reglab/statecodes huggingface dataset:
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 6 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) › Section 17-1737-58 - Diagnosis and treatment

Current through June, 2024
(a) Diagnostic and
				  treatment services shall be provided for problems identified during screening
				  regardless of whether the service is included in the department's state plan.
				  Provision of services that are not included in the state plan shall be based on
				  medical necessity and require prior authorization, and shall be limited to
				  services permitted under medicaid.
(b) Assistance in referral shall be provided
				  for treatment services not covered by the medical assistance program
				  (medicaid), but determined to be needed as a result of problems identified
				  during screening and diagnosis. Assistance in referral only shall include
				  giving the recipient or family the names, addresses, and telephone numbers of
				  providers who are able to furnish the needed treatment at little or no cost to
				  the recipient or family.
(c) Dental
				  care, at as early an age as necessary for relief of pain and infections,
				  restoration of teeth and maintenance of dental health in accordance with
				  section 17-1737-75. Dental diagnosis and treatment shall be started within
				  sixty days of the screening date and the treatment plan shall be completed
				  within one hundred-twenty days from the date a procedure was initiated, except
				  under noted extenuating circumstances.
(d) Diagnostic and treatment services shall
				  be started within six months from the request for screening services by the
				  recipient or family.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 6 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) › Section 17-1737-59 - EPSDT providers

Current through June, 2024
EPSDT providers shall deliver either directly or
					 indirectly through referral EPSDT services as set out in sections
					 17-1737-53 to
					 17-1737-58.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 6 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) › Section 17-1737-60 - Continuing care provider

Current through June, 2024
(a) Continuing care
				  means EPSDT services provided by a medical professional familiar with the
				  recipient's episodes of acute illness; and who has an ongoing relationship with
				  the recipient or family as their regular source of health care.
(b) Continuing care provider shall deliver
				  EPSDT services as set out in sections 17-1737-54 to 17-1737-59 with the
				  exception of dental services, and provide physician services as needed by the
				  recipient for acute, episodic, or chronic illnesses or conditions.
(1) Recipient or family shall agree to use
				  the continuing care provider of their choice as their regular source of
				  continuing care services.
(2)
				  Provider and recipient or family shall sign statements that reflect their
				  respective obligations under the continuing care arrangement.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 6 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) › Section 17-1737-61 - Provider requirements for participation in the medical assistance program

Current through June, 2024
(a) Participation
				  in the program as an EPSDT or a continuing care provider is open to public and
				  volunteer clinics and health agencies, health maintenance organizations,
				  prepaid health plans, group practices, and solo practitioners. EPSDT provider
				  and continuing care provider shall meet all the requirements as set out in
				  chapter 17-1736.
(b) EPSDT provider
				  and continuing care provider approved by the department for program
				  participation shall enter into a contractual agreement with the department.
				  Contractual agreement shall include but not be limited to:
(1) Provider responsibility to maintain
				  recipient's consolidated health history, including information received from
				  other providers; and
(2)
				  Department's responsibility to reimburse for:
(A) Medical screening services based on a
				  negotiated per patient rate; and
(B) Routine dental examinations in accordance
				  with the fee schedule established for the fee for services component of the
				  medical assistance program (medicaid).
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 6 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) › Section 17-1737-62 - Appeal and hearing

Current through June, 2024
An appeal and hearing process in accordance with chapter
					 17-1736 shall be available to all EPSDT providers and continuing care
					 providers.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 6 - EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) › Section 17-1737-63 to 17-1737-70 - Reserved

Current through June, 2024
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-71 - Drugs

Current through June, 2024
(a) Medical assistance payments shall be made
				  for drugs when dispensed to eligible recipients within the following
				  guidelines:
(1) When prescribed by a
				  practitioner licensed in the United States;
(2) The drug has been approved by the U.S.
				  Food and Drug Administration for the purpose for which it is
				  prescribed;
(3) The drug can be
				  expected to be of therapeutic value for the disease or condition under
				  treatment; and
(4) The drug
				  complies with the Medicaid drug formulary or prior authorization has been
				  obtained from the department's medical consultant or designee or there is
				  compliance with the prior authorization requirements set forth in section
				  17-1739.1-4.1.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-71.1 - Supplemental rebate agreement for a drug

