIAL 1700.1-5 (4) The household's right to request a hearing; (5) The household’s right to request and obtain an interpreter or auxiliary aids as needed, and shall be provided by the department at no cost; (6) The name of the person to contact for additional information; (7) The availability of continued benefits; (8) The liability of the household for any overpayments received while awaiting a hearing if the hearing official's decision is adverse to the household; and (9) The availability of free legal representation, if applicable. “Adjusted PPS rate” means the basic PPS rate and any adjustments to that rate that are applicable to a particular provider. A formula to determine the adjusted PPS rate is defined in section 17-1739.2- 19(f). “Administrative hearing” means an administrative proceeding which affords an individual an opportunity to present an appeal of an adverse action before an impartial department representative for a formal decision. “Adult” means an individual nineteen years of age or older. “Adverse action” means denial of or failure to act with reasonable promptness on a claim for medical assistance, or the suspension, reduction, termination, or withholding of medical assistance, or an increase in spenddown or premium-share amounts. “Affordable Care Act” means the Patient Protection and Affordable Care Act (Public Law 111- 148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law 111-152). “Aged” means an applicant or beneficiary of medical assistance from the department who is at least sixty-five years old. “Aid paid pending a hearing decision” means the continuation or reinstatement of medical assistance or coverage between the date of timely request for a hearing and the date the hearing decision is made.
UNOFFICIAL 1700.1-6 “Alien” means non-citizen. “Allogenic organ or tissue” means the source of the organ or tissue is from another person. “Ancillary payment” means a per diem payment outside of the basic PPS rate to reimburse certain providers for ancillary services that they provide to residents. The payment is available only to selected providers that are incapable of billing Medicaid on an itemized fee-for-services basis at this time. The payment is not an adjustment to the basic PPS rate. “Ancillary services” mean diagnostic or therapeutic services performed by specific facility departments as distinguished from general or routine patient care such as room and board. Ancillary services generally are those special services for which charges are customarily made in addition to routine charges, and include but not limited to laboratory, radiology, and surgical services. “Annual plan change period” means a period when an eligible individual is allowed to change from one participating health plan to another participating health plan. “Annuity means” a financial contract where the purchaser is assured a scheduled amount of payments for the duration of the contract. “Antigen means any substance which is capable under appropriate conditions of inducing a specific immune response. “Applicant” means an individual who is seeking an eligibility determination for medical assistance through submission of an application or a transfer from an insurance affordability program. An applicant may be a deceased individual. “Application” means the single streamlined application for all insurance affordability programs developed by the Secretary or an alternative single streamlined application designed specifically to determine eligibility on a basis other than the applicable MAGI standard and is not more burdensome on the applicant than the (single streamlined) application.
UNOFFICIAL 1700.1-7 “Asset” means cash and any other personal property, as well as real property, that an individual or family: (1) Owns; (2) Has the right, authority, or power to convert to cash (if not already cash); and (3) Is not legally restricted from using for the individual's or family's support and maintenance. “Assignment” means assigning to the department, in writing, the right to obtain medical support and other third party payments. “Assisted living facility” means a facility, as defined in HRS section 321-15.1 that is licensed by the department of health. This facility shall consist of a building complex offering dwelling units and services to allow individuals to maintain an independent assisted living lifestyle. “Attending physician” means a medical doctor (M.D.) or a doctor of osteopathy (D.O.), authorized to practice medicine and surgery by the state, who orders and directs the services required to meet the care needs of a Medicaid beneficiary. The attending physician may be a physician from a group practice who is designated as the primary physician or an alternate physician that has been delegated the role of the attending physician by the beneficiary's initial attending physician during the physician's absence. At the time he or she elects to receive hospice care, the attending physician has the most significant role in the determination and delivery of the individual’s medical care. “Audit adjustment factor” means a reduction to the costs reported in a cost report that has not been finally settled by the department to reflect the average amount of costs that the department has historically disallowed for facilities statewide as part of the final settlement process. “Authorized representative” means an individual or organization designated by an applicant or a beneficiary in writing with the designee’s signature or by legal documentation of authority to act on
UNOFFICIAL 1700.1-8 behalf of an applicant or beneficiary, in compliance with federal and state law and regulations. Designation of an authorized representative may be requested at time of application or at other times as required and will be accepted through the same modalities as applications for medical assistance. “Base year” for: (1) Acute and long-term care services means the state fiscal year used for initial calculation and recalculation of prospective payment rates. The base year shall be the most recent State fiscal year or years for which complete, finally-settled financial data is available. Base year data shall be supplemented with finally-settled cost data from previous years, if it is determined that extraordinary costs occurred in the most recent, finally-settled cost report. The 1983 state fiscal year shall be the base year for purposes of initial calculation of prospective payment rates. (2) Federally qualified health centers and rural health clinics means the first PPS year starting January 1, 2001 and ending December 31, 2001 or any subsequent year that rates are recalculated if a rebasing is determined to be necessary. “Base year cost report” means the cost report of a provider that covers the reporting period that ends during the base year. “Baseline PPS rate” means the rate calculated for the initial or first year under PPS. “Baseline status” means that the individual reached a level of condition where no further medical adjustments are indicated except for adjustments for growth and development. “Basic Health Hawaii” means the State funded medical assistance program for non-citizens age nineteen years and older who are citizens of a COFA nation, or legal permanent residents who have resided in the United States for less than five years.
UNOFFICIAL 1700.1-9 “Basic PPS rate” means the sum of the applicable per diem amounts for the direct nursing, capital, and general and administrative components for each provider and for each level of care that the provider is certified to provide, as calculated pursuant to the methodology defined in this chapter. It does not include the various adjustments or increases to the basic PPS rate defined in this chapter. “Bed days” mean inpatient days on the Medicaid cost report. “Benchmark prescription drug plan” means the Medicare Prescription Drug Plan (PDP) or the Medicare Advantage-Prescription Drug (MA-PD) plan that meets the regional low-income benchmark premium amount established by CMS. “BENDEX” or “beneficiary data exchange system” means an automated exchange system in which the SSA transmits social security beneficiary data to the department. “Beneficiary” means an individual who has been determined eligible and is currently receiving Medicaid. “Benefit period” means the period from the first day of a month following the close of the annual plan change period and extending for a period as designated by the department. “Benefit year” means a continuous twelve month period generally following an open enrollment period. “BESSD” means the benefit, employment and support services division within the department which administers the financial assistance and supplemental nutrition assistance program (SNAP). “Blind” means an individual who has been certified blind by the Social Security Administration or by the department's vocational rehabilitation services for the blind division, Ho'opono. “Board to determine and certify mental disability” means a board of licensed psychologists or licensed physicians whose specialty is psychiatry designated and paid for by the department. “Break-even point” means the point at which a hypothetical special care percentage in the base year
UNOFFICIAL 1700.1-10 would not have resulted in the elimination of any costs due to the application of the ceiling factors in calculating the PPS rates. “CAH” or “critical access hospital” means a hospital designated and certified as a critical access hospital under the Medicare Rural Hospital Flexibility Program. “Capital component reduction factor” means a fraction with the capital cost per diem projected by a new provider to obtain its initial PPS rates as the numerator and the total projected capital, direct nursing and G&A per diem costs as the denominator. “Capital incentive adjustment” means an increase to a provider's basic PPS rate that is calculated as follows: (1) If the capital per diem cost component of the provider's basic PPS rate is in the lowest quartile of its peer group, then the incentive payment shall be thirty-five per cent of the difference between the median capital per diem cost for the peer group and the provider's capital per diem cost component; (2) If the capital per diem cost component of the provider's basic PPS rate is in the second lowest quartile of its peer group, then the incentive payment shall be twenty- five per cent of the difference between the median capital per diem cost for the peer group and the provider's capital per diem cost component; (3) Notwithstanding the foregoing, the capital incentive adjustment shall not increase a provider's capital cost component above the capital component ceiling for the applicable acuity level in the provider's peer group. “Capital related costs” means costs associated with the capital costs of the provider's facilities and equipment under Medicare principles of reimbursement. For purposes of the prospective payment methodology, capital related costs shall include depreciation, interest, property taxes, property
UNOFFICIAL 1700.1-11 insurance, capital leases and rentals, and costs and fees related to obtaining or maintaining capital related financing. “Capitated payment” means a fixed monthly payment paid per person by the department to a participating health plan for which the health plan provides a defined set of benefits and the payment may be prorated for the portion of the month for which the person was enrolled with the health plan. “Capitated rate” means the fixed monthly payment per person paid by the State to a medical, behavioral or catastrophic coverage plan. “Caretaker relative” means a relative of a dependent child by blood, adoption, or marriage, or an adult with whom the child is living, who assumes primary responsibility for the child's care (as may, but is not required to, be indicated by claiming the child as a tax dependent for Federal income tax purposes). ”Case manager” means an individual who meets the requirements specified in one of the following sections for the respective target group: (1) Section 17-1738-4(b); (2) Section 17-1738-15(b); or (3) Section 17-1738-26(b). “Cash subsidies for patient services” means, without limitation, amounts appropriated by the state legislature or a local governmental entity, either as direct subsidies or general fund allotments, and paid to the provider. “Categorically needy” refers to families and children, aged, blind, or disabled individuals, and pregnant women, described under subparts B and C of 42 C.F.R. part 435 who are eligible for Medicaid. Subpart B of 42 C.F.R. part 435 describes the mandatory eligibility groups who, generally, are receiving or deemed to be receiving cash assistance under the social security Act. These mandatory groups are specified in sections 1902(a)(10)(A)(i), 1902(e), 1902(f), and 1928 of the Social Security Act. Subpart C of 42 C.F.R. part 435 describes the optional eligibility groups of individuals who, generally, meet
UNOFFICIAL 1700.1-12 the categorical requirements or income or resource requirements that are the same as or less restrictive than those of the cash assistance programs and who are not receiving cash payments. These optional groups are specified in sections 1902(a)(10)(A)(ii), 1902(e), and 1902(f) of the Social Security Act. “CCFFH” or “community care foster family home” means a home that is certified by the department to provide an individual with twenty-four hour living accommodations and home and community based services. “C.F.R.” or “Code of Federal Regulations” means the annual codification of executive agency regulations. The C.F.R. contains the general body of regulatory laws governing practice and procedures before federal administrative agencies. “Change in circumstance” means any event, reported or unreported to the department, which alters or changes the conditions on which eligibility for benefits was last determined. A change in circumstance shall include, but shall not be limited to a change in household composition, employment, training, the source or amount of countable income, the receipt or amount of a countable resource, the beneficiary's needs, residence, or severity of disability or blindness. “Charity care” means, without limitation, care for which the provider never expected or sought payment. Charity care includes care provided pursuant to the Hill-Burton program, but excludes cash subsidies for patient services as defined above. “Citizenship” means status as a citizen of the United States, and includes status as a national of the United States as defined in 8 U.S.C. §1101(a)(22). “Claim” means that document which is submitted by the provider for payment of health-related services rendered to a beneficiary. “Claim charge data” means charges and other information obtained from billing claim forms processed by the Medicaid fiscal agent. “Clean claim” means one that can be processed without obtaining additional information from the provider of the service from a third party.
UNOFFICIAL 1700.1-13 “Clinical nurse specialist” means a registered professional nurse who is currently licensed to practice in the State and who meets one or two of the following conditions: (1) Has completed an earned graduate degree, master's degree, or doctorate related to an advanced area of clinical practice within the scope of nursing; and (2) Is currently certified as a nurse specialist by a national nursing certifying organization. “CMS” or “Centers for Medicare and Medicaid Services” means the United States federal agency which administers the Medicare program and, working jointly with State governments, the Medicaid program and the State Children's Health Insurance Program (SCHIP). “Code” means the Internal Revenue Code of 1986. “COFA nation” means the Federated States of Micronesia, Republic of the Marshall Islands, or Republic of Palau, which have entered into Compacts of Free Association with the United States. “Co-insurance” means the amount that a beneficiary or a member must pay, usually a percentage, of the cost of a service. “Collateral contact” means verification of a household's statements through a personal or telephone contact with a person outside a household. “Community setting” means the place of residence of an individual receiving long-term care services that is not a nursing facility or a medical facility. “Community spouse” means the spouse of an institutionalized individual who is not residing in a medical facility or nursing facility. “Confirmation notice” means the document the individual receives from the department confirming their enrollment in a health plan. “Consultation” means an opinion or advice requested by a practicing physician from a psychiatrist or psychologist. “Continuing care retirement community” means a residential community that offers a long-term continuing care contract, usually for a resident's
UNOFFICIAL 1700.1-14 lifetime that provides for housing, residential services and nursing care. “Contract” means a contract between a participating health plan and the department to provide medical services. “Coordinated content” means information included in an eligibility notice regarding the transfer of the individual’s or household’s electronic account to another insurance affordability program for a determination of eligibility. “Co-payment” means the amount that a beneficiary or member must pay, usually a fixed amount of the cost of a service. “Cost reports” means the forms DHS 401 of a certified FQHC or RHC with all documentation and requirements which were necessary for acceptability. “Cost-share” means the amount identified by the department as an individual's excess income available for meeting a portion of the individual's own health care cost. “Cost-sharing related to Medicare part D” means any premiums, deductibles, co-payments, co-insurance, and any cost incurred within the Part D coverage gap. “Costs” mean total finally-settled allowable costs of acute inpatient services, unless otherwise specified. “Creditable coverage” means a medical insurance or health plan that will cover the treatment of breast or cervical cancer or a pre-cancerous condition of the breast or cervix. “Custodian” means any organization or individual, not a public agency or officer, responsible for centrally locating the program manuals and making the manuals publicly accessible to a substantial number of the medical assistance beneficiary population served. The agencies and organizations shall accept responsibility for filing all amendments and changes forwarded by the department. “DAC” or “disabled adult child” means a blind or disabled individual who is age eighteen years or older and who is receiving OASDI benefits as a dependent adult child of a beneficiary who is a parent,
UNOFFICIAL 1700.1-15 stepparent, grandparent or legal guardian of the individual. “Date of hearing request” means the date of DHS' receipt of a request for a hearing by an individual or authorized representative. When there is no prior written request by the individual naming the authorized representative, the date of hearing request shall be the date the authorization is received by the department. “Day-weighted median” means a numerical value determined by arraying the per diem costs and total patient days of each nursing facility and identifying the value at which half of the patient days are represented by providers with higher costs than this value.“DD” or “developmental disabilities” means a severe, chronic disability of a person to include epilepsy, cerebral palsy, or other developmental disabilities which: (1) Is attributable to a mental or physical impairment or combination of mental and physical impairments; (2) Is manifested before the person attains the age twenty-two years; (3) Is likely to continue indefinitely; (4) Results in substantial functional limitations in three or more of the following areas of major life activity: self care; receptive and expressive language; learning; mobility; self- direction; capacity for independent living; or economic sufficiency; and (5) Reflects the person's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services which are of lifelong or extended duration and are individually planned and coordinated. “Debt” means any liquidated sum exceeding twenty- five dollars which is due and owed to the department, regardless of whether there is an outstanding judgment for that sum and whether the sum has accrued through
UNOFFICIAL 1700.1-16 contract, subrogation, tort, operation of law, or judicial or administrative judgment or order. “Debtor” means any person who owes a debt to the department. “Deemed eligible” means an individual who is automatically eligible for the Low Income Subsidy program. These individuals are those who are: (1) Eligible for both Medicare and Medicaid; (2) Supplemental security income beneficiaries; or (3) Eligible for the Medicare savings programs. “Deemed individual” means an individual who met the requirements of subchapter 4 of chapter 17-1722.3 and was allowed to enroll in Basic Health Hawaii without filing a new application for medical assistance. “Dementia” means a primary diagnosis as described in the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, Revised (DSM-III-R) with the following diagnostic criteria: (1) Demonstrable evidence of impairment in short-term or long-term memory; (2) At least one of the following: (A) Impairment of abstract thinking; (B) Impaired judgment; (C) Other disturbances of higher cortical function; and (D) Personality change; (3) The disturbance in (1) or (2) significantly interferes with work or usual social activities or relationships with others; (4) Not occurring exclusively during the course of delirium; and (5) Either: (A) Evidence from the history, physical examination, or laboratory tests, of a specific organic factor that is judged to be etiologically related to the disturbance; or (B) In the absence of such evidence, an etiologic organic factor can be presumed if the disturbance cannot be
UNOFFICIAL 1700.1-17 accounted for by any nonorganic mental disorder. “Dental allowance add-on” means a per diem amount added to the facility’s basic PPS rate for dental services rendered to the facility’s inpatients. The per diem amount will be the same for all facilities as determined by the department using historical paid dental claims data. “Department” means the department of human services of the state of Hawaii, which includes the single state agency responsible for administering the medical assistance program. “Dependent child” means a child who is under the age of nineteen years. “Dependent family member” means the child, parent, or sibling of an institutionalized individual who is residing with the community spouse, or in the home of the institutionalized individual if there is no community spouse, who may be claimed as a tax dependent under the Internal Revenue Code by the institutionalized individual or the spouse of the institutionalized individual. “DHHS” means the United States Department of Health and Human Services. “DHS” means the department of human services. “Direct supervision” means a healthcare provider able to independently provide services shall be present and available in an inpatient facility or outpatient clinic to provide assistance and direction to a healthcare provider unable to independently provide services but able to provide services under supervision. “Director” means the administrative head of the department of human services unless otherwise specifically noted. “Disabled” means an individual who has been determined disabled by the Social Security Administration or by the department's aid to the disabled review committee (ADRC). “Discharge” means the release of an individual from an acute care facility. The following events are considered discharges:
UNOFFICIAL 1700.1-18 (1) The individual is formally released from the hospital; (2) The individual is transferred to an out-of- state hospital; (3) The individual is transferred to a long-term care level or facility; (4) The individual dies while hospitalized; (5) The individual signs out against medical advice; (6) In the case of a delivery where the mother and baby are discharged at the same time, release of the mother and her baby shall be considered two discharges for payment purposes. In cases of multiple births, each baby will be considered a separate discharge; or (7) A transfer shall be considered a discharge for billing purposes but shall not be reimbursed as a full discharge except as specified in section 17-1739-70(f)(1). “Disproportionate share” adjustment means the largest of the following adjustments: (1) Divide indigent acute inpatient days by total acute inpatient days. Each percentage point or fraction thereof in excess of fifteen per cent shall be converted to a decimal and added to 1.00 to obtain the disproportionate share adjustment; (2) Calculate the facility's Medicaid utilization rate and subtract one standard deviation above the statewide mean Medicaid utilization rate. Each percentage point in excess of this standard deviation shall be converted to a decimal and added to 1.00 to obtain the disproportionate share adjustment. A calculation resulting in a fraction of a percentage point shall be rounded up to the next percentage point. When the Medicaid utilization rate equals the rate at one standard deviation point, it will be considered a fraction of a percentage point and rounded up; or
UNOFFICIAL 1700.1-19 (3) Calculate the facility's low income utilization rate and subtract twenty-five per cent. Each percentage point or fraction thereof in excess of twenty-five per cent shall be converted to a decimal and added to 1.00 to obtain the disproportionate share adjustment. “Disproportionate share provider” means a facility that meets the following tests: (1) Either: (A) Has at least two obstetricians with staff privileges at the facility who have agreed to provide obstetric services to individuals who are eligible for assistance under the Medicaid program; or (B) Did not offer nonemergency obstetric services as of December 21, 1987; and (2) Either: (A) Has indigent inpatient days equal to or greater than fifteen per cent of total acute inpatient days; (B) Has a Medicaid utilization rate equal to or greater than one standard deviation above the statewide mean Medicaid utilization rate; or (C) Has a low income utilization rate equal to or greater than twenty-five per cent. In applying the foregoing, the Medicaid and total days and revenues shall be obtained from the facility's most recently filed cost report or related financial information for the period covered by that cost report. The Supplemental Security Income days shall be determined by the department based on the most recent information obtained from the Health Care Financing Administration. All other information shall be obtained from the most recent and reliable data available at the time the computation is made. “Distinct part” means a portion of a medical institution or institutional complex (e.g. nursing
UNOFFICIAL 1700.1-20 home or a hospital) that is certified to provide long term care services. “DOH” means the department of health. “Domiciliary care facility” means a licensed adult residential care facility which provides twenty- four hour living accommodation, personal care services, and appropriate medical care to adult beneficiaries by individuals unrelated to the beneficiaries. A treatment facility providing rehabilitative treatment services shall not be a domiciliary care facility. “Domiciliary care home” means any facility which provides twenty-four-hour living accommodations, personal care services, and appropriate health care, as needed, to adult beneficiaries unable to care for themselves by individuals unrelated to the beneficiaries in licensed adult residential care homes or other care homes regulated by the department of health. A domiciliary care home does not provide rehabilitative treatment services. “DRA” means the Deficit Reduction Act of 2005 enacted on February 8, 2006. “Drug formulary” means prescribed drugs, pursuant to 42 U.S.C. 1396r(8)(d)(4), for which payment may be made by the Hawaii Medicaid program. “Dynamic care” means care for pediatric patients which includes a pattern of continuous change and growth in treatment. “EAC” or “estimated acquisition cost” means the wholesale average cost. “E-ARCH” or “expanded adult residential care home” is a facility, as defined in section 11-100.1.2 and licensed by the department of health, that provides twenty-four hour living accommodations, for a fee, to adults unrelated to the family, who require at least minimal assistance in the activities of daily living, personal care services, protection, and healthcare services, and who may need the professional health services provided in a nursing facility. “Early intervention services” means services that are defined by 20 U.S.C. section 1472 and HRS chapter 321, part XXVIII which are available for infants and
UNOFFICIAL 1700.1-21 toddlers from birth through age three who have special needs. “Earned income” means cash received or available to be received by the household which require some activity on the part of the household to produce. Examples of earned income include, but shall not be limited to, wages, jury duty income (excluding reimbursement for transportation and meals), and self- employment income, including from the sale of blood, blood plasma, and parts of the body. “Effective date of eligibility” means the date on which health care services shall be covered either through fee-for-service reimbursement by the department, its fiscal agent, or through enrollment in a participating health plan. “Effective date of enrollment” means the date as of which a participating health plan is required to provide benefits to an enrollee. “Effective income level” means the income standard applicable under Medicaid for an eligibility group, after taking into consideration any disregard of a block of income applied in determining financial eligibility for such group. “Electronic account” means an electronic file that includes all information collected and generated by the department regarding each individual's Medicaid eligibility and enrollment including any information collected or generated as part of an administrative appeal process conducted under 42 C.F.R. part 431, Subpart E, or through the Exchange appeals process conducted under 45 C.F.R. part 155, Subpart F, and including all documentation required as follows: (1) Facts to support the department's decision on an application in each applicant's case record. (2) Disposition of each individual by a finding of eligibility or ineligibility, unless: (A) There is an entry in the case record that the individual voluntarily withdrew the application, and that the department sent a notice confirming this decision;
UNOFFICIAL 1700.1-22 (B) There is a supporting entry in the case record that the individual has died; or (C) There is a supporting entry in the case record that the individual cannot be located. “Eligibility determination” means an approval or denial of eligibility for medical assistance as well as a redetermination or termination of eligibility for medical assistance. “Emergency” means a situation where a person's life or health is in imminent danger as the result of illness or injury and specialized services must be provided without delay. “Emergency medical condition” means the sudden onset of a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms substance abuse) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of emergency services or immediate medical attention to result in: (1) Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (2) Serious impairment to body functions; (3) Serious dysfunction of any bodily organ or part; (4) Serious harm to self or others due to an alcohol or drug abuse emergency; (5) Injury to self or bodily harm to others; or (6) With respect to a pregnant woman who is having contractions: (A) That there is inadequate time to effect a safe transfer to another hospital before delivery; or (B) That transfer may pose a threat to the health or safety of the woman or her unborn child. “Emergency services” means covered inpatient and outpatient services that are needed to evaluate or
UNOFFICIAL 1700.1-23 stabilize an emergency medical condition that is found to exist using a prudent layperson standard. “Employer funded” means the employer is paying the temporary disability insurance benefit directly to the individual or is paying premiums to a third party. “Encumbrance” means a financial claim or lien upon real or personal property. “Enhanced prior authorization list” means non- preferred prescription drugs which require prior authorization. “Enrollee” means an individual who has selected or been assigned by the department to be a member of a participating health plan. “Enrollment fee” means the amount an enrollee is responsible to pay that is equal to the spenddown amount for a medically needy individual or cost share amount for an individual receiving long term care services. A resident of an intermediate care facility for individuals with intellectual disabilities or a participant in the Medicaid waiver program for individuals with developmental disabilities or intellectual disabilities are exempt from the enrollment fee. “EPSDT” or “early and periodic screening, diagnosis, and treatment program” means early and periodic screening, diagnosis, and treatment services, to identify physical or mental defects in individuals, and, to provide health care, treatment, and other measures to correct or ameliorate any defects and chronic condition discovered in accordance with section 1905r of the Social Security Act. EPSDT includes services to: (1) Seek out individuals and their families and inform them of the benefits of prevention and the health services available; (2) Help the individual or family use health resources, including their own talents, effectively and efficiently; and (3) Assure the problems identified are diagnosed and treated early, before they become more complex and their treatment more costly.
UNOFFICIAL 1700.1-24 “Equity” means fair market value minus encumbrances against the property. “Equity interest in home” means the value to the property less any encumbrances. “Estate” means the real and personal property included in an estate under the State’s probate law and any other real or personal property and other assets in which the individual had any title or interest in at the time of death (to the extent of such interest). This includes assets conveyed to a survivor, heir, or assign of the deceased through joint tenancy, tenancy in common, survivorship, life estate, living trust, or other arrangements. “EW” or “eligibility worker” means an employee of the department responsible for the determination of eligibility for medical assistance. “F/S NF” means freestanding nursing facility. “Facility” means an institution that furnishes health care services to inpatients. “Fair market value” means the amount an asset is expected to sell without discount on the open market for such asset in the geographic area involved, and under the existing economic conditions. Fair market value includes valuable consideration. “Family” means for a MAGI individual or household those individuals for whom a taxpayer properly claims a deduction for a personal exemption under section 151 of the Internal Revenue Code for the taxable year. For a MAGI-excepted individual or a group of individuals, family means those individuals living in the same household, generally consisting of parents and their natural, or adoptive children under age nineteen years, grandparents and their grandchildren under age nineteen years, an adult sibling and his or her siblings under age nineteen years, a married couple and siblings under age nineteen years of either spouse, an uncle or an aunt and his or her nephews and nieces under age nineteen years, a married couple and their nephews and nieces under age nineteen years, a single adult and his or her first cousins under age nineteen years, married couples and first cousins under age nineteen years of one of the spouses, any
UNOFFICIAL 1700.1-25 combination of the preceding relationships prefixed with grand, great-grand, great, great-great, half, and step. “Family therapy” means treatment involving three or more members of the same family and shall be considered a form of group therapy. “Federal medical assistance” means medical assistance in accordance with the State plan under Title XIX or Title XXI, or in accordance with a demonstration under Title XI of the Social Security Act. “Federal Register or Fed. Reg.” means the daily publication for making available to the public federal agency regulations and other legal documents of the executive branch including proposed changes. The regulations and rules as finally approved appear thereafter in the C.F.R. “Fee-for-service” means the component within the medical assistance program that reimburses providers for each eligible service provided. “Feeding assistant” means an individual who has successfully completed a state-approved feeding assistant training program and who is paid by a nursing facility or is used under an arrangement with another agency or organization to feed nursing facility residents who have no complicated feeding problems. Complicated feeding problems include, but are not limited to, difficulty swallowing, recurrent lung aspirations, and tube or parenteral or intravenous feeding. “Financial assistance” means public assistance, except for payments for medical care, social service payments, transportation assistance, and emergency assistance under HRS section 346-65, including funds received from the federal government. “Financial institution” means any bank, savings and loan association, credit union, or other similar organization. “Fiscal agent” means an entity that processes or pays vendor claims for the Medicaid agency. “FPL” or “federal poverty level” means the Federal poverty level updated periodically in the
UNOFFICIAL 1700.1-26 Federal Register by the Secretary of Health and Human Services under the authority of 42 U.S.C. §9902(2), as in effect for the applicable budget period used to determine an individual's eligibility in the medical assistance programs. “FQHC” or “federally qualified health center” means an entity that has been determined by the Secretary of the DHHS to meet the qualifications for a federally qualified health center, as defined in section 1861(aa)(4) of the Social Security Act. “Fraud” means an intentional deception or misrepresentation made by an individual with the knowledge that the deception could result in some unauthorized benefit to that individual or some other individual. It includes any act that constitutes fraud under applicable Federal or State law. “Freestanding” means a medical institution that is not a part of a parent medical institution or a medical institution that is separated geographically from the parent medical institution. “FUL” or “federal upper limits” means the price established by the Center for Medicaid and State Operations. “Full benefit dual eligible” means an individual who is eligible for both Medicare and Medicaid. “Furnished” means items and services provided directly by, or under the direct supervision of, or ordered by, a practitioner or other individual (either as an employee or in his or her own capacity), a provider, or other supplier of services. For purposes of denial of reimbursement within this part, it does not refer to services ordered by one party but billed for and provided by or under the supervision of another. “FY 98 rebasing” means the rebasing that used the cost reports for fiscal years that ended during the state fiscal year ending June 30, 1995. The basic PPS rates that resulted from the FY 98 rebasing are effective July 1, 1997. “G&A” means general and administrative.
UNOFFICIAL 1700.1-27 “G&A incentive adjustment” means an increase to a provider's basic PPS rates that is calculated as follows: (1) If the G&A per diem cost component of the provider's basic PPS rate is in the lowest quartile of its peer group, then the incentive payment shall be thirty-five per cent of the difference between the median G&A per diem cost for the peer group and the provider's G&A per diem cost component; (2) If the G&A per diem cost component of the provider's basic PPS rate is in the second lowest quartile of its peer group, then the incentive payment shall be twenty-five per cent of the difference between the median G&A per diem cost for the peer group and the provider's G&A per diem cost component; (3) Notwithstanding the foregoing, the G&A incentive adjustment shall not increase a provider's G&A cost component above the G&A component ceiling for the applicable acuity level in the provider's peer group. “G&A small facility adjustment” means an adjustment to small F/S NF’s basic PPS rates. To qualify for this adjustment, the F/S NF must: (1) Have fifty beds or less; and (2) Have a base year facility specific G&A cost per day in excess of their facility specific G&A cost component ceiling. To calculate the adjustment, the G&A cost component of the provider’s basic PPS rate calculation is recomputed as follows: (1) A cost differential in the average base year G&A cost per day, inflated to the PPS rate year, is computed between: (A) F/S NFs with fifty beds or less, and (B) F/S NFs with more than fifty beds but less than one hundred twenty-five. (2) The provider’s G&A cost component ceiling is increased by the computed cost differential described above.
UNOFFICIAL 1700.1-28 (3) The facility specific G&A cost per day is compared with the revised ceiling to determine the revised allowable G&A cost component of the provider’s basic PPS rate. (4) The increase in the G&A portion of the provider’s PPS rate as a result of the above calculations represents the adjustment. “GET adjustment” means the adjustment to the basic PPS rate of a proprietary provider to reimburse it for gross excise taxes paid to the State of Hawaii. The GET adjustment shall be 1.04167, provided, however, that if the gross excise tax rate is increased or decreased, then the GET adjustment shall be revised accordingly. “Grandfathered capital component” means the capital component of the basic PPS rates that a new provider or a provider with new beds was receiving immediately prior to the FY 98 rebasing. “Grandfathered direct nursing and G&A adjustment” means an increase to an eligible provider's basic PPS rates calculated as follows: first, the department shall determine the provider's combined direct nursing and G&A components (including all incentives) as calculated in the FY 98 rebasing, second, the department shall determine the combined direct nursing and G&A component in the total PPS rates that the provider was receiving prior to the FY 98 rebasing for its old beds, third, the department shall increase that second amount by one-half of the inflation adjustment for FY 98, and finally, if the difference between the second amount and the first amount is a positive number, that number shall be multiplied by the ratio of the provider's old beds to its total beds. The product shall be the per diem increase to the provider's basic PPS rates. “Grandfathered PPS rate” means the total PPS rate that a provider was receiving prior to the FY 98 rebasing. “Hawaii Medicaid fee schedule” means the schedule of rate of payment for services provided by non- institutional providers of medical care.
UNOFFICIAL 1700.1-29 “HBCCCP” means the Hawaii Breast and Cervical Cancer Control Program that is implemented by the State Department of Health in the detection of breast and cervical cancer or a pre-cancerous condition of the breast or cervix. “HCBS or home and community-based services” means long-term care services provided to an individual residing in a community setting who is certified by the department to be at nursing facility level of care and would be eligible for care provided to an individual in a nursing facility or a medical facility receiving nursing facility level of care. “HCPCS” means the Healthcare Common Procedural Coding System. “Health Insurance Exchange” or “Exchange” means a governmental agency or non-profit entity that meets the applicable standards in 45 C.F.R. Part 155 and makes qualified health plans available to qualified individuals and qualified employers. Unless otherwise identified, this term refers to State Exchanges, regional Exchanges, subsidiary Exchanges, and a Federally-facilitated Exchange. “Health intervention” means an activity undertaken for the primary purpose of preventing, improving, or stabilizing a medical condition. Activities that are primarily custodial, or part of normal existence, or undertaken primarily for the convenience of the individual, family, or practitioner, are not considered health interventions. “Health outcomes” mean outcomes of medical conditions that directly affect the length or quality of a person's life. “Health plan” means a plan offered by an insurance company or other organization, which provides different health care benefit packages. “Health plan contract period” means the period of time under which a health plan is continuously operating under a contract including amendments without a new procurement. “Hearing officer” means an impartial person assigned by the department to conduct administrative hearings and to render a final decision. The hearing
UNOFFICIAL 1700.1-30 officer shall not have been directly involved in the initial determination of the action in question. “HIB” means hospital insurance benefits of the Medicare program (part A). “Histocompatibility” means the matching of the tissue so the graft will not be rejected due to the presence of incompatible antigens. “HIV/AIDS” means human immunodeficiency virus/acquired immunodeficiency syndrome, an infectious disease caused by the human immunodeficiency virus that damages the body's immune system and leads to the body's inability to fight off infection. “Home” means the property that the individual lived in and in which the individual had an equity interest, prior to becoming medically institutionalized. “Home equity” means the fair market value of an individual’s home property less financial encumbrances. “Hospice program” means a public or private organization or subdivision of either, that is primarily engaged in providing care to terminally ill individuals and is qualified as a Medicaid provider. “HRS” or “Hawaii Revised Statutes” means the official codification of all the laws of a general and permanent nature of the State of Hawaii. “ICF” means intermediate care facility. “ICF-ID” means an intermediate care facility for individuals with intellectual disabilities. “IEVS” or “income eligibility verification system” means a system of information acquisition and exchange for purposes of income and eligibility verification which meets the requirements of section 1137 of the Social Security Act (42 U.S.C. §1320b-7). “Illegal non-citizen” means a non-citizen who is not lawfully admitted for permanent residence in the United States or was admitted legally for a limited period and did not leave when that time expired. “Immediate family member” means an individual, their spouse, natural or legal children, their
UNOFFICIAL 1700.1-31 siblings, their parents, and the spouses of these family members. “Implementation date” means the date determined by the department, but no later than July 1, 2010, when participating health plans began delivering Basic Health Hawaii benefits to enrollees. “INA” means the Immigration and Nationality Act. “Income” means any monies received by an individual or household during a given month. “Indigent” means an individual who is considered eligible for Supplemental Security Income (SSI) or Medicaid, or both. “Individual” psychotherapy means a face-to-face interaction between a therapist and an individual. The term encompasses a wide variety of therapies that differ in intensity and duration. “Individualized service plan” means a written plan based upon an assessment of the individual's needs. “Inflation adjustment” means the estimate of inflation in the costs of providing nursing facility services for a particular period as estimated in the CMS Nursing Home Without Capital Market Basket as reported in the Health Care Cost Review published quarterly by Global Insight, Inc., or its successor. “Informal review” means a preliminary review conducted by department's med-QUEST eligibility office, administrative office, recovery staff, or investigations office staff at the written or oral request of an individual. An informal review is not the same as the administrative hearing. “Informed consent” means a voluntary, knowing assent given in writing. “Inpatient” means an individual who has been admitted to a medical institution as an inpatient on recommendation of a physician or dentist and who: (1) Receives room, board and professional services in the institution for a 24 hour period or longer, or (2) Is expected by the institution to receive room, board and professional services in the institution for a 24 hour period or longer
UNOFFICIAL 1700.1-32 even though the individual subsequently dies, is discharged, or is transferred to another facility and does not actually stay in the institution for 24 hours. “Inpatient acute care” means inpatient acute care as defined by a nationally accepted severity and intensity standards (for example: interqual severity and intensity screening standards) provided in a hospital. “INS” means the United States Department of Justice, Immigration and Naturalization Service. “Institution for intellectual disability” means an institution (or distinct part of an institution) that: (1) Is primarily for the diagnosis, treatment, or rehabilitation of individuals with intellectual disability or related conditions, and (2) Provides, in a protected residential setting, ongoing evaluation, planning, twenty-four hour supervision, coordination, and integration of health or rehabilitative services to help individuals function at their greatest ability. “Institution for mental diseases” means a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of individuals with mental diseases, including medical attention, nursing care and related services. Whether an institution is an institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An institution for the intellectually disabled is not an institution for mental diseases. “Institution for tuberculosis” means an institution that is primarily engaged in providing diagnosis, treatment, or care of individuals with tuberculosis, including medical attention, nursing care, and related services. Whether an institution is
UNOFFICIAL 1700.1-33 an institution for tuberculosis is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of tuberculosis, whether or not it is licensed as such. “Institution or institutional facility” means an establishment that furnishes (in single or multiple facilities) food, shelter, and some treatment or services to four or more individuals unrelated to the proprietor. “Institutionalized individual” means an individual who is or is likely to be an inpatient at a medical facility receiving nursing facility level of care, or an inpatient at a nursing facility for a continuous period of institutionalization, or a beneficiary of home and community based services. “Insufficient experience” means that a provider's base year cost report indicates that the provider delivered less than one hundred days of care at a particular acuity level in the base year. “Insurance affordability program” means a program that is one of the following: (1) A State Medicaid program under title XIX of the Social Security Act. (2) A State children's health insurance program (CHIP) under title XXI of the Social Security Act. (3) A State basic health program established under section 1331 of the Affordable Care Act. (4) A program that makes coverage in a qualified health plan through the Exchange with advance payments of the premium tax credit established under section 36B of the Internal Revenue Code available to qualified individuals. (5) A program that makes available coverage in a qualified health plan through the Exchange with cost-sharing reductions established under section 1402 of the Affordable Care Act. “Intellectual disability” means significantly subaverage general intellectual functioning resulting
UNOFFICIAL 1700.1-34 in or associated with concurrent moderate, severe, or profound impairments in adaptive behavior and manifested during the developmental period: (1) General intellectual functioning is defined as the results obtained by assessment with one or more of the individually administered general intelligence tests developed for the purpose of assessing intellectual functioning; (2) Significantly subaverage intellectual functioning is defined as approximately IQ seventy or below; (3) Adaptive behavior is defined as the effectiveness or degree with which individuals meet the standards of personal independence and social responsibility expected for age and cultural group; and (4) Developmental period is defined as the period of time between birth and the eighteenth birthday. “IRA” means an individual retirement account. “Irrevocable trust” means a trust whose term and conditions cannot be amended under any circumstances, including a court order. “Joint tenancy” means equal, undivided interest in real property by two or more individuals throughout each respective owner's life. Upon the death of an owner, title automatically passes to the surviving owner or owners. Owners may sell their interest in the property without the consent of the other owners, but in doing so will break the joint tenancy and leave the new owner as tenancy in common with the remaining owners. “Lawfully present non-citizen” means a non- citizen who (1) Is a qualified non-citizen; (2) Is in a valid nonimmigrant status, as defined in 8 U.S.C. §1101(a)(15) or otherwise under the immigration laws as defined in 8 U.S.C. §1101(a)(17); (3) Is paroled into the United States in accordance with 8 U.S.C. §1182(d)(5) for
UNOFFICIAL 1700.1-35 less than 1 year, except for an individual paroled for prosecution, for deferred inspection or pending removal proceedings; (4) Belongs to one of the following classes: (A) Granted temporary resident status in accordance with 8 U.S.C. §1160 or §1255a, respectively; (B) Granted Temporary Protected Status (TPS) in accordance with 8 U.S.C. §1254a, and individuals with pending applications for TPS who have been granted employment authorization; (C) Granted employment authorization under 8 C.F.R. §274a.12(c); (D) Family Unity beneficiaries in accordance with section 301 of Public Law 101-649, as amended; (E) Under Deferred Enforced Departure (DED) in accordance with a decision made by the President; (F) Granted Deferred Action status; (G) Granted an administrative stay of removal under 8 C.F.R. part 241; (H) Beneficiary of approved visa petition who has a pending application for adjustment of status; (5) Is an individual with a pending application for asylum under 8 U.S.C. §1158, or for withholding of removal under 8 U.S.C. §1231, or under the Convention Against Torture who: (A) Has been granted employment authorization; or (B) Is under the age of 14 and has had an application pending for at least 180 days; (6) Has been granted withholding of removal under the Convention Against Torture; (7) Is a child who has a pending application for Special Immigrant Juvenile status as described in 8 U.S.C. §1101(a)(27)(J); (8) Is lawfully present in American Samoa under the immigration laws of American Samoa; or,
UNOFFICIAL 1700.1-36 (9) Is a victim of a severe form of trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, Public Law 106-386, as amended (22 U.S.C. §7105(b)); (10) Except that an individual with deferred action under the Department of Homeland Security’s deferred action for childhood arrivals process, as described in the Secretary of Homeland Security’s June 15, 2012 memorandum, shall not be considered to be lawfully present with respect to any of the above categories in paragraphs (1) through (9) of this definition. “Legal permanent resident” means a non-citizen who is lawfully admitted as a permanent resident under the Immigration and Nationality Act. “LEP” or “limited English proficient” means an individual does not speak English as their primary language and has a limited ability to read, write, speak, or understand English. “Level A rate” means the PPS rate for care delivered by a provider to an acuity level A beneficiary in a nursing facility. “Level B rate” means the PPS rate for care delivered by a provider to an acuity level B beneficiary in ICF/ID. “Level C rate” means the PPS rate for care delivered by a provider to an acuity level C beneficiary in a nursing facility. “Level D rate” means the PPS rate for care delivered by a provider to an acuity level D beneficiary in a nursing or medical facility. “Licensed health professional” means a physician, physician assistant, nurse practitioner, physical, speech or occupational therapist, registered professional nurse, licensed practical nurse, or licensed or certified social worker. “Life care community” means a continuing care retirement community that offers an insurance-type contract and provides all levels of care. Little or no change is made in the monthly fee, regardless of the
UNOFFICIAL 1700.1-37 level of medical care required by the beneficiary, except for cost of living increases. “Life estate” means the value of a property that is allocated between the life tenant and the remainderman. “Life interest” means a type of real property ownership that gives the owner the use of the property or the right to income generated by a property during the lifetime of the owner, or both. “Life tenant” means a life estate holder who is entitled to certain property rights and the right to reside on the property for the duration of the holder's life or the life of another. “Liquid asset” means cash and any other personal property that can be quickly converted to cash. Examples are bank accounts, bonds, and stocks. “LIS” or “Low Income Subsidy program” means a program that assists with the cost of the monthly premiums and cost-sharing related to Medicare Part D. “Long-term institutional services” means services provided to an individual by a medical institution such as a nursing facility or intermediate care facility for the intellectually or developmentally disabled. “Look-back period” means the period prior to and including the month of application for medical assistance for long-term care services during which assets that were transferred for less than fair market value shall be evaluated to determine if a penalty period is applicable. “Low income benchmark premium amount” means the minimum monthly premium that is charged for the standard prescription drug coverage under Part D by the CMS approved prescription drug plans. “Low income utilization rate” means the sum of the following: (1) A fraction (expressed as a percentage)— (A) The numerator of which is the sum (for a period) of (I) the total revenue paid the hospital for individual services under a state plan under Title XIX of the Social Security Act and (II) the
UNOFFICIAL 1700.1-38 amount of the cash subsidies for individual services received directly from state and local governments; and (B) The denominator of which is the total amount of revenues of the hospital for individual services (including the amount of such cash subsidies for individual services) in the period; and (2) A fraction (expressed as a percentage)— (A) The numerator of which is the total amount of the hospital's charges for inpatient hospital services which are attributable to charity care in a period; and (B) The denominator of which is the total amount of the hospital's charges for inpatient hospital services in the hospital in the period. The numerator under subparagraph 2(A) shall not include contractual allowances and discounts (other than for indigent individuals not eligible for medical assistance under a state plan approved under Title XIX of the Social Security Act). “LTC” or “long-term care” means services provided to a beneficiary by a medical institution such as a skilled nursing facility, intermediate care facility, or an intermediate care facility for the intellectually or developmentally disabled. “LTSS” or “long-term services and supports” means services provided to a beneficiary in an inpatient medical facility receiving nursing facility level of care or to a resident of a nursing facility level of care. These facilities include assisted living facilities, expanded adult care homes, community care foster family homes, nursing facilities, and sub-acute units. “MAGI” or “modified adjusted gross income” means adjusted gross income in accordance with 26 C.F.R. §1.62-1(c) increased by— (1) Amounts excluded from gross income under 26 U.S.C. §911-3;
UNOFFICIAL 1700.1-39 (2) Tax-exempt interest the taxpayer receives or accrues during the taxable year; and (3) Social security benefits in accordance with 26 U.S.C. §86(d), not included in gross income. “MAGI-excepted individual” means an individual, whose eligibility for medical assistance does not require a determination of income by the agency, including, but not limited to individuals: (1) Receiving or deemed to be receiving SSI benefits; (2) Age sixty-five years or older when age is a condition of eligibility; (3) Whose eligibility is being determined on the basis of being blind or disabled; (4) Requesting coverage of long-term services and supports for the purpose of being evaluated for an eligibility group under which long-term care services and supports are covered; (5) Eligible for Medicare cost sharing assistance; or (6) Who is being evaluated for coverage as medically needy. “Maintenance therapy” means medical and psychiatric services provided to individuals to prevent, decline, or sustain the maintenance of their functional state. “Managed care” means a comprehensive approach to the provision of healthcare that combines clinical services and administrative procedures within an integrated, coordinated system to provide timely access to primary care and other necessary services in a cost-effective manner. “Mass change” means a change initiated by the state or federal government which affects the eligibility criteria of the entire caseload or a significant and identifiable portion of the caseload. “Medicaid” means the following federal-state programs, established and administered by the State, that provide medical care and long-term care services to eligible individuals in the State:
UNOFFICIAL 1700.1-40 (1) Medicaid under Title XIX of the Social Security Act; (2) The State children's health insurance program (CHIP) under Title XXI of the Social Security Act; and (3) The section 1115 demonstration project under Title XI of the Social Security Act (42 U.S.C. subchapters XIX, XXI, and XI). “Medicaid agency” means the single State agency designated or established by the State in accordance with 42 C.F.R. §431.10(b) to administer or supervise the administration of the state plan. “Medicaid qualifying trust” means a trust or similar legal device, established on or before August 10, 1993 by an individual or an individual's spouse under which the individual is the beneficiary of all or part of the payments from the trust and the distribution of the trust is determined by the trustee(s) permitted to exercise any discretion in the distribution to the individual. “Medicaid utilization rate” means a fraction (expressed as a percentage), the numerator of which is the hospital's number of inpatient days attributable to individuals who (for such days) were eligible for medical assistance approved under Title XIX of the Social Security Act in a period, and the denominator of which is the total number of the hospital's inpatient days in that period. “Medical assistance” means medical care and long- term care services provided to or paid for on behalf of eligible individuals through Medicaid, and state medical assistance. “Medical condition” means a disease, an illness, or an injury. A biological or psychological condition that lies within the range of normal human variation is not considered a disease, illness, or injury. “Medical education” means direct costs associated with an approved intern and resident teaching program as defined in the Medicare provider reimbursement manual, publication HIM-15.
UNOFFICIAL 1700.1-41 “Medical evaluation” means an evaluation by a physician to eliminate the possibility that the mental impairment is due to a physical illness. “Medical facility” means a facility which: (1) Is organized to provide medical care, including nursing and convalescent care; (2) Has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health needs of the individuals on a continuing basis in accordance with accepted standards; (3) Is authorized under State law to provide medical care; and (4) Is staffed by professional personnel who have clear and definite responsibility to the institution in the provision of professional medical and nursing services including adequate and continual medical care and supervision by a physician, sufficient registered nurse or licensed practical nurse supervision and services and nurse aid services to meet nursing care needs, and appropriate guidance by a physician on the professional aspects of operating the facility. “Medical institution” means an institution that: (1) Is organized to provide medical care, including nursing and convalescent care; (2) Has the necessary professional personnel, equipment, and facilities to manage the medical, nursing, and other health needs of individuals on a continuing basis in accordance with accepted standards; (3) Is authorized under State law to provide medical care; and (4) Is staffed by professional personnel who are responsible to the institution for professional medical and nursing services. The services must include adequate and continual medical care and supervision by a physician; registered nurse or licensed practical nurse supervision and services and
UNOFFICIAL 1700.1-42 nurses' aid services, sufficient to meet nursing care needs; and a physician's guidance on the professional aspects of operating the institution. “Medical necessity” means those procedures and services, as determined by the department, which are considered to be necessary and for which payment will be made. Medically necessary health interventions (services, procedures, drugs, supplies, and equipment) must be used for a medical condition. There shall be sufficient evidence to draw conclusions about the intervention's effects on health outcomes. The evidence shall demonstrate that the intervention can be expected to produce its intended effects on health outcomes. The intervention's beneficial effects on health outcomes shall outweigh its expected harmful effects. The intervention shall be the most cost- effective method available to address the medical condition. Sufficient evidence is provided when evidence is sufficient to draw conclusions, if it is peer-reviewed, is well-controlled, directly or indirectly relates the intervention to health outcomes, and is reproducible both within and outside of research settings. “Medical pensioner” means a person receiving medical assistance under the medical payments for pensioner's program. “Medically frail” includes individuals: (1) With disabling mental disorders (including children with serious emotional disturbances and adults with serious mental illness); (2) With serious and complex medical conditions; (3) With a physical, intellectual or developmental disability that significantly impairs their ability to perform 1 or more activities of daily living; or (4) With a disability determination based on criteria under the Social Security Act. “Medically institutionalized” means an individual who is an inpatient in a nursing facility, intermediate care facility for the developmentally or
UNOFFICIAL 1700.1-43 intellectually disabled, or a medical facility receiving a nursing facility level of care. “Medically needy” means families, children, aged, blind, or disabled individuals who are otherwise eligible for Medicaid, who are not mandatory or optional categorically needy, whose resources are within limits set under the State Plan, but whose income exceeds the appropriate income standard and the excess may be reduced with incurred medical or remedial expenses or both to establish Medicaid eligibility. “Medically needy income standard” means the medical standard of assistance as determined by the department in compliance with federal regulations related to the financial assistance program for an individual or household of applicable size. “Medicare” means the health care insurance program for the aged and disabled administered by the Social Security Administration under title XVIII of the Social Security Act. “Medicare Advantage – Prescription Drug (MA-PD) Plan” means a health plan approved by Medicare and run by private companies. This plan must provide all Part A and Part B services and may offer additional services including Part D drug coverage. MA-PD plans include: Medicare Preferred Provider Organizations (PPO), Medicare Health Maintenance Organizations (HMO), Medicare Private Fee-for-Service (PFFS) plans, Medicare Medical Savings Account (MSA) plans and Medicare Special Needs Plans (SNP). “Medicare Part D Prescription Drug Benefit Program” means the federal prescription benefit provided under the Medicare Modernization Act. “Medicare principles of reimbursement” means that body of accounting, cost finding, cost allocation, and cost limit principles that has developed over time in the administration of the Medicare program under Title XVIII of the Social Security Act. It includes, without limitation, the principles identified in the following authorities: (1) The Social Security Act, 42 U.S.C. §§1395 et seq.;
UNOFFICIAL 1700.1-44 (2) The regulations promulgated pursuant to that Act, including 42 C.F.R. Part 413; (3) Manuals published by the Health Care Financing Administration, including HCFA Pub. No. 15; and (4) Intermediary letters and bulletins disseminated by the Health Care Financing Administration, now known as the Centers for Medicare and Medicaid Services (CMS). “Medicare savings programs” means the Qualified Medicare Beneficiary (QMB), Specified Low Income Medicare Beneficiary (SLMB) and the Qualifying Individual (QI) programs. “Med-QUEST administrator” means the administrative head of the Med-QUEST division of the department of human services. “Med-QUEST Division” means the offices of the department of human services which oversees, administers, determines eligibility, and provides medical assistance and services for State residents. “Member” means an individual who meets all eligibility requirements of the special group, and for whom all applicable expenditure shares have been paid. “Mental illness” refers to a current primary or secondary diagnosis of a mental disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition, Revised and does not have a primary diagnosis of dementia (including Alzheimer's disease or a related disorder). “Minimum essential coverage” means coverage defined in section 5000A(f) of subtitle D of the Code, as added by section 1401 of the Affordable Care Act, and implementing regulations of such section issued by the Secretary of the Treasury. “MMA” means the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. “National accreditation organization” means, but is not limited to, the following national accreditation organizations for community mental health rehabilitative services: (1) The Council on Accreditation (COA);
UNOFFICIAL 1700.1-45 (2) The Commission on Accreditation of Rehabilitation Facilities (CARF); or (3) The Joint Committee on Accreditation of Healthcare Organizations (JCAHO). “New beds” means beds of providers that were placed into service after the implementation of the Hawaii Medicaid program's initial prospective payment system. “New provider” means a provider that does not have a cost report in the base year that reflects at least a full twelve months of operations. “NF” or “nursing facility” means a free-standing or a distinct part of a facility that is licensed and certified to provide appropriate care to individuals referred by a physician. Such individuals are those who need twenty-four hour a day assistance with the normal activities of daily living, need care provided by licensed nursing personnel and paramedical personnel on a regular, long-term basis, and may have a primary need for twenty-four hours of skilled nursing care on an extended basis and regular rehabilitation services. “Non-applicant” means an individual who is not seeking an eligibility determination for himself and is included in an individual's household to determine eligibility for an applicant or beneficiary. “Non-citizen” has the same meaning as the term alien as defined in section 101(a)(3) of the Immigration and Nationality Act (INA), (8 U.S.C. §1101(a)(3)) and includes any individual who is not a citizen or national of the United States, as defined in 8 U.S.C. §1101(a)(22). “Non-covered services” means those services not covered under the scope and content of the medical assistance program. “Non-dual eligible” means an individual who does not meet the definition of a full benefit dual eligible. “Non-returning plan” means a participating health plan that has a current, but no new contract with the department.
UNOFFICIAL 1700.1-46 “Not at risk for rapid deterioration” mean individuals who can be placed in a non-acute care setting without risk to the individuals’ health and safety. “Nurse aide” means any individual providing nursing or nursing-related services to individuals in a nursing facility but does not include an individual who: (1) Is a licensed health professional; or (2) Volunteers to provide such services without monetary compensation. “Nurse practitioner” means a registered professional nurse who is currently licensed to practice in the state, and who meets one of the following conditions for practice in a NF or ICF-ID: (1) Is currently certified as a gerontological nurse practitioner by the American Nurses' Association; (2) Has satisfactorily completed a formal one academic year educational program that: (A) Prepares registered nurses to perform an expanded role in the delivery of care in the field of gerontology or intellectual disability, whichever is appropriate; (B) Includes at least four months (in the aggregate) of classroom instruction and a component of supervised clinical practice; and (C) Awards a degree, diploma, or certificate to individuals who successfully complete the program; or (3) Has successfully completed a formal educational program (for preparing registered nurses to perform an expanded role in the delivery of care in the field of gerontology or intellectual disability, whichever is appropriate) that does not meet the above requirements of (2) of this definition, and has been functioning in an expanded role in the delivery of care in the respective fields of gerontology or
UNOFFICIAL 1700.1-47 intellectual disability for a total of twelve months during the eighteen month period immediately preceding the effective date of appointment as a nurse practitioner by the facility administrator. “Nursing facility level of care” means the determination that a member requires the services of licensed nurses in an institutional setting to carry out the physician’s planned regimen for total care. These services can be provided in the home or in community-based programs as a cost-neutral, least restrictive alternative to institutional care in a hospital or nursing facility. “OASDI” means old-age, survivors, and disability insurance benefits authorized under Title II of the Social Security Act and administered by the Social Security Administration. “OBRA 87” means the Omnibus Budget Reconciliation Act of 1987, Pub. L. 100-203, and its interpretive guidelines and implementing regulations. “OBRA 87 adjustment” means the adjustment to the basic PPS rate to reimburse a provider for the incremental costs of complying with OBRA 87. The OBRA 87 adjustment was paid under a prior version of this provision during the period beginning June 1, 1993, and ending June 30, 1997. “Old beds” mean the beds of a provider that were placed in service prior to the implementation of the Hawaii Medicaid program's initial prospective payment system. “Open application period” means the only period during which applications for Basic Health Hawaii shall be accepted from individuals subject to a specified duration or the statewide enrollment limit. “Operating year” means the twelve consecutive month period beginning on the latest of the following dates: (1) The effective date of the plan amendment that adds this definition to the plan; or (2) The date that a hospital becomes a provider.
UNOFFICIAL 1700.1-48 “Outlier claims” means any claim which has total charges in excess of the outlier threshold, as defined in the State Plan. “Outpatient” means an individual of an organized medical facility, or distinct part of that facility who is expected by the facility to receive and who does receive professional services for less than a twenty-four hour period regardless of the hour of admission, whether or not a bed is used, or whether or not the individual remains in the facility past midnight. “Over-utilization” means to misuse the services of one or more physicians or providers for the same or similar conditions over a period of time. “PACE” means a Program of All-Inclusive Care for the Elderly authorized by the Balanced Budget Act of 1997 that provides a comprehensive service delivery system. PACE is a demonstration project to provide an array of health related services within a capitation payment. “Parent or caretaker relative” means a person who assumes primary responsibility for the care and control of a child under age nineteen years or of an individual who is under age twenty-one years and in receipt of foster care, kinship guardianship or adoption assistance who is residing in the household and is enrolled in Medicaid. “Participating health plan” means a health plan contracted by the State to provide covered services within the service area in which the eligible individual resides that is open to receiving new members. “PCP” or “primary care provider” means a practitioner selected by the beneficiary to manage the beneficiary's utilization of health care services who is licensed in Hawaii and is: (1) A physician, either an M.D. (doctor of medicine) or a D.O. (doctor of osteopathy), and must generally be a family practitioner, general practitioner, general internist, pediatrician or obstetrician-gynecologist
UNOFFICIAL 1700.1-49 (for women, especially pregnant women) or geriatrician; (2) An advanced practice registered nurse with prescriptive authority. PCPs have the responsibility for supervising, coordinating and providing initial and primary care to enrolled individuals and for initiating referrals and maintaining the continuity of their care; or (3) A physician's assistance recognized by the State Board of Medical Examiners as a licensed physician assistant. “PDP” means prescription drug plan. “Pediatric” mean individuals from twenty-eight days to under twenty-one years of age. “Penalty period” means a period in which Medicaid will not provide coverage of long-term care services for an individual, who is otherwise eligible for Medicaid, because the individual or the individual’s spouse transferred assets for less than fair market value. “Pensioner” means a person who is receiving a pension or retirement payment from the State or counties of the State. “Periods of crisis” means a period in which the individual requires continuous care to achieve palliation or management of acute medical symptoms. “Personal property” means any asset that is not real property. “Personal reserve” means the amount of countable assets held by an individual or household while establishing or maintaining eligibility for medical assistance. “Personal reserve standard” means the maximum amount of countable assets that may be held by an individual or a household while establishing or maintaining eligibility for medical assistance. “Pharmacy provider” means every place, shop, or store fully licensed and registered under all county, state, and federal laws to dispense or sell drugs at retail, or compound physicians' prescriptions or drug
UNOFFICIAL 1700.1-50 preparations, and under the supervision of a registered pharmacist. “Physical illness” means medical conditions exclusive of those listed in the current Diagnostic and Statistical Manual of Mental Disorders. “Physician assistant” means a person who is currently approved and certified as a physician assistant by the state board of medical examiners, state department of regulatory agencies. “Post-eligibility” means the process to determine an eligible individual’s share of monthly medical expenses for an individual receiving long-term care services. “PPS” means the prospective payment system of reimbursement. “PPS rate” means the prospective payment system annual rate assigned each Medicaid institutional provider. “Practitioner” mean a licensed doctor of medicine, dentistry, osteopathy, podiatry, and any other individual licensed practitioner of health care services the department chooses to include in its Medicaid program. “Preferred drug list” means prescription drugs, within specified therapeutic classes, or that are comparatively effective, that are designated as preferred for use as determined by a committee of physicians and pharmacists and approved by the department. “Pre-paid health benefits” means health benefits available through a current health plan. “Prescription drug plan” means a plan provided by non-governmental entities under contract with the federal Centers for Medicare and Medicaid Services to provide prescription benefits under the MMA. “Pretax setoff notice” means the initial setoff notice that is sent to inform the debtor that the department intends to setoff the debtor's state income tax refund. “Primary care physician” means a physician who treats and oversees the health needs of a beneficiary.
UNOFFICIAL 1700.1-51 “Promissory note” means a written agreement signed by a person who promises to pay a specific sum of money at a specified time, or on demand, to the holder of the note. “Proprietary provider” means a for-profit provider. “Provider” means any licensed or certified person or public or private institution, agency or business concern authorized by the department to provide health care, service or supplies to individuals receiving medical assistance. “Prudent layperson” means one who possesses an average knowledge of health and medicine. “Prudent layperson standard” refers to the determination of an emergency medical condition based on the judgment of a prudent layperson. “Psychiatric care” means an established mode of practice offering the most effective and humane treatment for the acutely ill. “Psychiatric providers” means those individuals and facilities authorized to provide psychiatric services under the Medicaid program. “Psychiatric service” means psychiatric care. “Public assistance programs” means financial or medical assistance, child support, or social service programs. “Public institution” means an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control. Examples include, but shall not be limited to, jails, prisons, correctional facilities and mental hospitals. “QDWI” or “Qualified Disabled Working Individual” means an individual who: (1) Is eligible to enroll for Medicare Part A under section 1818A of the Act; (2) Has income, as determined in accordance with SSI methodologies that does not exceed two hundred per cent of the Federal poverty guidelines (as defined and revised annually by the Office of Management and Budget) for
UNOFFICIAL 1700.1-52 a family of the size of the individual's family; (3) Has resources, as determined in accordance with SSI methodologies, that do not exceed twice the relevant maximum amount established, for SSI eligibility, for an individual or for an individual and the individual’s spouse; and (4) Is not otherwise eligible for Medicaid. “QEx” means the QUEST Expanded program that delivers medical and behavioral health services through health plans employing managed care concepts, to certain individuals in accordance with the State plan under Title XIX, or in accordance with a demonstration project under Title XI of the Social Security Act. “QExA” means the QUEST Expanded Access program that delivers medical and behavioral health services through health plans employing managed care concepts, to certain individuals who are aged, blind or disabled. “QMB” or “Qualified Medicare Beneficiary” means an individual who: (1) Is entitled to Medicare Part A, with or without payment of premiums, but is not entitled solely because the individual is eligible to enroll as a QDWI; (2) Has resources, as determined in accordance with SSI methodologies, that do not exceed twice the maximum amount established for SSI eligibility; and (3) Has income, as determined in accordance with SSI methodologies that does not exceed one hundred percent of the Federal poverty guidelines. “QMB only provider” means a provider of QMB services that is not certified to participate in the Medicaid program. “QMHP” or “qualified mental health professionals” means: (1) A psychiatrist licensed to practice medicine in the State of Hawaii in accordance with
UNOFFICIAL 1700.1-53 HRS chapter 453 and who is certified or is eligible to be certified in psychiatry by the American Board of Psychiatry or Neurology; (2) A psychologist licensed in accordance with HRS chapter 465; (3) A clinical social worker in behavioral health licensed in accordance with HRS chapter 467E; (4) An advance practice registered nurse (APRN) licensed in accordance with HRS chapter 457; or (5) Any other person as determined by the department of human services. “QMRP” means a qualified mental retardation professional who has at least one year of experience working directly with individuals with developmental disabilities or intellectual disabilities as defined in HRS section 333F-1, or related conditions, and is one of the following: (1) A doctor of medicine or osteopathy; (2) A registered nurse; or (3) An individual who holds at least a bachelor's degree in a professional category. “Qualified non-citizen” means: (1) An individual who is lawfully admitted as a permanent resident under the INA (8 U.S.C. §1101 et seq); (2) An individual who is granted asylum under section 208 of the INA (8 U.S.C. §1158); (3) A refugee admitted to the United States under section 207 of the INA (8 U.S.C. §1157); (4) An individual who is paroled into the United States under section 212(d)(5) of the INA (8 U.S.C. §1182(d)(5)) for a period of at least one year; (5) An individual whose deportation is being withheld under section 243(h) of the INA (8 U.S.C. §1253) or section 241(b)(3) of the INA (8 U.S.C. §1231(b)(3));
UNOFFICIAL 1700.1-54 (6) An individual who is granted conditional entry under section 203(a)(7) of the INA (8 U.S.C. §1153(a)(7)) as in effect before April 1, 1980; (7) An individual who is a Cuban and Haitian entrant (as defined in section 501(e) of the Refugee Educational Assistance Act of 1980); (8) An individual who has been battered or subjected to extreme cruelty in the U.S. by a spouse, parent, or household member with the spouse or parent’s consent or acquiescence, including a child (without the active participation of the parent(s) in the battery or cruelty) as described in 8 U.S.C. §1641(c), and has been approved for or has a petition pending that sets forth a prima facie case to be granted status by USCIS as a battered spouse, a child, or a parent of a battered child under clauses (i), (ii), (iii) and (iv) of section 204(a)(1)(A) or clauses (i), (ii) and (iii) of section 204(a)(1)(B) of the INA, provided that the individual responsible for such battery does not reside in the same household as the individual subjected to the battery; and (9) An individual who has been granted nonimmigrant status under section 101(a)(15)(T) of the INA (8 U.S.C. §1101(a)(15)(T)) as a victim of a severe form of trafficking in individuals or who has a pending application that sets forth a prima facie case for eligibility for such nonimmigrant status, provided that the individual responsible for such cruelty does not reside in the same household as the individual subjected to the cruelty. “QUEST” or “Hawaii QUEST” means the demonstration project developed by the department which will deliver medical and behavioral health services through health plans employing managed care concepts to certain individuals formerly covered by public assistance programs, including the aid to families with dependent
UNOFFICIAL 1700.1-55 children (AFDC) and related medical programs, General Assistance (GA), and the State Health Insurance Program (SHIP). Dental coverage is provided through the fee-for-service program. “QUEST-ACE” means the QUEST-Adult Coverage Expansion program that delivers limited medical and behavioral health services through health plans employing managed care concepts. “QUEST-Net” means the program that delivers medical and behavioral health services through health plans employing managed care concepts. “Rate reconsideration” means the formal process of submitting documentation and requesting a review of the PPS rates because of extraordinary circumstances beyond the control of the provider. “RCA” or “refugee cash assistance” means cash assistance provided under section 412(e) of the Immigration and Nationality Act to refugees who are ineligible for TANF, OAA, AB, APTD, AABD, or SSI. “RCL” or “routine cost limit” means the federal routine operating cost limits. Beginning with the effective date of these rules, the routine cost limit is calculated annually using the limit in effect on June 30th of the immediately preceding fiscal year multiplied by one plus the inflation adjustment. “Real property” means land, buildings and anything else erected on or affixed to the land or buildings. “Rebasing” for: (1) Long-term care services means calculating the basic PPS rates by reference to a new base year and new base year cost reports. Rebased basic PPS rates are the end product of a rebasing. (2) Federally qualified health centers means a determination by Congress that it is necessary to select another base year to recalculate the PPS rates or make necessary refinements to the PPS rates. “Recoupment” means any formal action by the State or its fiscal agent to initiate recovery of an
UNOFFICIAL 1700.1-56 overpayment without advance official notice by reducing future payments to a provider. “Redetermination” means a determination of an individual's or household's eligibility to continue to receive program benefits. “Remainder beneficiary” means the party that is designated to receive funds from an annuity, trust or similar legal contract, after the death of the owner. “Remainderman” means an individual who is given a remainder interest in a property which he or she will inherit upon the death of the life estate holder. “Representative” means an individual's authorized representative, legal guardian, conservator, or representative payee as designated by the Social Security Administration. “Respiratory therapist” means a person qualified to perform respiratory therapy as exemplified by certification by the national board for respiratory care (NBRC) or a person experienced in the performance of respiratory therapy services who is employed by a Medicaid certified agency or provider to specifically provide respiratory therapy services. “Respiratory therapy” means the performance of preventive, maintenance, and rehabilitative airway- related techniques and procedures including application of medical gasses, humidity, and aerosols, intermittent positive pressure, continuous artificial ventilation, the administration of drugs through inhalation, individual care and instruction, and the provision of consultation to other health personnel. “Respite care” means temporary institutional, community or home-based services that allow persons who ordinarily care for the enrollee, relief from these duties. “Revocable trust” means a trust whose terms and conditions can be amended. “ROE” means return on equity. “ROE adjustment” means the adjustment to the basic PPS rate to a proprietary provider to reimburse it for return on equity, as computed and paid according to this chapter.
UNOFFICIAL 1700.1-57 “Routine services” means daily bedside care, such as room and board, serving and feeding individuals, monitoring life signs, cleaning wounds, bathing, etc. “RSDI” means retirement, survivors, and disability insurance benefits which are administered by the Social Security Administration under Title II of the Social Security Act. “RHC” or “rural health clinic” means an entity that meets the qualifications for a rural health clinic, as defined in section 1861(aa)(2) of the Social Security Act. “SDX” or “state data exchange system” means an automated exchange system in which the SSA transmits information on all individuals currently receiving SSI benefits to the department. “Section 1915(c) or §1915(c) program” means a program established under section 1915(c) of the Social Security Act that provides home and community based services to eligible individuals. “Section 1931 of the Social Security Act” means the section that was added to the Social Security Act by the Personal Responsibility and Work Opportunity Act of 1996, which established a new mandatory eligibility group of low-income families with children. “Secure electronic interface” means an interface which allows for the exchange of data between Medicaid and other insurance affordability programs and adheres to the requirements in subpart C of 42 C.F.R. part 433. “Self-employment” means the performance of services or sale of goods by an individual or a group of individuals who have the legal right to determine what must be done and how it must be done and who are not subject to the will and control of an employer. “Service agency” means an agency providing employment services funded under the refugee resettlement program. “Service area” means the geographical area defined by zip codes, census tracts, or other geographic subdivisions that is served by a
UNOFFICIAL 1700.1-58 participating health plan as defined in the health plan's contract with the department. “Severe, disabling mental illness” means a mental disorder which exhibits emotional or behavioral functioning that is so impaired as to interfere substantially with a person's capacity to remain in the community without treatment or services of a long- term or indefinite duration. This mental disability is severe and persistent, encompassing individuals with serious mental illness (SMI), serious or persistent mental illness (SPMI), or requiring support for emotional and behavioral development (SEBD), resulting in a long-term limitation of a person's functional capacities for primary activities of daily living such as interpersonal relationships, homemaking, self-care, employment, and recreation. “Shared eligibility service” means a common or shared eligibility system or service used by a State to determine individuals' eligibility for insurance affordability programs. “SHIP” means the discontinued state health insurance program that was administered by the department of health. “SHOTT” means the State of Hawaii Organ and Tissue Transplant program. “Sixty-day grace period” means the first sixty- days after the date of the confirmation notice that an enrollee has to change health plans, with or without cause, provided the health plan is not at its maximum enrollment. “SLMB” means a specified low income Medicare beneficiary who is a member of a special Medicaid coverage group. These group members are only eligible for coverage of premiums for Medicare supplementary medical insurance. “SMAC” or “State maximum allowable cost” is based on drug prices obtained from a nationally recognized comprehensive data file maintained by a vendor under contract with the Department agent. A generic drug may be considered SMAC for the pricing if there are two or more therapeutically equivalent, multi-source, non-innovator drugs with a cost difference. The SMAC
UNOFFICIAL 1700.1-59 will be based on drug status (including non-rebatable, rebatable, therapeutic equivalency rating, etc.), marketplace availability in Hawaii and cost. The drug status will be taken into account to ensure that the SMAC pricing is not influenced by the process listed for drugs. “SMI” means supplementary medical insurance, also known as part B, which provides Medicare coverage of outpatient medical services. “SMI buy-in” means the enrollment and group coverage of beneficiaries for supplementary medical insurance (part B of Medicare) and payment of monthly premiums on the beneficiaries' behalf as provided in an agreement between the State and the Centers for Medicare and Medicaid Services. “SNF” or “skilled nursing facility” means a health care institution or distinct part of an institution that is primarily engaged in providing skilled nursing care or rehabilitative services to injured, disabled, or sick individuals. “Special care percentage” means the result of dividing the Medicaid special care days for a given cost reporting period by the total Medicaid days for the same period. The days reported in the nursery cost center on the cost report shall be excluded from the calculation. “Spenddown” means the amount of an individual’s income in excess of the medically needy income standard identified by the department as available to meet a portion of the individual’s health care cost. “Sponsor” means an individual, church, civic organization, State or local government, or other group or organization which has agreed to help in the reception and initial placement of refugees in the United States and other public and private non-profit agencies, wherever. “Spouse” means an individual who is lawfully married under Hawaii law. “SSA” means the Social Security Administration. “SSI” means supplemental security income under title XVI of the Social Security Act 42 U.S.C. §§1381- 1385).
UNOFFICIAL 1700.1-60 “SSN” means the social security number issued by the SSA. “SSP” means the State supplementary payments program administered by the federal Social Security Administration under Title XVI of the Social Security Act (42 U.S.C. §1382e), paid by the State to certain aged, blind, or disabled individuals in domiciliary care living arrangements, community care foster family homes, or expanded adult residential care homes. “Standard benefits package” means the minimum benefits and services that must be provided by each participating health plan to eligible medical assistance beneficiaries. “Standard of assistance” means a State need standard, expressed in a dollar amount, against which an individual's or family's income is compared, to determine eligibility for medical assistance. “State employment service” means the employment service of the state department of labor and industrial relations. “State fiscal year” means the period July 1 through the following June 30 of consecutive calendar years. “State medical assistance” means medical care and long-term care services provided or paid for by the State on behalf of to eligible individuals who are not eligible for Medicaid. “State mental health authority” means the adult mental health division of the department of health. “State mental health/developmental disability authority” means the developmental disabilities division of the department of health. “State plan” or “Hawaii Medicaid state plan” means the document approved by DHHS that defines how Hawaii operates its Medicaid program. The state plan addresses areas of state program administration, Medicaid eligibility criteria, service coverage, and provider reimbursement. “Stream of income” means income that can be anticipated to be received more than once (e.g. rental or lease payments, royalties, annuity payments, pensions, court ordered settlements, etc.).
UNOFFICIAL 1700.1-61 “Student” means a child under age nineteen years enrolled in a public or private elementary, secondary school, or in a program of an equivalent level of vocational or technical training, or officially released by the department of education and being provided an education in the home, and a child under eighteen years of age attending a post secondary institute, such as a college, vocational school, or technical trade institute. “Sub-acute” means a level of care that is needed by an individual not requiring acute care, but who needs more intensive skilled nursing care than is provided to the majority of patients in a skilled nursing facility. “Sub-acute unit” is a facility that provides care as defined in section 17-1737-116, that is needed by an individual not requiring acute care, but who needs more intensive skilled nursing care than is provided to the majority of individuals in a nursing facility. “Subrogation” means the substitution of one creditor for another, along with transference of the claims and rights of the old creditor. “Substance abuse” means excessive use of substances that alter or impair consciousness. “Substitute direct nursing component” means adjusting the direct nursing care component used to obtain a basic PPS rate for an acuity level as follows: (1) Increasing the facility-specific level A direct nursing component by dividing that component by the acuity ratio; or (2) Decreasing the facility-specific level C direct nursing component by multiplying it by the acuity ratio; (3) In calculating the substitute direct nursing component, the acuity ratio shall be applied to the provider's direct nursing component prior to the application of the direct nursing component ceiling. “Surveillance” means the process of monitoring the delivery and utilization of covered services and items of the beneficiaries and includes the use of
UNOFFICIAL 1700.1-62 itemized data and statistics to establish norms of care in order to detect improper or illegal utilization practices. “Survivor” means the lawfully married spouse, parent, natural and legally adopted child, grandparent, grandchild, great-grandparent, great grandchild, and any subsequent grandparent or grandchild with the designation 'great,' of a deceased beneficiary. “Suspension” means that items or services furnished by a specified provider who has been convicted of a program-related offense in a Federal, State, or local court will not be reimbursed under Medicaid. “Targeted case management services” means services which will assist certain individuals in gaining access to needed medical, social, educational, and other services. “Tax dependent” means an individual for whom another individual claims a deduction for a personal exemption under section 151 of the Internal Revenue Code for a taxable year. “Tax setoff” means the interception and retention of state income tax refund to recover a delinquent debt. “Tax setoff notice” means the notice that is sent at the time the debt is setoff against the debtor's state income tax refund. “Temporarily absent” means the child or caretaker relative is not present in the home for a period not to exceed sixty days, and from the date of departure there was a planned date of return. “Tenancy” means the right to possession of real property or otherwise, permanently or temporarily, with or without title to the property. “Tenancy in common” means ownership of property by two or more individuals whose undivided interests in the property may not be proportionate. The owners may sell their interest without the consent of the other owners. “Tenancy by the entirety” means the ownership of real or personal property by two individuals through
UNOFFICIAL 1700.1-63 marriage, civil union, or reciprocal beneficiary agreements at the same time through the same legal document. The right of survivorship is automatic. Neither individual can convey their interest in the property without the consent of the other individual. The ownership changes to tenancy in common with the dissolution of the marriage, civil union or reciprocal beneficiary agreement. “Terminally ill” means a medical prognosis that an individual's life expectancy is six months or less. “Termination for providers” means an exclusion of a provider from participation in the Hawaii medical assistance program by revoking the provider’s billing privileges and the provider has exhausted all applicable appeal rights or the timeline for appeal has expired. Termination is not for a specified period of time and the providers will be required to reenroll with the applicable program if they wish billing privileges to be reinstated. “Third party” means any individual, entity or program that is or may be liable to pay all or part of the expenditures for medical assistance. “Third party resource” means any resource or benefits from any source to which an eligible person may be entitled. “Title IV” means Title IV-D of the Social Security Act, child support enforcement program. “Title XX” means Title XX of the Social Security Act (42 U.S.C. §1397). “Total PPS rate” means the basic PPS rate plus all applicable adjustments, additions or increases to that rate that are defined and authorized in this chapter. “TPL” means a third party liability. “TPQY” or “third party query” request means a manual system in which the department requests SSA beneficiary or SSI information from the SSA. “Transition period end date” means, for purposes of Basic Health Hawaii, the last day of the second month following the implementation date. “Transplantation” means the grafting of organs and tissues taken from the individual's own body or
UNOFFICIAL 1700.1-64 from another for the purpose of replacing diseased tissues or diseased organ. “Transportation” means travel or transfer by taxicab, air and ground ambulance, out-of-state or inter-island airline to, from, or between medical facilities and other providers. “UCC” or “utilization control committee” means the committee that controls admissions and continued stay in acute hospital facilities based on the utilization control plan approved by the federal government for Hawaii's medical assistance program. “Unclaimed body” means a deceased person for whom no legally responsible individual has been identified and no one has assumed responsibility for disposition. “Unearned income” means cash received or available to be received by the household which is not classified as earned income. “Upper limit” means the limit on aggregate payments to providers imposed by 42 C.F.R. §447.272. “UR” means utilization review of inpatient long- term institutional services provided to beneficiaries in an ICF-ID to determine whether continued stay at the specific level of care is appropriate. “URC” means the utilization review committee, which is a group composed of one or more physicians and other health care professionals that conducts utilization review. “U.S.” means the United States of America. “U.S.C.” or “United States Code” means the official codification of all the laws of a general and permanent nature of the United States. “USCIS” means the United State Citizenship and Immigration Services, Department of Homeland Security. “Valuable consideration” means the value that an individual receives in exchange for the individual’s interest in an asset, some act, object, service, or other benefit which has a tangible or intrinsic value to the individual that is equivalent to or greater than the value of the transferred asset. “Vendor” means a third party provider who receives payment directly from the department in
UNOFFICIAL 1700.1-65 return for services or goods rendered on behalf of the individual. “Vendor payments” mean payments made by invoice billing or purchase order for valid services rendered to eligible individuals. “Verification” means the use of third party information or documentation to establish the accuracy of statements from an individual. “Visit” means a face-to-face encounter between an eligible beneficiary who is an individual receiving covered health care items or services from a FQHC or RHC, and either: (1) A health care professional; or (2) Another person who delivers health care services incident to the health care professional's practice. Encounters with more than one health care professional and multiple encounters with the same health care professional that take place on the same day and at a single location constitute a single visit, except when the individual, after the first encounter, suffers illness or injury requiring additional diagnosis or treatment. “Visiting consultant” means a Medicaid provider who has expertise or knowledge in a specific area and generally recognized by the community as a specialist and this expertise or service is not readily available on a particular island. Included as a visiting consultant are specialists who are requested by other providers to render second opinions or to participate in the medical treatment of Medicaid beneficiaries. “Voluntary resettlement agency” means a private, non-profit organization contracted by the federal government to provide initial resettlement services to refugees. “Wait-listed patient” means an individual who no longer requires acute care and is awaiting placement to a long-term care facility. “Wholesale average cost” means the wholesale acquisition cost (WAC) which is defined as the list price paid by a wholesaler, distributor and other direct accounts for drugs purchased from the
UNOFFICIAL 1700.1-66 wholesaler’s supplier. Generally, it is the price set by the manufacturer of drug before any rebates, discounts, allowances or other price concessions are offered by the supplier of the product. [Eff 09/30/13] (Auth: HRS §§88-4, 231-51 to 231-59, 325-101, 346-10, 346-12, 346-14, 346-15, 346-26, 346- 29, 346-37, 346-37(c) and (e), 346-44, 346-53, 346-56, 346-59, 346-59.4, 346-70, 346-71, 346D-2; 42 C.F.R. §§400.203, 405.1020, 423.774, 423.904, 430.25, 431.10, 431.18, 431.201, 431.301, 431.625, 433.36, 433.136, 433.138, 433.145, 433.146, 433.147, 435.4, 435.110, 435.112 to 435.117, 435.145, 435.150, 435.170, 435.213 to 435.215, 435.220, 435.222, 435.223, 435.226, 435.227, 435.229, 435.301, 435.310, 435.406, 435.601, 435.845, 435.1008, 435.1009, 440.2, 440.40, 440.50, 440.150, 440.230, 440.255, 447.250(a), 447.252, 455.2, 483.35; 45 C.F.R. §§206.10, 400.2; 8 U.S.C. §1641; 42 U.S.C. §§1383c(c), 1395 et seq., 1395i-2a, 1396(a), 1396(b), 1396a(a)(10)(A)(ii), 1396a(a)(10)(E), 1396d(p)(1)(B), 1396d(p)(2)(A), 1396n, 1396p, 1396r-5, 1396r, 1396u-1) (Imp: HRS §§88-4, 231-51 to 231-59, 325-101, 346-10, 346-12, 346-14, 346-15, 346-26, 346-29, 346-37, 346-37(c) and (e), 346-44, 346-53, 346-56, 346-59, 346-59.4, 346-70, 346-71, 346D-2; 42 C.F.R. §§400.203, 405.1020, 423.774, 423.904, 430.25, 431.10, 431.18, 431.201, 431.301, 431.625, 433.36, 433.136, 433.138, 433.145, 433.146, 433.147, 435.4, 435.110, 435.112 to 435.117, 435.145, 435.150, 435.170, 435.213 to 435.215, 435.220, 435.222, 435.223, 435.226, 435.227, 435.229, 435.301, 435.310, 435.406, 435.601, 435.845, 435.1008, 435.1009, 440.2, 440.40, 440.50, 440.150, 440.230, 440.255, 447.250(a), 447.252, 455.2, 483.35; 45 C.F.R. §§206.10, 400.2; 8 U.S.C. §1641; 42 U.S.C. §§1383c(c), 1395 et seq., 1395i-2a, 1396(a), 1396(b), 1396a(a)(10)(A)(ii), 1396a(a)(10)(E), 1396d(p)(1)(B), 1396d(p)(2)(A), 1396n, 1396p, 1396r-5, 1396r, 1396u-1)
UNOFFICIAL 1701-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12 MED-QUEST DIVISION
CHAPTER 1701
AVAILABILITY AND COST OF DEPARTMENT PROGRAM MANUALS
§17-1701-1 Purpose §17-1701-2 Definitions §17-1701-3 Availability of program manuals §17-1701-4 Cost of program manuals
Historical Note: This chapter is based substantially upon chapter 17-604. [Eff 7/19/82; R 3/19/93]
§17-1701-1 Purpose. The purpose of this chapter shall be to define the conditions under which the department shall make its program manuals available to the public, and to establish the costs of copies. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §91-5; 42 C.F.R. §431.18)
§17-1701-2 REPEALED. [R 09/30/13]
§17-1701-3 Availability of program manuals. (a) The program manuals shall be made available to interested individuals and organizations for review, study, or reproduction on regular work days during regular office hours.
(b) Custodians shall make the program manuals available for public review.
(c) The program manuals shall also be available upon request through any med-QUEST division offices or any family and adult services division public welfare offices. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §91-5; 42 C.F.R. §431.18)
UNOFFICIAL 1701-2
§17-1701-4 Cost of program manuals. (a) The department shall deposit, without charge, fifteen copies of the program manual of rules of the department with the state publications distribution center and one copy each with the state archives and the University of Hawaii.
(b) Upon request, copies of specific sections of the program manuals shall be provided without charge to an applicant or a recipient, or the individual's legal representative who requires specific sections of the program manuals to determine whether an administrative hearing should be requested or to prepare for a hearing.
(c) Upon request, copies of the program manuals shall be provided without charge to state or county agencies and officers, and public agencies and officers outside the State. (1) State or county agencies or officers, and public agencies and officers outside the State entitled to a free copy of the department's program manuals shall be placed on the mailing list of the department's, policy and program development offices, for the additional issuances of the rules and procedures. (2) State or county agencies or officers, and public agencies and officers outside the State placed on the mailing list shall be responsible to notify the department's policy and program development offices, for any reason, when the issuances are no longer needed.
(d) Custodians, individuals, or organizations not entitled to receive free copies as specified in subsections (a), (b), and (c) shall be assessed a fee related to the current cost of reproduction and current postal rates for copies of department program manuals or specific sections of the manuals. Payment shall be in advance and shall be made by cash, money order, or certified check.
(e) The fee for reproduction shall be the minimum cost established by the Hawaii Revised Statutes, and shall be paid in advance to the department by cash, money order, or certified check.
(f) Copies shall be provided within twenty working days by med-QUEST's policy and program development office, med-QUEST eligibility office, or unit office. [Eff 08/01/94; am 07/06/99; am 06/19/00 ] (Auth: HRS §346-14; 42 C.F.R.
UNOFFICIAL 1701-3 §431.18) (Imp: HRS §§91-5, 92-21, 93-3; 42 C.F.R. §431.18)
UNOFFICIAL 1702-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12 MED-QUEST DIVISION
CHAPTER 1702
CONFIDENTIALITY
§17-1702-1 Purpose §17-1702-2 Definitions §17-1702-3 Maintenance of records §17-1702-4 Confidential information §17-1702-5 Disclosure of information to administer
the public assistance or other federal
programs §17-1702-6 Disclosure of information to individuals
or agencies §17-1702-7 Dissemination of material §17-1702-8 Penalty
Historical Note: This chapter is based substantially upon chapter 17-1301. [Eff 6/29/92; R 08/01/94 ]
§17-1702-1 Purpose. The purpose of this chapter shall be to define the conditions under which the department (DHS) may disclose information relating to applicants and recipients of medical assistance. [Eff 08/01/94 ] (Auth: HRS §§346-10, 346-14; 42 C.F.R. §431.301) (Imp: HRS §§346-10, 346-14; 42 C.F.R. §431.301)
§17-1702-2 REPEALED. [R 09/30/13]
§17-1702-3 Maintenance of records. (a) The department of human services, med-QUEST division and family and adult services division (FASD), shall keep records to document information acquired about
UNOFFICIAL 1702-2 applicants and recipients in the administration of medical assistance programs.
(b) This information shall:
(1) Substantiate the expenditure of public funds;
(2) Be kept in confidential records and files of
the med-QUEST division and FASD; and (3) Not be subject to any other law permitting inspection of public records.
(c) The applicant or recipient shall have a right to privacy and shall be informed in writing about the confidential nature of the information acquired, except as noted in section 17-1702-5. [Eff 08/01/94 ] (Auth: HRS §§346-10, 346-14) (Imp: HRS §346-10; 42 C.F.R. §431.17)
§17-1702-4 Confidential information. (a) The following information shall be confidential and shall not be used or disclosed except as provided in section 17-1702-5: (1) Names and addresses of applicants and recipients, and amounts of medical assistance provided. This includes prohibition against release of information to any federal, state, or local committee or legislative body; (2) Information related to the social and economic condition or circumstances of a
particular individual, whether or not an
applicant or recipient, including wage
information obtained from the state
department of labor or from the Social
Security Administration; (3) Department's evaluation of recorded or unrecorded information about a particular individual, whether or not an applicant or recipient; (4) Medical, psychological, or psychiatric data, whether or not an applicant or recipient; (5) Correspondence concerning a particular individual, whether or not an applicant or recipient; and (6) The name of the worker or unit in which the case is or was active.
(b) The records of any person, including all communication, or specific medical or epidemiological information contained therein, that indicates that a person has or has been tested for HIV/AIDS, shall be strictly confidential, and shall only be released in
UNOFFICIAL 1702-3 accordance with HRS section 325-101, HIV/AIDS confidentiality statute. [Eff 08/01/94 ] (Auth: HRS §§92F-18, 346-10, 346-14, 325-101, 42 C.F.R. §431.300) (Imp: HRS §§92F-14, 346-10, 325-101; 42 C.F.R. §431.305)
§17-1702-5 Disclosure of information to administer the public assistance or other federal programs. (a) The use or disclosure of any of the information specified in section 17-1702-4(a) shall be limited to the persons or purposes stipulated in this section and, unless otherwise stated, this excludes inspection of the entire case record. b) Disclosure for purposes directly connected with the administration of the medical assistance program shall be allowed: (1) To an employee of the DHS and the U.S. government in the performance of the employee’s official duties, who shall have access to the entire case record; (2) To the extent necessary to provide services and to determine eligibility or the amount of medical assistance for applicants or beneficiaries; (3) To the following, who shall be subject to the standards of confidentiality that are comparable to those of the Medicaid agency: (A) Fiscal intermediary; (B) Other individuals contracted by the Medicaid agency to provide a service; (C) Medicaid providers who require eligibility, cost share or TPL information for billing or recovery purposes; (D) Participating health plans that require eligibility, co-payment, or TPL information for billing or recovery purposes; (E) Private social service agencies, including purchase of service (POS) providers, from which a beneficiary receives services; and (F) Agencies administering programs under the Social Security Act under such titles as XVI-SSI (42 U.S.C. §§1381- 1383), IV-A AFDC (42 U.S.C.
§§630-644), or XX-Social Services (42
UNOFFICIAL 1702-4
U.S.C. §1397).
(c) Disclosure for purposes directly connected with any investigation, prosecution, or criminal or civil proceedings conducted in connection with the administration of medical assistance program shall be permitted: (1) To police departments, prosecutors' offices, the attorney general's office, the ombudsman's office, or any other state or federal agency; and
(2) For such purposes as: (A) The detection, investigation, or prosecution of violations of applicable state and federal laws of regulations in connection with these programs, including any and all aspects of theft, fraud, deception, or overpayment; (B) DHS' claims against estates of deceased recipients, or initiation of paternity and nonsupport actions by DHS under Title IV-D of the Social Security Act (42 U.S.C. §§651-662); (C) Responding to requests for information in connection with lawsuits challenging the administration of the medical assistance program; and (D) Providing information to the ombudsman's office investigating complaints about
the administration of the medical assistance program.
(d) Disclosure may be allowed for purposes of the administration of other federal or federally assisted programs which provide assistance, in cash or in kind, or services directly to individuals on the basis of need. Disclosure shall be permitted for purposes of administering programs such as: (1) Social security - supplemental security income; and (2) Hawaii housing authority for the section 8 programs and the low income housing projects.
