reglab/statecodes huggingface dataset:
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-8 - Calculation of component per diem costs by reference to each provider's base year cost report

Current through June, 2024
(a) Cost data shall
				be abstracted from the base year cost report and categorized into the following
				three components:
(1) Direct nursing costs
				shall include all allowable costs involved in the direct care of the patient.
				Examples of such costs include the following:
(A) Salaries for nurses' aides, registered
				nurses, and licensed practical nurses not involved in administration;
(B) The portion of employee fringe benefits
				that are properly allocated to those salaries;
(C) Physician-ordered maintenance therapy,
				which is not billed directly to the department. The cost of maintenance therapy
				services provided by persons other than nursing staff shall be limited to an
				amount equivalent to the cost if performed by nursing staff or a physical
				therapy aide; and
(D) Costs of
				nursing supplies and medical supplies not separately billable to
				patients.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-9 - Application of component rate ceilings

Current through June, 2024
(a) Each provider's
				per diem cost components, as calculated in accordance with section 17-1739.2-8,
				shall be subject to component rate ceilings in determining a provider's basic
				PPS rates.
(b) For each
				classification identified in section 17-1739.2-5, component rate ceilings shall
				be established as follows:
(1) For each
				provider, multiply the provider-specific per diem component cost by the
				provider's total census days in the base period to determine total cost per
				component by provider. Any per diem component cost that is greater than two
				standard deviations above or below the statewide mean of the component cost
				shall be excluded in calculating the component rate ceilings;
(2) For each classification identified in
				section 17-1739.2-5, sum the providers and totals calculated in paragraph (1)
				to determine the total cost per component for each classification;
(3) Divide the classification component costs
				calculated in paragraph (2) by the total census days reported in the base year
				cost reports for all providers in the classification to determine an average
				cost per component by provider classification; provided, however, that if any
				per diem costs are excluded because they deviate more than two standard
				deviations from the statewide mean, then the days associated with those per
				diem costs shall also be deleted in calculating the average cost per component
				for the peer group; and
(4)
				Multiply the results of paragraph (3) above by the following factors to
				determine the cost component rate ceilings by each provider classification:
(A) General and Administrative-1.1;
(B) Capital-1.1; and
(C) Direct Nursing-1.15.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-10 - Treatment of new providers without historical costs

Current through June, 2024
(a)
				The following two types of providers shall have their basic PPS rates
				calculated, in whole or in part, under this section:
(1) A provider that began operating after the
				base year, and therefore has no base year cost report; or
(2) A provider that began operating a new
				facility during the base year, and therefore has no base year cost report that
				reflects a full twelve months of operations.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-11 - Treatment of new beds without historical costs

Current through June, 2024
(a) A
				provider that has expanded beds since or during the base year, and therefore
				has no base year cost report reflecting a full twelve months of operation with
				the new beds, shall have its basic PPS rates calculated, in whole or in part,
				under this section.
(b) Existing
				providers which add new beds during or after the base year shall receive basic
				PPS rates that "blend" the rates for the old and new beds.
(c) Basic PPS rates associated with the new
				beds shall be calculated in accordance with sections 17-1739.2-10(c) and
				17-1739.2-10(d). If applicable, the GET adjustment shall be increased to cover
				the higher gross excise taxes that will result.
(d) The result of subsection (c) above shall
				be multiplied by the number of new beds.
(e) The basic PPS rates calculated on the
				historical costs of the existing beds as defined in sections 17-1739.2-7,
				17-1739.2-8, and 17-1739.2-9 shall be multiplied by the number of existing
				beds.
(f) The sum of subsections
				(d) and (e) above shall be divided by the total number of existing and new
				beds.
(g) The rates calculated in
				subsection (f) above shall be the provider's basic PPS rate for all
				beds.
(h) The computation shall be
				performed separately for each acuity level.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-12 - Transition of new providers and new beds into the PPS