Current through June, 2024
(a) The department
				  may enter into an agreement with a pharmaceutical manufacturer to obtain a
				  rebate(s) in addition to the rebates pursuant to
				  42 U.S.C. Section
				  1396r-8(a).
(b) Participation by a pharmaceutical
				  manufacturer in a supplemental rebate agreement with the department is
				  voluntary.
(c) A supplemental
				  rebate agreement may be a factor in the placement of a drug on a preferred drug
				  list pursuant to section 17-1739.1-4.1(b).
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-72 - Durable medical equipment

Current through June, 2024
(a) Durable medical
				  equipment means equipment prescribed by a licensed physician to meet the
				  medical equipment needs of a patient. Durable medical equipment includes, but
				  is not limited to, wheelchairs, walkers, crutches, canes, hospital beds, side
				  rails, respirators, and oxygen equipment.
(b) Durable medical equipment may be provided
				  if it is:
(1) A medically necessary modality
				  in the treatment of a medical condition;
(2) Necessary to assist the recipient in
				  meeting or improving activities of daily living;
(3) Recommended by the attending physician
				  for medical care of a patient; or
(4) Suitable for use in the recipient's place
				  of residence.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-73 - Medical supplies

Current through June, 2024
(a) Medical
				  supplies means medical items prescribed by a licensed physician that are
				  medically necessary for the treatment, care, or observation of a medical
				  condition.
(b) Medical supplies
				  include, but are not limited to, insulin syringes and needles, ostomy
				  appliances and supplies, urine test materials, contraceptive devices,
				  incontinence pads or devices, catheters, urine bags and tubing, ice bags, and
				  hot water bottles or heating pads.
(c) Medical Authorization shall be required
				  when the line item billed cost of the items prescribed exceeds $50 per month,
				  except for intra-uterine devices for family planning purposes for which the
				  cost may exceed $50 per month.
(d)
				  The following items shall not be covered by the program:
(1) Tooth brushes of any type, including
				  standard or mechanical, except when distributed through the EPSDT program and
				  included as part of the oral screening visit, water cleansing devices,
				  toothpaste, denture cleaners, and mouth washes;
(2) Baby oil and powder;
(3) Sanitary napkins;
(4) Health food and food
				  supplements;
(5) Non-medicated
				  shampoos;
(6) Soaps including
				  medicated soaps;
(7) Lip
				  balm;
(8) Band aids;
(9) Prepared food formula except when
				  necessary for nutrition due to inborn metabolic abnormalities, abnormalities of
				  digestion or absorption, or when persons are being fed by nasogastric,
				  gastrostomy or jejunostomy tube. Milk substitutes and related compounds may be
				  made available under this exception with prior authorization;
(10) Bowel and bladder incontinence care
				  supplies with the exception of diapers, underpads and gloves, for a recipient
				  age three or older and catheters, subject to medical necessity;
(11) For individuals over the age of
				  twenty-one, incontinence care supplies in excess of two hundred diapers per
				  month, fifty underpads per month, and fifty pairs of gloves per month; and (12)
				  Other supplies not primarily medical in nature.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-74 - Prosthetic and orthotic appliances

Current through June, 2024
(a) Prosthetic and
				  orthotic appliances means those appliances prescribed by a physician, dentist,
				  or podiatrist for the restoration of function or replacement of functional body
				  parts.
(b) Prior authorization
				  shall be required when the original or cumulative cost for purchase, repair, or
				  manufacture of the appliances exceeds $50, except for dental prosthetic
				  appliances which are covered under section 17-1737-75.
(c) The following items may be covered by the
				  medical assistance program:
(1) Stock
				  prosthetic eyes to prevent the problems associated with an empty eye
				  socket;
(2) Orthopedic and
				  therapeutic shoes when prescribed by a physician and provided by a prosthetist
				  or an orthotist and when at least one of the shoes will be attached to a brace
				  or prosthesis or the individual is diabetic;
(3) Stock orthopedic shoes and high-topped
				  shoes for children under the age of six years;
(4) Modification of stock conventional or
				  orthopedic shoes when medically necessary;
(5) Custom-made orthopedic shoes when there
				  is a clearly established medical need that cannot be satisfied by the
				  modification of stock conventional or orthopedic shoes; and
(6) Implanted breast prosthesis provided the
				  surgical procedure of implantation is approved by the department.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-76 - Visual services

