Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1700.1 - DEFINITIONS › Section 17-1700.1-2 - Definitions

Current through June, 2024
For the purpose of this subtitle unless the context
				  otherwise indicates:
"Abuse" means provider practices that are inconsistent with
				  sound fiscal, business, or medical practices, and result in an unnecessary cost
				  to the Medicaid program, or in reimbursement for services that are not
				  medically necessary or that fail to meet professionally recognized standards
				  for health care. It also includes beneficiary practices that result in
				  unnecessary cost to the Medicaid program.
"Active treatment" means a continuous program for each
				  client as identified in an individualized plan of care:
(1) For individuals with mental illness (MI) the plan shall
				  be developed under and supervised by a physician. The prescribed components of
				  the individualized active treatment program shall be provided by a physician or
				  other qualified mental health professionals for the treatment of individuals
				  who are experiencing an acute episode of severe MI which necessitates
				  twenty-four hour supervision by trained mental health personnel to diagnose or
				  reduce the individual's psychotic or neurotic symptoms which necessitated
				  institutionalization, to improve the individual's level of functioning and,
				  whenever possible, to achieve the individual's discharge from inpatient status
				  at the earliest possible time ;
(2) For individuals with intellectual disability (ID) or with
				  related conditions, the individual program plan shall be developed and
				  supervised by an interdisciplinary team that represents areas that are relevant
				  to identifying the individual's needs and to designing programs that meet the
				  individual's needs, and is directed towards:
(A) The acquisition of the behaviors necessary for the
				  individual to function with as much self determination and independence as
				  possible; and
(B) The prevention or deceleration of regression or loss of
				  current optimal functional status; and
(3) It does not include, in the case of a resident of a
				  Nursing Facility (NF), services within the scope of services which the facility
				  shall provide or arrange for its resident.
"Actuarially sound" means an annuity, promissory note, or
				  similar financial contract where no payments will be made beyond the life
				  expectancy of the owner of the contract as determined in accordance with
				  actuarial publications of the Office of the Chief Actuary of the Social
				  Security Administration.
"Acuity based reimbursement system" means the Medicaid
				  reimbursement system for nursing facility (NF) level of care described in
				  exhibit A of chapter 17-1739.2. The acuity based reimbursement system applies
				  to acuity level A and acuity level C services, excluding services in critical
				  access hospitals.
"Acuity level or level of medical care" means one of the
				  following types of inpatient Services: NF or ICF-ID.
"Acuity level A" means that the department has applied its
				  standards of medical necessity and determined that an individual requires a
				  level of medical care from a nursing facility relatively lower than acuity
				  level C. Prior to October 1, 1990, that level of care was appropriately
				  obtained from an ICF.
"Acuity level B" means that the department has applied its
				  standards of medical necessity and determined that an individual requires the
				  level of medical care and special services that are appropriately obtained from
				  an ICF/MR.
"Acuity level C" means that the department has applied its
				  standards of medical necessity and determined that an individual requires a
				  level of medical care from a nursing facility relatively higher than acuity
				  level A. Prior to October 1, 1990, that level of care was appropriately
				  obtained from an SNF.
"Acuity level D" means that the department has applied its
				  standards of medical necessity and determined that an individual requires a
				  level of medical care that is relatively higher than acuity level C, but less
				  than acute.
"Acuity ratio" means the estimated average acuity level A
				  direct nursing costs divided by the estimated average acuity level C direct
				  nursing costs, as determined by the department. For the FY 98 rebasing, the
				  department has determined the ratio to be 1.00:0.8012.
"Acute care services" means the short term medical
				  treatment, usually in an acute care hospital, for individuals having an acute
				  illness or injury.