Current through June, 2024
(a)
				A new provider or a provider with new beds shall eventually have its basic PPS
				rates calculated in the same manner as other providers. The transition will
				begin with the first rebasing in which the new provider or provider with new
				beds has a base year cost report that reflects a full twelve months of
				operations.
(b) Unless the provider
				is eligible for the grandfathered direct nursing and G&A components, the
				G&A and direct nursing components of the provider's basic PPS rates shall
				be calculated in the same manner as existing providers. This calculation shall
				include the application of the component ceilings.
(c) For new providers or providers that added
				new beds, the capital component of the basic PPS rates subject to the capital
				component ceilings shall be determined as follows:
(1) The new provider or provider with new
				beds shall receive the lesser of the following two options as the capital
				component of its basic PPS rates:
(A) Its
				facility-specific capital per diem costs calculated in the same manner as
				existing providers (excluding the application of the capital component
				ceiling); or
(B) Its grandfathered
				capital component (excluding the application of the capital component ceiling);
				provided, however, that if the provider's facility-specific capital per diem
				amount after the application of the capital component ceiling is higher than
				its grandfathered capital component, then the provider shall receive the higher
				amount as the capital component of its basic PPS rates.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-13 - Treatment of providers who provide acuity level D care

Current through June, 2024
(a)
				Providers that furnish level D services after the base year shall submit costs
				and days to the department on forms and in the format defined by the
				department.
(b) Payment for acuity
				level D services will be based on the facility's reasonable projected allowable
				costs under Medicare reasonable cost principles of reimbursement (as defined in
				42 C.F.R. chapter 413 and as modified by this chapter). However, if a provider
				has historical costs data of providing acuity level D services under a state
				pilot program, the rate will be based on the lesser of the pilot program or the
				facility's projected costs.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-14 - Application of inflation and other adjustments to establish provider-specific prospective payment rates

Current through June, 2024
(a) Annual cost
				increases shall be recognized by applying the inflation adjustment to the
				provider's historical costs or basic PPS rates, or both. This provision shall
				not apply to Acuity Level A and Acuity Level C facilities. The provisions of
				section 17-1739.2-21 shall apply to Acuity Level A and Acuity Level C
				facilities.
(b) For years in which
				the department performs a rebasing, cost increases attributable to inflation
				that have occurred since the base year shall be recognized as follows:
(1) The basic PPS rates shall be standardized
				to remove the effects of varying fiscal year ends;
(2) The basic PPS rates shall be multiplied
				by one plus the cumulative inflation adjustment;
(3) For the purpose of determining the
				inflation adjustment, the department shall use the most current and accurate
				data that is then available; and
(4) To ensure the prospective nature of the
				system, the data shall not be retroactively modified or adjusted.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-15 - Limitations on long-term care provider reimbursement

Current through June, 2024
(a)
				Notwithstanding any other provision of this chapter, aggregate payments to each
				group of facilities (i.e., nursing facilities or intermediate care facilities
				for the mentally retarded) may not exceed the amount that can reasonably be
				estimated would have been paid for those services under Medicare reasonable
				cost principles of reimbursement (as defined in 42 C.F.R. Chapter 413). In
				addition, aggregate payments to each group of state-operated providers (i.e.,
				nursing facilities or intermediate care facilities for the mentally retarded)
				may not exceed the amount that can reasonably be estimated would have been paid
				under Medicare reasonable cost principles of reimbursement. If a formal and
				final determination is made that payments in the aggregate exceeded the upper
				limit and federal financial participation is disallowed, the department may
				recoup any payments made to providers in excess of the upper limit.
(b) Notwithstanding any other provisions of
				this chapter, payment for out-of-state long-term care facility services shall
				be the lesser of the facility's charge, the other state's Medicaid rate, or the
				statewide weighted average Hawaii Medicaid rate applicable to services provided
				by comparable Hawaii providers.
(c)
				Notwithstanding any other provision of this chapter, no payments shall be made
				for the improper admission of or care for mentally ill or mentally retarded
				individuals, as those terms are defined in section 4211(e)(7)(G) of OBRA
				87.
(d) Notwithstanding any other
				provisions of the chapter, should federal participation for CAH providers be
				disallowed, the department may recoup any such payments made to these CAH
				facilities.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-16 - Adjustments to base year cost

