reglab/statecodes huggingface dataset:
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1730.1 - MEDICALLY NEEDY SPENDDOWN › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS, AND DISENROLLMENT › Section 17-1730.1-20 - Freedom of choice

Current through June, 2024
(a) An eligible
				  child or pregnant woman, described in section 17-1730.1-11(a)(1), and an aged,
				  blind and disabled individual described in chapter 17-1719 with the exception
				  of those described in section 17-1735.1-2(a) shall be provided a choice of a
				  health plan and a provider as described in chapter 17-1720.1.
(b) An eligible aged, blind or disabled
				  individual described in section 17-1735.1-2(a) shall choose a department
				  approved provider described in section 17-1736-3.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1730.1 - MEDICALLY NEEDY SPENDDOWN › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS, AND DISENROLLMENT › Section 17-1730.1-21 - Enrollment

Current through June, 2024
(a) The effective date of coverage or
				  enrollment is the date on which the spenddown amount was met.
(b) An individual eligible in accordance with
				  this chapter, with the exception of an individual identified in section
				  17-1735.1-2(a), shall be enrolled in a health plan as described in chapter
				  17-1720.1.
(c) An eligible
				  individual described in section 17-1735.1-2(a) shall not be enrolled into a
				  health plan and services shall be provided on a fee-for-service
				  basis.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1730.1 - MEDICALLY NEEDY SPENDDOWN › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS, AND DISENROLLMENT › Section 17-1730.1-22 - Benefits

Current through June, 2024
(a) An individual eligible in accordance with
				  this chapter, with the exception of those described in section 17-1735.1-2(a),
				  shall be provided a standard benefits package by a participating health plan
				  and other services when appropriate as described in chapter
				  17-1720.1.
(b) An eligible
				  individual described in section 17-1735.1-2(a) shall be provided benefits under
				  the fee-for-service provisions described in chapter 171737, with the exception
				  of services identified in section 17-1735.1-3(b).
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1730.1 - MEDICALLY NEEDY SPENDDOWN › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS, AND DISENROLLMENT › Section 17-1730.1-23 - Disenrollment from a health plan

Current through June, 2024
An enrollee shall be disenrolled from a health plan under
					 the provisions as described in chapter 17-1720.1.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1731 - PREMIUM ASSISTANCE PROGRAM › Section 17-1731-1 - Purpose

Current through June, 2024
This chapter establishes, subject to the availability of
				  State funds, a premium assistance program for a low-income individual who
				  purchases a silver level qualified health plan through the Hawaii health
				  insurance exchange and receives advanced premium tax credit (APTC) and maximum
				  cost-sharing reduction (CSR). The department shall pay the eligible
				  individual's share of the premium to the qualified health plan in which the
				  eligible individual is enrolled.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1731 - PREMIUM ASSISTANCE PROGRAM › Section 17-1731-2 - Definitions

Current through June, 2024
The following definitions shall apply to this
				  subchapter:
"Exchange" means the Hawaii health insurance exchange
				  established under the Affordable Care Act.
"Qualified health plan" means a qualified health plan or a
				  qualified health plan issuer, as those terms are defined in
				  45
				  C.F.R. §155.20, and as the context may
				  dictate.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1731 - PREMIUM ASSISTANCE PROGRAM › Section 17-1731-3 - Eligibility requirements

Current through June, 2024
To be eligible for the premium assistance described in this
				  chapter, an individual shall:
(1) Have
				selected or be enrolled in a 94% actuarial value silver level qualified health
				plan through the Exchange;
(2) Be
				determined eligible for advanced premium tax credit (APTC), apply the maximum
				APTC amount available towards their premium and the maximum cost-sharing
				reduction (CSR) by the Exchange;
(3) Have household income of less than one
				hundred percent of the federal poverty level for the applicable household size
				as determined by the Exchange and communicated by the Exchange to the qualified
				health plan selected by the individual.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1731 - PREMIUM ASSISTANCE PROGRAM › Section 17-1731-4 - Benefits