"Adequate notice" means a notice sent to an individual no
				  later than the date of the action affecting medical eligibility that
				  includes:
(1) A statement of the action the department has taken or
				  intends to take;
(2) The reason for the intended action;
(3) The specific departmental rule supporting the
				  action;
(4) The household's right to request a hearing;
(5) The household's right to request and obtain an
				  interpreter or auxiliary aids as needed, and shall be provided by the
				  department at no cost;
(6) The name of the person to contact for additional
				  information;
(7) The availability of continued benefits;
(8) The liability of the household for any overpayments
				  received while awaiting a hearing if the hearing official's decision is adverse
				  to the household; and
(9) The availability of free legal representation, if
				  applicable.
"Adjusted PPS rate" means the basic PPS rate and any
				  adjustments to that rate that are applicable to a particular provider. A
				  formula to determine the adjusted PPS rate is defined in section
				  17-1739.2-19(f).
"Administrative hearing" means an administrative proceeding
				  which affords an individual an opportunity to present an appeal of an adverse
				  action before an impartial department representative for a formal
				  decision.
"Adult" means an individual nineteen years of age or
				  older.
"Adverse action" means denial of or failure to act with
				  reasonable promptness on a claim for medical assistance, or the suspension,
				  reduction, termination, or withholding of medical assistance, or an increase in
				  spenddown or premium-share amounts.
"Affordable Care Act" means the Patient Protection and
				  Affordable Care Act ( Public Law 111148 ), as amended by the Health Care and
				  Education Reconciliation Act of 2010 (
				  Public Law
				  111-152 ).
"Aged" means an applicant or beneficiary of medical
				  assistance from the department who is at least sixty-five years old.
"Aid paid pending a hearing decision" means the continuation
				  or reinstatement of medical assistance or coverage between the date of timely
				  request for a hearing and the date the hearing decision is made.
"Alien" means non-citizen.
"Allogenic organ or tissue" means the source of the organ or
				  tissue is from another person.
"Ancillary payment" means a per diem payment outside of the
				  basic PPS rate to reimburse certain providers for ancillary services that they
				  provide to residents. The payment is available only to selected providers that
				  are incapable of billing Medicaid on an itemized fee-for-services basis at this
				  time. The payment is not an adjustment to the basic PPS rate.
"Ancillary services" mean diagnostic or therapeutic services
				  performed by specific facility departments as distinguished from general or
				  routine patient care such as room and board. Ancillary services generally are
				  those special services for which charges are customarily made in addition to
				  routine charges, and include but not limited to laboratory, radiology, and
				  surgical services.
"Annual plan change period" means a period when an eligible
				  individual is allowed to change from one participating health plan to another
				  participating health plan.
"Annuity means" a financial contract where the purchaser is
				  assured a scheduled amount of payments for the duration of the contract.
"Antigen means any substance which is capable under
				  appropriate conditions of inducing a specific immune response.
"Applicant" means an individual who is seeking an
				  eligibility determination for medical assistance through submission of an
				  application or a transfer from an insurance affordability program. An applicant
				  may be a deceased individual.
"Application" means the single streamlined application for
				  all insurance affordability programs developed by the Secretary or an
				  alternative single streamlined application designed specifically to determine
				  eligibility on a basis other than the applicable MAGI standard and is not more
				  burdensome on the applicant than the (single streamlined) application.
"Asset" means cash and any other personal property, as well
				  as real property, that an individual or family:
(1) Owns;
(2) Has the right, authority, or power to convert to cash (if
				  not already cash); and
(3) Is not legally restricted from using for the individual's
				  or family's support and maintenance.
"Assignment" means assigning to the department, in writing,
				  the right to obtain medical support and other third party payments.
"Assisted living facility" means a facility, as defined in
				  HRS section
				  321-15.1 that is
				  licensed by the department of health. This facility shall consist of a building
				  complex offering dwelling units and services to allow individuals to maintain
				  an independent assisted living lifestyle.