Current through June, 2024
(a) Visual or
				  optometric services means services provided by an ophthalmologist or
				  optometrist licensed to practice under state law to correct visual problems
				  within the limits of their professional fields and includes the dispensing of
				  prescription eyeglasses on the written prescription of a licensed
				  practitioner.
(b) Visual services
				  shall include:
(1) Professional services
				  limited to:
(A) Eye examinations;
(B) Refraction, with coverage of a second
				  refraction for persons under the age of eighteen years within twelve months, or
				  eighteen years or older within twenty-four months only when indicated by
				  symptoms. The provider shall make a reasonable effort to determine the date of
				  any previous refraction; and
(C)
				  Vision analysis;
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-77 - Speech, hearing and language disorders

Current through June, 2024
(a) Services for
				  individuals with speech, hearing, and language disorders means diagnostic,
				  screening, preventive, or corrective services provided by, or under the
				  direction of, a speech pathologist or audiologist, to whom a patient is
				  referred by a physician. Necessary supplies and equipment shall be
				  included.
(b) A physician may
				  prescribe services for patients with speech, hearing, or language disorders who
				  are expected to improve in a reasonable period of time with therapy.
(c) All recommended speech, hearing, and
				  language evaluations shall require prior authorization by the department's
				  medical consultants according to the following procedures:
(1) For evaluation, information indicating
				  diagnosis, age, and duration of the clinical condition; and
(2) For therapy, information indicating:
(A) The evaluation and results of
				  standardized objective tests; and
(B) A plan of therapy with goals and time
				  frames.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-78 - Hearing evaluations and devices

Current through June, 2024
(a) All hearing aid
				  rentals, purchases, or repairs shall require medical approval by the
				  department.
(b) Persons requesting
				  hearing aids shall have a hearing evaluation by a physician who is an ear,
				  nose, and throat specialist who concurs with the need for a hearing
				  aid.
(c) The following conditions
				  and limitations shall apply:
(1) A hearing
				  evaluation may be permissible every twelve months;
(2) Hearing aids purchased by the medicaid
				  program shall be of the unilateral type. Miniaturized or "all in the ear"
				  hearing aids are excluded. Special models or modifications shall require
				  justification with documentation of medical necessity;
(3) Hearing aid purchase requests shall be
				  approved initially for one month of rental at $25 per month to determine the
				  appropriateness of the hearing aid;
(4) Purchase of the hearing aid may be
				  recommended based on the evaluation of the rental period of paragraph (1). A
				  new authorization form shall be submitted showing the model and serial number
				  of the hearing aid;
(5) If the
				  hearing aid purchase is not recommended, a factory reconditioning charge of no
				  more than $50 may be paid when supported by a copy of the manufacturer's
				  invoice;
(6) Repair of hearing aids
				  shall be itemized;
(7) Hearing aid
				  replacements may be purchased every two years with justification;
(8) Ear plugs may be purchased for
				  individuals with recurrent middle ear infections on recommendation by a
				  physician who is an ear, nose and throat specialist. Only one set of ear plugs
				  every twelve months shall be allowed; and
(9) Insurance premiums to cover hearing aid
				  losses or repair shall be a coverage only for children under twelve years of
				  age.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-79 - Physical therapy and occupational therapy services

