Hawaii Law HAR for QEXA

8/14/2019 Hawaii Law HAR for QEXA

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1721.1-1

HAWAII ADMINISTRATIVE RULES

TITLE 17

DEPARTMENT OF HUMAN SERVICES

SUBTITLE 12 MED-QUEST DIVISION

CHAPTER 1721.1

QUEST EXPANDED ACCESS

Subchapter 1 General Provisions

17-1721.1-1 Purpose

17-1721.1-2 Definitions17-1721.1-3 to 17-1721.1-5 (Reserved)

Subchapter 2 Freedom of Choice

17-1721.1-6 Choice of participating health plans17-1721.1-7 Choice of primary care provider17-1721.1-8 Assignment of primary care provider17-1721.1-9 to 17-1721.1-15 (Reserved)

Subchapter 3 Eligibility and Enrollment

17-1721.1-16 Individuals eligible for QExA17-1721.1-17 Enrollment17-1721.1-18 Annual plan change period17-1721.1-19 Effective date of enrollment17-1721.1-20 Limitations on health plan enrollment

17-1721.1-21 to 17-1721.1-35 (Reserved)

Subchapter 4 Disenrollment

17-1721.1-36 Authority to disenroll QExAbeneficiaries

17-1721.1-37 Disenrollment of enrollees from QExAhealth plans

17-1721.1-38 to 17-1721.1-40 (Reserved)

Subchapter 5 Reimbursement to Participating


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Health Plans

17-1721.1-41 Capitated payments

17-1721.1-42 to 17-17271-45 (Reserved)

Subchapter 6 Financial Responsibilities ofQExA Enrollees

17-1721.1-46 Enrollment fee17-1721.1-47 to 17-1721.1-50 (Reserved)

Subchapter 7 Scope and Content of Services

17-1721.1-51 Standard benefits package

17-1721.1-52 Primary and acute care services to beprovided by participating health plans

17-1721.1-53 Special provisions relating tobehavioral health benefits

17-1721.1-54 Home and community based services (HCBS)17-1721.1-55 Institutional care services17-1721.1-56 Dental services17-1721.1-57 to 17-1721.1-65 (Reserved)

Subchapter 8 Participating Health Plans

17-1721.1-66 Health plan participation in QExA17-1721.1-67 Service areas17-1721.1-68 Requirements of participating health

plans17-1721.1-69 Enforcement of contracts with

participating health plan17-1721.1-70 Termination of contract with

participating health plans

SUBCHAPTER 1

GENERAL PROVISIONS

17-1721.1-1 Purpose. This chapter describesQUEST expanded access, a demonstration projectauthorized by section 1115 of the Social Security Act.[Eff 01/31/09 ] (Auth: HRS 346-14) (Imp: HRS346-14)


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17-1721.1-2 Definitions. As used in thischapter:

Acute care services means the short term medical

treatment, usually in an acute care hospital, forpatients having an acute illness or injury.

Assisted living facility is a facility, asdefined in HRS section 321-15.1 that is licensed by thedepartment of health. This facility shall consist of abuilding complex offering dwelling units to individualsand services to allow residents to maintain anindependent assisted living lifestyle.

Benefit period means the period from the firstday of the month following the close of the annual planchange period and extending for no more than twelvemonths thereafter, as designated by the department.

"Capitated rate" means the fixed monthly payment

per person paid by the State to a medical, behavioralor catastrophic coverage plan.

"Catastrophic coverage" means the coveragepurchased to protect the State when eligible medicalcosts incurred by recipients exceed a specified dollarthreshold which is determined by contractual agreementbetween the department and the health plan.

Community care foster family home or CCFFH isa home that is certified by the department to provide aresident twenty-four hour living accommodations andhome and community based services.

Contract means a contract between a

participating health plan and the department to provideQExA services.Confirmation notice is the document the

individual receives from the department confirmingtheir enrollment in a health plan.

Cost share means the share of monthly medicalexpenses for long-term care services for aninstitutionalized individual.

"Date of approval" means the date on which thedepartment completes the administrative process tocertify that an individual or a family is eligible forQExA.

Early periodic diagnosis, screening, and

treatment program or EPSDT means early screening anddiagnostic services, to identify physical or mentaldefects in recipients, and, to provide health care,treatment, and other measures to correct or ameliorateany defects and chronic condition discovered inaccordance with section 1905r of the Social Security

Act. EPSDT includes services to:


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(1) Seek out recipients and their families andinform them of the benefits of prevention andthe health services available;

(2) Help the recipient or family use healthresources, including their own talents,effectively and efficiently; and

(3) Assure the problems identified are diagnosedand treated early, before they become morecomplex and their treatment more costly.

"Effective date of coverage" means the date onwhich eligibility is determined by the department andmay precede the date upon which the health planreceives notification of enrollment.

"Effective date of enrollment" means the date asof which a participating health plan is required toprovide benefits to an enrollee.

"Emergency medical condition" means a medicalcondition that manifests itself by acute symptoms ofsufficient severity (including severe pain) such that aprudent layperson, who possesses an average knowledgeof health and medicine, could reasonably expect theabsence of immediate medical attention to result in:

(1) Placing the health of the individual (or withrespect to a pregnant woman, the health ofthe woman or her unborn child) in seriousjeopardy;

(2) Serious impairment to body functions; or(3) Serious dysfunction of any bodily organ or

Part;(4) Serious harm to self or others due to analcohol or drug abuse emergency;

(5) Injury to self or bodily harm to others; or(6) With respect to a pregnant woman having

contractions:(A) That there is adequate time to effect a

safe transfer to another hospital beforedelivery; or

(B) That transfer may pose a threat to thehealth or safety of the woman or herunborn child.

An emergency medical condition shall not be defined or

limited based on a list of diagnoses or symptoms."Emergency services" means covered inpatient andoutpatient services that are needed to evaluate orstabilize an emergency medical condition that is foundto exist using a prudent layperson standard.


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"Enrollee" means an individual who has selected oris assigned by the department to be a enrollee of ahealth plan.

Enrollment fee means the amount an enrollee,except for an enrollee who is a resident of an ICF-MR,or a participant in the DD-MR waiver program, isresponsible to pay that is equal to the spenddownamount for a medically needy individual or cost shareamount for an individual receiving long term careservices.

Enrollment letter means a letter informing anindividual of their eligibility for QExA and theiroptions to select a plan.

Expanded adult residential care home or E-ARCHis a facility, as defined in section 11-100.1.2 andlicensed by the department of health, that provides

twenty-four (hour living accommodations, for a fee, toadults unrelated to the family, who require at leastminimal assistance in the activities of daily living,personal care services, protection, and healthcareservices, and who may need the professional healthservices provided in a nursing facility.

"Health plan or participating health plan" means aQExA health plan contracted by the State to providemedical or behavioral health care services, through amanaged care system, to individuals who are foundeligible to participate in QExA and have been enrolledin that health plan.

