Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1720.1 - FREEDOM OF CHOICE, ENROLLMENT AND DISENROLLMENT › Subchapter 3 - ENROLLMENT › Section 17-1720.1-18 - Change of a health plan for an individual prior to the annual plan change period

Current through June, 2024
(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);
(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.