Current through June, 2024
(a) Adjustments to
				a provider's base year cost report that occur subsequent to a rebasing that
				utilizes that base year cost report shall not result in any change to the
				component rate ceilings for the provider's peer group.
(b) Beginning with the FY 98 rebasing, the
				following rules shall apply to changes to a base year cost report that are made
				after a rebasing occurs. If a provider's PPS rates are based upon a cost report
				that is not finally settled, then the department shall not adjust those rates
				based upon subsequent changes to the base year cost report.
(c) The PPS rate calculation process is
				complex and requires an extensive commitment of the department's resources.
				Occasionally, the department may uncover or have brought to its attention minor
				data extraction or calculation errors that affect one or a few providers.
				Unless the department reasonably expects the correction of an error for one or
				a few providers to have a significant impact on the statewide weighted averages
				or component ceilings, the department need not recalculate those averages or
				ceilings to reflect a recalculation of the basic PPS rates of the one or few
				providers.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-17 - Rebasing the basic PPS rates

Current through June, 2024
The department shall perform a rebasing following the
				  methodology but using updated cost report data as described in section
				  17-1739.2-7 so that a provider
				  shall not have its basic PPS rates calculated by reference to the same base
				  year for more than eight state fiscal years.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-18 - Adjustments to the basic PPS rates

Current through June, 2024
(a) Each
				proprietary provider is eligible to receive the ROE adjustment. The ROE
				adjustment shall be calculated by identifying the appropriate amounts from the
				base year cost report or other sources, and dividing those amounts by the
				provider's base year patient days to obtain a base year ROE per diem. The base
				year ROE adjustments shall receive the same increase to reflect inflation as
				all other base year costs.
(b) All
				proprietary providers shall receive the GET adjustment. The GET adjustment
				shall be paid by increasing the basic PPS rates plus all applicable adjustments
				by 1.04167.
(c) Nursing facilities
				who qualify shall receive the capital incentive adjustment, the G&A
				incentive adjustment, or both. Due to the limited number of ICF/MRs, those
				facilities shall not be eligible to receive either the Capital Incentive or
				G&A incentive adjustments.
(d)
				Beginning with PPS rate year July 1, 1995 to June 30, 1996, qualifying NFs
				shall receive the G&A small facility adjustment.
(e) All facilities will have a per diem
				dental allowance add-on added to the basic PPS rate. This amount will be the
				same for all facilities, based on historical paid dental claims data, as
				determined by the department.
(f)
				Total PPS rates - A provider's basic PPS rates shall equal the sum of its
				direct nursing, G&A and capital per diem components for each acuity level
				as calculated under this chapter. A new provider's basic PPS rate shall be the
				per diem rate calculated under section 17-1739.2-10. The basic PPS rate for a
				provider with new beds shall be the per diem rate calculated under section
				17-1739.2-11.
(g) A provider's
				adjusted PPS rate shall be the product of the following formula:
Basic PPS Rate + Capital Incentive Adjustment (if
				  applicable)
+ G&A Incentive Adjustment (if applicable)
+ ROE Adjustment (if applicable)
+ G&A Small Facility Adjustment (if
				  applicable)
Subtotal
x GET Adjustment (if applicable)
= Adjusted PPS Rate
(h) A provider's total PPS rate shall be the
				adjusted PPS rate.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-19 - Administrative review - rate reconsideration

Current through June, 2024
(a) Providers shall
				have the right to request a rate reconsideration for the following conditions:
(1) A change in ownership, leaseholder, or
				operator, without a change in licensure and certification, which shall be
				grounds for rate reconsideration only to the extent authorized in section
				17-1739.2-3(f);
(2) Providers who
				receive no rate increase or a reduced rate due to implementation of the acuity
				based reimbursement system will not be able to file for a rate reconsideration
				under this section for adjustments or damages.
(3) Extraordinary circumstances including,
				but not limited to, the following: acts of God; changes in life and safety code
				requirements; changes in licensure law, rules, or regulation; significant
				changes in patient mix or nature of service occurring subsequent to the base
				year; errors by the department in data extraction or calculation of the per
				diem rates; subject to section 17-1739.2-16, inaccuracies or errors in the base
				year cost report; or additional capital costs resulting from renovation of a
				facility that does not result in additional beds but otherwise are attributable
				to extraordinary circumstances. Mere inflation of costs, absent extraordinary
				circumstances, shall not be a basis for rate reconsideration;
(4) To determine in advance the amount of
				rate reconsideration relief, if any, that will be granted to the provider for
				an anticipated future cost in excess of $50,000, or $1,000 per bed, whichever
				is less. The provider must be otherwise ready to incur the cost, and it must be
				attributable to a proposed capital expenditure, change in service or licensure
				or extraordinary circumstance. Any determination by the department is subject
				to the provider actually incurring the anticipated cost. If the actual cost is
				greater or lesser than the anticipated future cost submitted by the provider,
				then the department may adjust its rate reconsideration relief determination
				either on its own initiative or by supplemental request of the provider. A
				provider that fails to request an advance rate reconsideration from the
				department assumes the risk that no rate reconsideration relief may ultimately
				be available; and
(5) If the
				department reduces the grandfathered capital component of a new provider or a
				provider with new beds due to an inaccurate or unreasonable projection of
				capital costs by the provider.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-20 - Cost report requirements