(e) Disclosure may be allowed for purposes of an audit or similar activity, such as a financial review or review of expenditure reports, conducted in connection with the administration of the public assistance programs by any governmental entity which is authorized by law to conduct the audit or activity. [Eff 08/01/94; am 01/29/96; am 09/14/98; am 09/30/13] (Auth: HRS §§92F-18, 346-10, 346-14, 325-101; 42
UNOFFICIAL 1702-5 C.F.R. §431.301) (Imp: HRS §§346-10, 571-84, 325-101; 42 C.F.R. §431.306)
§17-1702-6 Disclosure of information to individuals or agencies. (a) Disclosure to individuals or agencies other than those specified in section 17-1702-5 shall be allowed only when a written authorization has been obtained from the applicant, the recipient, or the legal guardian of the applicant or recipient. The written authorization shall specifically include the applicant's, recipient's, or legal guardian's consent to have the information released or the record reviewed; (1) When individuals or agencies other than applicants, recipients, or legal guardians of applicants or recipients wish to obtain information, or to review a department record, the requesting party shall submit an authorization signed and dated by the applicant, recipient, or legal guardian of the applicant or recipient specifying: (A) The name of the individual or agency authorized to receive the information or to review the record, and the individual's agency connection, if any; (B) The specific information the department is authorized to release and the purpose for which the information is being sought; (C) Applicant or recipient's social security number or birthdate, and address; and (D) The expiration date, or expiration event that relates to the applicant or recipient or the purpose of the authorization, and also specifying that if no expiration date or expiration event is specified the authorization shall expire one year from the date the authorization is signed; (2) Reproduced copies of information requested shall be provided at a cost related to the cost of reproduction. When the information is required for the purpose of presenting the applicant's or recipient's administrative
UNOFFICIAL 1702-6 hearing appeal, there shall be no charge. In either case, actual postage cost shall be charged.
(b) Disclosure to persons directly connected with the administration or enforcement of programs which are required to participate in the State Income and Eligibility Verification System (IEVS). Information disclosed shall be limited to that which is required to enable IEVS operations and shall be protected from unauthorized disclosure.
(c) Disclosure to state or county law enforcement officers of the current residence and business address of a recipient, when the information is needed for: (1) An official administrative, civil, or criminal law enforcement purpose to identify a recipient as a fugitive felon or parole violator; or (2) An official purpose and the department has informed the recipient of the circumstances in which the recipient’s address may be released.
(d) The release or use of information concerning individuals applying for or receiving medical assistance shall be: (1) Limited by the provisions of section
17-1702-5; (2) Limited to the purposes for which they are furnished; (3) Subject to the standards of confidentiality of this chapter; and (4) In accordance with HRS section 325-101, HIV/AIDS confidentiality statute.
(e) The case record or information shall not be released in a judicial or administrative proceeding, either voluntarily or in response to any subpoena unless permitted by section 17-1702-5. This includes requests or subpoenas from a governmental authority, the courts, a law enforcement official, the ombudsman's office, the attorney general's office, or from any other outside source.
(f) Where disclosure is not permitted for the purpose of the administration of the medical assistance programs, the family or individual shall be informed whenever possible of a request for information from an
UNOFFICIAL 1702-7 outside source, and permission shall be obtained to meet the request. In an emergency situation, when the individual's consent for the release of information cannot be obtained, the individual shall be notified immediately. [Eff 08/01/94; am 09/14/98; am 10/21/05] (Auth: HRS §§346-10, 346-14, 325-101; 42 C.F.R. §431.300) (Imp: HRS §§92F-19; 346-10, 325-101; 42 C.F.R. §§431.305, 431.306, 45 C.F.R. §164.508)
§17-1702-7 Dissemination of material. All material sent or distributed to applicants, beneficiaries, or Medicaid providers, including material enclosed in envelopes containing checks, shall be limited to the administration of medical assistance programs. (1) Mailing or distribution of holiday greetings, general public announcements, partisan voting information, and non-citizen registration notices shall be prohibited. (2) Material relating to the health and welfare of applicants and beneficiaries, such as announcement of free medical exams, availability of surplus food, and consumer protection information may be mailed or distributed. (3) The Medicaid agency shall distribute voter registration information and registration materials as required by the National Voter Registration Act of 1993 (Pub. L. 103-931). (4) Only the names of the persons directly connected with the administration of the medical assistance programs and identified in an official capacity with the DHS shall be contained in material sent or distributed to applicants, beneficiaries, and providers. [Eff 08/01/94; am 09/30/13] (Auth: HRS §§346-10, 346-14; 42 C.F.R. §431.300) (Imp: HRS §§346-10, 346-14; 42 C.F.R. §431.307)
§17-1702-8 Penalty. (a) Any person who fails to safeguard confidential information or who violates rules governing the confidential nature of DHS
UNOFFICIAL 1702-8 information may be prosecuted for a violation. Violators shall include, but shall not be limited to: (1) Any person, including any person who acquires information through authorized inspection, who, knowing the information to have been acquired from the records or files of the
department, intentionally divulges the information other than as authorized by law; and (2) A person who intentionally and knowingly aids or abets an unauthorized person in the inspection of the records or files.
(b) If the court determines that DHS acted in a willful and intentional manner in failing to properly maintain the case record, the provisions of section 92F-17, HRS, shall apply.
(c) Any person or institution who wilfully violates any provision of the HIV/AIDS confidentiality statute shall be penalized in accordance with HRS section 325-102. [Eff 08/01/94 ] (Auth: HRS §§92F-17, 346-10, 346-14, 325-101) (Imp: HRS §§92F-11, 346-11, 346-14, 325-101; 42 C.F.R. §431.304)
UNOFFICIAL 1703.1-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1703.1
ADMINISTRATIVE APPEALS
§17-1703.1-1 Purpose §17-1703.1-2 Informal review §17-1703.1-3 Right to a hearing §17-1703.1-4 Action on request for hearing §17-1703.1-5 Payment status of medical assistance or coverage pending hearing §17-1703.1-6
Rights of the individual §17-1703.1-7 Med-QUEST Division responsibility §17-1703.1-8 Responsibility of hearing office §17-1703.1-9 Denial or dismissal of a request for hearing §17-1703.1-10 Group hearings §17-1703.1-11 Expedited hearings §17-1703.1-12 The hearing §17-1703.1-13 Hearing involving medical issues §17-1703.1-14 Hearing involving spousal support from institutionalized individuals §17-1703.1-15 Hearing decision §17-1703.1-16 Decisions pending over ninety days §17-1703.1-17 Recovery of aid paid pending §§17-1703.1-18 to 17-1703.1-22 (Reserved)
Historical Note: This chapter is based substantially upon chapter 17-1703 [Eff 08/01/94; am 01/29/96; am 09/14/98; am 7/18/83; am 9/29/86; R 09/30/13]
§17-1703.1-1 Purpose. The purpose of this chapter is to establish the administrative provisions of the department’s review and hearing process for individuals and beneficiaries dissatisfied with department or managed care health plan action or inaction. [Eff 09/30/13] (Auth: HRS §346-14)
UNOFFICIAL 1703.1-2 (Imp: HRS §§346-12, 346-14(9); 42 C.F.R §431.200)
§17-1703.1-2 Informal Review. (a) An individual may request an informal review of an adverse action from the Med-QUEST Division before or after filing a request for a hearing. However, the individual is not required to seek informal review prior to filing a request for a hearing. (b) When the oral or written request for an informal review is received by the Med-QUEST Division, the individual shall be given the opportunity to discuss reasons for the proposed adverse action and to present information to show that the proposed action is incorrect. Corrective action shall be made as necessary. If this informal review does not result in resolution, and the individual has not filed a request for a hearing, the individual may request a hearing subject to the timeliness limitations for filing requests for hearing as specified in this chapter. (c) During the informal review process, the department may use information regarding an individual obtained by the Health Insurance Exchange. [Eff 09/30/13] (Auth: HRS §346-14(9); 42 C.F.R. §431.202) (Imp: HRS §346-12)
§17-1703.1-3 Right to a hearing. (a) Every individual shall be provided an opportunity for a hearing where an adverse action affects the individual’s eligibility, benefits, services or claims. (b) Every individual shall be provided an opportunity for an expedited hearing in accordance with section 17-1703.1-11, if the time otherwise permitted as described in section 17-1703.1-15 (a)(1) or (a)(2) would jeopardize the individual’s life or health or ability to attain, maintain or regain maximum function. (c) Every individual filing for a hearing shall have the right to submit a written request naming an authorized representative for hearing purposes. The written authorization shall be received by the department before the department acknowledges any action taken by the authorized representative on the individual's behalf. (d) Every individual shall be informed in writing at the time of application denial or adverse
UNOFFICIAL 1703.1-3 action: (1) Of the individual's right to a hearing; (2) Of the method for obtaining a hearing; (3) That the individual may present the appeal independently or be represented by an authorized representative such as legal counsel, relative, friend, or any other person of the individual's choice; (4) The availability of interpreter services for a limited English proficient individual; and (5) Auxiliary aids for an individual with disabilities. [Eff 09/30/13] (Auth: HRS §346-14(9); 42 C.F.R. §431.206) (Imp: HRS §346-12; 42 C.F.R. §431.206)
§17-1703.1-4 Action on request for hearing. (a) An individual shall submit a hearing request: (1) By telephone; (2) Via mail; (3) In person; or (4) Through other commonly available electronic means. (b) The Med-QUEST Division must receive a hearing request within ninety (90) calendar days of the date of the notice for: (1) Eligibility related decisions; (2) Fee-for-service program coverage decisions; and (3) Managed care health plan coverage decisions after completion of the managed care health plan’s grievance and appeals process. If the ninetieth (90th) day falls on a weekend or holiday, the ninetieth day shall then be the first working day following the weekend or holiday. (c) Upon receipt by the hearing office, the request shall be date stamped and immediately forwarded to the Med-QUEST Division to: (1) Determine whether the request was received within the period specified in this section; (2) Enter the individual’s name, case number, and date received; (3) Verify the authority of a court appointed guardian filing on behalf of an individual through appropriate court documents. (d) If the hearing request was not filed within ninety (90) calendar days of the date the notice was sent to the individual as
UNOFFICIAL 1703.1-4 described in (b), the request shall be denied and the department shall send a notice of denial to the individual. (e) If an individual denied eligibility for Medicaid by the department files an appeal with the Health Insurance Exchange that appeal shall be treated as a request for hearing under this section. (f) When the requirements specified in section 17-1703.1-5 are met, the department shall reinstate or continue assistance. [Eff 09/30/13] (Auth: HRS §346-14(9); 42 C.F.R. §§431.221, 431.230, 431.231) (Imp: HRS §346-12; 42 C.F.R. §§431.221, 431.230, 431.231)
§17-1703.1-5 Payment status of medical assistance or coverage pending hearing. (a) The beneficiary is entitled to timely notice as to the status of medical assistance or coverage pending hearing. (b) Adequate notice that medical assistance shall be reinstated and continued shall be provided where: (1) Pertaining to eligibility or the fee-for- service program coverage denial, the beneficiary requests a hearing within fifteen (15) calendar days of the date of the adequate notice for adverse action. (2) Pertaining to a managed care health plan’s coverage denial, the beneficiary requests a hearing from the department within ten (10) calendar days of the date of the managed care health plan’s notice for adverse action, for continuation of benefits, which were ordered by an authorized provider, and the original period covered by the original authorization has not expired. (3) If the fifteenth (15th) day or tenth (10th) day as applicable falls on a weekend or holiday, the fifteenth (15th) day or tenth (10th) day as applicable shall be the first working day following the weekend or holiday. (4) If the last day of the month falls on a weekend or holiday, the last day shall be the first working day following the weekend or holiday. (c) The medical assistance or coverage
UNOFFICIAL 1703.1-5 reinstated under (b) shall continue until a hearing decision is rendered unless: (1) The beneficiary withdraws or abandons the request for hearing as specified in section 17-1703.1-9; (2) Action was due to the application or a change in state or federal law or policy; (3) Another change affecting the beneficiary’s eligibility occurs during the hearing process and the beneficiary fails to request a hearing after notice of the change; (4) The beneficiary does not request continued benefits pending a hearing decision. (5) In the case of a managed care health plan appeal, the time period or service limits of a previously authorized service has been met. (d) The department shall promptly send a notice to the beneficiary if benefits are to be reduced or discontinued pending the hearing decision for reasons other than withdrawal or abandonment of the request by the beneficiary. (e) If, while receiving aid paid pending hearing, the beneficiary: (1) Becomes eligible for a reduction of spenddown amount, or premium-share amount, the change shall be made; or (2) Sends a written request for and is denied a medical service, aid paid pending shall continue and a notice of the denial shall be sent to the beneficiary. The notice shall include a statement of the denial, reason for the denial, specific rule supporting the denial, and the person's right to appeal the decision. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§431.223, 431.223, 431.230, 431.231, 431,250) (Imp: HRS §346- 12; 42 C.F.R. §§431.223, 431.223, 431.230, 431.231, 431,250)
§17-1703.1-6 Rights of the individual. An individual with a timely appeal shall have an opportunity to: (1) Examine the electronic and physical case record as well as all documents and records to be used at the hearing at a reasonable time before the date of the hearing as well as during the hearing;
UNOFFICIAL 1703.1-6 (2) Present the case independently or with the aid of others including legal counsel; (3) Bring witnesses; (4) Request for an interpreter and shall be provided by the department during the hearing process if the individual is limited English proficient; (5) Request for auxiliary aid or services and shall be provided by the department during the hearing process if the individual is disabled; (6) Establish all pertinent facts and circumstances; (7) Advance any arguments appropriate to the issue being heard without undue interference; and (8) Question or refute any testimony or evidence, and to confront and cross examine any witness. [Eff 09/30/13] (Auth: HRS §346.14(9); 42 C.F.R. §431.242) (Imp: HRS §346-12; 42 C.F.R. §431.242)
§17-1703.1-7 Med-QUEST Division responsibility. (a) When the Med-QUEST Division assists an individual in filing for the hearing, the Med-QUEST Division shall provide the individual with an adequate notice of the individual's right to an interpreter, auxiliary aids, legal counsel, and inform the individual of legal resources in the community. (b) The Med-QUEST Division shall review all requests for a hearing to assure that all facts are properly considered. If any basis to support the grievance is found prior to the hearing, the Med-QUEST Division shall promptly take necessary corrective action. (c) The Med-QUEST Division shall determine whether the request for hearing is based on action taken by the department as a result of section 17- 1703.1-9(a). If applicable, the Med-QUEST Division shall make a recommendation to the hearing officer to deny the request. (d) The Med-QUEST Division shall be the contact during the duration of the hearing appeal process with the individual and shall immediately notify the hearing officer of any change in address or circumstances which may affect the status of the hearing. [Eff 09/30/13] (Auth: HRS §346-14(9);
UNOFFICIAL 1703.1-7 42 C.F.R. §§431.221, 431.231) (Imp: HRS §346-12; 42 C.F.R. §§431.221, 431.231)
§17-1703.1-8 Responsibility of hearing office. (a) The hearing office shall accept: (1) Any request directly submitted to the hearing office; and (2) All requests received through the Med-QUEST Division. (b) The hearing office shall acknowledge the request for the hearing through a written notice according to the provisions described in chapter 17- 1713.1 to the individual within fifteen (15) calendar days of the date of the hearing request to explain their right to: (1) Prompt administrative action; (2) Implementation of a hearing decision within ninety calendar days of the request; and (3) Receive medical assistance or any medical service which had been reduced or denied if a final decision has not been made and implemented within ninety (90) calendar days of the request and the individual is not already receiving aid paid pending. (c) Not less than fifteen (15) days prior to the hearing, the hearing office shall send a written notice in accordance with the provisions described in chapter 17-1713.1 to the individual and the Med-QUEST Division containing the following information: (1) The date, time, place, and nature of the hearing; (2) The legal authority under which the hearing is to be held; (3) The sections of the statutes and rules involved; (4) The issues involved and the basis for the department action; and (5) The individual’s right to retain legal counsel. (6) The individual’s right to request an interpreter or auxiliary aids, if required and shall be provided by the department at no cost. (d) When it becomes apparent to the hearing officer through facts presented by the department or other persons that the individual appealing lacks the ability or understanding to make or communicate
UNOFFICIAL 1703.1-8 decisions regarding the hearing process or to authorize another individual to act on the individual’s behalf, the hearing officer may designate one of the following persons to represent the individual in the hearing process: (1) A spouse or other adult relative who has actual custody of the individual or demonstrates a close, continuing concern for the individual’s well being; or (2) An adult friend who has demonstrated a continuing and current interest, by overt acts, in the individual’s well being. In situations in which the hearing officer questions the ability of the individual to participate in the hearing process, the hearing officer may request and authorize a medical evaluation at the department's expense before designating an authorized representative. [Eff 09/30/13] (Auth: HRS §346-14(9); 42 C.F.R. §§ 431.221, 431.244) (Imp: HRS §§91-9, 91-9.5, 346-12; 42 C.F.R. §§ 431.221, 431.244)
§17-1703.1-9 Denial or dismissal of a request for hearing. (a) A hearing shall not be granted by the department when either federal or state law requires automatic adjustment in the standard of assistance for classes of beneficiaries unless the appeal is for an incorrect determination of eligibility. (b) A hearing shall not be granted by the department when the individual has withdrawn the request in writing. Where the individual verbally communicates a desire to withdraw the hearing request through a mode of communication described in section 17-1703.1-4(a)(1) or (a)(3), the individual shall be advised that the withdrawal shall be submitted in writing or if the individual prefers, the department shall send a confirmation of the verbal request to withdraw to the individual. (c) A hearing shall not be granted by the hearing officer when the individual has abandoned the request. Abandonment occurs when the individual, without good cause, fails to appear at the hearing scheduled for the individual. (1) The hearing officer shall send the individual a letter stating that the appeal
UNOFFICIAL 1703.1-9 is considered abandoned unless there was good cause for the failure to appear. The individual shall be notified that the request shall continue only if the individual presents good cause for the failure to appear and contacts the agency within fifteen (15) calendar days of the notice. If no reply is received within the fifteen (15) calendar days, the hearing request shall be considered abandoned. If the fifteenth (15th) day falls on a weekend or holiday, the fifteenth (15th) day shall then be the first working day after the weekend or holiday. (2) Good cause may be established on the basis of one of the following factors: (A) Death in the family; (B) Personal injury or illness which reasonably prohibits the individual from attending the hearing; or (C) Sudden and unexpected emergencies. (d) When a request for a hearing is denied or dismissed, the department shall send the individual a notice in accordance with the provisions described in chapter 17-1713.1, stating the reasons for the denial or dismissal. Written notice shall be provided the individual within ninety (90) calendar days of the date of hearing request. [Eff 09/30/13] (Auth: HRS §346-14(9); 42 C.F.R. §§431.220, 431.223, 431.244) (Imp: HRS §346-12; 42 C.F.R. §§431.220, 431.223, 431.244)
§17-1703.1-10 Group hearings. A series of individual requests for a hearing may be consolidated into a single group hearing when the sole issue involved is one of state or federal law or policy, or changes in state or federal law. Each individual shall be permitted to present the individual’s own case or be represented by an authorized representative. [Eff 09/30/13] (Auth: HRS §346- 14(9); 42 C.F.R. §431.222) (Imp: HRS §346-12; 42 C.F.R. §431.222
§17-1703.1-11 Expedited hearings. (a) An expedited hearing request may be granted within three working days of the request for hearing, if the time
UNOFFICIAL 1703.1-10 otherwise permitted for a hearing as described in section 17-1703.1-15(a)(1) or (a)(2) would jeopardize the individual’s life or health or ability to attain, maintain or regain maximum function. (b) If the department determines that the request does meet the criteria for an expedited hearing, it must: (1) Initiate the hearing process as described in section 17-1703.1-12; and (2) All matters relating to the hearing shall be heard and disposed of as expeditiously as the individual’s health conditions requires, but no later than (3) working days after the department receives the request for an expedited hearing. (c) If the department determines that the request does not meet the criteria for an expedited hearing, it must: (1) Initiate the standard hearing process timeframe, in accordance with 17-1703.1- 15(a)(1) or (a)(2); and (2) Notify the individual orally or through an electronic notice as described in section 17-1713-6 of the denial and, if oral notification is provided, the department will follow up with a written notice within two (2) calendar days of the denial. (d) An individual enrolled in a managed care health plan shall first be required to complete that health plan’s internal expedited appeal process for any denied service. [Eff 09/30/13] (Auth: HRS §346- 14(9); 42 C.F.R. §431.224) (Imp: HRS §346- 12; 42 C.F.R. §431.224)
§17-1703.1-12 The hearing. (a) The hearing shall include consideration of: (1) Any adverse action by the department or managed care health plan which includes: (A) Failure to determine eligibility within the specific time limits of the medical assistance programs; (B) Refusal to consider a request for or failure to make a payment adjustment within time limits set by the medical assistance programs; or
UNOFFICIAL 1703.1-11 (C) Discontinuance, termination, suspension, withholding, or reduction of medical assistance or coverage; and (2) The department’s decision regarding: (A) An initial and subsequent determination of eligibility for medical assistance; (B) Amount of spenddown or change in spenddown; (C) Amount of premium share or change in premium share; or (D) The method of delivery of service, included restricted status. (b) The individual shall be required to appear in person at the hearing unless authorization for an authorized representative was received by the department. When mutually agreed upon by the individual and the department, a hearing may be conducted over the telephone or through videoconference. (c) Unless both the department and the individual agree to the presence of other persons in the hearing room, the hearing officer or person conducting the hearing shall limit attendance to the following individuals necessary for the conducting of the hearing: (1) The individual, the authorized representative, or both, interpreter, if any, legal counsel, and witnesses; (2) Representatives of the section or unit offices; (3) Representatives of the Med-QUEST Division; and (4) Hearing officer and staff. (d) The individual or the authorized representative shall, upon request, be able to examine the electronic and physical case record as well as all available documentary evidence used by the department at the hearing as specified in section 17-1703.1-6. (e) The hearing shall be conducted at a reasonable time, date, and place and generally be held in the jurisdiction of the department in which the individual is living at the time of the hearing. The hearing shall be conducted at a location or a videoconference specified by the hearing officer, or a teleconference is scheduled if the individual is unable to travel to the site because of health issues. (f) The hearing officer shall have access to the department’s information necessary to issue a proper
UNOFFICIAL 1703.1-12 hearing decision, including information concerning policies and regulations. (g) The decision of the hearing officer shall be based exclusively on evidence and other material introduced at the hearing. If, after a hearing has begun, additional evidence is necessary for the proper determination of the case, the hearing officer may: (1) Continue the hearing to a later date. The hearing officer may order further investigation and may direct either party to produce additional evidence; or (2) Close the hearing and hold the record open for a period not to exceed thirty (30) days to permit the receipt of additional documentary evidence. [Eff 09/30/13] (Auth: HRS §346-14(9); 42 C.F.R. §§431.240, 431.242, 431.241, 431.244) (Imp: HRS §346- 12; 42 C.F.R. §§431.240, 431.242, 431.241, 431.244)
§17-1703.1-13 Hearing involving medical issues. When the hearing involves medical issues such as issues concerning a diagnosis, an examining physician’s report, or a medical review team’s decision, the hearing officer may require an additional medical assessment of the individual. The evaluation shall be conducted by someone other than the persons involved in making the original decision. The additional medical assessment shall be obtained at the expense of the Med-QUEST Division and made part of the record. [Eff 09/30/13] (Auth: HRS §34614(9); 42 C.F.R. §431.240) (Imp: HRS §346-12; 42 C.F.R. §431.240)
§17-1703.1-14 Hearing involving spousal support from institutionalized individuals. (a) A hearing may be requested if either the institutionalized spouse or the community spouse is dissatisfied with the determination of the:(1) Community spouse monthly income allowance; (2) Computation of the spousal share of the resources; or (3) Community spouse resource allowance. Any hearing request resulting from the determination of the community spouse resource allowance shall be held within
UNOFFICIAL 1703.1-13 thirty (30) days of the request for hearing. (b) A community spouse may be allowed to maintain income that exceeds the standardized community spouse monthly income allowance when a community spouse's income needs are determined to be greater than the maximum income allowance limit. (c) A community spouse may be allowed to retain resources in excess of the standardized community resource allowance when income generated by those resources does not cause the community spouse's income to exceed the community spouse monthly income allowance. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §346-29; 42 U.S.C. §1396 r- 5)
§17-1703.1-15 Hearing decision. (a) All matters relating to the hearing shall be heard and disposed of as follows: (1) Within ninety (90) calendar days from the date of request for a hearing that is submitted in accordance with section 17- 1703.1-4; (2) Within forty-five (45) calendar days from the date of an appeal decision by the Health Insurance Exchange involving an earlier determination of Medicaid eligibility; or (3) As expeditiously as the individual’s health conditions requires, but no later than three (3) working days after the department receives the request for an expedited hearing. (b) Exception to the provision described in subsection (a), shall be when the hearing is continued or the record is held open as specified in section 17- 1703.1-12(g). The time limit shall be extended only for the period of the continuance. (c) Unless the record is held open for additional documentary evidence, after closing the hearing, the hearing officer shall prepare the decision in writing. The decision shall contain a statement concerning the individual’s right to judicial review, the reasons for the decision, the evidence, and the rules supporting the decision. A copy of the written decision shall be provided the individual and the department. (d) The transcript, recording, or an official record containing the substance of the hearing
UNOFFICIAL 1703.1-14 proceedings, together with all papers filed in the proceeding and the hearing officer's decision shall constitute the exclusive record and shall be made available to the individual during normal business hours through the hearing office. (e) The department shall comply with the hearing decision immediately upon receipt of the decision. (1) When the hearing decision is favorable to the individual, the department shall promptly make necessary corrections, retroactive to the date the incorrect action was taken, and shall notify the hearing office, in writing, of the action and the date the action was taken. (2) If the hearing decision is in favor of the individual on the issue involved, but for technical reasons such as computer problems, immediate corrections are not made, the department shall submit a notice to the hearing officer and include a statement of why the department could not immediately comply with the decision. (3) The hearing officer shall review the notice to assure that the department has correctly complied with the decision. (f) All hearing decisions shall be accessible to the public, subject to provision of safeguarding public assistance information stated in section 346- 10, HRS, and the department's confidentiality provisions specified in chapter 17-1702. [Eff 09/30/13] (Auth: HRS §346-14(9); 42 C.F.R. §431.244) (Imp: HRS §346-12; 42 C.F.R. §431.244)
§17-1703.1-16 Decisions pending over ninety days. (a) When a final decision has not been made and implemented within ninety (90) days of the request, the department shall reduce the premium-share amount or spenddown amount to what existed prior to the hearing request or restore or grant any service which was reduced or denied, if the individual is not already receiving aid paid pending. When the hearing decision is pending over ninety (90) days, aid paid shall be determined in accordance with subsections (d) and (e). (b) The hearing officer shall notify the Med- QUEST Division orally on the ninety-first(91st) day when a final decision is not reached within ninety
UNOFFICIAL 1703.1-15 (90) days. If the ninety-first (91st) day falls on a weekend or holiday, the ninety-first (91st) day shall then be the first working day following the weekend or holiday. A written confirmation shall be sent within three (3) working days. (c) In situations where an individual has requested or is otherwise responsible for a delay in the hearing process, the time period shall be tolled only for the period of the delay. (d) When a final decision is not made and implemented within ninety (90) days: (1) The specific medical care denied the individual which is the issue on appeal shall be authorized from the ninety-first (91st) day until the hearing decision is made and implemented; or (2) The individual applying for medical assistance shall be made presumptively eligible to secure assistance from the ninety-first (91st) day until the hearing decision is made and implemented. (e) The department shall review current need and eligibility factors exclusive to the issue on appeal. If the individual is found to be currently eligible, the department shall reduce the premium-share amount or spenddown amount to what existed prior to the hearing request effective the ninety-first(91st) day. The required action shall be taken within five (5) working days after the oral notice is received from the hearing officer. The amount of premium-share or spenddown amount shall be restored to the previous level until a final decision is made, provided the individual remains eligible and no other changes become necessary. (f) If, for reasons exclusive to the issue pending hearing, the department determines that the individual is ineligible to receive assistance, the department shall terminate or deny the assistance on or after the ninety-first (91st) day of the hearing request. The department shall send a notice indicating the reasons for not restoring assistance pending the final hearing decision. [Eff 09/30/13] (Auth: HRS §346-14(9); 42 C.F.R. §431.244) (Imp: HRS §346-12; 42 C.F.R. §431.244)
§17-1703.1-17 Recovery of aid paid pending. (a) Aid paid pending a hearing decision from the date aid
UNOFFICIAL 1703.1-16 paid pending begins through the ninetieth (90th) day shall be recoverable by the department if the department's action is sustained. (b) If, for reasons other than a settlement negotiated by the state attorney general's office, the individual withdraws or abandons the request as specified in section 17-1703.1-9, the department or the managed care health plan shall recover the aid paid pending the hearing decision. [Eff 09/30/13] (Auth: HRS §346-14(9); 42 C.F.R. §431.230) (Imp: HRS §§346-12, 346-44; 42 C.F.R. §431.230)
§§17-1703.1-18 to 17-1703.1-22 (Reserved).
UNOFFICIAL 1704-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12 MED-QUEST DIVISION
CHAPTER 1704
FRAUD PROVISIONS
Subchapter 1 General Provisions
§17-1704-1 Purpose §17-1704-2 Definitions
Subchapter 2 Recipient Fraud
§17-1704-3 Investigation of suspected fraud §17-1704-4 Penalty
Subchapter 3 Provider Fraud
§17-1704-5 Preliminary investigation §17-1704-6 Resolution of investigation
Historical Note: This chapter is based substantially upon chapter 17-1350 [Eff 6/29/92; R 08/01/94 ]
SUBCHAPTER 1
GENERAL PROVISIONS
§17-1704-1 Purpose. The purpose of this chapter is to define conditions under which the department will investigate suspected fraud in medical assistance cases. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-14)
UNOFFICIAL 1704-2 §17-1704-2 REPEALED. [R 09/30/13]
SUBCHAPTER 2
RECIPIENT FRAUD
§17-1704-3 Investigation of suspected fraud. (a) The department shall identify situations in which there are questions of suspected fraud such as, but not limited to, a recipient receiving medical assistance to which the individual is not entitled through willful misrepresentation of circumstances or the intentional concealment of information from the department.
(b) The DHS investigations office shall investigate suspected fraud and refer these cases to law enforcement officials.
(c) The methods of investigation shall not infringe on the legal rights of the persons involved and shall afford these individuals due process of law. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §§455.13, 455.14, 455.15, 455.16)
§17-1704-4 Penalty. The department may initiate referral for prosecution of an individual suspected of fraud. In addition, the individual may be subject to any other criminal, civil, or administrative sanction authorized by law. [Eff 08/01/94 ] (Auth: HRS §346.14; 42 C.F.R. §431.10) Imp: 42 C.F.R. §§455.15, 455.16)
SUBCHAPTER 3
PROVIDER FRAUD
§17-1704-5 Preliminary investigation. (a) DHS shall conduct a preliminary investigation of all medicaid fraud complaints from whatever sources received to determine whether there is sufficient basis to warrant a full investigation.
(b) If the findings of the preliminary investigation indicate there is potential for criminal
UNOFFICIAL 1704-3 prosecution of fraud, the cases shall be referred to the medicaid fraud control unit. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §§431.10, 455.14) (Imp: 42 C.F.R. §§455.13, 455.14)
§17-1704-6 Resolution of investigation. A full investigation shall continue until: (1) Appropriate criminal or civil legal action is initiated; (2) The matter is resolved between the department and the provider through any one or appropriate combination of the following actions: (A) A monitoring program of provider's medicaid practice is established to ensure corrective measures have been introduced; (B) A demand letter is sent to the provider requiring repayment of overpayments to the provider made by the medical assistance program and warning the provider that payment on that provider's pending claims may be withheld in part or in whole to be applied to overpayments previously made to the provider by the medical assistance program; (C) All claims of a provider are placed on
review prior to payment; (D) In the event that the department is
unable to determine whether the actions
of a provider constitute improper medical practice, the department requests an
opinion of the Hawaii Medical Association peer review committee; and (E) The provider is suspended or terminated
from participation in the medical
assistance program as described in sections 17-1736-17 and 17-1736-18. [Eff 08/01/94 ] (Auth: HRS §346- 14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §§455.13, 455.14, 455.15, 455.16)
UNOFFICIAL 1705-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1705
MEDICAL ASSISTANCE RECOVERY
Subchapter 1 General Provisions
§17-1705-1 Purpose §17-1705-2 Definitions §17-1705-3 Administrative procedures §§17-1705-4 to 17-1705-5 (Reserved)
Subchapter 2 Assignment of and Cooperation in
Obtaining Third Party Payments
§17-1705-6 Purpose §17-1705-7 Medical assignment requirements §17-1705-8 Cooperation requirements §17-1705-9 Good cause determination §17-1705-10 Denial or termination of medical
assistance §§17-1705-11 to 17-1705-15 (Reserved)
Subchapter 3 Assignment of and Cooperation in
Obtaining Medical Support
§17-1705-16 Purpose §17-1705-17 Assignment of rights to support §17-1705-18 Cooperation in obtaining support §17-1705-19 Determination of good cause for refusing
to cooperate §17-1705-20 Circumstances under which cooperation
may be against the best interest of
the child §17-1705-21 Granting or continuation of assistance §17-1705-22 to 17-1705-25 (Reserved)
Subchapter 4 Good Cause Claim Procedures
UNOFFICIAL 1705-2 §17-1705-26 Purpose §17-1705-27 Notice to applicant of right to claim
good cause §17-1705-28 Processing good cause claims §17-1705-29 Evidence §17-1705-30 Renewal of good cause claim §§17-1705-31 to 17-1705-35 (Reserved)
Subchapter 5 Third Party Liability
§17-1705-36 Definitions §17-1705-37 Determining liability of third parties §17-1705-38 Medical payment involving third party §§17-1705-39 to 17-1705-43 (Reserved)
Subchapter 6 Recovery of Overpayment to Providers
§17-1705-44 Definitions §17-1705-45 Recoupment of overpayment to providers §§17-1705-46 to 17-1705-50 (Reserved)
Subchapter 7 Recipient Recovery
§17-1705-51 Definitions §17-1705-52 Recovery of medical care payments from
recipients §17-1705-53 Recovery of misspent funds §17-1705-54 Fraud §17-1705-55 Suspension and waiver of overpayment §17-1705-56 Limiting provisions §§17-1705-57 to 17-1705-65 (Reserved)
Subchapter 8 Third Party Liability Subrogation
§17-1705-66 Definitions §17-1705-67 Accident liability §17-1705-68 Termination or waiver of subrogation
Historical Note: This chapter is based substantially upon chapter 17-1352. [Eff 06/29/92; R 08/01/94 ]
SUBCHAPTER 1
GENERAL PROVISIONS
UNOFFICIAL 1705-3
§17-1705-1 Purpose. The purpose of this chapter is to establish the requirements for applicants and recipients of medical assistance. Applicants and recipients shall: (1) Assign their rights to third party payments and medical support; (2) Cooperate in obtaining third party payments for medical assistance, pursuing any third party who may be liable for medical support, and obtaining child support; and (3) Be required to satisfy all conditions set
forth by the third party to receive coverage, to the extent coverage is available through that third party, before Medicaid reimbursement is allowed. [Eff 08/01/94; am 02/07/05] (Auth: HRS §346-14) (Imp: 42 C.F.R. §§433.138, 433.145, 433.146, 433.147; 45 C.F.R. §§232.11, 232.12)
§17-1705-2 REPEALED. [R 09/30/13]
§17-1705-3 Administrative procedures. (a) The adverse action notice requirements of chapter 17-1713 shall apply unless otherwise indicated in this chapter.
(b) The administrative hearing requirements of chapter 17-1703 shall apply.
(c) The department shall restore to the individual any future rights to benefits assigned to the department when medical assistance terminates and after all medical expenses have been met. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-14; 42 C.F.R. §433.148; 45 C.F.R. §205.10)
§§17-1705-4 to 17-1705-5 (Reserved).
SUBCHAPTER 2
ASSIGNMENT OF AND COOPERATION IN OBTAINING THIRD PARTY PAYMENTS
§17-1705-6 Purpose. The purpose of this chapter is to establish the requirements for assignment of and
UNOFFICIAL 1705-4 cooperation in obtaining third party payments that applicants and recipients shall be required to meet to receive medical assistance. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §433.137; 433.138; 45 C.F.R. §232.13, HRS §346-37)
§17-1705-7 Medical assignment requirements. (a) All individuals applying for or receiving medical assistance shall assign to the department or health plan: (1) The individual's rights to any third party payments; and (2) The rights of any other family member included in the application or receiving assistance for whom the applicant or recipient can legally make an assignment.
(b) Assignment of right to payments shall not include assignment of rights to medicare benefits.
(c) An applicant or recipient shall inform the department or health plan of an involvement in an accident within thirty days of the accident. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-37(b); 42 C.F.R. §§433.145, 433.146)
§17-1705-8 Cooperation requirements. (a) All applicants and recipients of medical assistance shall be required to cooperate with the department or health plan in obtaining third party payments unless there is good cause for refusing to cooperate.
(b) Cooperation shall include:
(1) Identifying any third party who may be liable for services covered under the Medicaid program; (2) Providing relevant information or attesting to the lack of information, under penalty of perjury, to assist the department or health plan in pursuing any such potentially liable third party; (3) Appearing at a department designated location to provide information or evidence relevant to the case; (4) Appearing as a witness at a court or other proceeding;
UNOFFICIAL 1705-5 (5) Paying to the department or health plan any support or medical care funds received that are covered by the assignment of rights; and (6) Taking any other reasonable steps to assist in securing medical support and payments.
(c) All applicants and recipients of medical assistance shall be required to apply, as a condition of eligibility, for Medicare coverage if: (1) The individual may meet the eligibility criteria for the Medicare program, and (2) The state agrees to pay any applicable premiums and cost-sharing, except for those related to Medicare part D. [Eff 08/01/94; am 01/29/96; am 12/26/05; am 09/30/13] (Auth: HRS §346-14) (Imp: 42 C.F.R. §433.138; §433.145; 45 C.F.R. §232.13; Pub. L. 108-173)
§17-1705-9 Good cause determination. (a) The department shall make a determination that cooperation is against the best interests of the individual or other family member to whom financial or medical assistance is being furnished when it is anticipated that cooperation will result in reprisal against, and cause physical or emotional harm to, the individual or other family member.
(b) When the department determines that good cause exists, the department shall make a further determination of whether collection activities could proceed without risk of harm to the family provided the activities will not involve the family's participation.
(c) The determination shall be made on a case-by-case evaluation of the circumstances and the family shall be notified of the decision.
(d) The good cause claim procedures of subchapter 4 shall apply. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §433.147; 45 C.F.R. §232.40)
§17-1705-10 Denial or termination of medical assistance. (a) The department shall deny or terminate medical assistance to any applicant or
UNOFFICIAL 1705-6 recipient who refuses to cooperate in obtaining third party payments, unless good cause exists.
(b) The department shall deny or terminate medical assistance to applicants or recipients who refuse to assign the individual's own rights or the rights of any other family member for whom the applicant or recipient can legally make an assignment.
(c) The department shall provide assistance to individuals who: (1) Cannot legally assign the individual's own
rights or the rights of other family members; (2) Have good cause for refusing to cooperate;
and (3) Would otherwise be eligible for assistance
but for the refusal by a person legally able to make the assignment or to cooperate.
(d) Any individual denied or terminated for medical assistance as a result of refusal to assign the individual's rights shall have the right to a fair hearing. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §433.148)
§§17-1705-11 to 17-1705-15 (Reserved).
SUBCHAPTER 3
ASSIGNMENT OF AND COOPERATION IN OBTAINING MEDICAL SUPPORT
§17-1705-16 Purpose. The purpose of this subchapter is to establish the requirements for applicants and recipients of medical assistance. Applicants and recipients shall: (1) Assign their rights to medical support; and (2) Cooperate in obtaining medical support. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-37.1; 42 C.F.R. §§433.146, 433.147; 45 C.F.R. §§232.11, 232.12)
§17-1705-17 Assignment of rights to support. (a) All individuals shall assign to the state any rights the individuals may have to receive medical support payments on the individual's own behalf or on behalf of
UNOFFICIAL 1705-7 any other family member applying for or receiving assistance.
(b) If the caretaker relative with whom the child is living, fails to complete the assignment, the caretaker relative shall be ineligible for medical assistance.
(c) The department shall provide medical assistance to individuals who would otherwise be eligible but for the refusal of the caretaker relative to complete the assignment. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-37.1; 42 C.F.R. §433.148; 45 C.F.R. §§ 232.11, 232.13, 234.60)
§17-1705-18 Cooperation in obtaining support. (a) Each individual applying for or receiving medical assistance shall be required to cooperate with the department in: (1) Identifying and locating the parent of the child for whom medical services are being claimed; (2) Establishing the paternity of a child born out of wedlock for whom medical services are being claimed; (3) Obtaining support payments due the individual and the child for whom medical services are being claimed; and (4) Obtaining any other payments due the individual and the child for whom medical services are being claimed.
(b) An individual may be required to: (1) Appear in court or at the department's child support enforcement agency as maybe necessary, to provide information and evidence, known to, possessed by, or obtainable by the individual that may be achieving the objective of enforcing child support obligations; (2) Appear as a witness in any legal proceedings; (3) Provide information, or attest to the lack of information, possessed or reasonably obtainable by the individual under penalty of perjury; and (4) Report to the department any child support payments received from the absent parent.
(c) The department shall provide medical assistance to individuals who would otherwise be eligible for medical assistance but for the refusal by
UNOFFICIAL 1705-8 the caretaker relative to cooperate. [Eff 08/01/94 ] (Auth: HRS §346-14) Imp: HRS §346-37.1, 42 C.F.R. §§433.147. 433.148; 45 C.F.R. §§232.12, 234.60)
§17-1705-19 Determination of good cause for refusing to cooperate. (a) The department shall determine whether good cause exists for the family's failure to comply with the requirements of section 17-1705-18: (1) With respect to establishing paternity or securing support for a child, the department shall make a determination that good cause exists only if the evidence establishes that cooperation is against the best interest of the child. (2) With respect to securing support for individuals not covered by paragraph (1), the department shall make a determination that good cause exists only if the evidence establishes that cooperation will result in reprisal against or cause physical or emotional harm to the applicant or recipient.
(b) When the department determines that good cause exists, the department shall make a further determination of whether child or medical support enforcement could proceed without risk of harm to the family provided the enforcement or collection activities will not involve the family's participation.
(c) The good cause determination shall be made on a case-by-case evaluation of the circumstances and evidence provided. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-37.1; 42 C.F.R. §433.147; 45 C.F.R. §232.40)
§17-1705-20 Circumstances under which cooperation may be against the best interest of the child. (a) Cooperation shall be against the best interest of the child only if it is reasonably anticipated to result in physical or emotional harm to the child or to the parent or caretaker relative, and the harm reduces the parent's or caretaker relative's capacity to care for the child adequately.
(b) Physical or emotional harm shall be of a serious nature that would affect the parent's or caretaker relative's ability to function if cooperation is required.
UNOFFICIAL 1705-9
(c) A determination that good cause exists shall also be applied in cases where: (1) The child was conceived as a result of incest or forcible rape; (2) Legal proceedings for the adoption of the child are pending before a court; or (3) The individual is currently being assisted by a public or private licensed social agency toresolve the issue of whether to keep the child or relinquish the child for adoption. The discussions on whether to keep or give up the child shall not have gone on for more than three months. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp. HRS §346-37.1; 42 C.F.R. §433.147; 45 C.F.R. §232.42)
§17-1705-21 Granting or continuation of assistance. The department shall not deny, delay, or discontinue medical assistance pending the final good cause determination if the individual has complied with the requirement to provide evidence and all other eligibility requirement have been met. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp. HRS §346-14; 42 C.F.R. §433.147; 45 C.F.R. §232.46)
§§17-1705-22 to 17-1705-25 (Reserved).
SUBCHAPTER 4
GOOD CAUSE CLAIM PROCEDURES
§17-1705-26 Purpose. This subchapter establishes the procedures for providing notice and processing an individual's good cause claim for refusing to cooperate in obtaining third party payments for medical assistance or securing medical support. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-14; 42 C.F.R. §433.147; 45 C.F.R. §§232.40, 232.41, 232.43, 232.47)
§17-1705-27 Notice to applicant of right to claim good cause. (a) The department shall notify applicants and recipients of medical assistance of the
UNOFFICIAL 1705-10 right to claim good cause as an exception to the cooperation requirement.
(b) The applicant or recipient shall be informed in writing that: (1) The potential benefits a child may derive
from establishing paternity and securing support and the potential benefits for providing information to assist the department in pursuing third party liability for medical services; (2) By law, cooperation in establishing paternity, securing support, and identifying and providing information to assist the department in pursuing third party liability for medical services is a condition of eligibility; (3) An unexcused refusal to cooperate shall result in loss of medical eligibility for the needy caretaker relative; (4) The individual has the right to claim good cause for refusing to cooperate and if the department determines there is good cause, the individual shall be excused from the cooperation requirements of sections 17-1705-8 and 17-1705-18; and (5) Upon an individual's request or following receipt of a good cause claim, the department shall provide further notice to the individual with additional details concerning a good cause claim.
(c) A second notice shall be provided in writing, to applicants or recipients who claim good cause or who notify the department of the individual's intention to claim good cause.
(d) The second notice shall be provided promptly, without the applicant or recipient having to reschedule a follow-up appointment. The notice shall inform the individual that: (1) The individual shall be required to provide corroborative evidence of a good cause circumstance as specified in section 17-1705-29, and when requested, shall furnish sufficient information in order to allow the department to investigate the circumstances of the claim; (2) Upon the individual's request, the department will provide reasonable assistance in obtaining the corroborative evidence;
UNOFFICIAL 1705-11 (3) The department shall determine whether cooperation would be against the best interest of the child for whom child or medical support would be sought or the individual for whom third party liability for medical services would be sought based on the corroborative evidence supplied; (4) The circumstances under which cooperation shall be determined to be against the best interests of the child or individual; (5) The state Title IVD child support enforcement agency (CSEA) may review the department's findings and basis for a good cause determination and may participate in any administrative hearings concerning the issue of good cause; and (6) CSEA may attempt to establish paternity and
collect support and the department may
attempt to collect third party information
and payment when the department determines that this can be done without risk to the applicant or recipient if done without their participation. [Eff 08/01/94 ] (Auth: HRS §346-24) (Imp: HRS §346-37.1; 42 C.F.R. §§433.147, 433.148; 45 C.F.R. §232.40)
§17-1705-28 Processing good cause claims. (a) An applicant or recipient who refuses to cooperate and who claims to have good cause shall: (1) Specify the circumstances which the individual believes establishes good cause to be excused from the cooperation requirement; (2) Provide corroboration of the good cause circumstances in accordance with section 17-1705-29 within twenty days from the day a good cause claim is filed; (3) Provide additional corroborative evidence the department deems necessary to make a good cause determination; and (4) Be notified promptly by the department of the specific types of additional evidence required.
(b) Where a claim is based upon the individual's anticipation of physical harm and corroborative evidence is not submitted, the department may at its own discretion, determine good cause based upon the individual's statement and upon further investigation.
UNOFFICIAL 1705-12
(c) The department's determination of whether good cause exists shall be made within forty-five calendar days from the day the good cause claim is made except when: (1) The department determines it needs additional time because the information required to verify the claim cannot be obtained within forty-five days; or (2) The individual cannot provide corroborative evidence within twenty days from the day the
claim is made. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-37.1; 42 C.F.R. §433.147; 45 C.F.R. §§232.41, 232.43)
§17-1705-29 Evidence. Good cause shall be corroborated with the following types of evidence: (1) Birth certificates or medical or law enforcement records which indicate that the child was conceived as a result of incest or forcible rape; (2) Court documents which indicate legal proceedings for adoption are pending before a court; (3) Court, medical, child protective services, social services, psychological, or law enforcement records which indicate that the alleged father, absent parent, or others may inflict physical or emotional harm on the child or other family member; (4) Medical records which indicate emotional health history and present emotional health status of the child or family member or written statements from mental health professionals indicating a prognosis concerning the diagnosis or emotional health of the individual or family if cooperation is required; (5) A written statement from a public or licensed private social agency that the parent or other caretaker is being assisted to resolve the issue of where to keep the child or relinquish the child for adoption; or (6) Sworn notarized statements from persons other than the individual with knowledge of the circumstances which provide the basis for the good cause claim. [Eff 08/01/94 ]
UNOFFICIAL 1705-13 (Auth: HRS §346-14) (Imp: HRS §346.37.1; 42 C.F.R. §433.147; 45 C.F.R. §232.43)
§17-1705-30 Renewal of good cause claim. (a) In all cases where an initial determination has been made that there is good cause for refusal to cooperate, the recipient shall have the responsibility of renewing a good cause claim at each annual redetermination of eligibility.
(b) If the department determines that circumstances have changed and good cause no longer exists, the department shall proceed to enforce the cooperation requirements. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-14; 42 C.F.R. §433.147; 45 C.F.R. §232.47)
§§17-1705-31 TO 17-1705-35 (Reserved).
SUBCHAPTER 5
THIRD PARTY LIABILITY
§17-1705-36 REPEALED. [R 09/30/13]
§17-1705-37 Determining liability of third parties. The department or health plan shall determine the legal liability of third parties to pay for services under the medical assistance program. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-37; 42 C.F.R. §433.138)
§17-1705-38 Medical payment involving third party. (a) The liability of a third party shall be treated as a resource applicable to the cost of needed medical services when: (1) It has been verified that a legal obligation actually exists; and (2) The amount of the obligation may be determined within thirty days from the time of the recipient's need for medical care.
(b) No Medicaid payment shall be made under a refund plan for that portion of cost for which a third
UNOFFICIAL 1705-14 party has been determined to be liable and reimbursement is forthcoming.
(c) If a liability by an identified third party exists, the recipient shall be required to satisfy all conditions set forth by that third party to receive coverage, to the extent coverage is available through that third party, before Medicaid payment is allowed.
(d) When the existence or extent of third party liability is in question, medical assistance payments may be made in: (1) Part, if the recipient has excess income and other assets; or (2) Whole, if the recipient accepts, in writing, an assignment of the recipient's third party payment to refund the department. However, when third party policy prohibits assignment of payment, the recipient, in writing, shall agree to refund the department or health plan upon being paid.
(e) After a claim is paid or medical services are rendered, if the department or health plan learns of the existence of a liable third party, the department or health plan shall seek reimbursement from the third party within thirty days after the end of the month it learned of the existence of the liable third party.
(f) The department or health plan shall suspend or terminate an effort to seek reimbursement from a liable third party if it determines that the effort would not be cost effective because the amount it reasonably expects to recover will be less than the cost of recovery.
(g) The department or health plan shall accumulate billings with respect to a liable third party when making a decision whether to seek recovery. When the accumulated amount is $500 or more, the department or health plan shall seek recovery. [Eff 08/01/94; am 11/25/96; am 04/11/03; am 02/07/05 ] Auth: HRS §§346-14, 346-37) (Imp: HRS §346-37; 42 C.F.R. §433.139)
§§17-1705-39 to 17-1705-43 (Reserved).
SUBCHAPTER 6
RECOVERY OF OVERPAYMENT TO PROVIDERS
UNOFFICIAL 1705-15
§17-1705-44 REPEALED. [R 09/30/13]
§17-1705-45 Recoupment of overpayment to providers. (a) The department shall recoup overpayment to providers when overpayment occurred for reasons including, but not limited to one of the following: (1) Ineligible provider; (2) Noncovered service; (3) Noncovered drug; (4) No approved prior authorization when a service requires one; (5) Incorrect payment allowance identified through post payment review by department staff; or (6) Claim processing error. (b) The responsibility of recoupment may be assigned to the fiscal agent with whom the department has a contract. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-44)
§§17-1705-46 to 17-1705-50 (Reserved).
SUBCHAPTER 7
RECIPIENT RECOVERY
§17-1705-51 REPEALED. [R 09/30/13]
§17-1705-52 Recovery of medical care payments from recipients. (a) Payments made to medical care providers and payments made to health plans shall be recovered by the department from individuals who: (1) Provided erroneous information in qualifying for medical assistance; (2) Failed to report a change in circumstances which would have rendered the individual or household ineligible for continued medical assistance; (3) Failed to notify the department that a family member is no longer a member of the assistance household;
UNOFFICIAL 1705-16 (4) Failed to pay the premium-share assessed to the family; or (5) Were adversely affected by a fair hearing decision, and who received medical assistance services pending the fair hearing decision.
(b) That portion of the payment to the health plan that is assessed to the recipient as the premium-share shall be recovered from recipients who are subject to recovery.
(c) Recovery of payments shall continue even though the individual is no longer a recipient of medical assistance. [Eff 08/01/94; am 01/29/96 ] (Auth: HRS §346-14; 42 C.F.R. §431.230) (Imp: HRS §346-44)
§17-1705-53 Recovery of misspent funds. (a) Individuals subject to recovery of misspent funds under the medical assistance program shall be provided written notice by the department stating: (1) The reasons, date, and the amount of the alleged misspent funds; (2) Proposed amount to be repaid each month; (3) Period over which the repayment shall be made; (4) Method by which the proposed overpayment shall be recovered; and (5) The right to request a hearing if the individual disagrees with the department's proposed action.
(b) The department may refer an individual to the comptroller of the State to recover overpayments from the individual's personal income tax refund when: (1) There is a repayment plan initiated against the individual; (2) The individual is delinquent in repayment; and (3) The amount owed by the individual exceeds $25.
(c) The department may place a lien on the real and personal property of an individual subject to recovery of misspent medical assistance funds. Any lien imposed with respect to this subsection shall be dissolved upon the individual's payment of the misspent funds. [Eff 08/01/94; am 11/25/96 ] (Auth: HRS §§231-51, 231-53, 346-14) (Imp: HRS §346-44)
UNOFFICIAL 1705-17
§17-1705-54 Fraud. If fraud is suspected in any misspent funds under the medical assistance program, the department shall refer the case to the appropriate agency to pursue the investigation of suspected fraud and take action as deemed appropriate. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-44)
§17-1705-55 Suspension and waiver of overpayment.
(a) The collection activities on a closed medical assistance case may be suspended when: (1) The department has sent one demand letter requesting payment for overpayments under $100, two demand letters for overpayments between $100 and $400, three demand letters for more than $400 and the department's
investigative and recovery services office determines that the cost of further collection action is likely to exceed the amount that can be recovered; or (2) The assistance unit cannot be located. Collection activities shall not be suspended until the department has initiated action to locate the former recipients. In locating the former recipients, the department shall use appropriate data sources such as state unemployment insurance files, state automobile registration, and the Social Security Administration's benefit data exchange (BENDEX).
(b) Collection activities shall not be suspended on any case where the court has ordered an individual to repay overpayments to the department.
(c) An overpayment on a closed medical assistance case may be determined uncollectible and the overpayment waived when: (1) Collection activities have been suspended; and (2) No payments have been collected for at least three consecutive years; or (3) All of the members of the assistance unit have died. [Eff 08/01/94 ] (Auth: HRS §§346-14, 346-44) (Imp: HRS §346-44)
§17-1705-56 Limiting provisions. (a) No liens or encumbrances shall be imposed upon both real and
UNOFFICIAL 1705-18 personal property of applicants or recipients prior to their deaths except under the circumstances described in section 17-1705-53 or 17-1705-57.
(b) No adjustment or recovery shall be made for correctly made medical assistance payments, except in the case of the following: (1) Individuals in nursing facilities, intermediate care facilities for the mentally retarded, or other medical institutions for all individuals on or after October 1, 1993; or (2) Benefits paid on or after October 1, 1993 for individuals age fifty-five or older at the time services were received. (c) Adjustments or recovery under subsection (b) can be made only after the death of the surviving spouse, if any, and when there is no surviving child who is under twenty-one years, or child who is blind or disabled as defined in chapter 17-1719.
(d) Adjustment or recovery, if any, shall be from the deceased recipient's estate or upon the sale of property subject to lien imposed under section 17-1705-57.
(e) Recovery may be waived due to hardship for the period the following conditions exist: (1) The estate subject to recovery is the sole income-producing asset of the survivors and the following conditions are met: (A) The estate is a family farm or other family business; (B) The income produced by the asset is not greater than one hundred per cent of the federal poverty guidelines for the number of survivors solely dependent on such asset. (2) The estate is a homestead of modest value that is occupied by survivors who meet the following conditions: (A) Lawfully resided in the home for a continuous period that started at least three months immediately before the recipient's admission to a medical institution and provided care to the recipient during that period that allowed the recipient to reside at home rather than in an institution and has continuously lived in the home since the admission;
UNOFFICIAL 1705-19 (B) Do not own any real property other than an interest in the home; and (C) Have income not greater than one hundred per cent of the federal poverty limit. [Eff 08/01/94; am 01/29/96; am 11/25/96; am 09/30/13] (Auth: HRS §346-14) (Imp: HRS §346-37; 42 C.F.R. §433.36; 42 U.S.C. §1396p)
§17-1705-57 Liens on real property of institutionalized individuals. (a) A lien may be placed on the real property of a medically institutionalized individual for the amount of medical assistance received, after a determination by the department that the individual cannot reasonably be expected to be discharged from the medical institution and returned home.
(b) A lien may not be placed on the home property of a medically institutionalized individual if any of the following individuals are lawfully residing in the home: (1) The individual's spouse; (2) The individual's dependent child; or (3) The individual's sibling who has an equity interest in the home and who was residing in the home for a period of at least one year prior to the individuals admission to the medical institution.
(c) The department shall not recover funds from the lien when the individual has: (1) A surviving spouse; or (2) A surviving dependent child.
(d) The department shall not recover funds from the lien when the individual has: (1) A sibling who was residing in the home for a period of at least one year immediately
before the individual's admission to the medical institution; or (2) A non-dependent child who was residing in the home for a period of at least two years immediately before the individual's admission to the medical institution and who provided care to the individual that allowed the individual to reside at home rather than in an institution; who has lawfully resided in the home on a continuous basis as a sole residence, without interruption or break,
UNOFFICIAL 1705-20 since the date of the individual's admission to the medical institution.
(e) Any lien imposed with respect to this section shall be dissolved upon the individual's discharge from the medical institution and return home. [Eff 01/29/96; am 11/25/96 ] (Auth: HRS §346-14) (Imp: HRS §§346-29.5, 346-37; 42 C.F.R. §433.36; 42 U.S.C. §1396p)
§§17-1705-58 to 17-1705-65 (Reserved).
SUBCHAPTER 8
THIRD PARTY LIABILITY SUBROGATION
§17-1705-66 REPEALED. [R 09/30/13]
§17-1705-67 Accident liability. (a) An applicant or recipient shall inform the department or health plan of an involvement in an accident within thirty days of the accident.
(b) The applicant or recipient shall be required to complete the assignment of rights form to assist the department or health plan in subrogation action.
(c) Refusal to sign the assignment of rights form constitutes cause for termination of medical coverage or denial of medical assistance application.
(d) Upon receipt of the assignment of rights form, the department or health plan shall immediately pursue possible recovery of medical care expenses paid on behalf of the recipient through the appropriate agencies. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-44)
§17-1705-68 Termination or waiver of subrogation. (a) Pursuit of recovery shall cease if: (1) The recoverable amount is less than the expense of pursuing the recovery; (2) The case is more than five years old and
amount recoverable is less than $1,000 and there are no outstanding federal or state issues;
UNOFFICIAL 1705-21 (3) The department or health plan does not have any legal recourse to pursue recovery; or (4) The whereabouts of the recipient are unknown.
(b) Pursuit of subrogation may be waived if the recoverable amount is $100 or less. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-44)
UNOFFICIAL 1706-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1706
INCOME TAX SETOFF PROGRAM
§17-1706-1 Purpose §17-1706-2 Definitions §17-1706-3 Tax setoff process §17-1706-4 Pretax setoff notice §17-1706-5 Informal review §17-1706-6 Tax setoff notice §17-1706-7 Right to an administrative hearing §17-1706-8 Rights of the claimant §17-1706-9 Action on request for an administrative
hearing §17-1706-10 Department's responsibility §17-1706-11 Responsibility of the administrative
appeals office §17-1706-12 Denial of request for administrative hearing §17-1706-13 The administrative hearing §17-1706-14 Administrative hearing decision §17-1706-15 Appeal rights of the claimant
§17-1706-1 Purpose. The purpose of this chapter is to establish the provisions by which the state income tax refunds of those persons who owe a debt to the department of human services, Med-QUEST division, shall be setoff to recover this debt, and to establish the provisions of the administrative hearing process to contest the tax setoff. These rules do not afford the debtor the opportunity to a hearing on any issue which has been previously litigated or for which an opportunity to a hearing has been previously provided. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §§231-51 to 231-59)
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§17-1706-2 REPEALED. [R 09/30/13]
§17-1706-3 Tax setoff process. (a) The department shall setoff any valid debt due and owing the department by the debtor against any debtor's refund. Any amount of the refund in excess of the amount retained to satisfy the debt shall be refunded to the debtor.
(b) The department shall compile an annual list of debtors identified for a tax setoff.
(c) A pretax setoff notice shall be mailed to each debtor.
(d) The debtor shall be provided an opportunity for an informal review of the debt.
(e) All debtors who receive an adverse informal review decision shall be provided an opportunity to request an administrative hearing.
(f) The informal review and pretax setoff administrative hearing shall be conducted and concluded prior to the setoff of the debtor's state tax refund.
(g) The debtor's name shall be referred to the comptroller, department of accounting and general services (DAGS), for tax setoff if no pretax setoff review is requested; or if the debt is established in the review or the pretax setoff administrative hearing.
(h) At the time the setoff is identified, the debtor shall be notified by the comptroller (DAGS) of the State's intention to apply the state income tax refund against the debt.
(i) The debtor shall be provided the opportunity to request an administrative hearing to contest the setoff, regardless of whether an administrative hearing was requested at the time of the pretax setoff notice.
(j) The setoff against the debtor's state income tax refund shall become final if an administrative hearing is not requested. [Eff 08/01/94; am 01/29/96 ] Auth: HRS §346-14) (Imp: HRS §§231-51 to 231-59)
§17-1706-4 Pretax setoff notice. (a) The department's administrative services office, recovery section (ASO-recovery) shall mail a pretax setoff notice annually to all debtors as identified by the department's administrative services office.
(b) The notice shall inform debtors of:
UNOFFICIAL 1706-3 (1) The department's intent to setoff the debtor's state income tax refunds due to nonpayment of a debt to the department; (2) The total amount of the debt (to include financial, medical and food stamp programs); (3) The opportunity to request an informal review of the debt within thirty calendar days from the date of the pretax setoff notice if they disagree with the department's intent; (4) The office address and toll free telephone numbers at which an informal review can be requested; (5) The opportunity to request a formal administrative hearing to all debtors who receive an adverse informal review decision; (6) The commonly used defenses in tax setoff administrative hearings; and (7) The opportunity to present the case independently or with the aid of others including legal counsel. [Eff 08/01/94; am 01/29/96 ] (Auth: HRS §346-14) (Imp: HRS §§231-51 to 231-59)
§17-1706-5 Informal review. (a) A debtor may request an informal review from ASO-recovery orally or in writing. The request shall be received by ASO-recovery within thirty calendar days of the date of the pretax setoff notice.
(b) The informal review shall be conducted by telephone or in person at the request of the debtor as follows: (1) ASO-recovery will review the debtor's account balances using account records and forward any unresolved requests to the investigations office (INVO). (2) INVO will review the requests referred by ASO-recovery to resolve account balances using the case records and applicable Hawaii Administrative Rules. (3) All debtors shall be informed in writing of: (A) The disposition of the review; (B) The opportunity to request an administrative hearing in writing within fourteen calendar days from the date of a written adverse informal review decision; and
UNOFFICIAL 1706-4 (C) The office and address at which the request for an administrative hearing may be submitted.
(c) Requests for informal reviews that are not received within the timeframe specified in subsection (a) shall be denied.
(d) The informal review shall be concluded prior to the setoff of the debtor's state tax refund and within forty-five calendar days of the date the request was received. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §§231-51 to 231-59)
§17-1706-6 Tax setoff notice. (a) The tax setoff notice shall be mailed to prospective tax refund recipients who are identified as having a debt at the time that the state income tax refund is identified for setoff by DAGS.
(b) The notice shall inform the debtors of the following: (1) The amount of the debtor's state income tax refund for a specified tax year; (2) The amount of the debt; (3) The amount that has been identified for setoff to repay a debt to the department; (4) The balance of the state tax refund that is due to the debtor; (5) The applicable state statute; (6) The opportunity to request an administrative hearing within thirty calendar days of the date of the tax setoff notice; (7) The setoff against the debtor's state income tax refund becomes final after thirty calendar days from the date of the tax setoff notice if an administrative hearing is not requested; (8) The commonly used defenses in tax setoff administrative hearings; (9) The rights of the debtor as specified in section 17-1706-8; and (10) The office, address, and toll free telephone numbers to which a written request for an administrative hearing may be submitted. [Eff 08/01/94; am 01/29/96 ] (Auth: HRS §346-14) (Imp: HRS §§231-51 to 231-59)
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§17-1706-7 Right to an administrative hearing. (a) Identified debtors may request an administrative hearing as follows: (1) Within fourteen calendar days of the date of the adverse pretax setoff review notice; and (2) Within thirty calendar days of the date of the tax setoff notice. (3) If the fourteenth or thirtieth day falls on a weekend or holiday, the fourteenth or thirtieth day shall then be the first working day after the weekend or holiday.
(b) All debtors requesting an administrative hearing shall have the right to submit a written request naming an authorized representative for administrative hearing purposes. The written authorization shall be received by the department before the department acknowledges any action taken by the authorized representative on the debtor's behalf. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §§231-51 to 231-59)
§17-1706-8 Rights of the claimant. The claimant or the authorized representative shall have an opportunity to: (1) Examine the case record as well as all
documents and records to be used at the hearing at a reasonable time before the date of the hearing as well as during the hearing; (2) Present the case independently or with the aid of others including legal counsel; (3) Bring witnesses, including an interpreter if the claimant is non-English speaking. If the claimant does not have an interpreter and the department believes an interpreter is necessary, an interpreter shall be obtained by the department; (4) Establish all pertinent facts and circumstances; (5) Advance any arguments appropriate to the issue being heard without undue interference; and (6) Question or refute any testimony or evidence, and to confront and cross examine any witness. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §§231-51 to 231-59)
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§17-1706-9 Action on request for an administrative hearing. (a) A request for an administrative hearing after an adverse informal review decision shall be received by the department within fourteen calendar days of the date of the written adverse informal decision. When an administrative hearing is requested due to an adverse informal review decision on a pretax setoff notice, the department shall not refer the name of the individual to DAGS as a debtor. The individual's name shall be referred to DAGS as a debtor only if the administrative appeals office renders a decision in favor of the department. A circuit court appeal shall not stay the referral.
(b) A request for an administrative hearing after a tax setoff notice shall be received by the department within thirty calendar days of the date of the tax setoff notice. When an administrative hearing is requested at the time of the tax setoff, the individual will receive that portion of their state tax refund that was setoff only after a decision favorable to the claimant has been rendered by the administrative appeals office.
(c) When an administrative hearing request is received by a unit other than ASO-recovery, the unit shall stamp the request with the date of receipt and immediately forward the hearing request to ASO- recovery.
(d) When an administrative hearing request is received by ASO-recovery, ASO-recovery shall: (1) Stamp the request with the date of receipt if the request is initially received by ASO- recovery; (2) Make one copy of the request and send the original request to the administrative appeals office if the request is initially received by ASO-recovery; (3) Make copies of the account ledgers of all debts (to include financial, medical, and food stamp claims) for the identified debtor; and (4) Forward the copy of the administrative hearing request and copies of the account ledgers to the respective division. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §§231-51 to 231-59)
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§17-1706-10 Department's responsibility. (a) The Policy and Program Development Office (PPDO) of the Med-QUEST Division shall review all requests for fair hearing to assure that all facts are properly considered. If any basis for the grievance is found prior to the hearing, the PPDO office shall promptly take necessary corrective action.
(b) The PPDO office shall complete the branch report.
(c) The PPDO office shall remain in touch with the claimant and shall immediately notify the hearing officer of any change in address or circumstances which may affect the need for the hearing.
(d) The PPDO office shall represent the department in tax setoff hearings on Oahu branch. In all other branches, the supervisors of the unit in the geographic area nearest the debtor's residence shall be the department's representative at the tax setoff hearing, if a PPDO representative is not requested. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §§231-51 to 231-59)
§17-1706-11 Responsibility of the administrative appeals office. (a) The administrative appeals office shall accept: (1) Any request directly at the administrative
appeals office; and (2) All requests cleared through the department.
(b) All parties shall be given written notice of hearing by registered or certified mail with return receipt requested at least fifteen calendar days before the hearing. The notice shall include a statement of: (1) The date, time, place, and nature of hearing; (2) The legal authority under which the hearing is held; (3) The particular sections of the statutes and rules involved; (4) The issues involved and the basis for the department's action; (5) The claimant's right to retain legal counsel; (6) The claimant's right to prompt administrative action; and (7) The administrative hearing decision shall be rendered within one hundred twenty calendar days of the date of request. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §§231-51 to 231-59)
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§17-1706-12 Denial of request for administrative hearing. (a) An administrative hearing shall not be granted by the department when the claimant has withdrawn the request in writing. Where the claimant verbally reports a desire to withdraw the administrative hearing request, the claimant shall be advised that the withdrawal shall be submitted in writing. If the claimant prefers, the department shall confirm the claimant's request to withdraw in writing to the claimant.
(b) An administrative hearing shall not be granted by the department when the department decides not to complete a tax setoff or refunds the tax setoff before a hearing is scheduled.
(c) An administrative hearing shall not be granted by the hearing officer when the claimant has abandoned the request. Abandonment occurs when the claimant or the authorized representative, without good cause, fails to appear at the administrative hearing scheduled for the claimant. (1) The hearing officer shall send the claimant a letter stating that the appeal is considered abandoned unless there was good cause for the claimant's failure to appear. The claimant shall be notified that the request shall
continue only if the claimant presents good cause for the failure to appear and contacts the agency within ten calendar days of the notice. If no reply is received within the ten calendar days, the administrative hearing request shall be considered abandoned. If the tenth day falls on a weekend or holiday, the tenth day shall then be the working day after the weekend or the holiday. (2) Good cause may be established on the basis of one of the following factors: (A) Death in the family; (B) Personal injury or illness which
reasonably prohibits the claimant from attending the administrative hearing; or (C) Sudden and unexpected emergencies.
(d) An administrative hearing shall not be granted if the administrative hearing request is not received within the timeframes specified in section 17-1706-7(a).
(e) When a request for an administrative hearing is denied or dismissed, the department shall inform the claimant in writing, stating the reasons for the denial
UNOFFICIAL 1706-9 or dismissal. Written notice shall be provided the claimant within one hundred twenty calendar days of the date of administrative hearing request. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §§231-51 to 231-59)
§17-1706-13 The administrative hearing. (a) The administrative hearing shall include consideration of: (1) Evidence received, including oral testimony and exhibits; and (2) Proposed findings and exceptions.
(b) The claimant shall be required to appear in person at the administrative hearing unless authorization for an authorized representative was received by the department. When mutually agreed upon by the claimant and the department, a hearing may be conducted over the telephone. Unless both the department and the claimant agree to the presence of other individuals, the hearing officer or other person conducting the administrative hearing shall limit attendance to the following individuals necessary for the conduct of the hearing: (1) The claimant, the authorized representative, or both, interpreter, if any, legal counsel,
and witnesses; (2) Representatives of the state med-QUEST division; and (3) Hearing officer and members of the administrative appeals office staff.
(c) An interpreter shall be provided by the department when requested by the claimant.
(d) The claimant or the authorized representative shall, upon request, be able to examine the case record as well as all available documentary evidence that shall be used by the department at the administrative hearing as specified in section 17-1706-8.
(e) The administrative hearing shall be conducted at a reasonable time, date, and place and shall generally be held in the jurisdiction of the branch in which the claimant is living at the time of the administrative hearing. The administrative hearing shall be conducted at a location specified by the hearing officer unless the claimant is unable to travel to the site because of health or transportation problems.
(f) The decision of the hearing officer shall be based exclusively on evidence and other material
UNOFFICIAL 1706-10 introduced at the administrative hearing. If, after an administrative hearing has begun, additional evidence is necessary for the proper determination of the case, the hearing officer may: (1) Continue the administrative hearing at a later date. The hearing officer may order further investigation and may direct either party to produce additional evidence; or (2) Close the administrative hearing and hold the record open for a period not to exceed thirty days to permit the receipt of additional documentary evidence. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §§231-51 to 231-59)
§17-1706-14 Administrative hearing decision. (a) All matters relating to the administrative hearing shall be heard and disposed of within one hundred twenty calendar days from the date of request for an administrative hearing except when the hearing is continued or the record is held open as specified in section 17-1706-13(f). The time limit shall be extended only for the period of the continuance.
(b) Unless the record is held open for additional documentary evidence, after closing the administrative hearing, the hearing officer shall prepare the decision in writing. The decision shall contain a statement concerning the claimant's right to judicial review, the reasons for the decision, the evidence, and the rules supporting the decision. A copy of the written decision shall be provided the claimant or the authorized representative and the department.
(c) The transcript, recording, or an official record containing the substance of the administrative hearing proceedings, together with all papers filed in the proceeding and the hearing officer's decision shall constitute the exclusive record and shall be maintained in the administrative appeals office. The record shall be made available to the claimant or the authorized representative during normal business hours through the administrative appeals office.
(d) The department shall comply with the administrative hearing decision immediately upon receipt of the decision. (1) When the pretax setoff administrative hearing is favorable to the department, the department shall refer the claimant's name to
UNOFFICIAL 1706-11 the comptroller, department of accounting and general services, as a debtor. A circuit court appeal shall not stay the referral. (2) When the tax setoff administrative hearing is in favor of the claimant, the claimant shall receive that portion of the claimant's state income tax refund that was setoff.
(e) All administrative hearing decisions shall be accessible to the public, subject to the provision of safeguarding public assistance information stated in section 346-10, HRS, and the department's confidentiality provisions specified in chapter 17-1702. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §§231-51 to 231-59)
§17-1706-15 Appeal rights of the claimant. The claimant may appeal an adverse administrative hearing decision to the state circuit court. At the time of the hearing decision which upholds the department's action, the claimant shall be notified of the right to pursue judicial review with the circuit court. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §§231-51 to 231-59)
UNOFFICIAL 1711.1-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1711.1
PROCESSING OF APPLICATIONS FOR MEDICAL ASSISTANCE
Subchapter 1 General Provisions
§17-1711.1-1 Purpose §17-1711.1-2 Availability of program information §§17-1711.1-3 to 17-1711.1-7 (Reserved)
Subchapter 2 Applicants
§17-1711.1-8 Purpose §17-1711.1-9 Who may apply §17-1711.1-10 Individuals who are not required to apply §17-1711.1-11 Application counselors §17-1711.1-12 Authorized representatives §17-1711.1-13 Applicant rights §17-1711.1-14 Applicant responsibilities §§17-1711.1-15 to 17-1711.1-19 (Reserved)
Subchapter 3 Application process
§17-1711.1-20 Purpose §17-1711.1-21 Filing an application for medical assistance §17-1711.1-22 Application withdrawn or discontinued
UNOFFICIAL 1711.1-2 §17-1711.1-23 Verification prior to approval §§17-1711.1-24 to 17-1711.1-28 (Reserved)
Subchapter 4 Eligibility Determination Process
§17-1711.1-29 Purpose §17-1711.1-30 Presumptive eligibility submitted by a qualified hospital §17-1711.1-31 Expedited processing for emergency medical services §17-1711.1-32 Determination of eligibility for Medicaid §17—1711.1-33 Effective date of eligibility §17-1711.1-34 Notice of disposition of the application §§17-1711.1-35 to 17-1711.1-39 (Reserved)
Historical Note: This chapter is based substantially upon repealed chapter 1711. [Eff 8/1/94; am 01/29/96; am 06/19/00; am 12/03/01; am 02/16/02; am 05/10/03; am 07/10/06; am 01/31/09; am 06/11/09; R 09/30/13]
SUBCHAPTER 1
GENERAL PROVISIONS
§17-1711.1-1 Purpose. This chapter describes the application process for medical assistance. [Eff 09/30/13] (Auth: HRS §§346-14, 346-29, 346-53; 42 C.F.R. §435.905, 435.907) (Imp: HRS §346-29; 42 C.F.R. §435.905, 435.907)
§17-1711.1-2 Availability of program information. (a) The department must provide the following information to any individual who requests it: (1) Eligibility requirements;
UNOFFICIAL 1711.1-3 (2) Available medical assistance services; and (3) Rights and responsibilities of an individual with respect to the State’s medical assistance programs. (b) The information listed in subsection (a) shall be: (1) Available in paper format, electronic format including through an internet web site, and orally; and (2) Provided in plain language and in a manner that is accessible and timely. (c) An individual who is limited English proficient shall be provided language assistance services at no cost to the extent required by Title VI of the Civil Rights Act of 1964 (42 U.S.C. §2000d, et seq.) to access the information listed in subsection (a). (d) An individual living with disabilities shall be provided access to auxiliary aids and services at no cost in accordance with the Disabilities Act and section 504 of the Rehabilitation Act to access the information listed in subsection (a). [Eff 09/30/13] (Auth: HRS §§346-14, 346-29; 42 C.F.R. §435.905) (Imp: HRS §346-29, 42 C.F.R. §435.905)
§§17-1711.1-3 to 17-1711.1-7 (Reserved).
SUBCHAPTER 2
APPLICANTS
§17-1711.1-8 Purpose. This subchapter describes the rights and responsibilities of an individual applying for participation in a medical assistance program. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.906, 435.907, 435.908) (Imp: HRS §346-14, 42 C.F.R. §§435.906, 435.907, 435.908)
UNOFFICIAL 1711.1-4 §17-1711.1-9 Who may apply. The department must accept an application for medical assistance and any documentation required to establish eligibility from an applicant, an adult who is in the applicant’s household or family, an authorized representative, or if the applicant is a minor or incapacitated, someone acting responsibly for the applicant. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.906, 435.907, 435.908) (Imp: HRS §346-14, 42 C.F.R. §§435.906, 435.907, 435.908)
§17-1711.1-10 Individuals who are not required to apply. The following individuals shall be automatically determined eligible for Medicaid: (1) A newborn up to one year of age born to a Medicaid beneficiary mother, including a mother receiving only emergency medical services under chapter 17-1723.1; (2) An individual receiving Title IV-E foster care or kinship guardianship payments who is: (A) Under twenty-one years of age; (B) Certified by a social worker of the department to be eligible for Title IV- E foster care maintenance or kinship guardianship payments; and (C) Placed in a licensed or authorized foster home or child caring institution that is appropriately supervised by a licensed child placement agency or the State family court; or (3) An individual covered under a Title IV-E Adoption Assistance Agreement, in effect with any state or Tribe regardless of whether adoption assistance is being provided or a temporary or other judicial decree of adoption has been issued who: (A) Is under twenty-one years of age; and (B) Resides in the state in a subsidized adoptive home. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R.
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§§435.117, 435.118, 435.145, 435.403, 435.903) (Imp: 42 C.F.R. §§435.117, 435.145, 435.403, 435.903)
§17-1711.1-11 Application counselors. (a) The department shall provide assistance to any individual seeking help with the medical assistance application or annual redetermination process in person, over the telephone, and online, in a manner that is accessible to individuals with disabilities and those who are limited English proficient, consistent with subsections 17-1711.1-2(b),(c) and (d). (b) The department may choose to designate organizations, subject to certification by the department or designee to provide assistance to an individual with the application or redetermination process, to include but not be limited to: (1) Completion or submission of an application or redetermination form for medical assistance; (2) Interaction with the department on the status of the application or redetermination; (3) Assistance with responses to the department; and (4) Case management following the initial approval and subsequent redeterminations in compliance with all federal requirements. (c) Application counselors shall not sign forms or receive notices on behalf of the individual unless the individual appoints the application counselor as the individual’s authorized representative under section 17-1711.1-12. (d) The application counselor must be: (1) Authorized and registered by the department or its designee to provide assistance at application and subsequent redeterminations; (2) Authorized by the applicant to function as an application counselor on their behalf; (3) Effectively trained in eligibility and benefit rules and regulations for all
UNOFFICIAL 1711.1-6
medical assistance and insurance affordability programs operated in the State; and (4) Trained in and subject to applicable federal and State laws and regulations regarding safeguarding and confidentiality of information and conflicts of interest. (e) Should the department elect to certify application counselors, the department shall establish: (1) A designated web portal for the exclusive use by certified application counselors for purposes of providing assistance under this section; (2) A secure mechanism to ensure that certified application counselors are able to perform only those activities for which they are certified; and (3) Procedures to ensure that an individual applying for medical assistance: (A) Is informed of the functions and responsibilities of a certified application counselor; and
(B) Is able to authorize an application counselor to receive confidential information about the individual related to the individual’s application for or annual redetermination of Medicaid. (f) Services provided by a certified application counselor shall be free of charge. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.908) (Imp: HRS §346-29, 42 C.F.R. §435.908)
§17-1711.1-12 Authorized representatives. (a) An individual applying for medical assistance may designate an individual or organization to be an authorized representative to act on their behalf to assist with an application, a redetermination of eligibility, and other on-going communications with the department.
UNOFFICIAL 1711.1-7 (b) The designation of an authorized representative must be in writing and signed by the individual. Legal documentation of authority to act on behalf of an individual under State law, to include a court order establishing legal guardianship, or power of attorney, shall serve in the place of a written authorization.
(c) The authority of an authorized representative is valid until: (1) The applicant or beneficiary withdraws the authorization by notifying the department that the representative is no longer authorized to act on the applicant’s or beneficiary’s behalf; (2) There is a change in the legal document of authority to act on the applicant’s or beneficiary’s behalf; or (3) The authorized representative informs the department that he is no longer acting as the individual’s authorized representative. (d) An authorized representative may be authorized to: (1) Sign an application on behalf of an applicant; (2) Receive copies of an individual’s notices and other communications from the department; (3) Act on behalf of the individual in all other matters with the department; and (4) Complete and submit redetermination forms. (e) An authorized representative must agree to maintain, or be legally bound to maintain, the confidentiality of any information regarding the applicant or beneficiary provided by the department. (f) An authorized representative who is a provider, staff member or volunteer of an organization must agree to sign an agreement to comply with regulations relating to: (1) Confidentiality of information (42 C.F.R. part 431, subpart F); (2) Prohibition against reassignment of provider claims as appropriate for a health facility
UNOFFICIAL 1711.1-8 or an organization acting on the facility’s behalf (42 C.F.R. §447.10); (3) Other relevant State and federal laws concerning conflicts of interest and confidentiality of information; and (4) Must meet the authentication and data security standards required under State and federal law or otherwise specified by the department. (g) The department shall accept electronic signatures, including telephonically recorded signatures and handwritten signatures transmitted by facsimile or other electronic transmission, and must accept such signatures through all of the methods specified in section 17-1711.1-21. [Eff 09/30/13] (Auth: HRS §§346-14, 346-29; 42 C.F.R. §435.923) (Imp: HRS §346-29, 42 C.F.R. §435.923)
§17-1711.1-13 Applicant rights. (a) The department must provide an individual the opportunity to apply for Medicaid without delay. (b) The department shall inform the individual of their right to language access services, and auxiliary aids and services for individuals with disabilities, and how to access those services. (c) The department shall not require an in- person interview as part of the application process for a determination of eligibility using MAGI-based income methodology. (d) An individual may withdraw, modify or terminate a submitted application as described in section 17-1711.1-22. (e) An individual eligible under more than one medical assistance program shall be afforded the opportunity to select the program of the individual’s choice. (f) A request for an administrative hearing may be submitted by the individual or the individual’s authorized representative when the individual is not satisfied with the department's eligibility
UNOFFICIAL 1711.1-9 determination, under the provisions of chapter 17- 1703.1. [Eff 09/30/13] (Auth: HRS §§346-14, 346-29; 42 C.F.R. §§435.404, 435.906, 435.907) (Imp: HRS §346-29; 42 C.F.R. §§435.404, 435.905, 435.906, 435.907)
§17-1711.1-14 Applicant responsibilities. (a) The individual shall: (1) Complete the application form(s) as prescribed by the department for medical assistance; (2) Provide all information requested by the department to establish eligibility and submit required documents as appropriate within the time period specified by the department; (3) Apply for and develop potential sources of income and assets as applicable; and (4) Assign any benefits due to a possible third party liability, including referral for child support and initiation of a referral to establish paternity as required under the provisions of chapter 17-1705. (b) An individual who fails to meet the requirements of subsection (a) shall be ineligible for medical assistance. [Eff 09/30/13] (Auth: HRS §§346-14, 346-29; 42 C.F.R. §435.907) (Imp: 42 C.F.R. §435.907)
§§17-1711.1-15 to 17-1711.1-19 (Reserved).
SUBCHAPTER 3
APPLICATION PROCESS
§17-1711.1-20 Purpose. This subchapter describes the application process to determine eligibility for participation in a medical assistance
UNOFFICIAL 1711.1-10 program. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.906, 435.907) (Imp: HRS §346-14, 42 C.F.R. §§435.906, 435.907)
§17-1711.1-21 Filing an application for medical assistance. (a) The application process shall begin when a completed application for medical assistance is received by the department or designee and ends with the department’s issuing an eligibility determination to the applicant. (b) The application shall be used for all insurance affordability programs and may be submitted according to the applicant’s preference by one of the following methods: (1) Via the department’s designated internet web site(s); (2) By telephone; (3) Via the United States Postal Service; (4) In person; and (5) Through other commonly available electronic means. (c) The date an application is received by the department or designee shall be considered the date for a determination of medical assistance. (d) An individual applying for assistance on a basis other than Modified Adjusted Gross Income (MAGI) methodology may be required to provide additional information, as determined by the department, in order to complete an eligibility determination. (e) The department may request a non-applicant’s SSN provided that: (1) The provision of the SSN is voluntary; (2) The SSN is used only to determine an applicant’s eligibility for Medicaid or other insurance affordability program or for a purpose directly connected to the administration of the State plan; and (3) At the time the SSN is requested, the agency notifies and ensures the applicant, or person acting on the applicant’s behalf, understands that the provision of the non-
UNOFFICIAL 1711.1-11 applicant’s SSN is voluntary and how the information regarding the SSN will be used. (f) The application shall be signed under penalty of perjury by the applicant, adult included in the household for an applicant who is a minor, authorized representative, or an individual acting on behalf of an incompetent or incapacitated applicant in accordance with this chapter. [Eff 09/30/13] (Auth: HRS §§346-l4, 346-29, 346-53; 42 C.F.R. §435.907) (Imp: HRS §346-29; 42 C.F.R. §435.907)
§17-1711.1-22 Application withdrawn or discontinued. (a) An individual may withdraw or discontinue an application in writing, verbally by telephone, in person or through other commonly available electronic means. (b) Requests for application withdrawal shall be documented in the individual’s record and a confirmation notice of withdrawal sent in accordance with chapter 17-1713.1. (c) The department may discontinue an application for medical assistance prior to an eligibility determination for any of the following reasons: (1) Death of the applicant, and: (A) Information provided at the point of application is insufficient to determine eligibility; or (B) No other individual is designated or able to continue the application process on behalf of the deceased; (2) Applicant whereabouts is unknown. (d) In the event an application is discontinued, an appropriate notice shall be sent to confirm the department’s action under the provisions of chapter 17-1713.1. (e) An individual whose application was denied or discontinued and reapplies within ninety days from the date of denial or discontinuation shall be able to: (1) Submit updated or supplemental information
UNOFFICIAL 1711.1-12 on the original application form as applicable with a new date of application entered; and (2) The updated application shall be processed in the same manner as a new application. [Eff 09/30/13] (Auth: HRS §§346-14, 346- 29; 42 C.F.R. §§435.907, 435.911, 435.912) (Imp: HRS §346-29; 42 C.F.R. §§435.907, 435.911, 435.912)
§17-1711.1-23 Verification prior to approval. (a) The department shall inform the individual of its intent to obtain and use information from other federal and State programs, as applicable and available, to verify information required to make an eligibility determination for Medicaid and other insurance affordability programs, including, but not limited to: (1) U.S. citizenship or non-citizen status and identity as required by chapter 17-1714.1; (2) Assignment of possible third party liability, including referral for child support and initiation of a referral to establish paternity as required by chapter 17-1705; (3) Date of birth and gender; (4) Social security number as required by chapter 17-1714.1; (5) Gross non-exempt income of the household as required by chapter 17-1724.1; (6) Non-exempt resources of the household as required by chapter 17-1725.1; (7) Blindness or disability as determined in accordance with the provisions of chapter 17-1719; (8) Prior determination of blindness or disability verified by the: (A) Social Security Administration (SSA); (B) Department's Aid to Disabled Review Committee (ADRC); or
UNOFFICIAL 1711.1-13 (C) Department's consultant ophthalmologist with the vocational rehabilitation and services for the blind division at Ho'opono. (b) The department must obtain and accept eligibility information through an electronic service and other means as determined, to the extent the information is available, under the provisions of chapter 17-1714.1. (c) The department shall only require documentation of information that is unavailable through or not reasonably compatible with other sources to complete a determination of eligibility for medical assistance or other insurance affordability or benefit programs. (d) An applicant, individual, or organization who is authorized to apply on behalf of the applicant who has been notified by the department to submit additional information to establish eligibility, shall be given a minimum of fifteen calendar days, which may be extended as determined necessary, to provide the information or verifying documentation from the date the request is sent by the department. [Eff 09/30/13] (Auth: HRS §§346-14, 346-29; 42 C.F.R. §§435.406, 435.407, 435.945, 435.949) (Imp: 42 C.F.R. §§435.406, 435.407, 435.945, 435.949)
§§17-1711.1-24 to 17-1711.1-28 (Reserved).
SUBCHAPTER 4
ELIGIBILITY DETERMINATION PROCESS
§17-1711.1-29 Purpose. This subchapter describes the process to determine eligibility for an individual who is applying for participation in a medical assistance program. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.907) (Imp: HRS §346-14, 42 C.F.R. §435.907)
UNOFFICIAL 1711.1-14 §17-1711.1-30 Presumptive eligibility submitted by a qualified hospital. (a) The department shall provide Medicaid to certain individuals who are determined presumptively eligible by a qualified hospital. (b) Approval for presumptive eligibility shall be limited to the coverage groups as determined by the department. (c) The department shall establish standards, policies, and measures of quality outcomes to qualify, and as appropriate disqualify, hospitals approved to determine presumptive eligibility. (d) The applicant shall be subject to departmental fraud penalties or recovery requirements for false or withheld information. [Eff 09/30/13] (Auth: HRS §§346-l4, 346-29; 42 C.F.R. §§435.906, 435.907, 435.908, 435.1110) (Imp: HRS §346-29; 42 C.F.R. §§435.906, 435.907, 435.908, 435.1110)
§17-1711.1-31 Expedited processing for emergency medical services. (a) An application shall be processed within two working days when: (1) The applicant is suffering from an emergency medical condition for which covered medical services are available; and (2) Failure to receive immediate treatment would result in any of the following consequences; (A) Serious risk of disease; (B) Threat to life or vital function; (C) Serious health complication; or (D) Serious irreparable harm. (b) The applicant shall be required to submit the following: (1) An application for medical assistance; and (2) The prescribed departmental form, signed by a licensed physician, advance practice registered nurse or dentist, certifying the need for immediate medical treatment based on any of the reasons in subsection (a) and that the individual will not be treated
UNOFFICIAL 1711.1-15 unless the department determines eligibility for medical assistance. (c) The applicant shall be subject to departmental fraud penalties or recovery requirements for false or withheld information. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.911, 435.930, 435.945) (Imp: 42 C.F.R. §435.911, 435.930, 435.945)
§17-1711.1-32 Determination of eligibility for Medicaid. (a) The department shall determine eligibility according to federal and State regulations and policies. The decision regarding eligibility or ineligibility shall be supported by facts in the applicant's record. Each application shall be determined as eligible or ineligible unless the application is withdrawn or discontinued under section 17-1711.1-22. (b) Timely dispositions of eligibility or ineligibility shall be made within: (1) Ninety days from the date of application for an applicant applying for medical assistance on the basis of disability including applications for long-term care; or (2) Forty-five days from the date of application for all other applicants. (c) A determination of eligibility or ineligibility shall be completed within the applicable time standards except in unusual circumstances such as: (1) A delay or failure of an applicant or appropriate required agency to take required action; or (2) An administrative or other type of emergency beyond the department's control. (d) The department shall not use the time standards specified in paragraph (b) of this section as a waiting period before determining eligibility or for a denial due to failure of the department to determine eligibility timely.