Current through June, 2024
(a)
				  Physical therapy means services prescribed by a physician that are provided to
				  a recipient by a qualified physical therapist licensed by the state and
				  certified by the medicaid program to provide services. Necessary supplies and
				  equipment shall be included as part of this service.
(b) Occupational therapy means services
				  prescribed by a physician provided to a recipient by a qualified occupational
				  therapist who has been certified by the American Occupational Therapy
				  Association and approved by the medicaid program to provide services. Necessary
				  supplies and equipment shall be included as part of the service.
(c) Physical and occupational therapy may be
				  prescribed by a physician when medically necessary and when the following
				  conditions are met:
(1) The services are
				  considered under accepted standards of medical practice, to be a specific and
				  effective treatment for the patient's condition;
(2) The services or patient's condition is of
				  a level of complexity requiring services that can be safely and effectively
				  performed only by a qualified therapist. Maintenance therapy which does not
				  require the performance and supervision of a therapist shall be considered as
				  nursing rather than therapy services for separate billing, even if performed or
				  supervised by a therapist;
(3)
				  There is an expectation that the patient's condition will improve significantly
				  in a reasonable period of time based on the assessment made by the physician of
				  the patient's restoration potential, or the services are necessary to establish
				  a safe and effective maintenance program required in connection with a specific
				  disease state; and
(4) The amount,
				  frequency, and duration of services are reasonable.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-80 - Podiatry services

Current through June, 2024
(a) Podiatry
				  services means services directed toward the treatment and care of feet ailments
				  or disorders of the foot and ankle that are provided by a podiatrist or a
				  physician, who is licensed to practice in the State of Hawaii.
(b) Podiatry services and appliances
				  (orthoses, prostheses) shall include, but are not limited to, the treatment of
				  conditions of the foot and ankle such as:
(1)
				  Professional services, not involving surgery, provided in the office and
				  clinic; professional services, not involving surgery, related to diabetic foot
				  care in the outpatient and inpatient hospital, skilled nursing facility, and
				  intermediate care facility under the following conditions:
(A) Podiatry services, not involving surgery,
				  in a hospital (inpatient or outpatient), skilled nursing facility, and
				  intermediate care facility shall be considered as adjuncts to general medical
				  care and limited to diabetic foot care;
(B) In the case of a patient requiring
				  inpatient hospital care, podiatry services shall be limited to diabetic foot
				  care only, must be ordered by the attending physician as noted by the physician
				  in the medical chart, and may be furnished after obtaining prior authorization
				  from the department's medical consultant; and
(C) In the case of a patient requiring
				  podiatry services in a skilled nursing or an intermediate care facility,
				  podiatry services shall be limited to diabetic foot care only and must be
				  ordered by the attending physician as noted by the physician in the medical
				  chart;
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-81 - Pediatric or family nurse practitioner services

Current through June, 2024
(a)
				  Pediatric or family nurse practitioners are registered nurses who meet the
				  following conditions:
(1) Licensed to
				  practice as a registered professional nurse in the State;
(2) Successfully completed an accredited,
				  advanced training program in pediatrics or family health;
(3) Currently certified by the American
				  Nurses Association or the National Board of Pediatric Nurse Practitioners and
				  Nurses to practice in either specialty named above; and
(4) Initially and biennially licensed with
				  the department of commerce and consumer affairs as an advanced practice
				  registered nurse (APRN) in their area of profession.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-81.1 - Nurse-midwife services

Current through June, 2024
(a) A nurse-midwife
				  is a registered nurse who meets the following conditions:
(1) Licensed to practice as a registered
				  professional nurse in the State;
(2) Initially and biennially licensed with
				  the department of commerce and consumer affairs as an advanced practice
				  registered nurse (APRN) certified nurse-midwife; and
(3) Successfully completed a program of study
				  and clinical experience for nurse-midwives and is currently certified as a
				  nurse-midwife by the American College of Nurse-Midwives as a
				  nurse-midwife.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-82 - Intra-state transportation

