reglab/statecodes huggingface dataset:
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 8 - SPECIAL GROUP FOR INDIVIDUALS FORMERLY COVERED BY SHIP › Section 17-1722-63 - Disqualification

Current through June, 2024
(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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 8 - SPECIAL GROUP FOR INDIVIDUALS FORMERLY COVERED BY SHIP › Section 17-1722-64 - Cost share

Current through June, 2024
(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.
(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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 8 - SPECIAL GROUP FOR INDIVIDUALS FORMERLY COVERED BY SHIP › Section 17-1722-65 - Covered services

Current through June, 2024
(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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 9 - QUALIFYING INDIVIDUALS › Section 17-1722-69 - Purpose

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 9 - QUALIFYING INDIVIDUALS › Section 17-1722-70 - Eligibility requirements

Current through June, 2024
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; and
(D) Furnish a social security number and
				  verification of that number.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 9 - QUALIFYING INDIVIDUALS › Section 17-1722-71 - Treatment of income and assets

Current through June, 2024
The income and assets of a qualifying individual shall be
					 treated as described in chapters 17-172 4.1 and 17-1725.1.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 9 - QUALIFYING INDIVIDUALS › Section 17-1722-72 - Limitations of coverage

Current through June, 2024
(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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 9 - QUALIFYING INDIVIDUALS › Section 17-1722-73 - Limit on the number of eligible individuals

Current through June, 2024
(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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 9 - QUALIFYING INDIVIDUALS › Section 17-1722-74 - Effective date of coverage

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 10 - MEDICAL ASSISTANCE FOR DISABLED CHILDREN WHO LOSE SSI BENEFITS › Section 17-1722-78 - Purpose

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 10 - MEDICAL ASSISTANCE FOR DISABLED CHILDREN WHO LOSE SSI BENEFITS › Section 17-1722-79 - Eligibility requirements

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 10 - MEDICAL ASSISTANCE FOR DISABLED CHILDREN WHO LOSE SSI BENEFITS › Section 17-1722-80 - Treatment of income and assets

Current through June, 2024
The income and assets of a child in this group shall be
					 treated as described in chapters 17-1724.1 and 171725.1.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 10 - MEDICAL ASSISTANCE FOR DISABLED CHILDREN WHO LOSE SSI BENEFITS › Section 17-1722-81 - Provision of coverage

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 10 - MEDICAL ASSISTANCE FOR DISABLED CHILDREN WHO LOSE SSI BENEFITS › Section 17-1722-82 - Effective date of coverage

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 11 - LOW INCOME SUBSIDY PROGRAM › Section 17-1722-86 - Purpose

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 11 - LOW INCOME SUBSIDY PROGRAM › Section 17-1722-88 - Application and eligibility determination for the LIS

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 11 - LOW INCOME SUBSIDY PROGRAM › Section 17-1722-89 - Eligibility requirements

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 11 - LOW INCOME SUBSIDY PROGRAM › Section 17-1722-90 - Benefits of the LIS program

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 11 - LOW INCOME SUBSIDY PROGRAM › Section 17-1722-91 - Eligibility redeterminations

Current through June, 2024
(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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 11 - LOW INCOME SUBSIDY PROGRAM › Section 17-1722-92 - Reporting requirements

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 11 - LOW INCOME SUBSIDY PROGRAM › Section 17-1722-93 - Termination of LIS benefits

Current through June, 2024
Benefits for the LIS shall be terminated effective the
					 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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 11 - LOW INCOME SUBSIDY PROGRAM › Section 17-1722-94 - Appeals and hearings

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 12 - STATE PHARMACY ASSISTANCE PROGRAM › Section 17-1722-116 - General provisions

Current through June, 2024
(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 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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 12 - STATE PHARMACY ASSISTANCE PROGRAM › Section 17-1722-118 - Application requirements

Current through June, 2024
(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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 12 - STATE PHARMACY ASSISTANCE PROGRAM › Section 17-1722-119 - Eligibility requirements

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 12 - STATE PHARMACY ASSISTANCE PROGRAM › Section 17-1722-120 - Benefits

Current through June, 2024
(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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 12 - STATE PHARMACY ASSISTANCE PROGRAM › Section 17-1722-121 - Eligibility reviews

Current through June, 2024
(a) Eligibility
				  reviews shall be conducted 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 program.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 12 - STATE PHARMACY ASSISTANCE PROGRAM › Section 17-1722-122 - State pharmacy assistance program card