Current through June, 2024
(a) The department shall, upon presentation
				of an invoice by a qualified health plan to the department, pay the share of
				premium that the eligible individual is required to pay to the qualified health
				plan to receive coverage.
(b)
				Benefit limitations:
(1) The department shall
				pay an eligible individual's share of premium to the qualified health plan only
				upon receipt of an invoice submitted by the qualified health plan to the
				department;
(2) The department
				shall not make any payments directly to eligible individuals; and
(3) The department shall not pay and the
				eligible individual shall be responsible for, any cost-sharing including, but
				not limited to, deductibles, co-payments or coinsurance.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1731 - PREMIUM ASSISTANCE PROGRAM › Section 17-1731-5 - Termination of premium assistance

Current through June, 2024
Premium assistance payable under this chapter on behalf of
				  an eligible individual shall be terminated at any time for any of the following
				  reasons:
(1) The individual fails to
				meet the eligibility requirements set forth in section 17-1731-3;
(2) The individual voluntarily terminates
				participation in the premium assistance program;
(3) The individual no longer resides in the
				State;
(4) Death of the
				individual;
(5) The individual's
				whereabouts are unknown;
(6)
				Insufficient State funds; or
(7)
				The premium assistance program is terminated.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1731 - PREMIUM ASSISTANCE PROGRAM › Section 17-1731-6 - Administration of the premium assistance program

Current through June, 2024
(a) The
				department may contract with a third party or parties to administer any
				component of this program, including, but not limited to, payment, auditing,
				and recovery.
(b) The department's
				provision of premium assistance under this chapter shall be administered at no
				cost to the eligible individual.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1731 - PREMIUM ASSISTANCE PROGRAM › Section 17-1731-7 - Appeal process

Current through June, 2024
(a) An eligible
				individual may appeal the department's failure to pay the benefit described in
				section 17-1731-4 only as provided in this section.
(b) Issues relating to the determination of
				an individual's household income by the Exchange under section 17-1731-3(3)
				must be directed to the Exchange.
(c) Issues relating to a qualified health
				plan requiring premium payment from an eligible individual must be directed to
				the qualified health plan before requesting informal review or an
				administrative hearing under this section.
(d) Requests for an informal review or
				administrative hearing under this chapter may be submitted by an eligible
				individual or the individual's authorized representative only when:
(1) The qualified health plan is requiring
				premium payment from the eligible individual; and
(2) The qualified health plan states in
				writing that the reason for requiring premium payment is because the department
				did not timely pay an invoice that was submitted by the individual's health
				plan to the department.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1733.1 - COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 1 - GENERAL PROVISION › Section 17-1733.1-1 - Purpose

Current through June, 2024
The purpose of this chapter is to establish coverage for
					 an individual who is eligible for the Centers for Disease Control and
					 Prevention (CDC) breast and cervical cancer early detection program (BCCEDP)
					 and was found through that program to have cancer or a precancerous condition
					 of the breast or cervix, requires treatment, and meets the eligibility
					 requirements of this chapter.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1733.1 - COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 1 - GENERAL PROVISION › Section 17-1733.1-2 - General requirements

Current through June, 2024
The confidentiality, administrative appeal, fraud, medical
					 assistance recovery, application processing, eligibility review, and adverse
					 action notice provisions described in subtitle 12 shall pertain to an
					 individual who applies or is eligible for coverage under this
					 chapter.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1733.1 - COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 2 - ELIGIBILITY REQUIREMENTS › Section 17-1733.1-8 - Purpose

Current through June, 2024
This subchapter describes the eligibility requirements for
					 participation in accordance with this chapter.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1733.1 - COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 2 - ELIGIBILITY REQUIREMENTS › Section 17-1733.1-9 - Basic requirements

Current through June, 2024
An individual shall meet the basic eligibility
					 requirements, which include but are not limited to, citizenship, qualified
					 non-citizen status, state residency, verification of identity, not residing in
					 a public institution and the provision of a social security number, as
					 described in chapter 17-1714.1.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1733.1 - COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 2 - ELIGIBILITY REQUIREMENTS › Section 17-1733.1-10 - Categorical requirements

Current through June, 2024
(a) An individual
				  shall meet the following requirements:
(1)
				  Under age sixty-five;
(2) Eligible
				  and screened for breast or cervical cancer or a precancerous condition of the
				  breast or cervix by an authorized CDC BCCEDP;
(3) Require treatment for breast or cervical
				  cancer or a precancerous condition of the breast or cervix;
(4) Not otherwise covered under creditable
				  coverage; and
(5) Not eligible
				  under any other Medicaid coverage group.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1733.1 - COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 2 - ELIGIBILITY REQUIREMENTS › Section 17-1733.1-11 - Non-financial eligibility requirements and effective date of coverage

