Page 3

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;