UNOFFICIAL 1711.1-16 (e) A delay beyond the applicable time standard under paragraph (b) of this section attributed to the department shall not result in the withholding of medical assistance from the applicant. A presumption of eligibility for medical assistance shall be made: (1) Effective the ninety-first day for an applicant applying on the basis of disability including for long-term care, or on the forty-sixth day for any other applicant until a determination of eligibility is completed; and (2) The reason for the delay shall be documented in the applicant's record. (f) For an applicant subject to MAGI methodology who meets the financial requirements for eligibility and for whom the department is providing a reasonable opportunity to provide documentation of citizenship or immigration status, the department, consistent with the applicable timeliness standard, shall furnish medical assistance. (g) For an applicant who is applying for a MAGI- excepted group and for whom additional information is required to determine eligibility, eligibility shall be determined under a MAGI group until the determination of eligibility on any other basis is completed. (h) For an individual determined ineligible for Medicaid, the department shall transfer the individual's application information for other insurance affordability programs as appropriate pursuant to 42 C.F.R. §435.1200(e). [Eff 09/30/13] (Auth: HRS §§346-14, 346-29; 42 C.F.R. §§435.907, 435.911, 435.912, 435.914, 435.945, 435.1200) (Imp: HRS §346-29; 42 C.F.R. §§435.907, 435.911, 435.912, 435.914, 435.945, 435.1200)
§17-1711.1-33 Effective date of eligibility. (a) The effective date of eligibility for an applicant approved for medical assistance shall be one of the following:
UNOFFICIAL 1711.1-17 (1) The date the application is received by the department; or (2) For an individual approved as medically needy, the date on which appropriate medical expenses, in accordance with chapter 17-1730.1, were incurred; or (3) The date on which all applicable eligibility requirements are met by the applicant; or (4) For a newborn of a beneficiary mother, the date of the child’s birth; (5) For a request for retroactive medical coverage of eligible services, the applicant shall: (A) Include the request for retroactive coverage on the application; or (B) Submit a written request to the department within thirty calendar days from the date of the eligibility determination; and (C) The effective date of coverage for eligible retroactive services received shall be no earlier than the first day of the third month prior to the month the application is received by the department for individuals applying for coverage of long-term care services or ten calendar days immediately prior to the date the application is received by the department for all other individuals. (b) If the individual is found to be ineligible for the month of application, the effective date of eligibility shall be the date of the subsequent month in which all eligibility requirements are met by the individual. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25; 435.915) (Imp: HRS §346-14; 42 C.F.R. §§430.25; 435.915)
§17-1711.1-34 Notice of disposition of the application. (a) A notice of disposition of the
UNOFFICIAL 1711.1-18 application shall be sent under the provisions of chapter 17-1713.1. (b) If determined eligible for medical assistance, the individual shall be issued a Medicaid identification card by the department as appropriate. (c) For an individual determined ineligible for Medicaid, the department shall transfer the individual's application information for other insurance affordability programs as appropriate pursuant to 42 C.F.R. §435.1200(e). [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§431.10, 435.911, 435.912, 435.917, 435.1200) (Imp: HRS §346-14; 42 C.F.R. §§431.10, 435.911, 435.912, 435.917, 435.1200)
§§17-1711.1-35 to 17-1711.1-39 (Reserved).
UNOFFICIAL 1712.1-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1712.1
ELIGIBILITY REDETERMINATIONS
§17-1712.1-1
Purpose §17-1712.1-2
Annual redetermination of a MAGI beneficiary §17-1712.1-3 Annual redetermination of a MAGI- excepted beneficiary §17-1712.1-4 Redetermination due to a change in beneficiary household circumstances §§17-1712.1-5 to 17-1712.1-9 (Reserved)
Historical Note: This chapter is based substantially upon repealed chapter 17-1712. [Eff 8/1/94; R 09/30/13]
§17-1712.1-1 Purpose. This chapter establishes the circumstances, time periods, and conditions under which a redetermination of eligibility for continuing medical assistance shall be made. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§431.10, 435.916) (Imp: 42 C.F.R. §§431.10, 435.916)
§17-1712.1-2 Annual redetermination of a MAGI beneficiary. (a) The beneficiary may request assistance with an annual redetermination under the
UNOFFICIAL 1712.1-2 provisions described in subchapter 2 of chapter 17- 1711.1. (b) The annual redetermination of an individual or household, whose Medicaid eligibility is based on modified adjusted gross income methods (MAGI), shall be completed by the department no more frequently than once every twelve months. (c) The annual redetermination of Medicaid eligibility shall be based on reliable information available to the department to include information through a federal or state database as described in chapter 17-1714.1, without requiring additional information from the beneficiary. (d) If able to redetermine eligibility based on available information, the department shall notify the beneficiary as described under the provisions of chapter 17-1713.1, of the following: (1) The eligibility redetermination decision and basis; and (2) If the information is accurate, the beneficiary is not required to sign and return the notice; or (3) If the information is not accurate, the beneficiary is required to correct, sign and return the notice. (e) If the department is unable to redetermine eligibility in accordance with paragraph (c) of this section, the department shall: (1) Send a pre-populated redetermination form containing information available to the department that is needed to redetermine eligibility, allowing at least thirty days from the date the redetermination form is sent to respond and provide any necessary information through any mode of communication under the provisions of chapter 17-1711.1; (2) Upon receipt, verify the information provided by the beneficiary; and (3) Inform the beneficiary of the eligibility decision under the provisions described in chapter 17-1713.1.
UNOFFICIAL 1712.1-3 (f) A beneficiary who is terminated for failure to submit the redetermination form or necessary information, then later submits the redetermination form within ninety days after the date of termination, shall not be required to submit a new application. The new effective date of eligibility shall be the date the redetermination form is received. (g) The beneficiary shall not be required to complete an in-person interview as part of the annual redetermination process. (h) Verification of eligibility criteria may occur between scheduled eligibility redeterminations as described in subchapter 5 of chapter 17-1714.1. [Eff 09/30/13] (Auth: HRS §346-14; Imp: 42 C.F.R. §§435.531, 435.541, 435.911, 435.916, 435.952) (Imp: 42 C.F.R. §§435.531, 435.541, 435.911, 435.916, 435.952)
§17-1712.1-3 Annual redetermination of a MAGI- excepted beneficiary. (a) The beneficiary may request assistance with an annual redetermination under the provisions as described in subchapter 2 of chapter 17-1711.1. (b) The annual redetermination of an individual or household whose Medicaid eligibility is based on MAGI-excepted methodology shall be completed by the department every twelve months. (c) The department shall: (1) Send a pre-populated redetermination form containing information available to the department to respond and provide necessary information, sign and return the form through any mode of communication, at least thirty days from the date the redetermination form is sent to the beneficiary in accordance with the provisions of chapter 17-1711.1; (2) Upon receipt of a signed redetermination form, verify the information provided by the beneficiary; and
UNOFFICIAL 1712.1-4 (3) Inform the beneficiary of the eligibility decision under the provisions described in chapter 17-1713.1. (d) A beneficiary who is terminated for failure to submit the redetermination form or necessary information, then later submits the redetermination form within ninety days after the date of termination shall not be required to submit a new application. The new effective date of eligibility shall be the date the redetermination form is received. (e) The department may consider: (1) Blindness as continuing until a reviewing physician determines that an individual's vision has improved beyond the definition of blindness under the provisions described in section 17-1719-10; or (2) Disability as continuing until the department receives verification that an individual's disability no longer meets the definition of disability under the provisions described in section 17-1719-10.
(f) Verification of eligibility criteria may occur between scheduled eligibility redeterminations as described in subchapter 5 of chapter 17-1714.1. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.531, 435.541, 435.911, 435.916, 435.952) (Imp: 42 C.F.R. §§435.531, 435.541, 435.911, 435.916, 435.952)
§17-1712.1-4 Redetermination due to a change in beneficiary household circumstances. (a) Between annual redeterminations of eligibility, an individual or household shall report any changes in circumstance that may affect eligibility through their elected mode of communication within ten days of the change. (b) Upon receipt of the change in circumstance information, the department shall redetermine eligibility according to the provisions of sections 17-1712.1-2 or 17-1712.1-3, as applicable.
UNOFFICIAL 1712.1-5 (c) For an individual determined eligible using MAGI-based methodology, the department shall: (1) Limit requests for additional information solely to the reported change in circumstance; (2) If able to redetermine eligibility of all requirements based on the reported change, a new twelve-month period of eligibility may be established; (3) If informed of an anticipated change, redetermine eligibility at the appropriate time of the change; (4) Process the addition of a new member to the household in accordance with paragraphs (b) and (c) of this section; and (5) Prior to making a determination of ineligibility, determine all bases of eligibility under other chapters under this subtitle; and (6) For an individual determined ineligible for Medicaid, the department shall transfer the individual's application information for other insurance affordability programs as appropriate pursuant to 42 CFR §435.1200(e). (d) For an individual determined eligible using MAGI-excepted methodology, the department: (1) May utilize the change in circumstance opportunity to collect additional information in order to complete a redetermination of eligibility for the household. Requests for non-applicant information shall be limited as described under section 17-1711.1-21(e); (2) May establish a new twelve month period of eligibility if able to redetermine eligibility of all requirements; (3) Except for the addition of a newborn to a household, shall require a beneficiary requesting the addition of a new household to submit a completed application and supporting documentation as described in chapter 17-1711.1. A redetermination of
UNOFFICIAL 1712.1-6
eligibility for the household shall be completed based upon the submitted application and information; (4) If informed of an anticipated change, shall redetermine eligibility at the appropriate
time of the change; (5) Prior to making a determination of ineligibility, shall determine all bases of eligibility under other chapters of this subtitle; and (6) For an individual determined ineligible for Medicaid, the department shall transfer the individual's application information for other insurance affordability programs as appropriate pursuant to 42 CFR §435.1200(e). [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.902, 435.916, 435.1200) (Imp: 42 C.F.R. §§435.902, 435.916, 435.1200)
§§17-1712.1-5 to 17-1712.1-9 (Reserved).
UNOFFICIAL 1713.1-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1713.1
NOTICES
§17-1713.1-1 Purpose §17-1713.1-2 Notice of eligibility or level of benefits and services §17-1713.1-3 Use of electronic notices §17-1713.1-4 Notice content §17-1713.1-5 Timely and adequate notice §17-1713.1-6 Termination of eligibility §§17-1713.1-7 to 17-1713.1-11 (Reserved)
Historical Note: This chapter is based substantially upon repealed chapter 17-1713. [Eff 08/01/94; am 01/29/96; am 03/30/96; am 10/26/01; R 09/30/13]
§17-1713.1-1 Purpose. The purpose of this chapter is to establish the circumstances, conditions, and deadlines under which the department shall notify an individual regarding a determination of eligibility, level of benefits or services, spenddown or premium amounts and adverse actions. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§431.206; 431-214, 431.917, 435.918) (Imp: HRS §346-14; 42 C.F.R. §§431.206; 431- 214, 431.917, 435.918)
§17-1713.1-2 Notice of eligibility, or level of benefits and services. (a) The department shall provide an individual with a written notice of any decision by the department or designee affecting the individual’s eligibility for benefits and services approval, denial, termination, or suspension of
UNOFFICIAL 1713.1-2 benefits or services. (b) The notice shall be written in plain language and be accessible to a person who is limited English proficient or has a disability. (c) The notice content shall include that an individual’s information may be transferred to all applicable insurance affordability programs. (d) Effective January 1, 2015, for MAGI determinations, the department shall provide a combined eligibility notice in coordination with the Health Insurance Exchange. [Eff 09/30/13] (Auth: HRS §346- 14; 42 C.F.R. §§431.206, 435.917, 435.1200) (Imp: HRS §346-14; 42 C.F.R. §§431.206, 435.917, 435.1200)
§17-1713.1-3 Use of electronic notices. (a) An individual shall be provided a choice to receive notices and information in electronic format in lieu of regular mail. When an electronic format is requested, the department shall: (1) Confirm by regular mail the individual’s election to receive notices electronically; (2) Inform the individual of the right to change the election, at any time, to regular mail; (3) Post notices to the electronic account within one business day of notice generation; (4) Send an email or other electronic communication to alert the individual of the posting of a notice to their electronic account. No confidential information shall be contained in the email or electronic alert; (5) If undeliverable, send the notice by regular mail within three (3) business days of the date of the failed electronic communication; and (6) Provide, upon request, a paper-based notice sent through regular mail of any notice posted to the electronic account. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.918) (Imp: HRS §346-14; 42 C.F.R. §435.918)
UNOFFICIAL 1713.1-3 §17-1713.1-4 Notice content. (a) A notice of approved eligibility includes, but is not limited to: (1) The basis and effective date of eligibility; (2) The circumstances and procedures under which reporting is required; (3) If applicable, the amount of medical expenses which must be incurred to establish eligibility for medically needy spenddown; (4) Information on the level of benefits and services approved, including, any premiums, enrollment fees and cost sharing; and (5) Information on administrative appeal rights as described in chapter 17-1703.1 to appeal eligibility or approved level of benefits and services. (b) A notice to deny or take other action affecting an individual’s eligibility or level of benefits and services, based on the individual’s household income at or below the applicable MAGI standard shall contain information on the basis for eligibility other than the MAGI standard and how to request a determination on a MAGI-excepted basis. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§431.210, 435.917) (Imp: HRS §346-14; 42 C.F.R. §§431.210, 435.917)
§17-1713.1-5 Timely and adequate notice. (a) Prior to the implementation of any adverse action which affects an individual, a timely and adequate notice shall be sent. (b) A notice of adverse action shall be considered timely when sent: (1) At least fifteen (15) calendar days prior to the effective date of adverse action except as described in paragraph (c). When a new address is reported to the department by the individual within the eligible period, a new notice shall be re-issued; or (2) Five (5) calendar days prior to the effective date of adverse action when the department has evidence of probable fraud by the individual. (c) Adequate notice shall be sent not later than the date of action when: (1) The department has factual information confirming the death of an individual;
UNOFFICIAL 1713.1-4 (2) The department received a clear written statement signed by the individual or authorized representative that: (A) Medical assistance is no longer wanted; or (B) Provides information that necessitates termination or reduction of services and indicates the individual understands that the consequences of supplying the information is the reduction or termination of assistance; (3) The individual has been admitted or committed to a public institution ineligible to receive medical assistance; (4) The individual is transferred or discharged from a long-term care facility or qualified home and community based home; (5) The individual's whereabouts are unknown and mail sent to the individual has been returned by the post office indicating no known forwarding address; (6) The department has verified the individual's receipt of medical assistance in another jurisdiction, state, territory or commonwealth; (7) A change in the level of medical care is prescribed by the individual’s physician; or (8) Involves an adverse action made in regards to preadmission screening requirements. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§431.206, 431.211, 431.213, 431.214, 435.917) (Imp: HRS §346-14; 42 C.F.R. §§431.206, 431.211, 431.213, 431.214, 435.917)
§17-1713.1-6 Termination of eligibility. (a) The department shall terminate an individual’s eligibility and send notice of the adverse action when: (1) A signed, written request for termination is received from the eligible individual; (2) The department has verified the death of an eligible individual; (3) The eligible individual is admitted or committed to a public institution; (4) The eligible individual is no longer residing in the state;
UNOFFICIAL 1713.1-5 (5) The eligible individual's whereabouts are unknown; (6) The eligible individual, when required to meet the asset standard, fails to provide the department with verification to determine the amount of the assets; (7) The eligible individual, whose eligibility determination is not based on the MAGI standard, fails to provide the department with verification to determine the amount of income; (8) The eligible individual fails to apply for and develop potential sources of assets and income when required; (9) An eligibility redetermination is not completed because of the eligible individual’s failure to provide the department with requested verification or to provide a completed eligibility redetermination form when required; (10) The eligible individual fails to meet any of the necessary requirements of the eligibility group; or (11) The eligible individual fails to cooperate or provide information to federal or state personnel who review the decisions regarding eligibility for assistance. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.903, 435-916) (Imp: HRS §§346- 14; 42 C.F.R. §§435.903, 435-916)
§§17-1713.1-7 to 17-1713.1-11 (Reserved).
UNOFFICIAL 1714.1-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1714.1
GENERAL ELIGIBILITY REQUIREMENTS FOR MEDICAL ASSISTANCE
Subchapter 1 General Provisions
§17-1714.1-1
Purpose §17-1714.1-2
Right to assistance §17-1714.1-3
Evidence of identity §17-1714.1-4
Determination of age §§17-1714.1-5 to 17-1714.1-9 (Reserved)
Subchapter 2 Social Security Number
§17-1714.1-10 Purpose §17-1714.1-11 Furnishing of social security number §17-1714.1-12 Verification of SSN §17-1714.1-13 Use of SSN §§17-1714.1-14 to 17-1714.1-18 (Reserved)
Subchapter 3 Residency and Institutional Status
§17-1714.1-19 Purpose §17-1714.1-20 Residency requirements §17-1714.1-21 Eligibility requirements for a resident of a public institution §§17-1714.1-22 to 17-1714.1-26 (Reserved)
UNOFFICIAL 1714.1-2 Subchapter 4 Citizenship and Non-Citizen Status
§17-1714.1-27 Purpose §17-1714.1-28 Citizen and non-citizen eligibility §17-1714.1-29 Declaration of citizenship and non- citizen status §17-1714.1-30 Verification of citizenship and non- citizen immigration status §17-1714.1-31 Documentary evidence of citizenship §§17-1714.1-32 to 17-1714.1-36 (Reserved)
Subchapter 5 Eligibility Verification
§17-1714.1-37 Purpose §17-1714.1-38 General requirements §17-1714.1-39 Verification of financial information §17-1714.1-40 Use of information and requests of additional information from an individual §§17-1714.1-41 to 17-1714.1-45 (Reserved)
Historical Note: This chapter is based substantially upon repealed chapter 17-1714. [Eff 08/01/94; am 01/29/96; am 01/02/97; am 02/10/97; am 05/17/97; am 12/27/97; am 06/19/00; am 07/10/06; am 09/10/09; am 04/01/10; am 04/30/10; R 09/30/13]
SUBCHAPTER 1
GENERAL PROVISIONS
§17-1714.1-1 Purpose. The purpose of this chapter is to establish the non-financial general eligibility requirements for medical assistance. [Eff 09/30/13] (Auth: HRS §346-14) (Imp: HRS §346- 14; 42 C.F.R. §435.401)
UNOFFICIAL 1714.1-3 §17-1714.1-2 Right to assistance. (a) The department shall promptly provide medical assistance without delay to any individual or household who meets all of the applicable eligibility requirements set forth by subtitle 12. (b) An individual shall receive assistance unless determined ineligible for coverage due to the individual’s or household’s failure to provide required verification or meet all Medicaid eligibility requirements. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.930) (Imp: HRS §346-14; 42 C.F.R. §435.930)
§17-1714.1-3 Evidence of identity. (a) The department shall verify the identity of an individual or household member prior to the approval of assistance. (b) Verification of an individual’s identity through a federal or State governmental agency, including but not limited to a public assistance, law enforcement, internal revenue or tax bureau, or corrections agency, or an Express Lane agency, under section 1902 of the Social Security Act, shall be accepted in lieu of documentation required under subsections (c), (d) and (e). (c) For an individual sixteen years of age or older, the department shall accept the following as proof of identity, provided the documentation has a photograph or other identifying information including, but not limited to, name, age, sex, race, height, weight, eye color, or address: (1) Driver’s license issued by a state or U.S. territory; (2) School identification card; (3) U.S. military card or draft record; (4) Identification card issued by the federal or state government; (5) Military dependent’s identification card; (6) Native American tribal documents; or (7) U.S. Coast Guard Merchant Mariner card.
UNOFFICIAL 1714.1-4 (d) For an individual under nineteen years of age, the department shall accept documentation from a clinic, doctor, hospital, or school record, including preschool or day care records. (e) Two of the following types of documents containing consistent information that corroborate an individual’s identity, including, but not limited to, employer identification card, high school and college diploma (including high school equivalency diploma), marriage certificate, divorce decree, and property deed or title. (f) If the individual does not have any document(s) specified in subsections (c), (d) and (e), and identity is not verified under subsection (b), the individual may submit an affidavit signed, under penalty of perjury, by another person who can reasonably attest to the individual’s identity. The affidavit shall contain the individual’s name and other identifying information establishing identity, as described in subsection (c) above. The affidavit does not have to be notarized. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.407; 8 C.F.R. §274a.2(b)(1)(v)(B)(1)) (Imp: HRS §346-14; 42 C.F.R. §435.407; 8 C.F.R. §274a.2(b)(1)(v)(B)(1))
§17-1714.1-4 Determination of age. (a) Verification of an individual's age shall be required when age is a factor in determining eligibility for medical assistance. (b) Verification of an individual’s age through a federal or State electronic service as described in section 17-1714.1-12(b) shall be accepted in lieu of documentation required under subsections (c) and (d). (c) The department may accept documentation that establishes citizenship or immigration status or identity of an individual under subsections 17-1714.1- 31(a), (b) and (d) for purposes of establishing the age of an individual provided that such documentation reflects the date of the birth of the individual. (d) When documentary sources are not available, the statements of relatives or friends who are
UNOFFICIAL 1714.1-5 knowledgeable of the individual's circumstances may be accepted as verification of age. The individual’s record shall contain documentation of the:
(1) Name of the relatives or friends; and (2) Facts on which the relatives' or friends' knowledge is based. (e) When all reasonable efforts to establish age have failed, an estimate of age based upon an examination by a physician shall be used. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.401, 435.520, 435.956) (Imp: HRS §346-14; 42 C.F.R. §§435.401, 435.520, 435.945, 435.952, 435.956)
§§17-1714.1-5 to 17-1714.1-9 (Reserved).
SUBCHAPTER 2
SOCIAL SECURITY NUMBER
§17-1714.1-10 Purpose. This subchapter establishes the requirement for a social security number (SSN) for determining an individual’s eligibility for medical assistance. [Eff 09/30/13] (Auth: HRS §346-14; 42 CFR §§435.910, 435.920, 435.930, 435.956) (Imp: HRS §346-14; 42 CFR §§435.910, 435.920, 435.930, 435.956)
§17-1714.1-11 Furnishing of social security number. (a) The department shall require, as a condition of eligibility, that each individual applying for medical assistance furnish a SSN, except as provided in paragraph (c). (b) If an individual is unable to furnish a SSN or has not been issued a SSN, the department shall: (1) Assist the applicant in completing an application for a SSN; (2) Obtain evidence required under the SSA regulations to establish the age,
UNOFFICIAL 1714.1-6
citizenship or non-citizen status, and the true identity of the individual; and (3) Send the application to SSA or, if there is evidence that the individual has previously been issued a SSN, request that the SSA furnish the number. (c) The following are exceptions to the requirements of subsection (a): (1) The department may give a Medicaid identification number to an individual who: (A) Is born to a Medicaid mother; (B) Is not eligible to receive a SSN; (C) Does not have a SSN and may only be issued a SSN for a valid non-work reason; or (D) Refuses to obtain a SSN because of well-established religious objections as defined in 42 C.F.R. §435.910(h)(3). (2) The identification number may be either a SSN obtained by the department on the individual’s behalf or another unique identifier. (3) A newborn under age one year is not required to provide a SSN. [Eff 09/30/13] (Auth: HRS §§346-14, 346-71; 42 C.F.R. §§435.910, 435.956) (Imp: HRS §346-14; 42 C.F.R. §§435.910, 435.956)
§17-1714.1-12 Verification of SSN. (a) The department shall verify the SSN furnished by an individual with SSA to insure the SSN was issued to that individual, and to determine whether any other SSNs were issued to that individual. (b) To the extent that the SSN information is available through a federal or State electronic service, the department shall obtain verification of the individual’s SSN information through the electronic service from SSA. For purposes of this chapter, “federal electronic service” means a service established by the federal government through which the department may verify certain information with, or
UNOFFICIAL 1714.1-7 obtain such information from, federal agencies and other data sources, including the SSA, Department of the Treasury, and the Department of Homeland Security. A “state electronic service” means a service established by the State through which the department may verify certain information with, or obtain such information from, state agencies and other data sources, including the Department of Labor, or other departments as appropriate. (c) If the department is not able to verify the SSN through a federal or State electronic service, the department shall verify the SSN through other means. (d) The department shall not deny or delay medical assistance to an individual who meets all other eligibility requirements pending the issuance or verification of the individual’s SSN by the SSA or if the individual meets one of the exceptions in subsection 17-1714.1-11(c). The individual shall be required to report the SSN to the department immediately upon receipt. (e) When the SSN has been verified, the department shall make a permanent entry to the individual’s electronic account to prevent the unnecessary reverification of the SSN. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.910, 435.920, 435.949, 435.956) (Imp: HRS §346- 71; 42 C.F.R. §§435.910, 435.920, 435.949, 435.956)
§17-1714.1-13 Use of SSN. The department shall notify the individual that the SSN is required by section 1137(a)(1) of the Social Security Act (42 U.S.C. § 1320b-7(a)(1)) to: (1) Verify income, eligibility, and benefits for purposes of medical assistance through computer matches authorized under the federal or State electronic services described in section 17-1714.1-12(b); and (2) Complete computer matching to prevent duplicate participation or assistance, to facilitate mass changes in federal benefits, and to verify the accuracy and reliability
UNOFFICIAL 1714.1-8
of the information provided by the household under subchapter 5. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.910) (Imp: HRS §346-14; 42 C.F.R. §435.910)
§§17-1714.1-14 to 17-1714.1-18 (Reserved).
SUBCHAPTER 3
RESIDENCY AND INSTITUTIONAL STATUS
§17-1714.1-19 Purpose. The purpose of this subchapter is to describe how an individual’s state of residence is determined for purposes of establishing eligibility for medical assistance. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.403) (Imp: HRS §346-14; 42 C.F.R. §§435.403)
§17-1714.1-20 Residency requirements. (a) An individual shall be considered to be a resident of the State when: (1) Residing or expressing intent to reside in the State, even if the individual does not have a fixed address; (2) Has entered the State with a job commitment or seeking employment (whether or not currently employed); or (3) Is in receipt of State Supplementary Payment (SSP). (b) For an individual under age twenty-one who is capable of indicating intent and who is not eligible for Medicaid based on receipt of assistance under Title IV-E of the Social Security Act and not receiving a State Supplementary Payment who is: (1) Emancipated from their parent(s) or who is married, the state of residence shall be in accordance with subsection (a);
UNOFFICIAL 1714.1-9 (2) Not described in paragraph (b)(1), the state of residence is: (A) The state where the individual resides, even if the individual does not have a fixed address; or (B) The state of residency of the parent or caretaker with whom the individual resides. (c) For an institutionalized individual who is neither married nor emancipated, and who: (1) Became incapable of indicating intent to reside before age twenty-one, except as provided in subsection (a)(3), the state of residence is that of the individual’s: (A) Parent(s) or guardian, if one has been appointed; or (B) Parent applying for medical assistance on the individual’s behalf if the parents reside in separate states and there is no appointed legal guardian. (2) Became incapable of indicating intent to reside after age twenty-one, the state of residence is the state in which the individual is physically present, except where another state makes the placement. (d) For purposes of subsection (b), an individual is considered incapable of indicating intent to reside when: (1) The individual’s I.Q. is forty-nine or less, or has a mental age of seven years or less, based on tests acceptable to the intellectual disability agency of the State; (2) The individual is judged legally incompetent; or (3) The individual is found incapable of indicating intent based on medical documentation obtained from a physician, psychologist, or other individual licensed by the State in the field of intellectual disability. (e) When a placement is initiated by a state due to the lack of appropriate facilities to provide
UNOFFICIAL 1714.1-10 services to its residents, the state making the placement is the individual’s state of residence. (f) A resident who is eligible for medical assistance and who is temporarily absent from the State with the intent to return when the purpose of the absence has been accomplished, does not interrupt a resident’s State residency unless another state has determined that the individual is a resident there for purposes of Medicaid. Within ninety days of the day of departure, the department shall re-evaluate the individual’s intent to return to the State based on the submission of the following: (1) The intended date of the out-of-state visit and the intended date of return back to the State; and (2) The intended date of return, if an extension from the original date previously submitted was changed. (g) Medical assistance shall be provided to a resident temporarily absent from the State who: (1) Meets all conditions of eligibility for medical assistance as specified in the department rules; and (2) Requires medical services outside the State under circumstances where services were emergent or when it would be impractical to return to the State for the necessary services. (h) The department may have a written agreement with another state setting forth rules and procedures to resolve disputes involving the place of residency. (i) Where two or more states disagree on an individual’s state of residence, the state where the individual is physically located shall be the state of residence. (j) The department shall accept a self- attestation by the individual or attestation by an adult who is in the household, authorized representative, or someone acting responsibly on behalf of a minor or incapacitated individual for information to verify State residency.
UNOFFICIAL 1714.1-11 (k) Evidence of immigration status may not be used to determine that an individual is not a State resident. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.403, 435.945, 435.956) (Imp: HRS §346- 14; 42 C.F.R. §§435.403, 435.945, 435.956)
§17-1714.1-21 Eligibility requirements for a resident of a public institution. (a) An individual shall not be eligible for medical assistance when the individual is: (1) An inmate in a public institution; or (2) Under age sixty-five who is a resident or patient in an institution for mental disease or tuberculosis, unless the individual is under age twenty-two and is in receipt of inpatient psychiatric services. (b) An individual described in paragraph (a) shall be eligible for medical assistance during that part of the month in which the individual has been paroled from a public institution, or is on conditional release or convalescent leave from an institution for mental diseases or tuberculosis. (c) An individual on conditional release or convalescent leave from an institution for mental diseases is not considered to be a patient in that institution, unless the individual is under age twenty-two and in receipt of inpatient psychiatric services, until the individual is unconditionally released or, if earlier, reaches age twenty-two years. (d) An individual shall not be considered an inmate of a public institution when the individual is in a public educational or vocational training institution for purposes of securing education or vocational training; or is in a public institution for a temporary period pending other arrangements appropriate to the individual’s needs. (e) An inmate of a public institution may be eligible, provided all other requirements are met, for inpatient services that are provided in a medical institution that is not located on the grounds of the public institution. [Eff 09/30/13] (Auth: HRS
UNOFFICIAL 1714.1-12 §§346-14, 346-29; 42 C.F.R. §§435.403, 435.1009, 435.1010) (Imp: HRS §346-29; 42 C.F.R. §§435.403, 435.1009, 435.1010)
§§17-1714.1-22 to 17-1714.1-26 (Reserved).
SUBCHAPTER 4
CITIZENSHIP AND NON-CITIZENSHIP STATUS
§17-1714.1-27 Purpose. The purpose of this subchapter is to establish the types of acceptable documentary evidence of citizenship and non-citizen status that an individual or household shall meet to be eligible for Medicaid. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.406, 435.407) (Imp: HRS §346- 14; 42 C.F.R. §§435.406, 435.407)
§17-1714.1-28 Citizen and non-citizen eligibility. (a) The following individuals meet the citizenship and non-citizen requirements to be eligible for Medicaid: (1) A citizen of the U.S. who has declared that the individual is a citizen or national of the U.S., and the department has verified the declaration under section 17-1714.1-30. For purposes of this subchapter, a citizen of the U.S. includes naturalized citizens, members of a federally-recognized Indian Tribe, and individuals born in the fifty states, the District of Columbia, Puerto Rico, Guam, American Virgin Islands, American Samoa, Swain's Island, or the Commonwealth of the Northern Mariana Islands. (2) A qualified non-citizen: (A) Who is granted asylum under section 208 of the INA (8 U.S.C. § 1158);
UNOFFICIAL 1714.1-13 (B) Who is admitted to the U.S. as a refugee under section 207 of the INA (8 U.S.C. § 1157); (C) Whose deportation is being withheld under section 243(h) of the INA (8 U.S.C. § 1253, as in effect immediately before the effective date of section 307 of division C of Public Law 104- 208) or section 241(b)(3) of the INA (8 U.S.C. §1231(b)(3), as amended by section 305(a) of division C of Public Law 104-208); or (D) Who is a Cuban or Haitian refugee or entrant as addressed in Title IV of the Immigration and Nationality Act and section 501 of the Refugee Education Assistance Act. (b) The following qualified non-citizen, who entered the U.S. on or after August 22, 1996, beginning five years after the individual’s entry into the U.S., who is a: (1) Legal permanent resident; (2) Non-citizen who is paroled into the U.S. under section 212(d)(5) of the INA (8 U.S.C. § 1182(d)(5)) for a period of at least one year; (3) Non-citizen who is granted conditional entry under section 203(a)(7) of the INA (8 U.S.C. § 1153(a)(7)) as in effect prior to April 1, 1980; (4) Non-citizen who has been battered or subjected to extreme cruelty in the U.S. by a spouse, parent, or household member with the spouse or parent’s consent or acquiescence, including a battered child and parent(s) of the battered child (without the active participation of the parent(s) in the battery or cruelty) as described in 8 U.S.C. § 1641(c), and has been approved for or has a petition pending that sets forth a prima facie case to be granted status by USCIS as a battered spouse, a child, or a parent of a
UNOFFICIAL 1714.1-14 battered child under clauses (i), (ii), (iii) and (iv) of section 204(a)(1)(A) or clauses (i), (ii) and (iii) of section 204(a)(1)(B) of the INA, provided that the individual responsible for such battery does not reside in the same household as the individual subjected to the battery; or (5) An individual who has been granted nonimmigrant status under section 101(a)(15)(T) of the INA (8 U.S.C. §1101(a)(15)(T)) as a victim of a severe form of trafficking in individuals or who has a pending application that sets forth a prima facie case for eligibility for such nonimmigrant status, provided that the individual responsible for such cruelty does not reside in the same household as the individual subjected to the cruelty. (c) The following lawfully present non-citizen who is: (1) Admitted to the United States as an Amerasian immigrant pursuant to section 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act, 1988 (as contained in section 101(e) of Public Law 100-202 and amended by the 9th proviso under Migration and Refugee Assistance in title II of the Foreign Operations, Export Financing, and Related Programs Appropriations Act, 1989, Public Law 100-461, as amended; (2) A legal permanent resident who has worked forty qualifying quarters of coverage as defined under title II of the Social Security Act and did not receive any federal means-tested public benefit, other than those listed in 8 U.S.C. §1613(c)(2) for any qualifying quarter after December 31, 1996; (3) An honorably discharged veteran or active member of the U.S. armed forces and the veteran or active member’s spouse or dependent child, or unremarried surviving
UNOFFICIAL 1714.1-15 spouse of the deceased veteran, under 8 U.S.C. §1612(b)(2)(C); (4) An American Indian born in Canada subject to section 289 of the INA (8 U.S.C. § 1359), or who is a member of an Indian tribe as defined in 25 U.S.C. §450b(e); (5) In receipt of SSI, or determined to be blind or disabled by the SSA on August 22, 1996; (6) Issued a record of lawful admission for permanent residence under section 249 of the INA (8 U.S.C. § 1259); or (7) A lawfully present non-citizen, including a citizen of a COFA nation, who is under age nineteen years or a pregnant woman.
[Eff 09/30/13] (Auth: HRS §§346-14, 346- 71; 42 C.F.R. §435.406; 8 U.S.C. §§1259, 1611, 1612, 1613, 1641) (Imp: HRS §§346-14, 346-71; 42 C.F.R. §435.406; 8 U.S.C. §§1259, 1611, 1612, 1613, 1641)
§17-1714.1-29 Declaration of citizenship and non-citizen status. (a) The department shall provide Medicaid to an otherwise eligible individual who is a citizen: (1) Provided the individual has declared that the individual is a citizen or national of the United States, and the department has verified such declaration; (2) Except the following individuals are exempt from the verification requirement in this subsection: (A) An individual in receipt of foster care services or benefits under Title IV-B or Title IV-E of the Social Security Act; (B) An individual entitled to or enrolled in Medicare; (C) An individual in receipt of disability benefits under Title II of the Social Security Act;
UNOFFICIAL 1714.1-16 (D) An SSI recipient under Title XVI of the Social Security Act; and (E) A newborn for the first year of life who is born to a Medicaid beneficiary mother. (b) The department shall provide Medicaid to an otherwise eligible qualified non-citizen provided that the individual has declared that the individual is a qualified non-citizen and has provided satisfactory documentary evidence of status as a qualified non- citizen, and the Department of Homeland Security has verified that the individual is in satisfactory immigration status. (c) For purposes of this section, “satisfactory immigration status” means an immigration status which does not make the individual ineligible for benefits under the applicable program. (d) The declaration of citizenship, national or immigration status and verification requirements for an individual under subsections (a) and (b) may be provided by the individual or an adult member of the individual’s household, an authorized representative, or if the individual is a minor or incapacitated, someone acting responsibly for the individual under a declaration signed under penalty of perjury. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.406, 435.949, 435.956) (Imp: HRS §346-14; 42 C.F.R. §§435.406, 435.949, 435.956)
§17-1714.1-30 Verification of citizenship and non-citizen immigration status. (a) The department shall verify citizenship or non-citizen immigration status through the federal electronic service under section 17-1714.1-12(b). (b) If the department is unable to verify citizenship or immigration status through the federal electronic service, the department shall: (1) Verify citizenship with acceptable documentary evidence and in accordance with section 17-1714.1-31.
UNOFFICIAL 1714.1-17 (2) Verify immigration status in accordance with section 1137(d) of the Social Security Act (42 U.S.C. §1320b-7(d)(1)(B)(iii)) and the requirements of section 17-1714.1-31. (c) If the department is unable to promptly verify the citizenship or non-citizen immigration status of an individual in accordance with subsection (a), the department: (1) Shall provide the individual with a reasonable opportunity to obtain or provide
the necessary information in accordance with subsections (e) through (i); and (2) May not delay, deny, reduce or terminate benefits for an individual who is otherwise eligible for Medicaid during the reasonable opportunity period. (d) The department shall maintain a record of having verified citizenship or non-citizen status for each individual, in an electronic database. The department may not re-verify or require an individual to re-verify citizenship or non-citizen status at a renewal or eligibility or subsequent application following a break in coverage. (e) The department shall notify the individual for whom the department is unable to promptly verify citizenship or satisfactory non-citizen status in accordance with chapter 1713.1. (f) During the reasonable opportunity period, the department shall, if relevant to verification of the individual’s status, assist the individual as follows: (1) Assist the individual in obtaining an SSN; (2) Attempt to resolve any inconsistencies between information provided by the individual and data from the electronic service, and resubmit corrected information; (3) Provide information on how to contact the source of the electronic data directly to resolve the issue; and (4) Permit the individual to provide other documentation of citizenship or immigration status.
UNOFFICIAL 1714.1-18 (g) The reasonable opportunity period shall begin on and shall extend ninety days from date the individual receives notice from the department that the department was unable to verify citizenship or satisfactory immigration status. The notice is considered to be received by the individual five days after the date of the notice, unless the individual can show it was not received within the five day period. (h) At the department’s option, the reasonable opportunity period may be extended beyond ninety days if the individual provides evidence of a good faith effort to resolve the issue or the department requires additional time to complete the verification process. (i) At the end of the reasonable opportunity period, and any extensions granted by the department, if the individual’s citizenship or non-citizen status has not been verified in accordance with subsection (a), the department shall take action within thirty days to terminate eligibility, subject to the provisions of chapter 17-1703.1. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.407, 435.956) (Imp: HRS §346-14; 42 C.F.R. §§435.407, 435.956)
§17-1714.1-31 Documentary evidence of citizenship. (a) The following documentary evidence of citizenship is acceptable: (1) U.S. passport, including a U.S. Passport Card issued by the Department of State, without regard to any expiration date as long as the passport or Card was issued without limitation; (2) A certificate of U.S. citizenship; (3) A certificate of naturalization; (4) A valid state-issued driver’s license if the state issuing the license requires proof of U.S. citizenship, or obtains and verifies a social security number from the applicant who is a citizen before issuing such license.
UNOFFICIAL 1714.1-19 (5) Documentary evidence issued by a federally recognized Indian Tribe, by the Bureau of Indian Affairs within the U.S. Department of the Interior, and including Tribes located in a State that has an international border which: (A) Identifies the federally recognized Indian Tribe that issued the document; (B) Identifies the individual by name; and (C) Confirms the individual’s membership,
enrollment, or affiliation with the Tribe. (6) Documents described in paragraph (5) above include, but are not limited to: (A) A Tribal enrollment card; (B) A certificate of degree of Indian blood; (C) A Tribal census document; and (D) Documents on Tribal letterhead, issued under the signature of the appropriate Tribal official, that meet the requirements of paragraph (5). (b) If documentary evidence of citizenship described in subsection (a) are unavailable, the following shall be accepted as satisfactory evidence to establish citizenship if also accompanied by an identity document listed in section 17-1714.1-4: (1) U.S. public birth certificate showing birth in: (A) One of the fifty states; (B) The District of Columbia; (C) Guam; (D) American Samoa; (E) Swain’s Island; (F) Puerto Rico (if born on or after January 13,1941); (G) U.S. Virgin Islands (if born on or after January 17,1917); (H) The Commonwealth of Northern Mariana Islands (CNMI) (if born on or after November 4, 1986);
UNOFFICIAL 1714.1-20 (I) If the birth record document issued by the State, commonwealth, territory or local jurisdiction shows the individual was born in Puerto Rico, the U.S. Virgin Islands or the CNMI before these areas became part of the U.S., the individual may be a collectively naturalized citizen. (2) Certification of report of birth, issued to a U.S. citizen who was born outside the U.S.; (3) Report of birth abroad of a U.S. citizen; (4) Certification of birth (5) U.S. citizen identification card; (6) Northern Marianas identification card, issued to a collectively naturalized citizen, who was born in the CNMI before November 4, 1986; (7) Documentation that a child meets the requirements of section 101 of the Child Citizenship Act of 2000 (8 U.S.C. §1431); (8) Final adoption decree or if an adoption is not final, a statement from a state-approved adoption agency with child’s name and U.S. place of birth; (9) Evidence of U.S. civil service employment by the U.S. government before June 1, 1976; (10) U.S. military record of service showing a U.S. place of birth; (11) Verification with the Department of Homeland Security’s Systematic Alien Verification for Entitlements (SAVE) database or any other process established by the Department of Homeland Security to verify an individual is a citizen; (12) Medical records, including, but not limited to, hospital, clinic, or doctor records or admission papers from a nursing facility, skilled care facility, or other institution that indicate a U.S. place of birth; (13) A life, health, or other insurance record that indicates a U.S. place of birth;
UNOFFICIAL 1714.1-21 (14) An official religious record recorded in the U.S. showing the birth occurred in the U.S.; (15) School records, including pre-school, Head Start and daycare, showing the child’s name and a U.S. place of birth; (16) A federal or State census record showing U.S. citizenship or a U.S. place of birth; (17) At the department’s option, a cross match with a State department of vital statistics documenting a record of birth; (c) If the individual does not have one of the documents listed in subsections (a) or (b), submission of an affidavit signed by another individual who can reasonably attest to the individual’s citizenship shall be accepted. The affidavit shall be signed under penalty of perjury and contain the individual’s name, date of birth, place of U.S. birth, and does not have to be notarized. (d) The department may rely on a verification of citizenship made by a federal agency or another State agency, without further documentation of citizenship or identity, if such verification was done on or after July 1, 2006. (e) The department shall provide assistance to individuals who need assistance in securing satisfactory documentary evidence of citizenship in a timely manner. (f) A photocopy, facsimile, scanned or other copy of a document shall be accepted to the same extent as an original document under this section, unless information on the submitted document is inconsistent with other information available to the department or the department otherwise has reason to question the validity of the document or the information on the document. (g) An individual unable to furnish the required documents or an affidavit shall not be eligible for medical assistance. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.406, 435.407, 435.912, 435.930) (Imp: HRS §346-14; 42 C.F.R. §§435.406, 435.407, 435.912, 435.930)
UNOFFICIAL 1714.1-22 §§17-1714.1-32 to 17-1714.1-36 (Reserved).
SUBCHAPTER 5
ELIGIBILITY VERIFICATION
§17-1714.1-37 Purpose. This subchapter is to identify the federal, State or other available data sources and how the department will use and process the information obtained from these matches to determine eligibility for medical assistance. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.940) (Imp: HRS §346-14; 42 C.F.R. §435.940)
§17-1714.1-38 General requirements. (a) The department shall accept self-attestation of an individual, attestation by an adult individual who is in the applicant’s household, an authorized representative, or, if the individual is a minor, incapacitated or deceased, someone acting on the applicant’s behalf, without requiring further information or documentation, except as allowed under section 17-1714.1-40 or where the law or this chapter requires other procedures, such as for verifying citizenship, immigration status, and SSN. (b) The department shall request and use information relevant to verifying an individual’s eligibility for Medicaid as described in this subchapter. (c) The department shall furnish in a timely manner income and eligibility information, subject to chapter 1702, required for verifying eligibility to the following programs: (1) Other agencies in the State and other states and to the federal programs both listed in section 17-1711.1-34 and identified in section 1137(b) of the Social Security Act; (2) Other insurance affordability programs;
UNOFFICIAL 1714.1-23 (3) The child support enforcement program under Part D of title IV of the Social Security Act; and (4) SSA for OASDI under title II and for SSI under title XVI of the Social Security Act. (d) All state eligibility determination systems shall conduct data matching through the Public Assistance Reporting Information System (PARIS). (e) Prior to requesting information for an individual from another agency or program under this subchapter, the department shall inform the individual that the department will obtain and use information available under this subchapter to verify income and eligibility or for other purposes directly connected to the administration of the State Plan. (f) Information exchanged electronically between the department and any other agency or program shall be sent and received via secure electronic interfaces. (g) The department shall execute written agreements with other agencies before releasing data to, or requesting data from, those agencies. These agreements shall provide for appropriate safeguards limiting the use and disclosure of information as required by federal or State law or regulations. (h) The department may request and use information from alternative sources other than those listed in section 17-1714.1-40, or through a mechanism other than the federal and state electronic services, provided it will reduce the administrative costs and burdens on an individual and states while maximizing accuracy, minimizing delay, meeting applicable requirements relating to the confidentiality, disclosure, maintenance, or use of information, and promoting coordination with other insurance affordability programs. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.945) (Imp: HRS §346-14; 42 C.F.R. §435.945)
§17-1714.1-39 Verification of financial information. (a) The department shall request from other agencies in the State or other states and
UNOFFICIAL 1714.1-24 federal programs the following information to verify financial eligibility of an individual: (1) Information related to wages, net earnings from self-employment, unearned income and resources from the State Wage Information Collection Agency (SWICA), the Internal Revenue Service(IRS), the Social Security Administration (SSA), the agencies administering the State unemployment compensation laws, the State-administered supplementary payment programs under section 1616(a) of the Social Security Act, and any State program administered under Titles I, X, XIV, or XVI of the Social Security Act; and (2) Information related to eligibility or enrollment from the Supplemental Nutrition Assistance Program (SNAP), the State program funded under Title IV-A of the Social Security Act, and other insurance affordability programs. (b) If the information identified in paragraph (a) is available through the federal and state electronic services the department shall obtain the information through these services. (c) The department shall request the information by an SSN or other personally identifying information in the individual’s electronic account, if possible. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.948, 435.949) (Imp: HRS §346-14; 42 C.F.R. §§435.948, 435.949)
§17-1714.1-40 Use of information and requests of additional information from an individual. (a) The department shall promptly evaluate the information it receives or obtains in accordance with this chapter to determine whether the information may affect the eligibility or benefits of an individual. (b) If the information provided by or on behalf of an individual is reasonably compatible with information obtained through an electronic service,
UNOFFICIAL 1714.1-25 the agency shall determine or renew eligibility based on such information. (c) An individual shall not be required to provide additional information or documentation unless information needed by the department cannot be obtained electronically or the information obtained electronically is not reasonably compatible with information provided by or on behalf of the individual. (1) Income information obtained through an electronic service shall be considered reasonably compatible with income information provided by or on behalf of an individual if both are either above, at or below the applicable income standard or other relevant income threshold within an amount as determined by the department. (2) If the information provided by or on behalf of an individual is not reasonably compatible with the electronic service, the department shall pursue additional information from the individual, including: (A) A statement which reasonably explains the discrepancy; or (B) Other information, provided that documentation from the individual is permitted only to the extent electronic data is not available and establishing a data match through an electronic service would not be feasible; (C) The department shall provide the individual a reasonable period to furnish any additional information required under this subsection. (d) The department shall permit on a case-by- case basis for special circumstances, except for citizenship and immigration status, self-attestation of an individual for all eligibility requirements when documentation does not exist at the time of application or is not reasonably available, such as for an individual who: (1) Is homeless;
UNOFFICIAL 1714.1-26 (2) Experienced domestic violence; (3) Was in a natural disaster; or (4) As otherwise determined by the department. (e) The department may not deny or terminate eligibility or reduce benefits for any individual on the basis of information received under this subchapter unless the department pursued additional information from the individual in accordance with subsection (c) and provided proper notice and hearing rights in accordance with chapters 17-1703.1 and 17- 1712.1. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.952) (Imp: HRS §346-14; 42 C.F.R. §435.952)
§§17-1714.1-41 to 17-1714.1-45 (Reserved).
• HAWAII ADMINISTRATIVE RULES TITLE 17 DEPARTMENT OF HUMAN SERVICES SUBTITLE 12 MED-QUEST DIVISION .. CHAPTER 1715 CHILDREN GROUP Subchapter 1 General Provisions §17-1715-1 Purpose §17-1715-2 General requirements §§17-1715-3 to 17-1715-7 {Reserved) $ubchapter 2 Eligibility Requirements Purpose Basic requirements Categorical requirements Income requirements Asset requirements Eligibility review requirements §17-1715-8 §17-1715-9 §17-1715-10 §17-1715-11 §17-1715-12 §17-1715-13 §§17-1715-14 to 17-1715-18 {Reserved) Subchapter 3 Freedom of Choice, Enrollment, Benefits and Disenrollment §17-1715-19 Purpose §17-1715-20 Freedom of choice §17-1715-21 Enrollment into a participating health plan §17-1715-22 Benefits §17-1715-23 Disenrollment from a health plan 1715-1 1320 6
§17-1715-1 §§17-1715-24 to 17-1715-28 (Reserved) Historical Note: This chapter is based substantially upon repealed chapters 17-1722.1, 17-1726, 17-1727, 17-1728, and 17-1732 [Eff 08/01/94; am 07/20/95; am 01/29/96; am 03/30/96; am 11/25/96; am 12/27/97; am 07/06/99; am 06/19/00; am 10/26/01; am 12/03/01; am 02/16/02; am 05/10/03; am 09/17/07; am 01/31/09; am 06/11/09; am 06/26/09, am 09/10/09; am 04/30/10; am 08/19/11; am 06/25/12; R 09/30/13] SUBCHAPTER 1 GENERAL PROVISIONS §17-1715-1 Purpose. This chapter establishes the Children Group. The infants and children under age nineteen group, commonly referred to as the Children Group, created through the enactment of the Affordable Care Act, provides Medicaid eligibility for individuals under age nineteen years, or under age twenty-one years and in receipt of foster care, kinship guardianship, or adoption assistance. [Eff 09/30/13; am and comp NOV 102016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 435.118, 435.145) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 435.118, 435.145) §17-1715-2 General requirements. The confidentiality, administrative appeal, fraud, medical assistance recovery, application processing, eligibility review, and adverse action provisions described in subtitle 12 shall pertain to an individual who applies or is eligible under this chapter. [Eff 09/30/13; comp NOVI02016 J (Auth: HRS §§346-14, 346-29, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.116, 435 . 201, 435.907, 435.916, 455.1) (Imp: HRS §§346-14, 346-29, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 1715-2 11n 6 j ·1
§17-1715-10 43~.230, 431.300, 435.116, 435.201, 435.907, 435.916, 455.1) §§17-1715-3 to _17-1715-7 (Reserved) . SUBCHAPTER 2 ELIGIBILITY REQUIREMENTS §17-1715-8 Purpose. This subchapter describes the eligibility requirements for participation in the Children Group. [Eff 09/30/13; comp NOV IO 2016 ] (Auth: HRS §346-14; 42 C.F.R. §435.118) (Imp: HRS §346-14, 42 C.F.R. §§435.117, 435.1+8) §17-1715-9 Basic requirements. An individual whose eligibility is being determined under this chapter shall meet the basic eligibility requirements which include, but are not limited to, citizenship, qualified non-citizen or lawfully present non- citizenship status, State residency, verification of identity, not residing in a public institution, and the provision of a social security number, as described in chapter 17-1714.1. [Eff 09/30/13; am and comp NOV IO 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.118, 435.400, 435.910) (Imp: HRS §346-14; 42 C.F.R. §§435.118, 435.400, 435.910) §17-1715-10 Categorical requirements. (a) To the Children Group, an individual be eligible under shall be: ( 1) ( 2) Under age nineteen years; or Under twenty-one years of age and in receipt of non-Title IV-E or Title IV-E foster care, kinship guardianship, or adoption assistance. 1715-3 1320 6
§17-1715-10 (b) An individual under age twenty-one years and in receipt of Title IV-E foster care, kinship guardianship, or adoption assistance who meets the following requirements is deemed eligible for assistance and is not required to complete an application: (1) Certified by a public agency responsible to make such determinations as eligible for Title IV-E foster care maintenance or kinship guardianship assistance; and (2) Placed in a licensed or authorized foster home or child caring institution appropriately supervised by the State licensed child placement agency or the State family court; or (3) Covered under a Title IV-E Adoption Assistance Agreement, regardless of the state with which the adoptive parents entered into the agreement, and currently residing in the State in an adoptive home. (c) A pregnant individual under age nineteen years, whose household income exceeds the age-specific income standard for a household of applicable size for participation under Title XIX of the Social Security Act, and a pregnant individual under age twenty-one years, who is in receipt of foster care, kinship guardianship, or adoption assistance, shall be subject to the requirements of chapter 17-1716 for the Pregnant Women Group. If ineligible under the Pregnant Women Group, the individual shall be evaluated for eligibility under the Children Group. (d) A blind or disabled individual under age nineteen years or under age twenty-one years in receipt of foster care, kinship guardianship, or adoption assistance who is applying on the basis of blindness or disability shall be subject to the provisions of chapters 17-1719, 17-1724.1, and 17- 1725.1. (e) A child born to a mother in receipt of Medicaid shall remain eligible for a period of one year following birth. The child's continued eligibility shall be determined for beginning the 1715-4 I t
§17-1715-11 month following the month the child attains one year of age and annually thereafter. (f) An individual under age nineteen years remains eligible for Medicaid under this chapter until the end of a Medicaid covered inpatient stay if the individual would lose eligibility during the stay because of attaining the maximum age for eligibility under this chapter. (g) An individual who is eligible under this chapter shall have eligibility redetermined under another eligibility group effective the month following the month the maximum age is attained under the Children Group. [Eff 09/30/13; am and comp NOV 1O2016 ] (Auth: HRS §346-14; 42 C.F.R . §§430.25, 435.117, 435.118, 435.145, 435.170, 435.222, 435.227, 435.301, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 435.117, 435.118, 435.145, 435.172, 435.222, 435.227, 435.301, 435.603, 435.916) §17-1715-11 Income requirements. (a) The modified adjusted gross income (MAGI) methodology described in chapter 17-1724.2 shall be used to determine the countable income for an individual subject to an income limit. (b) The income standards for participation in the Children Group are: (1) For a child under age one year, one hundred eighty-five per cent of the federal poverty level for a household of applicable size plus the income conversion percentage of six per cent. (2) For a child age one year but under six years, one hundred thirty-three per cent of the federal poverty level for a household of applicable size plus the income conversion percentage of six per cent. (3) For a child age six years but under nineteen years, one hundred thirty-three per cent of the federal poverty level for a household of applicable size. 1715-5 320 6
§17-1715-11 (4) For an individual under age twenty-one years who is a recipient of foster care, kinship guardianship, or adoption assistance, no income limit shall apply. An income disregard of five per cent of the applicable federal poverty level, as cited in paragraphs (1) through (3), is added to the highest income standard for an individual using MAGI-based methodology under the applicable title of the Social Security Act. (c) An uninsured child under age nineteen years whose household income exceeds the appropriate income limit under subsection (b) , but does not exceed three hundred per cent of the federal poverty level for a household of applicable size plus the income conversion percentage of eight per cent and the income disregard of five per cent shall be eligible for participation in this chapter. (d) When a child or an individual under twenty- one years of age in receipt of non-Title IV-E or Title IV-E foster care, kinship guardianship, or adoption assistance is determined ineligible under the Children Group, eligibility shall be redetermined under another eligibility group. [Eff 09/30/13; am and comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 435.4, 435.117, 435.118, 435.229, 435.308, 435.601, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 435.117, 435.118, 435.229, 435.308, 435.601, 435.603) §17-1715-12 Asset requirements. Assets shall not be considered in the determination of eligibility for participation in the Children Group. [Eff 09/30/13; comp NOVI02016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.118, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§435.118, 435.603) §17-1715-13 Eligibility review requirements. (a) An eligible child shall receive an annual eligibility review every twelve months. 1715-6 320 6 ' !
§17-1715-21 (b) Eligibility shall be redetermined in accordance with chapter 17-1712.1 and subchapter 5 of chapter 17-1714 .1. [Eff 09/30/13; comp NOV 1 O 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.118, 435.916, 435.940) (Imp: HRS §346-14; 42 C.F.R. §§435.118, 435.916, 435.940) §§17-1715-14 to 17-1715-18 (Reserved) • SUBCHAPTER 3 FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DIS ENROLLMENT §17-1715-19 Purpose. This subchapter addresses and refers to the provisions of freedom of choice, enrollment, benefits and disenrollment for an individual who is eligible in accordance with this chapter. [Eff 09/30/13; comp NOV102016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40) §17-1715-20 Freedom of choice. (a) A child eligible in accordance with this chapter, with the exception 0£ a child identified in section 17-1735.1- 2 (a), shall be provided a choice of a health plan and a provider as described in chapter 17-1720.1. (b) A child identified in section 17-1735.l-2(a) shall choose a department approved provider as described in chapter 17-1736-3. [Eff 09/30/13; comp NOV 10 2016] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 438.52) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 438.52) §17-1715-21 Enrollment into a participating health plan. (a) A child eligible in accordance with this chapter, with the exception of a child identified 1715-7 1320 6
? In 6 §17-1715-21 in section 17-1735.l-2(a), shall be enrolled in a health plan as described in chapter 17-1720.1. (b) A child identified in section 17-1735.1- 2 (a), shall not be enrolled into a health plan and their healthcare services shall be provided on a fee-for-service basis. [Eff 09/30/13; comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§430 . 25, 431.10, 431.40, 438.50) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40, 438.50) §17-1715-22 Benefits. (a) A child eligible in accordance with this chapter who is enrolled in a health plan shall be provided a standard benefits package by a participating health plan and other services when appropriate as described in chapter 17- 1720. (b} A child identified in section 17-1735.l-2(a) shall be provided coverage under the fee-for-service provisions as described in chapter 17-1737. [Eff 09/30/13; comp NOV 1 0 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6) §17-1715-23 Disenrollment from a health plan. An enrollee shall be disenrolled from a health plan under the provisions as described in chapter 17- 1720 .1. [Eff 09/30/13; am and comp NOV IO 2016 (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 4 3 8 . 5 6 ) ( I mp : HRS § 3 4 6 - 14 ; 4 2 C . F . R . § § 4 3 O . 2 5 , 431.40, 438.56) §§17-1715-24 to 17-1715-28 (Reserved) • 1715-8
HAWAII ADMINISTRATIVE RULES TITLE 17 DEPARTMENT OF HUMAN SERVICES SUBTITLE 12 MED-QUEST DIVISION CHAPTER 1715.1 FORMER FOSTER CARE CHILDREN GROUP Subchapter 1 General Provisions §17-1715.1-1 Purpose §17-1715.1-2 General requirements §§17-1715.1-3 to 17-1715.1-7 (Reserved) Subchapter 2 Eligibility Requirements Purpose Basic requirements Categorical requirements Income requirements Asset requirements Eligibility review requirements §17-1715.1-8 §17-1715.1-9 §17-1712.1-10 §17-1715.1-11 §17-1715.1-12 §17-1715.1-13 §§17-1715.1-14 to 17-1715.1-18 (Reserved) Subchapter 3 §17-1715.1-19 §17-1715.1-20 §17-1715.1-21 §17-1715.1-22 §17-1715.1-23 Freedom of Choice, Enrollment, Benefits and Disenrollment Purpose Freedom of choice Enrollment into a participating health plan Benefits Disenrollment from a health plan 1715.1-1 '20 6
§17-1715.1-1 §§17-1715.1-24 to 17-1715.1-28 (Reserved) SUBCHAPTER 1 GENERAL PROVISIONS §17-1715.1-1 Purpose. This chapter establishes the Former Foster Care Children Group. The Former Foster Care Children Group, created through the enactment of the Affordable Care Act, provides Medicaid eligibility for certain former recipients of foster care, kinship guardianship, or adoption assistance who are age eighteen years but under age twenty-six years. [Eff 09/30/13; am and comp NOV 1O2016 (Auth: HRS §346-14; 42 C.F . R §§430.25, 435.150) (Imp: HRS §346-14; 42 C.F.R §§430.25, 435.150) §17-1715.1-2 General requirements. The confidentiality, administrative appeal, fraud, medical assistance recovery, application processing, eligibility review, and ~dverse action provisions described in subtitle 12 shall pertain to an individual who applies or is eligible under this chapter. [Eff 09/30/13; comp NOV 10 2016 ] (Auth: HRS §346-14, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.150, 435.201, 435.907, 435.916, 455.1) (Imp: HRS §§346-14, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431 . 300, 435.150, 435.201, 435.907, 435.916, 455.1) §§17-1715.1-3 to 17-1715.1-7 (Reserved) . SUBCHAPTER 2 ELIGIBILITY REQUIREMENTS . 1715.1-2
§17-1715.1-10 §17-1715.1-8 Purpose. This subchapter describes the eligibility requirements for participation in the Former Foster Care Children Group. [Eff 09/30/13; comp NOV 1O2016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 435.150) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 435.150) §17-1715.1-9 Basic requirements. An individual who is a former recipient of foster care, kinship guardianship, or adoption assistance shall meet the following basic requirements which include, but are not limited to, citizenship, qualified non-citizen or lawfully present non-citizen status, State residency, verification of identity, not residing in a public institution, and the provision of a social security number, as described in chapter 17-1714.1. [Eff 09/30/13; am and comp NOV I 0 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 435.150, 435.400, 435.910) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 435.150, 435.400, 435.910) §17-1715.1-10 Categorical requirements. (a) To be eligible under the Former Foster Care Children Group, an individual shall: (1) Be at least eighteen years of age but under twenty-six years of age; (2) Not be eligible for or in receipt of coverage under any of the following chapters: (A) 17-1715, Children Group; (B) 17-1716, Pregnant Women Group; (C) 17-1717, Parents or Caretakers Relative Group; (D) 17-1719, Aged, Blind or Disabled Group, section 17-1719-11.1 (a) (1); and (E) 17-1717.1, Transitional Medical Assistance. (3) After attaining the age of sixteen years, have been in receipt of foster care or 1715.1-3 320 6
320 6 §17-1715.1-10 placed in kinship guardianship or adopted while under the State's responsibility; and (4) Have been in receipt of Medicaid services under the State Plan or the Hawaii section 1115 demonstration while receiving foster care, kinship guardianship, or adoption assistance. (b) A blind or disabled former foster child described in subsection (a) who is applying on the basis of blindness or disability shall be subject to the provisions of chapters 17-1719, 1724.1, and 1725.1. (c) An individual who is eligible under this chapter shall have eligibility redetermined under another eligibility group effective the month following the month the maximum age for eligibility under the Former Foster Care Children GrouF is attained. [Eff 09/30/13; am and comp NOV 1 0 2016 (Auth: HRS §346-14; 42 C.F.R §§435.4, 435.150, 435.603) (Imp: HRS §346-14; 42 C.F.R §§435.4, 435.150, 435.603) §17-1715.1-11 Income requirements. Income shall not be considered in the determination of eligibility for participation in the Former Foster Care Children Group. [Ef f 09 /3 O /13; comp NOV .1 0 2016 ] (Au th: HRS §346-14; 42 C.F.R §§430.25, 431.10, 435.150) (Imp: HRS §346-14; 42 C.F.R §§430.25, 431.10, 435.150) §17-1715.1-12 Asset requirements. Assets shall not be considered in the determination of eligibility for participation in the Former Foster Care Children Group. [Eff 09/30/13; comp NOVI02016] (Auth: HRS §346-14; 42 C.F.R §§430.25, 431.10, 435.150) (Imp: HRS §346-14; 42 C.F.R §§430.25, 431.10, 435.150) 1715.1-4
§17-1715.1-20 • §17-1715.1-13 Eligibility review requirements. (a) An eligible individual under this chapter shall receive an annual eligibility review every twelve months. (b) Eligibility shall be redetermined in accordance with chapter 17-1712.1 and subchapter 5 of chapter 17-1714.1. [Eff 09/30/13; comp NOV 1 n 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.150, 43~.916, 435.940) (I~p: HRS §346-14; 42 C.F.R. §§435.150, 435.916, 435.940 §§17-1715.1-14 to 17-1715.1-18 (Reserved) • SUBCHAPTER 3 FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DIS ENROLLMENT §17-1715.1-19 Purpose. This subchapter addresaes and refers to the provisions of freedom of choice, ·enrollment, benefits and disenrollment for an individual who is eligible in accordance with this chapter. [Eff 09/30/13; comp NOYI02016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40) §17-1715.1-20 Freedom of choice. (a) An individual eligible under the provisions of this chapter, with the exception of an individual identified in section 17-1735.l-2(a), shall be provided a choice of health plan and a provider as described in chapter 17-1720.1. (b) An individual identified in section 17- 1735.1-2 (a) shall choose a department approved provider as described in section 17-1736-3. [Eff 09/30/13; comp NOY I 0 2016 ] (Auth: HRS §346-14; 42 1715.1-5 320f
320 6 §17-1715.1-21 C . F . R . § § 4 3 O . 2 5 , 4 31. 51 , 4 3 8 . 5 2 ) ( I mp : HRS § 3 4 6 - 14 ; 42 C.F.R. §§430.25, 431.51, 438.52) §17-1715.1-21 Enrollment into a participating health plan. (a) An individual eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735 .1.-.2 (a), shall be enrolled in a health plan a~ described in chapter 17-1720.1. (b) An individual identified in section 17-1735.l-2(a) shall not be enrolled into a plan and their healthcare services shall be provided on a fee-for-service basis. [Eff 09/30/13; comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40, 438.50) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40, 438.50) §17-1715.1-22 Benefits. (a) An individual eligible in accordance with this chapter who is enrolled in a health plan shall be provided a standard benefits package by a participating health plan and other 'services when appropriate as described in chapter 17-1720. (b) An individual identified in section 17-1735.l-2(a) shall be provided coverage under the fee-for-service provisions as described in chapter 17-1737. [Eff 09/30/13; comp NOV102016 J (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6) §17-1715.1-23 Disenrollment from a health plan. An enrollee shall be disenrolled from a health plan under the provisions as described i~.~h~P.t~*' 17-1720.1. [Eff 09/30/13; comp NUV 10zut6] (Auth: HRS §346-14; 42 C.F.R. §430.25, 431.40, 438.56) (Imp: HRS §346-14; 42 C.F.R. §430.25, 431.40, 438.56) 1715.1-6 . :
§17-1715.1-28 §17-1715.1-24 to 17-1715.1-28 (Reserved). 1715.1-7 3206
DEPARTMENT OF HUMAN SERVICES
Amendment and Compilation of Chapter 17-1716 Hawaii Administrative Rules
July 1, 2024
SUMMARY
§17-1716-10 is amended. §17-1716-11 is amended. §17-1716-13 is amended.
Chapter 1716 is compiled.
HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1716
PREGNANT WOMEN GROUP
Subchapter 1 General Provisions
§17-1716-1 Purpose §17-1716-2 General requirements §§17-1716-3 to 17-1716-7 (Reserved)
Subchapter 2 Eligibility Requirements
§17-1716-8 Purpose
§17-1716-9 Basic requirements
§17-1716-10 Categorical requirements §17-1716-11 Income requirements
§17-1716-12 Asset requirements
§17-1716-13 Eligibility review requirements §§17-1716-14 to 17-1716-18 (Reserved)
Subchapter 3 Freedom of Choice, Enrollment, Benefits, and Disenrollment
1716-1 ~
3556
§17-1716-1
§17-1716-19 Purpose §17-1716-20 Freedom of choice §17-1716-21 Enrollment into a participating
health plan §17-1716-22 Benefits §17-1716-23 Disenrollment from a health plan §§17-1716-24 to 17-1716-28 (Reserved)
Historical Note: This chapter is based substantially upon repealed chapters 17-1722.2, 17-1726, 17-1727, 17-1728, and 17-1732. [E££ 08/01/94; am 07/20/95; am 01/29/96; am 03/30/96; am 11/25/96; am 12/27/97; am 07/06/99; am 06/19/00; am 10/26/01; am 12/03/01; am 02/16/02; am 05/10/03; am 04/08/05; am 09/17/07; am 01/31/09; am 06/11/09; am 09/10/09; am 04/30/10; am 08/19/11; am 06/25/12; R 09/30/13)
SUBCHAPTER 1
GENERAL PROVISIONS
§17-1716-1 Purpose. This chapter establishes the Pregnant Women Group. The Pregnant Women Group, created through the enactment of the Affordable Care Act, provides Medicaid eligibility for a woman who is pregnant, to include a pregnant individual under age nineteen years, whose household income exceeds the age-specific income standard for a household of applicable size for participation under Title XIX of the Social Security Act, or under age twenty-one years and in receipt of foster care, kinship guardianship, or adoption assistance. [Eff 09/30/13; am and comp 11/10/16; comp AUG 2? 2024 ] (Auth: HRS §346-14; 42 C.F.R. §§435.116, 435.145, 435.201) (Imp: HRS §346-14; 42 C.F.R. §§435.116, 435.145, 435.201)
1716-2 me,
3556
§17-1716-9
§17-1716-2 General requirements. The confidentiality, administrative appeal, fraud, medical assistance recovery, application processing, eligibility review, and adverse action notice provisions described in subtitle 12 shall pertain to a pregnant woman who applies or is eligible under this chapter. [Eff 09/30/13; comp 11/10/16; comp
AUG 22 2024 J] (Auth: HRS §§346-14, 346-29, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.116, 435.201, 435.907, 435.916, 455.1) (Imp: HRS §§346-14, 346-29, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.116, 435.201, 435.907, 435.916, 455.1)
§§17-1716-3 to 17-1716-7 (Reserved)
SUBCHAPTER 2
ELIGIBILITY REQUIREMENTS
§17-1716-8 Purpose. This subchapter describes the eligibility requirements for participation in the Pregnant Women Group. [Eff 09/30/13; comp 11/10/16; comp AUG 92 24 }) (Auth: HRS §346-14; 42 C.F.R. §435.116) (Imp: HRS §346-14; 42 C.F.R. §435.116)
§17-1716-9 Basic requirements. A pregnant woman whose eligibility is being determined under this chapter shall meet the basic eligibility requirements which include, but are not limited to, citizenship, qualified non-citizen or a lawfully present non- citizen status, State residency, verification of identity, not residing in a public institution, and the provision of a social security number, as
1716-3 mi
3556
§17-1716-9
described in chapter 17-1714.1. {Ef£ 09/30/13; am and comp 11/10/16; comp AUG 22 294 ] (Auth: HRS §346-14; 42 C.F.R. §§435.116, 435.400, 435.910) (Imp: HRS §346-14; 42 C.F.R. §§435.116, 435.400,435.910)
§17-1716-10 Categorical requirements. (a) A woman who self-attests that she is a pregnant woman, including during the post-partum period, shall be eligible to participate in the Pregnant Women Group throughout her pregnancy. For the purposes of this chapter, “pregnant woman” means a woman who is in the pregnancy period or is in the post-partum period, which begins on the date the pregnancy ends, and continues for twelve months through the last day of the month in which the twelve month period ends.
(b) A pregnant woman is not required to assist the State in establishing paternity for purposes of her eligibility, other than through reasonable attestation unless there is conflicting information that is not reasonably compatible with the attestation.
(c) A pregnant individual under age nineteen years, whose household income exceeds the age-specific income standard for a household of applicable size for participation under Title XIX of the Social Security Act, and an individual under age twenty-one years, who is in receipt of foster care, kinship guardianship, or adoption assistance, shall be subject to the provisions of this chapter. If ineligible under this chapter, the individual shall have eligibility determined under the Children Group.
(d) A blind or disabled pregnant woman described in subsection (a) who is applying on the basis of blindness or disability shall be subject to the provisions of chapters 17-1719, 17-1724.1, and 17-1725.1. [Eff 09/30/13; am and comp 11/10/16; am
and comp AUG 22 2024 ] (Auth: HRS §346-14; 42
C.F.R. §§435.116, 435.170, 435.603, 435.956; 42 U.S.C
§1396a(e) (16); 42 U.S.C. §1397gg(e) (1)) (Imp: HRS 1716-4
3556
§17-1716-12
§346-14; 42 C.F.R. §§435.116, 435.170, 435.603, 435.956; 42 U.S.C. §1396a(e) (16); 42 U.S.C. §1397gg(e) (1) )
§17-1716-11 Income requirements. (a) The modified adjusted gross income methodology described in chapter 17-1724.2 shall be used to determine the countable income for a pregnant woman.
(b) The income standard for participation in the Pregnant Women Group is one hundred eighty-five per cent of the federal poverty level for a household of applicable size, which includes the number of unborn child(ren) expected, plus the income conversion percentage of six per cent. An income disregard of five per cent of the applicable federal poverty level is added to the highest income standard for an individual using modified adjusted gross income based methodology under the applicable title of the Social Security Act.
(c) Regardless of changes in household income, eligibility under this group shall continue through the last day of the month in which the post-partum period ends.
(d) A woman who is determined ineligible under this chapter shall have eligibility determined under other applicable eligibility groups. [Eff 09/30/13; am and comp 11/10/16; am and comp A\JG 29 99/4 ] (Auth: HRS §346-14; 42 C.F.R. §§435.116, 435.170, 435.301, 435.601, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§435.116, 435.170, 435.301, 435.601, 435.603)
§17-1716-12 Asset requirements. Assets shall not be considered in the determination of eligibility for participation in the Pregnant Women Group.
[Ef£ 09/30/13; comp 11/10/16; comp AUG 9? 202%4 ] (Auth: HRS §346-14; 42 C.F.R. §§435.116, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§435.116, 435.603)
1716-5
3556
§17-1716-13
§17-1716-13 Eligibility review requirements.
(a) Eligibility under this chapter shall continue throughout the pregnancy and the post-partum period.
(b) An eligible pregnant woman shall receive an annual eligibility review every twelve months or the first month following the month in which the post- partum period ends, whichever is later, and at that time shall be redetermined under another eligibility group as applicable.
(c) Eligibility shall be redetermined in accordance with chapter 17-1712.1 and subchapter 5 of
chapter 17-1714.1. (Eff 09/30/13; comp 11/10/16; am and comp AUG 22 24 ] (Auth: HRS §346-14; 42 C.F.R. §§435.116, 435.916, 435.940; 42 U.S.C. §1396a(e) (16); 42 U.S.C. §1397gg(e) (1)) (Imp: HRS
§346-14; 42 C.F.R. §$435.116, 435.916, 435.940; 42 U.S.C §1396a(e) (16); 42 U.S.C. §1397gg(e) (1))
§§17-1716-14 to 17-1716-18 (Reserved)
SUBCHAPTER 3
FREEDOM OF CHOICE, ENROLLMENT, BENEFITS, AND DISENROLLMENT
§17-1716-19 Purpose. This subchapter addresses and refers to the provisions of freedom of choice, enrollment, benefits, and disenrollment for a pregnant woman who is eligible in accordance with this chapter. [Ef£ 09/30/13; comp 11/10/16; comp A\jG 292 204 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40)
1716-6 oe
§17-1716-22
§17-1716-20 Freedom of choice. (a) A pregnant woman eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735.1-2(a), shall be provided a choice of a health plan and a provider as described in chapter 17-1720.1.
(b) A pregnant woman identified in section 17-1735.1-2(a) shall choose a department approved provider as described in section 17-1736-3. (Eff 09/30/13; am and comp 11/10/16; comp A\j\¢ 09 N04 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 438.52) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 438.52)
§17-1716-21 Enrollment into a participating health plan. (a) A pregnant woman eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735.1-2(a), shall be enrolled in a health plan as described in chapter 17-1720.1.
(b) A pregnant woman identified in section 17-1735.1-2(a) shall not be enrolled into a health plan and their healthcare services shall be provided on a fee-for-service basis. {Eff 09/30/13; comp 11/10/16; comp AUG 99 294 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40, 438.50) (Imp:
HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40, 438.50)
§17-1716-22 Benefits. (a) A pregnant woman eligible in accordance with this chapter who is enrolled in a health plan shall be provided a standard benefits package by a participating health plan and other services when appropriate as described in chapter 17-1720.
(bo) A pregnant woman identified in section 17-1735.1-2(a) shall be provided coverage under the fee-for-service provisions as described in chapter 17-1737. [Eff 09/30/13; comp 11/10/16; comp
1716-7 ©
§17-1716-22
J
US 92 2n04 J (Auth: HRS §346-14; 42 C.F.R.
A 0 §430.25, 431.40, 438.6) (Imp: HRS §346-14; 42 C.F.R.
§430.25, 431.40, 438.6)
§17-1716-23 Disenrollment from a health plan. An enrollee shall be disenrolled from a health plan under the provisions as described in chapter 17-1720.1. [Eff 09/30/13; am and comp 11/10/16;
comp AUG 22 2024 ] (Auth: HRS §346-14; 42 C.F.R.
§§430.25, 431.40, 438.56) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.56)
§§17-1716-24 to 17-1716-28 (Reserved) .
1716-8
3556
HAWAII ADMINISTRATIVE RULES TITLE 17 DEPARTMENT OF HUMAN SERVICES SUBTITLE 12 MED-QUEST DIVISION CHAPTER 1717 PARENTS AND OTHER CARETAKER RELATIVES GROUP Subchapter 1 General Provisions §17-1717-1 Purpose §17-1717-2 General requirements §§17-1717-3 to 17-1717-7 (Reserved) Subchapter 2 Eligibility Requirements §17-1717-8 §17-1717-9 §17-1717-10 §17-1717-11 §17-1717-12 §17-1717-13 §§17-1717-14 Purpose Basic requirements Categorical requirements Income requirements Asset requirements Eligibility review requirements to 17-1717-18 (Reserved) Subchapter 3 Freedom of Choice, Enrollment, Benefits and Disenrollment §17-1717-19 §17-1717-20 §17-1717-21 §17-1717-22 Purpose Freedom of choice Enrollment into a participating health plan Benefits §17-1717-23 Disenrollment from a health plan §§17-1717-24 to 17-1717-28 (Reserved) 1717-1 320 6
§17-1717-1 Historical Note: This chapter is based substantially upon repealed chapters 17-1726 and 17-1727 [Eff 08/01/94; am 07/20/95; am 01/29/96; am 03/30/96; am 11/25/96; am 12/27/97; am 07/06/99; am 06/19/00; am 10/26/01; am 12/03/01; am 02/16/02; am 05/10/03; am 09/17/07; am 09/10/09; am 04/30/10; am 08/19/11; am 06/25/12; R 09/30/13] SUBCHAPTER 1 GENERAL PROVISIONS §17-1717-1 Purpose. This chapter establishes the Parents and Other Caretaker Relatives Group. The Parents and Other Caretaker Relatives Group, created through the enactment of the Affordable Care Act, consolidates Medicaid eligibility for a parent or other caretaker relative living with a child under age nineteeQ years. [Eff 09/30/13; am and comp NUV102016 ] (Auth: HRS §346-14; 42 CFR §435.110) (Imp: HRS §346-14; 42 CFR §435.110) §17-1717-2 General requirements. The confidentiality, administrative appeal, fraud, medical assistance recovery, application processing, eligibility review, and adverse action provisions described in subtitle 12 shall pertain to a parent or other caretaker relative who applies or is eligible under this chapter. [Eff 09/30/13; am and comp NOV 1O2016 J (Auth: HRS §§346-14, 346-29 346- 44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.119, 435.201, 435.907, 435.916, 455 . 1) (Imp: HRS §§346-14, 346-29 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.119, 435.201, 435.907, 435.916, 455.1) 1717-2
§17-1717-10 §§17-1717-3 to 17-1717-7 (Reserved) . SUBCHAPTER 2 ELIGIBILITY REQUIREMENTS §17-1717-8 Purpose. This subchapter describes the eligibility requirements for participation in the Parents and Other Caretaker Relatives Group. [Eff 09/30/13; am and comp NOV 1 0 2016 ] (Auth: HRS §346-14; 42 CFR §§435.110, 435.201) (Imp: HRS §346- 14; 42 CFR §§435.110, 435.201) §17-1717-9 Basic requirements. An individual whose eligibility is being determined under this chapter shall meet the basic eligibility requirements which include, but are not limited to, citizenship, qualified non-citizen or a lawfully present non- citizen status, State residency, verification of identity, not residing in a public institution, and the provision of a social security number, as described in chapter 17-1714.1 . [Eff 09/30/13; am and comp NOV 1 0 2016 ] (Auth: HRS §§346-14, 346-29; 42 C.F.R. §§435.110, 435.400, 435.910) (Imp: HRS §§346-14, 346-29; 42 C.F.R. §§435.110, 435.400, 435.910) §17-1717-10 Categorical requirements. (a) To be eligible under the Parents and Other Caretaker Relatives Group, an individual is not required to be a parent or a relative of the child but is required to have primary responsibility for the care and control of a child under age nineteen years with whom the individual is living; including, but not limited to, a child who is under the jurisdiction of the court, or whose legal custody is held by a public agency that does not have physical custody of the child. 1717-3
3 20 6 §17-1717-10 (b) An individual who meets the provisions of subsection (a), may be: (1) Aged, blind, or disabled, when age, blindness, or disability is not a condition of eligibility; or (2) In receipt of or eligible for Medicare benefits. (c) If living together, the spouse of the individual who meets the requirements of subsection (a) is also considered a parent or other caretaker relative. (d) An individual who is in receipt of supplemental security income (SSI) is not categorically eligible to participate in the Parents and Other Caretaker Relatives Group. (e) An individual who is in receipt of supplemental security income (SSI) or is applying on the basis of age, blindness, or disability, shall be subject to the provisions of chapters 17-1719, 17- 1724 .1,N~nd 17-1725 .1. [Eff 09/30/13; am and comp UV 1 0 2016 ] (Auth: HRS §346-14; 42 C. F .R. §§430.25, 435.4, 435.110, 435.603) (Imp: HRS §346- 14; 42 C.F.R. §430.25, §435.4, 435.110, 435.603) §17-1717-11 Income requirements. (a) The modified adjusted gross income (MAGI) methodology described in chapter 17-1724.2 shall be used to determine the countable income for an individual subject to an income limit. (b) The income standard for participation in the Parents and Other Caretaker Relatives Group is one hundred per cent of the federal poverty level for a household of applicable size. An income disregard of five per cent of the applicable federal poverty level is added to the highest income standard for an individual using MAGI-based methodology under the applicable title of the Social Security Act. (c) An individual who meets the requirements of section 17-1717-lO(a) may, but is not required to, claim the child in the household as a tax dependent for federal income tax purposes. An individual who is 1717-4
§17-1717-19 determined ineligible under this chapter, shall have eligibility determined under another eligibility group. [Eff 09/30/13; am and comp NOV102016 (Auth: HRS §346-14; 42 C.F.R. §§435.110, 435.601, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§435.110, 435.601, 435.603) §17-1717-12 Asset requirements. Assets shall not be considered in the determination of eligibility for participation in the Parents and Other Caretaker Relatives Group. [Eff 09/30/13; am and comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.110, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§435.110, 435.603) §17-1717-13 Eligibility review requirements. (a) An eligible individual shall receive an annual eligibility review every twelve months. (b) Eligibility shall be redetermined in accordance with chapter 17-1712.l and subchapter 5 of chapter 17-1714.1. [Eff 09/30/13; am and comp NOV 1O2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.110, 435.916) (Imp: HRS §346-14; 42 C.F.R. §§435.110, 435.916) §§17-1717-14 to 17-1717-18 (Reserved) • SUBCHAPTER 3 FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DIS ENROLLMENT §17-1717-19 Purpose. This subchapter addresses and refers to the provisions of freedom of choice, enrollment, benefits and disenrollment for an individual who is eligible in accordance with this chapter. [Eff 09/30/13; am and comp NOV 1 0 2016 1717-5 ~ ?n t.
§17-1717-20 (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40) §17-1717-20 Freedom of choice. (a) An individual eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735.l-2(a), shall be provided a choice of a health plan and a provider as described in chapter 17-1720.1. (b) An individual identified in section 17- 1735.1-2 (a) shall choose a department approved provider as described in section 17-1736-3. [Eff 09/30/13; am and comp NOV I 0 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 438.52) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 438.52) §17-1717-21 Enrollment into a participating health plan. (a) An individual eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735.1-2(a), shall be enrolled in a health plan as ·described in chapter 17-1720.1. (b) An individual identified in section 17- 1735.1-2 (a) shall not be enrolled into a plan and their healthcare services shall be provided on a fee- for-service basis. [Eff 09/30/13; am and comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40, 438.50) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40, 438.50) §17-1717-22 Benefits. (a) An individual eligible in accordance with this chapter who is enrolled in a health plan shall be provided a standard benefits package by a participating health plan and other services when appropriate as described in chapter 17-1720. (b) An individual identified in section 17- 1735.1-2 (a) shall be provided coverage under the fee- 1717-6 3 2 Q 6 . JI f
§17-1717-23 for-service provisions as described in chapter 17- 1737. [Eff 09/30/13; am and comp NOV 102016 (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6) §17-1717-23 Disenrollment from a health plan. An enrollee shall be disenrolled from a health plan under the provisions as described in chapter 17- 172O.1. [Eff 09 /3 o /13; comp NOV 1 0 2016 ] (Au th: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.56) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.56) §§17-1717-24 to 17-1717-28 (Reserved) . 1717-7
UNOFFICIAL 1717.1-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1717.1
TRANSITIONAL MEDICAL ASSISTANCE
Subchapter 1 General Provisions
§17-1717.1-1
Purpose §17-1717.1-2
General requirements §§17-1717.1-3 to 17-1717.1-7 (Reserved)
Subchapter 2 Eligibility Requirements
§17-1717.1-8
Purpose §17-1717.1-9
Basic requirements §17-1717.1-10 Categorical requirements §17-1717.1-11 Extension periods §17-1717.1-12 Income requirements §17-1717.1-13 Asset requirements §§17-1717.1-14 to 17-1717.1-18 (Reserved)
Subchapter 3 Freedom of Choice, Enrollment, Benefits and Disenrollment
§17-1717.1-19 Purpose §17-1717.1-20 Freedom of choice §17-1717.1-21 Enrollment into a participating health plan §17-1717.1-22 Benefits §17-1717.1-23 Disenrollment from a health plan §§17-1717.1-24 to 17-1717.1-28 (Reserved)
UNOFFICIAL 1717.1-2 Historical Note: This chapter is based substantially upon repealed subchapter 6 of chapter 17-1726. [Eff 12/03/01; am 05/10/03; am 04/30/10; R 09/30/13]
SUBCHAPTER 1
GENERAL PROVISIONS
§17-1717.1-1 Purpose. This chapter establishes and describes the provisions of transitional medical assistance for a pregnant woman, or parent or caretaker relative, to include a qualified non-citizen, living with a child under age nineteen or an individual who is under age twenty-one and in receipt of foster care, kinship guardianship or adoption assistance, who becomes ineligible for medical assistance as a result of increased earned income, or collection or increased collection of spousal support payments under section 1925 of the Social Security Act. [Eff 09/30/13] (Auth: HRS §346-14; 42 CFR §435.112) (Imp: HRS §346- 14; 42 CFR §435.112, Section 1925 of the Social Security Act)
§17-1717.1-2 General requirements. The confidentiality, administrative appeal, fraud, medical assistance recovery, application processing, eligibility review, and adverse action provisions described in subtitle 12 shall pertain to the household who applies or is eligible under this chapter. [Eff 09/30/13] (Auth: HRS §§346-14, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.112, 435.201, 435.907, 435.916, 455.1) (Imp: HRS §§346-14, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.112, 435.201, 435.907, 435.916, 455.1)
§§17-1717.1-3 to 17-1717.1-7 (Reserved).
UNOFFICIAL 1717.1-3 SUBCHAPTER 2
ELIGIBILITY REQUIREMENTS
§17-1717.1-8 Purpose. This subchapter describes the eligibility requirements for participation in transitional medical assistance for a household consisting of a pregnant woman or parent or caretaker relative with a child(ren) described in Section 1925 of the Social Security Act subject to federal authorization. [Eff 09/30/13] (Auth: HRS §346-14; 42 CFR §§435.112, 435.201) (Imp: HRS §346-14; 42 CFR §§435.112, 435.201)
§17-1717.1-9 Basic requirements. The household shall meet the basic eligibility requirements, which include but are not limited to, citizenship, qualified non-citizen status, state residency, verification of identity, not residing in a public institution and the provision of a social security number, as described in chapter 17-1714.1. [Eff 09/30/13] (Auth: HRS §346- 14; 42 C.F.R. §§435.112, 435.400, 435.910) (Imp: HRS §346-14; 42 C.F.R. §§435.112, 435.400, 435.910)
§17-1717.1-10 Categorical requirements. (a) A pregnant woman, or parent or caretaker relative with a child(ren) under age nineteen or an individual who is under age twenty-one and in receipt of foster care, kinship guardianship or adoption assistance who continues to reside in the household shall be eligible under this chapter when the household received medical assistance in at least three of the six months preceding the month the household became ineligible for the Pregnant Women Group, or the Parents or Caretakers Relative Group as follows: (1) Due to an increase in earned income, the household is eligible to receive an initial six months in accordance with section 17- 1717.1-11(a); and (2) An additional six months of coverage in accordance with section 17-1717.1-11(b); or
UNOFFICIAL 1717.1-4 (3) Due to the collection or increased collection of spousal support payments, the household is eligible to receive four months of coverage in accordance with section 17-1717.1-11(c). (b) A new household member may be added to the transitional medical assistance household when there is increased income from employment or increased hours of employment. If eligible, a new household member shall be added to the household as of the month of request and not extend beyond the date when the rest of the household is terminated. (c) The time-limited extension periods for transitional medical assistance coverage under section 17-1717.1-11 shall be rescinded when federal authorization or the allocation of federal funding is discontinued and shall encompass only the following: (1) An extension period of four consecutive calendar months when the household was terminated under the provisions of chapters 17-1716 or 17-1717, because of increased earnings or hours of employment; and (2) The household received assistance in at least three of the six months immediately preceding the month in which the household became ineligible for chapters 17-1716 or 17-1717. [Eff 09/30/13](Auth: HRS §346-14; 42 C.F.R. §435.112) (Imp: HRS §346-14; 42 C.F.R. §435.112)
17-1717.1-11 Extension periods. (a) Initial six-month period for transitional medical assistance: (1) Shall be extended to a household who is terminated solely because of increased income from employment or increased hours of employment of the household; (2) Received assistance at least three of the six-months immediately preceding the month in which the household became ineligible in the Pregnant Women Group, or the Parents or Caretakers Relative Group; and (3) Shall include a child as defined in this chapter, or eligibility shall terminate at the end of the first month in which the
UNOFFICIAL 1717.1-5 household ceases to include the child. (4) The department shall notify the household of the option to receive an additional six-month period of transitional medical assistance during the third and sixth month of this initial six-month period. (5) Shall terminate at the end of the sixth month period when the household fails to meet the reporting requirements of section 17-1717.1- 12(a), unless the household establishes good cause for failure to report timely. Failure to submit timely due to physical or psychiatric limitations may constitute good cause. (b) Additional six-month period for transitional medical assistance: (1) Shall be extended to a household when the household received transitional medical assistance during the entire initial six- month period according to subsection (a); and (2) Shall include a child as defined in this chapter, or eligibility shall terminate at the end of the first month in which the household ceases to include the child. (3) The department shall notify the household of the reporting requirements of section 17- 1717.1-12(b)(1) during the third month of the additional six-month transition period. (4) Shall terminate when the household fails to meet the reporting requirements of section 1717.1-12(b), unless the household establishes good cause for the failure to report timely. Failure to submit timely due to physical or psychiatric limitations may constitute good cause, or the household had no earnings in one or more of the previous months, unless the lack of earnings was due to involuntary loss of employment, illness, or other good cause. (c) Four-month period for transitional medical assistance: (1) Shall be extended to a household for a period of four consecutive months when the household is terminated from the Pregnant
UNOFFICIAL 1717.1-6 Women Group, or Parent or Caretaker Relatives Group because of the collection or increased collection of spousal support payments under Title IV-D of the Social Security Act; and (2) Received assistance in at least three of the six-months immediately preceding the month in which the household became ineligible for the Pregnant Women Group, or the Parent or Caretaker Relatives Group. (3) Shall begin on the date the household became ineligible for assistance and terminated from the Pregnant Women Group, or Parent or Caretaker Relatives Group. (4) When eligibility for the household is terminated retroactively, the four month period shall begin retroactively with the first month in which eligibility through the Pregnant Women Group, or Parents or Caretakers Relative Group was erroneously received. (d) When a household is determined ineligible or exhausts the extension period for transitional medical assistance, the department shall initiate and ensure timely determination of continued eligibility under provisions of this chapter or if terminated, eligibility under other applicable chapters shall be considered. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.112) (Imp: HRS §346-14; 42 C.F.R. §435.112)
§17-1717.1-12 Income requirements. (a) The initial six-month period of transitional medical assistance: (1) The household income shall not be considered in the determination of eligibility for participation. (2) The household shall report to the department, no later than the twenty-first day of the fourth month of the initial six-month period, on the household: (A) Gross monthly earned income for each of the first three months of the initial six-month period; and
UNOFFICIAL 1717.1-7 (B) Cost for childcare that is necessary for the employment of the household for each of the first three months of the initial six-month period. (b) The additional six-month period of transitional medical assistance: (1) The household shall report to the department, not later than the twenty-first day of the first and fourth month of the additional six- month period, on the household: (A) Gross monthly earned income for each of preceding three months; and (B) Cost for childcare that is necessary for the employment of the household for each of the preceding three months. (2) The reported household monthly earnings according to paragraph (1) shall be used to determine the countable income for the household of applicable size and shall not exceed one hundred eighty-five per cent of the federal poverty level for the additional six-month period. (c) The four-month period of transitional medical assistance household income shall not be considered in the determination of eligibility for participation. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.112) (Imp: HRS §346-14; 42 C.F.R. §§435.112)
§17-1717.1-13 Asset requirements. Assets shall not be considered in the determination of eligibility for participation in transitional medical assistance. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.112, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§435.112, 435.603)
§§17-1717.1-14 to 17-1717.1-18 (Reserved).