Current through June, 2024
Program members may be issued a state pharmacy assistance
					 program card from the department or the department's
					 designee.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 12 - STATE PHARMACY ASSISTANCE PROGRAM › Section 17-1722-123 - Quality control reviews

Current through June, 2024
(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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 12 - STATE PHARMACY ASSISTANCE PROGRAM › Section 17-1722-124 - Reporting requirements

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 12 - STATE PHARMACY ASSISTANCE PROGRAM › Section 17-1722-125 - Termination

Current through June, 2024
(a) An individual's participation under this
				  program shall be terminated for any of the following reasons:
(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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 12 - STATE PHARMACY ASSISTANCE PROGRAM › Section 17-1722-126 - Administration of the program

Current through June, 2024
(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.
(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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 12 - STATE PHARMACY ASSISTANCE PROGRAM › Section 17-1722-127 - Rebate agreement

Current through June, 2024
(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
				  1396 r.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 12 - STATE PHARMACY ASSISTANCE PROGRAM › Section 17-1722-128 - Pharmacy or PDP reimbursement

Current through June, 2024
(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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 12 - STATE PHARMACY ASSISTANCE PROGRAM › Section 17-1722-129 - State pharmacy assistance program special fund

Current through June, 2024
(a)
				  The state pharmacy assistance program special fund that is established within
				  the 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
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 13 - MEDICAL ASSISTANCE FOR DISABLED ADULT CHILDREN WHO LOSE SSI BENEFITS › Section 17-1722-145 - Purpose

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 13 - MEDICAL ASSISTANCE FOR DISABLED ADULT CHILDREN WHO LOSE SSI BENEFITS › Section 17-1722-147 - Eligibility requirements

Current through June, 2024
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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 13 - MEDICAL ASSISTANCE FOR DISABLED ADULT CHILDREN WHO LOSE SSI BENEFITS › Section 17-1722-148 - Financial eligibility determination

Current through June, 2024
(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.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 13 - MEDICAL ASSISTANCE FOR DISABLED ADULT CHILDREN WHO LOSE SSI BENEFITS › Section 17-1722-149 - Provision of coverage

Current through June, 2024
Individuals eligible as a DAC shall be eligible for all
					 services covered by the medical assistance program.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 1 - GENERAL PROVISIONS › Section 17-1722.3-1 - Purpose

Current through June, 2024
This chapter is established to provide, subject to the
					 availability of state funding, state medical assistance for citizens of COFA
					 nations and legal permanent residents admitted to the United States for less
					 than five years who are age nineteen years and older and lawfully present in
					 the state. Except as otherwise specifically provided herein, this chapter
					 supersedes any and all state medical assistance provided to such individuals
					 through the former QUEST, QExA, QUEST-Net, or QUEST-ACE programs, or the
					 fee-for-service or SHOTT programs prior to the implementation date of Basic
					 Health Hawaii.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 1 - GENERAL PROVISIONS › Section 17-1722.3-3 - Basic Health Hawaii Implementation

Current through June, 2024
(a) The department
				  shall determine the implementation date for Basic Health Hawaii when
				  participating health plans shall begin delivering Basic Health Hawaii
				  benefits.
(b) The implementation
				  date shall be no later than July 1, 2010.
(c) When the department has established the
				  implementation date, the department shall provide notice to deemed individuals
				  as provided under subchapter 4.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-6 - Purpose

Current through June, 2024
This subchapter describes individuals who are eligible to
					 participate in Basic Health Hawaii, the benefits to be provided, enrollment and
					 disenrollment provisions, and the financial responsibility of the
					 enrollees.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-7 - Eligibility requirements

Current through June, 2024
(a) An individual
				  requesting health care services under this chapter must meet the following
				  eligibility requirements:
(1) The basic
				  eligibility requirements described in chapter 17-1714 with the exception of
				  citizenship requirements;
(2) Is an
				  alien who is not eligible for federal medical assistance and is either:
(A) A citizen of a COFA nation; or
(B) A legal permanent resident;
(3) Is age nineteen years or
				  older; and
(4) Is not
				  pregnant.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-8 - Treatment of income and assets

Current through June, 2024
When determining financial eligibility for Basic Health
					 Hawaii, the provisions for treatment of income and assets described in chapters
					 17-1724.1 and 17-1725.1, respectively, shall apply.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-9 - Financial eligibility requirements

