STATE OF HAWAII
DEPARTMENT OF HUMAN SERVICES
MED-QUEST DIVISION
NOTICE OF PUBLIC HEARING
Pursuant to sections 91-3 and 92-41, Hawaii Revised Statutes, notice is hereby given that the Department of Human Services will hold a
public hearing to consider proposed amendments to existing rules, and the adoption of new rules of the Med-QUEST Division for the purpose
of conforming to State and Federal Statutes.
The proposed amendments are based on State and Federal laws. Brief descriptions of the proposed changes are listed below.
CHAPTER 17-1700 – OVERVIEW
§ 17-1700-2, Definitions. This section is amended by:
1. Adding the definitions of “Benefit, Employment and Support Services Division, (BESSD)”; “QExA”; and “SSP”.
2. Deleting the definition of “Family and adult service division (FASD)”.
3. Amending the definitions of “Code of Federal Regulations or C.F.R.”; “Fee-for-service”; Hawaii Revised Statutes or HRS”; “42 U.S.C.
§1396″; “Supplemental security income or SSI” and “United States Code or U.S.C.”.
CHAPTER 17-1711 – APPLICATION PROCESSING REQUIREMENTS
1. §17-1711-10, Application for retroactive medical assistance. Subsections: (a) paragraph (2) subparagraph (B) is amended to state that
retroactive medical assistance must be requested by submitting a written request if the request is made in conjunction with or after an
application for financial or medical assistance only has been made but prior to the date eligibility has been determined. Subsection (b)
is amended to state that retroactive eligibility shall be provided no earlier than thirty days prior to the date on which the application is
received by the department to comply with the implementation of the 1115 waiver.
2. §17-1711-12, Verification prior to approval. This section is amended to state that prior to the approval of eligibility, the Department must
verify all eligibility requirements not limited to the following: assignment of third party liability, child support benefits, gross income, nonexempt
resources, determination of blindness or disability, U.S. citizenship or alien status, and identity to comply with federal regulations.
3. §17-1711-13, Requirements for disposition of application. Subsections (a) is amended to state that the eligibility worker may contact
the applicant, if required to determine eligibility; subsection (c) paragraph (3) is amended to include proof of identity and residency as
eligibility requirements which must be confirmed; subsection (e) paragraph (1) is amended to state that timely dispositions of eligibility or
ineligibility shall be made within ninety days from the date of application for applicants applying for medical assistance on the basis of
disability to comply with federal regulations; subsection (h) paragraph (2) is amended to state the department shall not use the time
standards as a waiting period or to deny eligibility as the department failed to determine eligibility on a timely basis; and subsection (i) is
amended to state that a delay beyond the ninety days for applicants applying on the basis of disability shall be made presumptively eligible
from the ninety-first day until a determination is rendered.
4. §17-1711-16, Requirements for individuals to be added to a recipient household. Subsection (b) is amended to state that a non-blind or
disabled newborn born to a blind or disabled pregnant woman shall receive fee-for-service coverage until enrolled into a QUEST health
plan while a blind or disabled newborn shall receive coverage under the mother’s QExA health plan until the QExA health plan is notified
of the enrollment in a different QExA plan.
CHAPTER 17-1721 – MEDICAL ASSISTANCE TO THE AGED, BLIND AND DISABLED
A. The Federal Centers for Medicare and Medicaid Services (CMS) approved the extension of the QUEST Expanded Section 1115
Demonstration through June 30, 2013. Under QUEST Expanded, the State has the authority to create a new program, the QUEST
Expanded Access (QExA) that will provide medical coverage to Medicaid recipients who are aged, blind or disabled (ABD) through managed
care health plans. QExA will provide coverage primary and acute health needs, as well as long-term care in an institutional or community
setting. The amendments to sections of Chapter 1721 in Subchapters One, Two, Four, Five, and Six are being made to support the
implementation of QExA.
1. §17-1721-2, Definitions. This section is amended by:
a. Adding the definitions of “Community”, “Community Care Foster Family Home (CCFFH)”, “Cost share”, “Dependent family member”,
“FPL”, “Home and community based services”, “Long-term care services”, “Post-eligibility”, “Spenddown”, “Spenddown amount”, and
“Spouse”.
b. Deleting the definitions of “Institutionalized spouse” and “SSI”.
c. Amending the definitions of “Categorically needy”, “Community spouse”, “Institutionalized individual”, “Likely to remain”, and “Medical
facility”.