"Attending physician" means a medical doctor (M.D.) or a
				  doctor of osteopathy (D.O.), authorized to practice medicine and surgery by the
				  state, who orders and directs the services required to meet the care needs of a
				  Medicaid beneficiary. The attending physician may be a physician from a group
				  practice who is designated as the primary physician or an alternate physician
				  that has been delegated the role of the attending physician by the
				  beneficiary's initial attending physician during the physician's absence. At
				  the time he or she elects to receive hospice care, the attending physician has
				  the most significant role in the determination and delivery of the individual's
				  medical care.
"Audit adjustment factor" means a reduction to the costs
				  reported in a cost report that has not been finally settled by the department
				  to reflect the average amount of costs that the department has historically
				  disallowed for facilities statewide as part of the final settlement
				  process.
"Authorized representative" means an individual or
				  organization designated by an applicant or a beneficiary in writing with the
				  designee's signature or by legal documentation of authority to act on behalf of
				  an applicant or beneficiary, in compliance with federal and state law and
				  regulations. Designation of an authorized representative may be requested at
				  time of application or at other times as required and will be accepted through
				  the same modalities as applications for medical assistance.
"Base year" for:
(1) Acute and long-term care services means the state fiscal
				  year used for initial calculation and recalculation of prospective payment
				  rates. The base year shall be the most recent State fiscal year or years for
				  which complete, finally-settled financial data is available. Base year data
				  shall be supplemented with finally-settled cost data from previous years, if it
				  is determined that extraordinary costs occurred in the most recent,
				  finally-settled cost report. The 1983 state fiscal year shall be the base year
				  for purposes of initial calculation of prospective payment rates.
(2) Federally qualified health centers and rural health
				  clinics means the first PPS year starting January 1, 2001 and ending December
				  31, 2001 or any subsequent year that rates are recalculated if a rebasing is
				  determined to be necessary.
"Base year cost report" means the cost report of a provider
				  that covers the reporting period that ends during the base year.
"Baseline PPS rate" means the rate calculated for the
				  initial or first year under PPS.
"Baseline status" means that the individual reached a level
				  of condition where no further medical adjustments are indicated except for
				  adjustments for growth and development.
"Basic Health Hawaii" means the State funded medical
				  assistance program for non-citizens age nineteen years and older who are
				  citizens of a COFA nation, or legal permanent residents who have resided in the
				  United States for less than five years.
"Basic PPS rate" means the sum of the applicable per diem
				  amounts for the direct nursing, capital, and general and administrative
				  components for each provider and for each level of care that the provider is
				  certified to provide, as calculated pursuant to the methodology defined in this
				  chapter. It does not include the various adjustments or increases to the basic
				  PPS rate defined in this chapter.
"Bed days" mean inpatient days on the Medicaid cost
				  report.
"Benchmark prescription drug plan" means the Medicare
				  Prescription Drug Plan (PDP) or the Medicare Advantage-Prescription Drug
				  (MA-PD) plan that meets the regional low-income benchmark premium amount
				  established by CMS.
"BENDEX" or "beneficiary data exchange system" means an
				  automated exchange system in which the SSA transmits social security
				  beneficiary data to the department.
"Beneficiary" means an individual who has been determined
				  eligible and is currently receiving Medicaid.
"Benefit period" means the period from the first day of a
				  month following the close of the annual plan change period and extending for a
				  period as designated by the department.
"Benefit year" means a continuous twelve month period
				  generally following an open enrollment period.
"BESSD" means the benefit, employment and support services
				  division within the department which administers the financial assistance and
				  supplemental nutrition assistance program (SNAP).
"Blind" means an individual who has been certified blind by
				  the Social Security Administration or by the department's vocational
				  rehabilitation services for the blind division, Ho'opono.
"Board to determine and certify mental disability" means a
				  board of licensed psychologists or licensed physicians whose specialty is
				  psychiatry designated and paid for by the department.
"Break-even point" means the point at which a hypothetical
				  special care percentage in the base year would not have resulted in the
				  elimination of any costs due to the application of the ceiling factors in
				  calculating the PPS rates.