SUBCHAPTER 3
FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT
UNOFFICIAL 1717.1-8
§17-1717.1-19 Purpose. This subchapter addresses and refers to the provisions of freedom of choice, enrollment, benefits and disenrollment for an individual eligible in accordance with this chapter. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40)
§17-1717.1-20 Freedom of choice. When relocation results in the non-service of the health plan in which the household was enrolled, they shall be provided a choice of health plan and a provider as described in chapter 17-1720.1. [Eff 09/30/13] (Auth: HRS §346- 14; 42 C.F.R. §§430.25, 431.51, 438.52) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 438.52)
§17-1717.1-21 Enrollment into a participating health plan. (a) An individual eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735.1-2(a), shall continue to be enrolled in the selected health plan as a recipient in accordance with chapter 17-1720.1, except for the provision of section 17-1717.1-20. (b) An individual participating in transitional medical assistance shall not participate in the annual health plan open enrollment period. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.10)
§17-1717.1-22 Benefits. (a) An individual eligible in accordance with this chapter who is enrolled in a health plan shall be provided a standard benefits package by a participating health plan and other services when appropriate as described in chapter 17-1720. (b) An individual identified in section 17- 1735.1-2(a) shall be provided coverage under the fee- for–service provisions as described in chapter 17-1737. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6) (Imp: HRS §346-14; 42 C.F.R.
UNOFFICIAL 1717.1-9 §§430.25, 431.40, 438.6)
§17-1717.1-23 Disenrollment from a health plan. An enrollee shall be disenrolled from a health plan under the provisions as described in section 17-1720.1. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §430.25) (Imp: HRS §346-14; 42 C.F.R. §430.25)
§§17-1717.1-24 to 17-1717.1-28 (Reserved).
HAWAII ADMINISTRATIVE RULES TITLE 17 DEPARTMENT OF HUMAN SERVICES SUBTITLE 12 MED-QUEST DIVISION CHAPTER 1718 ADULTS GROUP Subchapter 1 General Provisions §17-1718-1 Purpose §17-1718-2 General requirements §§17-1718-3 to 17-1718-7 (Reserved) Subchapter 2 Eligibility Requirements §17-1718-8 §17-1718-9 §17-1718-10 §17-1718-11 §17-1718-12 §17-1718-13 §§17-1718-14 Purpose Basic requirements Categorical requirements Income requirements Asset requirements Eligibility review requirements to 17-1718-18 (Reserved) Subchapter 3 Freedom of Choice, Enrollment, Benefits and Disenrollment §17-1718-19 §17-1718-20 §17-1718-21 §17-1718-22 §17-1718-23 Purpose Freedom of choice Enrollment into a participating health plan Benefits Disenrollment from a health plan 1718-1 320 6
3 20 6 §17-1718-1 §§17-1718-24 to 17-1718-28 (Reserved) Historical Note: This chapter is based substantially upon repealed chapters 17-1727, 17-1728 and 17-1728.1. [Eff 08/01/94; am 07/20/95; am 01/29/96; am 03/30/96; am 11/25/96; am 12/27/97; am 07/06/99; am 06/19/00; am 10/26/01; am 12/03/01; am 02/16/02; am 05/10/03; am 09/17/07; am 09/10/09; am 04/30/10; am 08/19/11; am 06/25/12; R 09/30/13] SUBCHAPTER 1 GENERAL PROVISIONS §17-1718-1 Purpose. This chapter establishes the Adults Group. The eligibility group for individuals age nineteen years or older and under age sixty-five years, an option created through the enactment of the Affordable Care Act and commonly referred to as the Adults Group, provides coverage to eligible adults. [Eff 09/30/13; am and comp NOV I 0 2016 ] (Auth: HRS §346-14, 42 C.F.R. §435.119) (Imp: HRS §346-14, 42 C.F.R. §435.119) §17-1718-2 General requirements. The confidentiality, administrative appeal, fraud, medical assistance recovery, application processing, eligibility review, and adverse action provisions described in subtitle 12 shall pertain to an individual who applies or is eligible under this chapter. [Eff 09/30/13; am and comp (Auth: HRS §§346-14, 346-29, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.119, 435.201, 435.907, 435.916, 455.1) (Imp: HRS §§346-14, 346-29, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.119, 435.201, 435.907, 435.916, 455.1) 1718-2
§17-1718-10 §§17-1718-3 to 17-1718-7 (Reserved) . SUBCHAPTER 2 ELIGIBILITY REQUIREMENTS §17-1718-8 Purpose. This subchapter describes the eligibility requirements for participation in the Adults Group. [Eff 09/30/13; comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §435.119) (Imp: HRS §346-14; 42 C.F.R. §435.119) §17-1718-9 Basic requirements. An individual whose eligibility is being determined under this chapter shall meet the basic eligibility requirements which include, but are not limited to, citizenship, qualified non-citizen or lawfully present non-citizen status, State residency, verification of identity, not residing in a public institution, and the provision of a social security number, as described in chapter 17- 1714 .1. [Eff 09/30/13; am and comp NOV 1 0 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.119, 435.400, 435.910) (Imp: HRS §346-14; 42 C.F.R. §§435.119, 435.400, 435.910) §17-1718-10 Categorical requirements. (a) To be eligible under the Adults Group, an individual shall meet the following requirements: (1) Be age nineteen years or older, but under sixty-five years of age; (2) Not entitled to or enrolled for Medicare; (3) Not in receipt of Supplemental Security Income (SS!); and (4) Not eligible under any of the following chapters: (A) 17-1715, Children Group; 1718-3
§17-1718-10 (B) 17-1715.1, Former Foster Care Children Group; (C) 17-1716, Pregnant Women Group; (D) 17-1717, Parents and Other Caretaker Relatives Group; and (E) 17-1717.1, Transitional Medical Assistance. (b) An individual whose household's modified adjusted gross income (MAGI) based income exceeds the income standard for participation under the Parents and Other Caretaker Relatives Group may participate in the Adults Group if the individual: (1) Resides with a child under nineteen years of age; (2) Assumes primary responsibility for the care of the child described in paragraph (1); and (3) The child described in paragraph (1) is enrolled in Medicaid. (c) An individual who is applying on the basis of blindness or disability shall be subject to the provisions of chapters 17-1719, 17-1724.1, and 17- 1725 .1 . [Eff 09/30/13; am and comp NOV-1 0 2016 (Auth: HRS §346-14; 42 C.F.R. §§430.25, 435.119, 435.150, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 435.119, 435.150, 435.603) §17-1718-11 Income requirements. (a) The MAGI methodology described in chapter 17-1724.2 shall be used to determine the countable income for an individual subject to an income limit. (b) The income standard for participation in the Adults Group is one hundred thirty-three per cent of the federal poverty level for a household of applicable size. An income disregard of five per cent of the applicable federal poverty level is added to the highest income standard for an individual using MAGI-based methodology under the applicable title of the Social Security Act. (c) An individual who is determined under this chapter shall have eligibility for other applicable eligibility groups. 1718-4 ~ 20 6 .I j ineligible determined [Eff
§17-1718-19 09/30/13; am and comp NOV 1 O 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.119, 435.601, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§435.119, 435.601, 435.603) §17-1718-12 not be considered for participation 09/30/13; comp C.F.R. §§435.119, C.F.R. §§435.119, Asset requirements. Assets shall in the determination of eligibility in the Adults Group. [Eff NOV 10 2016 ] (Auth: HRS §346-14; 42 435.603) (Imp: HRS §346-14; 42 435.603) §17-1718-13 Eligibility review requirements. (a) An eligible individual shall receive an annual eligibility review every twelve months. (b) Eligibility shall be redetermined in accordance with chapter 17-1712.1 and subchapter 5 of chapter 17-1714.1. [Eff 09/30/13; am and comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.119, 435.916, 435.940) (Imp: HRS §346-14; 42 C.F.R. §§435.119, 435.916, 435.940) §§17-1718-14 to 17-1718-18 (Reserved) . SUBCHAPTER 3 FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DIS ENROLLMENT §17-1718-19 Purpose. This subchapter addresses and refers to the provisions of freedom of choice, enrollment, benefits and disenrollment for an individual who is eligible in accordance with this chapter. [Eff 09/30/13; am and comp NOV I 0 2016 (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 4 31 . 4 0 ) ( I mp : HRS § 3 4 6 - 14 ; 4 2 C . F . R . § § 4 3 0 . 2 5 , 431.10, 431.40) 1718-5
320 6 §17-1718-20 §17-1718-20 Freedom of choice. (a) An individual eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735.1-2(a), shall be provided a choice of a health plan and a provider as described in chapter 17-1720.1. (b) An individual identified in section 17- 1735.1-2 (a) shall choose a department approved provider as described in section 17-1736-3. [Eff 09/30/13; am and comp NOV I 0 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 438.52) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 438.52) §17-1718-21 Enrollment into a participating health plan. (a) An individual eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735.1-2(a), shall be enrolled in a health plan as described in chapter 17-1720.1. (b) An individual identified in section 17- 1735.1-2 (a) shall not be enrolled into a health plan and their healthcare services shall be provided on a fee-for-service basis. [Eff 09/30/13; am and comp NOV 10 2016] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40, 438.50) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40, 438.50) §17-1718-22 Benefits. (a) An individual eligible in accordance with this chapter who is enrolled in a health plan shall be provided a standard benefits package by a participating health plan and other services when appropriate as described in chapter 17-1720. (b) An individual identified in section 17- 1735.1-2 (a) shall be provided coverage under the fee- for-service provisions as described in chapter 17- 1737. [Eff 09/30/13; am and comp NOV I 0 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 1718-6
§17-1718-23 438.6) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6) §17-1718-23 Disenrollment from a health plan. An enrollee shall be disenrolled from a health plan under the provisions as described in chapter 17- 1720.1. [Eff 09/30/13; comp NOV102016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.56) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.56) §§17-1718-24 to 17-1718-28 (Reserved) . .. 1718-7 320 6
' HAWAII ADMINISTRATIVE RULES TITLE 17 DEPARTMENT OF HUMAN SERVICES SUBTITLE 12 MED-QUEST DIVISION .. CHAPTER 1719 AGED, BLIND, AND DISABLED GROUP Subchapter 1 General Provisions §17-1719-1 Purpose §17-1719-2 General requirements §§17-1719-3 to 17-1719-7 (Reserved) Subchapter 2 ' §17-1719-8 §17-1719-9 §17-1719-10 §17-1719-10.1 §17-1719-10.2 Eligibility Requirements Purpose Basic requirements Categorical requirements for an aged individual Categorical requirements for a blind individual Categorical requirements for a disabled individual §17-1719-11 Income requirements §17-1719-11.1 Standards of assistance §17-1719-12 Asset requirements §17-1719-13 Eligibility review requirements §§17-1719-14 to 17-1719-18 (Reserved) Subchapter 3 Freedom of Choice, Enrollment, Benefits and Disenrollment §17-1719-19 Purpose 1719-1 3 20 E
§17-1719-1 §17-1719-20 §17-1719-21 . Freedom of choice Enrollment into a participating health plan §17-1719-22 Benefits §17-1719-23 Disenrollment from a health plan §§17-1719-24 to 17-1719-28 (Reserved) Historical Note: This chapter is based substantially .. upon repealed chapter 17-1721. [Eff 08/01/94; am 11/13/95; am 01/29/96; am 11/25/96; am 10/26/01; am 12/26/05; am 01/31/09; am 10/19/09; am 06/25/12; R 09/30/13] SUBCHAPTER 1 GENERAL PROVISIONS §17-1719-1 Purpose. This chapter establishes the Aged, Blind, and Disabled Group. The Aged, Blind, and Disabled Group provides Medicaid eligibility for an ag~d, blind, or disabled individual under the provisions of Title XIX of the Social Security Act. [Eff 09/30/13; am and comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.121, 435.230, 435.330) (Imp: HRS §346-14; 42 C.F.R. §§435.121, 435.230, 435.330) §17-1719-2 General requirements. The confidentiality, administrative appeal, fraud, medical assistance recovery, application processing, eligibility review, and adverse action. provisions described in subtitle 12 shall pertain to an aged, blind, or disabled individual who applies or is eligible under this chapter. [Eff 09/30/13; comp NOV102D16 ] (Auth: HRS §§346-14, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.121, 435.230, 435.330, 435.907, 435.916, 455.1) (Imp: HRS §§346-14, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.121, 435 . 230, 435.330, 435.907, 435.916, 455.1) 1719-2 }20 6 d
§17-1719-10 §§17-1719-3 to 17-1719-7 (Reserved) . SUBCHAPTER 2 ELIGIBILITY REQUIREMENTS §17-1719-8 Purpose. This subchapter describes the basic, categorical, and financial eligibility requirements for participation in the Aged, Blind, and Disabled Group. [Eff 09/30/13; am and comp ~ov I 0 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.110, 435.121, 435.201, 435.230, 435.330) (Imp: HRS §346-14; 42 C.F.R. §§435.110, 435.121, 435.201, 435.230, 435.330) §17-1719-9 Basic requirements. An individual whose eligibility is being determined under this chapter shall meet the basic eligibility requirements which include, but are not limited to, citizenship, qualified non-citizen or a lawfully present non- citizen status, State residency, verification of identity, not residing in a public institution, and the provision of a social security number, as described in chapter 17-1714.1. [Eff 09/30/13; am and comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.121, 435.230, 435.330, 435.400, 435.910) (Imp: HRS §346-14; 42 C.F.R. §§435.121, 435 . 230, 435.330, 435.400, 435.910) §17-1719-10 Categorical requirements for an aged individual. (a) To be eligible under the Aged, Blind, and Disabled Group, an aged individual shall be at least sixty-five years of age in the month of eligibility. (b) Proof of age shall be required, and includes, but is not limited to: (1) Birth verification, legal documents, or church records; or (2) Eligibility for or receipt of SSI or RSDI benefits on the basis of being aged. 1719-3 320 6
§17-1719-10.1 [Eff 09/30/13; am and comp NOV I 0 2016 (Auth: HRS §346-14; 42 C.F.R. §§435.121, 435.520, 435.522) (Imp: HRS §346-14; 42 C.F.R. §§435.121,-435.520, 435.522) §17-1719-10.1 Categorical requirements for a blind individual. (a) To be eligible under the Aged, Blind, and Disabled Group, a blind individual shall have central visual acuity of 20/200 or worse in the better eye with correcting lens, or the widest field of vision subtends an angle no greater than twenty degrees (tunnel vision) . (b) Proof of blindness shall be required, and includes, but is not limited to: 320 6 d (1) Eligibility for or receipt of SSI or RSDI benefits based on blindness. (2) Certification of blindness by the department's division of vocational rehabilitation, Ho'opono, if the requirement of paragraph (1) is not met. (A) Recertification of blindness is not required if the department's division of vocational rehabilitation, Ho'opono, certified the blind individual's condition to be permanent with little chance of improvement and, therefore, specifies that reevaluation is not necessary or warranted. (B) Recertification of blin~ess is required if the individual's condition is not permanent, there is a possibility of improvement, or reevaluation is recommended by the department's division of vocational rehabilitation, Ho'opono. (i) Reevaluation of blindness shall be scheduled as recommended by the department's division of vocational rehabilitation, Ho'opono. (ii) If no evaluation date is indicated, recertification will be scheduled on an annual basis. [Ef f and comp NOV I 0 2016 ] (Auth: HRS §§346-14, 346-29; 346- 62; 42 C.F.R. §§435.121, 435.530, 435. 531,) .(Imp: HRS §346-29; 42 1719-4
§17-1719-10.2 C.F.R. §§435.121, 435.530, 435.531) §17-1719-10.2 Categorical requirements for a disabled individual. (a) To be eligible under the Aged, Blind, and Disabled Group, a disabled individual shall be unable to engage in substantial gainful activity because of a medically determinable physical or mental impairment which has lasted or is expected to last for a continuous period of not less than twelve months or which is expected to result in death. (b) Proof of disability shall be required, and includes, but is not limited to: (1) Eligibility for or receipt of SSI or RSDI benefits based on disability. (2) Certification of disability by the department's aid to the disabled review committee (ADRC) if the requirement of paragraph (1) is not met. (A) Recertification of disability is not required if the department's ADRC certifies the individual's condition to be permanent with little chance of significant improvement and therefore specifies that reevaluation is not necessary or warranted. (B) Recertification of disability is required if the individual's condition is not permanent, there is a possibility of improvement, or reevaluation is recommended by the department's ADRC. (i) Reevaluation shall be scheduled as recommended by the department's ADRC. (ii) If no evaluation date is indicated, recertification will be scheduled on an annual basis. [Eff and comp NOV 1 0 2016 ] (Auth: HRS §§346-14, 346-29; 42 C.F.R. §§435.121, 435.540, 4 3 5 . 5 41 ) ( I mp : HRS § 3 4 6 - 2 9 ; 4 2 C.F.R. §§435.121, 435.540, 435.541) 1719-5 320 6
§17-1719-11 §17-1719-11 Income requirements. (a) The income standards for participation in the Aged, Blind, and Disabled Group, are the standards of assistance as designated under this subchapter. (b) An individual who meets the requirements of more than one standard of assistance shall have eligibility determined based on the standard of assistance that would be most beneficial to the individual. (c) Countable income, as referred to in chapter 17-1724.1, after allowable disregards and exemptions, shall be compared to the standards of assistance which are established for the different coverage groups under the State Plan. (d) An individual applying for medical assistance shall not be required to apply for or receive SS!. (e) If income exceeds the applicable standards of assistance under section 17-1719-11.1, the provisions relating to an individual with excess income described in chapter 1730.1 shall apply. (f} The provisions of subchapter 8 of chapter 17-1724.1 shall apply to an individual who is requesting or receiving coverage of long-term care services. [Eff 09/30/13; am and comp NOV102016 (Auth: HRS §§346-14, 346-53; 42 C.F.R. §§431.10, 435.121, 435.210, 435.217, 435.230, 435.330, 435.601, 435.602, 435.811, 435.814, 435.831, 42 u.s.c. §1396a(m)) (Imp: HRS §346-53; 42 C.F.R. §§435.121, 435.210, 435.217, 435.230, 435.330, 435.601, 435.602, 435.811, 435.814, 435.831; 42 U. S.C. §1396a(m)) §17-1719-11.1 Standards of assistance. (a) In addition to meeting the categorical requirements for an aged, blind, or disabled individual under this chapter, the individual must be eligible for one of the following categorically needy groups: 3206 Ii (1) Mandatory Categorically Needy (MCN) for an individual or couple, as applicable, eligible for or in receipt of SS! payments or SSP payments, or both, and the standard of assistance shall be equal to the SS! standard. 1719-6
§17-1719-11.1 (2) Medically Needy (MN) for an individual financially ineligible for SS! benefits, but whose income is insufficient to meet medical expenses, and the standard of assistance shall be equal to fifty per cent of the 2006 federal poverty level for a household of applicable size. (3) Optional Categorically Needy (OCN) for an individual who is sixty-five years of age or older or whose eligibility is being determined on the basis of being disabled, and the standard of assistance shall be equal to one hundred per cent of the federal poverty level for a household of applicable (4) size. Optional Categorically Needy (OCN) for an individual in a licensed domiciliary care facility, both residential care facility and community care foster family home; and the standard of assistance shall be equal to the rate of payment of the SS! program and SSP for: ( i) A Type I domiciliary care facility has not more than five residents; or (ii) A Type II domiciliary care facility has six or more residents. (b) If income exceeds the applicable standards of assistance, the individual shall be evaluated for other available eligibility groups. [Eff and comp NOV 10 2016 ] (Auth: HRS §346-14) (Imp: HRS §§346-14, 346-53; 42 C.F.R. §§435.120, 435.121, 435.210, 435.217, 435.230, 435.330, 435.811, 435.831) §17-1719-12 Asset requirements. (a) The personal reserve standard is the maximum amount of countable assets that may be held by an individual or household while establishing or maintaining eligibility for medical assistance under this chapter. The personal reserve standards for an individual or two-member household shall be equal to the resource limits employed by the SS! program. 1719-7 3 20 6
320 6 §17-1719-12 (b) For each household member in households greater than two, $250 shall be added to the SSI personal reserve standard for two and the resultant amount is the personal reserve standard for a household of applicable size. (c) An individual or household whose equity in non-exempt assets as determined in chapter 17-1725.1 exceeds the personal reserve standard for medical assistance for a household of applicable size shall be ineligible for medical assistance. (d) An individual who is requesting or receiving coverage of long-term care services must meet the requirements of subchapter 7 of cha~ter 17-1725.1. [Eff 09/30/13; am and comp NOV 1 U 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.3, 435.121, 435.230, 435.330, 435.840, 435.843, 435.845) (Imp: 42 C.F.R. §§435.3, 435.121, 435.230, 435.330, 435.840, 435.843, 435.845) §17-1719-13 Eligibility review requirements. (a) An eligible individual shall receive an eligibility review every twelve months. (b) Eligibility shall be redetermined in accordance with chapter 17-1712.1 and subchapter 5 of chapter 17-1714.1. [Eff 09/30/13; comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.116, 435.916, 435.940) (Imp: HRS §346-14; 42 C.F.R. §§435.116, 435.916, 435.940) §§17-1719-14 to 17-1719-18 (Reserved) • SUBCHAPTER 3 FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT §17-1719-19 Purpose. This subchapter addresses and refers to the provisions of freedom of choice, enrollment, benefits and disenrollment for an aged, blind, or disabled individual who is eligible in accordance with this chapter. [Eff 09/30/13; 1719-8
§17-1719-21 comp NOV 10 -2016 ] (Auth: HRS §§346-14, 346-29; 42 C.F.R. §§435.121, 435.230, 435.330, 435.520, 435.522, 435.530, 435.531, 435.540, 435.541, 435.608; 45 C.F.R. §§233.39, 233.70, 233.80, 42 U.S.C. §1396(a) to (m)) (Imp: HRS §346-29; 42 C.F.R. §§435.121, 435.230, 435.330, 435.520, 435.522, 435.530, 435.531, 435.540, 435.541, 435.608; 45 C.F.R. §§233.39, 233.70, 233.80, 42 U.S.C. §1396(a) to (m)) §17-1719-20 Freedom of choice. (a) An aged, blind or disabled individual eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735.1-2(a), shall be provided a choice of a health plan and a provider as described in chapter 17-1720.1. (b) An aged, blind or disabled individual identified in section 17-1735.1-2(a) shall choose a department approved provider as described in section 17-1736-3. [Eff 09/30/13; comp NOV I 0 2016 J (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 435.131, 435.330, 435.520, 435.522, 435.530, 435.531, 435.540, 435.541, 438.52) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 435.131, 435.330, 435.520, 435.522, 435.530, 435.531, 435.540, 435.541, 438.52) §17-1719-21 Enrollment into a participating health plan. (a) An aged, blind or disabled individual eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735.l-2(a), shall be enrolled in a health plan as described in chapter 17-1720.1. (b) An aged, blind or disabled individual identified in section 17-1735.1-2(a) shall not be enrolled into a plan and services shall be provided on a fee-for-service basis. [Eff 09/30/13; comp NOV 1 O 2016 ] (Auth: HRS §§346-14, 346-29; 42 C.F.R. §§430.25, 431.51, 435.131, 435.330, 435.520, 435.522, 435.530, 435.531, 435.540, 435.541, 42 u.s.c. §1396 (a) to (m)) (Imp: HRS §346-29; 42 C.F.R. §§430.25, 431.51, 435.131, 435.330, 435.520, 435.522, 1719-9 3 20 ~
~ 2 0 6 di .. §17-1719-22 435.530, 435.531, 435.540, 435.541, 42 U.S.C. §1396(a) to (m) ) §17-1719-22 Benefits. (a) An aged, blind or disabled individual who is enrolled in a health plan shall be provided a standard benefits package by a participating health plan and other services when appropriate as described in chapter 17-1720. (b) An aged, blind or disabled individual identified in section 17-1735.l-2(a) shall be provided coverage under the fee-for-service provisions as described in chapter 17-1737. [Eff 09/30/13; comp NOV102016] (Auth: HRS §§346-14, 346-29; 42 C.F.R. §§435.131, 435.330, 435.520, 435.522, 435.530, 435.531, 435.540, 435.541, 435.608; 45 C.F.R. §§233.39, 233.70, 233.80; 42 U.S.C. §1396(a) to (m)) (Imp: HRS §346-29; 42 C.F.R. §§435.131, 435.330, 435.520, 435.522, 435.530, 435.531, 435.540, 435.541, 435.608; 45 C.F.R. §§233.39, 233.70, 233.80; 42 U.S.C. §1396(a) to (m)) §17-1719-23 Disenrollment from a health plan. An enrollee shall be disenrolled from a health plan under the provisions as described in chapter 17- 1720.1. [Eff 09/30/13; comp NOV102016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.56) ( I mp : HRS § 3 4 6 - 14 ; 4 2 C . F . R . § § 4 3 o . 2 5 , . 4 31 . 4 o , 438.56) §§17-1719-24 to 17-1719-28 (Reserved) . 1719-10
UNOFFICIAL HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1719.1
STATE FUNDED AGED, BLIND, AND DISABLED PROGRAM
Subchapter 1 General Provisions
§17-1719.1-1
Purpose §17-1719.1-2
General requirements §§17-1719.1-3 to 17-1719.1-7 (Reserved)
Subchapter 2 Eligibility Requirements
§17-1719.1-8
Purpose §17-1719.1-9
Basic requirements §17-1719.1-10 Categorical requirements for an
aged, blind, or disabled
individual §17-1719.1-11 Income requirements §17-1719.1-12 Asset requirements §17-1719.1-13 Application periods §17-1719.1-14 Eligibility review requirements §§17-1719.1-15 to 17-1719.1-19 (Reserved)
Subchapter 3 Freedom of Choice, Enrollment, Benefits and Disenrollment
§17-1719.1-20 Purpose §17-1719.1-21
Freedom of choice §17-1719.1-22 Enrollment into a participating health plan §17-1719.1-23 Benefits §17-1719.1-24 Disenrollment from a health plan 1719.1-1
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§§17-1719.1-25 to 17-1719.1-29 (Reserved)
SUBCHAPTER 1
GENERAL PROVISIONS
§17-1719.1-1 Purpose. This chapter establishes the State Funded Aged, Blind, and Disabled Program for certain lawfully present non-pregnant adult non- citizens who are aged, blind, or disabled and ineligible under chapter 17-1719 solely due to citizenship or non-citizen status. [Eff 02/27/15 ] (Auth: HRS §346-14) (Imp: HRS §346-14)
§17-1719.1-2 General requirements. (a) The confidentiality, administrative appeal, fraud, medical assistance recovery, application processing, eligibility review, and adverse action provisions described in subtitle 12 shall apply to an individual who applies or is determined eligible under this chapter. For purposes of this chapter, references to the terms “Medicaid” or “federal medical assistance” in the provisions listed above shall be replaced with “state medical assistance under chapter 17-1719.1”, when applicable. (b) Processing of applications shall be: (1) In accordance with chapter 17-1711.1; however, subsections 17-1711.1-32(b)-(e) shall not apply; and (2) Subject to section 17-1719.1-13. [Eff 02/27/15 ] (Auth: HRS §346-14, 346-44) (Imp: HRS §§346-14, 346-44)
§§17-1719.1-3 to 17-1719.1-7 (Reserved).
SUBCHAPTER 2
ELIGIBILITY REQUIREMENTS
§17-1719.1-8 Purpose. This subchapter describes the basic, categorical, and financial eligibility 1719.1-2
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requirements for participation under this chapter. [Eff 02/27/15 ] (Auth: HRS §346-14) (Imp: HRS §346-14)
§17-1719.1-9 Basic requirements. To be eligible under this chapter, an individual shall: (1) Meet the basic eligibility requirements described in chapter 17-1714.1, with the exception of citizenship or non-citizen status; (2) Be a lawfully present non-citizen; (3) Not be a beneficiary of Executive Actions including but not limited to, Deferred Action for Childhood Arrivals (DACA), or Deferred Action for Parental Accountability (DAPA); and (4) Be ineligible for Medicaid, with the exception of emergency medical assistance. [Eff 02/27/15 ] (Auth: 8 U.S.C. §1622; HRS §346-14) (Imp: HRS §346-14)
§17-1719.1-10 Categorical requirements for an aged, blind, or disabled individual. To be eligible under this chapter, an aged, blind, or disabled individual shall meet the categorical requirements for being aged, blind, or disabled, respectively, as described in chapter 17-1719. [Eff 02/27/15 ] (Auth: HRS §§346-14, 346-29) (Imp: HRS §§346-14, 346- 29)
§17-1719.1-11 Income requirements. (a) The applicable standards of assistance for participation under this chapter are set forth under chapter 17-1719. (b) An individual who meets the requirements of more than one standard of assistance shall have eligibility determined based on the standard of assistance that would be most beneficial to the individual. (c) Countable income, as set forth in chapter 17- 1724.1, after allowable disregards and exemptions, shall be compared to the standards of assistance set forth under chapter 17-1719. 1719.1-3
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(d) An individual applying for medical assistance under this chapter shall not be required to apply for or receive SSI. (e) If an individual’s income exceeds the applicable standards of assistance set forth under chapter 17-1719, the provisions relating to an individual with excess income described in chapter 1730.1 shall apply. (f) An individual who is requesting or receiving coverage of long-term care services shall be subject to chapter 17-1724.1, subchapter 8. [Eff 02/27/15 ] (Auth: HRS §§346-14, 346-53) (Imp: HRS §346-53)
§17-1719.1-12 Asset requirements. (a) The personal reserve standards are the maximum amount of countable assets, as set forth in chapter 17-1719, that may be held by the household while establishing or maintaining eligibility for medical assistance under this chapter and are equal to the resource limits employed by the SSI program. (b) An individual or household whose equity in non-exempt assets as determined in chapter 17-1725.1 exceeds the personal reserve standard for medical assistance for a household of applicable size shall be ineligible for medical assistance under this chapter. (c) An individual who is requesting or receiving coverage of long-term care services shall be subject to the requirements of chapter 17-1725.1, subchapter 7. [Eff 02/27/15 ] (Auth: HRS §346-14) (Imp: HRS §346-14)
§17-1719.1-13 Application periods. (a) The department shall begin receiving applications for state medical assistance under this chapter starting on the effective date of this chapter, and may stop accepting applications pursuant to subsection (d). (b) After the initial application period under subsection (a) is closed, the department shall accept applications under this chapter only during an announced open application period. (c) Prior to the start of an open application period, the department shall issue a public notice at least once statewide announcing the start of an open application period. 1719.1-4
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(d) The department may close the initial application period, or any subsequent open application period, by issuing a public notice once statewide at least thirty days prior to the date the application period will be closed. Applications received by the department after the open application period has ended shall be denied. (e) The restriction on submission of an application under subsection (b) shall not apply to an individual who loses eligibility under the Children Group as a result of reaching age nineteen years or under the Pregnant Women Group as a result of reaching the end of the post-partum period, and who is eligible under this chapter. (f) Upon adoption of this chapter, an individual receiving state medical assistance as an aged, blind or disabled individual shall be deemed eligible under this chapter. [Eff 02/27/15 ] (Auth: HRS §346-14) (Imp: HRS §346-14)
§17-1719.1-14 Eligibility review requirements. (a) An eligible individual shall receive an eligibility review every twelve months. (b) Eligibility shall be redetermined in accordance with chapter 17-1712.1 and chapter 17- 1714.1, subchapter 5. [Eff 02/27/15 ] (Auth: HRS §346-14) (Imp: HRS §346-14)
§§17-1719.1-15 to 17-1719.1-19 (Reserved).
SUBCHAPTER 3 FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT
§17-1719.1-20 Purpose. This subchapter addresses freedom of choice, enrollment, benefits and disenrollment for an individual who is eligible under this chapter. [Eff 02/27/15 ] (Auth: HRS §§346- 14, 346-29) (Imp: HRS §346-29) 1719.1-5
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§17-1719.1-21 Freedom of choice. (a) An individual eligible under this chapter, with the exception of an individual identified in section 17- 1735.1-2(a), shall be provided a choice of a health plan and a provider as described in chapter 17-1720.1. (b) An individual eligible under this chapter identified in section 17-1735.1-2(a) shall choose a department approved provider as described in section 17-1736-3. [Eff 02/27/15 ] (Auth: HRS §346-14) (Imp: HRS §346-14)
§17-1719.1-22 Enrollment into a participating health plan. (a) An individual eligible under this chapter, with the exception of an individual identified in section 17-1735.1-2(a), shall be enrolled in a health plan as described in chapter 17-1720.1, subchapter 2. (b) An individual eligible under this chapter identified in section 17-1735.1-2(a) shall not be enrolled into a plan, and services shall be provided on a fee-for-service basis. [Eff 02/27/15 ] (Auth: HRS §§346-14, 346-29) (Imp: HRS §346-29)
§17-1719.1-23 Benefits. (a) An individual eligible under this chapter shall be provided a standard benefits package by a participating health plan and other services when appropriate as described in chapter 17-1720. (b) An aged, blind or disabled individual identified in section 17-1735.1-2(a) shall be provided coverage under the fee-for-service provisions described in chapter 17-1737. [Eff 02/27/15 ] (Auth: HRS §§346-14, 346-29) (Imp: HRS §346-29)
§17-1719.1-24 Disenrollment from a health plan. An enrollee shall be disenrolled from a health plan under the provisions described in chapter 17-1720.1. [Eff 02/27/15 ] (Auth: HRS §346-14) (Imp: HRS §346-14)
§§17-1719.1-25 to 17-1719.1-29 (Reserved). 1719.1-6
HAWAII ADMINISTRATIVE RULES TITLE 17 DEPARTMENT OF HUMAN SERVICES SUBTITLE 12 MED-QUEST DIVISION CHAPTER 1720 BENEFITS PACKAGE Subchapter 1 General Provisions §17-1720-1 Purpose §§17-1720-2 to 17-1720-4 (Reserved) Subchapter 2 Scope and Content of Services §17-1720-5 Purpose §17-1720-6 Covered Services §§17-1720-7 to 17-1720-9 (Reserved) Subchapter 3 Standard Benefits Package §17-1720-10 Standard Benefits Package §§17-1720-11 to 17-1720-13 (Reserved) Subchapter 4 Specialized Behavioral Health Services §17-1720-14 Specialized Behavioral Health Services §§17-1720-15 to 17-1720-17 (Reserved) Subchapter 5 Home and Community Based Services §17-1720-18 Home and Community Based Services (HCBS) §§17-1720-19 to 17-1720-21 (Reserved) 1720-1 320 6
§17-1720-1 Subchapter 6 Institutional Care Services §17-1720-22 Institutional Care Services §§17-1720-23 to 17-1720-25 (Reserved) Subchapter 7 Dental Services §17-1720-26 Dental Services §§17-1720-27 to 17-1720-30 (Reserved) Subchapter 8 Exclusions and limitations §17-1720-31 Exclusions and limitations §§17-1720-32 to 17-1720-34 (Reserved) Historical Note: This chapter is based substantially upon repealed subchapter 7 of chapter 17-1721.1 and repealed subchapter 8 of chapter 17-1727. The source note for subchapter 7 of chapter 17-1721.1 is: [Eff 01/31/09; am 06/25/12; R 09/30/13] The source note for subchapter 8 of chapter 17-1727 is: [Eff 08/01/34; am 01/29/96; am 03/30/96; am 11/25/96; am 06/19/00; am 02/16/02; am 01/31/09; am 09/10/09; am 06/25/12; am 04/12/13; R 09/30/13] SUBCHAPTER 1 GENERAL PROVISIONS §17-1720-1 Purpose. This chapter describes covered services, exclusions and limitations provided to an enrollee by a partic~pating health plan. [Eff 09/30/13; am and comp NOV102016] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 438.6, 440.210) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 438.6, 440.210) §§17-1720-2 to 17-1720-4 (Reserved) . 1720-2 3 2 0 6 .l I
§17-1720-6 SUBCHAPTER 2 SCOPE AND CONTENT OF SERVICES §17-1720-5 Purpose. This subchapter describes covered services provided by a participating health plan to an enrollee. [Eff 09/30/13; am and comp ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 438.6, 440.210) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 438.6, 440.210) §17-1720-6 Covered services. (a) The services minimally required to be provided by each participating health plan are described in section 17-1720-10 and shall be known as the standard benefits package. (b) The standard benefits package is based on a twelve-month benefit period. Service limits are pro- rated for any benefit period less than twelve-months. If an enrollee changes health plans during a benefit period, the remaining unused service limits will be covered by the new health plan for the duration of the benefit period. (c) Based on clinical eligibility and medical necessity, a participating health plan may provide services described in section 17-1720-14 to an enrollee. (d) Based on level of care eligibility, the enrollee shall be provided services described in sections 17-1720-18 or 17-1720-22 by the health plan. (e) A health plan may, at the health plan's option, or as otherwise required by the contract between the health plan and the departmentL or the state plan, provide medically necessary services which exceed the requirements of the standard benefits package. [Eff 09/30/13; am and comp NOV I 0 2016 (Auth: HRS §346-14; 42 C.F.R. §§.430.25, 438.6, 4 4 0 . 21 0 ) ( I mp : HRS § 3 4 6 - 14 ; 4 2 C . F . R . § § 4 3 0 . 2 5 , 438.6, 440.210) 1720-3 320 6
§17-1720-10 §§17-1720-7 to 17-1720-9 (Reserved) . SUBCHAPTER 3 STANDARD BENEFITS PACKAGE §17-1720-10 Standard benefits package. Within a twelve-month benefit period, participating health plans shall provide the following medically necessary services which minimally include, but are not limited to, the following and which may require prior authorization and be subject to limitations as described in chapter 17-1737: 3206 .) (1) Medical inpatient days for medically necessary inpatient hospital care related to medical care, surgery, post-stabilization, acute rehabilitation and behavioral health inpatient days for psychiatric care include, but are not limited to, the following: (A) Semi-private room and board and general nursing care for inpatient stays related to medical care, surgery, and psychiatric care; (B) Intensive care room and board and general nursing care for medical care and surgery; (C) Use of an operating room and related facilities, inpatient anesthesia, radiology, laboratory and other diagnostic services agreed upon by the plan medical director for medical care and surgery; (D) Drugs, dressings, blood derivatives and their administration, general medical supplies, and diagnostic and therapeutic procedures as prescribed by the attending physician; and 1720-4
§17-1720-10 (E) Other ancillary services associated with hospital care except private duty nursing. (2) Outpatient services include, but are not limited to, the following: (A) Ambulatory surgical center procedures or outpatient hospital services; (B) Behavioral health services; (C) Bona fide emergency services, coverage shall be provided for bona fide emergency services including ground and air (fixed wing and rotor) ambulance for emergency transportation, emergency room services, and physician services in conjunction with the emergency room visits. Bona fide emergency room visits shall be restricted to those requiring services for emergency medical conditions; (D) Diagnostic testing, including laboratory and radiology; (E) Dialysis; (F) Durable medical equipment including visual appliances, prosthetic devices, orthotics and medical supplies; (G) Early and Periodic Screening, Diagnosis and Treatment services as described in chapters 17-1715 and 17-1715.1, for an enrollee under age twenty-one years who requires services that have either been exhausted or not described under section 17-1720-10; (H) Family planning services to include family planning services rendered by a physician or nurse midwife, and family planning drugs, supplies and devices approved by the federal Food and Drug Administration; (I) Habilitation services; (J) Home health services; (K) Hospice services; 1720-5
§17-1720-10 (L) (M) Pregnancy related, maternity and newborn care services; (N) Medical services related to dental needs; (0) Methadone management; (P) Non-emergency transportation; (P) Prescription or over-the-counter drugs with a prescription limited by a strict f ormulary and defined in the contract negotiated between the health plan and the department; (Q) Other practitioner services; (R) Out-of-State services; (S) Physician services; (T) Podiatry services; (U) Preventative services; (V) Rehabilitation services including physical, occupational, speech, and cognitive rehabilitation therapy; (W) Sterilization services; (X) Smoking cessation services; (Y) Substance abuse treatment services; (Z) Urgent care services; (AA) Vaccinations; and (BB) Vision and hearing services. [Eff 09/30/13; am and comp 'NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 438.6, 4 4 0 . 210 ) ( I mp : HRS § 3 4 6 - 14 ; 4 2 C . F . R . §§430.25, 438.6, 440.210) §§17-1720-11 to 17-1720-13 (Reserved) SUBCHAPTER 4 SPECIALIZED BEHAVIORIAL HEALTH SERVICES §17-1720-14 Specialized behavioral health services. (a) In addition to services included in the standard benefits package under section 17-1720-10 and 1720-6 3206 If
§17-1720-14 based on clinical eligibility and medical necessity, the following specialized behavioral health services may be provided for an enrollee with a severe and persistent mental illness, serious mental illness, or requiring support for emotional and behavioral development: (1) Biopsychosocial rehabilitation; (2) Clubhouse; (3) Community based residential programs; (4) Crisis management; (5) Crisis residential services; (6) Financial management; (7) Hospital-based residential services; (8) Intensive case management; (9) Intensive family intervention; (10) Intensive outpatient hospital services; (11) Peer Specialist; (12) Substance abuse treatment provided by a licensed or a certified substance abuse counselor; (13) Supportive employment; (14) Supported housing; and (15) Therapeutic living supports and therapeutic foster care supports. (b) An enrollee who is age eighteen years or older and certified by an independent clinical evaluator as diagnosed with severe and persistent mental illness or serious mental illness shall receive behavioral health services through the adult mental health division within the department of health, the health plan in which the enrollee is enrolled or community care services program as determined by the department. (c) An enrollee who is three to twenty years of age, and who is diagnosed with a severe emotional or behavioral disorder by an independent clinical evaluator, shall be referred to the child and adolescent mental health division within the department of health for behavioral .hialth services. [Eff 09/30/13; am and comp NOV 0 Z016 ] (Auth: HRS §346- 14; 42 C.F.R. §430.25) (Imp: HRS §346-14; 42 C.F.R. §430.25 1720-7 320f
§17-1720-18 §§17-1720-15 to 17-1720-17 (Reserved) . SUBCHAPTER 5 HOME AND COMMUNITY BASED SERVICES §17-1720-18 Home and Community Based Services (HCBS). (a) The participating health plan is not required to provide HCBS to an enrollee if: (1) The enrollee chooses institutional services; (2) The enrollee cannot be served safely in the community; (3) There are no adequate or appropriate providers for needed services; or (4) The cost of providing services in the home or community setting is expected to exceed the cost of providing care in an institution. (b) The health plan must receive prior approval from the department or its designee prior to disapproving a request for HCBS. (c) An enrollee must meet one of the following level of care criteria to receive home and community based services: · (1) At risk of deteriorating to institutional level of care; or (2) At institutional level of care. (d) The health plan shall provide HCBS services which minimally include, but are not limited to, the following and may require prior authorization: (1) Adult day care services provided by a licensed facility maintained and operated by an enrollee, organization, or agency for the purpose of providing regular supportive care to four or more disabled adult participants, with or without charging a fee. Adult day care services include therapeutic, social, educational, recreational, and other activities. Adult day care staff members may not perform healthcare related services such as medication administration, tube 1720-8
§17-1720-18 feedings, and other activities which require healthcare related training; (2) Adult day health services provided by an organized program of therapeutic, social and health activities and services provided to enrollees with functional impairments, for the purpose of restoring or maintaining the enrollee's optimal capacity for self-care. Adult day health facilities are licensed in accordance with chapter 11-96 and subchapter 2 of chapter 11-94.1; (3) Home delivered meals that are nutritionally sound and delivered to a location where the enrollee resides (excluding residential or institutional settings) . The meals will not replace or substitute for a full day's nutritional regimen, no more than two meals per day. Home delivered meals are provided to an enrollee who cannot prepare nutritionally sound meals without assistance and are determined, through an assessment, to require the service in order to remain independent in the community and to prevent institutionalization; (4) Personal assistance services - Level I are provided to enrollees requiring assistance with instrumental activities of daily living in order to prevent a decline in the health status and maintain enrollees safely in their home and communities. These services are primarily companion or home maker/chore services. The services are for the Medicaid beneficiary, not for other members of the household; (5) Personal assistance services - Level II are provided to enrollees requiring assistance with moderate/substantial to total assistance to perform activities of daily living and health maintenance activities. (6) Personal emergency response system that is an electronic system placed in homes of high risk enrollees who live alone or are alone 1720-9
3206 §17-1720-18 significant parts of the day, have no regular caregiver for extended periods of time, and who would otherwise require extensive routine supervision, to enable · them to secure immediate help in the event of a physical, emotional, or environmental emergency; and (7) Skilled nursing services are provided to enrollees requiring ongoing nursing care (in contrast to home health or part time, intermittent skilled nursing services) . The service is provided by licensed nurses as described in chapter 16-89. (e) The health plan shall provide the following services which minimally include, but are not limited to, the following and require prior authorization: (1) The services included in subsection (d); (2) Assisted living services that include personal care and supportive care services (such as homemaker services, chore services, attendant services, and meal preparation) that are furnished to enrollees who reside in an assisted living facility. Payment for room and board is prohibited; (3) Community care foster family home services provided in a home that is certified by the department to provide, for a fee, twenty- four hour living accommodations, including personal care, supportive services (such as homemaker services, chore services and attendant care and companion services) and medication oversight (to the extent permitted under State law) . Services shall be provided in a certified private home by a principal care provider who lives in the home for not more than three adults at any one time, at least two of whom shall be Medicaid recipients, and all of whom are at nursing facility level of care, are unrelated to the foster family, and are being monitored in the home by a licensed community case management agency. It does 1720-10
§17-1720-18 not include expanded adult residential care homes and assisted living facilities, which shall continue to be licensed by the department of health; (4) Community Care Management Agency (CCMA) services are provided to enrollees living in Community Care Foster Family Homes and other community settings. The following activities are provided by a CCMA: continuous and ongoing nurse delegation to the caregiver in accordance with subchapter 15 of chapter 16-89; initial and ongoing assessments to make recommendations to health plans for, at a minimum, indicated services, supplies, and equipment needs of enrollees; ongoing face-to-face monitoring and implementation of the enrollee's care plan; and interaction with the caregiver on adverse effects and changes in condition of enrollees, or both. CCMAs shall: communicate with an enrollee's physician(s) regarding the enrollee's needs including changes in medication and treatment orders; work with families regarding service needs of enrollees and serve as an advocate for their enrollees; and be accessible to the enrollee's caregiver twenty-four hours a day, seven days a week; (5) Counseling and training services that involve counseling for the enrollee, family or caregiver, and professional and paraprofessional caregivers to provide the necessary support to build and enhance coping skills, as well as training that may include, but not limited to, enrollee care training for enrollees, family and caregivers regarding the nature of the disease and the disease process; methods of transmission ·and infection control measures; biological, psychological care and special treatment needs-regimens; employer training for consumer directed services; instruction 1720-11
§17-1720-18 3206 If about the treatment regimens; use of equipment specified in the service plan; employer skills updates as necessary to safely maintain the enrollee at home; crisis intervention; supportive counseling; family therapy; suicide risk assessments and intervention; death and dying counseling; anticipatory grief counseling; substance abuse counseling; and nutritional assessment and counseling; (6) Environmental accessibility adaptations that are changes to the enrollee's living environment, but not including community care foster family homes and expanded adult residential care homes (E-ARCH) , to promote safety or facilitate the enrollee's self- reliance by enabling the enrollee to perform basic activities of daily living. Modifications may include installation of ramps and handrails, widening of doorways, removal of other architectural barriers, bathroom modifications, electrical, plumbing or air conditioners and modifications to the telephone system which enable the enrollee to function with greater independence in the home, and without which the enrollee would require institutionalization. Window air conditioners may be installed when it is necessary for the health and safety of the enrollee. Ex~luded are those adaptations or improvements to the home that are of general utility, and are not direct medical or remedial services to the enrollee, such as carpeting, roof repair, central air conditioning, etc. Adaptations which add to the total square footage of the home are excluded from these services. All services shall be provided in accordance with applicable State or local building codes; (7) Home maintenance that is a service necessary to maintain a safe, clean and sanitary environment. Home maintenance services are 1720-12
§17-1720-18 those services not included as a part of personal assistance and include heavy duty cleaning, which is utilized only to bring a home up to acceptable standards of cleanliness at the inception of service to an enrollee, minor repairs to essential appliances limited to stoves, refrigerators, and water heaters, and fumigation or extermination services. Home maintenance is provided to an enrollee who cannot perform cleaning and minor repairs without assistance and are determined, through an assessment, to require the service in order to prevent institutionalization; (8) Moving assistance that is provided in rare instances when it is determined through an assessment that an enrollee needs to relocate to a new home. The following are the circumstances under which moving assistance can be provided to an enrollee: unsafe home due to deterioration; the enrollee is wheel-chair bound living in a building with no elevator; multi-story building with no elevator, where the enrollee lives above the first floor; enrollee is evicted from their current living environment; or the enrollee is no longer able to afford the home due _to a rent increase. Moving expenses include packing and moving of belongings. Whenever possible, family, landlord, community and third party resources who can provide this service without charge will be utilized; (9) Non-medical transportation that is the necessary transportation provided to and from facilities, resources, and appointments in order for the enrollee to receive the services included in the plan of care; (10) Residential care services are personal care services, homemaker, chore, attendant care and companion services, and medication oversight (to the extent permitted by law) 1720-13
§17-1720-18 provided in a licensed private home by a principle care provider who lives in the home. Residential care is furnished in a: (A) Type I Expanded Adult Residential Care Home (EARCH) , allowing not more than five residents provided that up to six residents may be allowed at the discretion of the department to live in a Type I home with not more than two of whom may be at a nursing facility level of care (NF LOC) ; or (B) Type II EARCH, allowing six or more residents, no more than twenty percent of the home's licensed capacity may be enrollees meeting a NF LOC who receive these services in conjunction with residing in the home; (11) Respite care services are provided to enrollees unable to care for themselves and are furnished on a short-term basis because of the absence of or need for relief for those persons normally providing the care. Respite may be provided at three (3) different levels: hourly, daily, and overnight; and (12) Specialized medical equipment and supplies, including the purchase, rental, lease, warranty costs, installation, repairs and removal of devices, controls, or appliances, specified in a plan of care, that enable an enrollee to increase or maintain their abilities to perform activities of daily living, or to perceive, control, participate in, or communicate with the environment in which they live. [Eff 09/30/13; am and comp NOV 1 0 2016 ] (Au th: HRS §34 6-14; 42 C.F.R. §430.25) (Imp: HRS §346-14; 42 C.F.R. §430.25) §§17-1720-19 to 17-1720-21 (Reserved) . 1720-14
§17-1720-22 SUBCHAPTER 6 INSTITUTIONAL CARE SERVICES §17-1720-22 Institutional care services. (a) Institutional care services are provided in a licensed nursing facility to an enrollee who is referred by a physician and may require prior authorization. (b) Institutional care services shall be provided either directly by or under the general supervision of a licensed practical nurse or registered professional nurse. (c) Institutional care services shall minimally include, but are not limited to: (1) Activities of the enrollee's choice (including religious activities) that are designed to provide normal pursuits for physical and psychosocial well-being; (2) Administration of medication and treatment; (3) Basic nursing and treatment supplies include, but are not limited to: soap, skin lotion, alcohol, powder, applicators, tongue depressors, cotton ball, gauzes, adhesive tape, bandages, incontinent pads, V-pads, thermometers, blood pressure apparatus, plastic or rubber sheets, enema equipment, and douche equipment; (4) Development, management, and evaluation of the written care plan based on physician orders that necessitate the involvement of skilled technical or professional personnel to meet the enrollee's care needs, promote recovery, and ensure the enrollee's health and safety; (5) Durable medical eq~ipment and supplies used but which are reusable include, but are not limited to: ice bag, hot water bottle, urinal, bedpan, commode, cane, crutch, walker, wheelchair, and side rail and traction equipment; (6) Health education services provided by skilled technical or professional personnel to teach the enrollee self care, such as 1720-15
§17-1720-22 320 6 ' 1 gait training and self-administration of medications; (7) Laundry service for items of enrollee's washable personal clothing; (8) Nonrestorative or nonrehabilitative therapy, or both, provided by nursing staff; (9) Observation and assessment of the enrollee's unstable condition that requires the skills and knowledge of skilled technical or professional personnel to identify and evaluate the enrollee's need for possible medical intervention, modification of treatment, or both, to stabilize the enrollee's condition; (10) Review of the drug regimen of each institutionalized enrollee at least once a month by a licensed pharmacist, as required for a nursing facility to participate in Medicaid; (11) Therapeutic diet and dietary supplements as ordered by the attending physician; (12) Social services provided by qualified personnel; (13) Room and board; (14) Provision of and payment for, through contractual agreements with appropriate skilled technical or professional personnel, other medical and remedial services ordered by the attending physician which are not regularly provided by the provider. Other services that may be needed, such as transportation to realize the provision of services ordered by the attending physician, shall also be arranged through contractual agreements. The contractual agreement shall stipulate the responsibilities, functions, objectives, service fee, and other terms agreed to by the NF and the person or entity that contracts to provide the service; and (15) Feeding assistance performed by a feeding assistant, nurse aide, or nurse. The feeding assistant must work under the supervision of a registered nurse or licensed practical nurse that is licensed to practice in Hawaii. [Eff 09/30/13; am and comp ~0Vl02016 ] (Auth: HRS §346-14; Pub. L. No. 100-203; 42 C.F.R. §§434.10, 4 4 0 . 4 O , 4 4 0 . 15 0 , 4 8 3 . l , 4 8 3 . 2 O ) ( I mp : Pub . 1720-16
§17-1720-31 L. No. 100-203; 42 C.F.R. §§434.10, 440.40, 440.150, 483.1, 483.20) §§17-1720-23 to 17-1720-25 (Reserved) . SUBCHAPTER 7 DENTAL SERVICES §17-1720-26 Dental Services. (a) Required preventive dental services and medically necessary dental services shall only be provided on a fee-for- service basis under section 17-1737-75. (b) The health plans shall coordinate with the department or its designee to refer an eligible individual to the department's dental third party administrator for non-medically related dental services. [Eff 09/30/13; am and comp NOV 1 0 2016 (Auth: HRS §346-14; 42 C.F.R. §430.25) (Imp: HRS §346-14; 42 C.F.R. §430.25) §§17-1720-27 to 17-1720-30 (Reserved) . SUBCHAPTER 8 EXCLUSIONS AND LIMITATIONS §17-1720-31 Exclusions and limitations. A participating health plan shall not provide coverage for certain services, procedures, medications, supplies, equipment, or other items that are: (1) Specifically excluded from coverage by State or federal requirements; (2) Provided by providers not licensed or certified in the State to perform the service; (3) Available without charge to the general public through a separate state or federally administered federally-funded program; 1720-17
§17-1720-31 3206 ,~ (4) Covered by a third party medical or liability insurance, including Medicare; (5) Required to receive prior authorization but did not receive it; (6) Experimental in nature and have not been approved by the United States Food and Drug Administration, or both; (7) Elective and do not improve outcomes such as decreasing risk of morbidity or mortality; (8) Without sufficient evidence of effectiveness or net benefits as determined by the department and not covered under the currently approved Medicaid State Plan, Medicaid waivers, or both; (9) Comparatively effective to a tolerated lower cost alternative; or (10) Otherwise determined by the department to be non-covered, excluded, or limited. [Eff 09/30/13; am and comp NOV 1 0 2016 (Auth: HRS §346-14; 42 C.F.R. §438.210) (Imp: HRS §346-14; 42 C.F.R. §438.210) §§17-1720-32 to 17-1720-34 (Reserved) . 1720-18
UNOFFICIAL 1720.1-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1720.1
FREEDOM OF CHOICE, ENROLLMENT AND DISENROLLMENT
Subchapter 1 General Provisions
§17-1720.1-1
Purpose §§17-1720.1-2 to 17-1720.1-6 (Reserved)
Subchapter 2 Freedom of Choice
§17-1720.1-7
Purpose §17-1720.1-8
Choice of health plans §17-1720.1-9
Choice of primary care providers §§17-1720.1-10 to 17-1720.1-14 (Reserved)
Subchapter 3 Enrollment
§17-1720.1-15 Purpose §17-1720.1-16 Selection of a health plan for a
newly eligible individual §17-1720.1-17 Assignment to a health plan for a
newly eligible individual §17-1720.1-18 Change of health plan for an individual prior to the annual plan change period §17-1720.1-19 Exemptions to a health plan’s
enrollment limit §17-1720.1-20 Annual plan change period
UNOFFICIAL 1720.1-2 §17-1720.1-21 Effective date of enrollment §§17-1720.1-22 to 17-1720.1-26 (Reserved)
Subchapter 4 Disenrollment
§17-1720.1-27 Purpose §17-1720.1-28 Authority to disenroll §17-1720.1-29 Disenrollment §§17-1720.1-30 to 17-1720.1-34 (Reserved)
Historical Note: This chapter is based substantially upon repealed subchapters 2, 3 and 4 of chapter 17- 1721.1 and subchapters 2, 4 and 5 of chapter 17-1727.
The source note for subchapters 2, 3 and 4 of chapter 17-1721.1 is: [Eff 01/31/09; am 06/11/09; am 06/25/12; R 09/30/13].
The source note for subchapters 2, 4 and 5 of chapter 17-1727 is: [Eff 08/01/94; am 01/29/96; am 11/25/96; am 12/27/97; am 10/26/01; 02/16/02; am 05/10/03; am 09/17/07; am 08/19/11; am 06/25/12; R 09/30/13].
SUBCHAPTER 1
GENERAL PROVISIONS
§17-1720.1-1 Purpose. This chapter describes the freedom of choice, enrollment and disenrollment provisions for individuals participating in the demonstration project authorized by Section 1115 of the Social Security Act. [Eff 09/30/13] (Auth: HRS §346-14) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 438.50)
§§17-1720.1-2 to 17-1720.1-6 (Reserved).
UNOFFICIAL 1720.1-3 SUBCHAPTER 2
FREEDOM OF CHOICE
§17-1720.1-7 Purpose. This subchapter describes the provisions regarding an eligible individual’s freedom of choice in the selection of a participating health plan and a primary care provider. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 438.52) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 438.52)
§17-1720.1-8 Choice of health plans. (a) Except for the conditions in section 17-1720.1-13, an eligible individual shall be allowed to select from among the participating health plans, of which the individual is not subject to an enrollment limit, servicing the geographic area in which the individual resides. This provision shall not apply to an enrolled individual identified in subsection (c). (b) If a health plan has reached its maximum enrollment, the eligible individual shall select another participating health plan that is available. If only one other participating health plan is available, subsection (c) shall apply. (c) In the absence of a choice of health plans in a service area, an eligible individual shall be enrolled in the participating health plan accepting new members. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 438.52) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 438.52)
§17-1720.1-9 Choice of primary care providers. (a) In accordance with the procedures established by the participating health plan, an eligible individual shall be allowed to select a primary care provider from among those available within the health plan’s provider network.
UNOFFICIAL 1720.1-4 (b) In the absence of a timely selection among the available primary care providers within the health plan’s provider network, the enrolled individual shall be assigned to a primary care provider by the health plan. (c) An enrolled individual may change their primary care provider as frequently as, and for whatever reason, they choose. Exceptions to this provision shall be determined by the department. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.51) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.51)
§§17-1720.1-10 to 17-1720.1-14 (Reserved).
SUBCHAPTER 3
ENROLLMENT
§17-1720.1-15 Purpose. The purpose of this subchapter is to describe the selection and subsequent enrollment provisions into a participating health plan. An eligible individual described in section 17-1735.1-2(a) shall be provided fee-for-service coverage and will not have the freedom to choose and be enrolled in a participating health plan. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 438.50) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 438.50)
§17-1720.1-16 Selection of a health plan for a newly eligible individual. (a) With the exception of conditions in section 17-1720.1-17, at the time of notification of application approval, an eligible individual shall be provided the opportunity to select a participating health plan to provide the covered services effective the applicable date described in section 17-1720.1-21.
UNOFFICIAL 1720.1-5 (b) In the absence of a choice of health plan open to new members in a service area, an individual who resides in that particular service area shall be auto-assigned to the participating health plan open to new members. (c) If the individual selects a health plan at the time of notification of application approval, the department shall send an enrollment notice identifying the selected health plan and informing the enrolled individual of the sixty (60) calendar days grace period from the date of enrollment to select a different health plan available in the service area in which the individual resides and which is open to new members. (d) If the individual does not select a health plan at the time of notification of application approval, the individual shall be auto-assigned to a health plan by the department to provide the covered services effective the applicable date described in section 17-1720.1-21. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 438.50) (Imp: HRS §346- 14; 42 C.F.R. §§430.25, 438.50)
§17-1720.1-17 Assignment to a health plan for a newly eligible individual. (a) An individual meeting one of the following conditions will be auto-assigned to a health plan at the time of determination of eligibility. (1) A newborn of an enrolled individual shall be enrolled into the health plan of the mother, retroactive to the date of birth. The newborn auto-assignment shall be effective for at least the first (1st) thirty (30) calendar days following the birth; (2) An individual who lost eligibility for a period of six (6) months or less shall be re-enrolled into their previous health plan; (3) An enrolled individual who enters into the child welfare system shall remain in their current health plan;
UNOFFICIAL 1720.1-6 (b) Following the enrollment of a newly eligible individual into an auto-assigned health plan by the department, the individual shall be sent an enrollment notice that identifies the auto-assigned health plan and provides the individual the opportunity to select a different health plan, which is available in the service area in which the individual resides and open to new members, within the fifteen (15) calendar days grace period from the date of enrollment into an auto- assigned health plan. (1) If an individual does not select a different health plan within the fifteen (15) calendar days grace period, enrollment shall continue in the health plan to which auto-assigned, and the individual will be informed of the sixty (60) calendar days grace period from the date of initial enrollment to change health plans. (2) If the individual selects a different health plan during the fifteen (15) calendar days grace period, the date of enrollment into the selected health plan shall be the first of the next month following the month in which the selection occurred, and the department shall send an enrollment notice identifying the selected health plan and inform the individual of the sixty (60) calendar days grace period from the date of enrollment to select a different health plan available in the service area in which the individual resides open to new members. (3) If during the sixty (60) calendar days grace period an individual selects to change health plans, the date of enrollment into the selected health plan shall be the first (1st) of the next month following the month in which the selection occurred, and the department shall send a new enrollment notice identifying the selected health plan. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 438.50) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 438.50)
UNOFFICIAL 1720.1-7 §17-1720.1-18 Change of a health plan for an individual prior to the annual plan change period. (a) Except for changes made by a newly eligible individual during the fifteen (15) or sixty (60) calendar days grace periods, an enrolled individual shall only be allowed to change enrollment from one health plan to another during the annual plan change period. (b) Exceptions to (a) can occur for cause, which include the following circumstances: (1) A decision from an administrative appeals office allowing participating health plan change; (2) A court order allowing participating health plan change; (3) Provisions in federal or State statutes or administrative rules; (4) A non-returning plan or termination of the individual’s health plan’s contract or the start of a new contract; (5) Mutual agreement by the participating health plans involved, the enrolled individual and the department; (6) Violations by a participating health plan specified in chapter 17-1735.2; (7) Change in foster placement if necessary for the best interest of the child; (8) The individual’s PCP or long-term care residential facility is not in the health plan’s provider network and is in the provider network of a different participating health plan provided the health plan is not at its maximum enrollment; (9) The individual is eligible to receive HCBS or personal assistance services level I and is enrolled in a health plan with a waiting list for HCBS or personal assistance services level I and another health plan does not have a waiting list for the necessary service(s);
UNOFFICIAL 1720.1-8 (10) The participating health plan’s refusal, because of moral or religious objections, to cover the service the individual seeks as allowed for in the department’s contract with the participating health plan; (11) The individual’s need for related services(e.g., a cesarean section and a tubal ligation) to be performed at the same time and not all related services are available within the network and the individual’s primary care physician or another provider determines that receiving the services separately would subject the individual’s to unnecessary risk; (12) Lack of direct access to women’s health care specialists for breast cancer screening, pap smears and pelvic exams; (13) Other reasons, including but not limited to, poor quality of care, lack of access to covered services, or lack of access to providers experienced in dealing with the individual’s health care needs, lack of direct access to certified nurse midwives, pediatric nurse practitioners, family nurse practitioners, if available in the geographic area in which the individual resides; (14) Relocation of the individual to a service area where the health plan in which they were enrolled does not provide services; (15) The individual missed the annual plan change period due to a temporary loss of Medicaid eligibility and was re-enrolled in their previous health plan; or (16) Other special circumstances as determined by the department. (c) When changing health plans, an individual shall select among health plans participating in the service area in which the individual resides that are open to new members except as described in section 17- 1720.1-19.
UNOFFICIAL 1720.1-9 (d) In the absence of choice of health plans participating in the service area in which the individual resides and open to new members, except as described in section 17-1720.1-19, the individual shall be enrolled in the available health plan accepting new members. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 438.50) (Imp: HRS §346- 14; 42 C.F.R. §§430.25, 438.50)
§17-1720.1-19 Exemptions to a health plan’s enrollment limit. (a) The department may implement an enrollment limit on any health plan that has an enrollment equal to or exceeding the maximum enrollment allowed for the service area as determined by the department and the enrollment limit shall be effective at the start of and remain in effect for the benefit year. (b) Subject to approval by the department, a health plan may self-impose an enrollment limit, and the enrollment limit shall be effective when enrollment has reached the self-imposed limit as determined by the department. (c) When a health plan has an enrollment limit, the health plan may not be available for selection and shall not be available for auto-assignment until the restriction is lifted. (d) The following eligible individuals shall be exempt from a participating health plan’s enrollment limit: (1) A newborn born to an enrolled individual shall be enrolled in the mother’s health plan for a minimum of thirty (30) days, or if the mother is not eligible, enrolled in the health plan of the: (A) Youngest enrolled household member; or (B) Primary household member if there is no sibling enrolled. (2) An enrolled individual in a health plan with a waiting list for HCBS or personal assistance services–level I when another health plan in the same service area open to
UNOFFICIAL 1720.1-10 new members does not have a waitlist for these services; (3) An enrolled individual who lost eligibility for a period of six (6) months or less shall be re-enrolled into their previous health plan; (4) A child under Foster Care, previously under Foster Care, Kinship Guardianship or Subsidized Adoption; or (5) A newly determined eligible individual who has seen a PCP, exclusive to a capped health plan, within the previous six (6) months or longer as determined by the department. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 435.150, 438.50) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 435.150, 438.50)
§17-1720.1-20 Annual plan change period. (a) An individual shall be allowed to change enrollment from one participating health plan to another participating health plan within the service areas in which the individual resides that is open to receiving new members during the annual plan change period. (b) The annual plan change period shall occur each calendar year at a time designated by the department. (c) An individual who does not request to change health plan enrollment during annual plan change shall remain in their current health plan. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 438.50) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 438.50)
§17-1720.1-21 Effective date of enrollment. (a) The effective date of enrollment for a newly eligible individual shall be one of the following: (1) The date a completed application is received by the department; (2) Any date specified by the applicant on which appropriate Medicaid eligible services were
UNOFFICIAL 1720.1-11 incurred in accordance with chapter 17- 1730.1 and is no earlier than the first (1st) day of the third (3rd) month prior to the month the application is received by the department for individuals applying for the coverage of long-term care services or the tenth (10th) calendar day immediately prior to the date the application is received by the department for all other individuals; (3) The start date of the participating health plan contract period in which an eligibility determination is made for retroactive coverage; or (4) The date when all eligibility requirements were met. (b) For an individual with cause as defined in section 17-1720.1-18 who changes health plans, the effective date of enrollment in the new health plan shall be the first (1st) day of the month as designated by the department. (c) For an eligible individual disenrolled from a health plan due to temporary loss of eligibility for a period of six (6) months or less and as a result missed the annual plan change period, the effective date of enrollment shall be the same date as subsection (a)(4). (d) For an enrolled individual who relocates to a service area where the health plan does not provide service, the effective date of enrollment shall be the date of the individual’s relocation. (e) For a newborn born to an eligible individual, the effective date of enrollment shall be the date of birth. (f) For an individual changing from one health plan to another during the annual plan change period the effective date of enrollment shall be the first (1st) day of the second (2nd) month after the annual plan change period ends or as determined by the department. (g) For all other changes from one health plan to another, the effective date of enrollment shall be
UNOFFICIAL 1720.1-12 the first (1st) day of the month following the date on which the department authorizes the enrollment change. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 438.50) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 438.50)
§§17-1720.1-22 to 17-1720.1-26 (Reserved)
SUBCHAPTER 4
DISENROLLMENT
§17-1720.1-27 Purpose. The purpose of this subchapter is to describe the requirements for disenrollment from a participating health plan. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 438.56) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 438.56)
§17-1720.1-28 Authority to disenroll. The department shall have the sole authority to disenroll an individual from a participating health plan. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 438.56) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 438.56)
§17-1720.1-29 Disenrollment. An individual may be disenrolled for reasons that include, but are not limited to, the following: (1) A decision by an administrative appeals office for disenrollment from a participating health plan; (2) A court order for disenrollment from a participating health plan; (3) Provisions in federal or State statutes or administrative rules;
UNOFFICIAL 1720.1-13 (4) A non-returning plan or termination of the health plan’s contract or the start of a new contract; (5) Mutual agreement by the participating health plans involved, the individual and the department; (6) Violations by a participating health plan specified in chapter 17-1735.2; (7) Change in foster placement if necessary for the best interest of the child; (8) The individual selects a health plan that is not capped during the annual plan change period; (9) The individual’s PCP or long-term care residential facility is not in the health plan’s provider network and is in the provider network of a different health plan, provided the health plan is not at its maximum enrollment; (10) The individual is eligible to receive HCBS or personal assistance services level I and is enrolled in a health plan with a waiting list for HCBS or personal assistance services level I and the other health plan does not have a waiting list for the necessary service(s); (11) The participating health plan’s refusal, because of moral or religious objections, to cover the service the individual seeks as allowed for in the contract with health plan; (12) The individual’s need for related services (e.g., a cesarean section and a tubal ligation) to be performed at the same time and not all related services are available within the network and the individual’s primary care physician or another provider determines that receiving the services separately would subject the individual to unnecessary risk;
UNOFFICIAL 1720.1-14 (13) Lack of direct access to women’s health care specialists for breast cancer screening, pap smears and pelvic exams; (14) Other reasons, including but not limited to, poor quality of care, lack of access to covered services, or lack of access to providers experienced in dealing with the individual’s health care needs, lack of direct access to certified nurse midwives, pediatric nurse practitioners, family nurse practitioners, if available in the geographic area in which the individual resides; (15) Relocation to a service area where the health plan in which the individual was enrolled does not provide services; (16) The individual missed the annual plan change period due to a temporary loss of Medicaid eligibility and was re-enrolled in the previous health plan; (17) Voluntary withdrawal from participation in the medical assistance program by the individual or a authorized representative; (18) Not meeting the eligibility requirements; (19) Death of the enrolled individual; (20) The enrolled individual is a medically needy individual who is two full months in arrears in the payment of the designated enrollment fee, unless the failure to pay occurs because: (A) The individual is not in control of the individual’s personal finances, and the arrearage is caused by the party responsible for the individual’s finances, and action is being taken to remediate the situation, including but not limited to: (i) Appointment of a new responsible party for the individual’s finances; or (ii) Recovery of the individual’s funds from the responsible party which
UNOFFICIAL 1720.1-15 will be applied to the individual’s enrollment fee obligation. (B) The individual is in control of the individual’s finances, and the arrearage is due to the unavailability of the individual’s funds due to documented theft or financial exploitation, and action is being taken to: (i) Ensure that theft or exploitation does not continue; or (ii) Recover the individual’s funds to pay the individual’s enrollment fee obligation; (21) Incarceration of an enrolled individual into a public facility; (22) Admission to the State hospital; (23) Enrollment into the State of Hawaii Organ and Tissue Transplantation (SHOTT) program; (24) Relocation out-of-state by the State; (25) Provision of false information with the intent of enrolling in the medical assistance program under false pretenses; (26) Eligible for Medicare Special Savings benefits; (27) Other special circumstances as determined by the department; or (28) An individual disenrolled for cause. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 438.56) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 438.56)
§§17-1720.1-30 to 17-1720.1-34 (Reserved).
UNOFFICIAL 1722-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1722
SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS
Subchapter 1 General Provisions
§17-1722-1 Purpose §17-1722-2 (Reserved)
Subchapter 2 Qualified Severely Impaired
Individuals
§17-1722-3 Purpose §17-1722-4 Eligibility requirements §17-1722-5 Provision of coverage §§17-1722-6 to 17-1722-8 (Reserved)
Subchapter 3 Qualified Medicare Beneficiaries
§17-1722-9 Purpose §17-1722-10 Eligibility requirements §17-1722-11 Treatment of income and assets §17-1722-12 Limitations of coverage §17-1722-13 Effective date of coverage §§17-1722-14 to 17-1722-16 (Reserved)
Subchapter 4 Specified Low Income Medicare
Beneficiaries
§17-1722-17 Purpose §17-1722-18 Eligibility requirements §17-1722-19 Treatment of income and assets §17-1722-20 Provision of coverage §17-1722-21 (Repealed) §§17-1722-22 to 17-1722-24 (Reserved)
Subchapter 5 Qualified Disabled and Working
UNOFFICIAL 1722-2
Individuals
§17-1722-25 Purpose §17-1722-26 Eligibility requirements §17-1722-27 Treatment of income and assets §17-1722-28 Limitations of coverage §17-1722-29 Effective date of coverage §§17-1722-30 to 17-1722-32 (Reserved)
Subchapter 6 Medical Payments for Pensioners
§17-1722-33 Purpose §17-1722-34 Definitions §17-1722-35 Eligibility requirements §17-1722-36 Treatment of income and assets §17-1722-37 Limitations of coverage §17-1722-38 Application for payment of medical
services §17-1722-39 Eligibility review §§17-1722-40 to 17-1722-42 (Reserved)
Subchapter 7 Child Welfare Medical
§§17-1722-43 to 17-1722-49 (Repealed) §§17-1722-50 to 17-1722-55 (Reserved)
Subchapter 8 Special Group for Individuals
Formerly Covered By SHIP
§17-1722-56 Purpose §17-1722-57 Definitions §17-1722-58 Eligibility requirements §17-1722-59 Personal reserve standards §17-1722-60 Treatment of income §17-1722-61 Eligibility review §17-1722-62 Verification and reporting requirements §17-1722-63 Disqualification §17-1722-64 Cost share §17-1722-65 Covered services §17-1722-66 Excluded services §§17-1722-67 to 17-1722-68 (Reserved)
Subchapter 9 Qualifying Individuals
§17-1722-69 Purpose §17-1722-70 Eligibility requirements §17-1722-71 Treatment of income and assets §17-1722-72 Limitations of coverage
UNOFFICIAL 1722-3 §17-1722-73 Limit on the number of eligible
individuals §17-1722-74 Effective date of coverage §§17-1722-75 to 17-1722-77 (Reserved)
Subchapter 10 Medical assistance for disabled
children who lose SSI benefits
§17-1722-78 Purpose §17-1722-79 Eligibility requirements §17-1722-80 Treatment of income and assets §17-1722-81 Provision of coverage §17-1722-82 Effective date of coverage §§17-1722-83 to 17-1722-85 (Reserved)
Subchapter 11 Low Income Subsidy Program
§17-1722-86 Purpose §17-1722-87 Definitions §17-1722-88 Application and eligibility
determination for the LIS §17-1722-89 Eligibility and requirements §17-1722-90 Benefits of the LIS program §17-1722-91 Eligibility redeterminations §17-1722-92 Reporting requirements §17-1722-93 Termination of LIS benefits §17-1722-94 Appeals and hearings §17-1722-95 to 17-1722-115 (Reserved)
Subchapter 12 State Pharmacy Assistance Program
§17-1722-116 General provisions §17-1722-117 Definitions §17-1722-118 Application requirements §17-1722-119 Eligibility requirements §17-1722-120 Benefits §17-1722-121 Eligibility reviews §17-1722-122 State pharmacy assistance program card §17-1722-123 Quality control reviews §17-1722-124 Reporting requirements §17-1722-125 Termination §17-1722-126 Administration of the program §17-1722-127 Rebate agreement §17-1722-128 Pharmacy or PDP reimbursement §17-1722-129 State pharmacy assistance program
special fund
SUBCHAPTER 13 Medical Assistance For
UNOFFICIAL 1722-4
Disabled Adult Children Who
Lose SSI Benefits
§17-1722-145 Purpose §17-1722-146 Definitions §17-1722-147 Eligibility requirements §17-1722-148 Financial eligibility determination §17-1722-149 Provision of coverage
Historical Note: This chapter is based substantially -upon §17-742-2.02 [Eff 10/23/87; am 10/1/89; R 3/19/93]; and §17-742-2.1 [Eff 2/22/88; am 5/6/91; R 3/19/93]; and Chapter 17-752. [Eff 7/19/82; am 12/17/82; am 8/20/83; am 3/30/84; am 8/23/84; am 8/9/85; am 5/5/86; am 3/2/87; am 10/23/87; am 6/5/89; am 1/1/90; am 7/26/90; am 8/30/91; R 3/19/93].
SUBCHAPTER 1
GENERAL PROVISIONS
§17-1722-1 Purpose. The purpose of this chapter is to describe certain special coverages of the medical assistance program and to establish the requirements for eligibility and participation in the coverages. [Eff 08/01/94 ] (Auth: HRS §346- 14; 42 C.F.R. §431.10) (Imp: HRS §88-4, 42 U.S.C. §§1396a, 1396d; 42 C.F.R. §435.139)
§17-1722-2 (Reserved).
SUBCHAPTER 2
QUALIFIED SEVERELY IMPAIRED INDIVIDUALS
§17-1722-3 Purpose. The purpose of this subchapter is to describe the coverage of qualified severely impaired individuals and the eligibility criteria for that coverage group. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 U.S.C. §§1396a(a)(10)(A)(i)(II), 1396d(q))
UNOFFICIAL 1722-5
§17-1722-4 Eligibility requirements. (a) A qualified severely impaired individual is a person: (1) Who, for the month preceding the month to which this section applies; (A) Received SSI, SSP, or both on the basis of blindness or disability; and (B) Was eligible for medical assistance; and (2) Of whom, the Social Security Administration determines that: (A) The individual continues to be blind or disabled, and except for the individual's earnings, continues to meet SSI eligibility requirements; (B) Without medical assistance the individual's ability to continue or
obtain employment would be seriously inhibited; and (C) The individual's earnings are not sufficient to provide a reasonable equivalent to the benefits from SSI/SSP, medical assistance, and publicly funded attendant care services for which the individual would be eligible, were it not for the individual's earnings.
(b) For the purposes of this section, an individual, who is eligible for special SSI/SSP payments or for work incentive allowances under provisions of 42 U.S.C. §1382h shall be considered to have met the requirements of subsection (a). Thus, an individual with 1619 status, meeting the provisions of subsection (a), shall be considered a qualified severely impaired individual.
(c) An individual who meets the definition of a qualified severely impaired individual shall be eligible for medical assistance, provided the individual remains in 1619 status, as determined by the Social Security Administration.
(d) When an individual has more than one period of eligibility under 1619 status in the SSI Program, the first month of the most recent period shall be used to determine eligibility for medical assistance. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 U.S.C. §§1396a(a)(10)(A)(i)(II), 1396d(q))
UNOFFICIAL 1722-6
§17-1722-5 Provision of coverage. (a) Coverage for a qualified severely impaired individual shall be through enrollment in a health plan as described in chapter 17-1720.1. (b) Coverage under this section excludes payment for Medicare Part A premiums. [Eff 08/01/94; am 01/31/09; am 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §431.10; 42 U.S.C. §§1396a(a)(10)(A)(i)(II), 1396d(q)) (Imp: 42 U.S.C. §§1396a(a)(10)(A)(i)(II), 1396d(q))
§§17-1722-6 to 17-1722-8 (Reserved).
SUBCHAPTER 3
QUALIFIED MEDICARE BENEFICIARIES
§17-1722-9 Purpose. The purpose of this subchapter is to establish the requirements for eligibility of qualified medicare beneficiaries and limitations of coverage for that assistance group. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396d(p))
§17-1722-10 Eligibility requirements. A qualified medicare beneficiary shall meet all of the conditions as follows: (1) Entitled to hospital insurance benefits under the medicare program; (2) In receipt of income which does not exceed the federal poverty level for the household of applicable size; (3) In possession of assets which do not exceed three times the resource limit of the supplemental security income program adjusted by the annual percentage increase in the consumer price index; and (4) Required to meet basic eligibility conditions, detailed in chapter 17-1714.1, including: (A) A resident of the State; (B) A citizen of the United States or a legal resident non-citizen; (C) Not a resident of a public institution;
UNOFFICIAL 1722-7 (D) Assign to the department any benefits from a third party for coverage of medical expenses, to the extent of medical costs paid by the department; and
(E) Furnish a social security number and verification of that number. [Eff 08/01/94; am 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.10; 42 U.S.C. §§1396a(10)(E)(i), 1396d(p)) (Imp. 42 U.S.C. §§1396a(10)(E)(i), 1396d(p))
§17-1722-11 Treatment of income and assets. The income and assets of a qualified medicare beneficiary shall be treated as described in chapters 17-1724.1 and 17-1725.1. [[Eff: 08/01/94; am 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.10; §§1396a(a)(10)(E)(i), 1396d(p)) (Imp: 42 U.S.C. §§1396a(a)(10)(E)(i), 1396d(p))
§17-1722-12 Limitations of coverage. Individuals eligible under this subchapter shall be limited to coverage of the premiums, deductibles, and co-insurance amounts under the Medicare Part A and B. [Eff 08/01/94; am 12/26/05 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396d(p); Pub. L. 108-173)
§17-1722-13 Effective date of coverage. (a) Coverage as a qualified medicare beneficiary begins on the first day of the month after the month in which determination of eligibility is made.
(b) The retroactive provisions under chapter 17-1711.1 do not apply. [Eff 08/01/94; am 01/31/09; am 09/30/13] (Auth: HRS §346-14; 42 C.F.R §435.10; §§1396a(a)(10)(E)(i), 1396d(p)) (Imp: 42 U.S.C. §§1396a(a)(10)(E)(i), 1396d(p))
§§17-1722-14 to 17-1722-16 (Reserved).
SUBCHAPTER 4
SPECIFIED LOW INCOME MEDICARE BENEFICIARIES
UNOFFICIAL 1722-8
§17-1722-17 Purpose. The purpose of this subchapter is to establish the requirements for eligibility of specified low income medicare beneficiaries and the limitations of coverage for that assistance group. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396a(a)(10)(E))
§17-1722-18 Eligibility requirements. A specified low income medicare beneficiary shall meet all of the conditions as follows: (1) Entitled to hospital insurance benefits under the medicare program; (2) In receipt of income which does not exceed one hundred twenty per cent of the federal poverty level; (3) In possession of assets which do not exceed three times the resource limit of the supplemental security income program adjusted by the annual percentage increase in the consumer price index; and (4) Required to meet basic eligibility conditions detailed in chapter 17-1714.1 including: (A) A resident of the State; (B) A citizen of the United States or a legal resident non-citizen; (C) Not a resident of a public institution; (D) Furnish a social security number and verification of that number. [Eff 08/01/94; am 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.10; 42 U.S.C. §§1396a(a)(10)(E)(iii), 1396d(p)) (Imp: 42 U.S.C. §§1396a(a)(10)(E)(iii), 1396d(p), 1395w-114(a)(3)(D))
§17-1722-19 Treatment of income and assets. The income and assets of a specified low income medicare beneficiary shall be treated as described in chapters 17-1724.1 and 17-1725.1. [Eff 08/01/94; am 09/30/13](Auth: HRS §346-14; 42 C.F.R. §435.10; 42 U.S.C. §§1396a(a)(10)(E)(ii), 1396d(p)) (Imp: 42 U.S.C. §§1396a(a)(10)(E)(ii), 1396d(p))
UNOFFICIAL 1722-9
§17-1722-20 Provision of coverage. (a) Coverage as a specified low income Medicare beneficiary shall be limited to the payment of the Medicare supplemental medical insurance premium.
(b) Coverage shall be effective in the month in which eligibility begins, no earlier than the first day of the three months prior to the month the application was received by the department. [Eff 08/01/94; am 01/31/09; am 06/11/09 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396a(a)(10)(E))
§17-1722-21 REPEALED [Eff 08/01/94; R 01/31/09 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396a(a)(10)(E))
§§17-1722-22 to 17-1722-24 (Reserved)
SUBCHAPTER 5
QUALIFIED DISABLED AND WORKING INDIVIDUALS
§17-1722-25 Purpose. The purpose of this subchapter is to establish the requirements for eligibility of qualified disabled and working individuals and limitations of coverage for that assistance group. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396a(a)(10)(E))
§17-1722-26 Eligibility requirements. A qualified disabled and working individual shall meet all of the following requirements: (1) Entitled to enroll for hospital insurance benefits under Part A of Medicare based on 42 U.S.C. §1395i-2(a) which requires that the individual: (A) Is not yet sixty-five years of age; (B) Has been entitled to Social Security disability insurance benefits;
UNOFFICIAL 1722-10 (C) Continues to have a disabling physical or mental condition; (D) Is found to be ineligible for continued Social Security disability insurance benefits due to earnings exceeding the substantial gainful activity (SGA) limits; and (E) Is not otherwise entitled to Medicare. (2) Is in receipt of income which does not exceed two hundred per cent of the federal poverty level; (3) In possession of assets which do not exceed two times the resource limit of the supplemental security income program; (4) Required to meet basic eligibility conditions, as follows: (A) A resident of the State; (B) A citizen of the United States or a legal resident non-citizen; (C) Not a resident of a public institution; (D) Assign to the department any benefits from a third party for coverage of medical costs paid by the department; and (E) Furnish a social security number and verification of that number; and (5) Not otherwise eligible for medical assistance under Title XIX. [Eff 08/01/94; am 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.10; 42 U.S.C. §1396a(a)(10)(E)(ii), 1396a(p)(3), 1396d(s)) (Imp: 42 U.S.C. §§1396a(a)(10)(E)(ii), 1396a(p)(3), 1396d(s))
§17-1722-27 Treatment of income and assets. The income and assets of a qualified disabled and working individual shall be treated as described in chapters 17- 1724.1 and 17-1725.1. [Eff 08/01/94; am 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.10; 42 U.S.C. §§1396a(a)(10)(E)(ii), 1396a(p)(3), 1396d(s)) (Imp: 42 U.S.C. §§1396a(a)(10)(E)(ii), 1396a(p)(3), 1396d(s))
§17-1722-28 Limitations of coverage. Individuals eligible under this subchapter shall only be entitled to coverage of the premiums for hospital insurance coverage under the medicare program.
UNOFFICIAL 1722-11 [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396a(a)(10)(E))
§17-1722-29 Effective date of coverage. Coverage as a qualified disabled and working individual will coincide with the effective date of enrollment in Part A, as allowed under section 1818A of the Social Security Act (42 U.S.C. §1395i-2(a) and determined by the Social Security Administration but not earlier than the first day of the three months prior to the month the application is received by the department. [Eff 08/01/94; am 01/31/09; am 06/11/09 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396a(a)(10)(E))
§§17-1722-30 to 17-1722-32 (Reserved).
SUBCHAPTER 6
MEDICAL PAYMENTS FOR PENSIONERS
§l7-1722-33 Purpose. The purpose of this subchapter is to establish the program of medical coverage of persons receiving pensions or retirement payments from the state or counties of Hawaii. [Eff 08/01/94 ] (Auth: HRS §346-l4) (Imp: HRS §88-4)
§l7-1722-34 REPEALED. [R 09/30/13]
§l7-1722-35 Eligibility requirements. (a) A pensioner, a pensioner's spouse, or a pensioner's surviving spouse shall be eligible for coverage of medical services by meeting any of the following conditions. (l) The pensioner and the pensioner's spouse, if any, are actually and solely dependent on the state or county pension for maintenance and support; (2) The pensioner and the pensioner's spouse, if any, have total income from all sources, including the pension, social security
UNOFFICIAL 1722-12 benefits, interest and dividends, and any income of the spouse, of less than $2,400; (3) The spouse of a pensioner is currently eligible for coverage of medical care under this subchapter; or (4) The spouse of a deceased pensioner who was or would have been eligible under this subchapter remains unmarried.
(b) The following persons shall not be eligible under this program: (l) Dependent children of eligible pensioners; (2) Divorced or separated spouses of pensioners; and (3) Parents or other non-spousal relatives of pensioners
(c) Resources including, but not limited to savings, real property, medical benefit plans, bonds, stocks, insurance, and automobiles, shall not be taken into consideration in determining the pensioner's eligibility for coverage of medical care, under the provisions of this subchapter. [Eff 08/01/94 ] (Auth: HRS §346-l4) (Imp: HRS §88-4)
§17-1722-36 Treatment of income and assets. An eligible pensioner and the pensioner's spouse, if any, shall not be required to use any portion of the pensioner's or the pensioner's spouse's income or resources to meet medical costs covered under the provisions of this subchapter. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §88-4)
§17-1722-37 Limitations of coverage. (a) Eligible pensioners and pensioners' spouses shall be entitled to all health care coverage provided to medical assistance recipients, except for: (1) Payment of health insurance premiums payments, including that of medicare; and (2) Coverage of the portion of medical care expenses paid by a third party.
(b) Medical payments assistance for services covered by the department's medical assistance program shall be made available to eligible pensioners and pensioners' eligible spouses conditioned upon prior authorization for certain elective medical services, third party resources, and established payment
UNOFFICIAL 1722-13 practices in the medical assistance program. [Eff 08/01/94 ] (Auth: HRS §346-l4) (Imp: HRS §88-4)
§l7-1722-38 Application for payment of medical services. (a) A pensioner or a surviving spouse shall sign an application form as a condition for approval of the application. (b) A relative, friend, or a designee may be asked to complete and sign the application form on behalf of a pensioner or spouse when the pensioner or spouse is determined by the department to be unable to do so. [Eff 08/01/94 ] (Auth: HRS §346-l4) (Imp: HRS §346-l4)
§l7-1722-39 Eligibility review. Eligibility reviews shall be conducted every six months or at intervals determined necessary by the eligibility worker. [Eff 08/01/94 ] (Auth: HRS §346-l4) (Imp: HRS §346-l4)
§§17-1722-40 to 17-1722-42 (Reserved).
SUBCHAPTER 7
CHILD WELFARE MEDICAL
Repealed
§§17-1722-43 to 17-1722-49 REPEALED. [Eff 08/01/94; R 01/29/96 ]
§§17-1722-50 to 17-1722-55 (Reserved).
SUBCHAPTER 8
SPECIAL GROUP FOR INDIVIDUALS FORMERLY COVERED BY SHIP
§17-1722-56 Purpose. The purpose of this subchapter is to establish the eligibility requirements for a special group comprised of individuals who were enrolled the state health
UNOFFICIAL 1722-14 insurance program who were not eligible for inclusion in the Hawaii Med-QUEST program, and the coverage and limitations of coverage for that group. [Eff 11/13/95 ] (Auth: HRS §§346-14, 431N) (Imp: HRS §§346-14, 431N)
§17-1722-57 REPEALED. [R 09/30/13]
§17-1722-58 Eligibility requirements. (a) Members of this group must have been eligible for SHIP as of July 31, 1994 and would have maintained continued eligibility except for the discontinuance of SHIP, and were not eligible for inclusion in the formerly known QUEST program as of August 1, 1994. (b) A member of this group shall: (1) Be a resident of the State who is a citizen of the United States or a legal resident non-citizen; (2) Not be entitled to benefits under the Medicaid program with the exception of those whose eligibility is dependent on a spenddown of income; (3) Not be entitled to insurance benefits under the Medicare program; (4) Not be entitled to coverage under TRICARE or another federally sponsored program except for benefits under the Native Hawaiian Health Care Act of 1988; (5) Not be entitled for insurance benefits under the Hawaii Prepaid Health Care Act; and (6) Not have income exceeding three hundred percent of the FPL. (c) An exception to subparagraph (b)(6) are state emergency appointments and their families who are ineligible for health insurance coverage through the employer. (d) Any break in eligibility shall cause permanent exclusion from this group. [Eff 11/13/95; am 09/30/13] (Auth: HRS §§346-14, 431N; 42 U.S.C. §§11701 - 11714) (Imp: HRS §§346-14, 431N; 42 U.S.C. §§11701 - 11714)
UNOFFICIAL 1722-15
§17-1722-59 Personal reserve standards. There are no personal reserve standards for individuals in the special group. [Eff 11/13/95 ] (Auth: HRS §§346-14, 431N) (Imp: HRS §§346-14, 431N)
§17-1722-60 Treatment of income. (a) The gross income of members in the family unit will be considered in determining eligibility, whether or not all family members are eligible for special group benefits.
(b) Income that can be used for the maintenance and support of the family members includes, but is not limited to: (1) Earned income from wages, salaries, tips, or commissions; (2) Net income from self-employment or rentals; (3) Interest income; (4) Royalties and dividends; (5) Pensions; (6) Social Security benefits; (7) SSI; (8) UIB; (9) TDI and workers' compensation; and (10) Monetary contributions and gifts.
(c) Gross family income shall be compared to the FPL for the family size. [Eff 11/13/95 ] (Auth: HRS §§346-14, 431N) (Imp: HRS §§346-14, 431N)
§17-1722-61 Eligibility review. (a) Eligibility reviews shall be conducted annually or at intervals determined necessary by the department
(b) Individuals who fail to complete or fail to cooperate in the completion of the eligibility review shall be ineligible for benefits under this group. [Eff 11/13/95 ] (Auth: HRS §§346-14, 431N) (Imp: HRS §§346-14, 431N)
§17-1722-62 Verification and reporting requirements. (a) The department may require individuals to furnish verification of eligibility factors.
(b) Individuals shall furnish the requested information within ten days of the request.