Current through June, 2024
(a) An individual
				  whose countable family assets exceed the personal reserve standard for a family
				  of applicable size shall be ineligible for Basic Health Hawaii.
(1) For a one-member family, the personal
				  reserve standard shall be $2,000.
(2) For a two-member family, the personal
				  reserve standard shall be $3,000.
(3) For a family of more than two members,
				  the personal reserve standard shall be $3,000 plus $250 for each additional
				  family member.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-10 - Limitations to statewide enrollment in participating health plans

Current through June, 2024
(a) The department shall accept applications
				  during an announced open application period using one of the following methods
				  as determined by the department:
(1) For a
				  specified duration; or
(2) Up to a
				  statewide enrollment limit.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-11 - Effective date of eligibility

Current through June, 2024
The date of eligibility shall be one of the
					 following:
(1) The date of application
				  if the applicant is found to be eligible in the month of application;
				  or
(2) If the applicant is found to
				  be ineligible for the month of application, the first day of the subsequent
				  month on which all eligibility requirements are met by the applicant.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-12 - Termination of eligibility

Current through June, 2024
A recipient's eligibility for Basic Health Hawaii shall be
					 terminated for any of the following reasons:
(1) The recipient fails to meet any one of
				  the necessary requirements of sections 17-1722.3-7 and 17-1722.3-9;
(2) Death of the recipient;
(3) The recipient no longer resides in the
				  State;
(4) The recipient
				  voluntarily terminates coverage;
(5) The recipient is admitted to a public
				  institution as defined in chapter 17-1714;
(6) The recipient's whereabouts are
				  unknown;
(7) Lack of State funds;
				  or
(8) The program is terminated or
				  repealed.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-13 - Enrollment in and choice of a participating health plan

Current through June, 2024
(a)
				  The department has the sole authority to enroll and disenroll an individual in
				  a participating health plan.
(b) An
				  eligible individual shall be enrolled in a health plan for purposes of
				  providing the individual with covered services effective the date of
				  eligibility as described in 17-1722.3-11.
(c) After the individual is in a
				  participating health plan, the individual shall be:
(1) Sent an enrollment letter identifying the
				  assigned plan and the option to remain in the assigned plan or to select a
				  different health plan;
(2) Allowed
				  ten days from the date of the enrollment letter to select from among the
				  participating health plans available in the service area in which the
				  individual resides that are accepting new members. This provision shall not
				  apply to an individual identified in subsection (h).
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-15 - Disenrollment from a participating health plan

Current through June, 2024
(a) The
				  department shall have sole authority to disenroll a Basic Health Hawaii
				  enrollee.
(b) The department shall
				  disenroll an enrollee whose eligibility is terminated under section
				  17-1722.3-12.
(c) The department
				  may disenroll an enrollee for reasons that include, but are not limited to, the
				  following:
(1) Compliance with an
				  administrative or judicial decision; or
(2) mutual agreement between the individual,
				  the participating health plan involved, and the department.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-16 - Effective date of enrollment

Current through June, 2024
(a) The effective
				  date of enrollment into a participating health plan shall be the effective date
				  of eligibility as described in 17-1722.3-11.
(b) The effective date of enrollment
				  resulting from a change from one participating health plan to another during
				  the open enrollment period, shall be the first day of the month as determined
				  by the department and shall generally extend for the benefit period.
(c) The effective date of enrollment
				  resulting from a change from one participating health plan to another, other
				  than during the open enrollment period, shall be one of the following:
(1) The first day of the month following the
				  date on which the department authorizes the enrollment change; or
(2) If an individual changes residence from
				  one service area to another, the date the enrollment process has been
				  completed.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-18 - Basic Health Hawaii benefits