"CAH" or "critical access hospital" means a hospital
				  designated and certified as a critical access hospital under the Medicare Rural
				  Hospital Flexibility Program.
"Capital component reduction factor" means a fraction with
				  the capital cost per diem projected by a new provider to obtain its initial PPS
				  rates as the numerator and the total projected capital, direct nursing and
				  G&A per diem costs as the denominator.
"Capital incentive adjustment" means an increase to a
				  provider's basic PPS rate that is calculated as follows:
(1) If the capital per diem cost component of the provider's
				  basic PPS rate is in the lowest quartile of its peer group, then the incentive
				  payment shall be thirty-five per cent of the difference between the median
				  capital per diem cost for the peer group and the provider's capital per diem
				  cost component;
(2) If the capital per diem cost component of the provider's
				  basic PPS rate is in the second lowest quartile of its peer group, then the
				  incentive payment shall be twenty-five per cent of the difference between the
				  median capital per diem cost for the peer group and the provider's capital per
				  diem cost component;
(3) Notwithstanding the foregoing, the capital incentive
				  adjustment shall not increase a provider's capital cost component above the
				  capital component ceiling for the applicable acuity level in the provider's
				  peer group.
"Capital related costs" means costs associated with the
				  capital costs of the provider's facilities and equipment under Medicare
				  principles of reimbursement. For purposes of the prospective payment
				  methodology, capital related costs shall include depreciation, interest,
				  property taxes, property insurance, capital leases and rentals, and costs and
				  fees related to obtaining or maintaining capital related financing.
"Capitated payment" means a fixed monthly payment paid per
				  person by the department to a participating health plan for which the health
				  plan provides a defined set of benefits and the payment may be prorated for the
				  portion of the month for which the person was enrolled with the health
				  plan.
"Capitated rate" means the fixed monthly payment per person
				  paid by the State to a medical, behavioral or catastrophic coverage
				  plan.
"Caretaker relative" means a relative of a dependent child
				  by blood, adoption, or marriage, or an adult with whom the child is living, who
				  assumes primary responsibility for the child's care (as may, but is not
				  required to, be indicated by claiming the child as a tax dependent for Federal
				  income tax purposes).
"Case manager" means an individual who meets the
				  requirements specified in one of the following sections for the respective
				  target group:
(1) Section
				  17-1738-4(b);
(2) Section
				  17-1738-15(b);
				  or
(3) Section
				  17-1738-2 6(b).
"Cash subsidies for patient services" means, without
				  limitation, amounts appropriated by the state legislature or a local
				  governmental entity, either as direct subsidies or general fund allotments, and
				  paid to the provider.
"Categorically needy" refers to families and children, aged,
				  blind, or disabled individuals, and pregnant women, described under subparts B
				  and C of 42 C.F.R. part 435 who are eligible for Medicaid. Subpart B of 42
				  C.F.R. part 435 describes the mandatory eligibility groups who, generally, are
				  receiving or deemed to be receiving cash assistance under the social security
				  Act. These mandatory groups are specified in sections 1902(a)(10)(A)(i),
				  1902(e), 1902(f), and 1928 of the Social Security Act. Subpart C of 42 C.F.R.
				  part 435 describes the optional eligibility groups of individuals who,
				  generally, meet the categorical requirements or income or resource requirements
				  that are the same as or less restrictive than those of the cash assistance
				  programs and who are not receiving cash payments. These optional groups are
				  specified in sections 1902(a)(10)(A)(ii), 1902(e), and 1902(f) of the Social
				  Security Act.
"CCFFH" or "community care foster family home" means a home
				  that is certified by the department to provide an individual with twenty-four
				  hour living accommodations and home and community based services.
"C.F.R." or "Code of Federal Regulations" means the annual
				  codification of executive agency regulations. The C.F.R. contains the general
				  body of regulatory laws governing practice and procedures before federal
				  administrative agencies.