Current through June, 2024
(a) An individual who is determined eligible
				  in accordance with this chapter shall remain eligible while receiving required
				  treatment.
(1) Breast or cervical cancer
				  shall be medically reevaluated annually by a treating physician to verify and
				  confirm the need for continued treatment at the time of the annual eligibility
				  review; or
(2) A precancerous
				  condition of the breast or cervix shall be medically reevaluated at six-month
				  intervals by a treating physician to verify and confirm the need for continued
				  treatment, and one of the reevaluations shall coincide with the annual
				  eligibility review.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1733.1 - COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 2 - ELIGIBILITY REQUIREMENTS › Section 17-1733.1-12 - Income and asset requirements

Current through June, 2024
An individual's household income and assets shall not be
					 considered in determining eligibility for participation in this chapter.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1733.1 - COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 2 - ELIGIBILITY REQUIREMENTS › Section 17-1733.1-13 - Eligibility review

Current through June, 2024
(a) An individual
				  eligible under the provisions of this chapter shall receive an annual
				  eligibility review every twelve months.
(b) Eligibility shall be redetermined in
				  accordance with chapter 17-1712.1 and subchapter
				  5 of chapter 17-1714.1.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1733.1 - COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT › Section 17-1733.1-19 - Purpose

Current through June, 2024
This subchapter addresses the provisions of freedom of
					 choice, enrollment, benefits and disenrollment for an individual eligible in
					 accordance with this chapter.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1733.1 - COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT › Section 17-1733.1-20 - Freedom of choice

Current through June, 2024
(a) An individual
				  eligible in accordance with this chapter shall be provided a choice of a health
				  plan and a provider as described in chapter 17-1720.1.
(b) An individual identified in section
				  17-1735.1-2(a) shall choose a department approved provider as described in
				  chapter 17-1736.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1733.1 - COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT › Section 17-1733.1-21 - Enrollment into a participating health plan

Current through June, 2024
(a) An
				  individual eligible in accordance with this chapter, with the exception of an
				  individual identified in section 17-1735.1-2(a), shall be enrolled in a health
				  plan as described in chapter 17-1720.1.
(b) An individual identified in section
				  17-1735.1-2(a) shall not be enrolled into a health plan and services shall be
				  provided on a fee-for-service basis.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1733.1 - COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT › Section 17-1733.1-22 - Benefits

Current through June, 2024
(a) An individual enrolled in a health plan
				  shall be provided a standard benefits package by a participating health plan
				  and other services when appropriate as described in chapter 17-1720.
(b) An individual identified in section
				  17-1735.1-2(a) shall be provided coverage under the fee-for-service provisions
				  as described in chapter 171737.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1733.1 - COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT › Section 17-1733.1-23 - Disenrollment from a health plan

Current through June, 2024
An enrollee shall be disenrolled from a health plan under
					 the provisions as described in chapter 171720.1.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1733.1 - COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT › Section 17-1733.1-24 to 17-1733.1-28 - Reserved

Current through June, 2024
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1734.1 - STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 1 - GENERAL PROVISION › Section 17-1734.1-1 - Purpose

Current through June, 2024
The purpose of this chapter is to establish a State funded
					 medical assistance program for an individual who meets the requirements under
					 chapter 17-1733.1 except for citizenship status and the eligibility
					 requirements of this chapter.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1734.1 - STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 1 - GENERAL PROVISION › Section 17-1734.1-2 - General requirements

Current through June, 2024
The confidentiality, administrative appeal, fraud, medical
					 assistance recovery, application processing, eligibility review, and adverse
					 action notice provisions described in subtitle 12 shall pertain to an
					 individual who applies or is eligible for coverage under this
					 chapter.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1734.1 - STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 2 - ELIGIBILITY REQUIREMENTS › Section 17-1734.1-8 - Purpose

Current through June, 2024
This subchapter describes the eligibility requirements for
					 participation in accordance with this chapter.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1734.1 - STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 2 - ELIGIBILITY REQUIREMENTS › Section 17-1734.1-9 - Basic requirements