Current through June, 2024
(a) A participating
				  health plan shall be required to provide the benefits defined in this
				  subchapter.
(b) Within a benefit
				  year, a participating health plan shall provide each enrollee no more than ten
				  days of medically necessary inpatient hospital care related to medical care,
				  surgery, psychiatric care, and substance abuse treatment. The following
				  hospital services shall be made available to each enrollee:
(1) Semi-private room and board and general
				  nursing care for inpatient stays related to medical care, surgery, psychiatric
				  care, and substance abuse treatment;
(2) Intensive care room and board and general
				  nursing care for medical care and surgery;
(3) Use of an operating room and related
				  facilities, inpatient anesthesia, radiology, laboratory and other diagnostic
				  services agreed upon by the participating health plan medical director for
				  medical care and surgery;
(4)
				  Drugs, dressings, blood derivatives and their administration, general medical
				  supplies, and diagnostic and therapeutic procedures as prescribed by the
				  attending physician;
(5) Other
				  ancillary services associated with hospital care except private duty nursing;
				  and
(6) Ten inpatient physician
				  visits within a benefit year.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-20 - Emergency services

Current through June, 2024
(a) Emergency
				  medical services are available to enrollees under chapter 17-1723, subchapter
				  2, and may be covered by a participating health plan or on a fee-for-service
				  basis.
(b) Dental services shall be
				  limited to emergency treatments which do not include services aimed at
				  restoring or replacing teeth. Emergency dental treatment shall be covered on a
				  fee-for-service basis and be limited to services for the following:
(1) Relief of dental pain;
(2) Elimination of infection; and
(3) Treatment of acute injuries to the teeth
				  and supporting structures of the oro-facial complex.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-22 - Reimbursement to participating health plans

Current through June, 2024
Each participating health plan shall be paid a capitated
					 payment, under the contract negotiated with the department, for individuals
					 enrolled in the plan.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-23 - Enforcement and termination of contracts with participating health plans

Current through June, 2024
The provisions pertaining to enforcement and termination
					 of a contract with a health plan described in chapter 17- 1727 shall apply to
					 participating health plans.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 3 - SPECIAL BENEFIT PROVISIONS › Section 17-1722.3-27 - Purpose

Current through June, 2024
This subchapter describes special provisions to continue
					 providing state medical assistance to individuals who were receiving long-term
					 care or SHOTT services prior to the implementation date.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 3 - SPECIAL BENEFIT PROVISIONS › Section 17-1722.3-28 - Long-term care provisions

Current through June, 2024
(a) An individual
				  age nineteen years or older receiving state medical assistance for long-term
				  care services on the last day of the second month prior to the implementation
				  date, shall:
(1) Be enrolled in a
				  participating health plan and receive state funded long-term care services,
				  either through a participating health plan or through a program that provides
				  benefits similar to a 1915(c) program; and
(2) Continue to receive the benefits as
				  described in (1) under the following conditions:
(A) The individual maintains continuous
				  categorical and financial eligibility as described under chapter 17-1719;
				  and
(B) The individual maintains
				  continuous eligibility for coverage of long-term care services.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 3 - SPECIAL BENEFIT PROVISIONS › Section 17-1722.3-29 - SHOTT provisions

Current through June, 2024
(a) An individual
				  otherwise eligible under this chapter, who is participating in the SHOTT
				  program, and has received an organ or tissue transplant as of the last day of
				  the second month prior to the implementation date, shall continue to
				  participate in SHOTT under the following:
(1)
				  The individual maintains continuous eligibility; and
(2) The individual maintains continuous
				  coverage under the SHOTT program.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 4 - INDIVIDUALS DEEMED INTO BASIC HEALTH HAWAII › Section 17-1722.3-32 - Purpose

Current through June, 2024
This subchapter describes provisions regarding the deeming
					 of certain individuals into Basic Health Hawaii, the transition period, and the
					 enrollment provisions that are applicable to these
					 individuals.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 4 - INDIVIDUALS DEEMED INTO BASIC HEALTH HAWAII › Section 17-1722.3-33 - Individuals deemed into Basic Health Hawaii

Current through June, 2024
(a) A citizen of a
				  COFA nation age nineteen years or older shall be deemed into Basic Health
				  Hawaii effective on the implementation date if the individual:
(1) Was eligible for and was receiving state
				  medical assistance through the former QUEST, QExA, QUEST-Net, or QUEST-ACE
				  programs, or the Medicaid fee-for-service or SHOTT programs on the last day of
				  the second month prior to the implementation date;
(2) Maintained continuous eligibility for
				  state medical assistance through the last day of the month prior to the
				  implementation date;
(3) Was not
				  receiving long-term care services on the last day of the second month prior to
				  the implementation date; and
(4)
				  Was not participating in the SHOTT program or was participating in the SHOTT
				  program, but had not received an organ or tissue transplant as of the last day
				  of the second month prior to the implementation date.