Current through June, 2024
(a) Transportation
				  may be provided in order to enable a recipient to secure needed medical care
				  and related services.
(b)
				  Transportation shall be by the most economical means which would not be
				  hazardous or injurious to the recipient's health.
(c) Air transportation may be allowable where
				  the attending physician or a hospital refers a recipient to a specialist or
				  medical facility for diagnostic and treatment services not available or not
				  accessible on the recipient's island of residence. Air transportation requests
				  may be initiated by the department's social worker when a physician is not
				  available to refer an individual for medical care in Honolulu.
(d) In emergency situations, air
				  transportation:
(1) Shall be by regularly
				  scheduled commercial flight when:
(A)
				  Available;
(B) Medical care will
				  not be affected if travel is delayed until the next scheduled flight;
				  and
(C) The patient can sit in a
				  standard seat and requires no oxygen or other life support mechanisms enroute;
				  or
(D) If the patient is unable to
				  sit and a stretcher is required, the airline may accommodate the patient in
				  lieu of four passenger seats;
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-83 - Out-of-state transportation

Current through June, 2024
(a) Out-of-state
				  transportation may be provided to eligible recipients for covered medical
				  services which are unavailable in Hawaii and with prior authorization by the
				  department's medical consultant.
(b) Transportation shall be by the most
				  economical means which would not be hazardous or injurious to the recipient's
				  health.
(c) Transportation shall be
				  limited to a United States medical facility which is licensed to provide such
				  services and certified as a medicaid provider by the state where the facility
				  is located.
(d) Request for
				  out-of-state transportation shall be made by the attending physician or a
				  medical facility and shall include:
(1) All
				  information requested in the department designated forms; and
(2) A comprehensive clinical summary of the
				  patient's condition, need for out-of-state medical facility service, the name
				  and address of the out-of-state facility and the name and telephone number of
				  the authorized representative of that medical facility.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-83.1 - Out-of-state medical services

Current through June, 2024
(a) Out-of-state
				  medical services shall be covered for eligible Hawaii residents visiting in
				  another state. Medical services incurred while visiting in another state shall
				  be covered only when the requirements of temporary absence as stated in section
				  17-1714-22(d) are met.
(1) To receive payment
				  for services incurred out-of-state, the provider shall meet the requirements of
				  section 17-1736-13. In addition:
(A) The
				  services were required as they were an emergency;
(B) The services were needed and the
				  recipient's health would have been endangered if the recipient had to return to
				  the State of residence; or
(C) The
				  State has determined that the services sought are unavailable in Hawaii or more
				  readily available in another state; or
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 7 - ANCILLARY MEDICAL SERVICES › Section 17-1737-84 - Exclusions and limitations

Current through June, 2024
(a) Medical
				  assistance payments shall not be made for certain health services or items for
				  reasons including, but not limited to the following:
(1) The procedure, service, or material is of
				  generally unproven benefit;
(2) It
				  is of an experimental nature;
(3)
				  It is excluded by federal regulations or state rules;
(4) It is not considered by the department to
				  be medically necessary;
(5) The
				  same or similar results may be obtained by another method at a reduced
				  cost;
(6) The procedure is
				  frequently followed by severe complications which may be in themselves
				  life-threatening or require prolonged medical care or secondary operations;
				  or
(7) Prior authorization is
				  required but has not been obtained.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 8 - TISSUE AND ORGAN TRANSPLANTATION › Section 17-1737-91 - General provisions

Current through June, 2024
(a) Allogenic bone
				  marrow and cadaveric corneal transplants are covered under this
				  program.
(b) Kidney
				  transplantations are covered under this program.
(c) Other non-experimental,
				  non-investigational organ and tissue transplantations are covered when
				  performed in a facility certified by Medicare for the specific transplantation
				  and approved for medical necessity by the department's medical
				  consultant.
(d) Transplantation
				  shall be performed by experienced specialists with transplantation training and
				  with established success records in an approved Medicare-certified facility
				  with proper equipment and adequate and appropriately trained support staff,
				  except as provided in subsection (i).
(e) Prior authorization shall be required
				  from the department's medical consultant for all transplants.
(f) Immunosuppressive therapy shall be
				  covered as required.
(g) If a
				  transplant should fail or be rejected and the patient is still within the age
				  limits for transplantation, the program's medical consultant may review the
				  case for one additional transplantation for that patient.
(h) The program shall cover costs of tissue
				  typing of potential donors and cost of acquisition of the tissue or organ as
				  well as other studies necessary to determine the appropriateness of the
				  procedure and any post transplantation follow-up evaluations as
				  required.
(i) When approved by the
				  department's medical consultant, a patient may be treated at an appropriate
				  out-of-state Medicare-certified transplant center for the authorized
				  procedure.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 8 - TISSUE AND ORGAN TRANSPLANTATION › Section 17-1737-92 - Corneal transplant (keratoplasty)

Current through June, 2024
(a) Indications of
				  penetrating keratoplasty include:
(1) Corneal
				  opacification that sufficiently obscures visibility (vision) through the
				  anterior segment of the eye with at least light perception present. Causes for
				  this problem include:
(A) Corneal injury and
				  scarring;
(B) Corneal degeneration
				  (from Fuch's or other dystrophy or from previous cataract or intraocular lens
				  implantation, or both);
(C) Corneal
				  degeneration from keratoconus or familial causes;
(D) Corneal infection (e.g., herpes); and
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 8 - TISSUE AND ORGAN TRANSPLANTATION › Section 17-1737-93 - Allogenic bone marrow transplant

Current through June, 2024
(a) Indications for
				  allogenic bone marrow transplant include:
(1)
				  Severe aplastic anemia unresponsive to usual therapy;
(2) Acute myelogenous leukemia in first
				  remission;
(3) Acute lymphocytic
				  leukemia in second remission; and
(4) Chronic leukemia after first
				  year.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 8 - TISSUE AND ORGAN TRANSPLANTATION › Section 17-1737-94 - Kidney transplant

Current through June, 2024
(a) Indications are
				  irreversible kidney failure that has progressed to a point that a useful,
				  comfortable life can no longer be sustained by conventional medical treatment.
				  The following conditions may deteriorate to the point when kidney transplant
				  may be required:
(1) Glomerulonephritis:
(A) Proliferative;
(B) Membranous;
(C) Mesangio-capilliary;
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 9 - HOSPICE SERVICE › Section 17-1737-101 - Hospice care

Current through June, 2024
(a) Hospice care means care and services
				  provided to a terminally ill individual by a hospice program in home,
				  outpatient and inpatient settings.
(b) The hospice shall retain professional
				  management responsibility for services related to the terminal illness and
				  shall ensure that they are furnished in a safe and effective manner by persons
				  qualified to provide services, and in accordance with a plan of care as
				  specified in section 17-1737-102.
(c) Hospice services shall be provided by
				  hospice employees or by staff contracted by the hospice and includes the
				  following:
(1) Nursing care and services by
				  or under the supervision of a registered nurse;
(2) Medical social services provided by a
				  qualified social worker under the direction of a physician;
(3) Physician services provided by physician
				  employees of the hospice including physician members of the interdisciplinary
				  team;
(4) Counseling services
				  available to both the individual and the family including the following:
(A) Dietary, spiritual and any other
				  counseling services for the individual and family while enrolled in the
				  hospice; and
(B) Bereavement
				  counseling, provided after the patient's death;
(5) Physical therapy services, occupational
				  therapy services, and speech-language pathology services;
(6) Home health aide and homemaker services
				  to meet the needs of the patients;
(7) Medical supplies and appliances including
				  drugs and biologicals, provided as needed for the palliation and management of
				  the terminal illness and related conditions; and
(8) Inpatient care for pain control and
				  symptom management provided in a participating medicaid facility.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 9 - HOSPICE SERVICE › Section 17-1737-102 - Plan of care

Current through June, 2024
(a) A written plan of care shall be
				  established and maintained for each individual admitted to a hospice program
				  and the care provided to an individual shall be in accordance with the
				  plan.
(b) The plan shall be
				  established by the attending physician, medical director or physician designee
				  and interdisciplinary group prior to providing care.
(c) The plan shall be reviewed and updated by
				  the attending physician, the medical director, and interdisciplinary group at
				  intervals, as specified in the plan.
(d) The plan shall include all of the
				  following:
(1) Assessment of the individual's
				  needs;
(2) Identification of the
				  services including the management of discomfort and symptom relief;
				  and
(3) Statement in detail of the
				  scope and frequency of services needed to meet the patient's and family's
				  needs.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 9 - HOSPICE SERVICE › Section 17-1737-103 - Eligibility for hospice care