Current through June, 2024
(a) All providers
				shall maintain an accounting system that identifies costs in conformance with
				accepted accounting principles.
(b)
				Beginning with cost reporting periods on or after January 1, 1996,
				participating providers shall submit the following on an annual basis no later
				than five months after the close of each provider's fiscal year:
(1) Uniform cost report;
(2) Working trial balance;
(3) Provider cost report
				questionnaire;
(4) If the provider
				has its financial statement audited, then a copy of that audited financial
				statement;
(5) Disclosure of appeal
				items included in the cost report; and
(6) A listing of all Medicaid credit balances
				showing information deemed necessary by the State, and copies of provider
				policies and procedures to review Medicaid credit balances and refunds of
				overpayments to the State.
(7) Such
				other cost reporting and financial information as the department shall request.
				This information may include segregation of certain costs of delivering
				services to acuity level C residents as opposed to acuity level A
				residents.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-21 - Acuity based reimbursement system

Current through June, 2024
(a) Beginning with
				the effective date of these rules, the department will implement a phased in
				transition approach from PPS to an acuity based reimbursement system. The
				phased approach will be completed by June 30, 2008.
(b) The transition rate methodology uses a
				price based system with the following parameters:
(1) For the direct care rate component, the
				component price is set at one hundred ten per cent of the day-weighted median.
				The rate that is calculated is subject to a case mix adjustment based upon the
				change on each facility's overall case mix.
(2) For the administrative and general rate
				component, the component price is set at one hundred three per cent of the
				day-weighted median. The rate is not subject to a case mix
				adjustment.
(3) For the capital
				rate component, the component price is set at the day-weighted median. The rate
				is not subject to a case mix adjustment.
(4) The Hawaii general excise tax is treated
				as a pass-through.
The rate setting parameters will remain constant for all
				  future rate setting periods. The prices calculated for direct care,
				  administrative and general, and capital will reflect prices that relate to the
				  rate period beginning July 1, 2002 and ending June 30, 2003. The component
				  prices will be updated for each subsequent rate period by the inflation
				  adjustment for each period.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-22 - Audit requirements

Current through June, 2024
(a) The department
				or its fiscal agent shall conduct periodically either on-site or desk audits of
				cost reports, including financial and statistical records of a sample of
				participating providers in each provider classification.
(b) Reports of the on-site or desk audit
				findings shall be retained by the department or its fiscal agent for a period
				of not less than three years following the date of submission of the
				report.
(c) Each provider shall
				have the right to appeal audit findings in accordance with the procedural
				requirements of chapter 17-1736, subchapter 3, of the Hawaii Administrative
				Rules.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-23 - Bed-hold requirements for long-term care

Current through June, 2024
A Medicaid recipient's bed may be reserved during a
				  recipient's temporary absence from the long-term care facility if:
(1) The recipient's plan of care provides for
				absences other than for hospitalization, and is approved by the recipient's
				attending physician;
(2) Any single
				episode during which a bed is reserved does not exceed a period of three
				consecutive days, unless a request for prior approval is submitted to the
				program, reviewed, and approved by its medical consultant;
(3) The total number of days a recipient
				reserves a bed per calendar year does not exceed twelve days; and
(4) A record is maintained in the recipient's
				medical charts which accounts for the number of days and specific dates for any
				year that a recipient reserved a bed, subject to periodic review by the
				department's representatives.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM › Section 17-1739.2-24 - Public process

Current through June, 2024
The State has in place a public process, which complies with
				  the requirements of Section 1902(a)(13)(A) of the Social Security
				  Act.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1740.1 - REIMBURSEMENT OF FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 17-1740.1-1 - Purpose and general principles