UNOFFICIAL 1722-16
(c) Individuals who fail to respond within ten days shall be given a second notice with a request to furnish the information within five days.
(d) Failure to respond to the second notice shall result in disqualification.
(e) Individuals are required to report to the department any changes that would affect their eligibility or monthly cost share responsibility within ten days. [Eff 11/13/95 ] (Auth: HRS §§346-14, 431N) (Imp: HRS §§346-14, 431N)
§17-1722-63 Disqualification. (a) Individuals may be disqualified from the special group for the following reasons: (1) Failure to meet the eligibility requirements of section 17-1722-58; (2) Request for disqualification by the individual; (3) Failure to recertify as provided in section 17-1722-61; (4) Failure to provide requested verification of eligibility factors as provided in section 17-1722-62; (5) Failure to pay the required cost share for two consecutive months.
(b) Disqualified individuals will be given a ten day advance notice of disqualification. The notice must specify the effective date of disqualification, the reason for disqualification, and procedures to appeal the disqualification.
(c) If an appeal is requested prior to the effective date of the disqualification, the disqualification will be stayed pending the outcome of the appeal, provided the individual otherwise remains eligible and makes all required cost share payments
(d) The procedures for administrative hearings specified in chapter 17-1703 shall apply. [Eff 11/13/95 ] (Auth: HRS §§346-14, 431N) (Imp: HRS §§346-14, 431N)
§17-1722-64 Cost share. (a) Individuals shall be responsible for paying a monthly cost share according to a schedule established by the department. The amount of the cost share will be based on the gross family income and the number of family members.
UNOFFICIAL 1722-17
(b) The monthly cost share for members with income less than three hundred per cent of the FPL is as follows:
POVERTY LEVEL COST SHARE
100% or less
$0
101% - 125%
$10
126% - 150%
$15
151% - 200%
$20
201% - 250%
$40
251% - 300%
$60
(c) State emergency appointees and their eligible family members in the special group with income exceeding three hundred per cent of the FPL shall pay $73.50 in monthly cost share per family member.
(d) The cost share shall be paid to the department by the tenth day of the benefit month.
(e) A member who fails to to pay the cost share for two consecutive months shall be disqualified. [Eff 11/13/95 ] (Auth: HRS §§346-14, 431N) (Imp: HRS §§346-14, 431N)
§17-1722-65 Covered services. (a) Inpatient hospital care shall be limited to five days per state fiscal year per individual for the following services: (1) Semi-private room and board and general nursing care; (2) Intensive care room and board and general nursing care; (3) Use of operating room and related facilities, labor and delivery room, inpatient anesthesia, radiology, laboratory and other diagnostic services agreed upon by the director; (4) Drugs and medications administered while an inpatient; (5) Medically necessary dressings, casts, blood derivatives and their administration, and general medical supplies; and (6) Five inpatient physician visits per fiscal year.
(b) Physician office visits, including diagnosis and treatment, consultations, and second opinions are limited to twelve visits per fiscal year. Excluded from this limitation are adult health assessments and bona fide emergency room visits.
(c) Maternity care is limited to the following:
UNOFFICIAL 1722-18 (1) An all-inclusive fee that includes outpatient diagnostic tests, prenatal care, delivery, postpartum care, and complications of pregnancy; and (2) Two inpatient maternity days per fiscal year that will not count as an inpatient day in subsection (a) of this section.
(d) Ambulatory surgical care is limited to three procedures per year and must be for medically necessary care and not excluded in sections 17-1722-66 and 17-1737-84.
(e) Preventative services shall include: (1) Health assessments comprised of services and tests appropriate to the age and sex of the individual; and (2) Immunizations for diptheria, measles, mumps, rubella, whooping cough, polio, tetanus, influenza/pneumovex, hemophilus, influenza, cholera, typhoid and typhus.
(f) Emergency care is restricted by the following guidelines: (1) Coverage is limited to those medical conditions manifesting in acute symptoms of such severity that the absence of medical attention could reasonably be expected to result in placing the enrollee's health in serious jeopardy, or serious impairment to bodily functions, or serious dysfunction of any body organ or part; and (2) The need for emergency service shall be substantiated with appropriate documentation
from the enrollee's medical record or a report from a hospital or treating physician; (g) Three mental health visits, to include alcohol or drug dependency conditions, per fiscal year, with one treatment per day (h) The department shall not be responsible to pay for services that are not described in this section.
(i) The department will only pay for services described in this section that are also allowable under chapter 17-1737.
(j) Services to be provided by medicaid providers described in chapter 17-1736, and reimbursement for services will be based on the medicaid reimbursement schedule.
UNOFFICIAL 1722-19 [Eff 11/13/95 ] (Auth: HRS §§346-14, 431N) (Imp: HRS §§346-14, 431N)
§17-1722-66 Excluded services. The department will not be responsible to pay for the following medical services or conditions: (1) Custodial or domiciliary care; (2) Charges for care in intermediate care or skilled nursing facilities or intermediate care facilities for the mentally retarded; (3) Personal or comfort items as television, telephone, guest trays, or a private room in a hospital unless deemed medically necessary by the treating physician; (4) Emergency facility services for non- emergency conditions; (5) Medical, surgical or other health care procedures, services, drugs or devices that are considered experimental or investigational; (6) Transplant and open heart surgery procedures and coverage of organ donor services; (7) Prescription and non-prescription drugs and hormones and their administration, except those provided as an inpatient hospital service; (8) Sex change operations, investigation of and 0treatment for infertility, reversal of sterilization, artificial insemination, in vitro fertilization, and contraceptive supplies and devices; (9) Vision care services to include eyeglasses, contact lenses, routine eye examinations,
including eye refraction, except as provided as part of routine health assessments; (10) Hearing aids, prosthesis, orthopedic shoes, routine foot care; (11) Purchase or rental of hearing aids or durable medical equipment, including, but not limited to hospital beds, wheel chairs, walk-aids, or other medical equipment not specifically listed as a covered service, except as used while in the hospital; (12) Dental services for temporomandilar joint problems, except for repair necessitated by accidental injury to sound natural teeth or
UNOFFICIAL 1722-20 jaw provided such repair commences within ninety days of an accidental injury or as soon as medically feasible, and provided that the individual is eligible for covered services at the time services are provided and at the time of the accident; (13) Orthopedic services and supplies; (14) Biofeedback and acupuncture; (15) Obesity treatment and weight loss programs; (16) Medical services rendered outside the state; (17) Services which are not medically necessary to diagnose, treat, or to improve the functioning of a malformed body member, even though such services are not specifically listed as exclusions; (18) Cosmetic surgery, including treatment for complications of cosmetic surgery; (19) Reconstructive surgery for congenital or acquired conditions that do not involve severe functional impairment including but not limited to keloids, mammoplasty except for radical mastectomy, deviated septum for which psychological or psychiatric impairment alone shall not be a sufficient basis for reconstructive surgery; (20) Medical services received and paid for by the Veterans Administration; (21) Medical services that are payable under the terms of worker compensation, automobile medical and no-fault, underinsured or uninsured motorist, or similar contract of insurance; (22) Conditions resulting from acts of war, declared or not; (23) Transportation to medical providers to include ambulance services; (24) Hospice services; (25) Early and Periodic Screening Diagnostic and Treatment (EPSDT) services; (26) Outpatient renal services; (27) Case management services; (28) Personal care services; (29) Private duty nursing and medical social worker services; (30) Services provided by the community long term care branch; (31) Home Health Agency (HHA) services; (32) Targeted case management services;
UNOFFICIAL 1722-21 (33) State funeral payments services; (34) Adult day health services; (35) Chore services; (36) Any service excluded by medicaid under chapter 17-1737; or (37) Services not provided by medicaid providers. [Eff 11/13/95 ] (Auth: HRS §§346-14, 431N) (Imp: HRS §§346-14, 431N)
§§17-1722-67 to 17-1722-68 (Reserved).
SUBCHAPTER 9
QUALIFYING INDIVIDUALS
§17-1722-69 Purpose. The purpose of this subchapter is to establish the requirements for eligibility of a qualifying individual effective January 1, 1998 and the limitations of coverage for this group. [Eff 05/02/98 ] (Auth: HRS §346- 14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396a(a)(10)(E))
§17-1722-70 Eligibility requirements. A qualifying individual shall be: (1) Entitled to hospital insurance benefits under the Medicare program; (2) In receipt of income which exceeds one hundred twenty per cent of the federal poverty level but does not exceed one hundred thirty-five per cent of the federal poverty level; (3) In possession of assets which do not exceed three times the resource limit of the supplemental security income program adjusted by the annual percentage increase in the consumer price index; and (4) Required to meet basic eligibility conditions detailed in chapter 17-1714.1, including: (A) A resident of the State; (B) A citizen of the United States or a qualified non-citizen; (C) Not a resident of a public institution;
UNOFFICIAL 1722-22
and (D) Furnish a social security number and verification of that number. [Eff 05/02/98; am 01/31/09;
am 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.10; 42 U.S.C. §§1396a(a)(10)(E)(IV), 1396d(p)) (Imp: 42 U.S.C. §§1396a(a)(10)(E)(IV), 1396d(p))
§17-1722-71 Treatment of income and assets. The income and assets of a qualifying individual shall be treated as described in chapters 17-1724.1 and 17- 1725.1. [Eff 05/02/98; am 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.10; 42 U.S.C. §§1395w- 114(a)(3)(D), (1396a(a)(10)(E)(IV), 1396d(p)(3)(A)(ii)) (Imp: 42 U.S.C. §§1395w- 114(a)(3)(D), (1396a(a)(10)(E)(IV), 1396d(p)(3)(A)(ii))
§17-1722-72 Limitations of coverage. (a) Coverage for an individual eligible for assistance as a qualifying individual with countable income that exceeds one hundred twenty percent of the federal poverty limit but does not exceed one hundred thirty-five percent, the payment of the Medicare supplemental medical insurance premium. (1) For a qualifying individual with countable income that exceeds one hundred twenty percent of the federal poverty limit but does not exceed one hundred thirty-five percent, the payment of the medicare supplemental medical insurance premium; and (2) For a qualifying individual with countable income that exceeds one hundred thirty-five percent of the federal poverty limit but does not exceed one hundred seventy-five percent, payment of the increment to the medicare supplemental medical insurance premium caused by the shifting of certain home health services from the medicare hospital insurance. (b) A qualifying individual who receives assistance one month in a calendar year is eligible for coverage for the remaining balance of calendar
UNOFFICIAL 1722-23 year, provided all other eligibility requirements are met.
(c) Coverage under this subchapter is for a five year period from 1998 through 2002 and subject to allocation of funding for each calendar year. [Eff 05/02/98; am 01/31/09 ] (Auth: HRS §346- 14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396a(a)(10)(E))
§17-1722-73 Limit on the number of eligible individuals. (a) Participation in this group shall be limited in each calendar year to the estimated number of eligible qualifying individuals whose aggregate amount of assistance does not exceed the allocation of funds for that calendar year.
(b) For the calendar year 1998, eligible qualifying individuals shall be provided assistance in the order in which they apply for assistance up to the estimated limit in subsection (a).
(c) For calendar years after 1998, the following individuals shall be given preference for participation providing they were eligible for coverage in the last month of the previous year and who continue to be or become qualifying individuals: (1) A qualifying individual; (2) A qualified medicare beneficiary; (3) A specified low income medicare beneficiary; or (4) A qualified disabled and working individual. [Eff 05/02/98 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396a(a)(10)(E))
§17-1722-74 Effective date of coverage. Coverage as a qualifying individual begins in the month in which eligibility starts, no earlier than the first day of the three months prior to the month the application is received by the department. [Eff 05/02/98; am 01/31/09; am 06/11/09 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396a(a)(10)(E))
§§17-1722-75 to 17-1722-77 (Reserved).
SUBCHAPTER 10
UNOFFICIAL 1722-24 MEDICAL ASSISTANCE FOR DISABLED CHILDREN WHO LOSE SSI BENEFITS
§17-1722-78 Purpose. The purpose of this subchapter is to establish the requirements for eligibility of disabled children who lose SSI benefits because of provisions of the Personal Responsibilities and Work Opportunity Reconciliation Act of 1996. [Eff 05/02/98 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396a(a)(10)(A)(i)(II))
§17-1722-79 Eligibility requirements. Effective July 1, 1997, a disabled child eligible for this group shall meet all of the following conditions: (1) The child lost SSI benefits because of the enactment of section 211(a) the Personal Responsibilities and Work Opportunity Reconciliation Act of 1996; (2) The child would continue to be eligible for SSI but for the enactment of that section; and (3) The child shall meet basic eligibility conditions detailed in chapter 17-1714.1, including: (A) A resident of the State; (B) A citizen of the United States or a legal resident non-citizen; (C) Not a resident of a public institution; (D) Assign to the department any benefits from a third party for coverage of medical expenses, to the extent of medical costs paid by the department; and (E) Furnish a social security number and verification of that number. [Eff 05/02/98; am 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. 1396a(a)(10)(A)(i)(II))
§17-1722-80 Treatment of income and assets. The income and assets of a child in this group shall be treated as described in chapters 17-1724.1 and 17- 1725.1. [Eff 05/02/98; am 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. 1396a(a)(10)(A)(i)(II))
UNOFFICIAL 1722-25
§17-1722-81 Provision of coverage. Coverage for individuals eligible for assistance in this subchapter will be provided through enrollment in a health plan in accordance with chapter 17-1720.1. [Eff 05/02/98; am 01/31/09; am 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396a(a)(10)(A)(i)(II))
§17-1722-82 Effective date of coverage. Coverage under this group shall begin:
(a) On the date of application; (b) If specified by the applicant, retroactive coverage may begin no earlier than the first day of the three months prior to the month the application is received by the department; or
(c) If ineligible in the month of application, the date on which all eligibility requirements are met by the applicant in a subsequent month. [Eff 05/02/98; am 01/31/09; am 06/11/09 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1396a(a)(10)(A)(i)(II) §1396a(a)(10)(A)(i)(II))
§§17-1722-83 to 17-1722-85 (Reserved).
SUBCHAPTER 11
LOW INCOME SUBSIDY PROGRAM
§17-1722-86 Purpose. The purpose of this subchapter is to establish the requirements for the Low Income Subsidy program which provides assistance with the full or partial costs related to Medicare part D. Individuals who are deemed eligible shall automatically be enrolled into the Low Income Subsidy program while individuals who are not deemed eligible must apply for this extra benefit. [Eff 12/26/05 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §423.774; 423.904; Pub. L. 108-173)
§17-1722-87 REPEALED. [R 09/30/13]
UNOFFICIAL 1722-26
§17-1722-88 Application and eligibility determination for the LIS. Individuals may apply for the LIS and have their eligibility determined by the department by submitting an application on a form designated by the SSA upon request. [Eff 12/26/05 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §423.774; 423.904; Pub. L. 108-173)
§17-1722-89 Eligibility requirements. Individuals who are eligible for the LIS shall: (1) Have Medicare coverage; (2) Have income as evaluated under SSI regulations in 20 C.F.R. Part 416 Subparts K and L that does not exceed one hundred fifty
percent of the FPL for the family of applicable size; (3) Have resources as evaluated under SSI regulations in 20 C.F.R. Part 416 Subparts K and L that do not exceed the resource requirement under the MMA; (4) Be a resident of the State; (5) Not be an inmate of a public institution; and (6) Not be enrolled in PACE. [Eff 12/26/05 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §423.774; 423.904; Pub. L. 108-173)
§17-1722-90 Benefits of the LIS program. The LIS program provides full or partial assistance with the subsidy for the coverage of the monthly premiums and cost-sharing related to Medicare part D to individuals based on the countable income of their households:
(1) Full benefit dual eligible individuals with countable income up to one hundred percent of the FPL shall be responsible for:
(A) The portion of the premium that exceeds the low income benchmark premium amount for basic coverage; and
(B) Co-payments. (2) Full benefit dual eligible individuals above one hundred percent of the FPL, Medicare Savings Program beneficiaries, SSI recipients, and non-dual eligible
UNOFFICIAL 1722-27 individuals with countable income that does not exceed one hundred thirty-five percent of the FPL shall be responsible for:
(A) The portion of the premium that exceeds the low income benchmark premium amount for basic coverage; and
(B) Co-payments. (3) Non-dual eligible individuals with income that exceeds one hundred thirty-five percent
but does not exceed one hundred fifty percent of the FPL shall be responsible for:
(A) The portion of the monthly low income benchmark premium amount based on a sliding scale;
(B) A deductible; (C) The co-insurance portion incurred with the Part D coverage gap; and (D) Co-payments. (4) Full benefit dual eligible individuals who are residing in a medical institution will not be subject to any cost-sharing related to Medicare part D. [Eff 12/25/06 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §423.774; 423.904; Pub. L. 108-173)
§17-1722-91 Eligibility redeterminations. (a) Eligibility redeterminations for individuals for whom the LIS determination was made by the State shall be completed annually on a form designed by SSA.
(b) Individuals who fail to complete or fail to cooperate in the completion of the eligibility redetermination shall be ineligible for benefits under the LIS. [Eff 12/26/05 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §423.774; 423.904; Pub. L. 108-173)
§17-1722-92 Reporting requirements. Individuals who are deemed eligible are required to report changes in circumstances to the department within ten working days from the date of the change which may affect their eligibility for the subsidy or the level of subsidy. [Eff 12/26/05 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §423.774; 423.904; Pub. L. 108-173)
§17-1722-93 Termination of LIS benefits. Benefits for the LIS shall be terminated effective the
UNOFFICIAL 1722-28 first day of the month following the month in which the recipient is found ineligible if the conditions of adverse notice are met in accordance with chapter 17- 1713. Reasons for termination include, but are not limited to, the following: (1) Loss of Medicare eligibility; (2) An eligibility redetermination is not completed as the recipient failed to provide the department with requested verification or provide a completed eligibility redetermination form; (3) Loss of residency; (4) Inmate of a public institution; or (5) Enrollment in PACE. [Eff 12/26/05 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §423.774; 423.904; Pub. L. 108-173)
§17-1722-94 Appeals and hearings. All beneficiaries for whom adverse actions were taken for the LIS by the State shall be entitled to the appeal process of chapter 17-1703. [Eff 12/26/05 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §423.774; 423.904; Pub. L. 108-173)
§§17-1722-95 to 17-1722-115 (Reserved).
SUBCHAPTER 12
STATE PHARMACY ASSISTANCE PROGRAM
§17-1722-116 General provisions. (a) This subchapter describes the eligibility requirements for participation in the state pharmacy assistance program. This program may pay all, or some of, the required co-payments or co-insurance for prescriptions under Medicare Part D to certain elderly and disabled individuals and facilitate the enrollment and coordination of benefits between the state pharmacy assistance program and the Medicare Part D Prescription Drug Benefit Program provided by the Federal MMA. (b) The department shall work with any CMS approved benchmark prescription drug plan to provide
UNOFFICIAL 1722-29 the coordination of benefits between the state pharmacy assistance program and the Medicare Part D Prescription Drug Benefit Program. (c) The program shall conduct ongoing quality assurance activities determined by the department (d) The provisions of chapter 1702 addressing confidentiality shall apply to this program. (e) The provisions of chapter 1703 addressing administrative appeals shall apply to this program. However, in applying chapter 1703 to this program, the terms “eligibility branch,” “eligibility branch administrator,” “med-QUEST eligibility office,” and “eligibility worker” in chapter 1703 shall be replaced by the term “med-QUEST division staff or their designee.” (f) The provisions of chapter 1704 addressing fraud shall apply to this program. However, in applying chapter 1704 to this program, the terms “medical assistance” and “Medicaid” in chapter 1704 shall be replaced by the term “state pharmacy assistance program.” (g) The provisions of subchapter 7 of chapter 1705 addressing recipient recovery shall apply to this program. However, in applying subchapter 7 to this program, the term “medical assistance” in subchapter 7 of chapter 1705 shall be replaced by the term “state pharmacy assistance program.” (h) This program shall be administered by the med-QUEST division and contractors identified by the department of human services for the purposes of this program. [Eff 12/29/05; am 02/18/08 ] (Auth: SLH 2005, Act 209; SLH 2006, Act 264) (Imp: SLH 2005, Act 209; SLH 2006, Act 264)
§17-1722-117 REPEALED. [R 09/30/13]
§17-1722-118 Application requirements. (a) Individuals who qualify for medical assistance with income not exceeding one hundred fifty per cent of the federal poverty level, QMB’s, and SLMB’s shall be automatically eligible.
(b) All other individuals may apply for the state pharmacy assistance program on a form designated by the department. [Eff 12/29/05; am 02/18/08 ] (Auth: SLH 2005, Act 209; SLH 2006, Act 264) (Imp: SLH 2005, Act 209; SLH 2006, Act 264)
UNOFFICIAL 1722-30
§17-1722-119 Eligibility requirements. An individual shall meet the following requirements to participate in the state pharmacy assistance program: (1) Is a resident of Hawaii; (2) Receives Medicare Part D Prescription Drug Benefits; (3) Has countable income at or below one
hundred fifty per cent of the federal
poverty level for a household of applicable
size; and
(4) Meets the asset test in accordance with the
low income subsidy program addressed in
subchapter 11; (5) Is not receiving MMA prescription drug benefits through a retirement or union plan; (6) Does not have public assistance prescription coverage other than Medicaid, Medicare and Hawaii Rx Plus; (7) Is not enrolled in a private sector or government sponsored plan or any insurance providing payments for prescription drugs; and (8) Is enrolled in a benchmark prescription drug plan established by CMS. [Eff 12/29/05; am 02/18/08 ] (Auth: SLH 2005, Act 209; SLH 2006, Act 264) (Imp: SLH 2005, Act 209; SLH 2006, Act 264)
§17-1722-120 Benefits. (a) For an individual eligible for the state pharmacy assistance program, the program may pay all, or some of, the required co- payments or co-insurance actually paid only for drug claims defined as covered under the federal Medicare Part D Prescription Drug Benefit Program. (b) The state pharmacy assistance program is the payor of last resort. [Eff 12/29/05; am 02/18/08 ](Auth: SLH 2005, Act 209) (Imp: SLH 2005, Act 209
§17-1722-121 Eligibility reviews. (a) Eligibility reviews shall be conducted at intervals determined necessary by the department.
UNOFFICIAL 1722-31 (b) Individuals who fail to complete or fail to cooperate in the completion of the eligibility review shall be ineligible for benefits under this program. [Eff 12/29/05 ] (Auth: SLH 2005, Act 209) (Imp: SLH 2005, Act 209)
§17-1722-122 State pharmacy assistance program card. Program members may be issued a state pharmacy assistance program card from the department or the department’s designee. [Eff 12/29/05 ] (Auth: SLH 2005, Act 209) (Imp: SLH 2005, Act 209)
§17-1722-123 Quality control reviews. (a) Quality reviews shall be conducted at intervals determined necessary by the department. (b) Pharmacies or PDP’s selected for reviews shall furnish the requested information within ten working days of the request. (c) Failure to cooperate in the completion of a review shall result in termination from the program. [Eff 12/29/05 ] (Auth: SLH 2005, Act 209) (Imp: SLH 2005, Act 209)
§17-1722-124 Reporting requirements. Individuals are required to report changes in circumstances to the department within ten working days from the date of the change which may affect their eligibility. [Eff 12/29/05 ] (Auth: HRS §346-14; SLH 2005, Act 209) (Imp: SLH 2005, Act 209)
§17-1722-125 Termination. (a) An individual’s participation under this program shall be terminated for any of the following reasons:
UNOFFICIAL 1722-32 (1) Fails to meet the eligibility requirements set forth in section 17-1722-119. (2) The participant voluntarily terminates participation in the program; (3) The participant failed to recertify; (4) The participant failed to cooperate with the quality control reviewer; (5) Death of the participating individual; or (6) There are insufficient funds in the state pharmacy assistance program special fund. (7) Death of the participating individual; or (8) There is insufficient funds in the program due to lack of revenues received from rebates paid by pharmaceutical manufacturers. (b) An individual shall be given a ten day advance notice of termination. The notice must specify the effective date of termination, the reason for termination, and procedures to appeal the termination. (c) If an appeal is requested prior to the effective date of termination, the termination shall be stayed pending the outcome of the appeal, provided the individual otherwise remains eligible. [Eff 12/29/05; am 02/18/08 ] (Auth: SLH 2005, Act 209; SLH 2006, Act 264) (Imp: SLH 2005, Act 209; SLH 2006, Act 264)
§17-1722-126 Administration of the program. (a) The department may contract with a third party or parties to administer any component of the program, including outreach, eligibility, enrollment, claims, administration, rebate negotiations and recovery, and redistribution, in order to coordinate the prescription drug benefits of the state pharmacy assistance program and the federal Medicare Part D Prescription Drug Benefit Program. (b) Any third party that contracts with the department to administer any component of the program shall be established either at no cost to the State or on a contingency-fee basis and with no up-front costs to the State.
UNOFFICIAL 1722-33 (c) Any contract to administer any program component shall prohibit the contractor from receiving any compensation or other benefits from any pharmaceutical manufacturer participating in the program. [Eff 12/29/05 ] (Auth: SLH 2005, Act 209) (Imp: SLH 2005, Act 209)
§17-1722-127 Rebate agreement. (a) A drug manufacturer that sells prescription drugs in the State and who enters into a rebate agreement with the department shall be required to make rebate payments to the department according to a schedule established by the department. (b) The department or its designee shall attempt to obtain a rebate amount that is equal to or greater than the amount of any discount, rebate, or price reduction for prescription drugs provided to the federal government pursuant to 42 U.S.C. Section 1396r. [Eff 12/29/05 ] (Auth: SLH 2005, Act 209) (Imp: SLH 2005, Act 209)
§17-1722-128 Pharmacy or PDP reimbursement. (a) A pharmacy or a PDP shall submit claims to the department or its designee to verify the amount charged to program members. On a schedule to be determined by the department, the department shall reimburse each pharmacy or PDP for the co-payments or any portion thereof charged to, but not collected from, program members. (b) The department or its designee shall collect prescription drug utilization data necessary to calculate the amount of the manufacturer rebate under section 17-1722-127. The department shall protect the confidentiality of the data as required under State or federal law, rule, or regulation. (c) The department shall not impose transaction charges on participating pharmacies or PDPs that submit claims or receive payments under the program. [Eff 12/29/05 ] (Auth: SLH 2005, Act 209) (Imp: SLH 2005, Act 209)
§17-1722-129 State pharmacy assistance program special fund. (a) The state pharmacy assistance program special fund that is established within the
UNOFFICIAL 1722-34 State treasury and administered by the department, shall include: (1) All moneys received from manufacturers who pay rebates as provided in section 17-1722-127; (2) Appropriations made by the legislature to the fund; and (3) Any other revenues designated for the fund
(b) Moneys in this special fund shall be used for the following purposes: (1) Reimbursement payments to participating pharmacies for co-payments or co-insurance required under the federal Medicare Part D Prescription Pharmacy Benefit Program as provided to state pharmacy assistance program members; and (2) The administration or operation of the state pharmacy assistance program, including but not limited to, salary and benefits of employees, computer costs, and contracted services as provided in section 17-1722-126; All interest on special fund balances shall accrue to the special fund. Upon dissolution of the state pharmacy assistance program special fund, any unencumbered moneys in the fund shall lapse to the general fund. (c) The department shall spend all revenues received from rebates paid by pharmaceutical manufacturers pursuant to section 17-1722-127 to pay for the benefits to enrollees in the state pharmacy assistance program and the costs of administering the program. [Eff 12/29/05; am 02/18/08 ] (Auth: SLH 2005, Act 209; SLH 2006, Act 264) (Imp: SLH 2005, Act 209; SLH 2006, Act 264)
SUBCHAPTER 13
MEDICAL ASSISTANCE FOR DISABLED ADULT CHILDREN
WHO LOSE SSI BENEFITS
§17-1722-145 Purpose. The purpose of this subchapter is to establish the requirements for eligibility of disabled adults who are receiving OASDI benefits as a dependent adult child. [Eff 09/10/09
UNOFFICIAL 1722-35 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1383c(c))
§17-1722-146 REPEALED. [R 09/30/13]
§17-1722-147 Eligibility requirements. An individual who is eligible for medical assistance as a DAC shall meet all of the following conditions: (1) Is 18 years of age or older; (2) Is receiving OASDI benefits as a DAC; (3) Received SSI/SSP benefits based on blindness or disability, which began before age 22; (4) Lost SSI/SSP eligibility due to receipt of OASDI benefits as a DAC; (5) Would be eligible for SSI/SSP benefits if the OASDI benefit that caused SSI ineligibility, or an increase in that OASDI benefit, was disregarded; (6) Assigns to the department any benefits from a third party for coverage of medical expenses, to the extent of medical costs paid by the department; and (7) Meets the general eligibility conditions of chapter 17-1714. [Eff 09/10/09 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1383c(c))
§17-1722-148 Financial eligibility determination. (a) The income and assets of an individual under this subchapter shall be treated as specified under chapters 17-1724 and 17-1725 for a blind or disabled individual.
(b) An individual whose countable assets exceed the SSI personal reserve standard shall be ineligible for benefits under this subchapter.
(c) The amount of the OASDI benefit that exceeds the SSI/SSP payment standard shall be disregarded.
(d) An individual whose countable income after the disregard of OASDI income exceeds the SSI/SSP payment standard shall not be eligible for benefits as a DAC.
(e) The disregarded OASDI benefit amount shall not apply to post-eligibility treatment of income for a DAC who is receiving long term care level of service in a nursing home or medical facility. [Eff 09/10/09
UNOFFICIAL 1722-36 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) ((Imp: 42 U.S.C. §1383c(c))
§17-1722-149 Provision of coverage. Individuals eligible as a DAC shall be eligible for all services covered by the medical assistance program. [Eff 09/10/09 ] (Auth: HRS §346-14; 42 C.F.R. §435.10) (Imp: 42 U.S.C. §1383c(c))
UNOFFICIAL 1723.1-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1723.1
EMERGENCY MEDICAL ASSISTANCE FOR NON-CITIZENS
Subchapter 1 General Provisions
§17-1723.1-1
Purpose §17-1723.1-2
General requirements §§17-1723.1-3 to 17-1723.1-7 (Reserved)
Subchapter 2 Eligibility Requirements
§17-1723.1-8
Purpose §17-1723.1-9
Basic requirements §17-1723.1-10 Categorical requirements §17-1723.1-11 Income requirements §17-1723.1-12 Asset requirements §§17-1723.1-13 to 17-1723.1-17 (Reserved)
Subchapter 3 Freedom of Choice, Coverage, and Benefits
§17-1723.1-18 Purpose §17-1723.1-19 Freedom of choice §17-1723.1-20 Coverage §17-1723.1-21 Benefits §§17-1723.1-22 to 17-1723.1-26 (Reserved)
SUBCHAPTER 1
GENERAL PROVISIONS
UNOFFICIAL 1723.1-2 §17-1723.1-1 Purpose. The purpose of this chapter is to establish the requirements for eligibility and participation in emergency medical assistance for a non-citizen who is ineligible for Medicaid. [Eff 09/30/13] (Auth: HRS §§346-14, 346- 56; 42 C.F.R. §435.139) (Imp: HRS §§346-14, 346-56; 42 C.F.R. §435.139)
§17-1723.1-2 General requirements. The confidentiality, administrative appeal, fraud, medical assistance recovery, application processing, eligibility review, and adverse action notice provisions described in subtitle 12 shall pertain to an individual who applies or is eligible under this chapter. [Eff 09/30/13] (Auth: HRS §§346-14, 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.139, 435.907, 435.916, 455.1) (Imp: HRS §§346-14; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.139, 435.907, 435.916, 455.1)
§§17-1723.1-3 to 17-1723.1-7 (Reserved)
SUBCHAPTER 2
ELIGIBILITY REQUIREMENTS
§17-1723.1-8 Purpose. This subchapter describes the eligibility requirements for coverage of emergency medical services for a non-citizen under this chapter. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.10, 435.139, 435.406(c), 440.255) (Imp: 42 C.F.R. §§435.139, 435.406(c), 440.255)
§17-1723.1-9 Basic requirements. A non-citizen applying for assistance under this chapter shall meet the following basic requirements, which include but are not limited to non-citizen status, state residency, verification of identity, not residing in a public institution and, when applicable, the provision
UNOFFICIAL 1723.1-3 of a social security number. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.10, 435.139, 435.400, 435.406(c), 435.910) (Imp: 42 C.F.R. §§435.139, 435.400, 435.910)
§17-1723.1-10 Categorical requirements. (a) Coverage of emergency services may be provided to an individual who is ineligible for Medicaid, meets the conditions of subsections (b) and (c), and is: (1) Illegally residing in the United States; (2) A lawfully present non-citizen, including a citizen of a COFA nation, who is age nineteen or over and not pregnant; (3) A non-citizen who was never legally admitted to the U.S. for any period of time, or was admitted for a limited time and did not leave when the time expired; or (4) Lawfully admitted for a temporary or a specified time period as a legal non- immigrant such as a: (A) Visitor; (B) Tourist; (C) Diplomat; (D) Student who enters the U.S. temporarily with no intention of abandoning residence in a foreign country. (b) Has a sudden onset of a medical condition, including emergency labor and delivery, manifesting itself in acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could be expected to result in: (1) Placing the individual’s health in serious jeopardy; (2) Serious impairment to bodily functions; or (3) Serious dysfunction of any bodily organ or part. (c) Meets all other categorical and financial eligibility criteria for Medicaid with the exception of citizenship, lawfully present non-citizen status, and a SSN for an illegal non-citizen. Otherwise, the following conditions shall apply:
UNOFFICIAL 1723.1-4 (1) An individual who is aged, blind, or disabled (ABD) shall meet the categorical requirements for aged, blind, or disabled individuals described in chapter 17-1719; (2) A non-ABD individual shall meet the categorical eligibility requirements described in chapters 17-1715, 17-1716, 17- 1717, 17-1718 or 17-1730.1 as applicable. [Eff 09/30/13] (Auth: HRS §346-14; 42 U.S.C. §1320b-7(d), 42 C.F.R. §§435.10, 435.139, 435.406(c), 440.255) (Imp: 42 U.S.C. §1320b-7(d), 42 C.F.R. §§435.139, 435.406(c), 440.255)
Historical note: §17-1723.1-10 is based substantially upon repealed §17-1723-5. [Eff 08/01/94; am 05/17/97; am 12/27/97; am 09/17/07; R 09/30/13]
§17-1723.1-11 Income requirements. The following income standards must be met to be eligible for emergency medical assistance for non-citizens: (1) For an ABD individual, apply the income requirements described in chapter 17-1719. (2) For a non-ABD individual, apply the income requirements described in chapters 17-1715, 17-1716, 17-1717, 17-1718 or 17-1730.1 as appropriate. (3) For an individual determined ineligible for Medicaid, the department shall transfer the individual's application information for other insurance affordability programs as appropriate pursuant to 42 C.F.R. §435.1200(e). [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.10, 435.139, 435.406(c), 435.1200, 440.255) (Imp: 42 C.F.R §§435.139, 435.406(c), 435.1200, 440.255)
§17-1723.1-12 Asset requirements. Assets shall be considered as follows:
UNOFFICIAL 1723.1-5 (1) For an ABD individual, apply the asset provisions described in chapter 17-1719. (2) For a non-ABD individual, apply the asset provisions described in chapters 17-1715, 17-1716, 17-1717, 17-1718 or 17-1730.1 as appropriate. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R.§§ 435.139, 435.406(c), 440.255) (Imp: 42 C.F.R. §§435.139, 435.406(c), 440.255)
§§17-1723.1-13 to 17-1723.1-17 (Reserved).
SUBCHAPTER 3
FREEDOM OF CHOICE, COVERAGE, AND BENEFITS
§17-1723.1-18 Purpose. This subchapter addresses and refers to the provisions of freedom of choice, coverage and benefits for an individual who is eligible for emergency medical services under this chapter. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§431.10, 431.40, 435.406(c), 440.255) (Imp: 42 C.F.R §§431.10, 431.40, 435.406(c), 440.255)
§17-1723.1-19 Freedom of choice. An individual eligible under this chapter shall choose a department approved provider as described in section 17-1736-3. [Eff 09/30/13] (Auth: HRS §§346-14, 346-56; 42 C.F.R. §§431.51) (Imp: HRS §346-56; 42 C.F.R. §431.51)
§17-1723.1-20 Coverage. Coverage will be provided no earlier than the tenth calendar day immediately prior to the date the application is received by the department. [Eff 09/30/13] (Auth: HRS §§346-14, 346-56; 42 C.F.R. §§431.10,
UNOFFICIAL 1723.1-6 431.51, 440.255(c)) (Imp: HRS §346-56; 42 C.F.R. §§431.10, 431.51, 440.255(c))
§17-1723.1-21 Benefits. (a) An individual eligible under this chapter shall be provided benefits on a fee-for-service basis as described in chapter 17- 1737. (b) Benefits shall be limited to coverage of emergency medical services to stabilize the emergency medical condition described in section 17-1723.1- 10(b). (c) Services related to organ transplant procedures are not covered. [Eff 09/30/13] (Auth: HRS §§346-14, 346-56; 42 C.F.R. §§ 431.40, 440.255) (Imp: HRS §346-56, 42 C.F.R. §§431.40, 440.255)
Historical note: §17-1723.1-21 is based substantially upon repealed §17-1723-6. [Eff 08/01/94; am 05/17/97; am 01/31/09; am 06/11/09; R 09/30/13]
§§17-1723.1-22 to 17-1723.1-26 (Reserved).
UNOFFICIAL 1723.2-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1723.2
REFUGEE MEDICAL ASSISTANCE
Subchapter 1 General Provisions
§17-1723.2-1
Purpose §17-1723.2-2
General requirements §§17-1723.2-3 to 17-1723.2-7 (Reserved)
Subchapter 2 Refugee Medical Assistance (RMA) Program
§17-1723.2-8
Purpose §17-1723.2-9
Basic requirements §17-1723.2-10 Categorical requirements §17-1723.2-11 Income requirements §17-1723.2-12 Asset requirements §17-1723.2-13 Redetermination of eligibility §17-1723.2-14 Records §§17-1723.2-15 to 17-1723.2-19 (Reserved)
Subchapter 3 Freedom of Choice, Enrollment, Benefits, Disenrollment and Termination of Assistance
§17-1723.2-20 Purpose §17-1723.2-21 Freedom of choice §17-1723.2-22 Enrollment into a participating health plan §17-1723.2-23 Benefits §17-1723.2-24 Disenrollment from a health plan
UNOFFICIAL 1723.2-2 §17-1723.2-25 Termination of assistance §§17-1723.2-26 to 17-1723.2-30 (Reserved)
SUBCHAPTER 1
GENERAL PROVISIONS
§17-1723.2-1 Purpose. The purpose of this chapter is to establish the requirements for eligibility and participation in the Refugee Medical Assistance (RMA) program. [Eff 09/30/13] (Auth: HRS §§346-14, 346-56; 45 C.F.R. §§400.90, 400.91) (Imp: HRS §§346-14, 346-56; 45 C.F.R. §§400.90, 400.91)
§17-1723.2-2 General requirements. The confidentiality, administrative appeal, fraud, medical assistance recovery, application processing, eligibility review, and adverse action notice provisions described in subtitle 12 shall pertain to an individual who applies or is eligible under this chapter. [Eff 09/30/13] (Auth: HRS §§346-14, 346- 44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.907, 435.916, 455.1) (Imp: HRS §§346-14, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.907, 435.916, 455.1)
§§17-1723.2-3 to 17-1723.2-7 (Reserved).
SUBCHAPTER 2
REFUGEE MEDICAL ASSISTANCE (RMA) PROGRAM
§17-1723.2-8 Purpose. This subchapter describes the eligibility requirements for Refugee Medical Assistance (RMA). [Eff 09/30/13] Auth: HRS §§346- 14, 346-56, 45 C.F.R. §§400.90, 400.91) (Imp: HRS §§346-14, 346-56, 45 C.F.R. §§400.90, 400.91)
UNOFFICIAL 1723.2-3 §17-1723.2-9 Basic Requirements. An individual applying for assistance under this subchapter shall meet the following basic requirements, which include but are not limited to non-citizen status, state residency, verification of identity, not residing in a public institution, and the provision of a social security number when applicable. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.10, 435.400, 435.910; 45 C.F.R. §§400.90, 400.100) (Imp: 42 C.F.R. §§435.400, 435.910; 45 C.F.R. §§400.90, 400.100)
§17-1723.2-10 Categorical requirements. An individual eligible to participate in the Refugee Medical Assistance program shall: (1) Be ineligible for medical assistance under the provisions of chapters 17-1715, 17-1716, 17-1717, 17-1718, 17-1719 or 17-1730.1 with the following income not considered: (A) In-kind services and shelter provided by a sponsor or local resettlement agency; (B) Cash allotments provided by the resettlement agency and financial cash assistance payments provided by the department; and (C) Income remaining in the country of origin; (2) Provide documentation issued by the USCIS that the individual is: (A) Paroled as a refugee or asylee under section 212(d)(5) of the INA; (B) Admitted as a refugee under section 207 of the INA; (C) Granted asylum under section 208 of the INA; (D) A Cuban or Haitian entrant, in accordance with the requirements in 45 C.F.R Part 401; (E) An Amerasian from Vietnam who is admitted to the U.S. as an immigrant pursuant to section 584 of the Foreign
UNOFFICIAL 1723.2-4
Operations, Export Financing and Related Programs Appropriations Act of 1988 (Pub. L. 100-202, section 101(e)) and succeeding amendments; or (F) Admitted for permanent residence, provided the individual previously held one of the statuses identified above. (3) An individual who meets any of the requirements in section 17-1723.2-10(2) shall be referred to as a “refugee” in this chapter. (4) Provide the name of the resettlement agency which resettled them in order for the department to notify the agency upon receipt of an application. (5) Not be a full-time student in higher education, unless part of an employability plan for a refugee under 45 C.F.R. §400.79 or for an unaccompanied minor under 45 C.F.R. §400.112. [Eff 09/30/13] (Auth: HRS §§346-14, 346-56, §101(a)(42) of the INA, 45 C.F.R. §§400.43, 400.90, 400.100, 400.101, 400.102) (Imp: HRS §§346-14, 346- 56, §101(a)(42) of the INA, 45 C.F.R. §§400.43, 400.90, 400.100, 400.101, 400.102)
§17-1723.2-11 Income Requirements. (a) Income shall be based on information as of the date of application. The department may not employ prospective averaging of income methodology. (b) A refugee ineligible under section 17- 1723.2-10 due to excess income under chapters 17-1715, 17-1716, 17-1717, 17-1718, 17-1719, or 17-1730.1 is eligible under the provisions of this chapter if able to spend down to the applicable standard through incurred medical expenses. (c) A refugee initially determined eligible under chapters 17-1715, 17-1716, 17-1717, 17-1718, 17- 1719 or 17-1730.1 who is subsequently terminated due to earnings from employment shall be transferred to
UNOFFICIAL 1723.2-5 the Refugee Medical Assistance program without a determination of eligibility, until the end of the time-limited period for RMA.
(d) Earned income shall not affect continued eligibility for a refugee initially determined eligible for RMA.
(e) A refugee who is sixty-five years or older, or who is blind or disabled, shall be referred to the Social Security Administration to apply for Supplemental Security Income (SSI) and Medicare as appropriate.
(f) For an individual determined ineligible under this chapter, the department shall transfer the individual's application information for other insurance affordability programs as appropriate pursuant to 42 C.F.R. §435.1200(e). [Eff 09/30/13] (Auth: HRS §§346-14, 346-56; 42 C.F.R. §§435.10, 435.100, 435.1200, 45 C.F.R. §§400.100, 400.101, 400.102, 400.103, 400.104) (Imp: HRS §346-56, 42 C.F.R. §§435.10, 435.100, 435.1200, 45 C.F.R. §§400.100, 400.101, 400.102, 400.103, 400.104)
§l7-1723.2-12 Asset requirements. Assets shall be considered as follows: (1) For a non-ABD individual, apply the asset provisions described in chapters 17-1715, 17-1716, 17-1717, 17-1718, or 17-1730.1 as applicable. (2) For an ABD individual, apply the asset provisions described in chapter 17-1719. [Eff 09/30/13] (Auth: HRS §§346-14, 346- 56; 45 C.F.R. §§400.100, 400.101, 400.102, 400.103) (Imp: HRS §346-56, 45 C.F.R. §§400.100, 400.101, 400.102, 400.103)
§17-1723.2-13 Redetermination of eligibility. The provisions of section 17-1712.1-4 relating to redeterminations of eligibility due to a change in household circumstances shall apply to an individual eligible under this chapter. [Eff 09/30/13] (Auth: HRS §§346-14, 346-56; 42 C.F.R. §§431.10,
UNOFFICIAL 1723.2-6 435.916, 45 C.F.R §§400.93, 400.94) (Imp: HRS §346- 56; 42 C.F.R. §§431.10, 435.916, 45 C.F.R §§400.93, 400.94)
Historical note: §17-1723.2-13 is based substantially upon §17-1723-18. [Eff 08/01/94; R 09/30/13]
§17-1723.2-14 Records. The following information shall be entered in the record of each refugee: (l) The name and address of the sponsor; (2) The name of the national voluntary resettlement agency which resettled the refugee or the absence of an involved voluntary resettlement agency; and (3) The passport or alien registration number on the form I-94. [Eff 09/30/13] (Auth: HRS §346-14, §346-56; 45 C.F.R. §§ 400.93, 400.100) (Imp: HRS §346-56; 45 C.F.R. §§ 400.93, 400.100)
Historical note: §17-1723.2-14 is based substantially upon §17-1723-17. [Eff 08/01/94; [R 09/30/13]
§§17-1723.2-15 to 17-1723.2-19 (Reserved).
SUBCHAPTER 3
FREEDOM OF CHOICE, ENROLLMENT, BENEFITS, DISENROLLMENT AND TERMINATION OF ASSISTANCE
§17-1723.2-20 Purpose. This subchapter addresses and refers to the provisions of freedom of choice, enrollment, benefits and disenrollment for a refugee who is eligible for RMA under this chapter. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40, 435.10; 45 C.F.R. §§400.90, 400.105) (Imp: 42 C.F.R §§430.25, 431.10, 431.40, 45 C.F.R. §§400.90, 400.105)
UNOFFICIAL 1723.2-7 §17-1723.2-21 Freedom of choice. (a) A refugee eligible in accordance with this chapter, with the exception of a refugee identified in section 17- 1735.1-2(a), shall be provided a choice of a health plan and a provider as described in chapter 17-1720.1. (b) A refugee identified in section 17-1735.1- 2(a) shall choose a department approved provider as described in 17-1736-3. [Eff 09/30/13] (Auth: HRS §§346-14, 346-56; 42 C.F.R. §§430.25, 431.51, 438.52; 45 C.F.R. §400.105) (Imp: HRS §346-56; 42 C.F.R. §§430.25, 431.51, 438.52; 45 C.F.R. §400.105)
§17-1723.2-22 Enrollment into a participating health plan. (a) A refugee eligible in accordance with this chapter, with the exception of a refugee identified in section 17-1735.1-2(a), shall be enrolled in a health plan as described in chapter 17-1720.1. (b) A refugee identified in section 17-1735.1- 2(a) shall not be enrolled into a health plan and their health care services shall be provided on a fee- for-service basis. [Eff 09/30/13] (Auth: HRS §§346-14, 346-56; 42 C.F.R. §§430.25, 431.10, 431.40, 438.50, 45 C.F.R. §400.105) (Imp: 42 C.F.R. §§430.25, 431.10, 431.40, 438.50, 45 C.F.R. §400.105)
§17-1723.2-23 Benefits. (a) Benefits under this chapter shall be time-limited as determined by the Director of the federal Office of Refugee Resettlement. (b) A refugee who is enrolled in a health plan shall be provided a standard benefits package by a participating health plan and other services when appropriate as described in chapter 17-1720. (c) A refugee identified in section 17-1735.1- 2(a) shall be provided coverage under the fee-for- service provisions as described in chapter 17-1737. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6; 45 C.F.R. §400.105) (Imp:
UNOFFICIAL 1723.2-8 HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6; 45 C.F.R. §400.105)
§17-1723.2-24 Disenrollment from a health plan. An enrollee shall be disenrolled from a health plan under the provisions as described in chapter 17- 1720.1. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §430.25, 431.40, 438.56, 45 C.F.R. §400.105) (Imp: HRS §346-14; 42 C.F.R. §430.25, 431.40, 438.56, 45 C.F.R. §400.105)
§17-1723.2-25 Termination of assistance. (a) After a refugee is determined eligible for RMA under this chapter, the department shall review the refugee’s circumstances as appropriate for changes to determine eligibility for other medical assistance programs. (b) Refugee Medical Assistance shall be terminated when the first of the following conditions is met: (1) The refugee has been determined eligible for Medicaid; (2) Countable assets exceed the maximum allowable; or (3) The last day of the final month of the time limited benefit period. (c) When RMA is terminated, the department shall transfer the individual's application information for other insurance affordability programs as appropriate pursuant to 42 C.F.R. §435.1200(e). [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§431.200, 431.213, 435.1200; 45 C.F.R. §§400.94, 400.100) (Imp: HRS §346-14; 42 C.F.R. §§431.200, 431.213, 435.1200; 45 C.F.R. §§400.94, 400.100)
§§17-1723.2-26 to 17-1723.2-30 (Reserved).
UNOFFICIAL 1723.3-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1723.3
MEDICAL ASSISTANCE FOR REPATRIATES
Subchapter 1 General Provisions
§17-1723.3-1 Purpose §§17-1723.3-2 to 17-1723.3-6 (Reserved)
Subchapter 2 Eligibility Requirements
§17-1723.3-7
Purpose 8§17-1723.3-8 Eligibility requirements §§17-1723.3-9 to 17-1723.3-13 (Reserved)
Subchapter 3 Benefits, Termination and Repayment
§17-1723.3-14 Purpose §17-1723.3-15 Benefits §17-1723.3-16 Termination of assistance §17-1723.3-17 Repayment §§17-1723.3-18 to 17-1723.3-22 (Reserved)
SUBCHAPTER 1
GENERAL PROVISIONS
UNOFFICIAL 1723.3-2 §17-1723.3-1 Purpose. This chapter describes the temporary medical assistance provided by the department on behalf of the U.S. Department of Health and Human Services (HHS) to a United States citizen or national, or the dependent of a United States citizen, who has been returned from a foreign country under the provisions of the U.S. Repatriate program, as established by Section 1113 of the Social Security Act, 42 U.S.C. Section 1313, and as administered by HHS through the International Social Service-United States of America Branch (ISS-USA). [Eff 09/30/13] (Auth: HRS §346-14; 45 C.F.R. §§211,212) (Imp: HRS §346-14; 45 C.F.R. §§211,212)
§§17-1723.3-2 to 17-1723.3-6 (Reserved).
SUBCHAPTER 2
ELIGIBILITY REQUIREMENTS
§17-1723.3-7 Purpose. This subchapter describes the eligibility requirements for temporary medical assistance under the U.S. Repatriate program. [Eff 09/30/13] (Auth: HRS §346-14; 45 C.F.R §§211,212) (Imp: HRS §346-14, 45 C.F.R §§211,212)
§17-1723.3-8 Eligibility requirements. (a) An individual eligible to receive repatriate medical assistance shall meet the following requirements: (1) A citizen of the United States or a dependent of a citizen of the United States. (2) Identified as having returned or returning from a foreign country to the United States through a written statement transmitted to the department by an authorized official of the Department of State (DOS) because of one of the following reasons: (A) Destitution; (B) Illness of the individual or dependent; (C) War;
UNOFFICIAL 1723.3-3 (D) Threat of war; (E) Invasion; or (F) Similar crisis. (3) Without resources immediately accessible to meet the individual’s needs. (b) A mentally ill individual eligible to receive repatriate medical assistance shall be: (1) A U.S. citizen or U.S. national status; (2) Verified with a certificate from an authorized official of DOS or an appropriate authority (as determined by HHS) from the country of origin, that the individual has been legally declared insane in that foreign country or a certificate stating from such appropriate authority that the individual was in a named foreign country and was in need of care and treatment in a mental hospital; and (3) Identified as having returned or returning from a foreign country to the United States due to certified mental illness through a written statement transmitted to the department by an authorized official of DOS. (c) Individuals determined eligible for repatriate medical assistance by DOS who are subsequently determined eligible by the department for Medicaid will receive medical assistance under the state Medicaid program and not pursuant to this chapter. [Eff 09/30/13] (Auth: HRS §346-14; 45 C.F.R. §§211,212) (Imp: HRS §346-14; 45 C.F.R. §§211,212)
§§17-1723.3-9 to 17-1723.3-13 (Reserved).
SUBCHAPTER 3
BENEFITS, TERMINATION AND REPAYMENT
§17-1723.3-14 Purpose. This subchapter describes the benefit, termination and repayment
UNOFFICIAL 1723.3-4 provisions regarding temporary medical assistance under the U.S. Repatriate program. [Eff 09/30/13] (Auth: HRS §346-14; 45 C.F.R §§211,212) (Imp: HRS §346-14, 45 C.F.R §§211,212)
§17-1723.3-15 Benefits. (a) Benefits for an individual eligible under this chapter shall be time- limited for up to ninety (90) days from the date of arrival in the United States unless the provisions of (b) apply. (b) With prior authorization from the HHS, temporary medical assistance may be extended for up to nine (9) months if the individual is unable to attain self-support or self care due to age, disability or lack of vocational preparation. (c) Depending upon the circumstances of the individual, and in consultation with the ISS-USA case manager, an individual eligible for repatriate medical assistance will be provided medical assistance either as fee-for-service or enrolled in a health plan. (d) The level of benefits provided to individuals under the repatriate program shall be the same as that provided under §17-1737 for fee-for- service or §17-1720.1 for participating health plans. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6, 45 C.F.R. §§211.6, 212.4, 212.5) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6, 45 C.F.R. §§211.6, 212.4, 212.5)
§17-1723.3-16 Termination of assistance. (a) During the ninety (90) day repatriation period, the department shall review as appropriate changes in an individual’s situation to determine whether a different plan of assistance is appropriate or the individual is eligible for another medical assistance program. (b) Repatriate medical assistance shall be terminated when the first of the following conditions is met:
UNOFFICIAL 1723.3-5 (1) The individual has been determined eligible for assistance under the state’s Medicaid program; (2) The individual has sufficient resources to meet his or her needs; or (3) On the ninety-first (91st) day from the date of arrival, unless assistance has been extended by HHS as provided in section 17- 1723.3-15(b). (c) When repatriate medical assistance is terminated the department shall assist the individual in assessing eligibility for medical assistance under other state or federal programs. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§431.200, 431.213, 431.220, 435.912; 45 C.F.R. §§211.4, 211.6, 212.5, 212.6) (Imp: HRS §346-14; 42 C.F.R. §§431.200, 431.213, 431.220, 435.912; 45 C.F.R. §§211.4, 211.6, 212.5, 212.6)
§17-1723.3-17 Repayment. (a) Temporary medical assistance to eligible individuals under the repatriate program is provided on a loan basis from HHS and is not retroactive.
(b) Eligible individuals will be required to sign the Privacy Act Statement and Repayment Agreement, AFC-120, upon arrival in the United States.
(c) Assistance provided without a signed repayment agreement in cases of medical emergency conditions or unaccompanied minors remains on a loan basis.
(d) The department is not responsible for the repayment process of repatriate loans or any collection, compromise or waiver of repayment. [Eff 09/30/13] (Auth: HRS §346-14; 45 C.F.R §§211.13, 212.7) (Imp: HRS §346-14, 45 C.F.R §§211.13, 212.7)
§§17-1723.3-18 to 17-1723.3-22 (Reserved).
HAWAII ADMINISTRATIVE RULES TITLE 17 DEPARTMENT OF HUMAN SERVICES SUBTITLE 12 MED-QUEST DIVISION CHAPTER 1724.1 MODIFIED ADJUSTED GROSS INCOME (MAGI)-EXCEPTED BASED METHODOLOGY Subchapter 1 General Provisions Purpose Repealed §17-1724.1-1 §17-1724.1-2 §§17-1724.1-3 to 17-1724.1-7 (Reserved) Subchapter 2 §17-1724.1-8 §17-1724.1-9 Availability of Income Purpose Availability and verification of income §§17-1724.1-10 to 17-1724.1-14 (Reserved) Subchapter 3 §17-1724.1-15 §17-1724.1-16 Legal Responsibility For Support Purpose Availability of income of household members §§17-1724.1-17 to 17-1724.1-21 (Reserved) Subchapter 4 Earned Income Purpose Earnings Self-employment earned income Entitlements to military personnel Exempt earned income §17-1724.1-22 §17-1724.1-23 §17-1724.1-24 §17-1724.1-25 §17-1724.1-26 §§17-1724.1-27 to 17-1724.1-31 (Reserved) 1724.1-1 ~ ;> 0 6
320 6 Subchapter 5 §17-1724.1-32 §17-1724.1-33 §17-1724.1-34 §17-1724.1-35 §17-1724.1-36 §17-1724.1-37 Unearned Income Purpose Veteran's benefits Legal settlements, inheritance, insurance settlements, and compensations Educational loans, grants, scholarships, and benefits Lump sum benefits Income of the sponsor of a non- ci tizen Other unearned income Exempt unearned income §17-1724.1-38 §17-1724.1-39 §§17-1724.1-40 to 17-1724.1-44 (Reserved) Subchapter 6 §17-1724.1-45 §17-1724.1-46 Income Disregards Purpose Income disregarded for a MAGI- excepted individual or household §§17-1724.1-47 to 17-1724.1-51 (Reserved) Subchapter 7 Determination of Financial Eligibility Purpose Rounding of income General eligibility provisions Determining monthly income Determining monthly net income §17-1724.1-52 §17-1724.1-53 §17-1724.1-54 §17-1724.1-55 §17-1724.1-56 §§17-1724.1-57 to 17-1724.1-61 (Reserved) Subchapter 8 §17-1724.1-62 §17-1724.1-63 Financial Eligibility and Liability of MAGI-Excepted Individuals Receiving Long-Term Care Services Purpose Post-eligibility treatment of income for a MAGI-excepted individual meeting institutional level of 1724.1-2
§17-1724.1-2 care and receiving long-term care services §§17-1724.1-64 to 17-1724.1-68 (Reserved) Historical Note: This chapter is based substantially upon repealed subchapters 4, 5 and 7 of chapter 17- 1721 and repealed chapter 17-1724. The source notes for subchapters 4, 5 and 7 of chapter 17-1721 are: [Eff 08/01/94; am 11/13/95; am 11/25/96; am 10/26/01; am 01/31/09; am 10/19/09; am 06/25/12; R 09/30/13]. The source notes for chapter 17-1724 are: [Eff 08/01/94; am 07/20/95; am 01/29/96; am 11/25/96; am 02/10/97; am 05/17/97; am 12/27/97; am 05/02/98; am 06/19/00; am 10/26/01; am 12/03/01; am 05/10/03; am 08/25/07; R 09/30/13] . SUBCHAPTER 1 GENERAL PROVISIONS §17-1724.1-1 Purpose. This chapter describes the Modified Adjusted Gross Income (MAGI)-excepted income methodology used to determine financial eligibility for an individual or household having medical assistance eligibility determined in a MAGI- excepted eli~ibility group. [Eff 09/30/13; am and comp NOV 10 2016 ] (Auth: HRS §346-53; 42 C.F.R. §§431.10, 435.121, 435.230, 435.330, 435.601, 435.602) (Imp: HRS §346-53; 42 C.F.R. §§431.10, 435 . 121, 435.230, 435.330, 435.601, 435.602) §17-1724.1-2 CR NOV 10 2016 1 §§17-1724.1-3 to 17-1724.1-7 {Reserved). SUBCHAPTER 2 1724.1-3
§17-1724.1-8 AVAILABILITY OF INCOME §17-1724.1-8 Purpose. This subchapter describes the requirement for a MAGI-excepted individual to apply for and pursue any potentially available income sources. [Eff 09/30/13; am and comp NOV 1 0 2016 ] (Auth: HRS §346-53; 42 C.F.R. §435.608) (Imp: HRS §346-29; 42 C.F.R. §435.608) §17-1724.1-9 Availability and verification of income. (a) As a condition of eligibility, an individual shall apply for and develop any potential sources of income include, but are not limited to, annuities, pensions, retirement and disability benefits, veterans' compensation and unemployment compensation, unless good cause can be shown for not doing so. (b) The department shall deny or terminate medical assistance when the individual fails to: (1) Apply for, access, or develop potential sources of income; (2) Cooperate in providing accurate and complete information or verification; or (3) Complete any other action on the part of the individual or household that prevents a correct determination of eligibility to be made. [Eff 09/30/13; am and comp NOV 1 0 2016 ] (Au th: HRS §§34 6-14, 346-29, 346-53; 42 C.F.R §§435.608, 435.945, 435.952) (Imp: 42 C.F.R §§4:·35.608, 435.945, 435.952) §§17-1724.1-10 to 17-1724.1-14 (Reserved) . SUBCHAPTER 3 LEGAL RESPONSIBILITY FOR SUPPORT §17-1724.1-15 Purpose. This subchapter describes individuals whose income shall be considered available for the support of a MAGI-excepted spouse or child 1724.1-4 3206 I J
§17-1724.1-16 applying for medical assistance. [Eff 09/30/13; am and comp NOV 1 O 2016 ] (Auth: HRS §346-53; 42 C.F.R. §435.602) (Imp: HRS §346-29; 42 C.F.R. §435.602) §17-1724.1-16 Availability of income of household members. The following shall apply when determining financial responsibility of related household members and other household members of a MAGI-excepted individual: (1) The income of spouses living in the same residence shall be considered available to each other. (2) When spouses cease to reside together due to the institutionalization of one spouse, only the income actually contributed from one spouse to the other shall be considered available to the receiving spouse, beginning the first month after the spouses cease to reside together. (3) An individual receiving home and community based waiver services or hospice services shall be considered institutionalized and separated from the individual's spouse, under the provisions of paragraph (2). (4) When spouses cease to reside together for reasons other than the institutionalization of one spouse, only the income up to the month of separation shall be considered available to each other. After the month of separation, only the income that is actually contributed to the eligible spouse shall be considered available to the eligible spouse. (5) When determining the eligibility of a child under eighteen years of age who is applying for or receiving medical assistance under chapter 17-1719 as a blind or disabled individual: (A) The income of the parent or parents shall be considered available to the child if the child resides in the same residence; (B) Only the income that is actually contributed by the parent or parents shall be considered available to the child, beginning the first month following the month the child ceases to 1724.1-5 320 6
§17-1724.1-16 resid~ with a parent or parents. This provision applies even if the child returns to the residence for periodic visits. (6) When determining the eligibility of a household with a child under nineteen years of age, who is in the same household as his or her natural, legal, or adoptive parents, the parents' income shall be considered available to the child. However, if a child is not included as part of the household, the child's income and needs shall not be considered when determining eligibility for the remaining household members. (7) When determining the eligibility for a non- Title IV-E child covered under a: (A) State adoption assistance agreement, the income of the adoptive parent or parents shall not be considered available to the child. (B) Kinship guardianship assistance agreement, the income of the relative legal guardian or guardians shall not be considered available to the child. (C) State permanency assistance agreement, the income of the legal guardian or guardians or permanent custodian or custodians shall not be considered available to the child. [Eff 09/30/13; am and comp NOV 1 O 2016 (Auth: HRS §346-14; 42 C.F.R. § § 4 3 1 . 10 , 4 3 5 . 6 0 1 , 4 3 5 . 6 0 2 ) ( I mp : HRS §346-14; 42 C.F.R. §§435.601, 435.602) §§17-1724.1-17 to 17-1724.1-21 (Reserved) . SUBCHAPTER 4 EARNED INCOME §17-1724.1-22 Purpose. This subchapter describes the types of earned income considered countable or exempt in determining the financial eligibility of a MAGI-excepted individual or household. [Eff 09/30/13; am and comp NOV 1O2016 1724.1-6 3206 'f
§17-1724.1-24 (Auth: HRS §346-53; 42 C.F.R. §§431.10, 435.601, 4 3 5 . 6 O 2 ) ( I mp : HRS § 3 4 6 - 5 3 ; 4 2 C . F . R . § § 4 3 1 . 1 0 , 435.601, 435.602) §17-1724.1-23 Earnings. All employment-related income received that is not exempt under section 17- 1724.1-26, shall be considered countable earned income; include, but are not limited to: (1) Wages, back pay, birthday pay, cost of living allowance (COLA), funeral pay, holiday pay, sick leave pay, and vacation pay; (2) Tips, bonuses, and commissions; (3) Dismissal and severance pay; (4) Compensation from any on-the-job training (OJT) program; (5) Payments under the Workforce Investment Act (WIA) except for supportive services; (6) Compensation from public service employment ( PSE) ; (7) In-kind income received in lieu of cash for employment that is paid to an individual that includes perquisites, such as meals, food, shelter, utilities and medical insurance; (8) Royalties from an individual's work or any honorarium received for services rendered; or (9) Temporary disability insurance (TDI) benefits when an employer provides payments directly to an eligible employee for non work-related sickness or injury, including pregnancy. [Eff 09/30/13; am and comp NOV 1o2016 ] (Auth: HRS §346-53; 20 C.F.R. ~§4lb.ll10, 416.1121; 42 C.F.R. §§435.601, 435.631; 42 U.S.C. §1382a(a)) (Imp: HRS §§346-14, 346-29; 346-53; 20 C.F.R. §§416.1110, 416.1121; 42 C.F.R. §§435.601, 435.631; 42 U.S.C. §1382a(a)) §17-1724.1-24 Self-employment earned income. (a) Self-employment earned income is income received by an individual who: (1) Sells a service or product for a profit; 1724.1-7
3 20 6 §17-1724.1-24 (2) Is independently responsible for obtaining or providing a service or product; (3) Has independent costs and expenses necessary to provide a service or product; (4) Determines independently the manner, method, and process of business operations; and (5) Is independently responsible for the suc~ess or failure of the business operation. (b) Self-employment earned income shall be determined by deducting ordinary and necessary business expenses directly related to producing goods or services from the gross income amount received from the sale of the goods or services. (c) Only verified documentation of business expenses shall be deducted from the gross self- employment income. Verified business expenses include, but are not limited to, expenses that are listed on a profit and loss statement, itemized receipt, or billing statement such as: (1) Costs of the product or raw materials, (2) ( 3) ( 4) including shipping and storage costs; Factory overhead expenses; Employee wages; and Costs related to property used for the business, including rent, utilities, repairs, mortgage interest, taxes, and insurance. (d) Expenses that are not allowed as deductions include, but are not limited to: (1) Depreciation and depletion; (2) Personal business expenses such as lunches, transportation to and from work, and entertainment expenses; (3) Purchase of capital equipment; and (4) Payments on the principal of loans for capital assets or durable goods. (e) An individual who does not meet the self- employment requirements specified in subsection (a) , shall not be allowed to d~du 1 ct business expenses . [Eff 09/30/13; am and comp NUV 0 2016 ] (Auth: HRS §346- 53; 20 C.F.R. §§416.1110, 416.1111; 42 C.F.R. §§435.601, 435 . 631) (Imp: HRS §§346-14, 346-29; 20 C.F.R. §§416.1110, 416.1111; 42 C.F.R. §§435.601, 435.631) 1724.1-8
§17-1724.1-26 §17-1724.1-25 Entitlements to military personnel. Allowances available to military personnel on active duty identified under the entitlement section of the Leave and Earnings Statement (LES) are considered countable earned income include, but are not limited to: (1) Basic allowance for housing (BAH) which is housing compensation paid to military personnel not residing in government housing; (2) Basic allowance for subsistence (BAS) which is paid to military personnel to offset the cost of their meals when residing in non- governmental housing or without access to a military mess hall; (3) Clothing allowances (listed as BCRA, CCA, CMA, CRA, FCRA, SCRA, or UNIF) which are provided for the replacement of required uniform items based on normal wear rate, when additional uniform items are required, or when civilian clothing is required to perform assigned duties; (4) Continental United States cost of living allowance (CONUS COLA) which is provided to compensate military personnel stationed in certain "higher-cost" locations; and (5) Combat pay (listed as HFP, HFP/COMBAT ZONE, HSTL, or IDP) may be treated as earned income, if elected under the earned income tax credit. [Eff 09/30/13; am and comp NOV102016 ] (Auth: HRS §346-53; 42 C.F.R. §§435.601, 435.631); Executive Order 13239; Executive Order 13119; Executive Order 12744; Pub. L. 106-21; Pub. L. 104- 117) (Imp: HRS §§346-14, 346-29; 42 C.F.R. §§435.601, 435.631); Executive Order 13239; Executive Order 13119; Executive Order 12744; Pub. L. 106-21; Pub. L. 104-117) §17-1724.1-26 Exempt earned income. Work- related income that is exempt as earned income include, but are not limited to: 1724.1-9 320 6
1;20 6 §17-1724.1-26 (1) Federal earned income tax credit that reduces the federal tax liability for certain low income working taxpayers that results in advance payments from an employer or a refund from the IRS; (2) Federal child tax credit that is available to certain low income employed taxpayers with a dependent child and may result in a tax refund payment to the taxpayer from the IRS; (3) Infrequent earned income of thirty dollars per calendar quarter whether from a single source, unexpected source, or from more than one source of income; (4) Payments under the Workforce Investment Act (WIA) that are for supportive services; and (5) Wages paid by the Census Bureau for temporary employment related to census activities; and (6) Earned income of a blind or disabled student under age twenty-two years, up to the monthly and yearly maximum student earned income exclusion (SEIE) amounts as determined by the Social Security Administration and the cost- of-living adjustment(COLA) as described under 20 C. F. R. § ~.l6 .1112. [Eff 09/30/13; am and comp NUV 1 0 2016 ] (Au th: HRS §346- 14; 20 C.F.R. §§416.1102 to 416.1123, 416.1124 to 416.1167; 42 C.F.R. §§435.601, 4 3 5 . 6 3 1 ; Pub . L . 10 7 - 16 ) ( I mp : HRS § § 3 4 6 - - 14, 346-29; 20 C.F.R. §§416.1102 to 416.1123, 416.1124 to 416.1167; 42 C.F.R. §§435.601, 435.631; Pub. L. 107-16) §§17-1724.1-27 to 17-1724.1-31 (Reserved) . SUBCHAPTER 5 UNEARNED INCOME 1724.1-10
§17-1724.1-33 §17-1724.1-32 Purpose. This subchapter describes the types of unearned income considered countable or exempt when determining the financial eligibility of a MAGI-excepted individual or household. [Eff 09/30/13; am and comp NOV 1 O 2016 ] (Auth: HRS §346-53; 42 C.F.R . §§431.10, 435.601, 435.602) (Imp: HRS §346-53; 42 C.F.R. §§431.10, 435.601, 435.602) .. §17-1724.1-33 Veteran's benefits. All Veterans Administration (VA) benefits, if not excluded under sections 17-1724.1-39 or 17-1724.1-46, available to an individual who served in the Army, Navy, Marine Corps, Coast Guard, or Air Force or to their dependents; a spouse, child, or a dependent parent of a living veteran, a widow or a widower, or surviving dependent parent of a deceased veteran prior to any deductions, are considered countable unearned income include, but are not limited to: (1) Service-connected disability benefits; (2) Pension benefits for a veteran who is a: (A) Permanently and totally disabled individual who served ninety or more days of active military service to include a minimum of one day during a period of war not sustaining a service- connected disability; (B) Sixty-five years of age or older individual with limited income who served twenty or more years of active duty, full-time National guard duty, or satisfactory service as a reservist; or (C) Recipient of the medal of honor. [Eff 09/30/13 · am and comp NOV102016 ] (Auth: HRS §346- 53; 20 C.F.R. §§416.1103 (a) (7), 416.1121(a), 416.1124(c) (12); 42 C.F.R. §§435.601, 435.631; 38 u.s.c. §3203; Pub . L . 110 - 2 4 5 ) ( I mp : HRS § 3 4 6 - 2 9 ; 20 C.F.R. §§416.1103 (a) (7), 416.112l(a), 416.1124(c) (12); 42 C.F.R. §§435.601, 435.631; 38 u.s.c. §3203; Pub. L . 110-245 1724.1-11 320 6
;20 6 §17-1724.1-34 §17-1724.1-34 Legal settlements, inheritance, insurance settlements, and compensations. (a) Money received to settle any insurance, legal, or inheritance claim, personal injury awards and compensation for pain and suffering shall be considered unearned income, if not excluded under sections 17-1724.1-39 or 17-1724.1-46. (b) Any expense paid or incurred which is related to the settlement or award shall be deducted from the total amount awarded. (c) Allowable expense deductions include, but are not limited to, legal fees, medical payments, motor vehicle replacement, or replacement of personal property damaged or lost if proof of allowable expenses paid is provided to the department within ten calendar days from the date the settlement, inheritance, or award is received. Absent the submission of proof, the gross settlement, inheritance or award amount shall be considered unearned income. [Eff 09/30/13; am and comp NOV 10 2016 ] (Auth: HRS §346-53; 20 C.F.R. §416.1121; 42 C.F.R. §§435.601, 435.631) (Imp: HRS §346-29; 20 C.F.R. §416.1121; 42 C.F.R. §§435.601, 435.631) §17-1724.1-35 Educational loans, grants, scholarships, and benefits. (a) Any educational loans, grants, or scholarships, if not excluded under section 17-1724.1-46, obtained and used under conditions that preclude their use for current living expenses shall not be counted as unearned income. (b) Any educational loans, grants, or scholarships not excluded under section 17-1724.1-46, which are obtained and used for current living expenses, shall be counted as unearned income. (c} Educational grants or scholarships received by the student and used for expenses include, but are not limited to tuition, books, fees, equipment, transportation for school purposes, or child care services necessary for school attendance, shall not be counted as unearned income. (1) Expenses specified in this subsection shall be deducted first from the scholarships, loans or educational benefits specifically excluded under section 17-1724.1-46. 1724.1-12
§17-1724.1-37 (2) Expenses specified in this subsection that exceed the excluded benefits under section 17-1724.1-46 shall then be deducted from any non-excluded scholarship or educational benefits. (d) Educational loans, grants, and scholarships that are received in a lump sum and not excluded by sections 17-1724.1-36 or 17-1724.1-46, shall be prorated over the specified period for which the income is intended to determine the monthly amount to be budgeted. The expenses specified in subsection (c) shall be deducted from the lump sum prior to the proration. Any allowable expenses incurred after the proration shall be deducted from the monthly prorated amount for the month in which "{Jf le2CP~}lse is paid. [Eff 09/30/13; am and comp UlUlb ] (Auth: HRS §346-53; 20 C.F.R. §416.1124; 42 C.F.R. §§435.601, 435.631) (Imp: HRS §346-29; 20 C.F.R. §416 . 1124; 42 C.F.R. §§435.601, 435.631) §17-1724.1-36 Lump sum benefits. Any lump sum cash benefit, which is not considered to be earned income and not exempt under sections 17-1724.1-39 or 17-1724.1-46, shall be considered unearned income in the month of ~~~eipt. [Eff 09/30/13; am and comp NOV 10 ZU1b ] (Auth: HRS §346-53; 42 C.F.R. §§435.601, 435.631) (Imp: HRS §346-29; 42 C.F.R. §§435.601, 435.603, 435.631) §17-1724.1-37 Income of the sponsor of a non- citizen. (a) The sponsor of a non-citizen who executed an affidavit of support pursuant to section 213A of the Immigration and Nationality Act on or after December 19, 1997, shall have their income and their spouse's income deemed as available to a non- citizen requesting medical assistance. (b) The income of a non-citizen's sponsor and the sponsor's spouse shall be deemed available to the non-citizen until such time as the non-citizen: (1) Achieves United States citizenship through naturalization pursuant to ch~pter 2 of Title III of the INA; or 1724.1-13 1 ":t ") Ii l
§17-1724.1-37 (2) Has worked forty qualifying quarters of coverage as defined under Title II of the Social Security Act or can be credited with such qualifying quarters as provided under 8 U.S.C. §1645. In the case of any such qualifying quarter beginning after December 31,. 1996, the non-citizen must not have received any Federal means-tested public benefit during any such period. (c) The non-citizen's failure to provide information and verification regarding the income of their sponsor and the sponsor's spouse as applicable shall disqualify the non-citizen from receiving medical assistance. (d) The income of a non-citizen's sponsor and the sponsor's spouse shall not be deemed available to a non-citizen for coverage of emergency medical assistance as described in chapter 17-1723.1. (e) Special provisions shall apply in the case of an indigent non-citizen. The deeming of income in subsection (a) shall not be applicable for a twelve- month period from the date a non-citizen is determined to be indigent. 3 2 0 6 f.; (1) The department may determine a non-citizen to be indigent when the non-citizen is unable to obtain food and shelter because the non-citizen's own income plus any cash, food, housing, or other assistance provided by other individuals, including the sponsor and the sponsor's spouse does not exceed one hundred thirty-three per cent of the federal poverty level for the non-citizen's household size; (2) The department will only consider the actual amount contributed by the sponsor and the sponsor's spouse for a twelve month period, which begins on the date of such determination and ends twelve months after such date; (3) Each period of indigence is renewable for additional twelve month periods; and 1724.1-14
§17-1724.1-37 (4) The department must notify the federal Attorney General of each such determination, including the names of the sponsor and the sponsored non-citizen involved. (f) Special provisions for a battered spouse and child. Non-deeming of income of the sponsor and the sponsor's spouse described in subsection (a) if the sponsor and the sponsor's spouse are the batterer and the spouse of the batterer, applies only for the period the non-citizen is not residing in the same residence of the batterer not to exceed twelve months. (1) This provision applies to: (A) A non-citizen who was battered or subjected to extreme cruelty in the U.S. by a spouse or a parent, or by a member of the spouse's or parent's family residing in the same residence as the non-citizen and the spouse or parent consented to or acquiesced to such battery or cruelty; (B) A non-citizen whose child was battered or subjected to extreme cruelty in the U.S. by the spouse or parent of the non-citizen who did not actively participate in such battery or cruelty or by a member of the spouse's or parent's family residing in the same residence as the non-citizen when the spouse or parent consented or acquiesced to such battery or cruelty; or (C) A non-citizen child who was residing with the parent who was battered or subjected to extreme cruelty in the U.S. by that parent's spouse or by a member of the spouse's family residing in the same residence as the parent and the spouse consented to, or acquiesced in such battery or cruelty described in any of the paragraphs under this subsection. 1724.1-15 3206
§17-1724.1-37 (2) The department shall determine whether the battery or cruelty is substantially connected to the need for public benefits which means that without the support of the batterer, the non-citizen is unable to obtain food and shelter because the non- citizen' sown income plus any cash, food, housing, or assistance provided by other individuals including the sponsor, does not exceed one hundred thirty-three per cent of the federal poverty level for the non- citizen' s household size. (3) After the twelve month period ends, the department shall continue to exempt the batterer's income when the battery or cruelty is recognized in an order of a judge or administrative law judge or a prior determination of the users, and the department determines that such battery or cruelty still has a substantial connection to the need for benefits. [Eff 09/30/13; am and comp t40V 1 0 2016 ] (Au th: HRS §346-53; 42 C.F.R. §§435.631, 435.831; 8 U.S.C. §§1631, 1632, 1645; 42 USC §1396b(v) (4) (A)) (Imp: HRS §346-29; 42 C.F.R. §§435.631, 435.831; 8 U.S.C. §§1631, 1632, 1645; Sec. 214, P.L. 111-3; 42 USC §1396b(v) (4) (A)) §17-1724.1-38 Other unearned income. All non- work related income prior to any deductions and not exempt in section 17-1724.1-39, shall be considered countable unearned income that include, but are not limited to: 320 6 fj (1) Social security benefits include: (A) Early retirement benefits at age sixty- two years or full retirement benefits at age sixty-five years or older; (B) Disability benefits to an individual certified as unable to work because of a physical and or mental handicap; 1724.1-16
§17-1724.1-38 (C) Survivor's benefits to a spouse of a deceased wage earner; or (D) Benefits for children of a deceased or disabled parent. (2) Amount of Social Security benefits being recovered due to an overpayment that occurred when an individual was not receiving Medicaid. (3) Temporary disability insurance payments that are paid more than six consecutive months after work stopped because of a sickness or disability which are not ·paid by the employer if the individual is no longer an employee of the company. (4) Pension and retirement benefits, administered by the federal, state or city governments, unions, private corporations, insurance or trust companies, and other entities, prior to any deductions, may also be available to children and spouses of retired employees. (5) Unemployment insurance benefits received under a state or federal unemployment law or additional amounts paid by unions or employers as unemployment benefits. (6) SS! benefits of an institutionalized individual for whom the post-eligibility treatment of income under section 17-1724.1- 63 applies. (7) Worker's compensation benefits, prior to any deductions, or weekly benefits provided to a surviving spouse or dependent children of a deceased employee due to a work-related death to compensate them for the loss of financial support. (8) Railroad retirement board (RRB) benefits, prior to any deductions, when available to an individual who worked for a U.S. railroad company. (9) Strike benefits, prior to any deductions. (10) Alimony and spousal support payments received. (11) Child support payments received, including child support arrearage payments. (12) Regular cash contributions. 1724.1-17 ?206
1~20 6 §17-1724.1-38 (13) Occasional gifts and contributions in excess of $20 per household per month. (14) The dollar value of dividends and interest as returns on capital investments or interest paid on dividends from life insurance, or other sources that are received by an individual, set aside for an individual's use, or credited to an account of an individual from any financial institution, insurance company, or other source~: {Eff 09/30/13; am and comp NOV I 0 2016 ] (Auth: HRS §346-53; 20 C.F.R. §§404.1051, 416.1103, 416.1110, 416.1112, 416.1121, 416.1123, 416.1124; 42 C.F.R. §§431.10, 435.601, 435.631, 435.733, 435.735) (Imp: HRS §§346-53, 386 (Part II); 20 C.F.R. §§404.1051, 416.1103, 416.1110, 416.1112, 416.1121, 416.1123, 416.1124; 42 C.F.R. §§431.10, 435.601, 435.631, 435.733, 435.735) §17-1724.1-39 Exempt unearned income. (a) All non-work related income that is exempt as unearned income include, but are not limited to: (1) VA benefits that are: (A) Reduced to $90 for a veteran with no spouse or child and residing in a nursing facility or receiving domiciliary care services furnished by the VA for which the VA makes per diem payments pursuant to 38 U.S.C. §1741 (a) ; (B) For aid and attendance allowance, housebound allowance; and (C) Increased or an extra VA payment resulting from unusual medical expenses. (2) Any payment or relocation assistance received, such as reimbursement or allowances provided to an individual (or spouse) displaced by a State or county- assisted project, under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 1724.1-18
§17-1724.1-39 (42 U.S.C. §4636) including, but not limited to: (A) Moving expenses; (B) Reimbursement for tangible property losses; (C) Expenses for pursuing a business or farm; (D) Displacement allowances; (E) Amounts required to replace a dwelling exceeding the agency's acquisition cost for a prior dwelling; (F) Compensation for increased interest costs, expenses for closing costs, and other debt service costs of replacement dwelling (if encumbered by a mortgage); (G) Rental expenses for displaced tenants; (H) Amounts for down-payments on replacement housing for tenants who decide to buy; (I) Mortgage insurance through Federal programs with waiver of requirements of age, physical condition, personal characteristics that borrowers must meet; and (J) Direct provision of replacement housing (as a last resort) ; (3) Cash payments to the assistance unit responsible for payment of the household bills from a non-unit household member of their share of common household expenses; (4) Per capita payments distributed to or held in trust under 25 U.S.C.: (A) §117b for members of the Hoopa Valley Indian Tribe and the Yurok Indian Tribe; (B) §§459-495(d) for members of the: (i) Bad River Band of Lake Superior Tribe of Chippewa Indians of Wisconsin; (ii) Blackfeet Tribe; (iii) Cherokee Nation of Oklahoma; (iv) Cheyenne River Sioux Tribe; (v) Crow Creek Sioux Tribe; (vi) Lower Brule Sioux Tribe; 1724.1-19
§17-1724.1-39 3 20 b ,Jj (vii) Devils Lake Sioux Tribe; (viii) Fort Belknap Indian Community; (ix) Assiniboine and Sioux Tribes; (x) Lac Courte Oreilles Band of Lake Superior Chippewa Indians; (xi) Keweenaw Bay Indian Community; (xii) Minnesota Chippewa Tribe; (xiii) Navajo Tribe; (xvi) Oglala Sioux Tribe; (xv) Rosebud Sioux Tribe; (xvi) Shoshone-Bannock Tribes; and (xvii) Standing Rock Sioux Tribe; (C) §§609-609c-1 for members of the Confederated Tribes and Bands of the Yakima Indian Nation or the Apache Tribe of the Mescalero Reservation; (D) §§640-640d for members of the Hopi and Navajo Tribes; (E) §§687-689 for members of the Red Lake Band of Chippewa Indians; (F) §882 for members of the Sac and Fox Tribes; (G) §§1261-1265 for members of the Blackfeet and Gros Ventre tribes; (H) §§1401-1407 for members of the Bois Forte Band of Chippewa Indians except for per capita shares in excess of $2,000; (I) §1408 for members of the San Carlos Apache Indian Tribe of Arizona up to $2,000 per year derived from individual interests in trust or restricted lands; (J) §1728(c) for members of the Passamaquoddy Tribe, the Penobscot Nation, or the Houlton Band of Maliseet Indians; (K) §1774f for members of the Seneca Nation; and (L) §§2301-2307 to heirs of certain deceased Indians under §8 of the Old Age Assistance Claims Settlement Act; (5) Payments made to or held in trust for certain Native Americans as follows: (A) San Carlos Apache Indian Tribe of Arizona under §7 of Pub. L. 93-134 and Pub. L. 97-95; 1724.1-20
§17-1724.1-39 (B) Wyandot Tribe of Indians of Oklahoma under §6 of Pub. L. 97-371; (C) Shawnee Tribe of Indians (Absentee Shawnee Tribe of Oklahoma, Eastern Shawnee Tribe of Oklahoma, and the Cherokee Band of Shawnee descendants) under §7 of Pub. L. 97-372; (D) Clallam Tribe of Indians of the State of Washington (Port Gamble Indian Community, Lower Elwha Tribe Community, and the Jamestown Band of Clallam Indians) under §6 of Pub. L. 97-402; (E) Red Lake Band of Chippewa Indians under §3 of Pub. L. 98-123; (F) Saginaw Chippewa Indian Tribe of Michigan under §6 of Pub. L. 99-346; (G) Cow Creek Band of Umpqua Tribe of Indians under §4 of Pub. L. 99-377; (H) Santee Sioux Tribe of Nebraska, the Flandreau Santee Sioux Tribe, the Prairie Island Sioux, Lower Sioux, and Shakopee Mdewakanton Sioux Communities of Minnesota under §8 of Pub. L. 99-130 and §7 of Pub. L. 93-134 as amended by Pub. L. 97-458; (I) Distributions made to a household, an individual Native, or a descendent of a Native by a Native Corporation established in accordance with the Alaska Native Claims Settlement Act (Pub. L. 92-203 as amended) as provided by Pub . L. 100-241, §15 (43 U.S.C. §1626); (J) Assiniboine Tribe of Fort Belknap Indian Community of Montana and the Assiniboine Tribe of the Fort Peck Indian Reservation of Montana under §5 of Pub. L. 98-124; (K) White Earth Band of Chippewa Indians as allottees, or their heirs under §16 of Pub. L. 99-264; 1724.1-21 3206
3 20 6 §17-1724.1-39 1..il.~ (L) Sac and Fox Indian Nation under §6 of Pub. L. 94-189; (M) Grand River Band of Ottawa Indians under §6 of Pub. L. 94-540; (N) Confederated Tribes and Bands of the Yakima Indian Nation or the Apache Tribe of the Mescalero Reservation under §2 of Pub. L. 95-433; (0) Assiniboine Tribe of Fort Belknap Indian Community and the Papago Tribe of Arizona under §6 and §8 of Pub. L. 94-408; (P) Chippewas of Lake Superior and the Chippewas of the Mississippi under §6 of Pub. L. 99-146 or §4 of Pub. L . 99- 377; {Q) Delaware Tribe of Indians and the absentee Delaware Tribe of Western Oklahoma under §8 of Pub. L. 96-318; (R) Miami Tribe of Oklahoma and the Miami Indians of Indiana under §7 of Pub. L. 97-376; (S) Pembina Chippewa Indians (Turtle Mountain Band of Chippewa Indians, Chippewa Cree Tribe of Rocky Boy's Reservation, Minnesota Chippewa Tribe, Little Shell Band of the Chippewa Indians of Montana, and the non-member Pembina descendants) under §9 of Pub. L. 97-403; (T) Confederated Tribes of the Warm Springs Reservation up to $2,000 under §4 of Pub. L. 97-436; (U) Wyandotte Tribe of Oklahoma and the Absentee Wyandottes under §106 of Pub. L. 98-602; (V) Seminole Nation of Oklahoma, the Seminole Tribe of Florida, the Miccosukee Tribe of Indians of Florida and the independent Seminole Indians of Florida under §8 of Pub. L. 101-277; 1724.1-22
§17-1724.1-39 (W) Indian judgment funds under Pub. L. 93- 134, as amended by Pub. L. 97-458 (25 u.s.c. §1407) i (X) Wisconsin Band of Potawatomi (Hannahville Indian Community and Forest County Potawatomi) under §503 of Pub. L. 100-581; (Y) Passamaquoddy Tribe, Penobscott Nation, and the Houlton Band of Maliseet Indians under the Maine Indian Claims Settlement Act under §9 of Pub. L. 96- 420 (25U.S.C. §1728(c)); (Z) Michigan Indian Land Claims Settlement Act under Pub. L. 105-143 and §4 of the Cowlitz Indian Tribe Distribution of Judgment Funds Act under Pub. L. 108- 222; (AA) Shoalwater Bay Indian Tribe under §5 of Pub. L. 98-432; (BB) Coushatta Tribe of Louisiana under §2 of Pub. L. 100-411 and §7 of Pub. L. 93-134 as amended by Pub. L. 97-458 (25 u.s.c. §1407) i (CC) Hoopa Valley Indian Tribe and the Yurok Indian Tribe under § §4, 6 ,· and 7 of Pub. L. 100-580 and §3 of Pub. L. 98- 64; (DD) Red Lake Band of Chippewa Indians from the sale of timber and lumber on the Red Lake Reservation under §3 of Pub. L. 85-794; (EE) Blackfeet and GrosVentre by the Blackfeet and GrosVentre tribal government resulting from judgment funds under §4 of Pub. L. 92-254 and under §6 of Pub. L. 97-408; (FF) Under §102 of the Fallon Paiute Shoshone Indian Tribes Water Rights Settlement Act of 1990 under Pub. L. 101-618 and §7 of Pub. L. 93-134 as 1724.1-23 320 6
}20 6 §17-1724.1-39 amended by Pub. L. 97-458 (25 U.S.C. §4107) i (GG) Seneca Nation of New York under §8(b) of the Seneca Nation Settlement Act of 1990, Pub. L. 101-503 (25 U.S.C. §1774f) i (HH) Pueblo of Santa Ana and distributed to members of that tribe under §6 of Pub. L. 95-498; and the Pueblo of Zia of New Mexico and distributed to members of that tribe under §6 of Pub. L. 95-499; (II) Certain Indian tribes under §6 of Pub. L. 94-114 (25 U.S.C. §459e); (JJ) Hopi and Navajo Tribes under §22 of Pub. L. 93-531 as amended by Pub. L. 96-305; (KK) Puyallup Tribe under §10 of the Puyallup Tribe Indians Settlement Act of 1989, Pub. L. 101-41 (25 U.S.C. §17734 (c)) ; (LL) Catawba Indian Tribe of South Carolina under §ll(m) of Pub. L. 103-116; (MM) Confederated Tribes of the Colville Reservation under §7(b) of Pub. L. 103- 436; (6) Judgment funds distributed per capita to or made available for members of the: (A) Grand River Band of Ottawa Indians; (B) Delaware Tribe of Indians and the absentee Delaware Tribe of Western Oklahoma; (C) Wyandot Tribe of Indians of Oklahoma; (D) Shawnee Tribe of Indians (Absentee Shawnee Tribe of Oklahoma, the Eastern Shawnee Tribe of Oklahoma, and the Cherokee Band of Shawnee descendants) ; (E) Miami Tribe of Oklahoma and the Miami Indians of Indiana; (F) Clallam Tribe of Indians of the State of Washington (Port Gamble Indian Community, Lower Elwha Tribal Community and the Jamestown Band of Clallam Indians) ; 1724.1-24
§17-1724.1-39 (G) Pembina Chippewa Indians (Turtle Mountain Band of Chippewa Indians, Chippewa Cree Tribe of Rocky Boy's Reservation, Minnesota Chippewa Tribe, Little Shell Band of the Chippewa Indians of Montana, and the nonmember Pembina descendants); (H) Assiniboine Tribe of Fort Belknap Indian Community and the Papago Tribe of Arizona under §§6 and S(d) of Pub. L. 97-408; (I) Confederated Tribes of the Warm Springs Reservation up to $2,000 each; (J) Red Lake Band of Chippewa Indians; (K) Assiniboine Tribe of Fort Belknap Indian Community of Montana and the Assiniboine Tribe of the Fort Peck Indian Reservation of Montana or family interest payments; (L) Shoalwater Bay Indian Tribe; (M) Wyandotte Tribe of Oklahoma and the Absentee Wyandottes; (N) Chippewas of Lake Superior and the Chippewas of the Mississippi under §4 of Pub. L. 99-377 or under §6 of Pub. L. 99-146; (0) White Earth Band of Chippewa Indians as allottees, or their heirs; (P) Saginaw Chippewa Indian Tribe of Michigan; (Q} Cow Creek Band of Umpqua Tribe of Louisiana; (R) Wisconsin Band of Potawatomi, Hannahville Indian Community and Forest County Potawatomi; (S) Seminole Nation of Oklahoma, the Seminole Tribe of Florida, the Miccosukee Tribe of Florida and the independent Seminole Indians of Florida; (T) Catawba Indian Tribe of South Carolina; (U) Confederated Tribes of the Colville Reservation; or under the Michigan Indian Land Claims Settlement Act or Cowlitz Indian Tribe Distribution of Judgment Funds Act; (7) Payments made to volunteers under the National and Community Service Trust Act of 1724.1-25 )2_0 6
§17-1724.1-39 ,3 2 0 6 I j 1993 (42 U.S.C. §5044(f)) including the following programs under 42 U.S.C.: (A) Volunteers in Service to America (AmeriCorps VISTA) §§4951-4960; (B) Special Volunteer Programs §§4991-4993; (C) Retired and Senior Volunteer Program (RSVP) §5001; (D) Foster Grandparent Program §5011; and (E) Senior Companion Program §5013; (8) Payments made to volunteers, including the Service Corps of Retired Executives (SCORE) and the Active Corps of Executives (ACE) to provide technical, managerial, and informational aids to small business concerns (15 U.S.C. §637); (9) Foster care maintenance, kinship guardianship, and subsidized adoption payments to licensed caregivers for the provision of care and supervision to eligible children; (10) Housing and Urban Development (HUD) retroactive tax and utility cost subsidy payments issued pursuant to Underwood v. Harris, (Civil No. 76-0469 D.D.C.) against HUD to applicants and recipients of financial assistance shall be disregarded as income in the month received; (11) Supplemental Security Income and State Supplementary Payment benefits of non- institutionalized individuals for whom the post-eligibility treatment of income does not apply; (12) Reparation payments provided to certain individuals of Japanese ancestry and Aleuts for losses suffered as a result of evacuation, relocation, and internment during World War II under the Civil Liberties Act of 1988 and the Aleutian and Pribilof Islands Restitution Act; (13) Effective January 1, 1989, all Agent Orange Settlement payments to include payments from the Agent Orange Settlement Fund or any other fund established pursuant to the settlement of the In re Agent Orange Product Liability Litigation; 1724.1-26
§17-1724.1-39 (14) Effective August 1, 1994, payments made to victims of Nazi persecution under the Victims of Nazi Persecution Act; (15) Payments received under the Radiation Exposure Compensation Trust Fund established under the Radiation Exposure Compensation Act (RECA) to compensate an individual for injuries or death resulting from the exposure to radiation from nuclear testing or uranium mining under the National Defense Authorization Act for Fiscal Year 1991 and the Radiation Exposure Compensation Act Amendments of 2000 and succeeding amendments; (16) Assistance payments received under the Robert T. Stafford Disaster Relief and Emergency Assistance Act or under any Federal statute as a result of a catastrophe which is declared by the President of the United States, state or local government agency or disaster assistance organizations; (17) Crime Victim Compensation payments issued pursuant to the Victims of Crime Act of 1984 to victims of certain crimes or dependents of deceased victims include, but are not limited to, compensation ,paid by Hawaii's Crime Victim Compensation Commission; (18) Payments received from any fund as a result of the settlement in the case of Susan Walker v. Bayer Corporation, et al., to compensate an individual who contracted the human immunodeficiency virus (H.I.V.) from .contaminated blood products pursuant to Title IV, section 4735 of the Balanced Budget Act of 1997 (Pub. L. 105-33); (19) Payments received from the Ricky Ray Hemophilia Relief Fund Act of 1998 under Pub. L. 105-369 to compensate an individual with a hemophilia-clotting disorder who was treated with blood-clotting agents and contracted the H.I . V.; (20) VA benefits received by or on behalf of certain natural children of: (A) Vietnam veterans and Korean service veterans born with spina bifida under §421 of Pub. L. 104-204 and §102 of Pub. L. 108-183, respectively; and 1724.1-27 3206
3206 §17-1724.1-39 (B) Women Vietnam veterans born with certain birth defects that results in permanent physical or mental disability under §401 of Pub. L. 106-419; (21) Payments made to certain individuals under: (A) §606 of Pub. L. 105-78 who were captured and interned by North Vietnam; or (B) §657(d) (2) of Pub. L. 104-201 who were captured and incarcerated by the Democratic Republic of Vietnam after entering Vietnam under OPLAN 34A, or Laos under OPLAN 35, pursuant to certain Vietnamese commando operations; (22) State annuities paid to a certain individual or the individual's spouse on the basis that the individual is an aged, blind, or disabled veteran under §202 of P.L. 110-245; (23) Payment issued to eligible Filipino veterans who aided American troops during World War II that were established by the Filipino Veterans Equity Compensation Fund (FVECF) under the American Recovery and Reinvestment Act of 2009. Filipino veterans who are U.S. citizens are entitled to a one-time payment of $15,000 while non-U.S. citizen veterans are entitled to a one-time payment of $9,000. Surviving widows of Filipino veterans who filed for the FVECF payments prior to the Filipino veteran's death may also receive these payments on their spouse's behalf; and (24) Austrian social insurance payments granted exclusively under paragraphs 500 to 506 of the Austrian General Social Insurance Act; (b) The following unearned incomes are not considered when determining countable income in the post-eligibility process: (1) Restitution payments made under Pub. L. 100- 383 for the evacuation, relocation, and internment to an eligible Japanese-American citizen or permanent resident non-citizen of Japanese ancestry under §105 of the Civil Liberties Act of 1988 and to an eligible 1724.1-28
§17-1724.1-39 Aleut under §206 of the Aleutian and Pribilof Islands Restitution Act; (2) Reparation payments made under Pub. L. 103- 286 by the Netherlands' Act on Benefits for Victims of Persecution 1940-1945, to a persecuted victim during the Nazi occupation of the Netherlands and the Dutch East Indies during World War II; (3) Payments made under Pub. L. 101-239 from the Agent Orange Settlement Fund or any other fund established pursuant to the settlement in the In re Agent Orange Product Liability Litigation, M.D.L. No. 381 (E.D.N.Y.); and (4) Compensation payments made under Pub. L. 101-239 from the Radiation Exposure Compensation Trust Fund to an individual exposed to radiation during nuclear testing from 1944 to 1972 or exposed to radon while employed in uranium mines or mills from 1942 to 1971, and to atomic veterans who contracted specified cancers and other specified diseases as a direct result of exposure. The Radiation Exposure Compensation Act expanded benefits also to an on-site participant in atmospheric nuclear tests. [Eff 09/30/13; am and comp NOV102016 ] (Auth: HRS §§346-14, 346-29; 20 C.F.R. §§416.1103, 416.1121, 416.112l(a), 416.1124; 42 C.F.R. §§430.25, 435.601, 435.631, 435.726, 435.733, 435.735, 435.831, 435.832; 45 C.F.R. §233.20; 8 u.s.c. §§1631, 1632; 38 u.s.c. §5503; 42 U.S.C. §§1396r-5; Pub. L. No. 97-248; Pub. L . No . 1 0 8 - 2 0 3 ) ( I mp : HRS § 3 4 6 - 2 9 ; 2 0 C.F.R. §§416.1103, 416.1121, 416.112l(a), 416.1124; 42 C.F.R. §§430.25, 435.601, 435.631, 435.726, 435.733, 435.735, 435.831, 435.832; 45 C.F.R. §233.20; 8 U.S.C. §§1631, 1632; 38 U.S.C. §5503; 42 U.S.C. §§1396r-5; Pub. L. No. 97-248; Pub. L. No. 108-203) §§17-1724.1-40 to 17-1724.1-44 (Reserved) . SUBCHAPTER 6 1724.1-29 3206