Home and community based services or HCBSinclude, but are not limited to, adult day care, adultday health, assisted living, pediatric attendant care,community care management agency (CCMA) services,community care foster family home services, counselingand training activities, environmental accessibilityadaptations, E-ARCH or residential care services, homedelivered meals, home maintenance, medically fragileday care, moving assistance, non-medicaltransportation, personal assistance services - levelII, personal emergency response systems, private dutynursing, respite care, and specialized medicalequipment and supplies.

ICF-MR means intermediate care facility for thementally retarded.Long-term care residential facility means

a facility that cares for enrollees who are at nursingfacility level of care. These facilities are assisted


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living facilities, E-ARCHs, CCFFHs, nursing facilities,and sub-acute units.

Long-term care services means services provided

to an inpatient in a medical facility receiving anursing facility level of care or to a resident of anursing facility, or home and community based servicesprovided to individuals residing in a communitysetting.

"Managed care" means a comprehensive approach tothe provision of healthcare that combines clinicalservices and administrative procedures within anintegrated, coordinated system to provide timely accessto primary care and other necessary services in acost-effective manner.

"Medically needy" means aged, blind, or disabledindividuals who are otherwise eligible for Medicaid,

who are not categorically needy, and whose income andresources are within limits set under the MedicaidState Plan.

Ninety-day grace period means the firstninety-days after the date of the confirmation noticethat an enrollee has to change health plans, with orwithout cause, provided the health plan is not at itsmaximum enrollment.

"Non-returning health plan" means a health planthat has a current, but no new contract with thedepartment.

Nursing facility or NF is a facility, as

defined in section 11-94-2, which provides appropriatecare to persons referred by a physician. Such personsare those who need twenty-four hour a day assistancewith the normal activities of daily living, need careprovided by licensed nursing personnel and paramedicalpersonnel on a regular, long-term basis, and may have aprimary need for twenty-four hours of skilled nursingcare on an extended basis and regular rehabilitationservices. Nursing facility level of care means thedetermination that a member requires the services oflicensed nurses, in accordance with chapter 16-89, inan institutional setting to carry out the physiciansplanned regimen for total care. These services can be

provided in the home or in community-based programs asa cost-neutral, least restrictive alternative toinstitutional care in a hospital or nursing home.

"Personal reserve standard" means the maximumamount of countable assets that may be held by an


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individual or family while establishing or maintainingeligibility for medical assistance.

Primary care services means the provision of

integrated, accessible health services by cliniciansand providers of health care services who areaccountable for addressing a broad spectrum of anindividual's health care needs (including physical,mental and emotional).

"Primary care provider or PCP" means a providerwho is licensed in Hawaii and is 1) a physician, eitheran M.D. (doctor of medicine) or a D.O. (doctor ofosteopathy), and must generally be a familypractitioner, general practitioner, general internist,pediatrician or obstetrician-gynecologist (for women,especially pregnant women) or geriatrician; or 2) anadvanced practice registered nurse with prescriptive

authority. PCPs have the responsibility forsupervising, coordinating and providing initial andprimary care to the enrollee and for initiatingreferrals and maintaining the continuity of enrolleecare.

"Prudent layperson" means one who possesses anaverage knowledge of health and medicine.

"Prudent layperson standard" refers to thedetermination of an emergency medical condition basedon the judgment of a prudent layperson.

QExA" means QUEST expanded access program."Service area" means the geographical area defined

by zip codes, census tracts, or other geographicsubdivisions that is served by a participating healthplan as defined in the health plan's contract with thedepartment.

Spenddown amount" means the amount of anindividuals income in excess of the medically needyincome standard identified by the department asavailable to meet a portion of the individuals healthcare cost.

"Standard benefits package" means the minimumbenefits and services that must be provided by eachparticipating health plan which is contracted underQExA.

State plan or Hawaii Medicaid state plan isthe document approved by United States Department ofHealth and Human Services that defines how Hawaiioperates its Medicaid program. The state planaddresses areas of state program administration,


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Medicaid eligibility criteria, service coverage, andprovider reimbursement.

Sub-acute unit is a facility that provides care

as defined in section 17-1737-116, that is needed by apatient not requiring acute care, but who needs moreintensive skilled nursing care than is provided to themajority of patients in a nursing facility.[Eff 01/31/09 ] (Auth: HRS 346-14) (Imp: HRS346-14; 42 C.F.R. 430.25)

17-1721.1-3 to 17-1721.1-5 (Reserved).

SUBCHAPTER 2

FREEDOM OF CHOICE

17-1721.1-6 Choice of participating healthplans. (a) An eligible individual shall be allowed tochoose from among the participating health plans whichservice the geographic area in which the individualresides. This provision shall not apply to anindividual identified in subsection (b). If a healthplan has reached its maximum enrollment, the eligibleindividual shall select another health plan that isavailable.

(b) In the absence of a choice of health plan ina rural service area, an eligible individual whoresides in that particular service area shall beenrolled in the participating health plan.[Eff 01/31/09 ] (Auth: HRS 346-14) (Imp: HRS346-14; 42 C.F.R. 430.25, 430.51)

17-1721.1-7 Choice of primary care provider. Aneligible individual shall be allowed fifteen days,under the procedures established by the health plan, toselect a primary care provider from among thoseavailable within the health plan. [Eff 01/31/09 ]

(Auth: HRS 346-14) (Imp: HRS 346-14; 42 C.F.R.430.25, 430.51)

17-1721.1-8 Assignment of primary care provider.If an enrollee does not select a primary care providerfrom among the available primary care providers within


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the health plan, the health plan shall assign theenrollee to a primary care provider of the healthplan's choice. The enrollee may change their primary

care provider as frequently as, and for whateverreasons, they choose. [Eff 01/31/09 ] (Auth: HRS346-14) (Imp: HRS 346-14; 42 C.F.R. 430.25,430.51)

17-1721.1-9 to 17-1721.1-15 (Reserved).

SUBCHAPTER 3

ELIGIBILITY AND ENROLLMENT

17-1721.1-16 Individuals eligible for QExA. Thefollowing individuals shall be eligible for QExA:

(1) An aged, blind or disabled individual whomeets the provisions of chapter 17-1721;

(2) A blind or disabled individual who meets theprovisions of subchapter 2 and of chapter17-1722;

(3) An aged individual who meets the provisionsof subchapter 6 of chapter 17-1722;

(4) A blind or disabled child who meets theprovisions of subchapter 10 of chapter

17-1722;(5) An aged, blind or disabled individual whomeets the provisions of subchapter 13 ofchapter 17-1722;

(6) A blind or disabled immigrant child who meetsthe provisions of chapter 17-1722.1;

(7) A blind or disabled pregnant immigrant womanwho meets the provisions of chapter17-1721.2;

(8) An aged, blind or disabled individual whomeets the provisions of subchapter 3 ofchapter 17-1723;

(9) A blind or disabled child or pregnant woman

who meets the provisions of chapter 17-1732;(10) Individuals found eligible under theprovisions of chapter 17-1733; and

(11) Individuals found eligible under theprovisions of chapter 17-1734.[Eff 01/31/09 ] (Auth: HRS346-14) (Imp: HRS 346-14; 42 C.F.R.430.25)


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17-1721.1-17 Enrollment. (a) An individualeligible to participate in QExA shall be enrolled in ahealth plan.

(b) The department may enroll an eligibleindividual in a health plan for purposes of providingthe individual with covered services during the periodbetween the date the individual is determined eligiblefor QExA and the date that the individual selects or isassigned to a health plan pursuant to subsections (c)and (d).

(c) After being found eligible for coverage underQExA, an individual shall be allowed fifteen days afterthe date of the enrollment letter to select from amongthe participating health plans available in the servicearea in which the individual resides.

(d) If an individual does not select a health

plan within fifteen days after the date of theenrollment letter, enrollment in a health plan shall beassigned by the department.

(e) A confirmation notice will be mailed to theindividual once the individual is enrolled in a healthplan.

(f) After selecting or being assigned to a healthplan, an enrollee shall have a ninety-day grace periodto change health plans.

(g) Except for changes made by an enrollee duringthe ninety-day grace period, an enrollee shall only beallowed to change enrollment from one health plan to

another during the annual plan change period. Theexceptions to this provision include:(1) Change in residence by an enrollee from one

service area to another:(A) In this event the individual or family

shall be allowed fifteen days after thedate of the enrollment letter to selecta health plan servicing the new servicearea in which the individual resides.

(B) If a selection is not made withinfifteen days after the date of theenrollment letter, the individual shallremain enrolled in their current health

plan, provided that health plan servicesthat area.(2) Decisions from administrative hearings;(3) Provisions in federal or state statutes or

administrative rules;(4) Legal decisions;(5) Change in foster placement or subsidized


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adoption if it is in the best interest of thechild;

(6) The health plans refusal, because of moral

or religious objections, to cover the servicethe enrollee seeks as allowed for in thecontract with the health plan;

(7) The enrollees need for related services(i.e. a cesarean section and a tuballigation) to be performed at the same timeand not all related services are availablewithin the network and the enrollees PCP oranother provider determines that receivingthe services separately would subject theenrollee to unnecessary risk;

(8) Termination of the enrollees health planscontract;

(9) Mutual agreement by the health plansinvolved, the enrollee, and the department;

(10) Violations by a health plan as specified insections 17-1721.1-69 and 17-1721.1-70;

(11) Lack of direct access to womens healthcarespecialists for breast cancer screening, papsmears and pelvic exams;

(12) Other reasons, including but not limited to,poor quality of care, lack of access tocovered services, or lack of access toproviders experienced in dealing with theenrollees healthcare needs, lack of direct

access to certified nurse midwives, pediatricnurse practitioners, family nursepractitioners, if available in the geographicarea in which the enrollee resides; or

(13) Other special circumstances as determined bythe department.

(h) An enrollee who is disenrolled from a healthplan shall be allowed to select a health plan of theirchoice:

(1) If disenrollment extends for more than sixtycalendar days in a benefit period;

(2) If disenrollment occurred during the annualplan change period; or

(3) If disenrollment includes the first day of anew benefit period. [Eff 01/31/09 ](Auth: HRS 346-14) (Imp: HRS 346-14;42 C.F.R. 430.25; 431.51)

17-1721.1-18 Annual plan change period. (a)Except as limited by section 17-1721.1-6, an enrollee


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shall be allowed to change enrollment from one healthplan to another health plan within the service area inwhich the enrollee resides during the annual plan

change period.(b) The annual plan change period shall occur

each calendar year at a time designated by thedepartment, no more than twelve months after the startof the previous benefit period.

(c) An enrollee who is enrolled in anon-returning health plan shall be allowed to selectfrom the available health plans.

(d) If the enrollee is required to select ahealth plan, but does not select a health plan duringthe annual plan change period, enrollment in a healthplan shall be assigned by the department.[Eff 01/31/09 ] (Auth: HRS 346-14) (Imp: HRS

346-14; 42 C.F.R. 430.25; 431.51)

17-1721.1-19 Effective date of enrollment. (a)For individuals newly approved for coverage, theeffective date of enrollment shall be:

(1) The date of application;(2) Any date specified by the individual on which

appropriate Medicaid eligible services wereincurred and is no earlier than the first dayof the three months prior to the month ofapplication; or

(3) The date when all eligibility requirementsare met by the applicant.(b) The effective date of enrollment resulting

from a change from one health plan to another duringthe annual plan change period shall generally be thefirst day of the second month after the annual planchange period ends.

(c) The effective date of enrollment resultingfrom a change from one health plan to another, otherthan during the annual plan change period, shall be oneof the following:

(1) The first day of the month following the dateon which the department authorizes the

enrollment change.(2) If an enrollee changes residence from oneservice area to another, the date theenrollment process has been completed toenroll an individual in a health plan in thenew service area.


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(d) The effective date of enrollment resultingfrom a change from QUEST, QUEST-Net, or QUEST-ACE to aQExA health plan is the QExA eligibility start date.

An exception to this provision is for an individual whoattains the age of sixty-five. The effective date ofenrollment in a QExA plan is the first day of the monththe individual becomes age sixty-five.

(e) The effective date of enrollment for anewborn of a QExA recipient is as follows:

(1) A newborn who is not blind or disabled shallreceive coverage on a fee-for-service basiseffective the date of birth, regardless ofwhen the birth is reported, to the date theenrollment process has been completed toenroll the newborn in a QUEST plan, or

(2) If the newborn is blind or disabled, thenewborn shall receive coverage under themothers QExA health plan effective the dateof birth until the department notifies thehealth plan that the newborn is enrolled in adifferent health plan. [Eff 01/31/09; am06/11/09 ] (Auth: HRS 346-14)(Imp: HRS 346-14; 42 C.F.R. 430.25;431.51)

17-1721.1-20 Limitation on health planenrollment. (a) On the fifteenth of each month or on

the first business day following the fifteenth in theevent the day falls on a weekend or holiday, thedepartment will review the enrollments of the healthplans. If the health plan has an enrollment equal toor exceeding its maximum enrollment allowed for theservice area, the department will stop enrollment forthat health plan effective the following business day.This provision will remain in effect until thefifteenth of the following month when the departmentwill again review enrollment of the health plans. Ifthe enrollment is below the maximum enrollment allowedfor the island, the restriction from enrolling anindividual into a health plan will be lifted for the

following month. If the enrollment is equal to orexceeds its maximum enrollment allowed for the island,the restriction from enrolling an individual into ahealth plan will remain in effect.

(b) When a restriction from enrolling anindividual into a health plan is imposed on a healthplan, the health plan shall not be available as arecipients selection or nor will the department assign


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an individual into that health plan until therestriction is lifted. The exceptions to thisprovision are:

(1) Newborns who are eligible for the QExAprogram and born to a QExA mother who iscurrently enrolled in a QExA health plan thatis at its maximum enrollment, shall beenrolled in the mothers health plan;

(2) Enrollees enrolled in a health plan with awaiting list for HCBS or personal assistanceserviceslevel I may enroll in a health planthat has maximum enrollment; and

(3) Enrollees who have lost eligibility for aperiod of sixty days or less shall bereenrolled into the same health plan, even ifthat health plan is identified as having

maximum enrollment.(4) If the individual is enrolled in a health

plan that has statewide service, theindividual can continue to be enrolled inthat health plan. [Eff 01/31/09 ](Auth: HRS 346-14) (Imp: HRS 346-14; 42C.F.R. 430.25; 431.51)

17-1721.1-21 to 17-1727-35 (Reserved).

SUBCHAPTER 4

DISENROLLMENT

17-1721.1-36 Authority to disenroll QExAbeneficiaries. The department shall have soleauthority to disenroll an enrollee from a health plan.[Eff 01/31/09 ] (Auth: HRS 346-14) (Imp: HRS346-14; 42 C.F.R. 430.25; 438.56)

17-1721.1-37 Disenrollment of enrollees from

health plans. An enrollee may be disenrolled forreasons that include, but are not limited to, thefollowing:

(1) In compliance with administrative appealdecisions or court orders;

(2) A mutual agreement between the enrollee, theparticipating health plan involved, and thedepartment;


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(3) A voluntary withdrawal fromparticipation in QExA by the enrollee;

(4) The enrollee is a medically needy individualwho is two full months in arrears in thepayment of the designated enrollment fee,unless the failure to pay occurs because:(A) The enrollee is not in control of their

personal finances, and the arrearage iscaused by the party responsible for theenrollees finances, and action is beingtaken to remediate the situation,including but not limited to:(i) Appointment of a new responsible

party for the enrollees finances;(ii) Recovery of the enrollees funds

from the responsible party which

will be applied to the enrolleesenrollment fee obligation;

(B) The enrollee is in control of theirfinances, and the arrearage is due tothe unavailability of the enrolleesfunds due to documented theft orfinancial exploitation, and action isbeing taken to:(i) Ensure that theft or exploitation

does not continue;(ii) Recover the enrollees funds to pay

the enrollees enrollment fee

obligation;(5) The enrollee no longer meets QExA eligibilityrequirements;

(6) Death of the enrollee;(7) Incarceration of the enrollee;(8) The enrollee enters the Hawaii State

hospital;(9) The enrollee becomes a Program of

All-Inclusive Care forthe Elderly (PACE) participant;

(10) The enrollee enters the State of Hawaii organand transplant (SHOTT) program;

(11) The enrollee is in foster care or a

subsidized adoptionagreement and has been moved out-of-state bythe department;

(12) The enrollee provides false information withthe intent of enrolling in the QExA programunder false pretenses;

(13) The enrollee chooses another health plan


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during the annual plan change period and thathealth plan is not capped;

(14) The enrollee is enrolled in a health planwith a waiting list for HCBS or personalassistance level I and the other health plandoes not have a waiting list for thenecessary service(s);

(15) The enrollees long-term care residentialfacility is not in the health plans providernetwork and is in the provider network of adifferent health plan, provided the healthplan is not at its maximum enrollment; or

(16) The enrollees PCP is not in the healthplans provider network and is in theprovider network of a different health plan,provided the health plan is not at its

maximum enrollment. [Eff 01/31/09 ](Auth: HRS 346-14) (Imp: HRS 346-14; 42C.F.R. 430.25)

17-1721.1-38 to 17-1721.1-40 (Reserved).

SUBCHAPTER 5

REIMBURSEMENT TO PARTICIPATING HEALTH PLANS

17-1721.1-41 Capitated payments. (a) Eachparticipating health plan shall be paid on a capitatedbasis, as negotiated with the department, forindividuals enrolled in that health plan.

(b) The department shall provide the capitatedpayment, as stipulated in the contract between thedepartment and each participating health plan, inreturn for the health plans provision of allnegotiated services for the health plans enrollees.

(c) When an enrollee is responsible for paying anenrollment fee, this amount shall be deducted from thecapitated rate that is paid to the health plan by thedepartment for the enrollees coverage. The health

plan shall be responsible for collecting the enrollmentfee from the enrollee. [Eff 01/31/09 ] (Auth:HRS 346-14) (Imp: HRS 346-14; 42 C.F.R. 430.25)

17-1721.1-42 to 17-1721.1-45 (Reserved)


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SUBCHAPTER 6

FINANCIAL RESPONSIBILITIES OF QExA ENROLLEES

17-1721.1-46 Enrollment fee. (a) When anenrollee is determined responsible for paying anenrollment fee, this amount shall be applied to thecapitated rate that is paid by the department to theenrollees health plan for the enrollees coverage.

(b) An enrollee shall pay the enrollment fee tothe enrollees health plan.

(c) If a medically needy enrollee is two fullmonths in arrears in the payment of the enrollment feeto the enrollees health plan, then the departmentshall initiate disenrollment procedures.

[Eff 01/31/09 ] (Auth: HRS 346-14) (Imp: HRS346-14; 42 C.F.R. 430.25; 42 U.S.C. 1396u-1)

17-1727-47 and 17-1727-50 (Reserved).

SUBCHAPTER 7

SCOPE AND CONTENT OF SERVICES

17-1721.1-51 Standard benefits package. (a)Each of the participating health plans shall berequired to provide a standard benefits package thatminimally includes services identified in sections17-1721.1-52, 17-1721.1-53, 17-1721.1-54, and17-1721.1-55.

(b) A participating health plan may, at thehealth plans option, provide benefits which exceed therequirements of the standard benefits package.

(c) The health plan shall coordinate serviceslisted in section 17-1735-3 as appropriate.[Eff 01/31/09 ] (Auth: HRS 346-14) (Imp: HRS346-14; 42 C.F.R. 430.25)

17-1721.1-52 Primary and acute care services tobe provided by participating health plans. (a)Participating health plans shall provide all medicalservices that are required by the Hawaii Medicaid stateplan.


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(b) Participating health plans shall providemedically necessary preventive, psychiatric,diagnostic, and treatment services which minimally

include, but are not limited to, the following:(1) Inpatient hospital services for medical,

surgical, rehabilitative, maternity, andnewborn care, including room and board,nursing care, medical supplies, equipment,drugs, diagnostic services, physical andoccupational therapy, speech and languagepathology, and other medically necessaryservices;

(2) Outpatient hospital services, includingemergency room services, post stabilizationservices, ambulatory surgery, urgent careservices, medical supplies and equipment,

drugs, diagnostic services, therapeuticservices such as chemotherapy and radiationtherapy, and other medically necessaryservices;

(3) Preventive services, including initial andinterval histories, physical examinations anddevelopmental assessments, immunizations,diagnostic and screening laboratory andradiology services. Other preventativeservices includes screening (blood pressuremeasurement, weight-height measurement, totalcholesterol measurement, tuberculosis, and

screening for breast, cervical, colorectal,and prostate cancer), rubella serology orvaccine history, health education andcounseling, and chemoprophylaxis;

(4) Preventive services for children, includingnewborn screening, hospital stays for normal,term, healthy newborns for up to forty-eighthours after normal vaginal delivery or up toninety-six hours after cesarean sectiondelivery, other age appropriate laboratoryscreening tests, screening to assess healthstatus, tuberculin skin testing,immunizations, age appropriate dental

referral and oral fluoride, and ageappropriate health education;(5) Prescribed drugs, blood, and blood products

in accordance with the health plans ownformulary or prior authorization by thehealth plan.

(6) Radiology, laboratory, and other diagnosticservices including imaging, screening


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mammograms, screening and diagnosticlaboratory tests, therapeutic radiology, andother medically necessary diagnostic

services;(7) Physician services, including services of

psychiatrists provided at locationsincluding, but not limited to, a physician'soffice, clinic, private home, licensedhospital, licensed nursing facility, or alicensed or certified residential setting;

(8) Maternity services such as prenatal visitsand laboratory screening tests, healtheducation and screening, diagnosis ofpremature labor, diagnostic amniocentesis,diagnostic ultrasound, fetal stress, and non-stress testing, treatment of missed,

threatened, incomplete and electiveabortions, hospital stays for delivery ofinfants, postpartum care, and prenatalvitamins including folic acid;

(9) Medical services related to dental needs thatare provided in an inpatient hospital orambulatory surgery center, including but notlimited to referrals, follow-up, coordinationand provision of appropriate medicalservices.

(10) Other practitioner services includingpodiatrists, optometrists, psychologists,

certified nurse midwives, licensed advancedpractice registered nurse services (includingfamily, pediatric, geriatric, and psychiatrichealth specialists), and other health careprofessionals licensed or certified by theState;

(11) Personal assistance services level I shallinclude one or more of the followingactivities:(A) Routine housecleaning such as sweeping,

mopping, dusting, making beds, cleaningthe toilet and shower or bathtub, takingout rubbish;

(B) Care of clothing and linen by washing,drying, ironing, mending;(C) Marketing and shopping for household

supplies and personal essentials;(D) Light yard work such as mowing the lawn,


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raking the lawn, trimming hedges,bundling rubbish for refuse collection;

(E) Simple home repairs such as mendingscreens, replacing light bulbs,replacing light fixtures, fixing leakyfaucets, clearing stopped-up drains;

(F) Preparing meals;(G) Running errands such as paying bills,

picking up medication, escorting therecipient to medical care services,nutritional or recreational programs; or

(H) Assistance with bathing, dressing,grooming.

Maximum enrollment for personal assistancelevel- I services may be limited by thedepartment.

(12) Rehabilitation services include physicaltherapy, occupational therapy, speech andlanguage pathology, and audiology services,and other medically necessary therapeuticservices;

(13) Cognitive Rehabilitation services areprovided to cognitively impaired persons thatassess and treat communication skills,cognitive and behavioral ability, andcognitive skills related to performingactivities of daily living (ADL);

(14) Durable medical equipment, prosthetic

devices, orthotics, and medical suppliesincluding, but not limited to, oxygen tanks,oxygen concentrators, eyeglasses,ventilators, wheelchairs, crutches, canes,braces, hearing aids, pacemakers, and othermedically necessary appliances, supplies, andartificial aids;

(15) Home health services are part-time orintermittent care for enrollees who do notrequire hospital care. This service isprovided under the direction of a physicianin order to prevent re-hospitalization orinstitutionalization. The home health

service provider must meet Medicarerequirements. Medicaid services provided toenrollees receiving Medicare home healthservices that are duplicative of Medicarehome health benefits (i.e., physical therapy


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(B) Mentally competent;(C) Voluntarily gives informed consent by

completing the informed consent for

sterilization form DHS 1146;(D) The provider completes form DHS 1146;(E) At least thirty days, but not more than

one-hundred eighty days, have passedbetween the date of informed consent andthe date of sterilization, except in thecase of premature delivery or emergencyabdominal surgery; and

(F) An interpreter is provided when languagebarriers exist.

(20) Additional requirements for sterilizationsfor women at the time of premature deliveryor emergency abdominal surgery. At least

seventy-two hours must have passed sinceinformed consent for sterilization wassigned. In the case of premature delivery,the informed consent must have been given atleast thirty days before the expected date ofdelivery (the expected date of delivery mustbe provided on the consent form).

Arrangements are to be made to effectivelycommunicate the required information to anenrollee who is visually impaired, hearingimpaired or otherwise disabled. The enrolleeshall not be institutionalized in a

correctional facility, mental hospital orother rehabilitative facility;(21) Hysterectomies are a covered service when:

(A) The enrollee voluntarily gives informedconsent by completing the hysterectomyacknowledgement form DSSH 1145;

(B) Has been informed orally and in writingthat the hysterectomy will render theindividual permanently incapable ofreproducing (this is not applicable ifthe individual was sterile prior to thehysterectomy or in the case of anemergency hysterectomy); and

(C) The enrollee has signed and dated apatients acknowledgement of priorreceipt of hysterectomy informationform prior to the hysterectomy.


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Regardless of whether the requirements listedabove are met, a hysterectomy shall not becovered under the following circumstances:

(A) It is performed solely for the purposeof rendering a enrollee permanentlyincapable of reproducing;

(B) There is more than one purpose forperforming the hysterectomy but theprimary purpose is to render theenrollee permanently incapable ofreproducing; or

(C) It is performed for the purpose ofcancer prophylaxis;

(22) Urgent care services is the diagnosis andtreatment of medical conditions which areserious or acute but pose no immediate threat

to life and health but which require medicalattention within twenty-four hours.

(23) Vision services including visionexaminations, ophthalmic examination withrefraction, prescription lenses, cataractremoval, and prosthetic eyes;

(24) Services federally mandated by the Early andPeriodic Diagnosis, Screening, and TreatmentProgram (EPDST);

(25) Behavioral health services includingpreventive, diagnostic, therapeutic, andrehabilitative services, and subject to the

limitations set forth in section17-1721.1-53, including but not limited to:(A) Twenty-four hour care for acute

psychiatric illnesses;(B) Ambulatory services, with crisis

services available twenty-four hours aday, seven days a week;

(C) Acute day hospital and partialhospitalization;

(D) Health plans are not required to providebehavioral health services to enrolleeswhose services are not medicallynecessary or who have been criminally

committed for evaluation or treatment inan inpatient setting under HRS chapter706; and


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(E) Behavioral health services forindividuals with serious and persistentmental illness or with severe emotional

behavioral disorders may be providedpursuant to section 17-1721.1-53.

(26) Substance abuse services includingpreventive, diagnostic, therapeutic, andrehabilitative services, and includingmethadone-levo-alpha-acetyl-methadol (LAAM)services for acute opiate detoxification andmaintenance. The health plan may utilizecommunity-based substance abuse treatmentprograms that are accredited and monitored bythe alcohol and drug abuse division (ADAD);and

(27) Family planning service including services to

enrollees wishing to prevent pregnancies,plan the number of pregnancies, plan thespacing between pregnancies, or obtainconfirmation of pregnancy. These servicesshall include, at a minimum, education andcounseling necessary to make informed choicesand understand contraceptive methods;emergency contraception; follow-up, brief andcomprehensive visits; pregnancy testing;contraceptive supplies and follow-up care;diagnosis and treatment of sexuallytransmitted diseases; and infertility

assessment.(c) Emergency and post stabilization services.The health plan shall provide emergency servicestwenty-four hours a day, seven days a week to treat anemergency medical condition.

(1) Emergency services shall be covered whenfurnished by a qualified provider, even ifthe provider is not in the health plansnetwork.

(2) Emergency services shall not be subject toprior authorization.

(3) The emergency room physician or otherprovider that is qualified to furnish such

services actually treating the enrollee isresponsible for determining when an enrolleeis sufficiently stabilized for transfer ordischarge, which decision is binding upon thehealth plan. If agreed to by the hospital,


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the health plan may send one of its ownphysicians with appropriate emergency roomprivileges to assume the attending

physicians responsibilities to stabilize,treat, and transfer the enrollee, providedthat such arrangement does not delay theprovision of medical services.

(4) The health plan shall cover emergencyservices when the enrollees PCP or otherhealth plan representative instructs theenrollee to seek emergency services, withoutregard to whether the condition meets theprudent layperson standard.

(5) Inpatient and outpatient post-stabilizationservices related to an emergency medicalcondition for purposes of maintaining the

stabilized condition or, as prescribed in42 CFR 438.114, to improve or resolve theenrollees condition, shall be providedtwenty-four hours a day, seven days a week.

(6) Post-stabilization services are not subjectto prior authorization or pre-certificationby an in-network provider or health planrepresentatives, regardless of whether theservices are provided within or outside thehealth plans network of providers, if:(A) The health plan does not respond to the

providers request for pre-certification

or prior authorization within one hour;(B) The health plan cannot be contacted;(C) The health plans representative and the

enrollees attending physician cannotreach an agreement concerning theenrollees care and a health planphysician is not available forconsultation.

(D) The health plan must give the attendingphysician the opportunity to consultwith an in-network physician and theattending physician may continue withcare of the enrollee until a health plan

physician is reached or the healthplans responsibility for post-stabilization services that it has notapproved ends because:


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care plan shall be covered by the health plan.[Eff 01/31/09 ] (Auth: HRS 346-14) (Imp: HRS346-14; 42 C.F.R. 430.25)

17-1721.1-54 Home and community based services(HCBS). (a) Individuals who are determined to be atnursing facility level of care are eligible to receivehome and community based services when they areavailable and are cost neutral.

(b) The health plan must receive prior approvalfrom the department or its designee prior todisapproving a request for HCBS.

(c) The health plan is not required to provideHCBS if:

(1) The enrollee chooses institutional services;

(2) The enrollee cannot be served safely in thecommunity; or

(3) There are no adequate or appropriateproviders for needed services.

(d) The following are HCBS covered services asdescribed in the QExA program:

(1) Adult day care services provided by alicensed facility maintained and operated byan individual, organization, or agency forthe purpose of providing regular supportivecare to four or more disabled adultparticipants, with or without charging a fee.

Adult day care services include therapeutic,social, educational, recreational, and otheractivities. Adult day care staff members maynot perform healthcare related services suchas medication administration, tube feedings,and other activities which require healthcarerelated training;

(2) Adult day health services provided by anorganized program of therapeutic, social andhealth activities and services provided toenrollees with functional impairments, forthe purpose of restoring or maintaining theindividual's optimal capacity for self-care.

Adult day health facilities are licensed inaccordance with chapter 11-96 andsection 11-94-5;

(3) Assisted living services are services thatinclude personal care and supportive careservices (homemaker, chore, attendant


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services, meal preparation) that arefurnished to enrollees who reside in anassisted living facility. Payment for room

and board is prohibited;(4) Pediatric attendant care services is the

hands-on care, both supportive andhealth-related in nature, provided tomedically fragile children. The serviceincludes enrollee supervision specific to theneeds of a medically stable, physicallyhandicapped child. Attendant care mayinclude skilled nursing care to the extentpermitted by law. Housekeeping activitiesthat are incidental to the performance ofcare may also be furnished as part of thisactivity. Supportive services, a component

of attendant care, are those services thatsubstitute for the absence, loss, dimunition,or impairment of a physical or cognitivefunction;

(5) Community care management agency (CCMA)services are provided by a person, agency, ororganization that is licensed by thedepartment to locate, coordinate, and monitorcomprehensive services to meet the needs ofenrollees whom the case management agencyserves in community care foster family homesor enrollees in expanded adult residential

care homes, or assisted living facilities.CCMAs provides activities, to include butnot limited to, continuous and ongoing nursedelegation to the caregiver in accordancewith chapter 16-89 subchapter 15, initial andongoing assessments to make recommendationsto for, at a minimum, indicated services,supplies, and equipment needs of enrollees,ongoing face-to-face monitoring andimplementation of the enrollees care plan,and interaction with the caregiver on adverseeffects and changes in condition ofenrollees. CCMAs shall:

(A) communicate with an enrollees physicianregarding the enrollees needs includingchanges in medication and treatmentorders;


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specified in the service plan; employerskills updates as necessary to safelymaintain the individual at home; crisis

intervention; supportive counseling; familytherapy; suicide risk assessments andintervention; death and dying counseling;anticipatory grief counseling; substanceabuse counseling; and nutritional assessmentand counseling;

(8) Environmental accessibility adaptations arechanges to the enrollees living environment,but not including community care fosterfamily homes and expanded adult residentialcare homes (E-ARCH), to promote safety orfacilitate the enrollee's self-reliance byenabling the enrollee to perform basic

activities of daily living. Modificationsmay include installation of ramps andhandrails, widening of doorways, removal ofother architectural barriers, bathroommodifications, electrical, plumbing or airconditioners and modifications to thetelephone system which enable the individualto function with greater independence in thehome, and without which the enrollee wouldrequire institutionalization. Window airconditioners may be installed when it isnecessary for the health and safety of the

enrollee. Excluded are those adaptations orimprovements to the home that are of generalutility, and are not of direct medical orremedial benefit to the enrollee, such ascarpeting, roof repair, central airconditioning, etc. Adaptations which add tothe total square footage of the home areexcluded from this benefit. All servicesshall be provided in accordance withapplicable State or local building codes;

(9) Expanded adult residential care home (E-ARCH)or residential care services is any facilityproviding twenty four hour living

accommodations, for a fee, to adultsunrelated to the family, who require at leastminimal assistance in the activities of dailyliving, personal care services, protection,


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and health care services, and who may needthe professional health services provided inan intermediate care facility or skilled

nursing facility;(10) Home delivered meals are nutritionally sound

meals delivered to a location where anindividual resides (excluding residential orinstitutional settings). The meals will notreplace or substitute for a full daysnutritional regimen (i.e., no more than twomeals per day). Home delivered meals areprovided to individuals who cannot preparenutritionally sound meals without assistanceand are determined, through an assessment, torequire the service in order to remainindependent in the community and to prevent

institutionalization;(11) Home maintenance is a service necessary to

maintain a safe, clean and sanitaryenvironment. Home maintenance services arethose services not included as a part ofpersonal assistance and include heavy dutycleaning, which is utilized only to bring ahome up to acceptable standards ofcleanliness at the inception of service to anenrollee, minor repairs to essentialappliances limited to stoves, refrigerators,and water heaters, and fumigation or

extermination services. Home maintenance isprovided to individuals who cannot performcleaning and minor repairs without assistanceand are determined, through an assessment, torequire the service in order to preventinstitutionalization;

(12) Medically fragile day care is anon-residential service for children who aremedically or technology dependent, or both.The service includes activities focused onmeeting the psychological as well as thephysical, functional, nutritional and socialneeds of children. Services are furnished

four or more hours per day on a regularscheduled basis for one or more days per weekin an outpatient setting encompassing both


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health and social services needed to ensurethe optimal function of the individual;

(13) Moving assistance is provided in rare

instances when it is determined through anassessment that an individual needs torelocate to a new home. The following arethe circumstances under which movingassistance can be provided to an enrollee:unsafe home due to deterioration; theindividual is wheel-chair bound living in abuilding with no elevator; multi-storybuilding with no elevator, where the enrolleelives above the first floor; enrollee isevicted from their current livingenvironment; or the enrollee is no longerable to afford the home due to a rent

increase. Moving expenses include packingand moving of belongings. Whenever possible,family, landlord, community and third partyresources who can provide this servicewithout charge will be utilized;

(14) Non-medical transportation is thenecessary transportation provided to and fromfacilities, resources, and appointments inorder for the enrollee to receive theservices included in the plan of care;

(15) Personal assistance service level IIis the assistance with activities of daily

living such as ambulation, mobility, transferand lifting, positioning and turning, boweland bladder care, toileting, bathing,dressing, grooming, feeding, exercise andrange of motion, and assisting withmedications which are normallyself-administered; and instrumentalactivities of daily living which are directlyrelated to the wellbeing of the enrollee,such as meal preparation, bed, kitchen andbathroom cleanliness, essential errands, andmaintenance of health records;

(16) Personal emergency response system is an

electronic system placed in homes of highrisk enrollees who live alone or are alonesignificant parts of the day, have no regularcaregiver for extended periods of time, and


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who would otherwise require extensive routinesupervision, to enable them to secureimmediate help in the event of a physical,

emotional, or environmental emergency;(17) Private duty nursing is the provision of

skilled nursing services including, but notlimited to:(A) Observation and assessment of the

enrollees changing condition;(B) Enrollee education;(C) Skilled rehabilitation services;(D) Intravenous, intramuscular or

subcutaneous injections andintravenous feedings;

(E) Tube feedings;(F) Nasopharyngeal and tracheostomy

aspiration;(G) Insertion, sterile irrigation and

replacement of catheters;(H) Application of dressings involving

prescriptive medicines and aseptictechniques;

(I) Treatment of extensive decubitusulcers or other widespread skindisorders;

(J) Heat treatments which have beenspecifically ordered by a physician aspart of active treatment and which

require observation by a nurse toadequately evaluate the enrollee'sprogress;

(K) Initial phases of a regimeninvolving administration of oxygentherapy nebulizer; and

(L) Rehabilitation nursing proceduresincluding the related teaching andadaptive aspects of nursing that arepart of active treatment;

(18) Respite care is temporary institutional,community or home-based services needed toallow persons, who ordinarily care for the

enrollee, relief from these duties; and(19) Specialized medical equipment and suppliesentails the purchase, rental, lease, warrantycosts, installation, repairs and removal of


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devices, controls, or appliances, specifiedin a plan of care, that enable individuals toincrease or maintain their abilities to

perform activities of daily living, or toperceive, control, participate in, orcommunicate with the environment in whichthey live. [Eff 01/31/09 ] (Auth: HRS346-14) (Imp: 42 C.F.R. 440.180,430.25, 435.232)

17-1721.1-55 Institutional care services. (a)Institutional care services are provided in a licensednursing facility to enrollees who are referred by aphysician.

(b) Institutional care services shall be provided

either directly by or under the general supervision ofa licensed practical nurse or registered professionalnurse.

(c) Institutional care services shall include,but not be limited to:

(1) Room and board;(2) Administration of medication and treatment;(3) Development, management, and evaluation of

the written resident care plan based onphysician orders that necessitate theinvolvement of skilled technical orprofessional personnel to meet the resident's

care needs, promote recovery, and ensure theresident's health and safety;(4) Observation and assessment of the resident's

unstable condition that requires the skillsand knowledge of skilled technical orprofessional personnel to identify andevaluate the resident's need for possiblemedical intervention, modification oftreatment, or both, to stabilize theresident's condition;

(5) Health education services provided by skilledtechnical or professional personnel to teachthe recipient self care, such as gait

training and self administration ofmedications;(6) Provision of therapeutic diet and dietary

supplements as ordered by the attendingphysician;


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(7) Laundry service for items of recipient'swashable personal clothing;

(8) Basic nursing and treatment supplies, such as

soap, skin lotion, alcohol, powder,applicators, tongue depressors, cotton ball,gauzes, adhesive tape, bandages, incontinentpads, V-pads, thermometers, blood pressureapparatus, plastic or rubber sheets, enemaequipment, and douche equipment;

(9) Durable medical equipment and supplies usedby residents but which are reusable, such asice bag, hot water bottle, urinal, bedpan,commode, cane, crutch, walker, wheelchair,and siderail and traction equipment;

(10) Activities of the resident's choice(including religious activities) that are

designed to provide normal pursuits forphysical and psychosocial well-being;

(11) Social services provided by qualifiedpersonnel;

(12) A review of the drug regimen of each residentat least once a month by a licensedpharmacist, as required for a nursingfacility to participate in Medicaid;

(13) Nonrestorative or nonrehabilitative therapy,or both, provided by nursing staff; and

(14) Provision of and payment for, throughcontractual agreements with appropriate

skilled technical or professional personnel,other medical and remedial services orderedby the attending physician which are notregularly provided by the provider. Otherservices that may be needed, such astransportation to realize the provision ofservices ordered by the attending physician,shall also be arranged through contractualagreements. The contractual agreement shallstipulate the responsibilities, functions,objectives, service fee, and other termsagreed to by the NF and the person or entitythat contracts to provide the service.

[Eff 01/31/09 ] (Auth: HRS 346-14;Pub. L. No. 100-203; 42 C.F.R. 431.10,483.1) (Imp: Pub. L. No. 100-203; 42 C.F.R.440.40, 440.150, 483.1, 483.20)

17-1721.1-56 Dental services. (a) Dentalservices are not covered through a health plan, but are


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provided to enrollees by the department on a fee-for-service basis. The health plans shall coordinate withthe department or its designee to refer enrollees to

the departments dental third party administrator.[Eff 01/31/09 ] (Auth: HRS 346-14) (Imp: HRS346-14; 42 C.F.R. 430.25)

17-1721.1-57 to 17-1721.1-65 (Reserved).

SUBCHAPTER 8

PARTICIPATING HEALTH PLANS

17-1721.1-66 Health plan participation in QExA.(a) Health plans shall be selected through acompetitive purchase of services under HRS chapter103F.

(b) Contracts for participation in QExA shall beawarded to qualified health plans upon finalization offinancial agreements with the department.

(c) The department shall develop a request forproposals prior to the lapse of existing contracts withparticipating health plans to ensure that individualseligible for coverage through QExA shall receivecontinued health care coverage. [Eff 01/31/09 ]

(Auth: HRS 346-14) (Imp: HRS 346-14; 42 C.F.R.430.25)

17-1721.1-67 Service areas. (a) The departmentmay designate geographic areas as the areas for whichhealth plans will provide services.

(b) More than one health plan may be contractedby the department for any service area.[Eff 01/31/09 ] (Auth: HRS 346-14) (Imp: HRS346-14; 42 C.F.R. 430.25)

17-1721.1-68 Requirements of participatinghealth plans. (a) The health plans shall abide by theprovisions of their contracts with the department aswell as federal and state statutes and regulations.

(b) The requirements of each health plan shallinclude, but are not limited to, the following:


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(1) Provision of all services required by thecontract between the respective health planand the department;

(2) Provision of a primary care provider for eachenrollee in the health plan;

(3) Provision of service coordinators to ensurecoordination of primary, acute, HCBS andinstitutional care services for all of thehealth plans enrollees;

(4) Development and maintenance of a sufficientnetwork of health care providers to ensurethat required health services are provided toenrollees in a timely manner;

(5) Maintenance of adequate support staff andsystems to administer and conduct businessfunctions;

(6) Development and maintenance of requiredinformation systems;

(7) Development and maintenance of a qualityassurance program;

(8) Development and maintenance of a grievancesystem for dissatisfied enrollees;

(9) Development and maintenance of a toll-freetelephone hotline to confirm enrollment,respond to inquiries from enrollees, andprovide information to the general public;and

(10) Maintenance of a medical records systems that

enables the health plans to provideinformation pertinent to the care andmanagement of enrollees to the department.

(c) Each health plan will perform a face-to-facehealth and functional assessment for each enrollee.[Eff 01/31/09 ] (Auth: HRS 346-14) (Imp: HRS346-14; 42 C.F.R. 430.25)

17-1721.1-69 Enforcement of contracts withparticipating health plan. (a) The department willmonitor a health plans performance during any contractperiod.

(b) The contract shall provide for civil oradministrative monetary penalties not to exceed themaximum amount established by federal and statestatutes and regulations if the participating healthplan:

(1) Fails to provide medically necessary itemsand services that are required under law orunder contract;


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(2) Imposes upon beneficiaries excess premiumsand charges;

(3) Acts to discriminate among enrollees;(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.(c) The department may also impose financial

sanctions as described under the provisions of thecontract between the health plan and the department forinaccurate, incomplete, and untimely data and reportssubmitted to the department.

(d) If a health plan violates the contract,

violates federal or state statutes or regulations, orif there is a substantial risk to the health ofenrollees, the department may take any one or more ofthe following actions:

(1) Notify affected enrollees of the violations;(2) Allow affected enrollees to change health

plans without cause;(3) Suspend enrollment;(4) Suspend payment; or(5) Terminate the contract in accordance with

section 17-1721.1-70.(e) If a health plan continues to violate the

contract conditions or continues to violate federal orstate statutes and regulations, regardless of any otherpenalty that may be imposed, the department may takeany one or more of the following:

(1) Appoint temporary management to overseecompliance efforts;

(2) Notify affected enrollees of the violations;or

(3) Allow affected enrollees to change healthplans without cause.

(f) Temporary management may continue until thedepartment determines that the health plan can ensurethat the behavior that caused the penalty will not

recur.(g) Before imposing a sanction, with theexception of appointing temporary management to overseecompliance efforts, the department shall give thehealth plan timely written notice, as specified in thecontract with the participating plans.


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(h) The department shall notify the insurancecommissioner whenever a sanction under this section iscontemplated. [Eff 01/31/09 ] (Auth: HRS

346-59.5) (Imp: HRS 346-14; 42 C.F.R. 430.25;438.700, 438.702; 438.706; 438.710)

17-1721.1-70 Termination of contract withparticipating health plans. (a) The department shallhave the authority to terminate the health planscontract for any or all of the following reasons:

(1) Default by the health plan;(2) Failure by the health plan to abide by the

contract conditions or to meet federalstatutes;

(3) Convenience;(4) Expiration of QExA;(5) Insolvency of or declaration of bankruptcy by

the health plan; or(6) Unavailability of funds.(b) When termination of contract is due to

reasons identified under subsection (a) paragraphs (1)and (2), the department shall provide a hearing for theaffected health plan prior to termination of contract.

(c) After the department notifies the health planof its intent to terminate the contract due to reasonsidentified under subsection (a) paragraphs (1) and (2),the department may do the following:

(1)Provide the affected enrollees written noticeof the departments intent to terminate thecontract; and

(2) Allow the affected enrollees to change healthplans immediately without cause.[Eff 01/31/09 ] (Auth: HRS 346-14)

(Imp: HRS 346-14; 42 C.F.R. 430.25;

438.708)

Hawaii Law HAR for QEXA

Documents

Transcript of Hawaii Law HAR for QEXA