Current through June, 2024
(a) Hospice care
				  shall be provided to eligible applicants and recipients of medical assistance
				  who voluntarily elect hospice care. Medicaid will only cover services that are
				  unrelated to the hospice diagnosis except for individuals under twenty-one
				  years of age.
(b) Eligible
				  applicants and recipients under twenty-one years of age shall be provided
				  hospice service and curative treatment services related to the individual's
				  terminal illness or associated condition.
(c) All of the following conditions shall be
				  met:
(1) A written certification of terminal
				  illness is obtained by the hospice, signed by the hospice physician and the
				  individual's attending physician;
(2) The recipient or a representative
				  voluntarily elects to participate in the Medicaid hospice program and signs the
				  appropriate Medicaid form requesting this service; and
(3) Approval is obtained from the department
				  on a designated form.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 9 - HOSPICE SERVICE › Section 17-1737-104 - Election of hospice care

Current through June, 2024
(a) An eligible
				  individual who elects to receive hospice care shall file an election statement
				  with the hospice. A representative may also file an election
				  statement.
(b) An election to
				  receive hospice care shall be considered to continue through the initial ninety
				  day period and subsequent ninety and thirty day election periods without a
				  break in care if the individual:
(1) Remains
				  in the care of the hospice; and
(2)
				  Does not revoke the election of hospice care.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 9 - HOSPICE SERVICE › Section 17-1737-105 - Waiver of other Medicaid benefits

Current through June, 2024
(a) An individual
				  who elects hospice services shall waive all rights to Medicaid payments for
				  services related to the treatment of the terminal condition for which hospice
				  care was elected. This provision shall not apply to individuals under
				  twenty-one years of age.
(b)
				  Medicaid payments may be made for hospice and related services provided by:
(1) The designated hospice;
(2) Another hospice under arrangements made
				  by the designated hospice; and
(3)
				  The individual's attending physician if that physician is not an employee of
				  the designated hospice or receiving compensation from the hospice for services
				  to the individual.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 9 - HOSPICE SERVICE › Section 17-1737-106 - Revoking the election of hospice

Current through June, 2024
(a) An individual
				  or representative may revoke an election of hospice care at any time during an
				  election period.
(b) The individual
				  or representative shall file a signed statement with the hospice that revokes
				  medicaid coverage of hospice care and the effective date of the
				  revocation.
(c) The individual or
				  representative may at any time elect to again receive hospice care for any
				  other hospice election period the individual is eligible to receive.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 9 - HOSPICE SERVICE › Section 17-1737-107 - Payment for hospice care

Current through June, 2024
(a) Payments shall
				  be available to Medicaid providers certified by Medicare to render hospice care
				  as provided for under this subchapter.
(b) Payment for hospice care shall be made
				  using the same methodology as Medicare and in the amounts specified by
				  CMS.
(c) Payment for services or
				  items not related to the terminal illness and billed by other Medicaid
				  non-hospice providers are allowed.
(d) For a Medicaid recipient who resides in a
				  nursing facility and meets the nursing facility level of care requirements, but
				  elects hospice, the Medicaid program will pay the hospice provider:
(1) For routine hospice services;
				  and
(2) Ninety-five percent of the
				  facility specific per diem rate for ICF services. The Medicaid program shall
				  not pay the NF.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 9 - HOSPICE SERVICE › Section 17-1737-108 - Providers of hospice service

Current through June, 2024
(a) Providers of
				  hospice services shall meet applicable state and federal licensing and the
				  certification requirements of chapter 17-1736 including certification by
				  medicare to provide hospice service.
(b) Providers of service shall enter into a
				  contractual agreement with the state medicaid agency.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 9 - HOSPICE SERVICE › Section 17-1737-109 - Appeals and hearings

Current through June, 2024
(a) An appeal and
				  hearing shall be available to providers of hospice service in accordance with
				  chapter 17-1736.
(b) An appeal and
				  hearing for applicants and recipients shall be available in accordance with
				  chapter 17-1703.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 10 - SUBACUTE CARE › Section 17-1737-115 - Purpose