§17-1724.1-45 INCOME DISREGARDS §17-1724.1-45 Purpose. This subchapter describes the types of income that are disregarded when determining income eligibility of a MAGI-excepted individual. [Eff 09/30/13, am and comp NOV 10 2016 (Auth: HRS §346-14; 42 C.F.R. §§435.601, 435.631) (Imp: HRS §346-14; 42 C.F.R. §§435.601, 435.631) §17-1724.1-46 Income disregarded for a MAGI- excepted individual or household. The following shall be disregarded when determining income eligibility for a MAGI-excepted individual or household: 3 20 6 .... (1) The value of supplemental nutrition assistance benefits issued under the Food and Nutritional Act of 2008 (7 U.S.C. §§2011-2027); (2) The value of the U.S. Department of Agriculture donated foods (surplus commodities) ; (3) Any grant or loan to any undergraduate or graduate student made or insured under programs administered by the U.S. Secretary of Education, Title IV of the Higher Education Act, the Carl D. Perkins Career and Technical Education Improvement Act of 2006 (20 U.S.C. §§2301-2324), or the Bureau of Indian Affairs student assistance programs including, but not limited to: (A) Pell Grants; (B) Federal Supplemental Educational Opportunity Grant (FSEOG); (C) National Direct Student Loans (NDSL) ; (D) Guaranteed Student Loans (GSL) ; (E) Hawaii Student Incentive Grant (HSIG); (F) College Work Study (CWS) Program; (G) Academic Achievement Incentive Scholarships; {H) Byrd Scholars; (I) Federal Educational Loans (Federal PLUS Loans, Ford Loans, Perkins Loans, Stafford Loans, etc.); 1724.1-30
§17-1724.1-46 (J) Gaining Early Awareness and Readiness for Undergraduate Programs (GEAR UP) ; (K) Leveraging Educational Assistance Partnership (LEAP) ; (L) Special Leveraging Educational Assistance Partnership (SLEAP) ; (M) State Student Incentives; and (N) Upward Bound; (4) Any educational grant, fellowship, or scholarship from sources other than those listed in paragraph (3) that is obtained or used under conditions that preclude their use for current living expenses; (5) Tax exempt portions of payments made pursuant to the Alaska Native Claims Settlement Act (43 U.S.C. §1626(c)); (6) Any energy assistance received under the Low Income Home Energy Assistance Act of 1981 (42 u.s.c. §§8621-8629) i (7) Food which is raised, produced, or procured by members of the household through their own efforts; (8) The value of medical insurance, employer's share of contributions to a pension fund, and employer's share of social security contributions; (9) Amount of Social Security benefits being recovered due to an overpayment that occurred when an individual was receiving Medicaid; (10) Bona fide loans from any source including but not limited to educational loans, when defined as a debt that the borrower has an obligation to repay; (11) Any gift to, or for the benefit of, an individual who has not attained eighteen years of age and who has a life-threatening condition, from an organization described under §501 ( c) ( 3) of the Code; (12) Receipts derived from lands held in trust and distributed to members of: (A) Certain Indian tribes under 25 U.S.C. §459e; (B) The Pueblo of Santa Ana under §6 of Pub. L. 95-498; and {C) The Pueblo of Zia of New Mexico under §6 of Pub. L. 95-499; 1724.1-31 320 6
320 6 §17-1724.1-46 (13) The value of meals provided to a senior citizen, such as congregate meals, or home delivered meals funded by the Older American Act of 1965 (42 u.s.c. §§2001-3057); (14) Amount of RSDI cost of living allowance for recipients who lose SS! benefits for any ( 15) ( 16) ( 1 7) (18) ( 19) reason; The increase in RSDI disability benefits for a widow and widower age 60 to 64 resulting in the loss of SSI/SSP benefits due to mandatory receipt of widow's or widower's RSDI disability benefits; The amount of RSDI cost of living allowance for recipients resulting in the loss of SSI/SSP benefits as a result of RSDI cost of living increases received after April 1977 as required by §503 of Pub. L. 94-566 (also known as the "Pickle Amendment"); The amount of RSDI increase for a disabled widow's or widower's benefits due to the elimination of the additional reduction factor (ARF) required by Pub. L. 98-21, §134 (42 U.S.C. §1383c(b)), resulting in the loss of SSI/SSP benefits were it not for the amount of that increase and subsequent cost of living adjustments; Amount withheld from unemployment insurance benefit payments to recover overpayments or to pay child support obligations; Assistance provided by any public or private agency or organization if no duplication exists between such other assistance and that provided by the department. Non- duplication of assistance shall be assured by: (A) The different purpose for which the other agency grants aid such as vocational rehabilitation; or (B) The provision of goods and services that are not included in the department's standard of assistance; and (20) The income of the sponsor of a non-citizen and the sponsor's spouse when determining eligibility of a non-citizen when an affidavit of support was executed before December 19, 1997. [Eff 09/30/13; am and 1724.1-32
§17-1724.1-54 comp NOV102016] (Auth: HRS §346-14; 20 C.F.R. §416.1124; 42 C.F.R. §§430.25; 431.10, 435.121, 435.135, 435.137, 435.138; 8 U.S.C. §§1631, 1632; Pub. L. No. 108-203) (Imp: HRS §346-14; 20 C.F.R. §416.1124; 42 C.F.R. §§430.25; 431.10, 435.121, 435.135, 435.137, 435.138; 8 u.s.c. §§1631, 1632; Pub. L. No. 108-203) §§17-1724.1-47 to 17-1724.1-51 (Reserved) . SUBCHAPTER 7 DETERMINATION OF FINANCIAL ELIGIBILITY §17-1724.1-52 Purpose. This subchapter describes how financial eligibility is determined for a MAGI-excepted individual. [Eff 09/30/13; am and comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.601, 435.631) (Imp: HRS §346-14; 42 C.F.R. §§435.601, 435.631) §17-1724.1-53 Rounding of income. There are no provisions for the rounding of income to a whole dollar amount when determining eligibility for a MAGI- excepted individual or household except as described in paragraph 17-1724.1-56(8) and subsection 17-1724.l- 63(c). [Eff 09/30/13; am and comp NOV102016 ] (Auth: HRS §346-14) (Imp: HRS §346-14) §17-1724.1-54 General eligibility provisions. (a) Determination of financial eligibility for a MAGI-excepted individual shall be based upon the income standards established by the department. (b) Medical assistance shall be provided to a MAGI-excepted individual whose income: (1) Is equal to or less than the medical assistance standards of the applicable coverage group under chapter 17-1719; or (2) Exceeds the applicable standard of assistance in chapter 17-1719, but meets the applicable medically needy standard of assistance based on household size after the 1724.1-33 320 6
1}20 6 §17-1724.1-54 deduction of incurr.ed medical expenses under chapter 17-1730.1. (c) Medically needy individuals disenrolled from a health plan for being two months in arrears of the payment of their enrollment fee are excluded from coverage under this chapter until their arrearage responsibility is met. [Eff 09/30/13; am and comp NOV 1O2016 ] (Auth: HRS §346-14; 42 C.F.R. §§431.10, 435.811, 435.814, 435.831) (Imp: HRS §346- 53 (e); 42 C.F.R. §§435.811, 435.814, 435.831) §17-1724.1-55 Determining monthly income. (a) The determination of monthly income and household size is dependent on the period for which assistance is being requested and the circumstances involved. (1) The following methods shall be used when determining current income: (A) For a month prior to the current month, the actual income received within that month shall be considered income for that month. (B) For the current month, income already received and any income anticipated to be received within the current month, shall be considered income for that month. (2) The following methods shall be used when determining future income: (A) To account for future changes in income that can be reasonably anticipated, projected income shall be calculated by one of the following methods: (i) Current weekly income multiplied by 4.3333 to convert to monthly income; (ii) Current bi-weekly income multiplied by 2.1667 to convert to monthly income; (iii) When no significant fluctuation is anticipated, the income received in the month immediately prior to the current month can be used for the projection; or (iv) If there has been fluctuation, an average of the three months income immediately preceding the current month may be utilized. 1724.1-34
§17-1724.1-55 (B) Actual changes in income and circumstances, as required to be reported by the household, including deviations from reasonably anticipated fluctuations in income, shall be acted upon by the department. (b) The department shall determine the current and future household monthly income or the projected annual household income and household size for an applicant or beneficiary. The department shall adopt a reasonable percentage for an increase or decrease in income, and take into account verifying financial information with the Income Eligibility Verification System (IEVS) data and whether the IEVS income causes the total combined countable household income (IEVS income plus all previously reported income) to be above or below the medical assistance standard for the appropriate household size as described in chapter 17- 1714.1: (1) The department shall continue to use the self-attested income amount when: (A) The IEVS income amount is below or at ten per cent of the self-attested income amount, even if the total combined countable household's income exceeds the medical assistance income standard for the applicable household size; or (B) The IEVS income is above ten percent of the self-attested amount but the total combined countable household's income remains at or below the medical assistance standard; or (2) The department shall request for additional information from the household when the IEVS income differs more than ten per cent of the self-attested income amount. A change in the total combined countable household income requires the household to be redetermined under the appropriate category and medical assistance standard for the applicable household size. The department 1724.1-35 3206
1}20 6 §17-1724.1-55 shall redetermine household's eligibility based on the verified income amount; unless a reasonable explanation, and if necessary, appropriate documentation, are provided. (c) Availability of income of household members, shall be determined in accordance with section 17- 1724 .1-16. [Eff 09/30/13, am and comp NOV 1 O 2016 (Auth: HRS §346-14; 42 C.F.R. §§435.601, 435.602, 435.631, 435.952) (Imp: HRS §346-14; 42 C.F.R. §§435.601, 435.602, 435.631, 435.952) §17-1724.1-56 Determining monthly net income. Monthly net income used in determining eligibility for a MAGI-excepted individual or household shall be determined in the following order: (1) Determine unearned income according to subchapter 5; (2) Determine earned income according to subchapter 4; (3) Deduct $20, first from unearned income and any remainder from earned income; (4) If employed and aged, blind, or disabled, deduct $65 from the gross earned income; (5) Exclude impairment-related work expenses (!RWE) from the earned income of a disabled, but not blind, indiviqual who is under age sixty-five years or who received SS! disability benefits prior to attaining age sixty-five years, if the items or services are required to enable a disabled individual to work. The !RWE must be: (A) Paid in the same month of the earned income in which the services were received or item used; (B) Reasonable in cost, paid by the disabled individual, and is not reimbursable from another source; and (C) Necessary and not covered by Medicare or Medicaid include, but are not limited to, the costs of: ( i) Attendant care services; (ii) Drugs and medical devices; (iii) Expendable medical supplies; (iv) Guide dog; (v) Durable medical equipment; 1724.1-36
§17-1724.1-56 (vi) Other work-related items and services; (vii) Physical therapy; (viii) Prosthetic and orthotic appliances; (ix) Structural modifications to the individual's home to · create a work space or to allow the individual to get to and from work; (x) Training to use an impairment related item attributable to work; (xi) Transportation to and from work; and (xii) Vehicle modification; (6) Exclude blind work expenses (BWE) in any amount attributable to employment paid by a blind individual who is under age sixty-five years or who received SS! benefits due to blindness prior to attaining age sixty-five years. The amount of expenses excluded shall not exceed the earnings of the blind recipient for the month. The BWE shall be excluded in addition to expenses excluded as an !RWE and are related to: (A) Federal, state and local income taxes and Social Security and Medicare taxes; (B) Licenses, professional association or union dues; (C) Mandatory pension contributions attributable to earning income; and (D) Actual value of meals consumed during work hours; (7) If employed and age sixty-five years or older, blind or disabled, deduct one-half of the remainder of the earned income; (8) Any income remaining shall be rounded down to the whole dollar and countable as the monthly net income; and (9) If blind or disabled, exclude any remaining income if needed to fulfill a plan to achieve self support (PASS) . The PASS must be approved by Social Security Administration or approved by the Med-QUEST Division if developed by the department's vocational rehabilitation services. [Eff 09/30/13, am and comp NOV 1 0 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§431.10, 435.601, 1724.1-37 3206
§17-1724.1-62 435.631, 435.831) (Imp: HRS §346-14; 42 C.F.R. §§431.10, 435.601, 435.631, 435.831) §§17-1724.1-57 to 17~1724.1-61 (Reserved) . SUBCHAPTER 8 FINANCIAL ELIGIBILITY AND LIABILITY OF MAGI-EXCEPTED INDIVIDUALS RECEIVING LONG-TERM CARE SERVICES §17-1724.1-62 Purpose. This subchapter describes the methodology used to determine the cost share of a MAGI-excepted individual requesting coverage of long-term care services. [Eff 09/30/13, am and comp tmv 1 O 2015 J (Au th: HRS §346-14; 42 C.F.R. §§435.733, 435.735, 435.831, 435.832) (Imp: HRS §346-14; 42 C.F.R. §§435.733, 435.735, 435.831, 435.832) §17-1724.1-63 Post-eligibility treatment of income fqr a MAGI-excepted individual meeting institutional level of care and receiving long-term care services. (a) A MAGI-excepted individual meeting institutional level of care and determined eligible to receive long-term care services shall have countable income applied toward the cost share of long-term care and other medical care costs when the individual is: (1) Residing in a nursing facility or a medical facility; or (2) Medically needy and residing in the community receiving home and community based services {under 42 C.F.R. §435.217). (b) The cost share for an individual described in subsection (a) is determined by deducting the following from the individual's countable income: 3 2-0 6 114 (1) A personal needs allowance of: {A) $50 for an individual residing in a nursing facility or medical facility; 1724.1-38
§17-1724.1-63 (B) One hundred percent of the FPL for a household of one for an individual residing in their home in the community; or (C) The medically needy standard of assistance for a household of one for an individual residing in a community care foster family home or extended adult residential care home. (2) Amounts for the maintenance needs of the community spouse and dependent family member(s) of the individual meeting institutionalized level of care and receiving long term care services shall be deducted from the individual's income as follows: (A) The contribution from the individual to the community spouse shall not exceed the difference between the maximum monthly maintenance needs allowance and the gross monthly income of the community spouse. The maximum maintenance needs allowance for the community spouse is defined by federal statutes or regulations and is subject to increases by means of indexing or court order; (B) The dependent allowance for each dependent family member residing with the community spouse, shall be equal to one third the amount of the spousal allowance in subparagraph (A) which exceeds the gross monthly income of that family member; or (C) The family allowance for any or all dependent family members residing in the home of the institutionalized individual without the community spouse, shall be equal to ~he medically needy standard of assistance for a household of equal size minus the total 1724.1-39 3206
)20 6 §17-1724.1-63 monthly gross income of all dependent family members. (3) Any incurred medical expenses deducted from excess income pursuant to chapter 17-1730.1, that are not covered by the medical assistance program, excluding any unpaid portion of long-term care costs that were not payable by medical assistance during a penalty period for the transfer of assets for less than fair market value that was established under the provisions of chapter 1725.1. (c) Any income remaining, which shall be rounded down to the whole dollar following the procedures of subsection (b) , represents the amount of the individual's cost share. [Eff 09/30/13; am and comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.217, 435.726, 435.733, 435.735, 435.831, 435.832; 42 U.S.C. §§1315, 1396a(r), 1396r-5) (Imp: 42 C.F.R. §§435.217, 435.726, 435.733, 435.735, 435.831, 435.832; 42 U.S.C. §§1315, 1396a(r), 1396r-5) §§17-1724.1-64 to 17-1724.1-68 (Reserved) . 1724.1-40
HAWAII ADMINISTRATIVE RULES TITLE 17 DEPARTMENT OF HUMAN SERVICES SUBTITLE 12 MED-QUEST DIVISION CHAPTER 1724.2 MODIFIED ADJUSTED GROSS INCOME (MAGI) BASED INCOME METHODOLOGY Subchapter 1 §17-1724.2-1 §17-1724.2-2 \ §17-1724.2-3 §17-1724.2-4 §17-1724.2-4.1 §17-1724.2-5 §§17-1724.2-6 to Subchapter 2 General Provisions Purpose Repealed Special provisions for eligibility renewals MAGI-based income determination Income of the sponsor of a non- ci tizen Repealed 17-1724.2-10 (Reserved) Household Composition Purpose General requirements MAGI-related households §17-1724.2-11 §17-1724.2-12 §17-1724.2-13 §§17-1724.2-14 to 17-1724.2-18 (Reserved) Subchapter 3 Budget Periods §17-1724.2-19 Purpose §17-1724.2-20 Budget periods §§17-1724.2-21 to 17-1724.2-25 (Reserved) SUBCHAPTER 1 GENERAL PROVISIONS 1724.2-1 320 6
§17-1724 . 2-1 §17-1724.2-1 Purpose. This chapter describes the modified adjusted gross income (MAGI) based income methodology. MAGI-based income methodology, established by the Affordable Care Act, is used to determine financial eligibility for individuals described in chapters 17-1715 (Children Group), 17- 1716 (Pregnant Women Group), 17-1717 (Parents and Other Caretaker Relatives Group), and 17-1718 (Adults Group), collectively referred to as "MAGI groups." MAGI-based income methodology incorporates a household's composition, size, and the treatment of certain types of income. These conditions are generally based on information from the previous tax year, whether the household expects to file a tax return for the taxable year in which medical assistance is sought, and any expected change in circumstAp~e. l~ff 09/30/13; am and comp NUV 10 2016] (Auth: HRS §346-14; 42 C.F.R. §§435.4, 435.601, 435.603; 26 C.F.R. §1.36B) (Imp: HRS §346-14; 42 C.F.R. §§435.4, 435.601, 435.603; 26 C.F.R. §l.36B) §17-1724.2-2 REPEALED. [R NOV 1 0 2016 1 §17-1724.2-3 Special provisions for eligibility renewals. (a) Individuals who were beneficiaries prior to October 1, 2013, and were transferred to a MAGI group shall not have eligibility re-determined under the MAGI-based income methodology until March 31, 2014, or at the next scheduled re-determination of eligibility, whichever is later. (b) Individuals eligible under a MAGI group whose eligibility renewal would have occurred from October 1, 2013 through March 31, 2014 shall have their eligibility period extended by six months. [Eff 09/30/13; am and comp NOV 1O2016 ] (Auth: HRS §346-14; 26 C.F.R §1.36B; 42 C.F.R. §§435.4, 435.601, 435.602, 435.603) (Imp: HRS §346-14; 26 C.F.R. §l.36B; 42 C.F.R. §§435.4, 435.601, 435.602, 435.603) §17-1724.2-4 MAGI-based income determination. (a) MAGI-based income shall be calculated using the same methodology used to determine the modified 1724.2-2 3206 ' 1
§17-1724.2-4 adjusted gross income as defined in 26 C.F.R. §1.36B- 1 (e) (2). The Internal Revenue Service (IRS) Form 1040 is used as a guide to identify taxable income. (1) Income included in the MAGI-based determination includes the following: (A) Wages, salaries, tips, etc.; (B) Taxable interest; (C) Tax-exempt interest; (D) Ordinary dividends; (E) Qualified dividends; (F) Taxable refunds, credits, or offsets of state and local income taxes; (G) Alimony received; (H) Business income or (loss) ; (I) Capital gain or (loss); (J) Other gains or (losses); (K) Taxable amount of IRA distributions; (L) Taxable amount of pensions and annuities; (M) Rental real estate, royalties, partnerships, S corporations, trusts, etc.; (N) Farm income or (loss) ; (0) Unemployment compensation; (P) Taxable amount of social security benefits; and {Q) Other income. (2) Income excluded from the MAGI-based determination includes the following: (A) Child support; (B) Worker's compensation; (C) Veteran's benefits; and (D) Depreciation of business expenses. (3) Deductions allowed for the MAGI-based determination include the following: (A) Educator expenses; (B) Certain business expenses of reservists, performing artists, and fee-basis government officials; (C) Health savings account deduction; (D) Moving expenses; (E) Deductible part of self-employment tax; (F) Self-employed SEP (simplified employee pension), SIMPLE (savings incentive match plan for employees), and qualified plans; 1724.2-3 0206
§17-1724.2-4 (G) Self-employed health insurance deduction; (H) Penalty on early withdrawal of savings; (I) Alimony paid; (J) IRA (individual retirement account) deduction; (K) Student loan interest deduction; (L) Tuition and fees; and (M) Domestic production activities deduction. (b) The following are exceptions to the determination of MAGI-based income: 3206 ., . (1) Lump sum amounts shall be counted only in the month received; (2) Scholarships, awards, or fellowship grants used for educational purposes (not for living expenses) shall be excluded; (3) Certain American Indian/Alaska Native income as defined in 42 C.F.R. §435.603 shall be excluded: (A) Distributions from Alaska Native Corporations and Settlement Trusts; (B) Distributions from any property held in trust that are subject to Federal restrictions and located within the most recent boundaries of a prior Federal reservation or otherwise under the supervision of the Secretary of the Interior; (C) Distributions and payments from rents, leases, rights of way, royalties, usage rights, or natural resource extraction and harvest from: (i) Rights of ownership or possession in any lands described in subparagraph (B) ; or (ii) Federally protected rights regarding off-reservation hunting, fishing, gathering, or usage of natural resources; (D) Distributions resulting from real property ownership interests related to natural resources and improvements: (i) Located on or near a reservation or within the most recent boundaries of a prior Federal reservation; 1724.2-4
§17-1724.2-4 (ii) Resulting from the exercise of federally-protected rights relating to such real property ownership interests; (E) Payments resulting from ownership interests in or usage rights to items that have unique religious, spiritual, traditional, or cultural significance or rights that support subsistence or a traditional lifestyle according to applicable Tribal Law or custom; and (F) Student financial assistance provided under the Bureau of Indian Affairs education program. (c) After applying subsections (a) and (b), as applicable, add the following to arrive at the MAGI- based income: (1) Foreign income excluded from gross income under §911 of the Code; (2) Tax-exempt interest; and (3) Tax-exempt social security income. (d) The household income is the sum of the MAGI- based income, as determined under this section, of all individuals included in the applicant's or beneficiary's household, except for the income of: (1) An individual included in his or her natural or biological, adopted, or step parent's household who is not expected to be required to file a tax return for income not exceeding the taxable year's filing threshold, regardless of whether or not the individual files a tax return; (2) A tax dependent other than a spouse or natural or biological, adopted, or step child who is not expected to be required to file a tax return for income not exceeding the taxable year's filing threshold, regardless of whether or not the tax dependent files a tax return. When §17- 1724. 2-13 (b) (2) is applied, such tax dependent shall be considered for eligibility as a separate household. The income of such tax dependent, who is described in §1 7-1724.2-13 (b) (2) , is counted in its entirety when determining the tax dependent's own eligibility. [Eff 09/30/13; am and comp NOV I 0 2016 ] (Auth: HRS §346-14; 26 C.F.R. §l.36B; 42 C.F.R. 1724.2-5 320 6
§17-1724.2-4.1 §§435.4, 435.601, 435.602, 435.603) (Imp: HRS §346-14; 26 C.F.R . §1.36B; 42 C.F.R. §§435.4, 435.601, 435.602, 435.603) §17-1724.2-4.1 Income of the sponsor of a non- citizen. (a) The sponsor of a non-citizen who executed an affidavit of support pursuant to section 213A of the Immigration and Nationality Act (INA) on or after December 19, 1997, shall have their income and their spouse's income deemed as available to a non-citizen requesting medical assistance. For the purposes of this section: (1) "Sponsor" means an individual who is either required to execute or has executed an affidavit of support. (2) "Affidavit of support" means a document that an individual completes and signs to accept financial responsibility for another person, who may be, but is not required to be, a relative who is coming to the United States to live permanently. The person who completes and signs the affidavit of support becomes the sponsor of the relative (or other individual) coming to live in the United States. (b) The income of a non-citizen's sponsor and the sponsor's spouse shall be deemed available to the non-citizen until such time as the non-citizen: 1320 6 1 I (1) Achieves United States citizenship through naturalization pursuant to chapter 2 of Title III of the INA; or (2) Has worked forty qualifying quarters of coverage as defined under Title II of the Social Security Act or can be credited with such qualifying quarters as provided under 8 U.S.C. §1645. In the case of any such qualifying quarter beginning after December 31, 1996, the non-citizen must not have received any Federal means-tested public benefit during any such period. 1724.2-6
§17-1724.2-4.l (c) The non-citizen's failure to provide information and verification regarding the income of their sponsor and the sponsor's spouse, as applicable, shall disqualify the non-citizen from receiving medical assistance. (d) The income of a non-citizen's sponsor and the sponsor's spouse shall not be deemed available to a non-citizen for coverage of emergency medical assistance as described in chapter 17-1723.1. (e) Special provisions in the case of an indigent non-citizen. The deeming of income in subsection (a) shall not be applicable for a twelve- month period from the date a non-citizen is determined to be indigent as defined in this subsection. (1) The department may determine a non-citizen to be indigent when the non-citizen is unable to obtain food and shelter because the non-citizen's own income plus any cash, food, housing, or other assistance provided by other individuals, including the sponsor and the sponsor's spouse, does not exceed one hundred thirty-three per cent of the federal poverty level for the non-citizen's applicable household size; (2) The department will only consider the actual amount of income contributed by the sponsor and the sponsor's spouse for a twelve-month period, which begins on the date of such determination of indigent status and ends twelve months after such date; (3) Each period of indigence is renewable for additional twelve month periods; and (4) The department must notify the federal Attorney General of each such determination, including the names of the sponsor and the sponsored non-citizen involved. (f) Special provisions in the case of a non- citizen battered spouse or child. Deeming of income of the sponsor and the sponsor's spouse described in subsection (a) shall not apply for a twelve-month period if the non-citizen who was subjected to the 1724.2-7
§17-1724.2-4.1 battery or cruelty is not residing in the same residence of the batterer. 320 6 iii (1) This provision applies to: (A) A non-citizen who was battered or subjected to extreme cruelty in the U.S. by a spouse or parent, or by a member of the spouse's or parent's family residing in the same residence as the non-citizen and the spouse or parent consented or acquiesced to such battery or cruelty; (B) A npn-citizen whose child was battered or subjected to extreme cruelty in the U.S. by the non-citizen's spouse or parent, or by a member of the spouse's or parent's family residing in the same residence as the non-citizen and the non-citizen did not actively participate in the battery or cruelty, and the . spouse or parent consented or acquiesced to such battery or cruelty; or (C) A non-citizen child who was residing with a parent who was battered or subjected to extreme cruelty in the U.S. by the parent's spouse or by a member of the spouse's family residing in the same residence as the parent and non-citizen child and the spouse consented or acquiesced to such battery or cruelty. (2) The battery or cruelty must be substantially connected to the need for public benefits which means that without the support of the batterer, the non-citizen is unable to obtain food and shelter because the non- citizen' s own income plus any cash, food, housing, or assistance provided by other individuals including the sponsor, does not exceed one hundred thirty-three per cent of the poverty income level for the non- ci tizen' s applicable household size. 1724.2-8
§17-1724.2-4.1 (3) After the twelve-month period ends, the department shall continue to exempt the batterer's income when the battery or cruelty is recognized in an order of a judge or administrative law judge or a prior determination of the users, and the department determines that such battery or cruelty still has a substantial connection to the need for benefits. (g) The deeming of income provisions in subsection (a) shall not apply to a lawfully present non-citizen who is a child under age nineteen years or who is a pregnant woman. (h) The deemed income of the non-citizen's sponsor and the sponsor's spouse shall be determined in the following manner for each non-citizen's sponsor: ( 1) Count the MAGI-based income of the sponsor and his or her spouse (if living together); (2) Deduct one hundred thirty-three per cent of the federal poverty level for the sponsor's applicable household size which includes the sponsor, sponsor's spouse (if living together) and their dependents; (3) Deem any remaining balance as income to the ( 4) sponsored non-citizen; and If a sponsor sponsored more than one non- citizen, the income deemed available shall be prorated amongst the number of non- ci ti zens sponsored by that sponsor. The income of a sponsor and sponsor's spouse (if living together) I who expects to claim a sponsored non-citizen as a tax dependent, shall be counted as either income deemed available according to paragraphs (1) through (4), or part of the household's MAGI-based income. (i) If income deemed available for a sponsored non-citizen results in ineligibility for his or her household, redetermine the non-sponsored household member's eligibility in the following manner 1724.2-9
3 20 6 §17-1724.2-4.1 (1) Keep the household size the same and if applicable, continue to apply MAGI-based methodology; and (2) Do not count the income deemed available toward the non-sponsored ho~~~hqld member (s). [Eff and comp NUV 1 0 2016 (Auth: HRS §346-53; 8 C.F.R. §§213a.l, 213a.2; 42 C.F.R. §435.406; 8 U.S.C. §§1631, 16 3 2 , 16 4 5 ) ( I mp : HRS § 3 4 6 - 2 9 ; 8 C . F . R . §§213a.l, 213a.2; 42 C.F.R. §435.406; 8 u.s.c. §§1631, 1641, 1645) §17-1724. 2-5 REPEALED [R NOV I 0 2016 ] §§17-1724.2-6 to 17-1724.2-10 (Reserved) . SUBCHAPTER 2 HOUSEHOLD COMPOSITION §17-1724.2-11 Purpose. This subchapter identifies and describes the composition of a household for a MAGI-based income determination. [Eff 09/30/13; am and comp NOV 1 0 2016 ] (Auth: HRS §346-14; 42 C.F.R. §435.603) (Imp: HRS §346-14; 42 C.F.R. §435.~03) §17-1724.2-12 General requirements. The MAGI related household is generally based on the tax household concept, that incorporates tax filing status and relationships, with certain exceptions. The household generally consists of the tax filer including married tax filers filing jointly or separately if living together, and all individuals who are expected to be claimed as tax dependents for the taxable year in which medical ~~sistance is sought. [Eff 09/30/13; am and comp UV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.4, 435.601, 435.602, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§435.4, 435.601, 435.602, 435.603) 1724 . 2-10 .1 i
§17-1724.2-13 §17-1724.2-13 MAGI-related households. (a) The MAGI-related household as described in 42 C.F.R. §435.603 consists of the following individuals: (1) Tax filer who: (A) Expects to file a tax return for the taxable year in which medical assistance is sought; and (B) Does not expect to be claimed as a tax dependent by another tax filer; (2) Tax dependent who expects to be claimed as a tax dependent by the tax filer for the taxable year in which medical assistance is sought, except that subparagraph (b) (2) shall apply to the following tax dependents: (A) Individuals other than a spouse or a natural or biological, adopted, or step child who expect to be claimed as a tax dependent by the tax filer; (B) Individuals under age nineteen years who expect to be claimed by one parent as a tax dependent and are living with both parents, but whose parents do not expect to file a joint tax return; and (C) Individuals under age nineteen years who expect to be claimed as a tax dependent by a non-custodial parent. For purposes of this subparagraph, custody is determined by: (i) A court order or binding separation, divorce or custody agreement establishing physical custody; or (ii) If there is no such order or agreement or in the event of a shared custody agreement, the custodial parent is the parent with whom the child spends most nights; (3) Non-tax filer who does not expect to: (A) File a tax return for the taxable year in which medical assistance is sought; and (B) Be claimed as a tax dependent for the taxable year in which medical assistance is sought. (b) The household size used for initial determination or re-determination of eligibility for medical assistance for: 1724.2-11 3206
§17-1724.2-13 320 6 .iJ (1) A tax filer, shall consist of the tax filer, who meets the requirements of subsection ( a) ( 1 ) , and : (A) The tax filer's spouse if filing jointly or filing separately, but living together; and (B) All individuals whom the tax filer expects to claim as a tax dependent. A tax dependent, who meets the requirements of subsection (a) (2), may be related or unrelated to the tax filer. (C) When the tax filer cannot reasonably establish that an individual is a tax dependent of the tax filer for the taxable year in which medical assistance is sought, the inclusion of the individual shall be determined in accordance with paragraph (2). (2) The household of an individual who does not expect to file a tax return or does not expect to be claimed as a tax dependent for the taxable year in which medical assistance is sought, referred to as a non-tax filer, shall consist of the non-tax filer and, if residing with the non-tax filer: (A) The non-tax filer's spouse; (B) The non-tax filer's natural or biological, adopted, and step children under age nineteen years; and (C) If a non-tax filer is under age nineteen years, the non-tax filer's natural or biological, adopted, and step parents, and natural or biological, adopted, half, and step siblings under age nineteen years. (3) Each spouse of a married couple residing together shall be included in the household of the other spouse regardless of whether: (A) They expect to file a joint tax return; or (B) One spouse expects to be claimed as a tax dependent by the other spouse for the taxable year in which medical assistance is sought. (4) A pregnant woman only, notwithstanding paragraphs (1) through (3), shall include 1724.2-12
§17-1724.2-20 the number of children she is expected to deliver. [Eff 09/30/13; am and comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.4, 435.601, 435.602, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§435.4, 435.601, 435.602, 435.603) §§17-1724.2-14 to 17-1724.2-18 (Reserved) . SUBCHAPTER 3 BUDGET PERIODS §17-1724.2-19 Purpose. This subchapter identifies and describes the budget period for a MAGI- based income determination. [Eff 09/30/13; am and comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.4, 435.601, 435.602, 435.603) (Imp: HRS §346- 14; 42 C.F.R. §§435.4, 435.601, 435.602, 435.603) §17-1724.2-20 Budget periods. (a) The determination of monthly income and household size is dependent on the period for which assistance is being requested and the circumstances involved. (1) The following methods shall be used when determining current income: (A) For a month prior to the current month, the actual income received within that month shall be considered income for that month. (B) For the current month, income already received and any income anticipated to be received within the current month, shall be considered income for that month. (2) The following methods shall be used when determining future income: (A) To account for future changes in income that can be reasonably anticipated, projected income shall be calculated by one of the following methods: 1724.2-13
§17-1724.2-20 (i) Current weekly income multiplied by 4.3333 to convert to monthly income; (ii) Current bi-weekly income multiplied by 2.1667 to convert to monthly income; (iii) When no significant fluctuation is anticipated, the income received in the month immediately prior to the current month can be used for the projection; or (iv) If there has been fluctuation, an average of the three months income immediately preceding the current month may be utilized. (B) Actual changes in income and circumstances, as required to be reported by the household, including deviations from reasonably anticipated fluctuations in income, shall be acted upon by the department. (b) The department shall determine the current and future household monthly income or the projected annual household income and household size for an applicant or beneficiary. The department shall adopt a reasonable percentage for an increase or decrease in income, and take into account verifying financial information with the Income Eligibility Verification System (IEVS) data and whether the IEVS income causes the total combined countable household income (IEVS income plus all previously reported income) to be above or below the medical assistance standard for the appropriate household size as described in chapter 17- 1714.1: 3206 ,, (1) The department shall continue to use the self-attested income amount when: (A) The IEVS income amount is below or at ten per cent of the self-attested income amount, even if the total combined countable household's income exceeds the medical assistance income standard for the applicable household size; or 1724.2-14
§17-1724.2-20 (B) The IEVS income is above ten percent of the self-attested amount but the total combined countable household's income remains at or below the medical assistance standard; or (2) The department shall request for additional information from the household when the IEVS income differs more than ten per cent of the self-attested income amount. A change in the total combined countable household income requires the household to be redetermined under the appropriate category and medical assistance standard for the applicable household size. The department shall redetermine household's eligibility based on the verified income amount; unless a reasonable explanation, and if necessary, appropriate documentation, are provided. (c) If a household's MAGI-based income is above the applicable medical assistance income standard for a household of applicable size, but the household's income does not exceed one hundred per cent of the federal poverty level for advance payments of the premium tax credits (APTC) eligibility, MAGI as defined in chapter 17-1700.1, which the Exchange employs, shall apply. Differences in methodologies between medical assistance and APTC include, but are not limited to, treatment of certain types of income, annualizing income, and household composition. [Eff 09/30/13; am and comp NOV 102016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.4, 435.601, 435.602, 435.603, 435.945, 435.952) (Imp: HRS §346-14; 42 C.F.R. §§435.4, 435.601, 435.602, 435.603, 435.945, 435.952) §§17-1724.2-21 to 17-1724.2-25 (Reserved) . 1724.2-15 320 6
UNOFFICIAL 1725.1-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1725.1
ASSETS FOR MAGI-EXCEPTED INDIVIDUALS
Subchapter 1 General Provisions
§17-1725.1-1 Purpose §17-1725.1-2 General requirements §17-1725.1-3 Rounding of assets §§17-1725.1-4 to 17-1725.1-8 (Reserved)
Subchapter 2 Availability and Verification Of Assets
§17-1725.1-9 Purpose §17-1725.1-10 Availability and verification of assets §§17-1725.1-11 to 17-1725.1-15 (Reserved)
Subchapter 3 Assets To Be Considered
§17-1725.1-16 Purpose §17-1725.1-17 Assets to be considered §17-1725.1-18 Treatment of trusts established after August 10, 1993 §17-1725.1-19 Assets of the sponsor of a non- citizen §§17-1725.1-20 to 17-1725.1-24 (Reserved)
UNOFFICIAL 1725.1-2 Subchapter 4 Exempt Assets
§17-1725.1-25 Purpose §17-1725.1-26 Exempt assets §§17-1725.1-27 to 17-1725.1-31 (Reserved)
Subchapter 5 Evaluation Of Real Property
§17-1725.1-32 Purpose §17-1725.1-33 Equity value of real property §17-1725.1-34 Treatment of special forms of ownership of real or personal property §17-1725.1-35 Special provision for removal of legal impediments to availability §17-1725.1-36 Real property used as a home §§17-1725.1-37 to 17-1725.1-41 (Reserved)
Subchapter 6 Personal Reserve Standards
§17-1725.1-42 Purpose §17-1725.1-43 Personal reserve standard for MAGI- excepted individuals and households §§17-1725.1-44 to 17-1725.1-48 (Reserved)
Subchapter 7 Treatment of Assets for Individuals Requesting Coverage of Long-Term Care Services
§17-1725.1-49 Purpose §17-1725.1-50 Determination of the community spouse resource allowance §17-1725.1-51 Penalty period for the transfer of an asset for less than fair market value §17-1725.1-52 Treatment of annuities §17-1725.1-53 Treatment of promissory notes, loans and mortgages
UNOFFICIAL 1725.1-3 §17-1725.1-54 Treatment of the purchase of a life interest in the home property of another §17-1725.1-55 Treatment of the transfer of income §17-1725.1-56 Transfer of assets that are not
subject to the assessment of a
penalty §17-1725.1-57 Determining a penalty period §17-1725.1-58 Waiver of a transfer of asset penalty period due to undue hardship §17-1725.1-59 Individual with substantive equity in a home property §17-1725.1-60 Waiver of excess home equity due to undue hardship §§17-1725.1-61 to 17-1725.1-65 (Reserved).
Historical Note: This chapter is based substantially upon subchapters 3, 7 and 8 of chapter 17-1721 and repealed chapter of 17-1725.
The source notes for subchapters 3, 7 and 8 of chapter 17-1721 are: [Eff 08/01/94; am 11/13/95; am 11/25/96; am 10/26/01; am 01/31/09; am 10/19/09; am 06/25/12; R 09/30/13].
The source notes for chapter 17-1725 are: [Eff 08/01/94; am 11/13/95; am 01/29/96; am 03/30/96; am 11/13/96; am 11/25/96; am 05/02/98; am 06/19/00; am 10/26/01; am 12/03/01; am 04/11/03; am 05/10/03; am 09/10/09; am 10/19/09; am 04/12/13; R 09/30/13].
SUBCHAPTER 1
GENERAL PROVISIONS
§17-1725.1-1 Purpose. This chapter describes the types and amount of assets that apply to a MAGI- excepted individual and the treatment of resources for a MAGI-excepted individual or household and for
UNOFFICIAL 1725.1-4 individuals applying for or receiving long-term care services. [Eff 09/30/13] (Auth: HRS §§346-14, 346- 53; 42 C.F.R. §§431.10, 435.3, 435.120, 435.230, 435.301, 435.735, 435.840, 435.843, 435.845; 42 U.S.C. §§1315, 1396r-5) (Imp: HRS §346-14; 42 C.F.R. §§431.10, 435.3, 435.120, 435.230, 435.301, 435.735, 435.840, 435.843, 435.845; 42 U.S.C. §§1315, 1396r-5)
§17-1725.1-2 General requirements. This chapter identifies and describes the types of assets and how they are considered in determining the eligibility of a MAGI-excepted individual or household. [Eff 09/30/13] (Auth: HRS §346-53; 42 C.F.R. §§435.230; 435.601, 435.840, 435.845) (Imp: HRS §§346-14, 346-53, 346-71; 42 C.F.R. §§435.230; 435.601, 435.840, 435.845)
§17-1725.1-3 Rounding of assets. There are no provisions for the rounding of assets to a whole dollar amount when determining eligibility for a MAGI- excepted individual or household. [Eff 09/30/13] (Auth: HRS §346-14; 42 U.S.C. §§1382b, 1396a(a)(10)(A)(ii)(I)) (Imp: HRS §346.14, 42 U.S.C. §§1382b, 1396a(a)(10)(A)(ii)(I))
§§17-1725.1-4 to 17-1725.1-8 (Reserved).
SUBCHAPTER 2
AVAILABILITY AND VERIFICATION OF ASSETS
§17-1725.1-9 Purpose. This subchapter describes the requirements to provide verification of assets which are considered and evaluated to determine eligibility for a MAGI-excepted individual. [Eff 09/30/13] (Auth: HRS §346-53; 42 C.F.R. §§435.840, 435.845; 20 C.F.R. §416.1202) (Imp: HRS
UNOFFICIAL 1725.1-5 §§346-29, 346-53; 42 C.F.R. §§435.840, 435.845; 20 C.F.R. §416.1202)
§17-1725.1-10 Availability and verification of assets. (a) An individual shall apply for and develop potential sources of assets, when applicable. (b) The asset shall be considered as of the first moment of the calendar month for which medical assistance is being requested or received. (c) The asset of an individual and their legally responsible household members residing in the same residence shall be considered when determining eligibility for medical assistance. (d) Joint ownership of a liquid asset that is legally defined and available to the individual shall be considered. (e) Joint ownership of a liquid asset when legally defined to which only a portion is legally accessible, shall be considered an available resource only as to that portion. (f) Joint ownership of a non-liquid asset, including real and personal property that is legally defined to which only a portion is legally accessible, shall be considered an available resource only as to that portion. (g) The department shall deny or terminate medical assistance when an individual fails to: (1) Apply for, access, or develop potential sources of assets; (2) Cooperate in providing accurate and complete information or verification; or (3) Complete any other action on the part of the individual or household that prevents a correct determination of eligibility to be made. [Eff 09/30/13] (Auth: HRS §346-53; 42 C.F.R. §§435.121, 435.230, 435.602, 435.608, 435.840, 435.845) (Imp: 42 C.F.R. §§435.121, 435.230, 435.602, 435.608, 435.840, 435.845)
UNOFFICIAL 1725.1-6 §§17-1725.1-11 to 17-1725.1-15 (Reserved).
SUBCHAPTER 3
ASSETS TO BE CONSIDERED
§17-1725.1-16 Purpose. This subchapter describes assets which are considered in the determination of eligibility for a MAGI-excepted individual or household. [Eff 09/30/13] (Auth: HRS §346-53) (Imp: HRS §346-53)
§17-1725.1-17 Assets to be considered. The following assets shall be considered in the personal reserve of a MAGI-excepted individual or household and include, but are not limited to: (1) Cash on hand; (2) Cash in savings and checking accounts; (3) Value of stocks and bonds verified by a stock brokerage firm; (4) Value of time deposits and savings certificates verified by the financial institution where the funds are deposited; (5) State tax refunds, including state excise tax credits and state income tax credits; (6) Cash surrender value of a life insurance policy after the subtraction of outstanding loans or encumbrances from the cash value of the policy verified by the insurance company; (7) Value of governmental debenture bonds, such as U.S. savings bonds, treasury notes, or municipal bonds verified by the financial institutions or stock brokerage firms or issuers; (8) Value of mutual fund shares be verified by the stock brokerage firm; (9) Value of burial plots or burial vaults not exempt in section 17-1725.1-26(8) shall be
UNOFFICIAL 1725.1-7
determined by subtracting all encumbrances from the market value verified by the purchasing cemetery; (10) Value of funeral plans not exempt in subsection 17-1725.1-26(9) shall be determined by subtracting all encumbrances from the original purchase price; (11) Equity in personal property, such as jewelry, watercrafts or air transportation vehicles not exempt in subsection 17-1725.1- 26(3); (12) Equity in real property, not used as the family home, that is not exempt in section 17-1725.1-35 or section 17-1725.1-36; (13) Moneys or assets in an irrevocable trust fund established on or before August 10, 1993 if there is the opportunity to remove legal impediments to gain access to the available assets of the trust. Proof of irrevocability of the trust or evidence of legal impediments to acquiring access to the assets of the trust fund must be provided. Medical assistance shall be provided to an otherwise eligible individual while legal or other impediments to the potential availability of the assets are being removed, or title is being cleared on the condition the individual submits a plan of action within thirty days of the date of application to remove such legal or other impediments to current availability. (A) Failure to meet the deadline shall disqualify the individual from receiving further medical assistance. Benefits received thereafter shall constitute an ineligible payment recoverable by the department; (B) The department shall periodically review the submitted plan of action or failure to take appropriate action shall disqualify the individual from further medical assistance;
UNOFFICIAL 1725.1-8 For any Medicaid qualifying trust the maximum amount permitted to be distributed to the individual shall be counted regardless of whether the trust is irrevocable or established for purposes other than to qualify for medical assistance with the exception of a Medicaid qualifying trust or initial trust decree established prior to April 7, 1986, solely for the benefit of a developmentally disabled or intellectually disabled individual who resides in an intermediate care facility for the developmentally disabled or intellectually disabled individuals; (14) Payments made from protected retirement plans or annuities to include, but not be limited to, profit sharing plans, IRAs, or other retirement accounts, shall be considered an available asset if an individual has access to the distribution of funds; (15) Money received by the individual from the sale of assets; (16) Investments in diamonds, gold, silver, or other precious metals; (17) Equity in a business shall be determined as follows: (A) Subtract the current liabilities from the fair market value of the remaining assets. (B) Exempt the following assets that are essential to the production of goods or services in determining equity in a business, which includes, but are not limited to: (i) Stock and inventory; (ii) Tools and equipment; and (iii) Motor vehicles required for business use. (C) The remaining equity of all non-exempt assets, in part or in whole, shall be considered.
UNOFFICIAL 1725.1-9 (18) Equity value of any assets not exempt under section 17-1725.1-26 verified by an appropriate entity; (19) Federal tax refunds unless otherwise exempted by the Federal government; (20) Cash dividends from stocks, life insurance,
or other sources; (21) Refunds of utility and rental deposits not paid by the department; (22) Funds used to purchase an annuity that: (A) Is revocable and allows the annuitant access to the cash value of the annuity less early withdrawals and surrender fees; (B) Is assignable to allow the sale of the annuity on the open market; or (C) Does not address issues of revocability or assignability; (23) Value of the outstanding balance owed on a promissory note or a property agreement to the individual (creditor) who holds the promissory note or agreement of sale; (24) Entrance fees of an individual residing in a continuing care retirement community or life care community under the following conditions: (A) The entrance fee may be used to pay for care if the individual’s other resources or income is insufficient to pay for the care; (B) The entrance fee or any remaining portion is refundable when the individual dies or terminates the contract and leaves the continuing care retirement community or life care community; and (C) The entrance fee does not assign an ownership interest in the continuing care retirement community or life care community. [Eff 09/30/13] (Auth: HRS §§346-53, 346-71; 20 C.F.R. §416.1201, 42 C.F.R §§431.10, 435.601;
UNOFFICIAL 1725.1-10
435.811, 435.840, 435.845; 45 C.F.R. §233.20; 42 U.S.C. §1396p) (Imp: HRS §§346-29, 346-53, 346-71; 20 C.F.R. §416.1201; 42 C.F.R. §§431.10, 435.601;
435.811, 435.840, 435.845; 45 C.F.R. §233.20; 42 U.S.C. §1396p)
§17-1725.1-18 Treatment of trusts established after August 10, 1993. (a) An individual shall be considered to have established a trust if assets of the individual form all or part of the corpus of the trust and if the trust was formed other than by a will by any of the following: (1) The individual; (2) The individual's spouse; (3) A person, including a court or administrative body, with legal authority to act on behalf of the individual or the individual's spouse; or (4) A person, including a court or administrative body, acting at the direction of the individual or the individual's spouse. (b) If a trust contains assets of persons other than the individual, only the portion of the trust that contains the assets of the individual will be considered in this section. (c) The treatment of trusts in this section will be made without regard to: (1) The purpose for which the trust was established; (2) Whether the trustees have or exercise any discretion under the trust; (3) Any restrictions on when or whether distributions can be made from the trust; or (4) Any restrictions on the use of distributions from the trust. (d) In the case of a revocable trust the following shall apply: (1) The corpus of the trust is considered an available asset;
UNOFFICIAL 1725.1-11 (2) Payments from the trust to or for the benefit of the individual shall be considered income of the individual; and (3) Any other payments from the trust shall be considered assets disposed and subject to the provisions of subchapter 7. (e) In the case of irrevocable trusts the following apply: (1) If payments could be made to or for the benefit of the individual, the portion of the corpus from which the payment could be made is considered an available asset; (2) If payments could be made to or for the benefit of the individual, the income on the corpus from which the payment could be made is considered an available asset; (3) The payments in paragraphs (1) and (2) from the corpus or from the income on the corpus is considered income to the individual; and (4) The portion of the corpus from which no payments could be made to or on behalf of the individual is considered assets disposed and subject to the provisions of subchapter 7. [Eff 09/30/13] (Auth: HRS §346-53; 20 C.F.R. §416.1201; 42 C.F.R. §431.10; 45 C.F.R. §233.20; 42 U.S.C. §1396p) (Imp: HRS §346-29; 20 C.F.R. §416.1201; 42 C.F.R. §431.10; 45 C.F.R. §233.20; 42 U.S.C. §1396p)
§17-1725.1-19 Assets of the sponsor of a non- citizen. (a) The sponsor of a non-citizen who executed an affidavit of support pursuant to section 213A of the INA on or after December 19, 1997, shall have their assets and their spouse's assets deemed as available to a non-citizen requesting medical assistance. (b) The assets of a non-citizen's sponsor and the sponsor’s spouse shall be deemed available to the non-citizen until such time as the non-citizen:
UNOFFICIAL 1725.1-12 (1) Achieves U.S. citizenship through naturalization pursuant to chapter 2 of Title III of the INA; or (2) Has worked forty qualifying quarters of coverage as defined under Title II of the Social Security Act or can be credited with such qualifying quarters as provided under 8 U.S.C. §1645. In the case of any such qualifying quarter beginning after December 31, 1996, the non-citizen must not have received any Federal means-tested public benefit during any such period. (c) The non-citizen's failure to provide information and verification regarding the assets of their sponsor and the sponsor’s spouse as applicable shall disqualify the non-citizen from receiving medical assistance. (d) The assets of a non-citizen's sponsor and the sponsor’s spouse shall not be deemed available to a non-citizen for coverage of emergency medical assistance as described in chapter 17-1723.1. (e) Special provisions shall apply in the case of an indigent non-citizen. The deeming of assets in subsection (a) shall not be applicable for a twelve- month period from the date a non-citizen is determined to be indigent. (1) The department may determine a non-citizen to be indigent when the non-citizen is unable to obtain food and shelter because the non-citizen's own assets plus assets provided by other individuals, including the sponsor and the sponsor's spouse, does not exceed one hundred per cent of the asset retention limit for the non-citizen’s household size; (2) The department will only consider the actual amount contributed by the sponsor and sponsor’s spouse for a twelve month period, which begins on the date of such determination and ends twelve months after such date;
UNOFFICIAL 1725.1-13 (3) Each period of indigence is renewable for additional twelve month periods; and (4) The department must notify the federal Attorney General of each such determination, including the names of the sponsor and the sponsored non-citizen involved. (f) Special provisions for a battered spouse and child who are non-citizens. The assets of the sponsor and the sponsor's spouse described in subsection (a) shall not be deemed when the sponsor and the sponsor's spouse are the batterer and the spouse of the batterer, and only for the period the non-citizen is not residing in the residence of the batterer: (1) This provision applies to: (A) A non-citizen who was battered or subjected to extreme cruelty in the U.S. by the non-citizen’s spouse or parent, or by a member of the spouse's or parent's family residing in the same residence as the non-citizen and the spouse or parent consented to or acquiesced to such battery or cruelty; (B) A non-citizen whose child was battered or subjected to extreme cruelty in the U.S. by the spouse or parent of the non-citizen who did not actively participate in such battery or cruelty or by a member of the spouse's or parent's family residing in the same residence and the spouse or the parent consented to or acquiesced to such battery or cruelty; or (C) A non-citizen child who was residing with the parent who was battered or subjected to extreme cruelty in the U.S. by that parent's spouse or by a member of the spouse's family residing in the same residence as the parent and the spouse consented to or acquiesced to such battery or cruelty described in any of the paragraphs under this subsection;
UNOFFICIAL 1725.1-14 (2) The department shall determine whether the battery or cruelty is substantially connected to the need for public benefits which means that without the support of the batterer, the non-citizen is unable to obtain food and shelter because the non- citizen's own assets, or other assets provided by other individuals, including the sponsor and the sponsor's spouse, does not exceed one hundred per cent of the asset retention limit for the non-citizen's household size; and (3) After the twelve month period ends, the department shall continue to exempt the batterer's assets when the battery or cruelty is recognized in an order of a judge or administrative law judge or a prior determination of the USCIS and the department determines that such battery or cruelty still has a substantial connection to the non-citizen’s need for benefits. [Eff 09/30/13] (Auth: HRS §346-14; 20 C.F.R. §416.1204; 8 U.S.C. §§1631, 1632) (Imp: 20 C.F.R. §416.1204; 8 U.S.C. §§1631, 1632)
§§17-1725.1-20 to 17-1725.1-24 (Reserved).
SUBCHAPTER 4
EXEMPT ASSETS
§17-1725.1-25 Purpose. This subchapter describes assets which are exempt in the determination of eligibility for an individual or household. [Eff 09/30/13] (Auth: HRS §§346-14, 346-53) (Imp: HRS §346-53)
UNOFFICIAL 1725.1-15 §17-1725.1-26 Exempt assets. The following assets shall be exempted from consideration in the personal reserve of an individual or household which shall include, but are not limited to: (1) Household goods of limited value essential to day-to-day living including but not limited to clothing, furniture, appliances or electronic equipment; (2) Personal effects including but not limited
to one wedding ring and one engagement ring, personal care items and clothing, pets, educational or recreational items, or items of cultural or religious significance to an individual; (3) All motor vehicles, with the exception of watercrafts or air transportation vehicles, including but not limited to cars, trucks, vans, or motorcycles; (4) Any equity in the principal place of residence of an individual or household, as described in subchapter 5 except for the home of an individual requesting or receiving long-term care services placed in a trust; (5) Refunds of utility and rental deposits paid by the department; (6) Bona fide loans or agreements from any source, including but not limited to educational loans, is a debt that the individual (borrower) has an obligation to repay; (7) Cash payments to the assistance unit responsible for payment of the household bills by a non-unit household member for his or her share of common household expenses; (8) One burial space (including plots, vaults, and niches) per household member if specifically designated for the individual or immediate household member; (9) The value of bona fide funeral or burial plans or agreements per household member if
UNOFFICIAL 1725.1-16
specifically designated for the individual or immediate household member; (10) All funds contained in a trust established after August 10, 1993 for a disabled (as
defined in section 17-1719-8) individual under sixty-five years of age established under 42 U.S.C. §1396p(d)(4)(A) that meets the following conditions: (A) The trust was established with the assets of the disabled individual solely for the benefit of the individual by a parent, grandparent, legal guardian or by a court; and (B) The State will receive all amounts remaining in the trust upon the death of the disabled individual up to an amount equal to the total medical assistance received by the individual; (11) All funds contained in a trust established after August 10, 1993 for a disabled (as defined in section 17-1719-8) individual under sixty-five years of age, established and managed by a non-profit association established under 42 U.S.C. §1396p(d)(4)(C) that meets the following conditions: (A) A separate account is maintained for each beneficiary of the trust, but, for purposes of investment and management of funds, the trust may pool these accounts; (B) The accounts in the trust were established with the assets of the disabled individual solely for the benefit of the individual by a parent, grandparent, legal guardian or by a court; and (C) The State will receive all amounts remaining in the disabled individual's account in the trust upon the death of the disabled individual up to an amount equal to the total medical assistance received by the individual;
UNOFFICIAL 1725.1-17 (12) Funds used to purchase an annuity that is irrevocable and not assignable. (A) An annuity is irrevocable when the annuitant cannot void the contract and
obtain the cash value of the annuity less early withdrawals and surrender fees; and (B) An annuity is not assignable when the annuitant cannot sell the annuity on the open market; (13) Federal tax refund or payment made by an employer related to an earned income tax credit (EITC) received is excluded for nine months following the month the refund or payment is received; (14) Federal tax refund from a child tax credit (CTC) received is excluded from resources for nine months following the month the refund or payment is received; (15) One-time payment issued to eligible Filipino veterans who aided American troops during World War II that were established by the Filipino Veterans Equity Compensation Fund (FVECF) under the American Recovery and Reinvestment Act of 2009; (16) Any gift to, or for the benefit of, an individual under nineteen years of age who has a life-threatening condition, received from an organization described under §501(c)(3) of the Code. An in-kind gift that is converted to cash or a cash gift, only up to $2,000 is exempt in the calendar year in which the gift is made; (17) Restitution payments made under Pub. L. 100- 383 for the evacuation, relocation, and internment to an eligible Japanese-American citizen or permanent resident non-citizen of Japanese ancestry under §105 of the Civil Liberties Act of 1988 and to an eligible Aleut under §206 of the Aleutian and Pribilof Islands Restitution Act;
UNOFFICIAL 1725.1-18 (18) State annuities paid to an individual or the individual’s spouse on the basis that the individual is an aged, blind, or disabled veteran under §202 of P.L. 110-245; (19) Crime Victim Compensation payments issued pursuant to the Victims of Crime Act of 1984 to victims of certain crimes or dependents of deceased victims to include, but not limited to compensation paid by Hawaii’s Crime Victim Compensation Commission which are exempt up to nine months from the month of receipt; (20) Value of stocks or equity in protected retirement accounts which include, but are not limited to profit sharing plans, IRAs, annuities, or other retirement accounts, if an individual continues to be employed by the firm which controls the profit sharing distributions; (21) Unspent funds from payments made to or for an individual who is or was: (A) Captured and interned by North Vietnam pursuant to §606 of Pub. L. 105-78; (B) Captured and incarcerated by the Democratic Republic of Vietnam after entering Vietnam under OPLAN 34A, or Laos under OPLAN 35, pursuant to certain Vietnamese commando operations pursuant to §657(d)(2) of Pub. L. 104- 201; (C) Displaced by any federal or federally- assisted project pursuant to Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970 (42 U.S.C. §§460l-4655); (D) A volunteer under the Domestic Volunteer Service Act of 1973 as amended by the National and Community Service Trust Act of 1993 - Volunteers In Service to America (VISTA), Foster Grandparent Program, Retired and Senior Volunteer Program (RSVP), Senior
UNOFFICIAL 1725.1-19 Companion Program (42 U.S.C. §§4951- 5085) and under the Small Business Act - Service Corps of Retired Executives (SCORE), and the Active Corps of Executives (ACE) (15 U.S.C. §637); (E) Provided relocation assistance payments by a state or county government or through a state or county-assisted project up to nine months after receipt; (F) Paid pursuant to the Civil Liberties Act of 1988, Title I of Pub. L. 100- 383, and the Aleutian and Pribilof Islands Restitution Act, Title II of Pub. L. 100-383; (G) Paid from the Agent Orange Settlement Fund or any other fund established pursuant to the settlement in the In Re Agent Orange product liability litigation, M.D.L. No. 381 (E.D.N.Y.) effective to January 1, 1989; (H) A victim pursuant to the Netherlands' Act on Benefits for Victims of Persecution 1940-1945, to a persecuted victim during the Nazi occupation of the Netherlands and the Dutch East Indies during World War II pursuant to Pub. L. No. 103-286; (I) Compensated for losses during the period March 1933 and May 1945 due to political, religious, or ethnic reasons under paragraphs 500 to 506 of the Austrian General Social Insurance Act; (J) Paid from the Radiation Exposure Compensation Trust Fund established under the Radiation Exposure Compensation Act (RECA) (Pub. L. 101- 426) to compensate an individual for injuries or death resulting from the exposure to radiation from nuclear testing or uranium mining under the National Defense Authorization Act for
UNOFFICIAL 1725.1-20
Fiscal Year 1991 and RECA Amendments of 2000 and succeeding amendments; (K) Paid pursuant to the Disaster Relief and Emergency Assistance Act or any other assistance provided under a federal statute as a result of a catastrophe which is declared a major disaster by the President of the U.S. or comparable disaster assistance provided by any state, county agency or from a disaster assistance organization; (L) Paid for assistance to children under the School Lunch Programs (42 U.S.C. chapter 13), Child Nutrition Programs - School Breakfast Program, WIC Program, Milk Programs (42 U.S.C. chapter 13(A)); and (M) Paid for assistance to senior citizens under the Programs for Older Americans (42 U.S.C. §§3030d-3030g); (22) Settlement received in the case of Susan Walker v. Bayer Corporation, et al., to compensate an individual who contracted the human immunodeficiency virus (H.I.V.) from contaminated blood products pursuant to Title IV, section 4735 of the Balanced Budget Act of 1997 (Pub. L. 105-33); (23) Retroactive RSDI or SSI benefits retained in the form of cash or deposited into a bank account is exempt for a period of nine calendar months following the month of receipt; (24) VA benefits received by or on behalf of certain natural children of: (A) Vietnam and Korean Service veterans, born with spina bifida under §421 of Pub. L. 104-204 and §102 of Pub. L. 108-183, respectively; and (B) Vietnam veteran women, born with certain birth defects that results in
UNOFFICIAL 1725.1-21
permanent physical or mental disability under §401 of Pub. L. 106-419; (25) Ricky Ray Hemophilia Relief Fund Act of 1998 under Pub. L. 105-369 to compensate an individual with hemophilia-clotting disorder who was treated with blood-clotting agents and contracted the H.I.V.; (26) The following payments made to Native Americans: (A) San Carlos Apache Indian Tribe of Arizona under §7 of PL 93-134 and Pub. L. 97-95; (B) Wyandot Tribe of Indians of Oklahoma under §6 of Pub. L. 97-371; (C) Shawnee Tribe of Indians (Absentee Shawnee Tribe of Oklahoma, Eastern Shawnee Tribe of Oklahoma and the Cherokee Band of Shawnee descendants) under §7 of Pub. L. 97-372; (D) Clallam Tribe of Indians of the State of Washington (Port Gamble Indian Community, Lower Elwha Tribe Community and the Jamestown Band of Clallam Indians) under §6 of Pub. L. 97-402; (E) Red Lake Band of Chippewa Indians under §3 of Pub. L. 98-123; (F) Saginaw Chippewa Indian Tribe of Michigan under §6 of Pub. L. 99-346; (G) Cow Creek Band of Umpqua Tribe of Indians under §4 of Pub. L. 99-377; (H) Santee Sioux Tribe of Nebraska, the Flandreau Santee Sioux Tribe, the Prairie Island Sioux, Lower Sioux, and Shakopee Mdewakanton Sioux Communities of Minnesota under §8 of Pub. L. 99-130 and §7 of Pub. L. 93-134 as amended by Pub. L. 97-458; (I) Tax exempt portions of payments made pursuant to the Alaska Native Claims Settlement Act (43 U.S.C. §1620); (J) Distributions made to a household, an individual Native, or a descendent of a
UNOFFICIAL 1725.1-22
Native by a Native Corporation established in accordance with the Alaska Native Claims Settlement Act (Pub. L. 92-203 as amended) as provided by Pub. L. 100-241, §15 (43 U.S.C. §1626); (K) Assiniboine Tribe of Fort Belknap Indian Community of Montana and the Assiniboine Tribe of the Fort Peck Indian Reservation of Montana under §5 of Pub. L. 98-124; (L) White Earth Band of Chippewa Indians as allottees, or their heirs under §16 of Pub. L. 99-264; (M) Sac and Fox Indian Nation under §6 of Pub. L. 94-189; (N) Grand River Band of Ottawa Indians under §6 of Pub. L. 94-540; (O) Confederated Tribes and Bands of the Yakima Indian Nation or the Apache Tribe of the Mescalero Reservation under §2 of Pub. L. 95-433; (P) Assiniboine Tribe of Fort Belknap Indian Community and the Papago Tribe of Arizona under §6 and §8 of Pub. L. 94-408; (Q) Chippewas of Lake Superior and the Chippewas of the Mississippi under §6 of Pub. L. 99-146; (R) Chippewas of Lake Superior and the Chippewas of the Mississippi under §4 of Pub. L. 99-377; (S) Delaware Tribe of Indians and the absentee Delaware Tribe of Western Oklahoma under §8 of Pub. L. 96-318; (T) Miami Tribe of Oklahoma and the Miami Indians of Indiana under §7 of Pub. L. 97-376; (U) Pembina Chippewa Indians (Turtle Mountain Band of Chippewa Indians, Chippewa Cree Tribe of Rocky Boy's Reservation, Minnesota Chippewa Tribe,
UNOFFICIAL 1725.1-23 Little Shell Band of the Chippewa Indians of Montana, and the non-member Pembina descendants) under §9 of Pub. L. 97-403; (V) Confederated Tribes of the Warm Springs Reservation up to $2,000 under §4 of Pub. L. 97-436; (W) Wyandotte Tribe of Oklahoma and the Absentee Wyandottes under §106 of Pub. L. 98-602; (X) Seminole Nation of Oklahoma, the Seminole Tribe of Florida, the Miccosukee Tribe of Indians of Florida and the independent Seminole Indians of Florida under §8 of Pub. L. 101-277; (Y) Indian judgment funds under Pub. L. 93- 134, as amended by Pub. L. 97-458 (25 U.S.C. §1407); (Z) Wisconsin Band of Potawatomi (Hannahville Indian Community and Forest County Potawatomi) under §503 of Pub. L. 100-581; (AA) Passamaquoddy Tribe, Penobscott Nation, and the Houlton Band of Maliseet Indians under the Maine Indian Claims Settlement Act under §9 of Pub. L. 96- 420 (25 U.S.C. §1728(c)); (BB) Michigan Indian Land Claims Settlement Act under Pub. L. 105-143 and §4 of the Cowlitz Indian Tribe Distribution of Judgment Funds Act under Pub. L. 108- 222; (CC) Shoalwater Bay Indian Tribe under §5 of Pub. L. 98-432; (DD) Coushatta Tribe of Louisiana under §2 of Pub. L. 100-411 and §7 of Pub. L. 93-134 as amended by Pub. L. 97-458 (25 U.S.C. §1407); (EE) Hoopa Valley Indian Tribe and the Yurok Indian Tribe under §§4, 6, and 7 of Pub. L. 100-580 and §3 of Pub. L. 98- 64;
UNOFFICIAL 1725.1-24 (FF) Red Lake Band of Chippewa Indians from the sale of timber and lumber on the
Red Lake Reservation under §3 of Pub. L. 85-794; (GG) Blackfeet and GrosVentre by the Blackfeet and GrosVentre tribal government resulting from judgment funds under §4 of Pub. L. 92-254 and under §6 of Pub. L. 97-408; (HH) Under §102 of the Fallon Paiute Shoshone Indian Tribes Water Rights Settlement Act of 1990 under Pub. L. 101-618 and §7 of Pub. L. 93-134 as amended by Pub. L. 97-458 (25 U.S.C. §4107); (II) Seneca Nation of New York under §8(b) of the Seneca Nation Settlement Act of 1990, Pub. L. 101-503 (25 U.S.C. §1774f); (JJ) Pueblo of Santa Ana and distributed to members of that tribe under §6 of Pub. L. 95-498; and the Pueblo of Zia of New Mexico and distributed to members of that tribe under §6 of Pub. L. 95-499; (KK) Certain Indian tribes under §6 of Pub. L. 94-114 (25 U.S.C. §459e); (LL) Hopi and Navajo Tribes under §22 of Pub. L. 93-531 as amended by Pub. L. 96-305; (MM) Puyallup Tribe under §10 of the Puyallup Tribe Indians Settlement Act of 1989, Pub. L. 101-41 (25 U.S.C. §17734(c)); (NN) Catawba Indian Tribe of South Carolina under §11(m) of Pub. L. 103-116; (OO) Confederated Tribes of the Colville Reservation under §7(b) of Pub. L. 103- 436; and (PP) Heirs of certain deceased Indians under of the Old Age Assistance Claims Settlement Act §8 of Pub. L. 98-500;
UNOFFICIAL 1725.1-25 (27) Unspent financial assistance received, under:
(A) Title IV of the Higher Education Act which include but may not be limited to the following: (i) Academic Achievement Incentive Scholarships; (ii) Byrd Scholars; (iii) Federal Educational Loans (Federal PLUS Loans, Perkins Loans, Stafford Loans, Ford Loans, etc.); (iv) Federal Supplemental Educational Opportunities Grants (FSEOG); (v) Gear Up (Gaining Early Awareness and Readiness for Undergraduate Programs); (vi) LEAP (Leveraging Educational Assistance Partnership); (vii) Pell grants; (viii) SLEAP (Special Leveraging Educational Assistance Partnership); (ix) State Student Incentives; (x) Upward Bound; and (xi) Work-Study Programs; or (B) The Bureau of Indian Affairs student assistance programs which exempt all other grants, scholarships, fellowships, and gifts used to pay tuition, fees, and other necessary educational expenses at any educational institution, including vocational and technical education under Pub. L. 108- 203 for nine calendar months following the month of receipt.
[Eff 09/30/13] (Auth: HRS §346-29; 20 C.F.R. §§416.1201, 416.1237; 42 C.F.R. §§431.10; 435.631; 45 C.F.R. §233.20) (Imp: HRS §346-29; 20 C.F.R. §§416.1201, 416.1237; 42 C.F.R. §§431.10; 435.631; 45 C.F.R. §233.20)
UNOFFICIAL 1725.1-26 §§17-1725.1-27 to 17-1725.1-31 (Reserved).
SUBCHAPTER 5
EVALUATION OF REAL PROPERTY
§17-1725.1-32 Purpose. This subchapter identifies and describes the different types of property ownership and how they are considered in the determination of eligibility for a MAGI-excepted individual or household. [Eff 09/30/13] (Auth: HRS §346-53) (Imp: HRS §346-53)
§17-1725.1-33 Equity value of real property.
(a) The equity value of real property shall be determined by subtracting all encumbrances from the fair market value. (b) The equity value of any real property not designated within this chapter as exempt shall be considered an available asset counted towards the individual's personal reserve. (c) The fair market value of real property shall be determined by considering the following variables: (1) Geographic location; (2) Land use; (3) Amenities; and (4) Land configuration. (d) Acceptable verification of the current fair market value other than the county property tax assessment shall specify how the value was established based on the variables in subsection (c) and may include, but are not limited to the following sources: (1) A licensed appraiser’s written appraisal of the current fair market value of the property; (2) A current sales agreement that reflects the current property appraisal or an accurate valuation of the fair market value of the property; or
UNOFFICIAL 1725.1-27 (3) A licensed realtor’s written appraisal of the current fair market value of the property. [Eff 09/30/13] (Auth: HRS
§346-53; 42 C.F.R. §§431.10, 435.601, 435.845; 45 C.F.R. §233.20) (Imp: HRS §346-29; 42 C.F.R. §§431.10, 435.601, 435.845; 45 C.F.R. §233.20)
§l7-1725.1-34 Treatment of special forms of ownership of real or personal property. (a) The individual's interest in property shall be determined by the type and form of ownership which may affect the value of the property in determining eligibility. (b) Property held in joint tenancy shall be determined by: (1) An appraisal of the current fair market value of the individual’s interest in the property; or (2) Dividing the current fair market value of the property by the number of joint tenants; and (3) Upon the death of one of the joint tenants, the survivor or survivors become the sole owner or owners of the entire interest. (c) Property held in tenancy by the entirety shall be determined by: (1) An appraisal of the current fair market value of the individual's interest in the property; and (2) Dividing the current fair market value of the property equally between the husband and wife. (d) Property held by tenancy in common: (1) Shall be determined by an appraisal of the current fair market value based on the percentage of ownership of two or more individual owners; (2) Each owner may sell, transfer or dispose of his or her share of the property without the permission of the other owner or owners but
UNOFFICIAL 1725.1-28
cannot do so with respect to the entire property; and (3) There is no automatic survivorship rights to a deceased's ownership interest as it passes to his or her estate or heirs. (e) Property under an agreement of sale shall be allocated between the buyer and seller in accordance with their respective interests as follows: (l) The buyer's interest shall be the fair market value of the real property minus the balance due on the agreement of sale; and (2) The seller's interest shall be the balance on the agreement of sale. (f) Property subject to a life estate interest: (1) Is established by a will or deed which conveys property to a life estate owner or life tenant for life and to one or more remaindermen upon termination of life estate; (2) The current value of the property shall be allocated between the life tenant and the remainderman by determining the present worth of their respective interests using the Life Estate and Remainder Interest Table (26 C.F.R §20.2031-7 and 49 FR Vol. 49 No. 93/5-11-84), that corresponds to the age of the life tenant; (3) The life tenant: (A) Owns the physical property for the duration of the life estate; (B) Has the right to possess, use, and obtain profits from the property; (C) Can sell his or her life estate interest; but (D) Cannot take any action concerning the interest of the remainderman. (4) The remainderman: (A) Has ownership interest in the physical property; (B) Does not have the right to possess and use the property until termination of life estate; and
UNOFFICIAL 1725.1-29 (C) Unless restricted by will or deed, is able to sell his or her interest in the
physical property before the life estate interest expires but the market value of the remainder interest may be reduced as the sale is subject to life estate interest. (g) The individual's interest in real property shall not be considered available as an asset if a co- owner would be affected by the sale of the individual’s interest under the following: (1) The co-owner resides on the property; (2) The co-owner would have to move if the property was sold; and (3) The co-owner owns no other real property that could be used as the co-owner’s home property. [Eff 09/30/13] (Auth: HRS §346-53; 20 C.F.R. §§416.1201, 416.1245, 416.1246; 42 C.F.R §§435.230, 435.601, 435.840, 435.845) (Imp: HRS §346-53; 20 C.F.R. §§416.1201, 416.1245, 416.1246; 42 C.F.R §§435.230, 435.601, 435.840, 435.845)
§17-1725.1-35 Special provision for removal of legal impediments to availability. Medical assistance shall be provided to an otherwise eligible individual while legal impediments to the current availability of real property are being removed or title is being cleared based on the condition that the individual’s plan of action is submitted within thirty days of the date of request by the department to remove those legal impediments or to clear title. (1) Failure to meet the deadline shall disqualify the individual from receiving further medical assistance. (2) The department shall periodically review the status of the plan of action and determine whether a recipient's failure to take appropriate action shall disqualify the recipient from further assistance.
UNOFFICIAL 1725.1-30 [Eff 09/30/13] (Auth: HRS 346-14; 20 C.F.R. §§416.1201, 416.1245; 42 C.F.R. §§431.10, 435.601) (Imp: 20 C.F.R. §§416.1201, 416.1245; 42 C.F.R. §435.601)
§17-1725.1-36 Real property used as a home. (a) Real property which is considered the home or usual place of residence of the individual is generally exempt from consideration as a countable asset except for the home property of an institutionalized individual placed in a trust. (b) The home property exemption is extended to the land and all structures on the parcel of land. The home property exemption may include contiguous parcels of property, regardless of whether legally considered separate parcels of property, and adjoining structures on that property that are not separated by easements or public right of ways, and provided the individual owner or owners consider the parcels to be part of their home property. (c) For the purpose of this subsection, whether an individual is living on or away from the real property shall determine whether the property is considered home property or not, regardless of the form of the individual's interest such as a life tenant, remainderman, a buyer or seller under an agreement of sale, settlor or beneficiary under a trust, or any other form of leased or divided interest. (1) For an institutionalized individual home property shall not be considered other property if: (A) The individual states an intent to return to the home; or (B) A spouse or dependent relative is living in the home. (2) For a non-institutionalized individual in the community who is not residing on their home property, the home property may continue to be exempt if the individual states the intent to return home.
UNOFFICIAL 1725.1-31 (3) The intent to return home for individuals under paragraphs (1) and (2) shall be re- evaluated annually. [Eff 09/30/13]
(Auth: HRS §346-53; 42 C.F.R. §431.10; 45 C.F.R. §233.20; 42 U.S.C. §1396p) (Imp: HRS §346-53; 45 C.F.R. §233.20; 42 U.S.C. §1396p)
§§17-1725.1-37 to 17-1725.1-41 (Reserved).
SUBCHAPTER 6
PERSONAL RESERVE STANDARDS
§17-1725.1-42 Purpose. This subchapter identifies the personal reserve standards for a MAGI- excepted individual or household. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.3, 435.840, 435.843, 435.845) (Imp: 42 C.F.R. §§435.3, 435.840, 435.843, 435.845)
§17-1725.1-43 Personal reserve standard for a MAGI-excepted individual or household. (a) The personal reserve standards for an individual or household are the maximum amount of countable assets that may be held by the individual or household while establishing or maintaining eligibility. (b) An individual or a household whose equity in non-exempt assets as determined in this chapter exceeds the personal reserve standard for medical assistance shall be ineligible. (c) The personal reserve standards for a MAGI- excepted individual or household applying for or receiving assistance, is equal to standards employed by the SSI program. (d) For each additional family member, $250 shall be added to the SSI personal reserve standard for a household of two and the resultant amount is the
UNOFFICIAL 1725.1-32 personal reserve standard for a household of applicable size. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.840, 435.843, 435.845) (Imp: 42 C.F.R. §§435.840, 435.843, 435.845)
§§17-1725.1-44 to 17-1725.1-48 (Reserved).
SUBCHAPTER 7
TREATMENT OF ASSETS FOR INDIVIDUALS REQUESTING COVERAGE OF LONG-TERM CARE SERVICES
§17-1725.1-49 Purpose. The purpose of this subchapter is to establish the requirements for the treatment of assets for an individual who requests coverage of long-term care services. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §431.10; 42 U.S.C. §1396p(c)) (Imp: 42 U.S.C. §1396p(c))
§17-1725.1-50 Determination of the community spouse resource allowance. (a) At the time of initial eligibility determination, the community spouse of an institutionalized individual who received long-term care services on or after September 30, 1989, shall be allowed to maintain countable assets up to the maximum allowed by federal statutes or regulations with provisions for increase, as allowed by the Secretary of Health and Human Services by means of indexing, court order, or fair hearing. (b) At the time of initial eligibility determination of an institutionalized individual, the total value of assets of both spouses, regardless of how they are held, shall be considered available to the institutionalized individual, except for the community spouse resource allowance, as defined by subsection (a).
UNOFFICIAL 1725.1-33 (c) The assets retained by the community spouse, as allowed by subsection (a), shall not jeopardize the eligibility of the institutionalized individual. After the initial eligibility of the institutionalized individual is established, any assets of the community spouse, which do not include the institutionalized individual as a co-owner, shall not be considered during the continuous period of both eligibility and institutionalization of the institutionalized individual. (d) The post-eligibility interspousal transfer of assets shall be allowed for the legal transfer of assets from the institutionalized individual to the community spouse. After a protected period of ninety days from the date eligibility is determined, which may be extended if there are legal reasons or extenuating circumstances that delay such a transfer,any assets still legally available to the institutionalized individual shall be considered in the determination of continued eligibility of the institutionalized individual. (e) The provisions of subsections (a) through (d) apply to an institutionalized individual who qualifies for long-term care services. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R §431.10, 435.217; 42 U.S.C. §§1315, 1396r-5) (Imp: HRS §346- 29; 42 C.F.R. §435.217; 42 U.S.C. §§1315, 1396r-5)
§17-1725.1-51 Penalty period for the transfer of an asset for less than fair market value. (a) An individual who requests medical assistance for coverage of long-term care services shall be assessed a penalty period for coverage of these services if the individual or the individual’s spouse, transferred an asset for less than fair market value within the applicable look-back period. The length of the look- back period shall be sixty months for an asset transferred on or after February 8, 2006.
UNOFFICIAL 1725.1-34 (b) An asset that was transferred on or after the date of application shall be considered as follows: (1) A penalty period shall be assessed if an individual transfers an asset after being determined eligible for coverage of long- term care services. (2) A penalty period shall not be assessed for the transfer of an asset owned by the community spouse made after the individual has been determined eligible for coverage of long-term care services with the exception of subsection (d). (c) The transfer provision shall apply to an asset held by the individual and the individual’s spouse when any action is taken that reduces or eliminates such individual’s ownership or control of such asset. (d) The transfer provision shall apply to countable assets under this chapter owned by the individual or the individual’s community spouse or both and to the following exempt assets in subchapters 4 and 5: (1) The home property; (2) The value of basic maintenance items essential for day-to-day living including but not limited to clothing, furniture, and appliances; (3) All motor vehicles with the exception of watercrafts or air transportation vehicles, including but not limited to cars, trucks, vans, or motorcycles; (4) The equity value of a bona fide funeral or burial plan or agreement; and (5) The burial space (including plots, vaults, and niches) including those designated for immediate family members. (e) The transfer provision shall apply to the transfer of income of the individual and the individual’s spouse, or their right to receive income, either as a single payment or a stream of income that
UNOFFICIAL 1725.1-35 is countable in determining Medicaid eligibility under chapter 17-1724.1. (f) The unpaid portion of long-term care expenses incurred during a penalty period shall not be deducted in post-eligibility as an incurred medical expense when a penalized individual becomes eligible for coverage of long-term care services. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §431.10; 42 U.S.C. §§1382b(a), (c) and (d), and 1396p(c)) (Imp: 42 U.S.C. §§1382b(a), (c) and (d), and 1396p(c))
§17-1725.1-52 Treatment of annuities. (a) An individual who requires coverage of long-term care services or their community spouse shall disclose whether or not the individual or their community spouse has any ownership interest in annuities at the time of application and at each subsequent redetermination of Medicaid eligibility. (1) An individual shall not be eligible for coverage of long-term care services if the institutionalized individual or their community spouse fails to disclose any interest in an annuity. (2) The disclosure shall be required regardless of whether the annuity is irrevocable or treated as an asset under this chapter. (b) The portion of the funds of an annuity purchased by the institutionalized individual or their community spouse prior to February 8, 2006, that is not actuarially sound and is payable beyond the life expectancy of the annuitant shall be considered transferred. (c) All funds used to purchase an annuity on or after February 8, 2006, by the institutionalized individual or their community spouse shall be considered transferred if the department is not named as a remainder beneficiary in the first position, or in a position behind the community spouse and the institutionalized individual’s minor child under the age of twenty-one years or who is blind or disabled,
UNOFFICIAL 1725.1-36 for the amount of medical assistance paid on behalf of the institutionalized individual. (1) The department shall notify the issuer of an annuity issued on or after February 8, 2006, of the right of the department to be a preferred remainder beneficiary. (2) The issuer may inform other remainder beneficiaries of the department’s remainder interest. (d) Funds used to purchase an annuity on or after February 8, 2006, by the institutionalized individual or the community spouse, or on behalf of the institutionalized individual or their community spouse, shall not be considered transferred if: (1) The annuity is considered: (A) An individual retirement annuity that meets the requirements of section 408(b) of the IRC; or (B) A deemed IRA under a qualified employer plan under section 408(q) of the IRC; or (2) The annuity is purchased with proceeds from one of the following: (A) A traditional IRA under section 408(a) of the IRC; (B) An account or trust which is treated as a traditional IRA under section 408(c) of the IRC; (C) A simplified retirement account under section 408(p) of the IRC; (D) A simplified employee pension under section 408(k) of the IRC; or (E) A Roth IRA under section 408A of the IRC; or (3) The annuity meets all of the following requirements: (A) Is actuarially sound as determined by the department in accordance with actuarial publications of the Office of the Chief Actuary of the Social Security Administration;
UNOFFICIAL 1725.1-37 (B) Is irrevocable, non-assignable and cannot be sold; (C) Makes equal payments throughout the term of the contract and does not defer payments or allow balloon payments; and (D) Cannot be cancelled upon the death of the institutionalized individual or the community spouse. (e) Certain transactions or changes which occur on or after February 8, 2006, that affect the terms of a qualified annuity that was purchased by the institutionalized individual or their community spouse prior to February 8, 2006, shall be considered a transfer of asset to include, but are not limited to the: (1) Course of payment made by the annuity; (2) Treatment of income or principal of the annuity to include additions of principal, elective withdrawals or requests to change the distribution of the annuity; or (3) Election to annuitize the contract. (f) Routine changes or automatic events or both, made by the institutionalized individual or the community spouse for an annuity that was purchased prior to February 8, 2006, that are not considered a transfer of asset include: (1) Routine changes to include, but are not limited to notifications of address change, death, or divorce of a remainder beneficiary. (2) Changes based on the terms of an annuity which existed prior to February 8, 2006, which do not require a decision, election or action to be effective. (3) Changes that are beyond the control of the institutionalized individual or the community spouse to include, but are not limited to, changes in the law or the issuer’s policies. (g) Transactions or changes made for annuities purchased prior to February 8, 2006, that do not meet the criteria of subsection (f) of this section as well
UNOFFICIAL 1725.1-38 as a qualified annuity that is transferred to anyone except the community spouse or to another individual for the sole benefit of the community spouse, the individual’s child, or to a trust as described in section 1917(c)(2)(B) of the Social Security Act, shall be treated as a transfer of asset. [Eff 09/30/13](Auth: HRS §346-14; 42 C.F.R. §431.10; 42 U.S.C. §§1396(a), 1396p(c) and (e), 1396r-5(c)) (Imp: 42 U.S.C. §§1396(a), 1396p(c) and (e), 1396r- 5(c))
§17-1725.1-53 Treatment of promissory notes, loans and mortgages. (a) The assets used by an individual who requires coverage of long-term care services or their community spouse, to secure a promissory note, loan or mortgage on or after February 8, 2006, shall not be considered transferred if all of the following conditions apply to the promissory note, loan or mortgage: (1) The repayment term is actuarially sound; (2) It is irrevocable and cannot be sold; (3) Equal payments are made throughout the term of the contract with no deferral or balloon payments; and (4) The balance cannot be cancelled upon the death of the institutionalized individual or the community spouse. (b) If the provisions of subsection (a) are not met, the transferred amount is equal to the outstanding balance owed as of the date of the individual’s request for coverage of long-term care services. (c) The portion of the funds used to secure a promissory note, loan or mortgage prior to February 8, 2006, that is not actuarially sound and is payable beyond the life expectancy of the owner of the funds shall be considered transferred. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §431.10; 42 U.S.C. §1396p(c)) (Imp: 42 U.S.C. §1396p(c))
UNOFFICIAL 1725.1-39 §17-1725.1-54 Treatment of the purchase of a life interest in the home property of another. (a) The funds used by the individual who requires coverage of long-term care services or their community spouse to purchase a life interest in the home property of another, on or after February 8, 2006, shall be considered transferred if the purchaser did not reside on the property for a period of at least one year after the date of the purchase. (b) For the purchase of a life interest in the property of another made on or after February 8, 2006 that meet the requirements of subsection (a), the portion of the funds that exceed the value of the life interest property based on the life estate tables published by the SSA, shall be treated as transferred assets. (c) The portion of the funds used to purchase a life interest in the property of another by the individual or the individual’s spouse prior to February 8, 2006, that exceed the value of the life interest in the property based on the life estate tables published by the Social Security Administration, shall be treated as a transferred asset. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §431.10; 42 U.S.C. §1396p(c)) (Imp: 42 U.S.C. §1396p(c))
§17-1725.1-55 Treatment of the transfer of income. (a) A transfer of asset penalty period shall be assessed if the institutionalized individual or their community spouse transferred: (1) Lump sum payments received in the month; or (2) An entitled stream of income (disclaimed or voluntarily agreed). (b) The penalty period for the transfer of income shall be calculated by dividing the amount of income by the statewide average monthly cost of nursing facility services assessed to a private patient at the time the individual requests coverage of long-term care services. Disposal of such lump sum
UNOFFICIAL 1725.1-40 payments or the entitled stream of income constitutes a transfer of asset. (c) The amount of income used to calculate a penalty period shall be: (1) The gross amount of the lump sum income transferred in the month it was received; or (2) The total gross amount of income expected to be received during the individual’s lifetime when the entitled stream of income was transferred, which is calculated by multiplying the annual amount of income expected to be received during the individual’s lifetime based on the life expectancy tables established by the Social Security Administration's Office of the Actuary. [Eff 09/30/13] (Auth: HRS §346- 14; 42 C.F.R. §431.10; 42 U.S.C. §1396p(c)) (Imp: 42 C.F.R. §431.10; 42 U.S.C. §1396p(c))
§17-1725.1-56 Transfer of assets that are not subject to the assessment of a penalty. A penalty period shall not be applied when: (1) The asset transferred was the individual’s home property and title was transferred to the: (A) Spouse of such individual; (B) Child of such individual who is under age twenty-one years, or a blind or disabled child; (C) A sibling of such individual who has an equity interest in the home, and has resided in the home for at least one year immediately prior to the date the individual becomes an institutionalized individual; or (D) An adult child of such individual, other than a child described in paragraph (B), who has resided in the home with the individual for at least two years immediately prior to the date
UNOFFICIAL 1725.1-41 the individual becomes an institutionalized individual and who provided care which allowed the individual to reside at home. (2) The asset, other than a home, was transferred: (A) To the individual’s community spouse or to another individual or entity for the sole benefit of the community spouse; (B) From the community spouse to another individual or entity for the sole benefit of the community spouse; (C) To the individual’s child who is under age twenty-one years, a blind or disabled child, or to a trust established after August 10, 1993, for the child; or (D) To a trust established after August 10, 1993, solely for the benefit of an individual under age sixty-five years who is disabled as defined in section 17-1719-10. (3) The individual can substantiate that the individual intended to transfer the asset: (A) At either fair market value, or for other valuable consideration by providing substantiated evidence of attempts to dispose of the asset for fair market value, as well as evidence to support the value at which the asset was disposed; or (B) The asset was transferred exclusively for a purpose other than to qualify for medical assistance by providing convincing evidence as to the specific purpose for which the asset was transferred. (4) Circumstances that meet the requirements of this subsection include, but are not limited to:
UNOFFICIAL 1725.1-42 (A) The individual did not require long- term care services at the time of the transfer; (B) The individual was living independently at the time of the transfer; (C) The individual did not have a pre- existing condition that could have led to the need for long-term care or assisted living services at the time of the transfer; (D) The transfer was not within the individual's control (e.g. court ordered); or (E) A diagnosis of a previously undetected disabling condition that led to the need for long-term care services occurred after the date of transfer. (5) The asset transferred for less than fair market value has been returned. (A) The returned asset must be evaluated for the impact on the individual’s eligibility for Medicaid. (B) If the entire transferred asset has been returned, the penalty period is negated. Coverage of long-term care services shall be provided for any portion of a penalty period that was applied prior to the return of the asset. (C) If only a portion of the transferred asset has been returned, and the individual is eligible for coverage of long-term care services, the penalty period shall be recalculated based upon the balance of the unreturned asset. (i) The end date of the recalculated penalty period shall be applicable if it exceeds the amount of the penalty period already applied; and (ii) Coverage of long-term services shall be provided for the portion
UNOFFICIAL 1725.1-43
of the penalty period that exceeds the end date of the recalculated penalty period.