"Change in circumstance" means any event, reported or
				  unreported to the department, which alters or changes the conditions on which
				  eligibility for benefits was last determined. A change in circumstance shall
				  include, but shall not be limited to a change in household composition,
				  employment, training, the source or amount of countable income, the receipt or
				  amount of a countable resource, the beneficiary's needs, residence, or severity
				  of disability or blindness.
"Charity care" means, without limitation, care for which the
				  provider never expected or sought payment. Charity care includes care provided
				  pursuant to the Hill-Burton program, but excludes cash subsidies for patient
				  services as defined above.
"Citizenship" means status as a citizen of the United
				  States, and includes status as a national of the United States as defined in
				  8
				  U.S.C.
				  §1101(a)(22).
"Claim" means that document which is submitted by the
				  provider for payment of health-related services rendered to a
				  beneficiary.
"Claim charge data" means charges and other information
				  obtained from billing claim forms processed by the Medicaid fiscal
				  agent.
"Clean claim" means one that can be processed without
				  obtaining additional information from the provider of the service from a third
				  party.
"Clinical nurse specialist" means a registered professional
				  nurse who is currently licensed to practice in the State and who meets one or
				  two of the following conditions:
(1) Has completed an earned graduate degree, master's degree,
				  or doctorate related to an advanced area of clinical practice within the scope
				  of nursing; and
(2) Is currently certified as a nurse specialist by a
				  national nursing certifying organization.
"CMS" or "Centers for Medicare and Medicaid Services" means
				  the United States federal agency which administers the Medicare program and,
				  working jointly with State governments, the Medicaid program and the State
				  Children's Health Insurance Program (SCHIP).
"Code" means the Internal Revenue Code of 1986.
"COFA nation" means the Federated States of Micronesia,
				  Republic of the Marshall Islands, or Republic of Palau, which have entered into
				  Compacts of Free Association with the United States.
"Co-insurance" means the amount that a beneficiary or a
				  member must pay, usually a percentage, of the cost of a service.
"Collateral contact" means verification of a household's
				  statements through a personal or telephone contact with a person outside a
				  household.
"Community setting" means the place of residence of an
				  individual receiving long-term care services that is not a nursing facility or
				  a medical facility.
"Community spouse" means the spouse of an institutionalized
				  individual who is not residing in a medical facility or nursing
				  facility.
"Confirmation notice" means the document the individual
				  receives from the department confirming their enrollment in a health
				  plan.
"Consultation" means an opinion or advice requested by a
				  practicing physician from a psychiatrist or psychologist.
"Continuing care retirement community" means a residential
				  community that offers a long-term continuing care contract, usually for a
				  resident's lifetime that provides for housing, residential services and nursing
				  care.
"Contract" means a contract between a participating health
				  plan and the department to provide medical services.
"Coordinated content" means information included in an
				  eligibility notice regarding the transfer of the individual's or household's
				  electronic account to another insurance affordability program for a
				  determination of eligibility.
"Co-payment" means the amount that a beneficiary or member
				  must pay, usually a fixed amount of the cost of a service.
"Cost reports" means the forms DHS 401 of a certified FQHC
				  or RHC with all documentation and requirements which were necessary for
				  acceptability.
"Cost-share" means the amount identified by the department
				  as an individual's excess income available for meeting a portion of the
				  individual's own health care cost.
"Cost-sharing related to Medicare part D" means any
				  premiums, deductibles, co-payments, co-insurance, and any cost incurred within
				  the Part D coverage gap.
"Costs" mean total finally-settled allowable costs of acute
				  inpatient services, unless otherwise specified.
"Creditable coverage" means a medical insurance or health
				  plan that will cover the treatment of breast or cervical cancer or a
				  pre-cancerous condition of the breast or cervix.