Current through June, 2024
An individual shall meet the basic eligibility
					 requirements, which include but are not limited to, a lawfully present
					 non-citizen ineligible under chapter 17-1733.1 due to citizenship status, state
					 residency, verification of identity, not residing in a public institution and
					 the provision of a social security number, as described in chapter
					 17-1714.1.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1734.1 - STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 2 - ELIGIBILITY REQUIREMENTS › Section 17-1734.1-10 - Categorical requirements

Current through June, 2024
(a) An individual
				  shall meet the following:
(1) A lawfully
				  present non-citizen who meets the requirements under chapter 17-1733.1 except
				  for citizenship status;
(2) Under
				  age sixty-five;
(3) Eligible and
				  screened for breast or cervical cancer or a precancerous condition of the
				  breast or cervix through the Hawaii Comprehensive Breast and Cervical Cancer
				  Control Program (HCBCCCP) administered by the Department of Health;
(4) Require treatment for breast or cervical
				  cancer or a precancerous condition of the breast or cervix;
(5) Not otherwise covered under creditable
				  coverage; and
(6) Not eligible
				  under any other Medicaid coverage group.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1734.1 - STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 2 - ELIGIBILITY REQUIREMENTS › Section 17-1734.1-11 - Non-financial eligibility requirements and effective date of coverage

Current through June, 2024
(a) An individual who is determined eligible
				  in accordance with this chapter shall remain eligible while receiving required
				  treatment.
(1) Breast or cervical cancer
				  shall be medically reevaluated annually by a treating physician to verify and
				  confirm the need for continued treatment at the time of the annual eligibility
				  review; or
(2) A precancerous
				  condition of the breast or cervix shall be medically reevaluated at six-month
				  intervals by a treating physician to verify and confirm the need for continued
				  treatment, and one of the reevaluations shall coincide with the annual
				  eligibility review.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1734.1 - STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 2 - ELIGIBILITY REQUIREMENTS › Section 17-1734.1-12 - Income and asset requirements

Current through June, 2024
An individual's household income and assets shall not be
					 considered in determining eligibility for participation in this
					 chapter.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1734.1 - STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 2 - ELIGIBILITY REQUIREMENTS › Section 17-1734.1-13 - Eligibility review

Current through June, 2024
(a) An individual
				  eligible under the provisions of this chapter shall receive an annual
				  eligibility review every twelve months.
(b) Eligibility shall be redetermined in
				  accordance with chapter 17-1712.1 and subchapter
				  5 of chapter 17-1714.1.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1734.1 - STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT › Section 17-1734.1-19 - Purpose

Current through June, 2024
This subchapter addresses the provisions of freedom of
					 choice, enrollment, benefits and disenrollment for an individual eligible in
					 accordance with this chapter.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1734.1 - STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT › Section 17-1734.1-20 - Freedom of choice

Current through June, 2024
(a) An individual
				  eligible under the provisions of this chapter shall be provided a choice of a
				  health plan and a provider as described in chapter 17-1720.1.
(b) An individual identified in section
				  17-1735.1-2(a) shall choose a department approved provider of their choice as
				  described in chapter 171736.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1734.1 - STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT › Section 17-1734.1-21 - Enrollment into a participating health plan

Current through June, 2024
(a) An
				  individual eligible in accordance with this chapter, with the exception of an
				  individual identified in section 17-1735.1-2(a), shall be enrolled in a health
				  plan as described in chapter 17-1720.1.
(b) An individual identified in section
				  17-1735.1-2(a) shall not be enrolled into a plan and services provided on a
				  fee-for-service basis.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1734.1 - STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT › Section 17-1734.1-22 - Benefits

Current through June, 2024
(a) An individual enrolled in a health plan
				  shall be provided a standard benefits package by a participating health plan
				  and other services when appropriate as described in chapter 17-1720.
(b) An individual identified in section
				  17-1735.1-2(a) shall be provided coverage under the fee-for-service provisions
				  as described in chapter 171737.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1734.1 - STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT › Section 17-1734.1-23 - Disenrollment from a health plan

Current through June, 2024
An enrollee shall be disenrolled from a health plan under
					 the provisions as described in chapter 171720.1.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1734.1 - STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER › Subchapter 3 - FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DISENROLLMENT › Section 17-1734.1-24 to 17-1734.1-28 - Reserved

Current through June, 2024
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1735.1 - GENERAL PROVISIONS FOR FEE FOR-SERVICE MEDICAL ASSISTANCE › Section 17-1735.1-1 - Purpose