Current through June, 2024
The purpose of this chapter is to establish the Medicaid
				  prospective payment system (PPS) for federally qualified health centers (FQHCs)
				  and rural health clinics (RHCs) as described under section 702 of the Medicare,
				  Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) of 2000. The
				  FQHCs and RHCs prospective payment methodology shall apply to services provided
				  by FQHCs and RHCs as described by sections 1905(a)(2)(C) and 1905 (a)(2)(B) of
				  the Social Security Act, respectively, on or after January 1,
				  2001.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1740.1 - REIMBURSEMENT OF FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 17-1740.1-3 - Calculations of the baseline PPS rates for FQHCs and RHCs who, as of May 31, 2001, have filed two annual cost reports for their respective fiscal years ending 1999 and 2000

Current through June, 2024
For each FQHC and RHC, the baseline rate will be calculated
				  using the cost reports for their respective fiscal years ending in 1999 and
				  2000. The baseline rate will be calculated as follows:
(1) The total visits and costs shall be
				obtained from the "as filed" cost reports, submitted to the State for the
				respective FQHC or RHC fiscal years ending in 1999 and 2000. For those
				providers having more than one cost report ending in either of these years, a
				weighted average to the current year-end will be used to make both years
				consistent. Vision visits and costs will be included with the medical cost per
				visit baseline PPS rates.
(2) Each
				year's total costs will be divided by the total visits. The total costs should
				include the costs of all Medicaid covered services provided by the FQHC or RHC.
				This includes all ambulatory services which were previously paid under a
				fee-for-service basis.
(3) A
				two-year average of the calculated cost per visit rates for years 1999 and 2000
				will be used for each facility. The average cost per visit rate will be
				calculated separately for each year, then added together and divided by
				two.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1740.1 - REIMBURSEMENT OF FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 17-1740.1-4 - Calculation of the baseline PPS rates for FQHCs and RHCs who, as of May 31, 2001, could have filed two annual cost reports for their respective fiscal years ending 1999 and 2000, but only filed one such annual cost report

Current through June, 2024
For each FQHC and RHC, the baseline rate will be calculated
				  using the cost report submitted. The baseline rate will be calculated as
				  follows:
(1) The total visits and
				costs shall be obtained from the "as filed" cost report. Vision visits and
				costs will be included with the medical cost per visit baseline PPS rates. A
				separate PPS rate will be computed for dental visits.
(2) Each year's total costs will be divided
				by the total visits. The total costs should include the costs of all Medicaid
				covered services provided by the FQHC or RHC. This includes all ambulatory
				services which were previously paid under a fee-for service basis.
(3) If the FQHC or RHC believes it provides
				more in scope of services or caseload, or both, than reflected in the base
				rate, it may seek an adjustment by submitting data and documentation that
				substantiates the difference in services or costs.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1740.1 - REIMBURSEMENT OF FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 17-1740.1-5 - Calculations of the baseline PPS rates for FQHCs and RHCs who did not file cost reports as of May 31, 2001

Current through June, 2024
(a) FQHCs and RHCs
				who did not file cost reports are:
(1) Those
				who, prior to January 1, 2001, were certified as FQHCs or RHCs; or
(2) Those who are certified as FQHCs or RHCs
				on or after January 1, 2001.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1740.1 - REIMBURSEMENT OF FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 17-1740.1-6 - Calculation of the baseline PPS rates for FQHCs and RHCs who submitted cost reports as of May 31, 2001 for their respective fiscal years ending in 1999 and 2000 but were not certified as FQHCs or RHCs as of December 31, 2000 for a length of time sufficient to produce two annual cost reports based on their respective fiscal years

Current through June, 2024
(a) Baseline PPS rates for these FQHCs and
				RHCs will be the higher of the applicable assigned rate, as described in
				section 17-1740.1-4(b), or a cost per visit rate calculated using the most
				recent "as filed" cost report.
(b)
				If the FQHC or RHC believes it provides more in scope of services or caseload,
				or both, than reflected in the base rate, it may seek an adjustment by
				submitting data and documentation that substantiates the difference in services
				or costs.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1740.1 - REIMBURSEMENT OF FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 17-1740.1-7 - PPS rate year

Current through June, 2024
The FQHC and RHC rates will be effective for services
				  rendered from January 1 through December 31 of each year.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1740.1 - REIMBURSEMENT OF FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 17-1740.1-8 - PPS rates after baseline