"Custodian" means any organization or individual, not a
				  public agency or officer, responsible for centrally locating the program
				  manuals and making the manuals publicly accessible to a substantial number of
				  the medical assistance beneficiary population served. The agencies and
				  organizations shall accept responsibility for filing all amendments and changes
				  forwarded by the department.
"DAC" or "disabled adult child" means a blind or disabled
				  individual who is age eighteen years or older and who is receiving OASDI
				  benefits as a dependent adult child of a beneficiary who is a parent,
				  stepparent, grandparent or legal guardian of the individual.
"Date of hearing request" means the date of DHS' receipt of
				  a request for a hearing by an individual or authorized representative. When
				  there is no prior written request by the individual naming the authorized
				  representative, the date of hearing request shall be the date the authorization
				  is received by the department.
"Day-weighted median" means a numerical value determined by
				  arraying the per diem costs and total patient days of each nursing facility and
				  identifying the value at which half of the patient days are represented by
				  providers with higher costs than this value. "DD" or "developmental
				  disabilities" means a severe, chronic disability of a person to include
				  epilepsy, cerebral palsy, or other developmental disabilities which:
(1) Is attributable to a mental or physical impairment or
				  combination of mental and physical impairments;
(2) Is manifested before the person attains the age
				  twenty-two years;
(3) Is likely to continue indefinitely;
(4) Results in substantial functional limitations in three or
				  more of the following areas of major life activity: self care; receptive and
				  expressive language; learning; mobility; self-direction; capacity for
				  independent living; or economic sufficiency; and
(5) Reflects the person's need for a combination and sequence
				  of special, interdisciplinary, or generic care, treatment, or other services
				  which are of lifelong or extended duration and are individually planned and
				  coordinated.
"Debt" means any liquidated sum exceeding twenty-five
				  dollars which is due and owed to the department, regardless of whether there is
				  an outstanding judgment for that sum and whether the sum has accrued through
				  contract, subrogation, tort, operation of law, or judicial or administrative
				  judgment or order.
"Debtor" means any person who owes a debt to the
				  department.
"Deemed eligible" means an individual who is automatically
				  eligible for the Low Income Subsidy program. These individuals are those who
				  are:
(1) Eligible for both Medicare and Medicaid;
(2) Supplemental security income beneficiaries; or
(3) Eligible for the Medicare savings programs.
"Deemed individual" means an individual who met the
				  requirements of subchapter 4 of chapter 17-1722.3 and was allowed to enroll in
				  Basic Health Hawaii without filing a new application for medical
				  assistance.
"Dementia" means a primary diagnosis as described in the
				  Diagnostic and Statistical Manual of Mental Disorders, 3rd edition, Revised
				  (DSM-III-R) with the following diagnostic criteria:
(1) Demonstrable evidence of impairment in short-term or
				  long-term memory;
(2) At least one of the following:
(A) Impairment of abstract thinking;
(B) Impaired judgment;
(C) Other disturbances of higher cortical function;
				  and
(D) Personality change;
(3) The disturbance in (1) or (2) significantly interferes
				  with work or usual social activities or relationships with others;
(4) Not occurring exclusively during the course of delirium;
				  and
(5) Either:
(A) Evidence from the history, physical examination, or
				  laboratory tests, of a specific organic factor that is judged to be
				  etiologically related to the disturbance; or
(B) In the absence of such evidence, an etiologic organic
				  factor can be presumed if the disturbance cannot be accounted for by any
				  nonorganic mental disorder.
"Dental allowance add-on" means a per diem amount added to
				  the facility's basic PPS rate for dental services rendered to the facility's
				  inpatients. The per diem amount will be the same for all facilities as
				  determined by the department using historical paid dental claims data.
"Department" means the department of human services of the
				  state of Hawaii, which includes the single state agency responsible for
				  administering the medical assistance program.
"Dependent child" means a child who is under the age of
				  nineteen years.