Current through June, 2024
This chapter describes an individual covered under the
				  State's fee-for-service component of the medical assistance program. The
				  fee-for-service program is discussed in the following chapters: 17-1722,
				  special medical assistance coverages and programs; 17-1736, provider
				  provisions; 17-1737, scope and contents of the fee-for-service medical
				  assistance program; 17-1738, targeted case management services; 17-1739,
				  authorization, payment, and claims in the fee-for-service medical assistance
				  program; 17-1740.1, reimbursement of federally qualified health centers and
				  rural health clinics; and 17-1741, utilization control.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1735.1 - GENERAL PROVISIONS FOR FEE FOR-SERVICE MEDICAL ASSISTANCE › Section 17-1735.1-2 - An individual covered under fee-for-service medical assistance

Current through June, 2024
(a) An individual eligible for
				fee-for-service coverage under the medical assistance program includes, but is
				not limited to:
(1) A child in receipt of
				foster care, kinship guardianship or adoption assistance, under age twenty-one
				who is a resident of the State, and placed in another state as described in
				chapter 17-1715;
(2) A non-citizen
				ineligible for Medicaid assistance who receives emergency medical services as
				described in chapter 17-1723.1;
(3)
				An individual who enters the State of Hawaii Organ and Tissue Transplant
				(SHOTT) program as described in chapter 17-1737;
(4) An incarcerated individual who is
				admitted as an inpatient in a medical institution not on the grounds of the
				incarceration facility;
(5) An
				individual who receives a determination of eligibility on or after the start
				date of a new health plan contract period that is retroactive to a date prior
				to the start of the new health plan contract period with incurred services
				during the period from the effective date of coverage up to the start date of
				the new health plan contract period;
(6) A medically needy individual who is not
				aged, blind or disabled as described in chapter 171730.1; or
(7) An individual who is eligible for the
				Qualified Medicare Beneficiaries (QMB), Specified Low Income Medicare
				Beneficiaries (SLMB), Qualified Disabled and Working Individuals (QDWI), or
				Qualifying Individuals (QI) program described in chapter 17-1722.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1735.1 - GENERAL PROVISIONS FOR FEE FOR-SERVICE MEDICAL ASSISTANCE › Section 17-1735.1-3 - Effective date of authorization

Current through June, 2024
(a) The effective
				date for payments to be made for covered services under the fee-for-service
				program for an individual described in section 17-1735.1-2 shall be:
(1) The date the application is received by
				the department as described in chapter 17-1711.1;
(2) Any date specified by the individual on
				which appropriate Medicaid eligible services were incurred and is no earlier
				than the first day of the third month prior to the month the application is
				received by the department for an individual applying for the coverage of
				long-term care services, or the immediate ten calendar days prior to the date
				the application is received by the department for all other individuals;
				or
(3) The date when all
				eligibility requirements are met by the applicant.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1735.2 - GENERAL PROVISIONS FOR PARTICIPATING HEALTH PLANS › Section 17-1735.2-2 - Health plan participation in the medical assistance program

Current through June, 2024
(a) The department shall request proposals
				from managed care health plans for provision of healthcare services to an
				eligible individual to participate in the medical assistance program.
(b) The department shall evaluate the
				proposals from managed care plans to ensure that the plans meet the conditions
				and requirements described in the department's request for proposals.
(c) Contracts for participation in the
				medical assistance program shall be awarded to qualified health plans upon
				finalization of financial agreements with the department.
(d) The department shall develop a request
				for proposals prior to the lapse of existing contracts with participating
				health plans to ensure that beneficiaries receive continued health care
				coverage.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1735.2 - GENERAL PROVISIONS FOR PARTICIPATING HEALTH PLANS › Section 17-1735.2-3 - Service areas

Current through June, 2024
(a) The department
				shall designate geographic areas as the areas for which health plans will
				submit proposals to provide services.
(b) A health plan may submit proposals to
				service more than one service area.
(c) More than one health plan may be
				contracted by the department for each service area.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1735.2 - GENERAL PROVISIONS FOR PARTICIPATING HEALTH PLANS › Section 17-1735.2-4 - Requirements of participating health plans