Current through June, 2024
The annual PPS rates starting January 1, 2 002, will be the
				  prior year's rate adjusted for the Medicare Economic Index (MEI, as defined in
				  section 1842(i)(3) of the Social Security Act applicable to primary care
				  services as defined in section 1842(i)(4) of the Social Security Act for that
				  fiscal year).
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1740.1 - REIMBURSEMENT OF FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 17-1740.1-9 - Fee-for-service interim payments

Current through June, 2024
Until the baseline PPS rates are calculated and implemented,
				  interim payment to FQHCs and RHC will continue at rates established as of
				  December 31, 2000. When the PPS rates are implemented, adjustments for the
				  period from January 1, 2001 through the date of PPS implementation will be
				  made.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1740.1 - REIMBURSEMENT OF FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 17-1740.1-10 - Supplemental managed care payments under PPS methodology

Current through June, 2024
FQHCs or RHCs that provide services under a contract with a
				  Medicaid managed care entity (MCE) will receive quarterly state supplemental
				  payments for the cost of furnishing such services that are an estimate of the
				  difference between the payments the FQHC or RHC receives from MCE(s) (excluding
				  managed care risk pool accruals, distributions or losses) and payments the FQHC
				  or RHC would have received under the BIPA PPS methodology. At the end of each
				  calendar year, the total amount of supplemental and MCE payments received,
				  excluding managed care risk pool accruals or distributions, by the FQHC or RHC
				  will be reviewed against the amount that the actual number of visits provided
				  under the FQHCs or RHCs contract with the MCE(s) would have yielded under PPS.
				  The FQHC or RHC will be paid the difference between the PPS amount calculated
				  using the actual number of visits, and total amount of supplemental and MCE
				  payments received by the FQHC or RHC, if the PPS amount exceeds the total
				  amount of supplemental and MCE payments. The FQHC or RHC will refund the
				  difference between the PPS amount calculated using the actual number of visits,
				  and the total amount of supplemental and MCE payments received by the FQHC or
				  RHC, if the PPS amount is less than the total amount of supplement and MCE
				  payments.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1740.1 - REIMBURSEMENT OF FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 17-1740.1-11 - Adjustment for changes to scope of services

Current through June, 2024
The PPS payment rates may be adjusted for any increases or
				  decreases in the scope of services furnished by the FQHC or RHC.
(1) Providers must notify the department in
				writing of any changes to the scope of services and the reasons for those
				changes within sixty days of the effective date of such changes.
(2) Providers must submit data,
				documentation, and schedules that substantiate any changes in services and the
				related increases or decreases of reasonable costs following Medicare
				principles of reimbursement.
(3)
				Providers must propose a projected adjusted rate to which the department must
				agree. Upon agreement by the department, the provider will be paid the
				projected rate effective the date of change in scope of services through the
				date that a rate is calculated based on the submittal of cost reports for the
				first two full fiscal years which include change in scope of services as
				required by section 17-1740.1-13(b)(1).
(4) Upon receipt of the costs reports
				required by section 17-1740.1-13(b)(1), the PPS rate will be adjusted following
				a review by the fiscal agent of the cost reports and documentation.
1.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1740.1 - REIMBURSEMENT OF FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 17-1740.1-12 - Rate reconsideration

Current through June, 2024
(a) Providers shall
				have the right to request a rate reconsideration if extraordinary circumstances
				beyond the control of the provider occur after December 31, 2001 and PPS
				payments are insufficient due to these extraordinary circumstances.
				Extraordinary circumstances include, but are not limited to acts of God,
				changes in life and safety code requirements, and changes in licensure law, and
				rules or regulations. Mere inflation of cost, absent extraordinary
				circumstances, shall not be grounds for rate reconsideration. If a provider's
				PPS rate is sufficient to cover its overall costs including those associated
				with the extraordinary circumstances, then a rate reconsideration is not
				warranted.
(b) The department will
				accept a request for rate reconsideration for a prospective payment year at any
				time during that prospective payment year or within thirty days following the
				end of that prospective payment year.
(c) Requests for rate reconsiderations shall
				be submitted in writing to the department and shall set forth the reasons for
				the requests. Each request shall be accompanied by sufficient documentation to
				enable the department to act upon the request. Documentation shall include the
				data necessary to demonstrate that the circumstances for which reconsideration
				is requested meet the requirements noted above. Documentation shall include the
				following:
(1) A presentation of data to
				demonstrate reasons for the provider's request for a rate
				reconsideration.
(2) The rate
				reconsideration request must be accompanied by documentation showing the cost
				implications. The cost impact must be material and significant ($200,000 or one
				per cent of a facility's total costs, whichever is less). Documentation must be
				sufficient to compute an adjustment amount to the PPS rate for the purpose of
				determining a managed care supplemental payment amount if necessary.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1740.1 - REIMBURSEMENT OF FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 17-1740.1-13 - Cost reporting, record keeping, and audit requirements