2. §17-1721-4, Eligibility requirements for aged individuals. Subsection (a) is amended to state that individuals are considered to be aged
in the month of their sixty-fifth birthday.
3. §17-1721-8, Medical assistance only for aged, blind, or disabled individuals. Subsections (a) paragraph (1) is amended to include individuals
who are certified as being aged, blind, or disabled shall be categorically eligible under the mandatory categorically needy coverage
for the aged, blind, or disabled, are those members are eligible for or receive SSI and or SSP payments. Paragraph (4) is amended to
include the optional categorically needy coverage for individuals residing in the community who meet the requirements of 42 C.F.R.
§435.217.
4. §17-1721-13, Personal reserve standards. Subsection (c) is being repealed for housekeeping purposes as it currently lists that assets
are exempt for individuals eligible under chapter §17-1732 for the Coverage of Blind or Disabled Pregnant Women and Children program.
5. §17-1721-20, Standards of assistance for adults in domiciliary care facilities. Subsections (a) is amended to state that the standards of
assistance for adults in a Type 1 domiciliary care home consists of not more than five residents and Type 2 domiciliary care home consists
of six or more residents. Subsection (b) is amended to state that cost incurred for medical care shall not be deducted from income
as there are no spenddown provisions under these applicable standards. Subsection (c) is amended to state that if income exceeds the
applicable standards, the individual shall be evaluated for medical coverage under the medically needy coverage provision.
6. §17-1721-21, Standards of assistance for mandatory categorically needy aged, blind, or disabled individuals. Subsections (b) is amended
to state that cost incurred for medical care shall not be deducted from income as there are no spenddown provisions under these
applicable standards. Subsection (c) is amended to state that if income exceeds the applicable standards, the individual shall be evaluated
for medical coverage under the medically needy coverage provision.
7. §17-1721-23, Standards of assistance for medically needy blind or disabled pregnant women and children born after September 30,
1983. This section is being repealed for housekeeping purposes as it currently lists the standards of assistance for individuals eligible
under chapter 17-1732 under the Coverage of Blind or Disabled Pregnant Women and Children program.
8. §17-1721-28, Determining monthly net income for aged or disabled persons. This section is amended to reflect the same order of
earned and unearned income deductions used by the SSI program in calculating the net countable income for aged and disabled households.
9. §17-1721-36, Persons with excess income. Subsections (a) is amended to state the appropriate assistance standards for an aged, blind
or disabled person applying for or receiving medical assistance as an optional categorically needy individual, a mandatory categorically
needy individual, or an individual in a domiciliary care facility. Subsection (b) is amended to state that individuals with income that
exceeds the appropriate medical assistance standards shall be entitled to receive medical assistance if, the excess can be spent down to
the medically needy standard with the deduction of incurred medical expenses.
10. §17-1721-37, Incurred medical expenses. Subsections (a) paragraph (2) subparagraph (D) is amended to state that expenses that
exceed the limitations on the amount, duration or scope of services and (a) paragraph (2) subparagraph (E) is amended to consider
QExA enrollment fees as incurred medical expenses. Subsection (a) paragraph (3) is amended to allow expenses that were not previously
considered to be incurred medical expenses.
11. §17-1721-38, Spenddown of excess income for a medically needy individual. This section is amended for housekeeping purposes to differentiate
between an individual who must spenddown their excess income to gain eligibility whereas cost sharing refers to someone
whom the department must determine the individual’s share in cost of long term care services; subsection (a) is amended to reference
the amended §17-1721-37(b) which describes the process to gain eligibility by spending down their excess income to the appropriate
standard; subsection (b) is amended to include incurred medical expenses which are a current liability that were not previously used to
determine eligibility; subsection (c) is amended for housekeeping purposes; (d) is amended with a non-substantive change of capitalizing
Medicare; and subsection (e) is amended to state that a medically needy individual enrolled in a QExA plan meets the spenddown
obligation via the QExA enrollment fee.
12. §17-1721-39, Provision of coverage. This new section is added to list the provision of coverage for individuals eligible under chapter
§17-1721 who are exempt from coverage through enrollment by a QExA health plan.
B. The amendments to Subchapter 7 support the provision of long-term care services in a nursing facility, medical facility or in a community
setting. The QExA program allows the State to treat medically-needy individuals who receive long-term care services in a community setting
as though they were in a nursing facility. Thus, certain provisions for determining Medicaid eligibility and cost sharing that were only
applicable to individuals in a nursing facility or medical institution could be applicable to individuals in a community setting. The
amendments to Subchapter 7 will allow an individual who prefers to receive long-term care in a community setting to use more of their
income for living expenses. The amendments will also allow support for the spouse and dependent relatives living with the individual.
1. §17-1721-42, Purpose. This section is amended to clarify that the purpose of this subchapter is to describe the financial eligibility and
liability of an individual requesting coverage of long-term care services.
2. §17-1721-43, Determination of the community spouse resource allowance. This section is amended to state that the provisions to provide
asset support to the community spouse of an individual receiving long-term care services also apply to an individual eligible to
receive home and community based services who is medically needy or qualifies under the provisions of 42 C.F.R. §435.217.
3. §17-1721-44, Post-eligibility treatment of income for individuals in medical institutions who require coverage of long-term care services.
This section determines how much of an eligible individual’s income will be used to pay the individual’s share of long-term care and medical
expenses. Subsection (a) is amended to allow post-eligibility treatment of income for individuals receiving long-term care in the community;
subsection (b) paragraph (1) is amended to provide personal needs allowances based on the setting where the individual is
receiving services, either in a nursing or medical facility or in the community; subsection (b) paragraph (2) is amended to support for
dependent family members in situations where there is no community spouse, and includes the requirement that support to dependent
relatives must be taken from the individual’s income before considering the individual’s assets; and subsection (b) paragraph (3) is
amended to disallow the deduction of long-term care costs incurred during a penalty period for the transfer of assets.
CHAPTER 17-1721.1 – QUEST EXPANDED ACCESS
This new chapter describes QUEST Expanded Access (QExA) that will be implemented effective February 1, 2009. QExA will provide healthcare
in a managed care setting to aged, blind and disabled (ABD) individuals currently covered under the Department of Human Services
(DHS) Fee-For-Service (FFS) and Home and Community Based Services (HCBS) medical assistance programs.
The goals of QExA are to:
• Improve the health status of the member population;
• Establish a “provider home” for members through the use of assigned primary care providers (PCPs);
• Establish contractual accountability among the State, the health plan and healthcare providers;
• Expand and strengthen a sense of member responsibility and promote independence and choice among members;
• Assure access to high quality, cost-effective care that is provided, whenever possible, in a member’s home and/or community;
• Coordinate care for the members across the benefit continuum, including primary, acute and long-term care benefits;
• Provide home and community based services (HCBS) to persons with neurotrauma;
• Develop a program that is fiscally predictable, stable and sustainable over time;
• Develop a program that places maximum emphasis on the efficacy of services and offers health plans both incentives for quality and
sanctions for failure to meet measurable performance goals; and
• Decrease the percentage of uninsured individuals in the State.
QExA health plans will also have the flexibility to provide customized benefit packages for enrollees. The customized benefit packages must
cover all benefits in the Medicaid State Plan, except for intermediate care facility for mentally retarded (ICF/MR). In addition, they will cover
HCBS, including those services offered in the State’s 1915(c) waivers. The amount, duration, and scope of all covered services may vary to
reflect the needs of the individual in accordance with the prescribed Care Coordination Plan.
CHAPTER 17-1722 – SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS
The following sections are amended to state that the effective date of eligibility and coverage shall not exceed thirty days prior to the date
the application is received by the Department, to be in compliance with the Special Terms and Conditions for the 1115 waiver of the QExA
program.
1. §17-1722-5, Provision of coverage. This section is amended to state the provision of coverage for a qualified severely impaired individual
shall be through enrollment in a QExA health plan and amended with a non-substantive change to the spelling of Medicare.
2. §17-1722-13, Effective date of coverage. Subsection (b) is amended to state that the thirty-day retroactive coverage provision does not
pertain to a Qualified Medicare Beneficiary and amended with a non-substantive change to the spelling of Medicare.
3. §17-1722-20, Provision of coverage. This section is amended to state the effective date for the provision of coverage shall not exceed
thirty days prior to the date the application is received by the Department for an individual applying as a Specified Low Income Medicare
Beneficiary and amended with a non-substantive change to the spelling of Medicare.
4. §17-1722-21, Effective date of coverage. This section is being repealed as it is being incorporated into §17-1722-20.
5. §17-1722-29, Effective date of coverage. This section is amended to state the effective date of coverage shall not exceed thirty days
prior to the date the application is received by the Department for an individual applying as a Qualified and Disabled Working Individual.
6. §17-1722-70, Eligibility requirements. This section is amended for housekeeping purposes as the provision for States to pay certain
Qualifying Individuals, the payment of the increment to the Medicare Part B premium caused by the shifting of certain home health services
from the Medicare Part A to Part B has been terminated as of December 31, 2002 and amended with a non-substantive change to the
spelling of Medicare.
7. §17-1722-72, Limitations of coverage. This section is amended for housekeeping purposes as the provision for States to pay certain
Qualifying Individuals, the payment of the increment to the Medicare Part B premium caused by the shifting of certain home health services
from the Medicare Part A to Part B has been terminated as of December 31, 2002 and amended with a non-substantive change to the
spelling of Medicare.
8. §17-1722-74, Effective date of coverage. This section is amended to state the effective date of coverage shall not exceed thirty days
prior to the date the application is received by the Department for an individual applying as a Qualifying Individual.
9. §17-1722-81, Provision of coverage. This section is amended to state the provision of coverage for a disabled child who lost SSI benefits
due to the Personal Responsibilities and Work Opportunity Reconciliation Act (PRWORA) of 1996 shall be through enrollment in a QExA
health plan.
10. §17-1722-82, Effective date of coverage. This section is amended to state the effective date of coverage shall not exceed thirty days
prior to the date the application is received by the Department for an individual applying as disabled child who lost SSI benefits due to
the PRWORA.
CHAPTER 17-1723 – MEDICAL ASSISTANCE TO ALIENS AND REFUGEES
§17-1723-6, Limitations of coverage. This section is amended to state that the effective date of coverage for medical assistance for
aliens limited to coverage of only emergency medical services, shall not exceed thirty days prior to the date the application is received
by the Department and amended with a non-substantive change to the spelling of fee-for-service. Coverage shall be provided through
the existing fee-for-service program to be in compliance with the Special Terms and Conditions for the 1115 waiver for all medical
assistance programs.
CHAPTER 17-1727 – HAWAII HEALTH QUEST
§17-1727-25, Coverage of QUEST eligibles prior to the date of enrollment. Subsection (b) is amended to state that retroactive coverage
for QUEST eligibles shall be no earlier than thirty days prior to the date the application is received by the Department and the
services incurred are not limited to only appropriate emergency room or hospital expenses to be in compliance with the Special Terms
and Conditions for the 1115 waiver for all medical assistance programs.
CHAPTER 17-1730 – QUEST-SPENDDOWN PROGRAM
§17-1730-28, Effective date of eligibility. Subsections (a) is amended to state that the effective date of coverage for applicants
applying for the QUEST Spenddown program shall not exceed thirty days prior to the date the application is received by the
Department to be in compliance with the Special Terms and Conditions for the 1115 waiver for all medical assistance programs; subsection
(b) is amended to state that the effective date of coverage for QUEST or QUEST-Net recipients applying for QUEST Spenddown
program shall not exceed thirty days prior to the date the request for QUEST-Spenddown is received.
CHAPTER 17-1732 – COVERAGE OF BLIND OR DISABLED PREGNANT WOMEN AND CHILDREN
1. §17-1732-15, Method of coverage. This section is amended to state that eligible individuals shall be enrolled in a QExA health plan and
provided coverage under chapter 17-1721.1.
2. §17-1732-16, Effective date of coverage. This section is amended to state that the effective date of coverage shall begin on one of the
following:
a. The date of application;
b. If specified by the applicant, retroactive coverage may begin no earlier than thirty days prior to the date the application is received by
the Department; or
c. If ineligible for the month of application, the date on which all eligibility requirements are met by the applicant in a subsequent month.
CHAPTER 17-1733 – COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER
1. §17-1733-16, Method of coverage. This section is amended to state that eligible individuals shall be enrolled in a QExA health plan and
provided coverage under chapter 17-1721.1.
2. §17-1733-17, Effective date of coverage. This section is amended to state that retroactive coverage for eligible individuals shall begin
no earlier than thirty days prior to the date the application is received by the Department.
3. §17-1733-18, Scope and content. Subsections (a) states that eligible individuals shall be entitled to services under the scope and content
of the QExA program under chapter 17-1721.1. Subsection (b) states that a medical assistance card shall be issued.
CHAPTER 17-1734-STATE FUNDED COVERAGE OF INDIVIDUALS WITH BREAST AND CERVICAL CANCER
1. §17-1734-16, Method of coverage. This section is amended to state that eligible individuals shall be enrolled in a QExA health plan and
provided coverage under chapter 17-1721.1.
2. §17-1734-17, Effective date of coverage. This section is amended to state that retroactive coverage for eligible individuals shall begin no
earlier than thirty days prior to the date the application is received by the Department.
3. §17-1734-18, Scope and content. Subsections (a) states that eligible individuals shall be entitled to services under the scope and content
of the QExA program under chapter 17-1721.1. Subsection (b) states that a medical assistance card shall be issued.
CHAPTER 17-1735 – GENERAL PROVISIONS FOR FEE FOR SERVICE MEDICAL ASSISTANCE
1. §17-1735-3, Individuals covered under fee-for-service medical assistance. This section is amended to describe individuals who will continue
to be covered under the State’s fee-for-service program.
2. §17-1735-5, Effective date of authorization. Subsection (a) is amended to state that retroactive coverage for the fee-for-service program
shall be authorized beginning the date the application is received by the Department; Subsection (b) is amended to state that retroactive
eligibility shall be no earlier than thirty days prior to the date the application is received by the Department.
A public hearing will be held at the following time and place:
Monday, December 8, 2008, 9:00 a.m., Liliuokalani Building, 1390 Miller Street, 2nd Floor Conference Rooms, Honolulu, Hawaii.
All interested parties are invited to attend the hearing and to state their views relative to the proposed rules either orally or in writing.
Should written testimony be presented, five (5) copies shall be made available to the presiding officer at or before the public hearing to:
Department of Human Services
Med-QUEST Division
P. O. Box 700190
Kapolei, Hawaii 96709-0190
Residents of Hawaii, Kauai, Maui, and Molokai wishing to present oral testimonies may also contact the Med-QUEST Division on the respective
islands no earlier than seven (7) days before the Honolulu hearing date to have their testimony recorded:
East Hawaii Section West Hawaii Section
88 Kanoelehua Avenue, Room 107 Lanihau Professional Center
Hilo, Hawaii 96720 (933-0339) 75-5591 Palani Road, Ste. 3004
Kailua-Kona, Hawaii 96740 (327-4970)
Kauai Section Maui Section
4473 Pahee Street, Suite A 210 Imi Kala Street, Suite 101
Lihue, Hawaii 96766 (241-3575) Wailuku, Hawaii 96793 (243-5780)
Molokai Section Lanai Unit
State Civic Center Call toll free 1-800-894-5755
65 Makaena Street, Room 110
Kaunakakai, Hawaii 96748 (553-1758)
A copy of the proposed rules will be mailed at NO COST to any interested person by requesting a copy by writing to:
Department of Human Services
Med-QUEST Division
P. O. Box 700190
Kapolei, Hawaii 96709-0190
or by calling 692-8132. Neighbor island residents may request a copy of the proposed rules at NO COST by contacting the Med-QUEST
Division Sections as noted above.
A copy of the proposed rule changes will be available for public viewing from the first working day that the legal notice appears in the
Honolulu Star Bulletin, The Honolulu Advertiser, Hawaii Tribune Herald, West Hawaii Today, The Maui News, and The Garden Island, through
the day the public hearing is held, from Monday – Friday between the hours of 7:45 a.m. to 4:30 p.m. at the appropriate Med-QUEST
Division offices on their respective islands listed above. On Oahu, the proposed rules will be available at 601 Kamokila Boulevard, Room
518, Kapolei, Hawaii 96707 and 801 Dillingham Boulevard, 3rd Floor, Honolulu, Hawaii 96817.
Proposed rules are also available at the Virtual Rules Center located at the following website: http://www.hawaii.gov/dhs/main/har/
Special accommodations (i.e. Sign Language Interpreter, large print, taped materials, or accessible parking) can be made, if requested at
least seven (7) working days before the scheduled public hearing on Oahu by calling 692-8132. Neighbor island residents needing special
accommodations should contact the Med-QUEST Division Sections on the respective islands with their requests.
DEPARTMENT OF HUMAN SERVICES
LILLIAN B. KOLLER, DIRECTOR~