reglab/statecodes huggingface dataset:
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-66 - Final prospective payment calculation

Current through June, 2024
(a) Based on the
				  prospective payment rates as adjusted in section 17-1739-65, and inflated in
				  section 17-1739-68, a facility's payment for each inpatient stay in each
				  classification shall be calculated as follows:
(1) For psychiatric discharges, multiply the
				  per diem rate for a psychiatric discharge by the number of days of the
				  psychiatric inpatient stay. The result shall be the payment for a psychiatric
				  discharge;
(2) For nonpsychiatric
				  service discharges in classification I facilities, multiply the per diem rate
				  for the discharge by the number of days of the inpatient stay. The result shall
				  be the payment for a nonpsychiatric service discharge;
(3) For surgical, maternity, and medical
				  service discharges in classification II and III facilities, calculate the
				  prospective payment for each facility as follows:
(A) Multiply the per diem rate component for
				  the appropriate nonpsychiatric inpatient service category by the number of days
				  of care for each service category for the inpatient discharge;
(B) Add the ancillary rate per discharge for
				  the appropriate service category; and
(C) The result shall be the payment for each
				  nonpsychiatric service discharge.
(4) If a woman delivers a child, then payment
				  for the mother and baby shall be made separately. A per diem payment shall be
				  made separately for care delivered to a normal newborn based on the costs and
				  days associated with nursery care; and
(5) The following situations shall not be
				  considered as constituting care that is delivered to a normal newborn, and
				  shall be reimbursed as indicated:
(A) If it
				  is medically necessary for the baby to remain in the hospital more than six
				  days following birth (including the birthday), then the payment shall be
				  determined separately based on the same criteria as any other
				  discharge;
(B) If the claim form
				  for services delivered to the newborn indicates an intensive care unit revenue
				  code, then the payment for a medical case shall be made; or
(C) If both of the following requirements are
				  met:
(i) The claim form reflects information
				  that would result in the claim being characterized as a surgical case under
				  section 17-1739-59(2); and
(ii) The
				  newborn remains in the hospital for more than three days; then the payment for
				  a surgical case shall be made.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-67 - Special prospective payment rate considerations

Current through June, 2024
(a)
				  For a facility with insufficient observations (less than five claims) in a
				  given service category, the prospective payment rate shall be calculated using
				  the weighted average for the applicable service category for the facility's
				  classification.
(b) Prospective
				  payment rates for classification IV, the freestanding rehabilitation hospital,
				  shall be calculated in the following manner:
(1) Facility-specific claim charge data shall
				  be prepared in accordance with section 17-1739-61;
(2) A facility-specific per diem base rate
				  for psychiatric services shall be calculated in accordance with section
				  17-1739-62;
(3) A facility-specific
				  per diem base rate for nonpsychiatric services shall be calculated by dividing
				  total nonpsychiatric costs, excluding capital related costs for the hospital by
				  nonpsychiatric medicaid inpatient days; and
(4) The facility-specific factors shall be
				  computed or reimbursed as defined in section 17-1739-65.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-68 - Adjustment to base year costs for inflation