[Eff 09/30/13] (Auth: HRS §346- 14; 42 C.F.R. §431.10; 42 U.S.C. §1396p(c)) (Imp: 42 C.F.R. §431.10; 42 U.S.C. §1396p(c))
§17-1725.1-57 Determining a penalty period. (a) A penalty period shall be calculated by dividing the total uncompensated value of the asset transferred, by the statewide average monthly cost of nursing facility services assessed to a private patient at the time the individual requests and is determined eligible for the coverage of long-term care services. (b) A penalty period that results in a partial month penalty shall not be rounded down or disregarded. (c) A penalty period established for an asset that was transferred, shall be applied as follows: (1) The value of all non-exempt transfers during the applicable look-back period specified in subsection 17-1725.1-51(a) shall be combined and a single penalty period shall be determined. (2) A separate penalty period shall be determined for non-exempt transfers which occurred while a penalty is being applied for a previous transfer by an individual determined eligible for coverage of long- term care services. (3) The penalty period shall commence the later of: (A) The date of request for long-term care services; (B) The date the individual would be eligible for coverage of long-term care services but a penalty is being imposed under this subchapter; or
UNOFFICIAL 1725.1-44 (C) The date a negative action can be taken in situations when timely notice of adverse action is required for the individual currently receiving coverage of long-term care services. (4) A penalty period that would commence within the term of another penalty period shall commence at the end of the prior penalty period. (d) An established penalty period shall continue to run, regardless of whether the penalized individual no longer is eligible for medical assistance, or is not receiving long-term care services. (e) The department shall send a denial notice to an individual requesting coverage of long-term care services, or an adverse action notice to an individual who is receiving coverage for long-term care services when imposing a penalty period. The notices shall meet the requirements of chapter 17-1713.1, and must inform the individual of: (1) The type and amount of the transferred asset used to determine the penalty period; (2) The length of the penalty period; (3) The start and end date of the penalty period; (4) The authority under the Hawaii administrative rules to impose the negative action; and (5) The individual’s right to request a hardship waiver of the penalty period. (f) If the spouse of a penalized individual becomes eligible for coverage of long-term care services, the remaining penalty period may be allocated between both spouses. (g) If one of the spouses should die before completing the allocated penalty period, the remaining spouse shall be allocated the balance remaining for the deceased spouse. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §431.10; 42 U.S.C. §1396p(c)) (Imp: 42 C.F.R. §431.10; 42 U.S.C. §1396p(c))
UNOFFICIAL 1725.1-45 §17-1725.1-58 Waiver of a transfer of asset penalty period due to undue hardship. (a) A penalty period may be waived if the department determines that the imposition of the penalty will cause undue hardship for the individual. (b) Undue hardship exists if the application of a penalty period would deprive the individual of: (1) Medical care such that the individual’s life or health would be endangered; or (2) Food, clothing, shelter, or other necessities of life. (c) A waiver of a penalty period due to undue hardship may be granted if the individual provides satisfactory evidence to the department that the asset transferred: (1) Has been depleted below the resource standard specified in section 17-1725.1-43; (2) Has been converted to another asset that is not liquid or redeemable; (3) The return of the transferred assets would put the receiving party in serious deprivation such that the loss of income or the asset would qualify the receiving party for medical assistance; (4) The receiving party cannot be located by the individual or another including but not limited to the individual’s spouse, other family member, representative, or an agent of the nursing facility, after all attempts to locate the receiving party have been exhausted; or (5) The asset was transferred due to theft, fraud, or financial exploitation upon the individual or their community spouse. (d) The process for requesting and reviewing a waiver of a penalty period imposed for a transfer of asset due to undue hardship is as follows: (1) The department shall send the individual a notice of denial or a notice of adverse action according to the requirements of chapter 17-1713.1 to inform the individual of the establishment of the penalty period
UNOFFICIAL 1725.1-46 and the individual’s right to request a hardship waiver. (2) The individual shall have twenty calendar days from the mailing of the notice of denial or adverse action as specified in paragraph (1) to request a hardship waiver and provide all documentation to support the basis of a hardship waiver request. (3) The department shall make a determination to grant a hardship waiver within ten business days after receiving the waiver request and supporting documentation. (4) An individual who is denied a hardship waiver shall be informed of the enforcement date of the penalty period and the right to request a fair hearing under chapter 17- 1703.1. (e) Nursing facilities may request a hardship waiver on behalf of their resident with the written consent of the resident or the resident’s personal representative and may represent the resident or the resident’s personal representative throughout the appeals process. [Eff 09/30/13] (Auth: HRS §346- 14; 42 C.F.R. §431.10; 42 U.S.C. §1396p(c)) (Imp: 42 C.F.R. §431.10; 42 U.S.C. §1396p(c))
§17-1725.1-59 Individual with substantive equity in a home property. (a) An individual shall not be eligible for coverage of long-term care services if the individual’s home equity interest exceeds $750,000. (b) The individual’s home equity interest shall be determined by the fair market value less encumbrances. (c) The provisions of this subsection do not apply if the individual’s spouse, a child under age twenty-one years, a blind child, or a disabled child is residing in the individual’s home. (d) An individual affected by the provisions of this subsection is allowed to reduce their equity in
UNOFFICIAL 1725.1-47 the home property through the use of a reverse mortgage or a home equity loan without penalty. (e) An individual affected by this subsection has the right to file for a waiver due to demonstrated hardship by which the individual is legally barred from taking action to access the equity in the property. (f) Effective 2011, the amount of the equity interest shall be subject to increase each calendar year based on the percentage increase in the consumer price index for all urban consumers, rounded to the nearest $1,000. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §431.10; 42 U.S.C. §1396p(c)) (Imp: 42 U.S.C. §1396p(c))
§17-1725.1-60 Waiver of excess home equity due to undue hardship. (a) The denial for the coverage of long-term care services may be waived if the department determined that the imposition of ineligibility will cause the individual undue hardship. (b) Undue hardship exists if the denial of coverage of long-term care services would deprive the individual of: (1) Medical care such that the individual’s life or health would be endangered; or (2) Food, clothing, shelter, or other necessities of life. (c) Undue hardship may be granted if the individual provides a written statement with satisfactory evidence to the department of the legal inaccessibility of the excess home equity through any means provided by the individual, spouse, legal representative or authorized representative from the nursing facility. (d) The process for requesting and reviewing a waiver of ineligibility due to excess home equity is as follows: (1) The department shall send the individual a notice of denial or a notice of adverse action according to the requirements of
UNOFFICIAL 1725.1-48 chapter 17-1713.1 to inform the individual of ineligibility due to excess home equity and of the individual’s right to request a hardship waiver. (2) The individual shall have twenty calendar days from the mailing of the denial or adverse notice as specified under paragraph (1) to request a hardship waiver and provide all documentation to support the basis of the hardship waiver request. (3) The department shall make a determination of whether to grant a hardship waiver within ten business days after receiving the waiver request and supporting documentation. (4) An individual who is denied a hardship waiver shall be informed of the right to request a fair hearing under chapter 17- 1703.1. (e) Nursing facilities may request a hardship waiver on behalf of their resident with specific written consent of the resident or the resident’s personal representative and may represent the resident or the resident’s personal representative throughout the appeals process. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §431.10; 42 U.S.C. §1396p(c)) (Imp: 42 C.F.R. §431.10; 42 U.S.C. §1396p(c))
§§17-1725.1-61 to 17-1725.1-65 (Reserved).
UNOFFICIAL 1730.1-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1730.1
MEDICALLY NEEDY SPENDDOWN
Subchapter 1 General Provisions
§17-1730.1-1 Purpose §17-1730.1-2 General requirements §§17-1730.1-3 to 17-1730.1-7 (Reserved)
Subchapter 2 Eligibility Requirements
§17-1730.1-8 Purpose §17-1730.1-9 Basic requirements §17-1730.1-10 Categorical requirements §17-1730.1-11 Income requirements §17-1730.1-12 Asset Requirements §17-1730.1-13 Spenddown calculation for continued eligibility §§17-1730.1-14 to 17-1730.1-18 (Reserved)
Subchapter 3 Freedom of Choice, Enrollment, Benefits, and Disenrollment
§17-1730.1-19 Purpose §17-1730.1-20 Freedom of choice §17-1730.1-21 Enrollment §17-1730.1-22 Benefits §17-1730.1-23 Disenrollment from a health plan §§17-1730.1-24 to 17-1730.1-28 (Reserved)
Historical Note: This chapter is based substantially upon repealed chapter 17-1730. [Eff 12/27/97;
UNOFFICIAL 1730.1-2 am 07/06/99; am 06/19/00; am 12/03/01; am 05/10/03; am 01/31/09; am 06/11/09; am 09/10/09; R 09/30/13]
SUBCHAPTER 1
GENERAL PROVISIONS
§17-1730.1-1 Purpose. This chapter describes the spenddown of excess income for children under age nineteen years, pregnant women, and aged, blind or disabled (ABD) individuals with incurred medical expenses to qualify for medical assistance who are ineligible to participate in a coverage group established under the provisions of the Affordable Care Act of 2010, or the mandatory or optional categorically needy coverage group under Title XIX of the Social Security Act. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.2, 435.301, 435.310, 435.320, 435.322, 435.324) (Imp: HRS §346-14; 42 C.F.R. §§435.2, 435.301, 435.310, 435.320, 435.322, 435.324)
§17-1730.1-2 General requirements. The confidentiality, administrative appeal, fraud, medical assistance recovery, application, eligibility review, and adverse action provisions described in subtitle 12 shall pertain to an individual who applies or is eligible under this chapter. [Eff 09/30/13] (Auth: HRS §§346-14, 346-29, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.116, 435.201, 435.907, 435.916, 455.1) (Imp: HRS §§346-14, 346-29, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.116, 435.201, 435.907, 435.916, 455.1)
§§17-1730.1-3 to 17-1730.1-7 (Reserved).
SUBCHAPTER 2 ELIGIBILITY REQUIREMENTS
§17-1730.1-8 Purpose. This subchapter describes the requirements for participation under this chapter.
UNOFFICIAL 1730.1-3 [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.2 435.301, 435.811) (Imp: HRS §346-14; 42 C.F.R. §§435.2 435.301, 435.811)
§17-1730.1-9 Basic requirements. An individual shall meet the basic eligibility requirements which include but are not limited to, citizenship, state residency, verification of identity, not residing in a public institution, and the provision of a social security number, as described in chapter 17-1714.1. [Eff 09/30/13] (Auth: HRS §§346-14, 346-29; 42 C.F.R. §§435.110, 435.400, 435.910) (Imp: HRS §§346- 14, 346-29; 42 C.F.R. §§435.110, 435.400, 435.910)
§17-1730.1-10 Categorical requirements. An individual eligible to participate under this chapter would otherwise be eligible under chapters 17-1715, 17- 1716 or 17-1719 except for having income in excess of the applicable income standard but is insufficient to meet incurred medical expenses which are likely to be required on a continuing basis. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 435.301, 435.310, 435.320, 435.322, 435.324) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 435.301, 435.310, 435.320, 435.322, 435.324)
§17-1730.1-11 Income requirements. (a) The maximum allowable countable income, prior to spenddown, determined under the provisions of chapter 17-1724.1 for eligibility under this chapter is: (1) Three hundred percent of the Federal Poverty Level for a child, or pregnant woman; or (2) For an aged, blind, or disabled individual, no maximum shall be considered. Unlimited for an aged, blind, or disabled individual. (b) The amount of the individual’s monthly countable income that exceeds the medically needy income standard of a household of applicable size shall be the excess income amount. (c) The medically needy income standard as determined by the department in compliance with federal regulations related to the financial assistance program, shall serve as the maximum retainable income for an individual or household of applicable size.
UNOFFICIAL 1730.1-4 [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.2 435.602, 435.811, 435.814, 435.831; 45 C.F.R. 233.20) (Imp: HRS §346-14; 42 C.F.R. §§435.2 435.602, 435.811, 435.814, 435.831; 45 C.F.R. 233.20)
§17-1730.1-12 Asset requirements. The countable assets of an individual shall follow the personal reserve requirements described in chapter 17-1719 and the provisions under chapter 17-1725.1 for a household of applicable size. [Eff 09/30/13] (Auth: HRS §346- 14; 42 C.F.R. §§430.25, 435.602, 435.840, 435.843, 435.845) (Imp: HRS §346-14; 42 C.F.R. §§435.2, 435.602, 435.840, 435.843, 435.845)
§17-1730.1-13 Spenddown calculation for continued eligibility. (a) An individual’s excess income is the countable income which exceeds the medically needy income standard for the household of applicable size. (b) Medical expenses incurred by an individual or financially responsible relative not subject to payment by a third party shall be deducted from the excess income in the following order: (1) Expenses for Medicare and other health insurance premiums, deductibles or co-insurance charges including enrollment fees and co-payments. Payments made quarterly or for longer intervals shall be pro-rated on a monthly basis. (2) Necessary medical and remedial services recognized under State law but not included in the department’s medical assistance plan to include expenses prior to the month of application not previously considered that remain a liability. (3) Necessary medical and remedial services that exceed the department’s medical assistance plan in regards to amount, duration or scope of services to include expenses prior to the month of application not previously considered that remain a liability. (c) An employer’s contribution to a health plan and any premium voluntarily paid in whole or in part
UNOFFICIAL 1730.1-5 by someone other than the individual shall not be deducted from excess income. (d) Evidence of medical services received shall be required to determine eligibility for a given month. (e) The number of unborn child(ren) shall be included in the household for a pregnant woman only. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.2, 435.831) (Imp: HRS §346-14; 42 C.F.R. §§435.2, 435.831)
§§17-1730.1-14 to 17-1730.1-18 (Reserved).
SUBCHAPTER 3
FREEDOM OF CHOICE, ENROLLMENT, BENEFITS, AND DISENROLLMENT
§17-1730.1-19 Purpose. This subchapter addresses and refers to the provisions of freedom of choice, enrollment, benefits, and disenrollment for an individual who is eligible in accordance with this chapter. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.2) (Imp: HRS §346-14; 42 C.F.R. §430.25)
§17-1730.1-20 Freedom of choice. (a) An eligible child or pregnant woman, described in section 17-1730.1-11(a)(1), and an aged, blind and disabled individual described in chapter 17-1719 with the exception of those described in section 17-1735.1-2(a) shall be provided a choice of a health plan and a provider as described in chapter 17-1720.1. (b) An eligible aged, blind or disabled individual described in section 17-1735.1-2(a) shall choose a department approved provider described in section 17-1736-3. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.2, 431.51, 438.52, 447.51) (Imp: HRS §346-14; 42 C.F.R. §§435.2, 431.51, 438.52, 447.51)
UNOFFICIAL 1730.1-6
§17-1730.1-21 Enrollment. (a) The effective date of coverage or enrollment is the date on which the spenddown amount was met. (b) An individual eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735.1-2(a), shall be enrolled in a health plan as described in chapter 17-1720.1. (c) An eligible individual described in section 17-1735.1-2(a) shall not be enrolled into a health plan and services shall be provided on a fee-for-service basis. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.2, 431.10, 438.50) (Imp: HRS §346-14; 42 C.F.R. §435.2, 431.10, 438.50)
§17-1730.1-22 Benefits. (a) An individual eligible in accordance with this chapter, with the exception of those described in section 17-1735.1-2(a), shall be provided a standard benefits package by a participating health plan and other services when appropriate as described in chapter 17-1720.1. (b) An eligible individual described in section 17-1735.1-2(a) shall be provided benefits under the fee-for-service provisions described in chapter 17- 1737, with the exception of services identified in section 17-1735.1-3(b). [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.2, 431.10, 438.6, 440.1) (Imp: HRS §346-14; 42 C.F.R. §§435.25, 431.10, 438.6, 440.1)
§17-1730.1-23 Disenrollment from a health plan. An enrollee shall be disenrolled from a health plan under the provisions as described in chapter 17-1720.1. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.2 431.40, 438.56) (Imp: HRS §346-14; 42 C.F.R. §§435.2 431.40, 438.56)
§§17-1730.1-24 to 17-1730.1-28 (Reserved).
UNOFFICIAL
HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1731
PREMIUM ASSISTANCE PROGRAM
§17-1731-1 Purpose §17-1731-2 Definitions §17-1731-3 Eligibility requirements §17-1731-4 Benefits §17-1731-5 Termination of premium assistance §17-1731-6 Administration of the premium
assistance program §17-1731-7 Appeal process §§17-1731-8 to 17-1731-10
(Reserved)
§17-1731-1 Purpose. This chapter establishes, subject to the availability of State funds, a premium assistance program for a low-income individual who purchases a silver level qualified health plan through the Hawaii health insurance exchange and receives advanced premium tax credit (APTC) and maximum cost- sharing reduction (CSR). The department shall pay the eligible individual’s share of the premium to the qualified health plan in which the eligible individual is enrolled. [Eff 02/27/15 ] (Auth: HRS §346- 14) (Imp: HRS §346-14)
§17-1731-2 Definitions. The following definitions shall apply to this subchapter: 1731-1
UNOFFICIAL
“Exchange” means the Hawaii health insurance exchange established under the Affordable Care Act. “Qualified health plan” means a qualified health plan or a qualified health plan issuer, as those terms are defined in 45 C.F.R. §155.20, and as the context may dictate. [Eff 02/27/15 ] (Auth: HRS §346.14) (Imp: HRS §346.14)
§17-1731-3 Eligibility requirements. To be eligible for the premium assistance described in this chapter, an individual shall: (1) Have selected or be enrolled in a 94% actuarial value silver level qualified health plan through the Exchange; (2) Be determined eligible for advanced premium tax credit (APTC), apply the maximum APTC amount available towards their premium and the maximum cost-sharing reduction (CSR) by the Exchange; (3) Have household income of less than one hundred percent of the federal poverty level for the applicable household size as determined by the Exchange and communicated by the Exchange to the qualified health plan selected by the individual. [Eff 02/27/15 ] (Auth: HRS §346.14) (Imp: HRS §346.14)
§17-1731-4 Benefits. (a) The department shall, upon presentation of an invoice by a qualified health plan to the department, pay the share of premium that the eligible individual is required to pay to the qualified health plan to receive coverage. (b) Benefit limitations: 1731-2
UNOFFICIAL
(1) The department shall pay an eligible individual's share of premium to the qualified health plan only upon receipt of an invoice submitted by the qualified health plan to the department; (2) The department shall not make any payments directly to eligible individuals; and (3) The department shall not pay and the eligible individual shall be responsible for, any cost-sharing including, but not limited to, deductibles, co-payments or co- insurance. (c) The department is not responsible for ensuring that the qualified health plan timely submits an invoice for an eligible individual's share of premium to the department. [Eff 02/27/15 ] (Auth: HRS §346-14) (Imp: HRS §346-14)
§17-1731-5 Termination of premium assistance. Premium assistance payable under this chapter on behalf of an eligible individual shall be terminated at any time for any of the following reasons: (1) The individual fails to meet the eligibility requirements set forth in section 17-1731-3; (2) The individual voluntarily terminates participation in the premium assistance program; (3) The individual no longer resides in the State; (4) Death of the individual; (5) The individual's whereabouts are unknown; (6) Insufficient State funds; or (7) The premium assistance program is terminated. [Eff 02/27/15 ] (Auth: HRS §346-14) (Imp: HRS §346-14)
§17-1731-6 Administration of the premium assistance program. (a) The department may contract with a third party or parties to administer any 1731-3
UNOFFICIAL
component of this program, including, but not limited to, payment, auditing, and recovery. (b) The department's provision of premium assistance under this chapter shall be administered at no cost to the eligible individual. [Eff 02/27/15 ] (Auth: HRS §346-14) (Imp: HRS §346-14)
17-1731-7 Appeal process. (a) An eligible individual may appeal the department’s failure to pay the benefit described in section 17-1731-4 only as provided in this section. (b) Issues relating to the determination of an individual's household income by the Exchange under section 17-1731-3(3) must be directed to the Exchange. (c) Issues relating to a qualified health plan requiring premium payment from an eligible individual must be directed to the qualified health plan before requesting informal review or an administrative hearing under this section. (d) Requests for an informal review or administrative hearing under this chapter may be submitted by an eligible individual or the individual’s authorized representative only when: (1) The qualified health plan is requiring premium payment from the eligible individual; and (2) The qualified health plan states in writing that the reason for requiring premium payment is because the department did not timely pay an invoice that was submitted by the individual's health plan to the department. (e) An eligible individual or the individual’s authorized representative may request an informal review. (1) A request for an informal review must: 1731-4
UNOFFICIAL
(A) Be submitted in writing and received by the department within thirty (30) calendar days after the date of the bill sent by the qualified health plan to the individual. (B) Include both a copy of the bill sent by the qualified health plan to the individual and a copy of the notice from the qualified health plan stating that the individual was sent a bill because the department did not timely pay the health plan’s invoice. (2) The eligible individual is not required to seek an informal review prior to filing a request for an administrative hearing. (3) The department shall respond in writing to the request for an informal review and provide notice to the eligible individual of the right to request an administrative hearing under subsection (f). An individual shall have fifteen (15) calendar days from the date of the informal review decision to file a request for an administrative hearing. (f) An eligible individual or the individual’s authorized representative may file a request for an administrative hearing. (1) A request for an administrative hearing must: (A) Be submitted in writing and received by the department within thirty (30) calendar days after the date of the bill sent by the qualified health plan to the individual, or within fifteen (15) calendar days from the date of the decision notice for an informal review. (B) Include both a copy of the bill sent by the qualified health plan to the individual and a copy of the notice from the health plan stating that the individual was sent a bill because the 1731-5
UNOFFICIAL
department did not timely pay the health plan’s invoice. (2) The provisions of chapter 17-1703.1 shall not apply to appeals under this chapter, except for section 17-1703.1-6. [Eff 02/27/15 ] (Auth: HRS §346-14) (Imp: HRS §346-12)
§§17-1731-8 to 17-1731-10 (Reserved) 1731-6
UNOFFICIAL 1733.1-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1733.1
COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER
Subchapter 1 General Provisions
§17-1733.1-1
Purpose §17-1733.1-2
General requirements §§17-1733.1-3 to 17-1733.1-7 (Reserved)
Subchapter 2 Eligibility Requirements
§17-1733.1-8
Purpose §17-1733.1-9
Basic requirements §17-1733.1-10 Categorical requirements §17-1733.1-11 Non-financial eligibility requirements and date of coverage §17-1733.1-12 Income and asset requirements §17-1733.1-13 Eligibility review §§17-1733.1-14 to 17-1733.1-18 (Reserved)
Subchapter 3 Freedom of Choice, Enrollment, Benefits and Disenrollment
§17-1733.1-19 Purpose §17-1733.1-20 Freedom of choice §17-1733.1-21 Enrollment into a participating health plan §17-1733.1-22 Benefits §17-1733.1-23 Disenrollment from a health plan
UNOFFICIAL 1733.1-2 §§17-1733.1-24 to 17-1733.1-28 (Reserved)
Historical Note: This chapter is based substantially upon repealed chapter 17-1733. [Eff 02/16/02; am 05/10/03; am 01/31/09; am 06/11/09; R 09/30/13]
SUBCHAPTER 1
GENERAL PROVISION
§17-1733.1-1 Purpose. The purpose of this chapter is to establish coverage for an individual who is eligible for the Centers for Disease Control and Prevention (CDC) breast and cervical cancer early detection program (BCCEDP) and was found through that program to have cancer or a precancerous condition of the breast or cervix, requires treatment, and meets the eligibility requirements of this chapter. [Eff 09/30/13] (Auth: HRS §346-14; 42 CFR §435.213) (Imp: HRS §346-14; 42 CFR §435.213)
§17-1733.1-2 General requirements. The confidentiality, administrative appeal, fraud, medical assistance recovery, application processing, eligibility review, and adverse action notice provisions described in subtitle 12 shall pertain to an individual who applies or is eligible for coverage under this chapter. [Eff 09/30/13] (Auth: HRS §§346-14, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.116, 435.201, 435.907, 435.916, 455.) (Imp: HRS §§346-14, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.116, 435.201, 435.907, 435.916, 455.1)
§§17-1733.1-3 to 17-1733.1-7 (Reserved).
SUBCHAPTER 2
UNOFFICIAL 1733.1-3 ELIGIBILITY REQUIREMENTS
§17-1733.1-8 Purpose. This subchapter describes the eligibility requirements for participation in accordance with this chapter. [Eff 09/30/13] (Auth: HRS §346-14; 42 CFR §435.213) (Imp: HRS §346-14; 42 CFR §435.213)
§17-1733.1-9 Basic requirements. An individual shall meet the basic eligibility requirements, which include but are not limited to, citizenship, qualified non-citizen status, state residency, verification of identity, not residing in a public institution and the provision of a social security number, as described in chapter 17-1714.1. [Eff 09/30/13] (Auth: HRS §§346-14, 346-29; 42 C.F.R. §§435.110, 435.400, 435.910) (Imp: HRS §§346-14, 346-29; 42 C.F.R. §§435.110, 435.400, 435.910)
§17-1733.1-10 Categorical requirements. (a) An individual shall meet the following requirements: (1) Under age sixty-five; (2) Eligible and screened for breast or cervical cancer or a precancerous condition of the breast or cervix by an authorized CDC BCCEDP; (3) Require treatment for breast or cervical cancer or a precancerous condition of the breast or cervix; (4) Not otherwise covered under creditable coverage; and (5) Not eligible under any other Medicaid coverage group. (b) A new period of eligibility may be established for an individual who is screened by an authorized CDC BCCEDP with a recurrence or a new occurrence of breast or cervical cancer or a precancerous condition of the breast or cervix that requires treatment and meets the provisions of subsection (a). [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§435.213) (Imp: HRS §346-14; 42 C.F.R. §§435.213)
UNOFFICIAL 1733.1-4 §17-1733.1-11 Non-financial eligibility requirements and effective date of coverage. (a) An individual who is determined eligible in accordance with this chapter shall remain eligible while receiving required treatment. (1) Breast or cervical cancer shall be medically reevaluated annually by a treating physician to verify and confirm the need for continued treatment at the time of the annual eligibility review; or (2) A precancerous condition of the breast or cervix shall be medically reevaluated at six-month intervals by a treating physician to verify and confirm the need for continued treatment, and one of the reevaluations shall coincide with the annual eligibility review. (b) Eligibility shall be effective retroactively to the date the individual is screened and initially diagnosed with breast or cervical cancer or a precancerous condition of the breast or cervix by the authorized CDC BCCEDP or ten calendar days immediately prior to the date the application is received by the department as described in chapter 1720.1, whichever occurs first. [Eff 09/30/13] (Auth: HRS §346-14; 42 CFR §§430.25, 431.40, 435.213, 438.6) (Imp: HRS §346-14; 42 CFR §§430.25, 431.40, 435.213, 438.6)
§17-1733.1-12 Income and asset requirements. An individual’s household income and assets shall not be considered in determining eligibility for participation in this chapter. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §430.25) (Imp: HRS §346-14; 42 C.F.R. §430.25)
§17-1733.1-13 Eligibility review. (a) An individual eligible under the provisions of this chapter shall receive an annual eligibility review every twelve months. (b) Eligibility shall be redetermined in accordance with chapter 17-1712.1 and subchapter 5 of chapter 17-1714.1. [Eff 09/30/13] (Auth: HRS
UNOFFICIAL 1733.1-5 §346-14; 42 C.F.R. §§435.213, 435.916) (Imp: HRS §346- 14; 42 C.F.R. §§435.213, 435.916)
§§17-1733.1-14 to 17-1733.1-18 (Reserved).
SUBCHAPTER 3
FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT
§17-1733.1-19 Purpose. This subchapter addresses the provisions of freedom of choice, enrollment, benefits and disenrollment for an individual eligible in accordance with this chapter. [Eff 09/30/13] (Auth: HRS §346-14; 42 CFR §435.213) (Imp: HRS §346-14; 42 CFR §435.213)
§17-1733.1-20 Freedom of choice. (a) An individual eligible in accordance with this chapter shall be provided a choice of a health plan and a provider as described in chapter 17-1720.1. (b) An individual identified in section 17- 1735.1-2(a) shall choose a department approved provider as described in chapter 17-1736. [Eff 09/30/13] (Auth: HRS §346-14; 42 CFR §§430.25, 431.51, 438.52) (Imp: HRS §346-14; 42 CFR §§430.25, 431.51, 438.52)
§17-1733.1-21 Enrollment into a participating health plan. (a) An individual eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735.1-2(a), shall be enrolled in a health plan as described in chapter 17-1720.1. (b) An individual identified in section 17- 1735.1-2(a) shall not be enrolled into a health plan and services shall be provided on a fee-for-service basis. [Eff 09/30/13] (Auth: HRS §346-14; 42
UNOFFICIAL 1733.1-6 CFR §§430.25, 431.10, 431.40, 438.50) (Imp: HRS §346- 14; 42 CFR §§430.25, 431.10, 431.40, 438.50)
§17-1733.1-22 Benefits. (a) An individual enrolled in a health plan shall be provided a standard benefits package by a participating health plan and other services when appropriate as described in chapter 17-1720. (b) An individual identified in section 17- 1735.1-2(a) shall be provided coverage under the fee- for-service provisions as described in chapter 17- 1737. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6)
§17-1733.1-23 Disenrollment from a health plan. An enrollee shall be disenrolled from a health plan under the provisions as described in chapter 17- 1720.1. [Eff 09/30/13] Auth: HRS§346-14; 42 CFR §§430.25, 431.40, 438.56) (Imp: HRS §346-14; 42 CFR §§430.25, 431.40, 438.56)
§§17-1733.1-24 to 17-1733.1-28 (Reserved).
UNOFFICIAL 1734.1-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1734.1
STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER
Subchapter 1 General Provisions
§17-1734.1-1
Purpose §17-1734.1-2
General requirements §§17-1734.1-3 to 17-1734.1-7 (Reserved)
Subchapter 2 Eligibility Requirements
§17-1734.1-8
Purpose §17-1734.1-9
Basic requirements §17-1734.1-10 Categorical requirements §17-1734.1-11 Non-financial eligibility requirements and effective date of coverage §17-1734.1-12 Income and asset requirements §17-1734.1-13 Eligibility review §§17-1734.1-14 to 17-1734.1-18
(Reserved)
Subchapter 3 Freedom of Choice, Enrollment, Benefits and Disenrollment §17-1734.1-19 Purpose §17-1734.1-20 Freedom of choice §17-1734.1-21 Enrollment into a participating health plan §17-1734.1-22 Benefits §17-1734.1-23 Disenrollment from a health plan
UNOFFICIAL 1734.1-2 §§17-1734.1-24 to 17-1734.1-28
(Reserved)
Historical Note: This chapter is based substantially upon repealed chapter 17-1734. [Eff 02/16/02; am 05/10/03; am 01/31/09; am 06/11/09; R 09/30/13]
SUBCHAPTER 1
GENERAL PROVISION
§17-1734.1-1 Purpose. The purpose of this chapter is to establish a State funded medical assistance program for an individual who meets the requirements under chapter 17-1733.1 except for citizenship status and the eligibility requirements of this chapter. [Eff 09/30/13] (Auth: HRS §§346-14, 346-59.2) (Imp: HRS §§346-14, 346-59.2)
§17-1734.1-2 General requirements. The confidentiality, administrative appeal, fraud, medical assistance recovery, application processing, eligibility review, and adverse action notice provisions described in subtitle 12 shall pertain to an individual who applies or is eligible for coverage under this chapter. [Eff 09/30/13] (Auth: HRS §§346-14, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.116, 435.201, 435.907, 435.916, 455.1) (Imp: HRS §§346-14, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.116, 435.201, 435.907, 435.916, 455.1)
§§17-1734.1-3 to 17-1734.1-7 (Reserved).
SUBCHAPTER 2
ELIGIBILITY REQUIREMENTS
UNOFFICIAL 1734.1-3 §17-1734.1-8 Purpose. This subchapter describes the eligibility requirements for participation in accordance with this chapter. [Eff 09/30/13] (Auth: HRS §§346-14; 346-59.2) (Imp: HRS §§346-14; 346-59.2)
§17-1734.1-9 Basic requirements. An individual shall meet the basic eligibility requirements, which include but are not limited to, a lawfully present non-citizen ineligible under chapter 17-1733.1 due to citizenship status, state residency, verification of identity, not residing in a public institution and the provision of a social security number, as described in chapter 17-1714.1. [Eff 09/30/13] (Auth: HRS §§346-14; 346-59.2, 42 C.F.R. §§435.400, 435.910) (Imp: HRS §§346-14; 346-59.2, 42 C.F.R. §§435.400, 435.910)
§17-1734.1-10 Categorical requirements. (a) An individual shall meet the following: (1) A lawfully present non-citizen who meets the requirements under chapter 17-1733.1 except for citizenship status; (2) Under age sixty-five; (3) Eligible and screened for breast or cervical cancer or a precancerous condition of the breast or cervix through the Hawaii Comprehensive Breast and Cervical Cancer Control Program (HCBCCCP) administered by the Department of Health; (4) Require treatment for breast or cervical cancer or a precancerous condition of the breast or cervix; (5) Not otherwise covered under creditable coverage; and (6) Not eligible under any other Medicaid coverage group. (b) A new period of eligibility may be established for an individual who is screened by the HCBCCCP with a recurrence or a new occurrence of breast or cervical cancer or a precancerous condition of the
UNOFFICIAL 1734.1-4 breast or cervix that requires treatment and meets the provisions of subsection (a). [Eff 09/30/13] (Auth: HRS §§346-14; 346-59.2) (Imp: HRS §§346-14; 346-59.2)
§17-1734.1-11 Non-financial eligibility requirements and effective date of coverage. (a) An individual who is determined eligible in accordance with this chapter shall remain eligible while receiving required treatment. (1) Breast or cervical cancer shall be medically reevaluated annually by a treating physician to verify and confirm the need for continued treatment at the time of the annual eligibility review; or (2) A precancerous condition of the breast or cervix shall be medically reevaluated at six-month intervals by a treating physician to verify and confirm the need for continued treatment, and one of the reevaluations shall coincide with the annual eligibility review. (b) Eligibility shall be effective retroactively to the date the individual is screened and initially diagnosed with breast or cervical cancer or a precancerous condition of the breast or cervix by the authorized CDC breast and cervical cancer early detection program or ten calendar days immediately prior to the date the application is received by the department as described in chapter 1720.1, whichever occurs first. [Eff 09/30/13] (Auth: HRS §346-14; 42 CFR §§430.25, 431.40, 435.213, 438.6) (Imp: HRS §346-14; 42 CFR §§430.25, 431.40, 435.213, 438.6)
§17-1734.1-12 Income and asset requirements. An individual’s household income and assets shall not be considered in determining eligibility for participation in this chapter. [Eff 09/30/13] (Auth: HRS §§346- 14; 346-59.2) (Imp: HRS §§346-14; 346-59.2)
§17-1734.1-13 Eligibility review. (a) An individual eligible under the provisions of this
UNOFFICIAL 1734.1-5 chapter shall receive an annual eligibility review every twelve months. (b) Eligibility shall be redetermined in accordance with chapter 17-1712.1 and subchapter 5 of chapter 17-1714.1. [Eff 09/30/13] (Auth: HRS §346- 14; 42 C.F.R. §§435.213, 435.916) (Imp: HRS §346-14; 42 C.F.R. §§435.213, 435.916)
§§17-1734.1-14 to 17-1734.1-18 (Reserved).
SUBCHAPTER 3
FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT
§17-1734.1-19 Purpose. This subchapter addresses the provisions of freedom of choice, enrollment, benefits and disenrollment for an individual eligible in accordance with this chapter. [Eff 09/30/13] (Auth: HRS §§346-14, 346-59.2) (Imp: HRS §§346-14, 346-59.2)
§17-1734.1-20 Freedom of choice. (a) An individual eligible under the provisions of this chapter shall be provided a choice of a health plan and a provider as described in chapter 17-1720.1. (b) An individual identified in section 17- 1735.1-2(a) shall choose a department approved provider of their choice as described in chapter 17- 1736. [Eff 09/30/13] (Auth: HRS §§346-14, 346- 59.2; 42 CFR §§430.25, 431.51, 438.52) (Imp: HRS §§346-14, 346-59.2; 42 CFR §§430.25, 431.51, 438.52)
§17-1734.1-21 Enrollment into a participating health plan. (a) An individual eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735.1-2(a), shall be enrolled in a health plan as described in chapter 17-1720.1.
UNOFFICIAL 1734.1-6 (b) An individual identified in section 17- 1735.1-2(a) shall not be enrolled into a plan and services provided on a fee-for-service basis. [Eff 09/30/13] (Auth: HRS §§346-14, 346-59.2; 42 CFR §§430.25, 431.10, 431.40, 438.50) (Imp: HRS §§346-14, 346-59.2; 42 CFR §§430.25, 431.10, 431.40, 438.50)
§17-1734.1-22 Benefits. (a) An individual enrolled in a health plan shall be provided a standard benefits package by a participating health plan and other services when appropriate as described in chapter 17-1720. (b) An individual identified in section 17- 1735.1-2(a) shall be provided coverage under the fee- for-service provisions as described in chapter 17- 1737. [Eff 09/30/13] (Auth: HRS §§346-14, 346- 59.2; 42 CFR §430.25) (Imp: HRS §§346-14, 346-59.2; 42 CFR §430.25)
§17-1734.1-23 Disenrollment from a health plan. An enrollee shall be disenrolled from a health plan under the provisions as described in chapter 17- 1720.1. [Eff 09/30/13] (Auth: HRS §§346-14, 346- 59.2; 42 CFR §§430.25, 431.40, 438.56) (Imp: HRS §§346-14, 346-59.2; 42 CFR §§430.25, 431.40, 438.56)
§§17-1734.1-24 to 17-1734.1-28 (Reserved).
UNOFFICIAL 1735.1-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1735.1
GENERAL PROVISIONS FOR FEE-FOR-SERVICE MEDICAL ASSISTANCE
§17-1735.1-1 Purpose §17-1735.1-2 An individual covered under fee-for- service medical assistance §17-1735.1-3 Effective date of authorization §§17-1735.1-4 to 17-1735.1-8 (Reserved)
Historical Note: This chapter is based substantially upon repealed chapter 17-1735. [Eff 08/01/94; am 07/20/95; am 02/10/97; am 07/06/99; am 02/16/02; am 05/10/03; 01/31/09; am 06/11/09; am 06/25/12; R 09/30/13]
§17-1735.1-1 Purpose. This chapter describes an individual covered under the State's fee-for-service component of the medical assistance program. The fee- for-service program is discussed in the following chapters: 17-1722, special medical assistance coverages and programs; 17-1736, provider provisions; 17-1737, scope and contents of the fee-for-service medical assistance program; 17-1738, targeted case management services; 17-1739, authorization, payment, and claims in the fee-for-service medical assistance program; 17-1740.1, reimbursement of federally qualified health centers and rural health clinics; and 17-1741, utilization control. [Eff 09/30/13] (Auth: HRS §346-14) (Imp: HRS §346- 14)
UNOFFICIAL 1735.1-2 §17-1735.1-2 An individual covered under fee-for- service medical assistance. (a) An individual eligible for fee-for-service coverage under the medical assistance program includes, but is not limited to: (1) A child in receipt of foster care, kinship guardianship or adoption assistance, under age twenty-one who is a resident of the State, and placed in another state as described in chapter 17-1715; (2) A non-citizen ineligible for Medicaid assistance who receives emergency medical services as described in chapter 17-1723.1; (3) An individual who enters the State of Hawaii Organ and Tissue Transplant (SHOTT) program as described in chapter 17-1737; (4) An incarcerated individual who is admitted as an inpatient in a medical institution not on the grounds of the incarceration facility; (5) An individual who receives a determination of eligibility on or after the start date of a new health plan contract period that is retroactive to a date prior to the start of the new health plan contract period with incurred services during the period from the effective date of coverage up to the start date of the new health plan contract period; (6) A medically needy individual who is not aged, blind or disabled as described in chapter 17- 1730.1; or (7) An individual who is eligible for the Qualified Medicare Beneficiaries (QMB), Specified Low Income Medicare Beneficiaries (SLMB), Qualified Disabled and Working Individuals (QDWI), or Qualifying Individuals (QI) program described in chapter 17-1722. (b) While enrolled in a participating health plan, an individual is excluded from the fee-for- service program, except for the following additional services that may be provided on a fee-for-service basis, subject to approval by the department: (1) Services provided through the Medicaid waiver program for an individual with developmental disabilities or intellectual disabilities (DD-ID);
UNOFFICIAL 1735.1-3 (2) ICF-ID institutional services; (3) School-based health related services; (4) Early intervention program services; (5) Specialized behavioral health services; and (6) Dental services as described in section 17- 1737-75. (c) The department shall determine on a case-by- case basis, whether an individual enrolled in a managed care program may have additional services covered on a fee-for-service basis. [Eff 09/30/13] (Auth: HRS §§88-4, 346-14; 42 C.F.R. §§430.25, 435.1009, 435.1010, 440.150; 42 U.S.C.§1396d(a)(28)(A)) (Imp: HRS §§88-4, 346-14; 42 C.F.R. §§430.25, 435.1009, 435.1010, 440.150; 42 U.S.C.§1396d(a)(28)(A))
§17-1735.1-3 Effective date of authorization. (a) The effective date for payments to be made for covered services under the fee-for-service program for an individual described in section 17-1735.1-2 shall be: (1) The date the application is received by the department as described in chapter 17-1711.1; (2) Any date specified by the individual on which appropriate Medicaid eligible services were incurred and is no earlier than the first day of the third month prior to the month the application is received by the department for an individual applying for the coverage of long-term care services, or the immediate ten calendar days prior to the date the application is received by the department for all other individuals; or (3) The date when all eligibility requirements are met by the applicant. (b) An applicant's eligibility for medical assistance within a retroactive period is established when: (1) A submittal of a signed application is received from an applicant, an individual or department’s representative on behalf of a deceased individual. (2) Part or all of the individual’s medical bills remain unpaid;
UNOFFICIAL 1735.1-4 (3) The expenses incurred by the individual were for medical care and services within the scope of services covered under the fee-for- service program as described in chapter 17- 1737 and authorization for medically necessary services approved as described in chapter 17-1739.1; and (4) The care and services were provided by an eligible participating provider. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §346-14; 42 C.F.R. §§435.914, 440.10, 440.20, 440.30, 440.40, 440.50, 440.60, 440.70, 440.80, 440.90, 440.100, 440.110, 440.120, 440.130, 440.140, 440.150, 440.155, 440.160, 440.165, 440.166, 440.167, 440.168, 440.169, 440.170, 440.180, 440.181, 440.185)
§§17-1735.1-4 to 17-1735.1-8 (Reserved).
UNOFFICIAL 1735.2-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1735.2
GENERAL PROVISIONS FOR PARTICIPATING HEALTH PLANS
§17-1735.2-1 Purpose §17-1735.2-2 Health plan participation in the
medical assistance program §17-1735.2-3
Service areas §17-1735.2-4
Requirements of participating health plans §17-1735.2-5
Capitated payments §17-1735.2-6
Enforcement of contracts with participating health plan §17-1735.2-7
Termination of contract with participating health plan §§17-1735.2-8 to 17-1735.2-10 (Reserved)
Historical Note: This chapter is based substantially upon repealed subchapters 5 and 8 of chapter 17-1721.1 and subchapter 9 of chapter 17-1727.
The source notes for subchapters 5 and 8 of chapter 17-1721.1 are: [Eff 01/31/09; am 06/25/12; R 09/30/13].
The source notes for subchapter 9 of chapter 17-1727 is: [Eff 08/01/94; am 01/29/96; am 06/19/00; am 02/16/02; am 09/17/07; am 06/25/12; R 09/30/13].
UNOFFICIAL 1735.2-2 §17-1735.2-1 Purpose. This chapter describes the requirements for the participation of health plans under the medical assistance program. [Eff 09/30/13] (Auth: HRS §346-14) (Imp: HRS §346- 14; 42 C.F.R. §430.25)
§17-1735.2-2 Health plan participation in the medical assistance program. (a) The department shall request proposals from managed care health plans for provision of healthcare services to an eligible individual to participate in the medical assistance program. (b) The department shall evaluate the proposals from managed care plans to ensure that the plans meet the conditions and requirements described in the department's request for proposals. (c) Contracts for participation in the medical assistance program shall be awarded to qualified health plans upon finalization of financial agreements with the department. (d) The department shall develop a request for proposals prior to the lapse of existing contracts with participating health plans to ensure that beneficiaries receive continued health care coverage. [Eff 09/30/13] (Auth: HRS §346-14) (Imp: HRS §346- 14; 42 C.F.R. §430.25)
§17-1735.2-3 Service areas. (a) The department shall designate geographic areas as the areas for which health plans will submit proposals to provide services. (b) A health plan may submit proposals to service more than one service area. (c) More than one health plan may be contracted by the department for each service area. [Eff 09/30/13] (Auth: HRS §346-14) (Imp: HRS §346- 14; 42 C.F.R. §430.25)
UNOFFICIAL 1735.2-3 §17-1735.2-4 Requirements of participating health plans. (a) Health plans participating in the medical assistance program shall abide by the provisions of their respective contracts with the department as well as federal and state statutes and regulations. (b) The requirements of each participating health plan shall include, but are not limited to, the following: (1) Provision of all services required by the contract between the respective plan and the department; (2) Provision of a primary care provider for each eligible individual who is enrolled in the health plan; (3) Provision of a case management system to ensure that health services identified by an eligible individual’s primary care provider as medically necessary are received; (4) Development and maintenance of a sufficient network of health care providers to ensure the provision of required health services are provide to an eligible individual in a timely manner; (5) Maintenance of adequate support staff and systems to administer and conduct business functions; (6) Development and maintenance of required information systems; (7) Development and maintenance of a quality assurance program; (8) Development and maintenance of a grievance and appeal system for a dissatisfied eligible individual; (9) Development and maintenance of a toll-free telephone hotline in the State to confirm enrollment, respond to inquiries from an eligible individual, and provide information to the general public; and (10) Maintenance of a medical records system to enable the provision of information
UNOFFICIAL 1735.2-4
pertinent to the care and management of an eligible individual to the department. [Eff 09/30/13] (Auth: HRS §346-14) (Imp: HRS §346-14; 42 C.F.R. §430.25)
§17-1735.2-5 Capitated payments. (a) Each participating health plan shall be paid on a capitated basis, as negotiated with the department, for an eligible individual enrolled in that health plan. (b) The department shall provide the capitated payment, as stipulated in the contract between the department and each health plan, in return for the health plan's provision of all contracted coverage for the health plan's eligible individuals. [Eff 09/30/13] (Auth: HRS §346-14) (Imp: HRS §346-14; 42 C.F.R. §430.25)
§17-1735.2-6 Enforcement of contracts with participating health plan. (a) The department may monitor a participating health plan’s performance during any contract period. (b) The department may impose civil or administrative monetary penalties not to exceed the maximum amount established by federal and state statutes and regulations if the health plan: (1) Fails to provide medically necessary items and services that are required under law or under contract; (2) Imposes upon beneficiaries excess premiums and charges; (3) Acts to discriminate among an eligible individual; (4) Misrepresents or falsifies information; (5) Violates marketing guidelines established by the department; (6) Violates other contract provisions and requirements; or (7) Violates federal or state statutes or regulations.
UNOFFICIAL 1735.2-5 (c) If a health plan violates the contract conditions between the health plan and the department, federal or State statutes or regulations, the Hawaii Administrative Rules, or if there is a substantial risk to the health of an eligible individual, the department may: (1) Notify the affected individual of the violations; (2) Allow the affected individual to change plans without cause; (3) Suspend enrollment; or (4) Suspend payment. The department may also impose financial sanctions as described under the provisions of the contract between the respective plan and the department for inaccurate, incomplete, and untimely data and reports submitted to the department. (d) If a health plan continues to violate the contract conditions between the health plan and the department, federal or state statutes and regulations, or the Hawaii Administrative Rules, regardless of any other penalty that may be imposed, the department shall: (1) Appoint temporary management to oversee compliance efforts; (2) Notify the affected eligible individual of the violations; or (3) Allow the affected eligible individual to change plans without cause. (e) Temporary management may continue until the department determines that the health plan can ensure that the behavior that caused the penalty will not recur. (f) Before imposing a sanction, with the exception of appointing temporary management to oversee compliance efforts, the department shall give the health plan timely written notice, as specified in the contract with the participating health plans. [Eff 09/30/13] (Auth: HRS §346-59.5) (Imp: HRS §346-14; 42 C.F.R. §§430.25; 438.700, 438.702; 438.706; 438.710)
UNOFFICIAL 1735.2-6 §17-1735.2-7 Termination of contract with participating health plan. (a) The department shall have the authority to terminate the participating health plan’s contract for any or all of the following reasons: (1) Convenience; (2) Default by the health plan; (3) Expiration of the medical assistance program; (4) Failure by the health plan to abide by the contract conditions; (5) Insolvency of or declaration of bankruptcy by the health plan; (6) Failure to meet federal or state statutes, or both; or (7) Unavailability of funds. (b) When termination of contract is due to reasons identified under subsections (a)(2), (4) or (6), the department shall provide a hearing for the affected health plan prior to termination of the contract. (c) After the department notifies the health plan of its intent to terminate the contract due to reasons identified under subsections (a)(2), (4) or (6), the department may do the following: (1) Provide the affected eligible individual written notice of the department’s intent to terminate the contract; and (2) Allow the affected eligible individual to change health plans immediately without cause. [Eff 09/30/13] (Auth: HRS §346- 14) (Imp: HRS §346-14; 42 C.F.R. §§430.25; 438.708)
§§17-1735.2-8 to 17-1735.2-10 (Reserved).
UNOFFICIAL 1736-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12 MED-QUEST DIVISION
CHAPTER 1736
PROVIDER PROVISIONS
Subchapter 1 Free Choice of Providers
§17-1736-1 Purpose §17-1736-2 Definitions §17-1736-3 Right to free choice of providers of
medical services §17-1736-4 Medical care resources affecting freedom
of choice §§17-1736-5 to 17-1736-10 (Reserved)
Subchapter 2 Providers of the Fee for Service
Program
§17-1736-11 Purpose §17-1736-12 Definitions §17-1736-13 Application for provider participation §17-1736-14 Approval or denial of provider
application and notification §17-1736-15 Requirements for participation in the
program by providers §17-1736-16 Provider requirements regarding advance
directives §17-1736-17 Record keeping requirements for
providers §17-1736-18 Confidential communications and
disclosure requirements for physician
and psychologist providers §17-1736-19 Disclosure by providers and their fiscal
agents of information concerning
provider's ownership and control §17-1736-20 Provider requirements prior to
certification §17-1736-21 Disclosure by providers of information
on persons convicted of crimes
UNOFFICIAL 1736-2 §17-1736-22 Cause for suspension or termination of
providers §17-1736-23 Suspension or termination §17-1736-24 Notification and effective date of
suspension or termination of provider
certification §§17-1736-25 to 17-1736-30 (Reserved)
Subchapter 3 Administrative Proceedings for
Provider Review
§17-1736-31 Purpose §17-1736-32 Definitions §17-1736-33 Providers' right to review §17-1736-34 Limitation of the right to review §17-1736-35 Appearance by representatives of the
provider and the department §17-1736-36 Forms for papers §17-1736-37 Notice, service, and proof of service §17-1736-38 Notice of formal hearing; notice of
decision §17-1736-39 Conduct of hearing §17-1736-40 Witnesses and subpoenas §17-1736-41 Amendments §17-1736-42 Continuances or further hearings §17-1736-43 Record of hearing §17-1736-44 Decision of the hearing officer §17-1736-45 Dismissal upon failure to appear at
hearings §17-1736-46 Administrative appeal to the director §§17-1736-47 to 17-1736-56 (Reserved) §17-1736-57 Determination of medicaid reimbursement
for hospital and institutional
providers §17-1736-58 Hospital and institutional provider's
right to review §17-1736-59 Limitation of the right to review for
hospital and institutional providers §17-1736-60 Appearance by representatives of
hospital and institutional providers
and the department §17-1736-61 Forms for papers for hospital and
institutional providers §17-1736-62 Notice, service, and proof of service
for hospital and institutional
providers
UNOFFICIAL 1736-3 §17-1736-63 Notice of formal hearing; notice of
results of formal hearing for hospital
and institutional providers §17-1736-64 Waiver of the right for oral hearing for
hospital and institutional providers §17-1736-65 Prehearing conference for hospital and
institutional providers §17-1736-66 Conduct of hearing for hospital and
institutional providers §17-1736-67 Prehearing discovery for hospital and
institutional providers §17-1736-68 Witnesses and subpoenas for hospital and
institutional providers §17-1736-69 Amendments for hospital and
institutional providers §17-1736-70 Continuances or further hearings for
hospital and institutional providers §17-1736-71 Record of hearing for hospital and
institutional providers §17-1736-72 Decision of the hearing officer for
hospital and institutional providers §17-1736-73 Dismissal upon failure to appear at
hearings for hospital and
institutional providers §17-1736-74 Administrative review by the director
for hospital and institutional
providers §17-1736-75 Reopenings for hospital and
institutional providers
Historical Note: Subchapter 1 is based substantially upon Title 17, chapter 17-1302 [Eff 6/29/92; R 08/01/94 ], Subchapter 2 is based substantially upon Title 17, chapter 17-1320 [Eff 6/29/92; am 9/3/93; R 08/01/94 ], Subchapter 3 is based substantially upon Title 17, chapter 17-1321, Hawaii Administrative Rules. [Eff 6/29/92; R 08/01/94 ]
SUBCHAPTER 1
FREE CHOICE OF PROVIDERS
§17-1736-1 Purpose. The purpose of this chapter shall be to set forth conditions on the free choice of providers in the fee for services component under the
UNOFFICIAL 1736-4 medical assistance program. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-14)
§17-1736-2 REPEALED. [R 09/30/13]
§17-1736-3 Right to free choice of providers of medical services. (a) A client shall have freedom to choose health care providers certified by the department to participate in the medical assistance program.
(b) Freedom of choice includes the right to seek medical services elsewhere within the State when physician recommended care is not available or readily accessible.
(c) Medical care and services shall be provided on the client's home island unless otherwise recommended by the client's physician.
(d) A client who decides on the services of a clinic shall be considered as having exercised the client's right to choose a provider, even though a physician may be assigned to the client by the clinic under the clinic's normal practices. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §431.51)
§17-1736-4 Medical care resources affecting freedom of choice. (a) A client who has pre-paid or earned health benefits shall utilize these benefits before utilizing medical assistance payments.
(b) A client may be encouraged but shall not be required to utilize public and private health resources available to groups meeting financial and eligibility standards. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §433.135)
§17-1736-5 to §17-1736-10 (Reserved).
SUBCHAPTER 2
PROVIDERS OF THE FEE FOR SERVICE PROGRAM
UNOFFICIAL 1736-5
§17-1736-11 Purpose. The purpose of this chapter is to establish conditions for provider participation in the fee for service component of Hawaii's medical assistance program. The provisions of this chapter govern provider applications and procedures for approval or denial of those applications, the requirements to be met by a provider before that person or organization is certified or denied provider status, and the requirements that providers keep records to participate in the program. Also described are procedures to be used for suspension or termination of providers from the Hawaii medical assistance program. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §431.10)
§17-1736-12 REPEALED. [R 09/30/13]
§17-1736-13 Application for provider participation. (a) Any provider who wishes to provide care, goods, or services to receive reimbursement from the Hawaii medical assistance program, shall apply in writing to the med-QUEST division of DHS. The provider shall, at the request of the DHS med-QUEST administrator, supply all information requested concerning the provider's education and qualifications as a provider, financial status of the provider's practice, background history of the provider, and if the provider is required to maintain a license, the status of that license. The DHS med-QUEST administrator shall, in the administrator's sound discretion, have the right to approve or deny any application for certification as a provider under the Hawaii medical assistance program. If a provider is denied certification by the DHS med-QUEST administrator, the provider may request a fair hearing as provided by section 17-1736-33. Application forms to request certified provider status shall be furnished by the DHS med-QUEST administration.
(b) Except for providers exempted in subsections (c) and (d), all providers participating or applying to participate in Hawaii's medical assistance program shall have a current and valid written agreement or contract on file with DHS. Failure to maintain such a contract shall constitute grounds for suspension, termination, or withholding payment of claims submitted under the Hawaii medical assistance program until a
UNOFFICIAL 1736-6 current and valid written agreement is signed and on file with DHS.
(c) A provider outside of the State of Hawaii who furnishes goods and services authorized to be provided under the Hawaii medical assistance program to eligible Hawaii residents visiting in that state and urgently requiring care and services shall be exempt from the certification requirement so long as that provider is properly licensed to provide health care services in accordance with the laws of the provider's home state, and the provider is certified by Medicaid in the provider's home state to furnish the health care services actually rendered.
(d) Provider outside of the State of Hawaii who satisfy the requirements of subsection (c) also furnish services not available in Hawaii to eligible Hawaii residents as long as that provider obtains prior oral or written authorization from the DHS med-QUEST division's medical consultant prior to providing the goods, care, and services that the provider deems necessary. The medical consultant granting the prior authorization shall immediately reduce the substance of the authorization into writing and mail a copy to the out-of-state provider.
(e) Pharmacy providers who are the exclusive suppliers of prescribed drugs and supplies to a long term care facility shall apply for a separate provider agreement and provider number for each facility served as described in subsection (a). [Eff 08/01/94; am 03/30/96; am 02/10/97 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §§431.51, 447.15)
§17-1736-14 Approval or denial of provider application and notification. (a) DHS, upon finding that a provider applicant meets the requirements for participation in the medicaid program, shall promptly notify the person or entity in writing of the department's approval of the provider's application. The department shall arrange with its fiscal agent to issue to the new provider: (1) A provider code number and instructions regarding the use of that number; (2) A provider manual complete with all letter updates; and (3) Notification of federal and state penalties for fraud.
UNOFFICIAL 1736-7 (b) The department shall promptly notify any applicant in writing who does not meet all the requirements for participation. The notice shall state the reasons for the department's denial of the application. The notice shall inform the provider of the provider's right to a fair hearing. The department's fair hearing procedure as provided in subchapter 3 shall be utilized if a hearing is requested. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §§431.51, 455.22)
§17-1736-15 Requirements for participation in the program by providers. (a) Except for payments authorized to out-of-state providers in emergency situations and to Qualified Medicare Beneficiaries (QMB) only providers, or as authorized under section 17-1736-13, payments under the medical assistance program for goods, care, and services shall be made only to providers approved by DHS to participate in the Hawaii medical assistance program.
(b) An individual, institution, or organization shall meet all of the following requirements in order to become and retain eligibility as a provider under the medical assistance program: (1) The provider shall be licensed or approved as follows: (A) The provider, if an individual, shall be licensed to practice the provider's profession in accord with state law. Permits, temporary licenses, provisional licenses, expired or unrenewed licenses, or any form of license or permit which requires supervision of the licensee shall not serve to qualify the licensee as an approved provider of service under the Hawaii medical assistance program; (B) The provider, if a medical or health related institution, shall be certified by the state department of health under applicable public health rules of the state and standards of the federal government. The following shall apply regarding Medicare certification for participation in Medicaid: (i) Hospitals are required to be Medicare certified; (ii) Facilities that provide SNF
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services are required to be Medicare certified; (iii) Facilities that provide SNF and
ICF services, but are not Medicare certified, may participate as an ICF; and (iv) Facilities that provide ICF
services only are unable to obtain Medicare certification, therefore, participation as an ICF is allowed. (C) The provider of any other health care services shall comply with standards and all licensure, certification and other requirements as applicable; (2) The provider shall comply with the
non-discrimination provisions of Title VI of the Civil Rights Act of l964 (42 U.S.C. §2000d) by not discriminating against program beneficiaries on the basis of race, color, national origin, or mental or physical handicap; and (3) The provider shall accept Medicaid’s established rates of payments whether based on DHS's fee schedule, negotiated rate, reasonable cost reimbursement, or other adopted rates, whichever is applicable, as payment in full for goods, care, or services furnished. The provider shall not require any participation in payment by the Medicaid recipient for goods, care, or services furnished by the provider. The provider shall not demand or receive any additional payment from any Medicaid recipient with the exception of the department's proviso for cost sharing of medical care costs. [Eff 08/01/94; am 02/07/05 ] (Auth: HRS §346-14) (Imp: HRS §346-59; 42 C.F.R. §§440.40, 442.12, 442.101, 447.15, 482.1, 483.1; Pub. L. No. 100-360 §301)
§17-1736-16 Provider requirements regarding advance directives. (a) Hospitals, hospices, nursing homes, health maintenance organizations, and other health care facilities that receive funds from medicare or medicaid are required by law (Pub. L. No. 101-508 and chapter 327D, HRS) to have in place a mechanism for advising patients of their legal rights and options for
UNOFFICIAL 1736-9 refusing or accepting treatment if they are or become incapacitated.
(b) Providers must offer written information as well as summaries of pertinent institutional policies to all adult patients regarding their rights under State laws to accept or refuse treatment and to make advance directives. (1) An advance directive is a document that is written in advance of an incapacitating illness that state a patient's choices about treatment, or name someone to make such choices, if the patient becomes unable to make decisions. (2) Through advance directives such as living wills and durable powers of attorney for health care, patients will be able to make
legally valid decisions about their future medical treatment. (3) The patient's medical record must be documented to indicate whether the patient has an advance directive.
(c) Institutions may not discriminate against or condition care provided to a patient on the basis of whether the patient has, or has not, executed an advance directive.
(d) Institutions must provide (individually or with others) education to staff and community regarding issues associated with advance directives. [Eff 08/01/94 ] (Auth: HRS §346-14, 42 U.S.C. §1396 a(w)) (Imp: HRS §327D)
§17-1736-17 Record keeping requirements for providers. (a) In order to determine the correct amount of medicaid program payments due to any provider, and to protect the medicaid program from fraud and abuse, the DHS's representative, agent, investigative and recovery service, the fiscal agent, and the medicaid fraud control unit of the attorney general's office shall have the right to examine, inspect, copy, and if necessary, seize all records of a provider pertaining to medicaid patients which are necessary to fully disclose the type and extent of health care services or supplies provided to eligible medicaid recipients. The provider, for a period of three calendar years, shall maintain thorough records of medicaid patients, including but not limited to the following:
UNOFFICIAL 1736-10 (1) Billings and account ledgers; (2) Records of patient appointments; (3) Patient history forms, medical records, diagnosis, and orders prescribed and treatment plans; (4) Records of requests for and results of tests and examinations ordered or furnished; (5) Records of prescriptions, medications, assistive devices, or appliances prescribed, ordered, or furnished; and (6) All records which are necessary to justify the amount of claims for payment which are determined by cost reimbursement or a similar basis, including billing documents showing the cost of services or supplies provided to the recipient.
(b) A provider shall make these records available to any duly authorized DHS representative or agent, including the DHS investigative and recovery service, a representative of the fiscal agent, and any representative of the medicaid fraud control unit. These records shall be made available at the provider's place of business during normal business hours or upon agreement of the provider and appropriate representatives of the state at any other mutually convenient time or place.
(c) In addition to those records required to be maintained in accordance with subsection (b), institutional providers shall also make available to the agencies specified in subsection (b) records of receipts and disbursements of patient trust funds by the provider, including ledger accounts reflecting credits, debits and balances for each recipient.
(d) The records described in subsections (a) and (b) shall be maintained for a period not less than three calendar years. For purposes of this section, a record shall not be counted as three calendar years old until the last entry made in that record is three years old.
(e) All records obtained by the state agency, the investigative and recovery service, the fiscal agent or the medicaid fraud control unit, pursuant to this section, shall be maintained in safe keeping and may be used for auditing, scientific examination and writing analysis, photocopying, or testing in any other way, so long as that test does not significantly alter, damage, or destroy the record taken. Records which are not undergoing examination or testing as defined in this
UNOFFICIAL 1736-11 subsection and are not intended to be used as evidence in a judicial or administrative hearing by the State shall be immediately returned to the provider.
(f) Cost report files of an institutional provider shall contain the following information: (1) Reimbursable cost; (2) Cost finding schedules; and (3) Other financial and statistical data to support reimbursable cost, including: (A) Employment records; (B) Work shift and schedules; and (C) Payroll records of all institutional personnel, owners, and corporate officers. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §346-40)
§17-1736-18 Confidential communications and disclosure requirements for physician and psychologist providers. (a) There is no privilege under this section in any administrative proceeding where the: (1) Competency; (2) Practitioner's license; (3) Provider status; or (4) Practice; of the physician is an issue, including fair hearing criminal cases involving fraud, or civil cases involving over-payment under the medicaid program. However, the identifying data of a patient whose records are admitted into evidence at an administrative hearing shall be kept confidential among the parties to the hearing unless waived by the patient. The administrative agency, board, or commission may close its proceedings to the public to protect a patient's confidentiality.
(b) The DHS director may require providers of health care goods and services, including physicians and psychotherapists, to seek written authorization from the med-QUEST administration to provide care, goods, or services to medicaid patients. A provider's request for authorization shall include: (1) The patient's name; (2) A diagnosis of the patient's psychiatric, physical, or psychological condition; (3) Whether or not the patient can work, either part-time or full-time; (4) The number of times the patient has seen the provider over a given prior period;
UNOFFICIAL 1736-12 (5) The number of future visits the doctor anticipates needing in order to properly treat the patient; (6) Information on whether the patient is working and if so, whether on a full-time or part- time basis; and (7) Any other information requested by the med- QUEST division which properly relates to the patient's present or prior condition or appropriate care to be rendered to the patient.
(c) For purposes of this section, confidential communication shall consist only of the statements made between a physician or psychologist and a patient during a therapy session. The provider's diagnosis, finding, and treatment plan shall not be considered confidential communications.
(d) Whenever a provider refuses to disclose unprivileged information to the med-QUEST division, then payment of claims for which the information is lacking may, at the discretion of the director, be denied, or if payment is already made, recovery may be initiated by the department. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §431.10)
§17-1736-19 Disclosure by providers and their fiscal agents of information concerning provider's ownership and control. (a) Providers shall disclose to the med-QUEST division the following information upon request: (1) The name and address of each person with an ownership or controlling interest in the provider; (2) The name, address, and ownership or controlling interest which the provider may have in any other entity which also has certification as a provider under the Hawaii medical assistance program or the medicare program; (3) The name of any business, either in the State or elsewhere, whether incorporated or not, in which the provider has a financial or management interest and which is itself a supplier of medical goods, care, or services to any provider certified under the medical assistance program;
UNOFFICIAL 1736-13 (4) The name of any business either in the State or elsewhere, whether incorporated or not, in which a blood relative of an individual provider has a financial or management interest and which is itself a supplier of medical goods, care, or services to any provider certified under the medical assistance program; (5) The name of any blood relatives or in-laws of an individual provider who have a financial or management interest in any business concern which is itself a supplier of medical goods, care, or services to any provider certified under the Hawaii medical assistance program; and (6) The name of any blood relative or in-laws of an individual provider who is also a provider certified under the medical assistance program.
(b) The provider shall upon discovery of any information required by subsection (a), immediately notify the med-QUEST division in writing of the information required to be provided.
(c) If the DHS director, as a result of any of the information provided pursuant to subsection (a), determines in the director's sound discretion that a conflict of interest exists based upon a relationship revealed by a provider pursuant to the requirements of subsection (a), then the DHS director may withdraw certification of the provider until the relationship which creates the conflict of interest is terminated.
(d) Failure by any provider to reveal the existence of any relationship specified in subsection (a) shall be grounds for suspension or termination of that provider's certification under the medical assistance program. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §455.104)
§17-1736-20 Provider requirements prior to certification. (a) Prior to certification as a provider under the medical assistance program, a provider must submit to the department full and complete information about: (1) The ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the twelve
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month period ending on the date that certification is requested; and (2) Any significant business transactions between the provider and any supplier of services or goods wholly owned, or between the provider and any subcontractor during the five year period ending on the date of the request for certification.
(b) The information required by subsection (a) must be provided within thirty-five days of the date of any request by the secretary of DHHS or the medicaid agency of the State. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §455.105)
§17-1736-21 Disclosure by providers of information on persons convicted of crimes. (a) The provider shall disclose to DHS the identity of any person who has an ownership or controlling interest in the provider, or who is an agent, managing employee, or employee of the provider and who has been convicted of a criminal offense relating to that person's involvement in the medical assistance program, medicare, or any Title XX service program since the start of those programs.
(b) DHS shall notify DHHS immediately of any disclosures made pursuant to subsection (a).
(c) DHS may refuse to enter into or renew an agreement with a provider if a person with ownership or controlling interest in that provider, or an agent or managing employee of that provider is a person who has been convicted of a criminal offense relating to the person's involvement in a program established under the medical assistance program, medicare, or any Title XX program.
(d) DHS may refuse to enter into or may terminate a provider agreement if the full and accurate disclosure requirements under this section are not met by the provider. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §455.106)
§17-1736-22 Cause for suspension or termination of providers. DHS may suspend or terminate a provider from the medical assistance program based upon any one or combination of reasons established in section 17-1736-33(c). [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §455.l3)
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§17-1736-23 Suspension or termination. (a) The decision to suspend or terminate a provider from participation in the medical assistance program and the duration of any suspension shall be made by the DHS director.
(b) The duration of the suspension imposed by the DHS director shall be conditioned upon the seriousness of the infraction but shall not exceed a period of five years.
(c) The DHS director shall suspend or terminate any provider in the medical assistance program who has been suspended or terminated from the medicare program. Suspension or termination from the medical assistance program if based upon suspension from the medicare program shall be at least under the same conditions and for the same period of time as the suspension from the medicare program. The DHS director may determine that more stringent action under the medical assistance program than was taken under the medicare program is justified. In that event, the director shall take such steps as the director deems appropriate subject to the provisions of subchapter 3.
(d) The DHS director shall suspend or terminate any provider in the medical assistance program whose license, certification, authorization or permit to practice is not current or has been suspended, revoked, or restricted by a state or federal government, court, or agency.
(e) A provider who has terminated from the medical assistance program for a violation may not petition the director for reinstatement to the program for a period of five years at which time reinstatement may be permitted by the director, if justified, provided that at the time reinstatement is requested that no medicare sanctions remain applicable.
(f) All legal actions, both civil and criminal, against providers certified under the medicaid program shall be handled by the State's medicaid fraud control unit.
(g) Actions for suspension or termination of a provider may be initiated or continued even though a provider voluntarily withdraws from the program. The procedures for determining whether suspension or termination are appropriate and the length of time shall be governed by this subchapter and subchapter 3. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §§455.16, 455.21)
UNOFFICIAL 1736-16
§17-1736-24 Notification and effective date of suspension or termination of provider certification. (a) The provider shall be informed by certified mail of DHS's intent to suspend or terminate the provider's participation as a medical assistance provider. The notice shall include the following: (1) The reasons for the action; (2) If the action is a suspension, the duration of the suspension; (3) The provider's rights to request an administrative review, and to be represented at the provider's own expense by legal counsel or a designated representative at the administrative hearing provided for by subchapter 3; and (4) The effective date of the suspension or termination.
(b) A suspension or termination of a provider's certification in the medical assistance program shall be effective thirty calendar days following the mailing of DHS's notice of intent to suspend or terminate, except a suspension or termination based on section 17-1736-23(d) which shall be effective from the date of license, certification, authorization, or permit suspension or revocation.
(c) DHS shall notify DHHS whenever a state or federal court convicts a provider for a criminal office relating to the medical assistance program. This notice shall be sent within fifteen days of the time that DHS learns of the conviction. [Eff 08/01/94; am 01/29/96 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §455.212)
§§17-1736-25 to 17-1736-30 (Reserved).
SUBCHAPTER 3
ADMINISTRATIVE PROCEEDINGS FOR PROVIDER REVIEW
§17-1736-31 Purpose. The purpose of this chapter shall be to establish provisions for a provider's right to review and hearing following any administrative decision made by the DHS which directly and adversely affects the rights of that provider or the reimbursement claimed under the medical assistance
UNOFFICIAL 1736-17 program. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §346-14; 42 C.F.R. §§431.10, 455.12)
§17-1736-32 REPEALED. [R 09/30/13]
§17-1736-33 Providers' right to review. (a) A provider may request an administrative hearing following the department's administrative decision to do any one of the following: (1) Withhold, terminate, or suspend a provider's certification to participate in the medical assistance program; (2) Withhold payment of claims as a result of audit or investigation; (3) Recover money claimed to have been overpaid to the provider by medicaid; or (4) Impose remedies established in section 17- 1736-40 for nursing facilities that do not meet the requirements of participation.
(b) Any notice of intent to do any of the actions specified in subsection (a) shall be sent to the provider by certified mail. The provider shall have thirty days from the date that notification is mailed to request in writing an administrative hearing. There shall be no required format for the provider's written request for an administrative hearing, though the provider must clearly state that the provider requests an administrative hearing. At the time the provider requests an administrative hearing, the provider shall include with the request all documents and written evidence that the provider wishes to be considered at the hearing. Where a provider makes a timely request for an administrative hearing, the provider shall not be terminated or suspended until the hearing has been held and a decision has been rendered.
(c) DHS may suspend or terminate a provider from the medicaid program for one or more of the following reasons: (1) Failure by the provider to maintain with DHS a signed agreement identifying the terms and conditions under which the provider may participate in the Hawaii medical assistance program; (2) Refusal or failure by the provider to make available at the provider's place of business
UNOFFICIAL 1736-18
or at an appropriate location, either during normal business hours, or at the mutual convenience of the parties, immediate access to all records and all diagnostic devices required to be maintained by section 346- 40(b), HRS; (3) Refusal or failure by a provider without reasonable justification to keep those adequate written records necessary to
disclose fully the type and extent of health care, service,s or supplies provided to medicaid recipients as provided by section 346-40(a) and (c), HRS; (4) Revocation or suspension of the provider's license, certification, authorization, or permit to practice or provide service in the provider's health care specialty by a state
or federal government, court, or agency; (5) Failure to maintain a current and valid license, certification, or permit to practice the provider's profession; (6) A criminal complaint against the provider, indictment by grand jury, or information about or conviction of the provider by a state or federal court for an offense involving the provider's participation in the medicaid program. A criminal complaint against the provider, indictment, or information may remain the basis for a suspension or termination by the department even though the complaint, information, or indictment results in acquittal; (7) Any fraud against the medicaid program or abuse of health care services as defined in this section; (8) A determination by a peer review organization that the provider has failed to provide adequate quality services to medicaid recipients as judged against accepted medical community standards in Hawaii; (9) Any intentional failure to repay overpayments made by the medicaid program to the provider; or (10) Any effort by the provider to interfere with, hinder, or stop an investigation by any state or federal agency into fraud or abuse in the medicaid program.
UNOFFICIAL 1736-19
(d) During the period of time from the notice of suspension or termination until the department orders a decision after administrative hearing, payment on any claims of the provider requesting review shall, at the med-QUEST administrator's discretion, be withheld pending the hearing officer's final determination. If the administrative hearing officer upholds suspension or termination, decides that the contested claim shall not be paid, or renders a decision denying the provider's appeal, then the provider claims for which payment was withheld shall not be paid. If, after the administrative hearing, the hearing officer overturns a provider's suspension or termination, decides that any contested claims shall be paid, or renders a favorable decision on the provider's appeal, then the provider claims for which payment was withheld shall be paid.
(e) A provider may request an administrative hearing only after an administrative decision by the department is made against that provider. There shall be no right of hearing for class actions on the part of other providers and there shall be no right to administrative hearing for the purpose of obtaining advisory opinions. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R §431.10) (Imp: HRS §§346-14, 346-40; 42 C.F.R. §§431.10, 455.13)
§17-1736-34 Limitation of the right to review. A provider shall not have a right to an administrative hearing if: (1) The provider fails to request in writing a fair hearing from the med-QUEST administrator of DHS within the time specified in section 17-1736-33(b); (2) The administrative action is one of suspension or termination, based upon a final administrative decision of a state or federal agency withdrawing the license, certification, authorization, or permit of the provider to practice or furnish the health care specialty for which the provider is certified under the Hawaii medical assistance program; or (3) The administrative action is for suspension or termination and is based upon a state or federal court conviction of the provider of an offense involving fraud or abuse relating to the medicaid program.
UNOFFICIAL 1736-20
[Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §§431.10, 455.16)
§17-1736-35 Appearance by representatives of the provider and the department. (a) In all matters involving an administrative hearing, a provider may represent him or herself or be represented by an attorney or other person. A provider shall not have a right to legal counsel appointed at state expense. If the provider is represented by another person, that person's name, address, and telephone number shall be provided to the DHS med-QUEST administrator and to the hearing officer prior to the administrative hearing.
(b) Upon receipt of the name of the provider's representative, the med-QUEST administrator shall provide to that representative, the name, address, and telephone number of the department's representative. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §91-9; 42 C.F.R. §455.13)
§17-1736-36 Forms for papers. An original and two copies of all papers filed in any proceeding under this chapter shall be filed with the department, shall be typewritten on one side only, and be on 8½ by 13 inch white paper. Documents shall bear on the first page the title of the proceeding at the top of the page, together with any administrative or court number assigned to the hearing, and the signatures of the party or the party's representative. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §346-14; 42 C.F.R. §431.10)
§17-1736-37 Notice, service, and proof of service. (a) All papers, notices, and other documents shall be served by the party offering them upon all other parties to the proceeding. Proof of service upon the parties shall be filed with the DHS.
(b) Service of process may be accomplished in any manner permitted by law. The department shall serve the provider in person or by mail. If the provider is represented by an attorney or other person, service upon that attorney or other person shall be sufficient.
(c) Proof of service of any document shall be by certificate of attorney, affidavit, or acknowledgment.
UNOFFICIAL 1736-21
(d) Where written notice is required by this chapter, notice shall be considered effective on the date of mailing. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §91-9; 42 C.F.R. §455.13)
§17-1736-38 Notice of formal hearing; notice of decision. (a) The department shall notify any provider, who is entitled to an administrative hearing in accordance with section 17-1736-34 of the scheduled date and location of the administrative hearing. Such notice shall be in writing and mailed to the provider no fewer than thirty calendar days before the scheduled date of hearing.
(b) The department shall notify any provider who has received an administrative hearing of the hearing officer's decision by mailing a written copy of the decision within fourteen calendar days of the date of the decision. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §§91-9, 91-9.5; 42 C.F.R. §455.13)
§17-1736-39 Conduct of hearing. (a) The hearing shall be conducted by an impartial hearing officer appointed by the DHS director. Prior to conducting the hearing, the hearing officer shall become familiar with sections 84-1 to 84-19, HRS, and the published opinions of the state ethics commission and determine that participation as an administrative hearing officer will create no conflicts of interest or ethical violations.
(b) Testimony shall be taken only on oath or affirmation and such testimony shall be subject to sections 710-1060, 710-1061, and 710-1062, HRS.
(c) Each party may: (1) Call and examine witnesses; (2) Introduce exhibits into evidence; (3) Cross-examine witnesses called by the other party; (4) Object to the presentation of any evidence deemed by the party to be not properly admitted; (5) Present rebuttal evidence to the opposing party's case-in-chief; and (6) Present an opening statement to the hearing officer prior to the taking of evidence, and
UNOFFICIAL 1736-22
a closing argument to the hearing officer at the conclusion of the taking of evidence.
(d) The hearing officer shall not require strict adherence to any rules of evidence. The hearing officer shall admit all evidence including, but not limited to, testimony, documents, photographs, opinions, objects, or diagrams, so long as that evidence has any tendency to make the existence of any fact of consequence to the hearing more or less probable than it would be without the evidence. The hearing officer may, in the hearing officer's discretion, allow the presentation or hearsay evidence, allow cross-examination beyond the scope of direct examination, and allow the party calling a witness to cross-examine or impeach that witness. Rulings on evidence made by the administrative hearing officer shall be in the officer's discretion and not subject to appeal.
(e) The hearing officer may ask questions of any witness or request production of further evidence by any party to the hearing.
(f) The administrative hearing officer shall have discretion to exclude irrelevant, immaterial, or unduly repetitious evidence as provided in section 91-10(1), HRS.
(g) In administrative hearings, the provider shall have the burden of proof, including the burden of producing evidence as well as the burden of persuasion. The amount of proof necessary to prevail shall be a preponderance of the evidence in accordance with section 91-10(5), HRS. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §91-10; 42 C.F.R. §455.13)
§17-1736-40 Witnesses andsubpoenas. (a) Each party to the administrative hearing shall arrange for the presence of its witnesses at the hearing.
(b) The DHS director hereby designates the hearing officer as a representative of the director, empowered to conduct a hearing. Any party to the administrative hearing may request of the hearing officer a subpoena to compel the attendance of a witness or the production of books, papers, documents, or other objects deemed relevant to the investigation, except that no subpoena shall affect any privilege established by law. Each subpoena shall be signed by the administrative hearing officer who at any point in
UNOFFICIAL 1736-23 the proceedings may, on the hearing officer's own motion, subpoena witnesses, books, papers, documents, correspondence, memoranda, or other records in furtherance of the administrative hearing.
(c) Applications for subpoenas for the production by a witness of books, papers, documents, correspondence, memoranda, or other written records, shall be made by affidavit to the hearing officer and shall contain: (1) The name and address of the organization upon whom the subpoena is to be served; (2) A description of the documents, papers, books, correspondence, memoranda, photographs, or other written records that are desired; (3) A statement by the affiant that to the best of the affiant's knowledge and belief, the person to be subpoenaed has information about or possesses the documents, papers, books, correspondence, memoranda, photographs, or other objects that the subpoena seeks; and (4) The basis for the affiant's belief that the person or organization has information about or possesses the documents, papers, books, correspondence, memoranda, photographs, or other objects that the subpoena seeks.
(d) Each party to the administrative hearing shall arrange for the service of all subpoenas issued on its behalf. A copy of the affidavit in support of the issuance of the subpoena shall be served along with the subpoena.
(e) All witnesses who are summoned to an administrative hearing by subpoena may claim witness fees and mileage allowance at the same rate established for witnesses in the circuit court of the first circuit of the State.
(f) The parties shall bear their own costs. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §§92-16, 346-13; 42 C.F.R. §455.13)
§17-1736-41 Amendments. (a) If during the course of the hearing, evidence taken reveals that the provider was involved with conduct which would properly be the basis for suspension, termination, or other administrative sanction, and which was not alleged by the State as grounds for suspension, termination, or
UNOFFICIAL 1736-24 other administrative sanction, the State, at the discretion of the hearing officer, may amend its allegations to conform with the evidence.
(b) If, during the course of an administrative hearing, it becomes apparent to either party or to the administrative hearing officer that an absent party should be joined or afforded the opportunity to make an appearance, then the State, at the discretion of the hearing officer, may amend its allegations to include the additional party, or if appropriate, substitute the additional party for the present provider.
(c) Where allegations are amended pursuant to subsection (a), or parties are added or substituted pursuant to subsection (b), the administrative hearing shall be continued for the length of time the hearing officer deems appropriate to afford any additional party notice and to afford any existing or additional party a chance to address additional allegations.
(d) Notice of amendments or substitutions shall be mailed in writing to the last known address of each party affected by the amendment or substitution. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §346-14; 42 C.F.R. 455.13)
§17-1736-42 Continuances or further hearings. (a) At any time during the administrative hearing, if the hearing officer determines that the hearing shall be held at another time or at any other locations in the State, the hearing officer, at the hearing officer's discretion or on the motion of any party, may continue the hearing.
(b) If the hearing officer determines at any point in the hearing that it is necessary to seek additional evidence, the hearing officer may continue the hearing to a later date and seek additional evidence, or direct one or both parties to seek further evidence, provided that the hearing officer shall furnish written justification on the record for any continuance under this section lasting in excess of thirty days. Failure of either party to provide additional evidence as directed by the hearing officer shall not be used as the sole basis for an adverse decision against that party on the issues presented at the hearing. In the event that further evidence is not produced as directed, the hearing officer shall proceed to a decision based upon the entirety of the evidence presented at the hearing.
UNOFFICIAL 1736-25
(c) Written notice of the time and place of any continued or additional hearings shall be given in accordance with section 17-1736-37, except that when a continuance or additional hearing to a certain date is ordered during a hearing, then oral notice of the time and place of the hearing shall be sufficient for all parties present at the hearing. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §346-14; 42 C.F.R. §455.13)
§17-1736-43 Record of hearing. A verbatim record of all portions of the hearing shall be made. The record may be in the form of a transcript of verbatim shorthand, or by an audio or video recording, provided that in the event any party to the hearing notifies the hearing officer in writing of an intent to file exceptions to the hearing officer's findings of fact as provided in section 91-11, HRS, or if any party appeals an agency decision, as provided in section 91-14, HRS, a verbatim written transcript shall be prepared. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §91-9; 42 C.F.R. §455.13)
§17-1736-44 Decision of the hearing officer. (a) At the conclusion of the evidence and arguments by the parties, the hearing officer shall declare the hearing to be closed, at which time each party shall have thirty calendar days, not counting the day that the hearing is closed, to present written proposed findings of fact.
(b) At the conclusion of the thirty day period prescribed in subsection (a), the hearing officer shall have sixty calendar days to prepare a written decision accompanied by separate findings of fact, conclusions of law, and basis for findings. The hearing officer, if clarification of any evidence or any proposed finding of fact is desired, may reconvene the hearing to clarify the existing evidence. The period of time during which the hearing has been reconvened shall toll the time within which the hearing officer is required to prepare the written decision.
(c) The hearing officer shall not have informal, unrecorded conversations with any party concerning the case. All discussions concerning the evidence shall be at sessions of record with all parties to the hearing present except to the extent those discussions are
UNOFFICIAL 1736-26 required for the disposition of ex parte matters authorized by law. [Eff 08/01/94 ] (Auth: HRS §346-l4; 42 C.F.R. §43l.l0) (Imp: HRS §§9l-l2, 9l-l3; 42 C.F.R. §§455.l3, 455.l6)
§17-1736-45 Dismissal upon failure to appear at hearings. (a) If, after timely, proper written notice, a provider fails to appear at a scheduled hearing, the hearing officer may issue a written dismissal of the provider's request for an administrative hearing, which shall be mailed to each party with notice to the provider that the provider may request written consideration.
(b) In order to request written consideration, the provider shall, within ten days of the mailing of written dismissal, appeal to the hearing officer in writing showing good cause for the provider's failure to appear at the hearing. The hearing officer may, in the hearing officer's sound discretion, either sustain the dismissal, or reinstate the hearing with proper written notice to parties. In the event that the hearing officer sustains the dismissal, the hearing officer shall provide a written dismissal order including the circumstances upon which the dismissal is based. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §346-14; 42 C.F.R. §§455.13, 455.16)
§17-1736-46 Administrative appeal to the director. (a) In the event of a decision adverse to the provider, a copy of the order and decision shall be served upon all parties pursuant to section 17-1736-37. The provider shall have ten calendar days following the date of mailing of the order and decision to file written exceptions and present written argument to the DHS director.
(b) The director shall have thirty calendar days following the receipt of written exceptions and argument to decide the appeal. The director's decision on the appeal must be based upon the applicable rules and the facts as established in the record, provided that the director may communicate with the hearing officer while deciding the appeal. The director may sustain or reverse the decision and order of the the hearing officer and in either event, shall within thirty calendar days, mail the decision on appeal to
UNOFFICIAL 1736-27 all parties. The decision of the hearing officer and any appeal made to the DHS director shall be subject to judicial review as provided in section 91-14, HRS. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §346-14; 42 C.F.R. §§455.13, 455.16)
§§17-1736-47 to 17-1736-56 (Reserved).
§17-1736-57 Determination of medicaid reimbursement for hospital and institutional providers. The provider shall be notified of the reimbursement determination (NPR) and notice of PPS rate through the fiscal agent. The notices shall be sent to the provider by certified mail. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431-10) (Imp: 42 C.F.R. §431.10)
§17-1736-58 Hospital and institutional provider's right to review. (a) A provider may request an administrative hearing if it is dissatisfied with the department's determination of medicaid reimbursement: (1) Following any request for rate reconsideration determination under PPS; or (2) Following the issuance of an NPR under cost reimbursement; and (3) The amount in dispute is at least $1,000.