Current through June, 2024
(a) Health plans
				participating in the medical assistance program shall abide by the provisions
				of their respective contracts with the department as well as federal and state
				statutes and regulations.
(b) The
				requirements of each participating health plan shall include, but are not
				limited to, the following:
(1) Provision of
				all services required by the contract between the respective plan and the
				department;
(2) Provision of a
				primary care provider for each eligible individual who is enrolled in the
				health plan;
(3) Provision of a
				case management system to ensure that health services identified by an eligible
				individual's primary care provider as medically necessary are
				received;
(4) Development and
				maintenance of a sufficient network of health care providers to ensure the
				provision of required health services are provide to an eligible individual in
				a timely manner;
(5) Maintenance of
				adequate support staff and systems to administer and conduct business
				functions;
(6) Development and
				maintenance of required information systems;
(7) Development and maintenance of a quality
				assurance program;
(8) Development
				and maintenance of a grievance and appeal system for a dissatisfied eligible
				individual;
(9) Development and
				maintenance of a toll-free telephone hotline in the State to confirm
				enrollment, respond to inquiries from an eligible individual, and provide
				information to the general public; and
(10) Maintenance of a medical records system
				to enable the provision of information pertinent to the care and management of
				an eligible individual to the department.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1735.2 - GENERAL PROVISIONS FOR PARTICIPATING HEALTH PLANS › Section 17-1735.2-5 - Capitated payments

Current through June, 2024
(a) Each
				participating health plan shall be paid on a capitated basis, as negotiated
				with the department, for an eligible individual enrolled in that health
				plan.
(b) The department shall
				provide the capitated payment, as stipulated in the contract between the
				department and each health plan, in return for the health plan's provision of
				all contracted coverage for the health plan's eligible individuals.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1735.2 - GENERAL PROVISIONS FOR PARTICIPATING HEALTH PLANS › Section 17-1735.2-6 - Enforcement of contracts with participating health plan

Current through June, 2024
(a)
				The department may monitor a participating health plan's performance during any
				contract period.
(b) The department
				may impose civil or administrative monetary penalties not to exceed the maximum
				amount established by federal and state statutes and regulations if the health
				plan:
(1) Fails to provide medically
				necessary items and services that are required under law or under
				contract;
(2) Imposes upon
				beneficiaries excess premiums and charges;
(3) Acts to discriminate among an eligible
				individual;
(4) Misrepresents or
				falsifies information;
(5) Violates
				marketing guidelines established by the department;
(6) Violates other contract provisions and
				requirements; or
(7) Violates
				federal or state statutes or regulations.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1735.2 - GENERAL PROVISIONS FOR PARTICIPATING HEALTH PLANS › Section 17-1735.2-7 - Termination of contract with participating health plan

Current through June, 2024
(a)
				The department shall have the authority to terminate the participating health
				plan's contract for any or all of the following reasons:
(1) Convenience;
(2) Default by the health plan;
(3) Expiration of the medical assistance
				program;
(4) Failure by the health
				plan to abide by the contract conditions;
(5) Insolvency of or declaration of
				bankruptcy by the health plan;
(6)
				Failure to meet federal or state statutes, or both; or
(7) Unavailability of funds.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1736 - PROVIDER PROVISIONS › Subchapter 1 - FREE CHOICE OF PROVIDERS › Section 17-1736-1 - Purpose

Current through June, 2024
The purpose of this chapter shall be to set forth
					 conditions on the free choice of providers in the fee for services component
					 under the medical assistance program.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1736 - PROVIDER PROVISIONS › Subchapter 1 - FREE CHOICE OF PROVIDERS › Section 17-1736-3 - Right to free choice of providers of medical services

Current through June, 2024
(a)
				  A client shall have freedom to choose health care providers certified by the
				  department to participate in the medical assistance program.
(b) Freedom of choice includes the right to
				  seek medical services elsewhere within the State when physician recommended
				  care is not available or readily accessible.
(c) Medical care and services shall be
				  provided on the client's home island unless otherwise recommended by the
				  client's physician.
(d) A client
				  who decides on the services of a clinic shall be considered as having exercised
				  the client's right to choose a provider, even though a physician may be
				  assigned to the client by the clinic under the clinic's normal
				  practices.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1736 - PROVIDER PROVISIONS › Subchapter 1 - FREE CHOICE OF PROVIDERS › Section 17-1736-4 - Medical care resources affecting freedom of choice