Current through June, 2024
(a) All participating facilities shall
				maintain an accounting system that identifies costs in a manner that conforms
				to generally accepted accounting principles and maintain documentation to
				support all data.
(b) Annual cost
				reports will not generally be required, with the following exceptions:
(1) For participating FQHCs and RHCs that
				request changes to their scope of services under section 17-1740.1-11, cost
				reports for the first two full fiscal years reflecting the change in scope of
				services and significant related data as identified in paragraph (3) must be
				submitted.
(2) For participating
				FQHCs and RHCs that request rate reconsiderations under section 17-1740.1-12,
				cost reports for the provider's fiscal years covering the period for which the
				rate reconsideration was authorized and significant related data as identified
				in paragraph (3) must be submitted.
(3) As related to provisions of paragraphs
				(1) and (2), the following shall be submitted no later than five months after
				the close of each facility's applicable fiscal year and shall be subject to all
				provisions in this section.Uniform cost report;
(A) Working trial balance;
(B) Provider cost report
				questionnaire;
(C) Audited
				financial statements, if available;
(D) Disclosure of appeal items included in
				the cost report;
(E) Disclosure of
				increases or decreases in scope of services; and
(F) Other schedules as identified by the
				department.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1740.1 - REIMBURSEMENT OF FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 17-1740.1-14 - Rebasing

Current through June, 2024
There are no provisions for rebasing after the initial
				  computation of the baseline PPS rates, unless authorized by
				  Congress.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1740.1 - REIMBURSEMENT OF FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL HEALTH CLINICS › Section 17-1740.1-18 - Billing

Current through June, 2024
(a) Each FQHC or RHC shall complete and
				submit to the department's fiscal agent the appropriate claim form for any
				covered item or service, regardless of whether a claims-based interim payment
				will result.
(b) The claims shall
				either be on forms provided by the department or in a format that the
				department has indicated in advance is acceptable.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1741 - UTILIZATION CONTROL › Section 17-1741-3 - Surveillance and utilization review

Current through June, 2024
To safeguard against unnecessary or inappropriate use of
				  services under the medical assistance program, excess payments and to assess
				  the quality of those services, the department shall:
(1) Conduct post payment reviews and audits
				of a statistically significant sampling of provider claims;
(2) Compare provider and recipient
				utilization of services to establish statistical models of average provider and
				recipient utilization patterns;
(3)
				Select for review those providers and recipients with exceptional utilization
				patterns; and
(4) Take necessary
				remedial measures and corrective action to ensure the effectiveness of the
				program.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1741 - UTILIZATION CONTROL › Section 17-1741-4 - Provider over-utilization or abuse

Current through June, 2024
(a) If the findings
				of the review indicate possible abuse, the department shall conduct a full
				investigation.
(b) 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.
(c) When incorrect practices result in
				overpayment, the department shall:
(1) Notify
				the provider of any aberrances;
(2)
				Request the provider to take corrective action; and
(3) Establish a monitoring program of the
				provider's medicaid practice to ensure corrective measures have been
				introduced.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1741 - UTILIZATION CONTROL › Section 17-1741-5 - Referrals to the medicaid investigations division

Current through June, 2024
Referrals shall include all cases of suspected provider
				  fraud and complaints alleging abuse or neglect of patients in health care
				  facilities including misappropriation of patient's private funds in such
				  facilities.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1741 - UTILIZATION CONTROL › Section 17-1741-6 - Recipient over-utilization or abuse

Current through June, 2024
(a) Freedom of
				choice in selecting health care providers shall not include the expedient
				utilization or over-utilization of the community's health care providers and
				supplies.
(b) When a recipient
				over-utilizes medical services, the department shall request the recipient's
				voluntary cooperation in curbing abusive utilization practices and shall
				monitor the recipient's case for no less than six months.
(c) When a recipient has been shown to be
				over-utilizing controlled drugs with multiple prescriptions filled at more than
				one pharmacy and written by multiple prescribers, the department shall require
				the recipient to choose one primary care physician and one pharmacy to be the
				only approved providers of usual care. The department also reserves the right
				to ask the recipient to choose another provider if the physician is known to
				the department to be over-prescribing medications or medical services. Refer to
				section 17-1741-7 for specific details regarding restrictions.
(d) When a recipient has been determined to
				be using excessive medical services provided by multiple physicians, the
				department may assist the recipient in receiving appropriate coordinated care.
				As a result, the department shall ask the recipient to choose one primary care
				provider to coordinate all usual services for the recipient and make referrals
				to other providers, as needed. Refer to section 17-1741-7 for specific details
				regarding restrictions.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1741 - UTILIZATION CONTROL › Section 17-1741-7 - Restriction

Current through June, 2024
(a) If over-utilization or abuse continues,
				the recipient shall be administratively restricted for no less than twenty-four
				months to a primary care physician who is:
(1) Of the client's choice;
(2) Willing to provide and coordinate
				services to the client; and
(3)
				Certified by the department to participate in the medical assistance
				program.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1744 - COVERAGE OF MEDICARE PREMIUMS › Subchapter 1 - GENERAL PROVISIONS › Section 17-1744-1 - Purpose

Current through June, 2024
This chapter describes the coverage of Medicare premiums
					 for four groups of medical assistance recipients. These groups are:
(1) Aged or disabled recipients of financial
				  or medical assistance who are eligible for all benefits covered under the
				  medical assistance program;
(2)
				  Qualified Medicare beneficiaries (QMBs) are only eligible for coverage of
				  premiums, deductibles and coinsurance amounts, under Medicare part A and
				  B;
(3) Qualified disabled working
				  individuals (QDWIs) who under the medical assistance program are only eligible
				  for coverage of Medicare hospital insurance (part A) premiums; and
(4) Specified low income Medicare
				  beneficiaries (SLMBs) who under the medical assistance program are only
				  eligible for coverage of Medicare supplementary medical insurance (part B)
				  premiums.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1744 - COVERAGE OF MEDICARE PREMIUMS › Subchapter 2 - SUPPLEMENTARY MEDICAL INSURANCE (SMI) › Section 17-1744-3 - Referral of recipients for medicare coverage

Current through June, 2024
(a) All
				  recipients who are eligible but not enrolled for medicare coverage shall be
				  referred to the Social Security Administration for enrollment through the SMI
				  buy-in process. Among those who are eligible for medicare are those who meet
				  the requirement of five years of residency in the United State, and who:
(1) Are sixty-five years of age or
				  older;
(2) Have received at least
				  twenty four months of RSDI disability benefits; or
(3) Are end-stage renal disease (ESRD)
				  patients.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1744 - COVERAGE OF MEDICARE PREMIUMS › Subchapter 2 - SUPPLEMENTARY MEDICAL INSURANCE (SMI) › Section 17-1744-4 - Effective date of medicare part B (SMI) premium coverage

Current through June, 2024
(a) For financial assistance applicants who
				  are aged, blind, disabled or AFDC- related and are also SMI enrollees, the
				  effective date of SMI premium coverage, through buy-in enrollment, shall be the
				  first month for which financial assistance is approved.
(b) For supplemental security income (SSI)
				  beneficiaries who are approved for medical assistance only and are SMI
				  enrollees, the effective date of SMI premium coverage, through the buy-in
				  process, shall be the effective date of medical assistance coverage.
(c) For applicants newly approved for medical
				  assistance only under federally funded assistance groups with the exception of
				  QMBs, SLMBs, and QDWIs, the effective date of coverage of SMI premiums shall be
				  the first day of the second month after the month in which eligibility for
				  medical assistance is determined.
(d) For all aged, blind, disabled, and
				  AFDC-related recipients of financial or medical assistance, who subsequently
				  become eligible for SMI, the effective date of coverage of SMI premiums through
				  the buy-in process shall be the effective date of SMI coverage.