Current through June, 2024
(a) Cost
				  increases due to varying fiscal year ends and inflation shall be recognized for
				  purposes of establishing prospective payment rates in accordance with the
				  following general methodology.
(b)
				  Base year facility-specific costs shall be standardized to remove the effects
				  caused by varying fiscal year ends of the facility. This shall be accomplished
				  by dividing the inflation factor for the base year, as determined in accordance
				  with section 17-1739-57 by twelve and multiplying this result by the number of
				  months between the hospital's base year fiscal year end and June 30 of each
				  year. This result shall be added to 1.00 to yield an inflation adjustment or
				  which shall then be multiplied by the facility-specific costs.
(c) Cost increases due to inflation which
				  occurred from the base year shall utilize the inflation factor specified in
				  section 17-1739-57(c):
(1) For years during
				  which the department does not recalculate the rates by reference to a new base
				  year, cost increases due to inflation for state fiscal years 1987 and beyond
				  shall be recognized by multiplying the prospective payment rate (excluding rate
				  reconsideration relief) in effect on June 30 of the fiscal year by one plus the
				  inflation factor for the following fiscal year. To insure the prospective
				  nature of the PPS, the inflation factor shall not be retroactively adjusted nor
				  modified except as noted below;
(2)
				  For each year in which the department does recalculate the rates by reference
				  to a new base year, cost increases due to inflation shall be recognized by
				  multiplying the base year rates by one plus the inflation factor for each
				  subsequent year, using the most current and accurate inflation data then
				  available from Data Resources, Inc. (DRI). To insure the prospective nature of
				  the PPS, that data shall not be retroactively adjusted nor modified;
				  and
(3) For years in which the
				  department does not recalculate the rates by reference to a new base year and
				  in which the inflation factor for the prior year was reduced pursuant to
				  subsection (d), then the average rates for the prior fiscal year shall be
				  deemed to be the rates in effect on June 30.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-69 - Treatment of new facilities

Current through June, 2024
(a) Rates for new
				  providers shall be calculated by a separate method. A new provider shall
				  receive the statewide weighted average payment rates for its classification
				  times the following new provider adjustment factor:
(1) First Operating Year - one hundred fifty
				  per cent;
(2) Second Operating Year
				  - one hundred forty per cent;
(3)
				  Third Operating Year - one hundred thirty per cent; and
(4) Fourth Operating Year and thereafter one
				  hundred twenty five per cent;
(5)
				  If a facility's operating year does not coincide with the PPS fiscal year, then
				  the new provider's rates shall be prorated based on the PPS fiscal year. For
				  example, a new provider that begins its first operating year on January 1 would
				  receive one hundred forty-five per cent of the statewide weighted average
				  payment rates for its classification for the entire PPS fiscal year that begins
				  on the immediately following July 1.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-71 - Payment for readmission

Current through June, 2024
(a) Readmissions to
				  the same facility within twenty four hours of discharge for the same spell of
				  illness and for the same general diagnosis as the original admission shall be
				  considered to be the same admission and shall be billed as a single stay. The
				  department may deny full or partial payment for the original inpatient stay or
				  the subsequent readmission if it is determined that the facility could have
				  provided all required services during the original inpatient stay. This section
				  shall not apply in cases where a patient leaves the hospital against medical
				  advice.
(b) Readmission to the same
				  facility within thirty days of a previous discharge for a similar diagnosis
				  shall be subject to utilization review. The department may deny full or partial
				  payment for the original stay or the subsequent readmission if it is determined
				  that the facility could have provided all required services during the original
				  stay. This section shall not apply in cases where a patient leaves the hospital
				  against medical advice.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-72 - Payment for nonpsychiatric cases which exceed $35,000

Current through June, 2024
If charges for nonpsychiatric services rendered to a
					 patient during an inpatient stay are in excess of $35,000, billing and payment
					 for this stay shall be as follows:
(1)
				  For classification I facilities and the freestanding rehabilitation hospital,
				  payment shall be made at applicable per diem rates for the full inpatient
				  stay;
(2) For classification II and
				  III facilities:
(A) An initial interim bill
				  shall be submitted covering the period from the admission date through the date
				  the charge for the case reaches $35,000. Payment for this interim bill shall be
				  the classification per diem rate for the service category multiplied by the
				  number of days covered by the bill plus the full appropriate ancillary rate as
				  calculated in section 17-1739-68; and
(B) Sixty days after a patient reaches
				  outlier status, monthly thereafter, and upon discharge, a facility shall bill
				  the department for charges in excess of the outlier threshold. The facility
				  shall also document to the department's reasonable satisfaction the medical
				  necessity for the days of care and services rendered. The department shall pay
				  such bills that are appropriately documented and properly within the scope of
				  the acute care medicaid program no less than quarterly. The department shall
				  pay for the full per diem and eighty per cent of the ancillary charges,
				  excluding amounts included in computing the outlier threshold; and
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-73 - Wait listed reimbursements

Current through June, 2024
(a) Payments for
				  wait listed patients shall reflect the level of care required by the patient.
				  The facility shall receive a routine per diem for each day that a wait listed
				  patient remains in the acute care part of the facility. Room and board wait
				  listed rates are to be determined based upon the statewide weighted average
				  costs of providing either SNF or ICF services by distinct part facilities per
				  the medicaid long-term care prospective payment rate calculations with the
				  following exceptions:
(1) The wait listed
				  rates cannot exceed the facility's own distinct part SNF or ICF prospective
				  payment rates;
(2) A facility with
				  a distinct part SNF, but no ICF, would have an ICF wait listed rate based on
				  the statewide weighted average but not to exceed the facility's distinct SNF
				  prospective payment rate; and
(3)
				  In no case will any relief granted under rate reconsideration be used to adjust
				  the wait listed rates.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-74 - Payment for services rendered to patients with other health insurance

Current through June, 2024
medicaid is a secondary payor. In no case shall medicaid
					 pay a sum, when considered in conjunction with payments from all other sources
					 (including the patient's cost share and Medicare), that exceeds the amount that
					 would have been paid if no other source of reimbursement
					 existed.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-75 - Limitations on acute care facility payment

Current through June, 2024
(a) Calculation of
				  the prospective payment rate shall not be affected by a public provider's
				  imposition of nominal charges in accordance with federal regulations. However,
				  for providers whose charges are less than costs on the most recently filed cost
				  report and who do not qualify as a nominal charge provider, the prospective
				  rate shall be reduced during the interim until the applicable cost report is
				  filed and a settlement adjustment is made. The interim reduction shall be in
				  proportion to the ratio of costs to charges on the most recent filed cost
				  report. Updated data and charge structures may be provided to the department's
				  fiscal intermediary if the provider believes that its rate structure has
				  changed significantly since the most recent filed cost report, but the
				  department will be responsible for approving the final interim rate reduction
				  necessary to approximate final settlement as closely as possible.
(b) Payment for out-of-state acute care
				  facility services shall be the medicaid rate applicable in the facility's
				  state. If an out of state medicaid rate is not available, the weighted average
				  Hawaii medicaid rate applicable to services provided in comparable Hawaii
				  facilities shall be used.
(c) The
				  department or its utilization review agent may deny full or partial payment if
				  it is determined that the admission or transfer was not medically necessary or
				  the diagnosis or procedure code was not correctly assigned, or the patient was
				  retained in the facility longer than necessary. The department shall recover
				  amounts due using the most expedient methods possible which shall include but
				  not be limited to offsetting amounts against current payments due
				  providers.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-76 - Adjustments for costs under appeal

Current through June, 2024
A change in a facility's base year costs due to appeals to
					 the base year cost report that occur subsequent to the effective date of these
					 rules shall not result in changes to the rate ceilings for the classification
					 group until the next recalculation of rates. The facility-specific prospective
					 payment rate calculated under section
					 17-1739-66 shall be adjusted to
					 reflect the appeal decision. Base year costs shall be adjusted to reflect the
					 appeal decision, and the facility-specific prospective rate shall be
					 recalculated, effective the first day of the rate year, based on the adjusted
					 base year costs, as long as the rate ceilings are not
					 exceeded.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-77 - Future redetermination of prospective payment rates

Current through June, 2024
(a)
				  In future years, prospective payment rates for acute care facilities shall be
				  established by trending forward the base year prospective payment rates by
				  adjusting estimated to actuals and applying the projected inflation factor, as
				  defined in section 17-1739-57, for the prospective payment year at the start of
				  each fiscal year.
(b) Reimbursement
				  for capital related costs shall be computed annually as defined in section
				  17-1739-65(b).
(c) The department
				  shall recalculate the prospective payment rates periodically by reference to a
				  new base year. This recalculation shall be performed at least once every five
				  years, except under extraordinary circumstances.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-78 - Requests for rate reconsideration

Current through June, 2024
(a) Acute care
				  providers shall have the right to request a rate reconsideration if one of the
				  following conditions has occurred since the base year:
(1) Extraordinary circumstances including but
				  not limited to acts of God, changes in life and safety code requirements,
				  changes in licensure law, rules or regulations, significant changes in case mix
				  or the nature of service, or addition of new services occurring subsequent to
				  the base year. Mere inflation of costs, absent extraordinary circumstances,
				  shall not be a ground for rate reconsideration;
(2) Reduction in medicaid average length of
				  stay within a facility which produced a decrease in the average cost per
				  discharge but an increase in the average cost per day. This paragraph shall not
				  include reductions in average length of stay resulting from a change in case
				  mix. The rate reconsideration relief provided under this section shall be the
				  lesser of actual growth in the cost per day since the base year or seventy-five
				  per cent of the reduction in the average cost per discharge (inflated) since
				  the base year divided by the current average length of stay. In no case shall
				  the add-on exceed the actual ancillary and room and board costs of the
				  facility; and
(3) The addition of
				  an approved intern and resident teaching program. This is the only circumstance
				  that is eligible for a rate reconsideration request by a new
				  provider.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-79 - Cost report requirements

Current through June, 2024
(a) All
				  participating acute care facilities shall maintain an accounting system which
				  identifies costs in a manner that conforms to generally accepted accounting
				  principles.
(b) Participating
				  facilities shall submit the following on an annual basis no later than ninety
				  days after the close of each facility's fiscal year:
(1) Uniform cost report;
(2) Working trial balance;
(3) Provider cost report
				  questionnaire;
(4) Audited
				  financial statements if available; and
(5) Disclosure of appeal items included in
				  the cost report.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-80 - Audit requirements

Current through June, 2024
(a) All costs
				  reports shall be analyzed within six months after receipt to verify that each
				  acute care provider has complied with medicaid cost reporting
				  requirements.
(b) On-site audits of
				  cost reports, including financial and statistical records of a sample of
				  participating facilities in each facility classification, shall be conducted
				  annually.
(c) Upon conclusion of
				  each on-site audit, a report of the audit findings shall be retained by the
				  medicaid agency for a period of not less than three years following the date of
				  submission of the report.
(d)
				  Facilities shall have the right to appeal audit findings.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-81 - Effective date of amendments to subchapter 3

Current through June, 2024
Unless otherwise stated, amendments to this subchapter
					 shall be effective concurrent with the effective date of federal approval to a
					 corresponding amendment to the Hawaii medicaid State Plan for inpatient
					 hospital reimbursement.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-1 - Purpose

Current through June, 2024
This chapter shall implement the state plan requirements for
				  payments made by the state Medicaid agency for the fee-for-service component
				  for services received under the medical assistance program.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-3 - Controlling factors for payment

Current through June, 2024
(a) The department
				shall pay for the cost of medical care when the department's medical
				consultants determine medical care to be necessary to the eligible patient's
				well-being and medical care is provided, under standards generally acceptable
				to the medical community, by a practitioner approved by the department to
				participate in Medicaid.
(b) The
				department shall not increase the payment made to any provider to offset
				uncollected amounts for deductibles, coinsurance, copayments, or similar
				charges.
(c) No payment shall be
				made where program rules are violated, or when services furnished are
				inappropriate to the patient's health care management as determined by the
				department's medical consultant.
(d) Rates of payment to providers of medical
				care who are individual practitioners shall be based upon the Hawaii Medicaid
				fee schedule. The amount paid shall not exceed the maximum permitted to be paid
				to individual practitioners or other individuals under federal Medicaid laws
				and regulations, the Medicare fee schedule applicable in the year the service
				was rendered, the state limits as provided in the appropriation act, the
				provider's billed amount, or the rate set by the department.
(e) Rates of payment to out-of-state
				providers of medical care who are individual practitioners shall be the
				Medicaid rate paid in the practitioner's state, subject to the conditions of
				section 17-1736-13. In the absence of a Medicaid payment rate, payment will be
				according to the Hawaii Medicaid fee schedule.
(f) Payments may be prepaid to health
				maintenance organizations which the department contracts to provide medical
				care to eligible public assistance recipients.
(g) The department may withhold payment of
				claims to recoup overpayments, or may withhold payment pending completion of an
				audit or investigation.
(1) Payment of
				pending or future claims may be withheld in an amount reasonably calculated to
				approximate the amounts of past overpayments.
(2) Payment of pending claims may be withheld
				until completion of a pending audit or investigation, at which time the
				department may initiate actions to recoup the amounts of any overpayments
				discovered.
(3) The department
				shall notify the provider in writing of its intent to withhold payments and
				shall include reasons for the proposed action, the effective date of the
				action, and a statement of the provider's right to request administrative
				review of the proposed action.
(4)
				The effective date of withholding shall be sixteen calendar days following the
				issuance of the notice.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-4 - Authorization of services

Current through June, 2024
(a) The department
				shall provide:
(1) Methods of administration
				necessary for the proper operation of the Medicaid program; and
(2) Procedures relating to the utilization of
				and the payment for care and services available under the program. Among the
				procedures the department may employ shall be a system of authorization of
				selected types of costly health care.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-4.1 - Prior authorization of drugs

Current through June, 2024
(a) Selected drugs
				designated by the medical assistance program through the processes set forth in
				section 17-1737-71 pursuant to
				42 U.S.C.
				1396 r(8)(d)(5) require prior medical
				authorization.
(b) Preferred drug
				list:
(1) The department may maintain a
				preferred drug list containing the names of drugs for which prior authorization
				will not be required under the medical assistance program. All other drugs not
				on the preferred drug list, but are in the same drug class as drug(s) placed on
				the preferred drug list, shall be placed on an enhanced prior authorization
				list. The department may seek the recommendations of an advisory committee to
				be comprised of licensed medical and pharmacy professionals regarding the
				products that may be placed on a preferred drug list.
(2) The members of the advisory committee
				referred to in subsection (b)(1) shall be as determined by the department. The
				composition and number of members may change from time to time.
(3) The advisory committee shall meet at
				times and locations as may be requested by the department.
(4) The advisory committee's recommendations
				may take into consideration all, or some, of the following:
(A) Therapeutic value for the disease or
				condition under treatment;
(B)
				Clinical efficacy;
(C)
				Safety;
(D) Cost; and
(E) Other considerations as determined by the
				committee.
(5) The
				advisory committee's recommendation(s) to the department shall be advisory
				only. The department may accept or reject all, or a portion, of the
				recommendation(s) of the advisory committee.
(6) Pharmaceutical products which have been
				placed on a preferred drug list pursuant to the provisions of this subsection
				may also be temporarily deleted from the list by the department pending further
				review and recommendation of the advisory committee described in section
				17-1737-71(b) or the decision of the department. The circumstances under which
				the department may temporarily delete a drug from the preferred drug list are
				for clinical and safety reasons and administrative cost.
(7) Providers will be notified of changes
				made to the preferred drug list.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-5 - Methods of payment

Current through June, 2024
(a) State payments
				for medical services shall not be provided to anyone except the:
(1) Provider; or
(2) Recipient for settlement of a legal suit
				or fair hearing.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-6.1 - Hawaii Medicaid fee schedule

Current through June, 2024
(a) Payment to
				providers of medical care who are individual practitioners, including doctors
				of medicine, dentists, podiatrists, psychologist, osteopaths, optometrists, and
				other individuals providing services, shall be based upon the Hawaii Medicaid
				fee schedule.
(b) Payment for
				noninstitutional items and services, with the exception of prescribed drugs and
				EPSDT services, shall be based on the Hawaii Medicaid fee schedule. These items
				and services include, but are not limited to:
(1) Laboratory services;
(2) X-ray services;
(3) Physician services;
(4) Podiatric services;
(5) Optometric services;
(6) Other practitioner services including
				nurse midwife, pediatric nurse practitioner, advanced practice registered nurse
				in behavioral health, and licensed social worker in behavioral
				health;
(7) Dental Services
				(including dentures);
(8) Physical
				therapy;
(9) Occupational
				therapy;
(10) Services for persons
				with speech, language, and hearing disorders (exception: There shall be a flat
				rate for hearing evaluations.);
(11) Durable medical equipment, except eye
				glass frames and hearing aides;
(12) Medical supplies;
(13) Sleep services;
(14) Other services specified by the
				department.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-7 - Payments to individual practitioners providing therapy services in long-term care facilities

Current through June, 2024
(a) Payment for
				physical and occupational therapy, and speech, language, and hearing disorder
				services provided to a Medicaid recipient in a long-term care facility shall be
				based on a fee schedule established by the department for services provided at
				fifteen minute time increments.
(b)
				Payment shall be made for only those covered therapy services specified in
				sections 17-1737-79, which are determined to be medically necessary, prescribed
				by a physician, and provided by a licensed or certified therapist approved by
				the Medicaid program.
(c) Payment
				shall be made only upon submission of a Hawaii claim form (UB-82 or DHS-1500),
				by a provider eligible to bill for the services under the Medicare and Medicaid
				programs. Facilities with Medicare numbers shall use the form UB-82. Individual
				therapists shall use the form DHS-1500.
(d) In the case of speech evaluation and
				training, and hearing evaluation and hearing aids, an authorization form (DHS
				1144), shall be attached to the claim form.
(e) In the case of persons eligible for both
				Medicare and Medicaid who reside in an intermediate care facility, payment
				shall be made only if Medicare payment has been sought and denied.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-8 - Medicaid payments for other noninstitutional items and services not included in the Medicaid fee schedule

Current through June, 2024
The following services shall be limited to billed charges
				  not to exceed Medicare's upper limit of payment or the rate established by the
				  department:
(1) Hearing
				aids;
(2) Home health agency
				services;
(3) Outpatient hospital
				services;
(4) Emergency room
				services;
(5) Frames for
				eyeglasses;
(6) Hearing devices
				shall be the actual claim charge or $300, whichever is lower. Exceptions may be
				made for special models or modifications.
(7) Clinic services (other than
				physician-based clinics); The types of clinics include government sponsored
				non-profit, and hospital-based clinics.
(8) Teaching physicians shall be paid to the
				teaching fund, not to the physician;
(9) Prescribed drugs shall be made as
				described in section 17-1739.1-11.
(10) The Hawaii Medicaid program shall not
				pay more than the billed amount for any noninstitutional item or service or
				more than the amount permitted by federal law or regulation; and
(11) Payments to a facility for non-emergency
				care rendered in an emergency room and to an emergency room physician for the
				screening and assessment of a patient who receives non-emergency
				care.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-9 - Payments for intra-state transportation and related services

Current through June, 2024
(a) Payments for the following intra-state
				transportation and related services are based upon the Hawaii Medicaid fee
				schedule:
(1) Payments for emergency air
				ambulance, services;
(2) Payments
				for emergency ground ambulance services;
(3) Payments for non-emergency air and ground
				ambulance services. Air and ground ambulances must be authorized by the
				department; and
(4) Payments for
				non-emergency transportation (e.g. handicabs, but not taxis).
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-10 - Payments for out-of-state transportation and related services

Current through June, 2024
(a) Payments shall be made for out-of-state
				transportation, meals and lodging when these services are authorized in
				accordance with section 17-1739.1-9.
(b) Out-of-state air transportation shall be
				paid by a purchase order made out to the airlines or travel agency.
(c) Ground transportation expenses, subject
				to subsection 17-1739.1-9(f), shall be allowed when these expenses are incurred
				by the recipient. Verification of ground transportation expenses shall be
				documented completely on the proper departmental form when reimbursement is
				requested.
(d) Payment for meals
				and lodging shall be the lesser of the per diem rate of $100 a day or the
				actual charge for lodging plus a daily per diem of $30 for meals.
(e) The $30 per diem shall be prorated
				equally for three meals and shall begin with the first meal upon arrival at the
				specified destination and ending with the last meal prior to flight departure
				home.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-11 - Payment for drugs and related supplies

Current through June, 2024
(a) The state
				medical assistance program shall determine reimbursement for the ingredient
				cost of prescription drugs using the following criteria:
(1) Single source drugs shall not exceed the
				lower of:
(A) The provider's invoice
				price;
(B) The provider's usual and
				customary charge to the general public; or
(C) The estimated acquisition cost
				(EAC).
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-13 - Drug use review (PUR) board

Current through June, 2024
(a) An advisory
				drug use review board shall be appointed by the director of the department, and
				shall consist of:
(1) The department's
				pharmacy consultant or medical consultant or both, shall serve as the drug use
				review coordinator(s);
(2) Four
				persons licensed and actively engaged in the practice of medicine in the
				state;
(3) Four persons licensed
				and actively practicing pharmacy in the state; and
(4) One person actively practicing as a
				medical service representative in the state.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-14 - Medical payment involving third party liability

Current through June, 2024
(a)
				The liability of a third party for the cost of the medical services shall be
				treated as a resource applicable to the cost of needed medical services when:
(1) It has been verified that a legal
				obligation actually exists; and
(2)
				The amount of the obligation may be determined within thirty days from the time
				of the recipient's need for medical care.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-15 - Timely claims payment

Current through June, 2024
(a) The department
				shall pay ninety per cent of all clean claims from practitioners, who are in
				individual or group practice or who practice in shared health facilities,
				within thirty days, and ninety-nine per cent of the clean claims within ninety
				days of the date of receipt.
(b)
				The department shall pay all other claims within twelve months of the date of
				receipt, except where:
(1) Retroactive
				adjustments are paid to providers who are reimbursed under a retrospective
				payment system;
(2) Claims are from
				providers under investigation for fraud or abuse; or
(3) Payments are made in accordance with a
				court order, hearing decision, corrective action, or to extend benefits of
				these actions to others in the same situation as those directly
				affected.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739.1 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM FOR NON-INSTITUTIONAL SERVICES › Section 17-1739.1-16 - Time limit for claims submittal and one year claim filing deadline waiver request

Current through June, 2024
(a) The provider
				shall submit all claims for payment within twelve months from providing care or
				services. No Medicaid payment shall be made for any claim submitted after this
				period except as allowed by subsections (c) and (d). For retroactive cases
				involving retroactive assistance, the twelve-month period for claim submittal
				shall start from the date of service or the date retroactive eligibility was
				determined, whichever is later. This subsection shall not apply to payment of
				deductibles and coinsurance for cases that are eligible for both Medicare and
				Medicaid in which the circumstances leading to a submittal of claim after
				twelve months are acceptable to Medicare's fiscal agent or carrier.
(b) In cases where the provider disputes the
				department's allowance or claim adjudication, a request for reconsideration of
				the payment amount or claim adjudication must be made within sixty days of the
				Medicaid payment or claim adjudication date. The Medicaid payment or claim
				adjudication date is the date on the remittance advice or the date on the
				explanation of benefit (EOB).
(c) A
				claim received after the twelve-month period shall only be accepted for
				consideration of payment if all of the following conditions are met:
(1) The department finds that the delay was
				caused by the provider's efforts to obtain coverage from Medicare or any other
				source or third party liability;
(2) The provider filed a claim with Medicare
				or another source of third party liability on a timely basis, as determined by
				Medicare or the source of third party liability involved; and
(3) The claim is received by the department
				or its Medicaid fiscal agent within six months of a final disposition of
				coverage by Medicare or the source of third party liability involved.
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 17-1739.2-2 - General provisions - purpose and objective

Current through June, 2024
(a) The
				purpose of this chapter is to establish a prospective payment reimbursement
				system for long-term care facilities that complies with the Social Security Act
				and the Code of Federal Regulations. This chapter describes principles to be
				followed by providers in making financial reports and describes procedures to
				be followed by the department in setting rates, making adjustments to those
				rates, and auditing cost reports.
(b) Pursuant to the requirements of the
				Balanced Budget Act of 1997, the objective of this chapter is to establish
				rates for long-term care facilities in conformity with applicable State and
				Federal laws and regulations and include Medicaid provisions for the Rural
				Hospital Flexibility Program.
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 17-1739.2-3 - Reimbursement principles

Current through June, 2024
(a) Except as noted
				herein, the Hawaii medical assistance program shall reimburse providers based
				on the number of days of care that the provider delivers to the resident, the
				acuity level that is medically necessary for each day of care, and the
				provider's PPS rate. The provider shall receive payment at the level A rate for
				residents who require care at acuity level A, at the level B rate for residents
				who require care at acuity level B, at the level C rate for residents who
				require care at acuity level C, and at level D rate for residents who require
				care at the acuity level D. Any payments made by residents or other third
				parties on behalf of residents shall be deducted from the reimbursement paid to
				providers.
(b) Except as noted
				herein, the Medicaid program shall pay for institutional long-term care
				services through the use of a facility-specific prospective per diem
				rate.
(c) The basic PPS rate shall
				be developed based on each provider's historical costs (as reflected in its
				base year cost report) and allocated to three components, which are subject to
				component cost ceilings.
(d) A
				proprietary provider shall receive the GET and ROE adjustments to its basic PPS
				rate to account for gross excise taxes and return on equity.
(e) Rates for acute facilities with federally
				designated swing beds shall be established according to
				42 C.F.R.
				§447.280.
(f) Changes in ownership, management,
				control, operation, and leasehold interests which result in increased costs for
				the successor owner, management, or leaseholder shall be recognized for
				reimbursement purposes only to the following extent: Pursuant to the provisions
				of Pub. L. No. 99-272, section 9509 (a)(4)(C), the valuation of capital assets
				shall not be increased (as measured from the date of acquisition by the seller
				to the date of the change of ownership), solely as a result of a change of
				ownership, by more than the lesser of:
(1)
				One-half of the percentage increase (as measured over the same period of time,
				or, if necessary, as extrapolated retrospectively by the Secretary) in the
				Dodge Construction Systems Costs for Nursing Homes, applied in the aggregate
				with respect to those facilities which have undergone a change of ownership
				during the fiscal year; or
(2)
				One-half of the percentage increase (as measured over the same period of time)
				in the Consumer Price Index for all urban consumers (United States city
				average).
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 17-1739.2-5 - Classification of long-term care providers into peer groups

Current through June, 2024
For the purpose of establishing the basic PPS rates,
				  providers and costs shall be grouped into the following five mutually exclusive
				  classifications or peer groups:
(1)
				The costs of delivering care to acuity level A patients in free-standing
				nursing facilities;
(2) The costs
				of delivering care to acuity level C patients in free-standing nursing
				facilities;
(3) The costs of
				delivering care to acuity level A patients in hospital-based nursing
				facilities;
(4) The costs of
				delivering care to acuity level C patients in hospital-based nursing
				facilities; and
(5) The costs of
				delivering care to acuity level B patients in an ICF/MR.
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 17-1739.2-6 - Basic PPS rate calculation methodology

Current through June, 2024
Unless otherwise noted, the basic PPS rates shall be
				  calculated using the methodology set forth in this chapter.
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 17-1739.2-7 - Data sources for rate calculation

Current through June, 2024
(a) The department
				shall select the base year. The base year selected shall be the most recent
				state fiscal year for which cost reports for the significant majority of
				providers are available. The department shall select the most recent year for
				which cost reports for the significant majority of providers are available but
				are not finally settled (i.e., the "as filed" cost reports). The department
				shall identify and apply an audit adjustment factor to the "as filed" cost
				reports.
(b) Cost and census day
				data to be used in the development of the basic PPS rates shall be abstracted
				from the uniform cost report that is submitted to the Medicaid agency by each
				provider. If the department determines that additional data is required, then
				additional cost and census data shall be solicited from the provider.