(b) A written request for administrative hearing must be received by the department within ninety days from the date of the rate reconsideration determination or NPR as provided in subsection (a) and shall refer to that specific notification.
(c) The provider's request for an administrative hearing shall include the following: (1) Individual adjustment items and the specific reimbursement issue and the dollar amount entailed; (2) The reasons for the disagreement; (3) Any material or evidence the provider considers necessary to support its position; and (4) The notice with which the provider disagrees.
(d) A group of providers may request an administrative hearing if the issue involves a common question of fact or interpretation, and the amount in
UNOFFICIAL 1736-28 controversy is in the aggregate of $50,000 or more. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §447.258)
§17-1736-59 Limitation of the right to review for hospital and institutional providers. A provider shall not have the right to an administrative hearing as provided under this subchapter if: (1) The provisions of section 17-1736-58 are not met; or (2) The administrative hearing concerns the following: (A) A determination of non-payment for items or services provided a recipient but which are not covered by the medicaid program; (B) The constitutionality of the law, rules, or medicaid reimbursement methodology; (C) Issues not addressed on the NPR or in the notice of rate reconsideration
determination; (D) Issues related to DHHS rules or policies; or (E) Issues not addressed in the Hawaii Administrative Rules. [Eff
08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §447.258)
§17-1736-60 Appearance by representatives of hospital and institutional providers and the department. (a) In all matters involving an administrative hearing, a provider may choose representation by itself or by an attorney or other person. A provider shall not have a right to legal counsel appointed at state expense.
(b) If the provider is represented by another person, that person's name, address, and telephone number shall be provided to the DHS med-QUEST administrator prior to the administrative hearing.
(c) Upon receipt of the name of the provider's representative, the med-QUEST administrator shall provide to that representative, the name, address, and telephone number of the department's representative. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §447.258)
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§17-1736-61 Forms for papers for hospital and institutional providers. An original and two copies of all papers filed in any proceeding under this subchapter shall be filed with the department and shall be typewritten on one side only. [Eff 08/01/94 ] ( Auth: HRS §346-14) (Imp: HRS §91.9; 42 C.F.R. §447.258)
§17-1736-62 Notice, service, and proof of service for hospital and institutional providers. (a) All papers, notices, and other documents shall be served by the party offering them upon all other parties to the proceeding. Proof of service upon the parties shall be filed with the DHS.
(b) Service of process may be accomplished by any manner permitted by law. The department shall serve the provider in person or by mail. If the provider is represented by an attorney or other person, service upon that attorney or other person shall be sufficient.
(c) Proof of service of any document shall be by certificate of attorney, affidavit, or acknowledgement.
(d) Where written notice is required by these rules, notice shall be considered effective on the date of mailing. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §91.9; 42 C.F.R. §447.258)
§17-1736-63 Notice of formal hearing; notice of results of formal hearing for hospital and institutional providers. (a) The department shall notify any provider who is entitled to an administrative hearing of the scheduled date and location of the administrative hearing. The notice shall be in writing and mailed to the provider not less than thirty calendar days before the scheduled date of hearing.
(b) The department shall notify by mail any provider who has received an administrative hearing of the hearing officer's decision. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §91.9; 42 C.F.R. §447.258)
§17-1736-64 Waiver of the right for oral hearing for hospital and institutional providers. (a) A provider may request that the hearing officer base the decision solely upon the documentary evidence submitted
UNOFFICIAL 1736-30 for the record without an oral hearing or appearance by either party. The request may be made at any time before or during the hearing. A waiver of an oral hearing is valid only if all parties agree with the request and if it is approved by the hearing officer.
(b) Approval of the request shall rest exclusively with the hearing officer.
(c) Where a request has been made and approved, the parties shall file with the hearing officer a written waiver of their right to a personal appearance before the hearing officer. The waiver may be withdrawn by any party with adequate notice to the opposing party and to the hearing officer as specified in section 17-1736-63.
(d) Once a waiver has been withdrawn, as provided in subsection (c), the hearing officer shall promptly notify all parties of the withdrawal and the need for an oral hearing. The hearing shall be held within one hundred eighty calendar days following the date of withdrawal of the waiver. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §91.9; 42 C.F.R. §447.258)
§17-1736-65 Prehearing conference for hospital and institutional providers. (a) At any time before the actual formal hearing as specified in section 17-1736-64 or 17-1736-66, a prehearing conference may be held to clarify the issues under dispute.
(b) The conference shall be informal in nature, and a record as described in section 17-1736-71 shall not be required.
(c) The decision to have, or to not have a prehearing conference shall rest solely with the hearing officer. The decision shall not be subject to appeal.
(d) The decision to record or not record the prehearing conference shall rest solely with the hearing officer. The decision shall not be subject to appeal.
(e) At the sole discretion of the hearing officer, a prehearing order regarding the proceedings may be issued. The order shall control the subsequent course of the evidentiary hearing unless modified at the hearing to prevent manifest injustice. The prehearing order regarding the proceedings shall not be subject to appeal. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §91.9; 42 C.F.R. §447.258)
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§17-1736-66 Conduct of hearing for hospital and institutional providers. (a) The hearing shall be conducted by an impartial hearing officer appointed by the DHS director. Before conducting the hearing, the hearing officer shall become familiar with sections 84-1 to 84-19, HRS, and the published opinions of the State's ethics commission and determine that participation as an administrative hearing officer shall not create conflicts of interest or ethical violations.
(b) Testimony shall be taken only on oath or affirmation and the testimony shall be subject to sections 710-1060, 710-1061, and 710-1062, HRS.
(c) Each party may: (1) Call and examine witnesses; (2) Introduce exhibits into evidence; (3) Cross-examine witnesses called by the other party; (4) Object to the presentation of any evidence deemed by the party to be not properly admitted; (5) Present rebuttal evidence to the opposing
party's case-in-chief; and (6) Present an opening statement to the hearing officer before the taking of evidence, and a closing argument to the hearing officer at the conclusion of the taking of evidence.
(d) The hearing officer shall not require strict adherence to any rules of evidence. The hearing officer shall admit all evidence having any bearing on the hearing including, but not limited to, testimony, documents, photographs, opinions, objects, or diagrams. The hearing officer may allow the presentation of hearsay evidence, allow cross-examination beyond the scope of direct examination, and allow the party calling a witness to cross-examine or impeach that witness. Rulings on evidence made by the administrative hearing officer shall not be subject to appeal.
(e) The hearing officer may ask questions of any witness or request production of evidence by any party to the hearing.
(f) The administrative hearing officer may exclude irrelevant, immaterial, or unduly repetitious evidence as provided in section 91-10(1), HRS.
(g) In administrative hearings, the provider shall have the burden of proof, including the burden of producing evidence as well as the burden of persuasion.
UNOFFICIAL 1736-32 The amount of proof necessary to prevail shall be a preponderance of the evidence in accordance with section 91-10(5), HRS. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §91.10; 42 C.F.R. §447.258)
§17-1736-67 Prehearing discovery for hospital and institutional providers. Any party may request data from any other party to the proceeding. If the requested party does not respond within fifteen calendar days of the request, the requesting party may notify the hearing officer. Upon notice, the hearing officer shall allow the requested party fifteen calendar days to state why the requested data was not furnished. If inadequate or no response is received, the hearing officer may take one of the following actions: (1) Subpoena the requested data under section 17-1736-68; (2) Issue an order that the matters regarding which the request was made or any designated facts shall be taken to be established for the purposes of the hearing in accordance with the claim of the requesting party; (3) Issue an order prohibiting the non-compliant party from supporting or opposing designated claims or defenses, or prohibiting that party from introducing designated matters in evidence; or (4) Issue an order continuing or suspending further proceedings in the provider's request for review until the requested data is furnished as provided for in section 17-1736-70. (5) The hearing officer, on the application of one of the parties, shall have the authority to determine that the request is unduly burdensome. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §91.10; 42 C.F.R. §447.258)
§17-1736-68 Witnesses and subpoenas for hospital and institutional providers. (a) Each party to the administrative hearing shall arrange for the presence of its witnesses at the hearing.
(b) The DHS director shall designate the hearing officer as a representative of the director and
UNOFFICIAL 1736-33 empowered to conduct a hearing. Any party to the administrative hearing may request of the hearing officer a subpoena to compel the attendance of a witness or the production of books, papers, documents, or other objects deemed relevant to the investigation, except that no subpoena shall affect any privilege established by law. Each subpoena shall be signed by the administrative hearing officer who at any point in the proceedings may, subpoena witnesses, books, papers, documents, correspondence, memoranda, or other records in furtherance of the administrative hearing.
(c) Applications for subpoenas for the production by a witness of books, papers, documents, correspondence, memoranda, or other written records, shall be made by affidavit to the hearing officer and shall contain all of the following: (1) The name and address of the person or organization upon whom the subpoena is to be
served; (2) A description of the documents, papers, books, correspondence, memoranda,
photographs, or other written records that are desired; (3) A statement by the affiant that to the best of the affiant's knowledge and belief, the person to be subpoenaed has information about or possesses the documents, papers, books, correspondence, memoranda, photographs, or other objects that the subpoena seeks; and (4) The basis for the affiant's belief that the person or organization has information about or possesses the documents, papers, books, correspondence, memoranda, photographs, or other objects that the subpoena seeks.
(d) Each party to the administrative hearing shall arrange for the service of all subpoenas issued on its behalf. A copy of the affidavit in support of the issuance of the subpoena shall be served along with the subpoena.
(e) All witnesses who are summoned to an administrative hearing by subpoena may claim witness fees and mileage allowance at the same rate established for witnesses in the circuit court of the first circuit of the State.
(f) The parties shall bear their own costs. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §447.258)
UNOFFICIAL 1736-34
§17-1736-69 Amendments for hospital and institutional providers. (a) If, subsequent to the provider's request for hearing under section 17-1736-58(b), the provider identifies further issues with which it disagrees, the provider, with notice to the opposing party and to the hearing officer, may include those issues in the appeal. The provider shall only amend the appeal if the initial request was made in accordance with section 17-1736-58, and the additional issues are not excluded as specified in section 17-1736-59. The provider shall not amend the appeal following the close of the formal hearing. Final determination of the right to amend shall be at the sole discretion of the hearing officer.
(b) Where the issues are amended pursuant to subsection (a), the administrative hearing process shall be continued for a length of time as the hearing office deems appropriate to afford all parties notice and a chance to examine and address the additional issues.
(c) Notice of amendments shall be served in accordance with section 17-1736-62. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §447.258)
§17-1736-70 Continuances or further hearings for hospital and institutional providers. (a) At any time during the administrative hearing, if the hearing officer determines that the hearing shall be held at another time or at any other location in the State, the hearing officer shall have discretion to continue the hearing.
(b) If the hearing officer determines at any point in the hearing that it is necessary to seek additional evidence, the hearing may be continued at a later date or one or both parties may be directed to seek further evidence, provided the hearing officer furnish written justification on the record for any continuance under this section lasting in excess of thirty days. Failure of either party to provide additional evidence as directed by the hearing officer shall not be used as the sole basis for an adverse decision against that party on the issues presented at the hearing. In the event that further evidence is not produced as directed, the hearing office shall proceed to a decision based upon the entirety of the evidence presented at the hearing.
UNOFFICIAL 1736-35
(c) Written notice of the time and place of any continued or additional hearings shall be given in accordance with section 17-1736-63, except when a continuance or additional hearing to a certain date is ordered during a hearing, then oral notice of the time and place of the hearing shall be sufficient for all parties present at the hearing. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §447.258)
§17-1736-71 Record of hearing for hospital and institutional providers. A verbatim record of all portions of the hearing shall be made. The record may be in the form of a transcript of verbatim shorthand, or by an audio or video recording. If any party to the hearing notifies the hearing officer in writing of an intent to file exceptions to the hearing officer's findings of fact as provided in section 91-11, HRS, or if a party appeals an agency decision, as provided in section 91-14, HRS, a verbatim written transcript shall be prepared. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §91; 42 C.F.R. §447.258)
§17-1736-72 Decision of the hearing officer for hospital and institutional providers. (a) At the conclusion of the evidence and argument by the parties, the hearing officer shall declare the hearing closed, at which time each party shall have thirty calendar days, not counting the day that the hearing is closed, to present written proposed findings of fact.
(b) At the conclusion of the thirty day period prescribed in subsection (a), the hearing officer shall have sixty calendar days to prepare a written decision accompanied by separate findings of fact, conclusions of law, and basis for findings. The hearing officer, if clarification of any evidence or any proposed finding of fact is desired, may reconvene the hearing to clarify the existing evidence. The period of time during which the hearing has been reconvened shall toll the time within which the hearing officer is required to prepare the written decision.
(c) The hearing officer shall not have informal, unrecorded conversations with any party concerning the case. All discussions concerning the evidence shall be at sessions of record with all parties to the hearing present, except to the extent those discussions are required for the disposition of ex parte matters
UNOFFICIAL 1736-36 authorized by law. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: HRS §§91-12, 91-13; 42 C.F.R §447.258)
§17-1736-73 Dismissal upon failure to appear at hearings for hospital and institutional providers. (a) If, after timely, proper written notice, a provider fails to appear at a scheduled hearing, the hearing officer may issue a written dismissal of the provider's request for an administrative hearing, which shall be mailed to each party with notice that the provider may request written consideration.
(b) In order to request written consideration, the provider shall, within ten days of the mailing of written dismissal, appeal to the hearing officer in writing showing good cause for the provider's failure to appear at the hearing. At the sole discretion of the hearing officer, the hearing officer may either sustain the dismissal or reinstate the hearing with proper written notice to parties. If the hearing officer sustains the dismissal, the hearing officer shall provide a written dismissal order including the circumstances upon which the dismissal is based. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §447.258)
§17-1736-74 Administrative review by the director for hospital and institutional providers. (a) The DHS director shall have the authority to review the hearing officer's written decision. The review may take place following issuance of the decision as specified in section 17-1736-63.
(b) The director shall have thirty calendar days following the date of the hearing officer's decision to mail notice of review to the parties of the director's intention to review the decision. The director's review shall be based upon the applicable rules and the facts as established in the record, provided that the director may communicate with the hearing officer during the review.
(c) The director may sustain, reverse, modify, or remand the decision of the hearing officer and in any event shall mail notice of his intention to review within thirty calendar days following the date of the hearing officer's decision.
UNOFFICIAL 1736-37
(d) The director's decision shall be mailed to all parties within thirty days following the notice of review.
(e) The decision of the hearing officer and DHS director shall be subject to judicial review as provided in section 91-14, HRS. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §447.258)
§17-1736-75 Reopenings for hospital and institutional providers. (a) A hearing officer may reopen a decision at any time within three years after the date of the decision.
(b) Notice shall be given to all parties of the hearing officer's intent to reopen and the reasons therefore.
(c) The decision to reopen, or not to reopen rests solely with the hearing officer and shall not be subject to appeal.
(d) The three years time limit shall be waived if the reopening is due to evidence of fraud. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R §447.258)
UNOFFICIAL 1737-1 HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1737
SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM
Subchapter 1 General Provisions
§17-1737-1 Purpose §17-1737-2 Definitions
Subchapter 2 Inpatient and Outpatient Hospital
Services, Physicians Services
§17-1737-3 Inpatient hospital care §17-1737-4 Length of inpatient hospital care and
extension of stay §17-1737-5 Physician services §17-1737-5.1 Physician assistant services §17-1737-6 Outpatient hospital services §§17-1737-7 to 17-1737-10 (Reserved)
Subchapter 3 Psychiatric Care
§17-1737-11 Definitions §17-1737-12 Authorized providers of psychiatric
services §17-1737-13 Psychiatric consultation §17-1737-14 Diagnostic and evaluative procedures
for psychiatric care §17-1737-15 Repealed [Eff 08/01/94;
R 09/14/98 ] §17-1737-15.1 Examination for, determination, and
certification of mental disability §17-1737-16 Medical evaluation §17-1737-17 Psychiatric service and treatment §17-1737-18 Inpatient psychiatric care §17-1737-18.1 Inpatient psychiatric Services for
UNOFFICIAL 1737-2
individuals under age twenty-one in
psychiatric facilities or programs §17-1737-19 Licensed general hospital §17-1737-20 Inpatient care for substance abusers §17-1737-21 Outpatient psychiatric care §17-1737-22 Exclusion to the psychiatric program §§17-1737-23 to 17-1737-25 (Reserved)
Subchapter 4 Long Term Institutional
Services
§17-1737-26 Scope and purpose §17-1737-27 Definitions §17-1737-28 Eligibility requirements §17-1737-29 Content of NF services §17-1737-30 Content of ICF-MR services §17-1737-31 Determining the applicant's or
recipient's need for long-term
institutional services §17-1737-32 Authorization for admission to a NF or
ICF-MR §17-1737-33 Preadmission screening and annual
resident review (PASRR) §17-1737-34 Utilization control for NFs §17-1737-35 Utilization control for ICF-MRs §17-1737-36 Inspection of care (IOC) reviews in
ICF-MR facilities §17-1737-37 Other service requirements §17-1737-38 Termination of long-term institutional
services §17-1737-39 Sharing of federal financial
participation payment penalty
assessment §17-1737-40 Remedies for nursing facilities that do
not meet the requirements for
participation §17-1737-41 State-approved feeding assistant
training program §§ 17-1737-42 (Reserved)
Subchapter 5 Preventive and Rehabilitative
Services
§17-1737-43 Preventive services §17-1737-44 Rehabilitative services §17-1737-44.1 Community mental health rehabilitative
services §17-1737-45 Home health services
UNOFFICIAL 1737-3 §17-1737-46 Family planning services §17-1737-47 Hysterectomy §17-1737-48 Sterilization §17-1737-49 Respiratory care services §17-1737-50 Home pharmacy services §17-1737-51 Sleep services §17-1737-51.1 Telehealth services §§17-1737-52 (Reserved)
Subchapter 6 Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT)
§17-1737-53 Early and periodic screening, diagnosis,
and treatment (EPSDT) §17-1737-54 Recipient eligibility requirements §17-1737-55 Informing §17-1737-56 Periodicity schedule §17-1737-57 Screening §17-1737-58 Diagnosis and treatment §17-1737-59 EPSDT providers §17-1737-60 Continuing care provider §17-1737-61 Provider requirements for participation
in the medical assistance program §17-1737-62 Appeal and hearing §§17-1737-63 to 17-1737-70 (Reserved)
Subchapter 7 Ancillary Medical Services
§17-1737-71 Drugs §17-1737-71.1 Supplemental rebate agreement for a drug §17-1737-72 Durable medical equipment §17-1737-73 Medical supplies §17-1737-74 Prosthetic and orthotic appliances §17-1737-75 Dental services §17-1737-75.1 Repealed [Eff 12/07/06; R 08/10/09] §17-1737-76 Visual services §17-1737-77 Speech, hearing and language disorders §17-1737-78 Hearing evaluations and devices §17-1737-79 Physical therapy and occupational
therapy services §17-1737-80 Podiatry services §17-1737-81 Pediatric or family nurse practitioner
Services §17-1737-81.1 Nurse-midwife services §17-1737-82 Intra-state transportation §17-1737-83 Out-of-state transportation §17-1737-83.1 Out-of-state medical services §17-1737-84 Exclusions and limitations
UNOFFICIAL 1737-4 §§17-1737-85 to 17-1737-89 (Reserved)
Subchapter 8 Tissue and Organ Transplantation
§17-1737-90 Definitions §17-1737-91 General provisions §17-1737-92 Corneal transplant (keratoplasty) §17-1737-93 Allogenic bone marrow transplant §17-1737-94 Kidney transplant §§17-1737-95 to 17-1737-99 (Reserved)
Subchapter 9 Hospice Service
§17-1737-100 Definitions §17-1737-101 Hospice care §17-1737-102 Plan of care §17-1737-103 Eligibility for hospice care §17-1737-104 Election of hospice care §17-1737-105 Waiver of other Medicaid benefits §17-1737-106 Revoking the election of hospice §17-1737-107 Payment for hospice care §17-1737-108 Providers of hospice service §17-1737-109 Appeals and hearings §§17-1737-110 to 17-1737-114 (Reserved)
Subchapter 10 Subacute Care
§17-1737-115 Purpose §17-1737-116 Definitions §17-1737-117 General provisions §17-1737-118 Staff standards §17-1737-119 Physician services §17-1737-120 Subacute patient care characteristics §17-1737-121 Exclusions
Historical Note: This chapter is based substantially upon chapter 17-1370. [Eff 6/29/92; am 11/12/93; am 2/22/94; R 08/01/94 ]
SUBCHAPTER 1
GENERAL PROVISIONS
UNOFFICIAL 1737-10
§17-1737-12 Authorized providers of psychiatric services. Individuals and facilities authorized to participate under the Medicaid program shall meet the provisions of chapter 17-1736. In addition the authorized provider shall meet the following requirements: (1) Psychiatrists shall be: (A) Licensed to practice in the state; (B) Have completed an approved three year residency training program or "Certified" by the American Board of Psychiatry and Neurology; and (C) In active clinical practice; (2) Psychologists shall: (A) Be licensed to practice in the State; (B) Have earned a doctoral degree in clinical, educational, or counseling psychology; (C) Be in active clinical practice; (3) An advanced practice registered nurse (APRN) in behavioral health shall be: (A) Licensed to practice as a registered professional nurse in the State; Successfully completed an accredited advanced training program in behavioral health; (B) Have a masters in nursing with emphasis in psychiatric nursing and currently certified by the American Nurses Association to practice as an advanced (C) practice registered nurse in behavioral health; (D) Limited to the scope of practice a behavioral health advanced practice registered nurse is legally authorized to perform under State law; and (E) Initially and biennially licensed with the department of commerce and consumer affairs as an advanced practice registered nurse (APRN) in mental health. (4) A licensed clinical social worker (LCSW) in behavioral health shall: (A) Be licensed to practice in the State as a licensed clinical social worker and meets all of the requirements in accordance with chapter 467E, HRS; (B) Be currently licensed by the department of commerce and consumer affairs and
UNOFFICIAL 1737-11 uses the designation of licensed clinical social worker; and
(C) Be limited to the scope of practice of a qualified licensed clinical social worker in behavioral health as authorized under State law; (5) General hospitals with a separate license as a psychiatric facility under Hawaii Administrative Rules, Title 11, chapter 93, shall have: (A) Qualified professional, technical, and consultant personnel available to evaluate each patient at the time of admission; (B) Qualified, professional, technical, and supporting personnel to carry out an intensive and comprehensive treatment program; (C) A seclusion room; (D) Psychiatric services available at all times; and (E) The capability to admit voluntary and involuntary commitments; and
(6) State community mental health centers
and psychiatric outpatient clinics attached to a general hospital with a separate license
as a psychiatric facility may provide psychiatric care through the centers' therapeutic teams. A therapeutic team shall: (A) Be under the direct supervision of a psychiatrist; or (B) For patients who are not prescribed medications, be under the supervision of a psychologist; and (C) Provide care that meets the patient's specified needs. [Eff 08/01/94, am 10/26/01; am 01/06/05] (Auth: HRS §§346-14, 467E-7, 467E-9; 42 C.F.R. §431.10) (Imp: HRS §§346E-7, 346E-9;
42 C.F.R. §§405.232(a), 440.60)
§17-1737-13 Psychiatric consultation. (a) A psychiatrist's or psychologist's consultation shall be for diagnostic evaluation and treatment planning of a patient. (1) Consultation shall be limited to a total of two hours, in one or two visits, for interview and documentation. (2) Prior authorization is not required.
UNOFFICIAL 1737-12 (3) A copy of the report shall be provided to the department's medical or psychiatric consultant upon the department's request.
(b) Restrictions on psychiatric consultations are requests by: (1) Friends; (2) Relatives; or (3) Other interested persons. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §405.231)
§17-1737-14 Diagnostic and evaluative procedures for psychiatric care. (a) Psychological testing shall be authorized as a diagnostic or evaluative procedure.
(b) Prior authorization is required for all psychological testing except when given in an inpatient facility or when requested by the department's professional staff. (1) The request for prior authorization shall be completed, signed, and dated by the psychiatrist or psychologist; (2) The request for prior authorization shall be received in the medical assistance program (medicaid) office within five working days
from the date of testing. The postmarked date shall be accepted provided it is within the five working days requirement; (3) Reimbursement to the psychiatrist or psychologist shall be denied when forms are not received within the specified time.
(c) Authorization shall be for a maximum of six hours per twelve month period.
(d) The number of hours authorized includes time for interview, appraisal, and concluding documentation.
(e) Only time spent by a qualified psychiatrist or psychologist in administering, monitoring, and evaluating tests shall be reimbursable. Time spent by a technician is not reimbursable.
(f) A copy of the testing report shall be provided to the department's psychiatric or medical consultant upon request.
(g) Testing requested by the following agencies and individuals for their use shall not be authorized: (1) Friends; (2) Relatives; or (3) Other interested persons.
(h) Evaluation to determine mental impairment for general assistance applicants and recipients between
UNOFFICIAL 1737-13 eighteen and sixty-five years of age shall be completed by designated providers. No prior authorization is required. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §405.231)
§17-1737-15 REPEALED. [Eff 08/01/94; R 09/14/98 ] (Auth: HRS §346-14, 346-71; 42 C.F.R. §430.10) (Imp: 42 C.F.R. §405.231)
§17-1737-15.1 Examination for, determination, and certification of mental disability. (a) The department shall designate providers to conduct the mental examinations. (1) Selection of the providers shall be based on the following: (A) Past history of conducting and reporting on mental examinations that meet the department’s standards. (B) An understanding of the purpose, pertinent issues and potential problems of the new examination and the services that the department expects it to provide. (C) Responsiveness and responsibility to assist the department in achieving its goals.
(b) For a determination and certification of mental disability, the department shall designate a board to determine and certify mental disability. The following shall apply to the board to determine and certify mental disability: (1) The board shall consist of licensed
physicians who are actively engaged in the practice of psychiatry in the State and a licensed psychologist actively engaged in the practice of psychology in the State; and (2) The duties of the board shall be to determine and certify mental disability of applicants and recipients for general assistance. [Eff 09/14/98 ] (Auth: HRS §§346-14, 346-71; 42 C.F.R. §430.10) (Imp: 42 C.F.R. §405.231)
§17-1737-16 Medical Evaluation. (a) Applicants who have been determined eligible for medicaid due to
UNOFFICIAL 1737-14 mental impairment shall be required to enter into outpatient treatment. They shall also be required to be medically evaluated by a physician to eliminate the possibility that their mental impairment is due to a physical illness.
(b) The medical evaluation may include and shall be limited to: (1) History and physical examination; (2) Complete blood count (CBC), urinalysis, and SMAC 20 or its equivalent; and (3) Additional tests or further studies may be done if they are medically indicated. Justification for further studies shall be provided to the department's medical or psychiatric consultant upon the department's request.
(c) The medical evaluation shall be completed no later than four weeks from the date of approved benefits. The result of the medical evaluation shall be submitted to the branch or unit requesting the information. The medical evaluation shall indicate whether the mental impairment was or was not due to a physical illness. [Eff 08/01/94 ] (Auth: HRS §364-14; 42 C.F.R. §430.10) (Imp: 42 C.F.R. §405.231)
§17-1737-17 Psychiatric service and treatment. (a) Psychiatric service shall be allowed where: (1) It is provided under an individualized treatment or diagnostic plan which may be revised during treatment if necessary. (2) Psychiatric service furnished without a planned program of therapy does not
constitute treatment and is not reimbursable; and (3) There is a reasonable expectation that service will improve the patient's condition. If the patient's condition is not altered after the authorized outpatient visits in the authorized period of treatment the frequency and number of subsequent outpatient visits requested may be reduced.
(b) A psychiatrist shall serve as a source of information and guidance when psychiatric service is provided by authorized mental health therapeutic teams;
(c) Drug management alone shall not be considered psychiatric care but shall be considered general medical care. Payments for drug management shall be made to:
UNOFFICIAL 1737-15 (1) Authorized outpatient clinics for the cost of the drugs; or (2) Psychiatrists at a general medical visit rate when accepting referrals for the purpose of prescribing psychiatric medications or evaluation of psychiatric medications.
(d) Psychiatric treatment shall be authorized for: (1) Individual therapy, in a behavioral or analytic framework; (2) New but non-experimental modes of therapy with prior authorization. The prior authorization will be granted if the provider can demonstrate adequate training and experience in that particular mode of therapy; (3) Group therapy or its variant, including family therapy, which can provide dimensions of treatment not available by other modes of treatment; (4) Combined therapy, a combination of group and individual psychotherapy, except that: (A) Visits shall be either for group or individual therapy, but not for both, on the same day; (B) The patient may have different therapists for group and individual psychotherapy; but (C) The involved therapists must be co-jointly responsible for coordinating the care and treatment of the patient; (5) Maintenance therapy, provided by physicians other than psychiatrists where: (A) The physician shall prescribe psychiatric medication and observe the patient for any changes in the patient's condition or behavior; (B) The physician shall provide supportive care, however, justification and prior authorization shall be required on the designated form requesting outpatient
care if supportive care visits are made more frequently than monthly; (C) Psychiatric consultation by a psychiatrist shall be readily available to the physician providing maintenance therapy; and (D) Reimbursement for maintenance therapy shall be equivalent to that of a general medical office visit; and
UNOFFICIAL 1737-16 (6) Patients with alcohol and drug problems may require monitoring by pertinent laboratory data. Such decisions regarding the monitoring of data will be decided after consultation and approval of the treating physician.
(e) Exclusions for psychiatric care and treatment are those for: (1) Sex; (2) Marriage; (3) Diet; (4) Employment counseling; (5) Primal therapy; ( (6) Long term character analysis; (7) Marathon group therapy; (8) Consortiums; and (9) Other modalities as determined by the department. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §405.231)
§17-1737-18 Inpatient psychiatric care. (a) Inpatient psychiatric care shall be provided only in an authorized psychiatric facility and by authorized psychiatric providers.
(b) Admission to a psychiatric facility shall be by: (1) A psychiatrist; or (2) A non-psychiatrist physician with a psychiatrist concurring that admission is needed.
(c) Authorization for inpatient psychiatric care is required for: (1) All application or pending cases; and (2) Medicaid patients with third party coverage or any other available resources except for medicare.
(d) The department of human services form for medical authorization shall be used to request authorization for inpatient psychiatric care. The following procedures shall be taken: (1) The form shall be completed by the inpatient psychiatric facility and shall be signed and dated by a psychiatrist or countersigned and dated by a psychiatrist when the patient is admitted by non-psychiatrist physician; (2) The psychiatric facility and the physician shall both be responsible for submitting the
UNOFFICIAL 1737-17 form to the medical assistance program (medicaid) office; (3) The form shall be received in the medical assistance program (medicaid) office of the department within five working days from the time of the patient's admission. The postmarked date shall be accepted provided it is within the five working days requirement from the time of patient's admission; (4) Reimbursements to the physician and psychiatric facility is subject to denial when forms are not received within the specified time; (5) A form shall be submitted for each admission; and (6) An extension form will not be required regardless of length of stay.
(e) The length of hospital stay is applicable to all categories and the following shall be followed: (1) No more than thirty days per calendar year shall be authorized. Inpatient days not used in the authorized calendar year shall not be added to the inpatient days allowed for the following calendar year; (2) The number of inpatient days available through a third party coverage shall be
counted as part of the authorized number of days under Medicaid. The psychiatric facility shall apply the number of inpatient days that are available from the third party resource to the authorized number of days under Medicaid; and
(3) One inpatient day can be exchanged for two outpatient hours.
(f) Emergency inpatient psychiatric care shall be provided as follows: (1) In communities where a psychiatric facility is not readily available, emergency inpatient psychiatric service may be provided for up to
forty-eight hours at the closest licensed general hospital; and (2) A patient shall be transferred to an authorized psychiatric facility or to a long-term psychiatric facility if the attending physician determines that the patient requires inpatient psychiatric service beyond the forty-eight hour period.
(g) Voluntary patients may obtain psychiatric inpatient hospital passes only as needed for discharge
UNOFFICIAL 1737-18 planning purposes. Involuntary patients will be regulated according to legal requirements. (1) A patient is authorized eight hours to assist in his discharge preparation. The hours may be used in a flexible and judicious manner throughout the duration of admission. (2) Exceptions may be made for patients who will benefit from program under the auspices of the treating hospital. (3) All other types of hospital passes are not reimbursable. [Eff 08/01/94; am 06/19/00 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §431M-4; 42 C.F.R. §§440.10, 440.160)
§17-1737-18.1 Inpatient psychiatric Services for individuals under age twenty-one in psychiatric facilities or programs. (a) Inpatient psychiatric services for recipients under age twenty-one shall be provided: (1) Under the direction of a physician; (2) By: (A) A psychiatric hospital or an inpatient psychiatric program that is accredited by the joint commission on accreditation of healthcare organizations; or (B) A psychiatric facility which is accredited by the joint commission on accreditation of healthcare organizations, the commission on accreditation of rehabilitation facilities, the council on accreditation of services for families and children, or by any other accrediting organization, with comparable standards that is recognized by the State; and (C) Is authorized to practice under the Medicaid program and meets the provisions of chapter 17-1736. (3) Before the individual reaches the age twenty-one or, if the individual was receiving the services immediately before he or she reached age twenty-one, services will continue until the earlier of the following: (A) The date the individual no longer requires the services; or (B) The date the individual reaches age twenty-two.
UNOFFICIAL 1737-19 (4) To an individual certified to be in need of the services. (A) Ambulatory care resources available in the community do not meet the treatment needs of the recipient; and (B) The services can reasonably be expected to improve the recipient’s condition or prevent further regression so that the services will no longer be needed. (b) The individual shall receive active treatment which involves a developed and supervised individual plan of care to improve the individual’s condition to the extent that inpatient care is no longer necessary. The plan of care shall: (1) Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral and developmental aspect of the recipient’s situation and reflects the need for inpatient psychiatric care; (2) Be developed by a team of professionals in consultation with the recipient, and his parents, legal guardians, or others in whose care he will be released after discharge; (3) State treatment objectives; (4) Prescribe an integrated program of therapies, activities, and experiences designed to meet the objectives; (5) Include, at an appropriate time, post-discharge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the recipient’s family, school, and community upon discharge; (6) The plan shall be reviewed every thirty days to: (A) Determine that services being provided are or were required on an inpatient basis; and (B) Recommend changes in the plan as indicated by the recipient’s overall adjustment as an inpatient. (c) The individual plan of care must be developed by an interdisciplinary team of physicians and other personnel who are employed by, or provide services to patients in, the facility. (1) The interdisciplinary team shall be capable of:
UNOFFICIAL 1737-20 (A) Assessing the recipient’s immediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities; (B) Assessing the potential resources of the recipient’s family; (C) Setting treatment objectives; and (D) Prescribing therapeutic modalities to achieve the plan’s objectives. (2) The team shall include, as a minimum, either: (A) A board-eligible or board-certified psychiatrist; or (B) A clinical psychologist who has a doctoral degree and a physician licensed to practice medicine or osteopathy; (3) The team shall also include one of the following: (A) A psychiatric social worker; (B) A registered nurse with specialized training or one year’s experience in treating mentally ill individuals; or (C) An occupational therapist who is licensed, if required by the State, and who has specialized training or one year of experience in treating mentally ill individuals; (d) Prior authorization is required before inpatient psychiatric services for recipients under age twenty-one are provided. [Eff 02/16/02 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §§441.150 through 441.156)
§17-1737-19 Licensed general hospital. (a) A patient admitted to a licensed general hospital for a medical condition may be provided psychiatric care on the medical unit only when it is determined through psychiatric consultation that the patient's condition does not require the patient to be admitted to a psychiatric facility. (1) A maximum of four visits for psychiatric care shall be allowed. (A) Prior authorization is required before inpatient psychiatric services for recipients under age twenty-one are provided. (2) Prior authorization shall be required through the designated outpatient request form if the patient requires more treatment than the authorized four hours. It shall be noted in
UNOFFICIAL 1737-21 the required form that the patient is in a licensed general hospital.
(b) Prior authorization is required to admit a patient to a psychiatric facility from a medical unit for all applications and pending cases. (1) The appropriate department of human services form for prior medical authorization shall be used to request authorization for inpatient psychiatric care. (2) All other appropriate policies for inpatient psychiatric care shall apply. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §§431.10, 405.1020) (Imp: 42 C.F.R. §§405.116, 405.1020)
§17-1737-20 Inpatient care for substance abusers. (a) Prior authorization for medical pensioners plan cases are required for inpatient care for alcohol and non-alcohol substance abuse regardless of whether the patient is admitted to a medical unit of the hospital or to the psychiatric unit of the hospital.
(b) Inpatient care for alcohol substance abuse shall be as follows: (1) Patients requiring only detoxification shall be referred to a detoxification facility for treatment; (2) If a detoxification facility is not available, the attending physician may admit the patient to a licensed general hospital; and (3) Patients requiring detoxification in addition to psychiatric or medical care shall be referred to an authorized inpatient psychiatric facility for psychiatric care or
to a licensed general hospital for medical care.
(c) Inpatient care for non-alcohol substance abuse shall be as follows: (1) Patients requiring only detoxification for substance abuse shall be referred by the attending physician to an appropriate facility for detoxification; and (2) Patients requiring detoxification in addition to psychiatric or medical care shall be referred by the attending physician to an appropriate facility for treatment.
(d) Prior authorization shall not be required for the initial forty-eight hours of emergency care. If the attending physician determines that the patient
UNOFFICIAL 1737-22 requires further inpatient care the patient shall be transferred to an appropriate facility.
(e) Maximum hospital stay for patients requiring only detoxification shall be ten days.
(f) Hospital stay for patients requiring more than ten days for detoxification may be allowed provided that there is a justification that patient requires more than ten days for inpatient care. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §§431.10, 405.1020) (Imp: 42 C.F.R. §§405.116, 405.1020)
§17-1737-21 Outpatient psychiatric care. (a) Outpatient psychiatric care shall be provided by authorized psychiatric providers.
(b) Prior authorization is required for outpatient psychiatric care for: (1) All eligible recipients in need of outpatient psychiatric care; (2) Non-Medicaid patients who become eligible for medical assistance and whose outpatient visits may be covered retroactively. The prior authorization form shall be submitted by the provider immediately upon learning that the patient became eligible for retroactive coverage; and (3) Medicaid patients with third party coverage or any other available resources except for Medicare.
(c) The appropriate department of human services form for prior medical authorization shall be used to request authorization for outpatient psychiatric care. The following procedure shall be taken: (1) The form shall be completed, signed, and dated by the psychiatrist or psychologist; (2) The form shall be received in the medical assistance program (Medicaid) office of the department within five working days from the time of the patient's first visit. The postmarked date shall be accepted provided it is within the five working days requirement from the time of patient's first visit; (3) Subsequent requests shall be submitted to the medical assistance program (Medicaid) office within five working days from the date of the last visit authorized. The postmarked date shall be accepted provided it is within the five working days requirement; and
UNOFFICIAL 1737-23 (4) Reimbursements to the physician or psychologist shall be denied when forms are not received within the specified time. (d) Outpatient visits for psychiatric care shall be as follows: (1) Emergency room service in a licensed general hospital may be provided to patients with psychiatric problems. Services shall consist of examination for clinical impression and treatment; and Office or clinic visits shall be a face to face, personal contact between the patient and the authorized therapist for therapy or for a diagnostic purpose. (e) Outpatient visits shall not be reimbursed for time spent beyond one hour for individual therapy; or two hours for group therapy. (f) The number of visits shall be as follows: (1) The maximum number of visits for the primary mode of therapy is twenty-four one hour individual visits or twenty-four one and one- half to two hour group visits within a twelve month period; (2) For a combination of group and individual psychotherapy, the maximum for the primary modality is twenty-four visits and the maximum for the secondary modality (when twenty-four of the primary modality is approved) is six visits within a twelve month period; (3) Any combination of group and individual psychotherapy is allowed, provided the total of thirty visits and the maximum for the primary modality are not exceeded; (4) One-half hour (twenty to thirty minutes), or one quarter hour (ten to fifteen minutes), as well as one hour (forty-five to fifty minutes) individual psychotherapy visits are allowed. Any combination of visits is allowed, provided the total does not exceed twenty-four one hour visits within a twelve month period; and (5) One inpatient day can be exchanged for two outpatient hours.
(g) Approval of a second request and subsequent requests shall be based on the severity of the patient's illness. (1) Severe cases shall be allowed a maximum of twenty-four visits within a twelve month period;
UNOFFICIAL 1737-24 (2) Moderate cases shall be allowed a maximum of eighteen visits within a twelve month period; (3) Maintenance cases shall be allowed a maximum of twelve visits within a twelve month period; and (4) Personality disorders without acute crisis shall be eligible for extension after one year of treatment, with sufficient justification. (h) Visits not used in the authorized twelve month period shall not be added to the outpatient visits allowed for the following twelve month period. (i) A summary of the patient-therapist relationship may be requested at any interval after the onset of treatment: (1) The summary should include such information as a justification for said diagnosis, a logical expressed treatment plan and observed changes since the onset of patient-therapist relationship; and (2) The summary shall be utilized by the department's psychiatric consultant or by the department's established peer review committee to determine the number of subsequent out-patient visits that shall be authorized.
(j) Patients who have been under continuous psychiatric treatment for longer than a year may have their records reviewed by the department's psychiatric consultant for progress towards rehabilitation and general productivity of therapy before further outpatient visits are approved. If the provider is in disagreement with the department's psychiatric consultant's determination, the case shall be referred to the department's established peer review committee for review.
(k) Psychiatric outpatient visits available through third party coverage shall be counted as part of a patient's authorized visits under Medicaid. It shall be the provider's responsibility to apply the number of visits available from the third party coverage to the authorized number of visits under Medicaid. [Eff 08/01/94; am 06/19/00; am 02/16/02 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §440.20)
§17-1737-22 Exclusions to the psychiatric program. Excluded from the psychiatric program are: Partial hospitalization, day, evening, and night care;
UNOFFICIAL 1737-25 (1) Residential treatment centers; (2) Skilled nursing facilities; (3) Intermediate care facilities; (4) Consortiums; and (5) Home visits to a residence, care home, boarding home, or other living arrangement, except in an emergency situation. [Eff 02/16/02 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §456.3)
§§17-1737-23 to 17-1737-25 (Reserved).
SUBCHAPTER 4
LONG TERM INSTITUTIONAL SERVICES
§17-1737-26 Scope and purpose. (a) This subchapter governs the standard for payment which providers of long-term institutional services shall meet to qualify for medical payments for services provided to medicaid recipients.
(b) This subchapter shall ensure provision of effective and appropriate long-term institutional services and the on-going evaluation of the quality, appropriateness and timeliness of such services to medicaid recipients. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §§430.10, 431.10; Pub. L. No. 100-203) (Imp: 42 C.F.R. §§440.40, 440.150, 440.260, 483.1)
§17-1737-27 REPEALED. [R 09/30/13]
§17-1737-28 Eligibility requirements. (a) The individual applicant shall meet the basic eligibility requirements of the medicaid program in order to qualify for medicaid assistance.
(b) Long-term institutional services shall be available to recipients who have been approved by the department to receive these services. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §§430.10, 431.10, 442.1) (Imp: 42 C.F.R. §§431.10, 442.1)
UNOFFICIAL 1737-26
§17-1737-29 Content of NF services. (a) Long- term institutional services shall be provided by free-standing or distinct part NFs that shall meet the eligibility requirements specified in chapters 17-1736 and 17-1739.
(b) NFs shall provide: (1) Skilled nursing care and related services for residents who require medical or nursing care; (2) Rehabilitation services for the rehabilitation of injured, disabled, or sick persons; or (3) On a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases.
(c) NF services shall be provided either directly by or under the general supervision of licensed practical nurses or registered professional nurses.
(d) NF services shall include, but shall not be limited to: (1) Room and board; (2) Administration of medication and treatment; (3) Development, management, and evaluation of the written resident care plan based on physician orders that necessitate the involvement of skilled technical or professional personnel to meet the resident's care needs, promote recovery, and ensure the resident's health and safety; (4) Observation and assessment of the resident's unstable condition that requires the skills and knowledge of skilled technical or professional personnel to identify and evaluate the resident's need for possible medical intervention, modification of treatment, or both, to stabilize the resident's condition; (5) Health education services provided by skilled technical or professional personnel to teach the recipient self care, such as gait training and self administration of medications; (6) Provision of therapeutic diet and dietary supplement as ordered by the attending physician;
UNOFFICIAL 1737-27 (7) Laundry service, including items of recipient's washable personal clothing; (8) Basic nursing and treatment supplies, such as soap, skin lotion, alcohol, powder, applicator, tongue depressor, cotton ball, gauze, adhesive tape, band aids, incontinent pad, V-pad, thermometer, blood pressure apparatus, plastic or rubber sheet, enema equipment, and douche equipment; (9) Durable medical equipment and supplies used by residents but which are reusable, such as ice bag, hot water bottle, urinal, bedpan, commode, cane, crutch, walker, wheelchair, and siderail and traction equipment; (10) Activities of the resident's choice (including religious activities) that are designed to provide normal pursuits for physical and psychosocial well-being; (11) Social services provided by qualified personnel; (12) A review of the drug regimen of each resident at least once a month by a licensed pharmacist, as required for a nursing facility to participate in Medicaid; (13) Nonrestorative or nonrehabilitative therapy, or both, provided by nursing staff; and (14) Provision of and payment for, through contractual agreements with appropriate skilled technical or professional personnel, other medical and remedial services ordered by the attending physician which are not regularly provided by the provider. Other services that may be needed, such as transportation to realize the provision of services ordered by the attending physician, shall also be arranged through contractual agreements. The contractual agreement shall stipulate the responsibilities, functions, objectives, service fee, and other terms agreed to by the NF and the person or entity that contracts to provide the service. (15) Feeding assistance performed by a feeding assistant, nurse aide, or nurse. The feeding assistant must work under the supervision of a registered nurse or licensed practical nurse who is licensed to practice in Hawaii. [Eff 08/01/94; am 02/10/97; am 05/05/05; am 05/24/07] (Auth: HRS §346-14; 42 C.F.R. §§430.10, 431.10, 483.1) (Imp: 42 C.F.R.
UNOFFICIAL 1737-28 §§440.40, 483.1, 483.20, 483.30, 483.35, 483.160)
§17-1737-30 Content of ICF-MR services. (a) Long-term institutional services shall be provided by freestanding or distinct part ICF-MR facilities that shall meet the eligibility requirements specified in chapters 17-1736 and 17-1739.
(b) ICF-MR facilities shall provide inpatient or authorized community-based services designed primarily for the treatment and rehabilitation of the mentally retarded or persons with related conditions.
(c) ICF-MR services shall include but not be limited to: (1) Twenty-four hour supervision of mentally
retarded individuals or persons with related conditions in a protected residential setting; (2) A continuous active treatment program which includes aggressive, consistent implementation of a program of specialized and generic training, treatment health services and related services described in this subsection, that is directed towards: (A) The acquisition of the behaviors necessary for the client to function with as much self-determination and independence as possible; and (B) The prevention or deceleration of regression or loss of current optimal functional status. Active treatment does not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program; (3) Interventions to manage inappropriate client behavior that are employed with sufficient safeguards and supervision to ensure that the safety, welfare and civil and human rights of clients are adequately protected; (4) Sufficient direct care staff to manage and supervise clients in accordance with their individual program plans, to respond to injuries and symptom of illness and to handle emergencies in each defined residential living unit;
UNOFFICIAL 1737-29 (5) Preventive and general medical care as well as annual physical exams of each client that include: (A) Evaluation of vision and hearing; (B) Immunizations, using as a guide the recommendations of the Public Health Service Advisory Committee on Immunization Practices or of the Committee on the Control of Infectious Diseases of the American Academy of Pediatrics; (C) Routine screening lab exams and special studies; and (D) TB control, appropriate to the facility's population, and in accordance with the recommendations of the American College of Chest Physicians or the section of diseases of the American Academy of Pediatrics, or both; (6) Licensed nursing services sufficient to care for clients health needs, including those clients with medical care plans; (7) Provision of or arrangements for comprehensive dental diagnostic services and comprehensive dental treatment services that include: (A) The availability of emergency dental treatment on a twenty-four hours a day basis by a licensed dentist; and (B) Dental care needed for relief of pain and infections, restoration of teeth, and maintenance of dental health; (8) Provision of or arrangements for routine and emergency drugs and biologicals that are administered in compliance with physician's orders; (9) At least three meals a day that comprise a nourishing, well-balanced diet including modified and specially prescribed diets; (10) Physician services available twenty-four hours a day to: (A) Develop and maintain, in coordination with licensed nursing personnel, a medical care plan of treatment for a client if the physician determines that an individual client requires twenty-four hours licensed nursing care; and
UNOFFICIAL 1737-30 (B) Participate in establishing an initial individual program plan for a newly admitted client; and (11) Provision of necessary services, including emergency and other health care through contractual agreements which shall: (A) Stipulate the responsibilities, functions, objectives, service fee, and other terms agreed to by the ICF-MR and the provider; and (B) Provide that the ICF-MR is responsible for assuring that the outside services meet the standards for quality of services. [Eff 08/01/94; am 02/10/97 ] (Auth: HRS §346- 14; Pub. L. No. 100-203; 42 C.F.R. §§430.10, 431.10, 483.400) (Imp: Pub. L. No. 100-203; 42 C.F.R. §§483.400; 483.480)
§17-1737-31 Determining the applicant's or recipient's need for long-term institutional services. (a) The provision for the determination of need for admission to a long-term institution are based on a physician's and other appropriate health care professional's assessment of the applicant's or recipient's condition and recommendation of the applicant's or recipient's need for a specific acuity level (or level of medical care).
(b) Their recommendation of the applicant's or recipient's need for a specific acuity level (or level of medical care) shall be based on the following criteria: (1) Acuity Level A recipient requires licensed nursing and ancillary nursing personnel services on a regular and long-term basis to maintain, improve, or safeguard health, or to minimize disability or pain. The services provided shall be beyond room, board, and personal care services available in personal care home, and shall: (A) Be available to recipients who require assistance with the normal activities of daily living twenty-four hours a day; (B) Be ordered by a physician and shall be provided under the direction of the attending physician or staff physician; (C) Be planned, provided, and maintained by licensed and ancillary nursing personnel
UNOFFICIAL 1737-31 and other professional personnel, in accordance with a written resident care plan; (D) Be provided on an inpatient basis only after consideration of the recipient's condition and the feasibility and availability of utilizing more economical alternative facilities and services have been ruled out; and (E) Be less than twenty-four hours of skilled nursing or regular rehabilitation services; (2) Acuity Level B recipient shall: (A) Be evaluated by an interdisciplinary professional team, who shall recommend admission based on their evaluation, which shall be completed not more than three months prior to admission, or before the ICF-MR requests payment for a client applying for medicaid after admission; (B) Be diagnosed as mentally retarded or with other related conditions; and (C) Require the medical care and special services that are appropriately obtained from an ICF-MR as described in section 17-1737-30; and (3) Acuity Level C recipient requires skilled nursing services provided directly or under the general supervision of registered professional nurses on a twenty-four hour basis, rehabilitation services, or both and shall: (A) Be provided on a seven-days a week basis, except rehabilitation services may be needed by the recipient and provided on a five-days a week basis; and (B) Include subparagraphs (1)(A),(B),(C), and (D). [Eff 08/01/94 ] (Auth: HRS §§346-14, 346-49; Pub. L. No. 100- 203; 42 C.F.R. §§430.10, 431.10) (Imp: Pub. L. No. 100-203; 42 C.F.R. §§435.1009, 440.40, 440.150, 456.270, 456.271, 456.370, 483.30, 483.440)
§17-1737-32 Authorization for admission to a NF or ICF-MR. (a) Authorization by the department for the recommended acuity level (or level of medical care)
UNOFFICIAL 1737-32 required by an applicant or recipient shall be in accordance with the provisions of chapter 1739 and section 17-1737-31.
(b) Authorization granted by the department for admission to a NF or ICF-MR shall be based on the determination that the applicant or recipient requires the services stipulated in sections 17-1737-29 and 17- 1737-30. [Eff 08/01/94; am 02/10/97 ] (Auth: HRS §§346-14, 346-49; 42 C.F.R. §§430.10, 431.10, 435.1009) (Imp: 42 C.F.R. §§435.1009, 440.150, 456.271, 456.370, 483.440)
§17-1737-33 Preadmission screening and resident review (PASRR). The state PASRR program shall require that: (1) NFs shall not admit, on or after January 1, 1989, any new resident with: (A) "Mental illness" as defined in section 17-1737-27 unless the state mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the state mental health authority, prior to admission, whether: (i) Because of the physical and mental condition of the individual, the individual requires the level of services provided by a NF; and (ii) If the individual requires such level of services, the individual requires active treatment for mental illness; or (B) "Mental retardation" or "persons with related conditions" as defined in section 17-1737-27 unless the state mental retardation/developmental disability authority has determined prior to admission whether: (i) Because of the physical and mental condition of the individual, the individual requires the level of services provided by a NF; and (ii) If the individual requires such level of services, the individual requires active treatment for mental retardation;
UNOFFICIAL 1737-33 (2) For those residents who entered the NF prior to January 1, 1989, and were identified with a diagnosis of: (A) "Mental illness" as defined in section 17-1737-27, the state mental health authority shall determine whether, because of the resident's physical and mental condition, the resident requires: (i) The level of services provided by a NF; and (ii) Active treatment for mental illness; or (B) "Mental retardation" or identified as "persons with related conditions" as defined in section 17-1737-27, the state mental retardation/developmental disability authority shall determine whether because of the resident's physical and mental condition, the resident requires: (i) The level of services provided by a NF; and (ii) Specialized services for mental retardation or related conditions in an ICF-MR; (3) The nursing facility shall notify the State mental health authority or the State mental retardation or developmental disabilities authority within twenty-one days after a significant change in the physical or mental condition of a resident who meets criteria for mental illness or mental retardation. For an individual with mental illness, if their condition worsens notification must be made to the State mental health authority within twenty-one days. For individuals with mental retardation, if their condition improves where the individual may benefit from specialized services, notification to the State mental retardation or developmental disabilities authority must be made within twenty-one days. [Eff 08/01/94; am 08/25/07 ] (Auth: HRS §346-14; 42 C.F.R. §§430.10, 431.10; Pub. L. No. 100-203) (Imp: Pub. L. No. 100-203; 42 C.F.R. §483.20)
§17-1737-34 Utilization control for NFs. (a) This section defines the utilization control process
UNOFFICIAL 1737-34 which shall be administered in accordance with state and federal regulations to achieve optimal quality control of the utilization of services provided under the state plan.
(b) The provisions for utilization control are as follows: (1) Providers of NF services shall admit only those recipients whose health care needs may be met by the facility; (2) Each resident shall receive the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive resident assessment and plan of care; (3) The NF shall operate and provide services in compliance with all state, federal, and local laws, regulations, and codes and with accepted professional standards and principles that apply to professionals providing services in the NF; (4) The services provided by or arranged by the NF shall meet professional standards of quality and be provided by qualified persons in accordance with each resident's written plan of care; and (5) The following requirements regarding nurse aides shall be met: (A) A nursing facility shall not use any individual working in the facility as a nurse aide for more than four months unless the individual: (i) Has completed a nurse aide training and competency evaluation program certified by the State; and (ii) Is competent to provide such services; (B) A nursing facility shall provide for individuals used as nurse aides a nurse aide training competency and evaluation program certified by the State and such preparation as may be necessary to complete such a program; (C) A nursing facility shall not permit an individual to serve as a nurse aide or provide services of a type for which the individual has not demonstrated competency. A nursing facility shall not use such an individual as a nurse aide unless the facility has inquired of
UNOFFICIAL 1737-35 the state registry as to information in the registry concerning the individual; (D) A nursing facility shall not use any individual as a nurse aide if there has been a period of twenty-four consecutive months during which no nursing or nursing-related services were performed by the individual for monetary compensation. Such individual will need to complete a new training and competency evaluation program; (E) A nursing facility shall provide regular performance reviews and regular in- service education to assure that individuals used as nurse aides are competent to perform services as nurse aides, including training for individuals providing nursing and nursing-related services to residents with cognitive impairments; (F) Any findings of abuse or neglect of residents or misappropriations of residents' property by nurse aides shall be reported to the state department of health; and (G) The State shall: (i) Establish and maintain a registry of all individuals who have satisfactorily completed a nurse aide training and competency evaluation program certified by the State; (ii) The registry shall include specific documented findings by the State of resident neglect or abuse or misappropriation of resident property as well as any brief statement of the individual disputing the findings; and (iii) When inquiries to the registry are made concerning an individual listed in the registry, any information disclosed concerning such a finding shall also include disclosure of any such statement in the registry relating to the finding or a clear and accurate summary of such a statement. [Eff 08/01/94, am 08/25/07 ] (Auth: HRS §346-14; 42 U.S.C.
UNOFFICIAL 1737-36 §§1395, 1396; Pub. L. No. 100-203; 42 C.F.R. §§431.10, 435.1009, 456.1, 483.1) (Imp: Pub. L. No. 100-203; 42 C.F.R. §§435.1009, 442.1, 456.1, 456.250, 483.1, 483.20, 483.25, 483.75)
§17-1737-35 Utilization control for ICF-MRs. (a) This section defines the utilization control process which shall be administered in accordance with state and federal regulations to achieve optimal quality control of the utilization of services provided under the state plan.
(b) The provisions for the utilization control for ICF-MRs are as follows: (1) A written certification or recertification statement that the client require a specific level of care is required as follows: (A) Admission certification shall be provided by a physician or a nurse practitioner or a clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician, on admission or not more than sixty days prior to authorization of medicaid payment for the provision of long-term institutional services to the client; (B) A recertification statement shall be provided by a physician or a physician assistant under the supervision of a physician or a nurse practitioner or a clinical nurse specialist who is not an employee of the facility but is working in collaboration with a physician, no more than twelve months following certification and thereafter no more than twelve months intervals until discharge from the ICF-MR; (C) The written certification and recertification statements shall be placed on a form designed either by the facility or the department specifically for certification and recertification documentations, and said form shall be placed in each client's active medical record; and (D) The written certification and recertification statements shall clearly
UNOFFICIAL 1737-37 indicate the client's need for a specific level of care, and shall include: (i) A physician's signature or initials clearly identified with the acronym "M.D." for medical doctor, or "D.O." for doctor of osteopathy; (ii) A physician assistant's signature or initials, clearly identified with the acronym "P.A." for physician assistant; (iii) A nurse practitioner's signature or initials, clearly identified with the acronym "R.N.C."or "R.N." whichever is appropriate; or (iv) A clinical nurse specialist's signature or initials clearly identified with the acronym "R.N.M.S." or "R.N.C.S." whichever is appropriate; and (v) The date of certification or recertification statement is signed or initialed by a physician or a physician assistant or a nurse practitioner or a clinical nurse specialist; (2) The facility shall have in effect a written utilization review plan approved by the department which shall include the following methods and procedures: (A) Use of cross reference file numbers in all UR related documentation to assure the anonymity of the medicaid client; (B) Identification of the administrative entity and sub-group of the entity responsible for the performance of UR and the medical staff of a medical institution; (C) Development and selection and adoption of forms utilized for the UR process; (D) Review of documentation necessary to verify justification for continued stay cases. The information shall be an integral part of the client's medical record and shall include the following: (i) Name of the attending physician; (ii) Date of admission to the facility; (iii) Date of application if made after admission to the facility;
UNOFFICIAL 1737-38 (iv) The written plan of care; (v) The reasons for and the plan for continued stay when deemed necessary by the attending physician; and (vi) As necessary, other documented material to support the utilization review committee's decision; (E) Utilization review committee members shall not be involved in the care of a client whose case is being reviewed and shall not be employed by, or have a financial interest in any facility in which the URC functions; (F) URC members must include at least one physician and one other professional responsible for review of continued stay cases and at least one member shall be a QMRP; (G) Development and adoption of inhouse criteria by which continued stay cases shall be reviewed at least once in a six month period; (H) Review by a physician member of the URC of cases not meeting the applicable in-house ICF-MR criteria for continued stay; and (I) Notification of continued stay denial to the affected client shall be as follows: (i) The client's QMRP shall be notified within one working day, and an allowance of two working days shall be afforded to the QMRP to respond to the URC's continued stay denial before it becomes final; and (ii) Written notification of continued stay denial by the URC within two working days after the final URC determination shall be given to the facility administrator, the client, and the client's next of kin; and (3) The facility shall operate and provide services in compliance with all state, federal and local laws, regulations, and codes and with accepted professional standards and principles that apply to professionals providing services in the facility. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §§430.10, 431.10, 456.1, 483.410; 42 U.S.C. §§1395, 1396) (Imp: 42
UNOFFICIAL 1737-39 C.F.R. §§456.350, 456.351, 456.360, 456.370, 456.380, 456.381, 456.400, 456.401, 456.405 - 456.407, 456.411 - 456.413, 456.431 - 456.438)
§17-1737-36 Inspection of care (IOC) reviews in ICF-MR facilities. The department shall be responsible for conducting periodic inspection of care review in ICF-MRs to evaluate the utilization of care and services provided to the client: (1) Inspection of care team members shall be employees of the department, and may consist of a physician or a registered nurse, and a social worker. One of the team members shall be a QMRP. If a physician is not on the team, a physician shall be available to provide consultation to the team; (2) Frequency of inspection shall be based on the quality of care and services provided by the facility, and on the condition of clients in the facility. However, at the minimum, each client shall be evaluated once annually; (3) No facility shall be notified of the time of inspection more than forty-eight hours before the scheduled arrival of the team; (4) Method of inspection shall be by personal contact with and observation of each client, and review of each client's medical record to determine the following: (A) Whether the facility services are adequate to meet the health needs of each client, the rehabilitative and social needs of each client and to promote maximum physical, mental, and psychosocial functioning; (B) Whether continued stay in the facility is necessary and desirable; (C) Whether it is feasible to meet the client's health needs, and in an ICF-MR the client's rehabilitative needs through alternative institutional or noninstitutional services; and (D) Whether each client is receiving active treatment in accordance with the provisions of section 17-1737-30; (5) The determinations on adequacy of services and related matters stipulated in paragraph (4) shall be based on, but not limited to, such items as whether:
UNOFFICIAL 1737-100 recipient, if an attendant is required by the transportation carrier or recommended by the
attending physician or the medical facility and authorized by the department's medical consultant.
(f) Other related travel expenses may be allowed with prior authorization by the department's medical consultant and may include but not be limited to: (1) Cost of meals and lodging for the recipient and one attendant; (2) Taxi or other non-emergency ground transportation when such transportation is related to the provision of authorized medical coverage; and (3) Services of an attendant provided the attendant is unrelated to the recipient. (g) Transportation services shall be available for those individuals eligible for medical assistance, provided all the provisions in this section are met. An individual who utilizes benefits for other than their intended purpose, may be referred for potential prosecution of fraud. A provider who knowingly and willfully falsifies, misrepresents, conceals, or fails to disclose material facts to obtain transportation services for an individual, may be referred by the department to the Medicaid fraud control unit for investigation and potential prosecution of fraud. The department may seek the recovery of monies associated with the fraudulent act. [Eff 08/01/94; am 02/07/05] (Auth: HRS §346-14) (Imp: 42 C.F.R. §§431.53, 440.170)
§17-1737-83.1 Out-of-state medical services. (a) Out-of-state medical services shall be covered for eligible Hawaii residents visiting in another state. Medical services incurred while visiting in another state shall be covered only when the requirements of temporary absence as stated in section 17-1714-22(d) are met. (1) To receive payment for services incurred out- of-state, the provider shall meet the requirements of section 17-1736-13. In addition: (A) The services were required as they were an emergency; (B) The services were needed and the recipient's health would have been endangered if the recipient had to return to the State of residence; or
UNOFFICIAL 1737-101 (C) The State has determined that the services sought are unavailable in Hawaii or more readily available in another state; or (2) Out-of-state Services shall require prior authorization by the department, with the
exception to the services indicated in subsection (b), paragraphs (1) and (2).
(b) Children under the age of nineteen and children under the age of twenty-one years who are in foster care placement or are covered by subsidized adoption agreements shall be eligible for out-of-state medical services. [Eff 02/10/97 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §§430(a); 431.52)
§17-1737-84 Exclusions and limitations. (a) Medical assistance payments shall not be made for certain health services or items for reasons including, but not limited to the following: (1) The procedure, service, or material is of generally unproven benefit; (2) It is of an experimental nature; (3) It is excluded by federal regulations or state rules; (4) It is not considered by the department to be medically necessary; (5) The same or similar results may be obtained by another method at a reduced cost; (6) The procedure is frequently followed by severe complications which may be in themselves life-threatening or require prolonged medical care or secondary operations; or (7) Prior authorization is required but has not been obtained.
(b) Based on subsection (a), the following procedures or services are excluded and the medical assistance program shall not pay any services in association with them: (1) Drugs not approved by the U.S. Food and Drug Administration; (2) Long term psychiatric institutional treatment; (3) Treatment of a person confined to a public institution regardless of where the treatment is performed; (4) The follow-up examination or treatment of Hansen's disease after the diagnosis has been established regardless of whether the
UNOFFICIAL 1737-102 patient is contagious except for surgical or rehabilitative procedures to restore useful function; (5) Treatment for tuberculosis when such treatment is available free to the general public; (6) Acupuncture; (7) Naturopathic, chiropractic, or Christian Science or faith healing services; (8) Private duty nursing; (9) Circumcision after twelve months of age unless there is documentation of phimosis severe enough to prevent retraction, recurrent balanitis, severe verrucae of or under the prepuce or severe adhesions between glans and prepuce; (10) Repair of umbilical or ventral herniae unless they are painful or bowel is present in the sac; (11) Excision or destruction of benign skin or subcutaneous lesions except hemangiomas, plantar warts, molluscum contagiosum, leukiplakia or milia without medical justification; (12) Hysterectomies and sterilization procedures not complying with the restrictions under sections 17-1737-47 and 17-1737-48; (13) Reversal of elective sterilization procedures; (14) Rhinoplasties except following accidental injury resulting in significant obstruction of breathing; (15) Gastroplasty or other surgical procedures on the stomach or bowel, or both, when performed for morbid obesity unless the operation may logically be expected to improve an established medical condition such as cardiac or respiratory decompensation or severe hypertension. Guidelines issued by the department shall be met; (16) Orthodontic services except for the provisions of section 17-1737-75(c)(1) and fixed bridgework; (17) Orthoptic training; (18) Tinted and contact lenses except as described under section 17-1737-76 (visual services);
UNOFFICIAL 1737-103 (19) Personal comfort items such as radios, televisions, telephones, fans, or air conditioners; (20) Standard household items such as beds, linens, cooking utensils, or blenders; (21) Cosmetic, reconstructive, or plastic surgery performed primarily to improve or change
physical appearance, performed primarily for psychological purposes, or to restore form
but which does not correct or materially improve bodily function. However, consideration may be given when the purpose of the procedure is to: (A) Correct a congenital anomaly; (B) Restore body form following an accidental injury; or (C) Revise disfigurement or extensive scars, or both, resulting from neoplastic surgery; (22) Specific cosmetic surgery procedures including: (A) Sex transformation treatments, procedures, hormones, or other
medication for the establishment or
maintenance of gender reassignment except that medication may be allowed if the sex of the individual has been changed by court order; (B) Cosmetic, reconstructive, or plastic surgery procedures performed primarily for psychological reasons or as a result of the aging process; (C) Augmentation mammoplasties except following medically indicated
mastectomies for carcinoma, precancerous conditions, or extensive fibrosis or traumatic amputation; (D) Reduction mammoplasties unless there is medical documentation of intractable
pain not amenable to other forms of treatment as a result of increasingly large pendulous breasts; (E) Paniculectomies and other body sculpturing procedures; (F) Removal of tattoos; (G) Hair transplants; (H) Electrolysis; (I) Insertion of testicular prostheses, unilateral or bilateral;
UNOFFICIAL 1737-104 (J) Jejuno-ileal by-pass procedures for morbid obesity; (K) Ear piercing; (23) In vitro fertilization procedures; (24) Medications, devices, or agents for the treatment of erectile dysfuction in males; (25) Swimming lessons, summer camp, gym membership, weight control classes, or smoking cessation classes; (26) Personal use of physical therapy equipment that is customarily used by a physical therapist in a physical therapy treatment or modality including, but not limited to, tilt tables, whirlpools, mats, play equipment, or exercise equipment; (27) Modifications to motor vehicles; and (28) Equipment to access motor vehicles or modifications to access motor vehicles.
(c) The UCC shall apply these exclusions in facilities and for recipients under its review. In other cases authorization of the department shall be obtained before performing any of the above procedures where exclusions are allowed.
(d) A medical service, supply, or durable medical equipment excluded from coverage may be approved on a case by case basis by the deparment if there is sufficient justification to support the medical necessity, as determined by its medical consultant.
(e) All other forms or types of health care services and supplies not specifically mentioned in this chapter shall not be included in the program. Questions regarding a form or type of health care service or supply shall be directed to the medical consultant.
(f) New tests, procedures, equipment, supplies, and other services for which payment has not been claimed previously shall not be considered for inclusion until information satisfactory and acceptable to the program has been received and approval given. This particularly applies to tests and procedures not included in the HCPCS code, where several procedures are being clumped under one heading, or a single procedure is divided into several components. [Eff 08/01/94; am 03/30/96; am 11/25/96; am 02/10/97; am 07/06/99; am 06/19/00; am 10/26/01; 09/17/07 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §456.3)
UNOFFICIAL 1737-105
§§17-1737-85 to 17-1737-89 (Reserved).
SUBCHAPTER 8
TISSUE AND ORGAN TRANSPLANTATION
§17-1737-90 REPEALED. [R 09/30/13]
§17-1737-91 General provisions. (a) Allogenic bone marrow and cadaveric corneal transplants are covered under this program.
(b) Kidney transplantations are covered under this program.
(c) Other non-experimental, non-investigational organ and tissue transplantations are covered when performed in a facility certified by Medicare for the specific transplantation and approved for medical necessity by the department's medical consultant.
(d) Transplantation shall be performed by experienced specialists with transplantation training and with established success records in an approved Medicare-certified facility with proper equipment and adequate and appropriately trained support staff, except as provided in subsection (i).
(e) Prior authorization shall be required from the department's medical consultant for all transplants.
(f) Immunosuppressive therapy shall be covered as required.
(g) If a transplant should fail or be rejected and the patient is still within the age limits for transplantation, the program's medical consultant may review the case for one additional transplantation for that patient.
(h) The program shall cover costs of tissue typing of potential donors and cost of acquisition of the tissue or organ as well as other studies necessary to determine the appropriateness of the procedure and any post transplantation follow-up evaluations as required.
(i) When approved by the department's medical consultant, a patient may be treated at an appropriate out-of-state Medicare-certified transplant center for the authorized procedure. [Eff 08/01/94; am 11/25/96 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §440.230; 42 U.S.C. §1396b(i))
UNOFFICIAL 1737-106
§17-1737-92 Corneal transplant (keratoplasty). (a) Indications of penetrating keratoplasty include: (1) Corneal opacification that sufficiently obscures visibility (vision) through the anterior segment of the eye with at least light perception present. Causes for this problem include: (A) Corneal injury and scarring; (B) Corneal degeneration (from Fuch's or other dystrophy or from previous
cataract or intraocular lens implantation, or both); (C) Corneal degeneration from keratoconus or familial causes; (D) Corneal infection (e.g., herpes); and (2) Therapeutic graft for relief of pain with at least light perception vision present, from corneal degeneration because of inflammation with pain in the eye and useful vision still present.
(b) Indications of lemellar keratoplasty include: (1) Superficial layer corneal scarring and deformity due to: (A) Trauma; (B) Degeneration; (C) Infection; or (D) Congenital deformity (anterior); (2) Aphakia; (3) High myopia; (4) High refractive error; (5) Keratoconus; and (6) Recurrent pterygium.
(c) Conditions and limitations affecting corneal transplant include: (1) A relative contraindication is intractable glaucoma in the eye under consideration for surgery; (2) No active eye infection at the time of surgery; (3) No general medical contraindications to surgery or anesthesia; (4) Informed consent shall be obtained from the patient or patient's representative; and (5) No age restriction. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §440.230; 42 U.S.C. §1396b(i))
§17-1737-93 Allogenic bone marrow transplant.
UNOFFICIAL 1737-107 (a) Indications for allogenic bone marrow transplant include: (1) Severe aplastic anemia unresponsive to usual therapy; (2) Acute myelogenous leukemia in first remission; (3) Acute lymphocytic leukemia in second remission; and (4) Chronic leukemia after first year.
(b) Conditions and limitations affecting allogenic bone marrow transplant include: (1) Human leukocyte group A (HLA) histocompatible donor shall be available; (2) Patient has no other major systemic disease which would result in poor potential for recovery (such as a heart condition, liver disease, kidney damage, brain lesions, cancer in other organs or lung disease); (3) Patient shall have been properly evaluated by a qualified authority in Hawaii and bone marrow transplant is recommended as a possible curative procedure or if palliative, with reasonable likelihood for prolongation of life and return to an active life; (4) No active infection at the time of the procedure; (5) No general medical contraindication for the procedure and anesthesia; (6) Informed consent shall be obtained from the patient or the patient's representative; and (7) Age restricted to fifty or under except when identical twin is histocompatible and then
age limit may be fifty-five. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §440.230; 42 U.S.C. §1396b(i))
§17-1737-94 Kidney transplant. (a) Indications are irreversible kidney failure that has progressed to a point that a useful, comfortable life can no longer be sustained by conventional medical treatment. The following conditions may deteriorate to the point when kidney transplant may be required: (1) Glomerulonephritis: (A) Proliferative; (B) Membranous; (C) Mesangio-capilliary; (2) Chronic pyelonephritis; (3) Hereditary:
UNOFFICIAL 1737-108 (A) Polycystic disease; (B) Medullary cystic disease; (C) Nephritis (including Alport's syndrome); (4) Hypertensive nephrosclerosis; (5) Metabolic: (A) Cystinosis; (B) Amyloid; (C) Gout; (6) Congenital: (A) Hyperplasia; (B) Horseshoe kidney; (7) Toxic: (A) Analgesic nephropathy; (B) Heavy metal poisoning; (8) Irreversible acute renal failure: (A) Cortical necrosis; (B) Acute tubular necrosis; and (9) Trauma.
(b) Conditions and limitations affecting kidney transplant include: (1) A living, related donor with major blood group (ABO) and human leukocyte group A (HLA) histocompatibility, or an appropriate
cadaveric kidney with major blood group (ABO) and human leukocyte group A (HLA) histocompatibility shall be available; (2) Patient shall be in a stable emotional state; (3) There is no active infection at the time of transplant; (4) There are no general medical contraindications to major surgery and anesthesia; (5) Patient has a normal lower urinary tract; (6) There are no other major systemic disease which would preclude successful recovery potential (such as cancer, polyarteritis,
systemic lupus erythematosis or heart, lung or liver disease); (7) Patient is evaluated by a qualified authority in Hawaii and renal transplant is recommended; (8) Informed consent shall be obtained from the patient or the patient's representative; and (9) Age limits five through fifty. [Eff 08/01/94 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: 42 C.F.R. §440.230; 42 U.S.C. §1396b(i))
§§17-1737-95 to 17-1737-99 (Reserved).
UNOFFICIAL 1737-109 SUBCHAPTER 9
HOSPICE SERVICE
§17-1737-100 REPEALED. [R 09/30/13]
§17-1737-101 Hospice care. (a) Hospice care means care and services provided to a terminally ill individual by a hospice program in home, outpatient and inpatient settings.
(b) The hospice shall retain professional management responsibility for services related to the terminal illness and shall ensure that they are furnished in a safe and effective manner by persons qualified to provide services, and in accordance with a plan of care as specified in section 17-1737-102.
(c) Hospice services shall be provided by hospice employees or by staff contracted by the hospice and includes the following: (1) Nursing care and services by or under the supervision of a registered nurse; (2) Medical social services provided by a qualified social worker under the direction of a physician; (3) Physician services provided by physician employees of the hospice including physician members of the interdisciplinary team; (4) Counseling services available to both the individual and the family including the following: (A) Dietary, spiritual and any other counseling services for the individual and family while enrolled in the hospice; and (B) Bereavement counseling, provided after the patient's death; (5) Physical therapy services, occupational therapy services, and speech-language pathology services; (6) Home health aide and homemaker services to meet the needs of the patients; (7) Medical supplies and appliances including drugs and biologicals, provided as needed for the palliation and management of the terminal illness and related conditions; and (8) Inpatient care for pain control and symptom management provided in a participating medicaid facility.
UNOFFICIAL 1737-110
(d) Coverage for hospice care shall be limited to two periods of ninety days each and subsequent periods of sixty days unless Medicare requirements for continuing services are not met. [Eff 08/01/94; am 09/17/07 ] (Auth: HRS §346-14) (Imp: 42 U.S.C. §1396(a) and (d))
§17-1737-102 Plan of care. (a) A written plan of care shall be established and maintained for each individual admitted to a hospice program and the care provided to an individual shall be in accordance with the plan.
(b) The plan shall be established by the attending physician, medical director or physician designee and interdisciplinary group prior to providing care.
(c) The plan shall be reviewed and updated by the attending physician, the medical director, and interdisciplinary group at intervals, as specified in the plan.
(d) The plan shall include all of the following: (1) Assessment of the individual's needs; (2) Identification of the services including the management of discomfort and symptom relief; and (3) Statement in detail of the scope and frequency of services needed to meet the patient's and family's needs. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 U.S.C. §1396(a) and (d))
§17-1737-103 Eligibility for hospice care. (a) Hospice care shall be provided to eligible applicants and recipients of medical assistance who voluntarily elect hospice care. Medicaid will only cover services that are unrelated to the hospice diagnosis except for individuals under twenty-one years of age.
(b) Eligible applicants and recipients under twenty-one years of age shall be provided hospice service and curative treatment services related to the individual’s terminal illness or associated condition.
(c) All of the following conditions shall be met: (1) A written certification of terminal illness is obtained by the hospice, signed by the
hospice physician and the individual's attending physician;
UNOFFICIAL 1737-111 (2) The recipient or a representative voluntarily elects to participate in the Medicaid hospice program and signs the appropriate Medicaid form requesting this service; and (3) Approval is obtained from the department on a
designated form. [Eff 08/01/94; am 06/25/12 ] (Auth: HRS §346-14) (Imp: 42 U.S.C. §1396(a) and (d))
§17-1737-104 Election of hospice care. (a) An eligible individual who elects to receive hospice care shall file an election statement with the hospice. A representative may also file an election statement.
(b) An election to receive hospice care shall be considered to continue through the initial ninety day period and subsequent ninety and thirty day election periods without a break in care if the individual: (1) Remains in the care of the hospice; and (2) Does not revoke the election of hospice care.
(c) Additional days of hospice care beyond the two hundred ten days stipulated in subsection (b) may be allowed if the personal or hospice physician recertifies the individual to be terminally ill.
(d) An individual or representative may designate an effective date for the election of hospice care beginning with the first day of hospice care but no earlier than the date the election is made.
(e) Individuals electing hospice care who are eligible for both medicare and medicaid shall have their hospice election periods counted concurrently.
(f) Individuals who have private insurance coverage for hospice care shall utilize that resource before medicaid coverage. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 U.S.C. §1396(a) and (d))
§17-1737-105 Waiver of other Medicaid benefits. (a) An individual who elects hospice services shall waive all rights to Medicaid payments for services related to the treatment of the terminal condition for which hospice care was elected. This provision shall not apply to individuals under twenty-one years of age.
(b) Medicaid payments may be made for hospice and related services provided by: (1) The designated hospice; (2) Another hospice under arrangements made by the designated hospice; and
UNOFFICIAL 1737-112 (3) The individual's attending physician if that physician is not an employee of the designated hospice or receiving compensation
from the hospice for services to the individual.
(c) Medicaid payments may be made for other Medicaid covered services unrelated to the terminal condition for which hospice care was elected. [Eff 08/01/94; am 06/25/12 ] (Auth: HRS §346-14) (Imp: 42 U.S.C. §1396(a) and (d))
§17-1737-106 Revoking the election of hospice. (a) An individual or representative may revoke an election of hospice care at any time during an election period.
(b) The individual or representative shall file a signed statement with the hospice that revokes medicaid coverage of hospice care and the effective date of the revocation.
(c) The individual or representative may at any time elect to again receive hospice care for any other hospice election period the individual is eligible to receive. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 U.S.C. §1396(a) and (d))
§17-1737-107 Payment for hospice care. (a) Payments shall be available to Medicaid providers certified by Medicare to render hospice care as provided for under this subchapter.
(b) Payment for hospice care shall be made using the same methodology as Medicare and in the amounts specified by CMS.
(c) Payment for services or items not related to the terminal illness and billed by other Medicaid non- hospice providers are allowed.
(d) For a Medicaid recipient who resides in a nursing facility and meets the nursing facility level of care requirements, but elects hospice, the Medicaid program will pay the hospice provider:
(1) For routine hospice services; and (2) Ninety-five percent of the facility specific per diem rate for ICF services. The Medicaid program shall not pay the NF.
(e) The following categories shall be utilized to determine payment:
UNOFFICIAL 1737-113 (1) Routine home care day. A routine home care day is a day on which an individual who has elected to receive hospice care is at home and is not receiving continuous care as defined in paragraph (2); (2) Continuous home care day. A continuous home care day is a day on which an individual who has elected to receive hospice care is not in an inpatient facility and receives hospice care consisting predominantly of nursing care on a continuous basis at home. Home health aide or homemaker services or both may also be provided on a continuous basis.
Continuous home care is furnished during periods of crisis and only as necessary to maintain the terminally ill patient at home. A minimum of eight hours of care shall be required to qualify for the continuous home care rate; (3) Inpatient respite care day. An inpatient respite care day is a day on which the individual who has elected hospice care receives care in an approved facility on a short-term basis for respite. Respite care may not be reimbursed for more than five consecutive days at a time; and (4) General inpatient care day. A general inpatient care day is a day on which an individual who has elected hospice care receives general inpatient care in an inpatient facility for pain control or acute or chronic symptom management which cannot be managed in other settings. [Eff 08/01/94; am 02/07/05] (Auth: HRS §§346-14, 346-59) (Imp: 42 U.S.C. §1396(a) and (d); HRS §346-59)
§17-1737-108 Providers of hospice service. (a) Providers of hospice services shall meet applicable state and federal licensing and the certification requirements of chapter 17-1736 including certification by medicare to provide hospice service.
(b) Providers of service shall enter into a contractual agreement with the state medicaid agency. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 C.F.R. §431.107, 42 U.S.C. §1396(a) and (d))
UNOFFICIAL 1737-114
§17-1737-109 Appeals and hearings. (a) An appeal and hearing shall be available to providers of hospice service in accordance with chapter 17-1736.
(b) An appeal and hearing for applicants and recipients shall be available in accordance with chapter 17-1703. [Eff 08/01/94 ] (Auth: HRS §346-14) (Imp: 42 U.S.C. §1396(a) and (d))
§§17-1737-110 to 17-1737-114 (Reserved).
SUBCHAPTER 10
SUBACUTE CARE
§17-1737-115 Purpose. The purpose of this subchapter is to describe a level of care needed by a patient not requiring inpatient acute care, but who needs more intensive nursing care than is provided at the skilled nursing level of care. [Eff 11/25/96 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §346-14)
§17-1737-116 REPEALED. [R 09/30/13]
§17-1737-117 General provisions. (a) Beds shall be specifically certified for subacute care and costs for providing subacute services shall be shown separately on the facility's cost report. Each participating facility shall be required to establish a subacute unit (SACU) as follows: (1) Freestanding SNF - A minimum of six to a maximum of sixty beds; or (2) Acute care hospital - A minimum of six to a maximum of sixty beds or more with the department's approval.
(b) The facility shall accept and retain only those subacute patients for whom it can provide adequate care.
(c) The facility shall maintain complete and accurate patient information, in sufficient detail to provide for continuity of care, for patients transferred to a subacute unit.
UNOFFICIAL 1737-115
(d) The freestanding SNF shall maintain written agreements with one or more acute care hospitals to ensure that the acute services are accessible in emergency situations and to facilitate the transfer of patients.
(e) The subacute unit shall have provisions for twenty-four hour emergency services including but not limited to laboratory, radiology, respiratory therapy, and pharmacy services, and if necessary, ventilator support by qualified respiratory technicians.
(f) The subacute unit shall make arrangements for emergency medical care as needed and shall consult with the attending physician or designee when available. Pulmonologist consultant shall be available twenty-four hours a day for telephone consultations and visits or both whenever a facility has ventilator patients. The telephone numbers of those physician(s) shall be posted in a conspicuous area in the subacute unit.
(g) Freestanding subacute units shall be licensed specifically as freestanding subacute units in the State of Hawaii by the department of health.
(h) The facilities caring for group III and group IV pediatric patients shall provide all mandated developmental and educational services.
(i) The department through its medical consultants will determine the medical necessity of the subacute level of care for patients who do not have a medically justified need for the acute level of care, do not qualify for the skilled nursing facility (SNF) level of care, or the intermediate care facility (ICF) level of care, and who meet the criteria of the subacute level of care and cannot be discharged from the acute care facility. [Eff 11/25/96; am 06/19/00 ] (Auth: HRS §346-14; 42 C.F.R §431.10) (Imp: HRS §346-14)
§17-1737-118 Staffing standards. (a) For the purpose of this section, each licensed nursing staff shall be counted as one. Each subacute unit shall be under the supervision of a registered nurse twenty-four hours a day.
(b) Subacute units authorized to provide care to respirator or ventilator dependent patients shall provide a minimum daily average of 9.0 nursing care hours of which 5.0 hours shall be provided by the nursing staff. Where there is a mix of ventilator- dependent and other patients, the facility shall provide no less than 5.0 licensed and certified hours per patient per day. Subacute units without
UNOFFICIAL 1737-116 ventilator patients shall employ sufficient licensed staff to provide a minimum daily average of 5.0 licensed and certified nursing hours.
(c) The department may require a facility to provide additional staff in accordance with subsection (b).
(d) Registered nurses and licensed practical nurses shall have a minimum of six months experience (within the past two years) in a direct participatory general acute care facility where the caseload included patients requiring intensive care and the use of special equipment. Completion of a department of human services approved subacute training course may be substituted for this requirement.
(e) The experience stated in subsection (d) or substitute clinical training for licensed nurses shall include respirator and tracheostomy care, nasogastric tube and gastrostomy care, administration of total parenteral nutrition and traction care. In addition, this requirement shall be completed prior to treating subacute patients. Registered nurses shall be certified by the facility to perform intravenous procedures and cardiopulmonary resuscitation.
(f) The facility shall provide documentation that all staff participating in direct patient care, including the director of nursing, registered nurses, licensed practical nurses, and nurse's aide staff have continuing in-service training pertinent to the subacute level of care and shall make documentation available upon request by the department of human services at the time of the facility inspection. [Eff 11/25/96 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §346-14)
§17-1737-119 Physician services. Physician services shall include, but not be limited to: (1) The evaluation and completion of forms used to establish and continue the subacute level of care for a recipient; (2) Physicians visits at least weekly during the first month and a minimum of once every two weeks thereafter until the stability of the patient's condition allows for monthly visits; (3) A plan of care shall be entered into the medical record and shall include: (A) Medical history, physical findings, and diagnosis indicating the need for admission;
UNOFFICIAL 1737-117 (B) A description of the functional level of the patient; (C) Objectives to be achieved by the plan of care; (D) Any orders for medications, treatments, restorative, and rehabilitative services, activities, therapies, social services, therapeutic diet, and special
procedures recommended for the health and safety of the patient; (E) Plans for continuing care, including review and modification to the plan of care; (F) Plans for discharge, including responsible family member or care givers; and (G) The attending or staff physician and other personnel involved in the recipients care shall review each plan of care at least every thirty days. [Eff 11/25/96 ] (Auth: §346-14; 42 C.F.R. §431.10) (Imp: HRS§346-14; 42 C.F.R. 431.10, 440.50, 456.60, 456.80, 456.250)
§17-1737-120 Subacute patient care characteristics. (a) To qualify for subacute level of care under group I, patients, age twenty-one years and older, must be medically stable and require continuous mechanical ventilation for at least fifty per cent of each day.
(b) To qualify for subacute level of care under group II, non-ventilator patients, age twenty-one years and older, who require a higher level of service than SNF, but who do not require acute hospital care, must be medically stable and require the following services: (1) Tracheostomy care with suctioning required at least once an hour; (2) Any combination of mechanical ventilation, tracheostomy care with suctioning and inhalation treatment with or without oxygen at least once a shift; (3) Total parenteral nutrition; (4) Continuous intravenous therapy for the administration of therapeutic agents or hydration, or intermittent IV therapy for the administration of therapeutic drugs at least once a shift through a peripheral or central line or both. Therapeutic agents are to
UNOFFICIAL 1737-118
include antibiotics, non-vescicant oncology chemotherapy, and analgesics; (5) Stable newborns or premature infants under age one, who have been inpatients in the acute hospital for at least a week and cannot be discharged because they require any of the following services: (A) Monitoring episodes of bradycardia and apnea which are resolved by manual
stimulation in infants for whom discharge from a facility is medically inappropriate; or (B) Nasogastric tube or gastrostomy feedings; (6) Stable patients admitted to the acute care hospital for infections, who are afebrile for twenty-four hours on intravenous or parenteral antibiotics and undergoing twenty-four to forty-eight hour trials of oral antibiotics or being trained to infuse parenteral antibiotics in the home in
preparation for discharge to the home; (7) Two or more of the following services: (A) Tracheostomy care with suctioning required at least once a shift; (B) Traction and pin care for fractures (Bucks Traction is not included); (C) Medically necessary isolation precautions as recommended by the Centers for Disease Control. (Infection control measures for the care of decubitus ulcers do not apply in this category); (D) Debridement, packing, and medicated irrigation with or without whirlpool treatment, aseptic dressing changes, management of extensive (stage III) decubitus ulcers or wound infection, and JP drains; (E) Skilled nursing services including but not limited to the monitoring, observation, and care of patients with HIV infection/AIDS, patients who have terminal diseases, patients who require chronic dialysis treatment, patients receiving radiation therapy, patients receiving treatment for dehydration or monitoring of hydration, or patients receiving treatment for pain control who
UNOFFICIAL 1737-119
have or are at high risk for significant medical complications; (F) Skilled nursing care including observation, monitoring for the side effects of treatment for patients receiving radiation therapy, or the monitoring of hydration and pain control
who have or are at high risk for significant medical complications; (H) At least daily ventilation or inhalation therapy services or both with or without oxygen; (I) Treatment of patients with eating disorders including bulimia and anorexia nervosa who require skilled supervision and monitoring of food intake and psychiatric inpatient care and are medically stable in the inpatient facility, but who are at high risk of
medical complications if discharged to outpatient care; or (J) Treatment of psychiatric patients who
are not an immediate danger to
themselves or others, but who require
inpatient monitoring, supervision, and
psychiatric care because of high risk
for life-threatening complications to
themselves or others if discharged to
outpatient care; or
(c) Group III pediatric patients who no longer require inpatient acute care, must be at baseline status, and not at risk for rapid deterioration. Requires dynamic care meeting the following:
(1) Weekly medical interventions and monitoring; and
(2) Twenty-four hours a day skilled nursing;
(3) Types of interventions required in group III pediatric subacute level of care are:
(A) Pediatric patients who are ventilator dependent;
(B) Tracheostomy care with skilled interventions (e.g. suctioning greater than once in an eight hour shift.
(d) Group IV pediatric patients who no longer requires acute care, must be at baseline state, and not at risk for rapid deterioration. Requires chronic care meeting the following:
(1) Medical interventions and monitoring at least weekly; and
UNOFFICIAL 1737-120
(2) Skilled nursing intervention at least once per shift.
(3) Types of interventions required in group IV pediatric subacute level of care are:
(A) Continuous intravenous therapy for administration of therapeutic agents or hydration, or intermittent IV therapy
for the administration of therapeutic drugs at least once a shift through a
peripheral of central line (antibiotics, nonvesican oncology chemotherapy, and analgesics, TPN).
(B) Two or more of the following services:
(i) Tracheostomy care with suctioning not more than once in an eight hour shift and does not require continuous monitoring;
(ii) Debridement, packing, and medicated irrigation, aseptic dressing
changes, extensive care of decubiti (stage III), or wound infection and drains.
(iii) Skilled supervision and monitoring of nutritionally compromised patients with eating disorders at high risk of medical complications
if managed in an outpatient setting;
(iv) At least daily inhalation therapy by skilled staff; or
(v) Multiple (two or more modalities) rehabilitative services required daily with short and long term attainable goals.
(e) Admission to the subacute level for individuals who require other services shall be made on a case-by-case basis. [Eff 11/25/96; am 06/19/00 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §346-14)
§17-1737-121 Exclusions. Subacute payments shall not be made for the following patients: (1) Patients who are medically unstable and require acute inpatient care in an acute care hospital; or (2) Patients whose level of care is appropriately level C (SNF), level A (ICF), level B
(ICF-MR), or lower. Included in this group are the following:
UNOFFICIAL 1737-121 (A) Stable newborns or premature infants under one year of age who require training of the sucking reflex and monitoring of weight and oral feeding to
gain weight sufficient for discharge to the home setting; (B) Stable children, newborns, or infants under the care of the child protective services awaiting placement; and (C) Patients in terminal phases of disease who request or whose legal guardians have requested in writing the desire not to be resuscitated and no subacute services have been or will be rendered. [Eff 11/25/96 ] (Auth: HRS §346-14; 42 C.F.R. §431.10) (Imp: HRS §§346-14, 346-59)
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