Current through June, 2024
(a) A client
				  who has pre-paid or earned health benefits shall utilize these benefits before
				  utilizing medical assistance payments.
(b) A client may be encouraged but shall not
				  be required to utilize public and private health resources available to groups
				  meeting financial and eligibility standards.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1736 - PROVIDER PROVISIONS › Subchapter 2 - PROVIDERS OF THE FEE FOR SERVICE PROGRAM › Section 17-1736-11 - Purpose

Current through June, 2024
The purpose of this chapter is to establish conditions for
					 provider participation in the fee for service component of Hawaii's medical
					 assistance program. The provisions of this chapter govern provider applications
					 and procedures for approval or denial of those applications, the requirements
					 to be met by a provider before that person or organization is certified or
					 denied provider status, and the requirements that providers keep records to
					 participate in the program. Also described are procedures to be used for
					 suspension or termination of providers from the Hawaii medical assistance
					 program.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1736 - PROVIDER PROVISIONS › Subchapter 2 - PROVIDERS OF THE FEE FOR SERVICE PROGRAM › Section 17-1736-14 - Approval or denial of provider application and notification

Current through June, 2024
(a) DHS, upon finding that a provider
				  applicant meets the requirements for participation in the medicaid program,
				  shall promptly notify the person or entity in writing of the department's
				  approval of the provider's application. The department shall arrange with its
				  fiscal agent to issue to the new provider:
(1) A provider code number and instructions
				  regarding the use of that number;
(2) A provider manual complete with all
				  letter updates; and
(3)
				  Notification of federal and state penalties for fraud.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1736 - PROVIDER PROVISIONS › Subchapter 2 - PROVIDERS OF THE FEE FOR SERVICE PROGRAM › Section 17-1736-15 - Requirements for participation in the program by providers

Current through June, 2024
(a)
				  Except for payments authorized to out-of-state providers in emergency
				  situations and to Qualified Medicare Beneficiaries (QMB) only providers, or as
				  authorized under section 17-1736-13, payments under the medical assistance
				  program for goods, care, and services shall be made only to providers approved
				  by DHS to participate in the Hawaii medical assistance program.
(b) An individual, institution, or
				  organization shall meet all of the following requirements in order to become
				  and retain eligibility as a provider under the medical assistance program:
(1) The provider shall be licensed or
				  approved as follows:
(A) The provider, if an
				  individual, shall be licensed to practice the provider's profession in accord
				  with state law. Permits, temporary licenses, provisional licenses, expired or
				  unrenewed licenses, or any form of license or permit which requires supervision
				  of the licensee shall not serve to qualify the licensee as an approved provider
				  of service under the Hawaii medical assistance program;
(B) The provider, if a medical or health
				  related institution, shall be certified by the state department of health under
				  applicable public health rules of the state and standards of the federal
				  government. The following shall apply regarding Medicare certification for
				  participation in Medicaid:
(i) Hospitals are
				  required to be Medicare certified;
(ii) Facilities that provide SNF services are
				  required to be Medicare certified;
(iii) Facilities that provide SNF and ICF
				  services, but are not Medicare certified, may participate as an ICF;
				  and
(iv) Facilities that provide
				  ICF services only are unable to obtain Medicare certification, therefore,
				  participation as an ICF is allowed.
(C) The provider of any other health care
				  services shall comply with standards and all licensure, certification and other
				  requirements as applicable;
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1736 - PROVIDER PROVISIONS › Subchapter 2 - PROVIDERS OF THE FEE FOR SERVICE PROGRAM › Section 17-1736-16 - Provider requirements regarding advance directives

Current through June, 2024
(a)
				  Hospitals, hospices, nursing homes, health maintenance organizations, and other
				  health care facilities that receive funds from medicare or medicaid are
				  required by law ( Pub. L.
				  No. 101-508 and chapter
				  327D, HRS) to have in place a
				  mechanism for advising patients of their legal rights and options for refusing
				  or accepting treatment if they are or become incapacitated.
(b) Providers must offer written information
				  as well as summaries of pertinent institutional policies to all adult patients
				  regarding their rights under State laws to accept or refuse treatment and to
				  make advance directives.
(1) An advance
				  directive is a document that is written in advance of an incapacitating illness
				  that state a patient's choices about treatment, or name someone to make such
				  choices, if the patient becomes unable to make decisions.
(2) Through advance directives such as living
				  wills and durable powers of attorney for health care, patients will be able to
				  make legally valid decisions about their future medical treatment.
(3) The patient's medical record must be
				  documented to indicate whether the patient has an advance directive.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1736 - PROVIDER PROVISIONS › Subchapter 2 - PROVIDERS OF THE FEE FOR SERVICE PROGRAM › Section 17-1736-17 - Record keeping requirements for providers