"Dependent family member" means the child, parent, or
				  sibling of an institutionalized individual who is residing with the community
				  spouse, or in the home of the institutionalized individual if there is no
				  community spouse, who may be claimed as a tax dependent under the Internal
				  Revenue Code by the institutionalized individual or the spouse of the
				  institutionalized individual.
"DHHS" means the United States Department of Health and
				  Human Services.
"DHS" means the department of human services.
"Direct supervision" means a healthcare provider able to
				  independently provide services shall be present and available in an inpatient
				  facility or outpatient clinic to provide assistance and direction to a
				  healthcare provider unable to independently provide services but able to
				  provide services under supervision.
"Director" means the administrative head of the department
				  of human services unless otherwise specifically noted.
"Disabled" means an individual who has been determined
				  disabled by the Social Security Administration or by the department's aid to
				  the disabled review committee (ADRC).
"Discharge" means the release of an individual from an acute
				  care facility. The following events are considered discharges:
(1) The individual is formally released from the
				  hospital;
(2) The individual is transferred to an out-of-state
				  hospital;
(3) The individual is transferred to a long-term care level
				  or facility;
(4) The individual dies while hospitalized;
(5) The individual signs out against medical advice;
(6) In the case of a delivery where the mother and baby are
				  discharged at the same time, release of the mother and her baby shall be
				  considered two discharges for payment purposes. In cases of multiple births,
				  each baby will be considered a separate discharge; or
(7) A transfer shall be considered a discharge for billing
				  purposes but shall not be reimbursed as a full discharge except as specified in
				  section 17-1739-70(f)(1).
"Disproportionate share" adjustment means the largest of the
				  following adjustments:
(1) Divide indigent acute inpatient days by total acute
				  inpatient days. Each percentage point or fraction thereof in excess of fifteen
				  per cent shall be converted to a decimal and added to 1.00 to obtain the
				  disproportionate share adjustment;
(2) Calculate the facility's Medicaid utilization rate and
				  subtract one standard deviation above the statewide mean Medicaid utilization
				  rate. Each percentage point in excess of this standard deviation shall be
				  converted to a decimal and added to 1.00 to obtain the disproportionate share
				  adjustment. A calculation resulting in a fraction of a percentage point shall
				  be rounded up to the next percentage point. When the Medicaid utilization rate
				  equals the rate at one standard deviation point, it will be considered a
				  fraction of a percentage point and rounded up; or
(3) Calculate the facility's low income utilization rate and
				  subtract twenty-five per cent. Each percentage point or fraction thereof in
				  excess of twenty-five per cent shall be converted to a decimal and added to
				  1.00 to obtain the disproportionate share adjustment.
"Disproportionate share provider" means a facility that
				  meets the following tests:
(1) Either:
(A) Has at least two obstetricians with staff privileges at
				  the facility who have agreed to provide obstetric services to individuals who
				  are eligible for assistance under the Medicaid program; or
(B) Did not offer nonemergency obstetric services as of
				  December 21, 1987; and
(2) Either:
(A) Has indigent inpatient days equal to or greater than
				  fifteen per cent of total acute inpatient days;
(B) Has a Medicaid utilization rate equal to or greater than
				  one standard deviation above the statewide mean Medicaid utilization rate;
				  or
(C) Has a low income utilization rate equal to or greater
				  than twenty-five per cent.
In applying the foregoing, the Medicaid and total days and
				  revenues shall be obtained from the facility's most recently filed cost report
				  or related financial information for the period covered by that cost report.
				  The Supplemental Security Income days shall be determined by the department
				  based on the most recent information obtained from the Health Care Financing
				  Administration. All other information shall be obtained from the most recent
				  and reliable data available at the time the computation is made.
"Distinct part" means a portion of a medical institution or
				  institutional complex (e.g. nursing home or a hospital) that is certified to
				  provide long term care services.
"DOH" means the department of health.