Current through June, 2024
The purpose of this subchapter is to describe a level of
					 care needed by a patient not requiring inpatient acute care, but who needs more
					 intensive nursing care than is provided at the skilled nursing level of
					 care.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 10 - SUBACUTE CARE › Section 17-1737-116 - Definitions

Current through June, 2024
For the purpose of this subchapter:
"Acute care hospital services" means services ordinarily
					 furnished in a licensed and certified hospital for the care and treatment of
					 inpatients and does not include skilled nursing facility and intermediate care
					 facility services.
"Baseline status" means that the patient reached a level
					 of condition where no further medical adjustments are indicated except for
					 adjustments for growth and development.
"Dynamic care" means care for pediatric patients which
					 includes a pattern of continuous change and growth in treatment.
"Freestanding " means a medical institution that is not
					 part of a parent medical institution or a medical institution that is separated
					 geographically from the parent medical institution.
"Inpatient acute care" means inpatient acute care as
					 defined by a nationally accepted severity and intensity standards (for example:
					 interqual severity and intensity screening standards).
"Not at risk for rapid deterioration" means individuals
					 that can be placed in a non-acute care setting without risk to the individuals'
					 health and safety.
"Pediatric" means individuals from twenty-eight days to
					 twenty-one years of age.
"Skilled nursing facility or SNF" means a facility that is
					 licensed and certified as meeting the requirements of participation to provide
					 skilled nursing.
"Subacute" means a level of care that is needed by a
					 patient not requiring acute care, but who needs more intensive skilled nursing
					 care than is provided to the majority of patients in a skilled nursing
					 facility.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 10 - SUBACUTE CARE › Section 17-1737-117 - General provisions

Current through June, 2024
(a) Beds shall be
				  specifically certified for subacute care and costs for providing subacute
				  services shall be shown separately on the facility's cost report. Each
				  participating facility shall be required to establish a subacute unit (SACU) as
				  follows:
(1) Freestanding SNF - A minimum of
				  six to a maximum of sixty beds; or
(2) Acute care hospital - A minimum of six to
				  a maximum of sixty beds or more with the department's approval.
Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1737 - SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 10 - SUBACUTE CARE › Section 17-1737-118 - Staffing standards

Current through June, 2024
(a) For the purpose
				  of this section, each licensed nursing staff shall be counted as one. Each
				  subacute unit shall be under the supervision of a registered nurse twenty-four
				  hours a day.
(b) Subacute units
				  authorized to provide care to respirator or ventilator dependent patients shall
				  provide a minimum daily average of 9.0 nursing care hours of which 5.0 hours
				  shall be provided by the nursing staff. Where there is a mix of
				  ventilator-dependent and other patients, the facility shall provide no less
				  than 5.0 licensed and certified hours per patient per day. Subacute units
				  without ventilator patients shall employ sufficient licensed staff to provide a
				  minimum daily average of 5.0 licensed and certified nursing hours.
(c) The department may require a facility to
				  provide additional staff in accordance with subsection (b).
(d) Registered nurses and licensed practical
				  nurses shall have a minimum of six months experience (within the past two
				  years) in a direct participatory general acute care facility where the caseload
				  included patients requiring intensive care and the use of special equipment.
				  Completion of a department of human services approved subacute training course
				  may be substituted for this requirement.
(e) The experience stated in subsection (d)
				  or substitute clinical training for licensed nurses shall include respirator
				  and tracheostomy care, nasogastric tube and gastrostomy care, administration of
				  total parenteral nutrition and traction care. In addition, this requirement
				  shall be completed prior to treating subacute patients. Registered nurses shall
				  be certified by the facility to perform intravenous procedures and
				  cardiopulmonary resuscitation.
(f)
				  The facility shall provide documentation that all staff participating in direct
				  patient care, including the director of nursing, registered nurses, licensed
				  practical nurses, and nurse's aide staff have continuing in-service training
				  pertinent to the subacute level of care and shall make documentation available
				  upon request by the department of human services at the time of the facility
				  inspection.