Current through June, 2024
(a) In order
				  to determine the correct amount of medicaid program payments due to any
				  provider, and to protect the medicaid program from fraud and abuse, the DHS's
				  representative, agent, investigative and recovery service, the fiscal agent,
				  and the medicaid fraud control unit of the attorney general's office shall have
				  the right to examine, inspect, copy, and if necessary, seize all records of a
				  provider pertaining to medicaid patients which are necessary to fully disclose
				  the type and extent of health care services or supplies provided to eligible
				  medicaid recipients. The provider, for a period of three calendar years, shall
				  maintain thorough records of medicaid patients, including but not limited to
				  the following:
(1) Billings and account
				  ledgers;
(2) Records of patient
				  appointments;
(3) Patient history
				  forms, medical records, diagnosis, and orders prescribed and treatment
				  plans;
(4) Records of requests for
				  and results of tests and examinations ordered or furnished;
(5) Records of prescriptions, medications,
				  assistive devices, or appliances prescribed, ordered, or furnished;
				  and
(6) All records which are
				  necessary to justify the amount of claims for payment which are determined by
				  cost reimbursement or a similar basis, including billing documents showing the
				  cost of services or supplies provided to the recipient.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1736 - PROVIDER PROVISIONS › Subchapter 2 - PROVIDERS OF THE FEE FOR SERVICE PROGRAM › Section 17-1736-18 - Confidential communications and disclosure requirements for physician and psychologist providers

Current through June, 2024
(a) There is no
				  privilege under this section in any administrative proceeding where the:
(1) Competency;
(2) Practitioner's license;
(3) Provider status; or
(4) Practice;
of the physician is an issue, including fair hearing
					 criminal cases involving fraud, or civil cases involving over-payment under the
					 medicaid program. However, the identifying data of a patient whose records are
					 admitted into evidence at an administrative hearing shall be kept confidential
					 among the parties to the hearing unless waived by the patient. The
					 administrative agency, board, or commission may close its proceedings to the
					 public to protect a patient's confidentiality.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1736 - PROVIDER PROVISIONS › Subchapter 2 - PROVIDERS OF THE FEE FOR SERVICE PROGRAM › Section 17-1736-19 - Disclosure by providers and their fiscal agents of information concerning provider's ownership and control

Current through June, 2024
(a) Providers shall
				  disclose to the med-QUEST division the following information upon request:
(1) The name and address of each person with
				  an ownership or controlling interest in the provider;
(2) The name, address, and ownership or
				  controlling interest which the provider may have in any other entity which also
				  has certification as a provider under the Hawaii medical assistance program or
				  the medicare program;
(3) The name
				  of any business, either in the State or elsewhere, whether incorporated or not,
				  in which the provider has a financial or management interest and which is
				  itself a supplier of medical goods, care, or services to any provider certified
				  under the medical assistance program;
(4) The name of any business either in the
				  State or elsewhere, whether incorporated or not, in which a blood relative of
				  an individual provider has a financial or management interest and which is
				  itself a supplier of medical goods, care, or services to any provider certified
				  under the medical assistance program;
(5) The name of any blood relatives or
				  in-laws of an individual provider who have a financial or management interest
				  in any business concern which is itself a supplier of medical goods, care, or
				  services to any provider certified under the Hawaii medical assistance program;
				  and
(6) The name of any blood
				  relative or in-laws of an individual provider who is also a provider certified
				  under the medical assistance program.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1736 - PROVIDER PROVISIONS › Subchapter 2 - PROVIDERS OF THE FEE FOR SERVICE PROGRAM › Section 17-1736-20 - Provider requirements prior to certification

Current through June, 2024
(a) Prior to
				  certification as a provider under the medical assistance program, a provider
				  must submit to the department full and complete information about:
(1) The ownership of any subcontractor with
				  whom the provider has had business transactions totaling more than $25,000
				  during the twelve month period ending on the date that certification is
				  requested; and
(2) Any significant
				  business transactions between the provider and any supplier of services or
				  goods wholly owned, or between the provider and any subcontractor during the
				  five year period ending on the date of the request for certification.