"Domiciliary care facility" means a licensed adult
				  residential care facility which provides twenty-four hour living accommodation,
				  personal care services, and appropriate medical care to adult beneficiaries by
				  individuals unrelated to the beneficiaries. A treatment facility providing
				  rehabilitative treatment services shall not be a domiciliary care
				  facility.
"Domiciliary care home" means any facility which provides
				  twenty-four-hour living accommodations, personal care services, and appropriate
				  health care, as needed, to adult beneficiaries unable to care for themselves by
				  individuals unrelated to the beneficiaries in licensed adult residential care
				  homes or other care homes regulated by the department of health. A domiciliary
				  care home does not provide rehabilitative treatment services.
"DRA" means the Deficit Reduction Act of 2005 enacted on
				  February 8, 2006.
"Drug formulary" means prescribed drugs, pursuant to
				  42 U.S.C.
				  1396r(8)(d)(4), for which
				  payment may be made by the Hawaii Medicaid program.
"Dynamic care" means care for pediatric patients which
				  includes a pattern of continuous change and growth in treatment.
"EAC" or "estimated acquisition cost" means the wholesale
				  average cost.
"E-ARCH" or "expanded adult residential care home" is a
				  facility, as defined in section 11-100.1.2 and licensed by the department of
				  health, that provides twenty-four hour living accommodations, for a fee, to
				  adults unrelated to the family, who require at least minimal assistance in the
				  activities of daily living, personal care services, protection, and healthcare
				  services, and who may need the professional health services provided in a
				  nursing facility.
"Early intervention services" means services that are
				  defined by
				  20 U.S.C. section
				  1472 and HRS chapter
				  321, part XXVIII which are available
				  for infants and toddlers from birth through age three who have special
				  needs.
"Earned income" means cash received or available to be
				  received by the household which require some activity on the part of the
				  household to produce. Examples of earned income include, but shall not be
				  limited to, wages, jury duty income (excluding reimbursement for transportation
				  and meals), and self-employment income, including from the sale of blood, blood
				  plasma, and parts of the body.
"Effective date of eligibility" means the date on which
				  health care services shall be covered either through fee-for-service
				  reimbursement by the department, its fiscal agent, or through enrollment in a
				  participating health plan.
"Effective date of enrollment" means the date as of which a
				  participating health plan is required to provide benefits to an
				  enrollee.
"Effective income level" means the income standard
				  applicable under Medicaid for an eligibility group, after taking into
				  consideration any disregard of a block of income applied in determining
				  financial eligibility for such group.
"Electronic account" means an electronic file that includes
				  all information collected and generated by the department regarding each
				  individual's Medicaid eligibility and enrollment including any information
				  collected or generated as part of an administrative appeal process conducted
				  under 42 C.F.R. part 431, Subpart E, or through the Exchange appeals process
				  conducted under 45 C.F.R. part 155, Subpart F, and including all documentation
				  required as follows:
"FPL" or "federal poverty level" mean
(1) Facts to support the department's
				  decision on an application in each applicant's case record.
(2) Disposition of each individual by a
				  finding of eligibility or ineligibility, unless:
(A) There is an entry in the case record that
				  the individual voluntarily withdrew the application, and that the department
				  sent a notice confirming this decision;
(B) There is a supporting entry in the case
				  record that the individual has died; or
(C) There is a supporting entry in the case
				  record that the individual cannot be located. "Eligibility determination" means
				  an approval or denial of eligibility for medical assistance as well as a
				  redetermination or termination of eligibility for medical assistance.
				  "Emergency" means a situation where a person's life or health is in imminent
				  danger as the result of illness or injury and specialized services must be
				  provided without delay. "Emergency medical condition" means the sudden onset of
				  a medical condition that manifests itself by acute symptoms of sufficient
				  severity (including severe pain, psychiatric disturbances and/or symptoms
				  substance abuse) such that a prudent layperson, who possesses an average
				  knowledge of health and medicine, could reasonably expect the absence of
				  emergency services or immediate medical attention to result in: