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 and repeal of 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 17-1722.1 STATE MEDICAL ASSISTANCE FOR IMMIGRANT CHILDREN PROGRAM:
§17-1722.1-10, Treatment of income. The section is amended to address the treatment of both income and assets; thus, the heading is changed to Financial eligibility requirements. A new subsection (a) is added to state that assets are not evaluated in determining eligibility for the State Medical Assistance for Immigrant Children Program. Renumbered subsections (b) and (c) are amended to insert, with the exception of deemed income of a sponsor and sponsors spouse. The deemed income of a sponsor and sponsors spouse is not considered under this chapter.
CHAPTER 17-1723 MEDICAL ASSISTANCE TO ALIENS AND REFUGEES
§17-1723-5, Eligibility requirements. This section is amended to include the phrase a sudden onset which defines what instigates an emergency medical condition.
CHAPTER 17-1726 MEDICAL ASSISTANCE FOR FAMILIES WITH CHILDREN DESCRIBED IN SECTION 1931 OF THE SOCIAL SECURITY ACT:
§17-1726-20, Determining income eligibility for families with children described in section 1931 of the Social Security Act. Subsections (a) and (b) are amended to replace 2001 and 2003, respectively, with as reflected in the Hawaii Medicaid state plan. The Hawaii Medicaid State Plan is amended each year to reflect the federal poverty level for the current year. These amendments will no longer require amending the administrative rules when the State Plan is amended for that reason.
CHAPTER 17-1727 HAWAII HEALTH QUEST:
§17-1727-22, Initial enrollment. Subsection (c) has been reformatted for clarity. A new paragraph (5) of subsection (c) is added to include as an exception, violations by health plan as specified in sections 17-1727-61 and 17-1727-62. The newly renumbered paragraph (8) is amended to allow as an exception other special circumstances as determined by the department. This amendment allows the State to be in compliance with the Balanced Budget Act of 1997 that revised various areas of the Medicaid law as it applies to managed care programs. The Medicaid law allows an enrollee to change enrollment from one medical plan to another outside of the annual open enrollment period for that reason.
§17-1727-28, Authority to disenroll QUEST beneficiaries. Subsection (b) is amended to include and when requested by the enrollee as a reason the Department shall consider disenrollment from a health plan. New subsection (c) is added to require the Department to decide within a specified timeframe whether to allow disenrollment; otherwise the request to disenroll is considered approved. These amendments allows the State to be in compliance with the Balanced Budget Act of 1997 that revised various areas of the Medicaid law as it applies to managed care programs. The Medicaid law allows an enrollee to request disenrollment from a health plan and also requires the State to decide within a specific timeframe.
§17-1727-60, Requirements of participating plans. Subsection (a) is amended to state that the plans participating in QUEST shall abide by the provisions of their respective contracts with the department and federal and state statutes and regulations.
§17-1727-61, Enforcement of contracts with participating health plan.
a. The Balanced Budget Act of 1997 allows states to impose civil or administrative monetary penalties when a health plan violates federal or state statutes and regulations. Thus, subsection (b) is amended to add new paragraph (7) to address that provision.
b. Subsection (c) is amended to state the Department may notify affected enrollees of the violations, allow affected enrollees to change plans without cause, suspend enrollment, and suspend payment if the health plan violates contract conditions, violates Federal or State statutes and regulations, violates the Hawaii Administrative Rules, or if there is substantial risk to the health of enrollees. The Department may also impose financial sanctions for inaccurate, incomplete, and untimely data and reports submitted to the Department. The amendment allows the State to be in compliance with the Balanced Budget Act of 1997 that revised various areas of the Medicaid law as it applies to managed care programs.
c. New subsection (d) is added to state if the health plan continues to violate the contract conditions, continues to violate Federal or State statutes and regulations, or continues to violate the Hawaii Administrative Rules, regardless of any other penalty that may be imposed, the Department shall appoint temporary management to oversee compliance efforts, notify affected enrollees of the violations, and allow affected enrollees to change plans without cause. The amendment allows the State to be in compliance with the Balanced Budget Act of 1997 that revised various areas of the Medicaid law as it applies to managed care programs.
d. New subsection (e) is added to state that temporary management may continue until the Department determines that the health plan can ensure that the behavior that caused the penalty will not recur. The amendment allows the State to be in compliance with the Balanced Budget Act of 1997 that revised various areas of the Medicaid law as it applies to managed care programs.
e. New subsection (f) is added to state that before imposing a sanction, with the exception of appointing temporary management to oversee compliance efforts, the Department shall give the health plan timely written notice. The amendment allows the State to be in compliance with the Balanced Budget Act of 1997 that revised various areas of the Medicaid law as it applies to managed care programs.
f. Subsection (d) is renumbered to subsection (g).
§17-1727-62, Termination of contract with participating health plan. This section is added to identify reasons the Department shall terminate a health plans contract. The section also states that, for certain reasons, the Department shall provide a hearing for the affected plan prior to termination of contract. Finally, the section states that the Department may notify the plans enrollees of its intent to terminate the health plans contract and allow the enrollees to change plans without cause. The amendments allows the State to be in compliance with the Balanced Budget Act of 1997 that revised various areas of the Medicaid law as it applies to managed care programs.
CHAPTER 17-1728 QUEST-NET:
1. §17-1728-2, Definitions. This section is amended to amend the definitions of adult to mean a person who is nineteen years of age or older and child to mean a person under age nineteen. Current definitions are confusing and do not account for certain children under age nineteen. The proposed definitions provide clarity.
2. §17-1728-8, Categorical eligibility requirements. This section is amended to allow 1) a person under age nineteen to participate in QUEST-Net without prior QUEST or Medicaid FFS participation (subsection (a) and paragraph (b)(2)); and 2) an employed person who is participating in the Departments Grant Diversion or Supporting Employment Empowerment Programs to have employer-sponsored medical coverage available (paragraph (b)(5)).
3. §17-1728-9, Financial eligibility requirements. Deleting a sentence from sub- section (b) amends this section, The provision in subsection (c) shall pertain to this person. New subsection (c) is added to require that a person under age nineteen whose countable family income is greater than 200% FPL, must meet the provision of subsection (d). Subsections (c) and (d) have been renumbered to (d) and (e), respectively. Paragraph (e)(1) is amended by deleting, who is born after September 30, 1983, because since 2003 there is no need to calculate whether a person under age nineteen was born after that specific date.
4. §17-1728-25, Changes from one QUEST-Net plan to another. Subsection (a) has been reformatted for clarity. A new paragraph (5) of subsection (a) is added to include as an exception, violations by health plan as specified in sections 17-1727-61 and 17-1727-62. The newly renumbered paragraph (7) is amended to allow as an exception other special circumstances as determined by the department. This amendment allows the State to be in compliance with the Balanced Budget Act of 1997 that revised various areas of the Medicaid law as it applies to managed care programs. The Medicaid law allows an enrollee to change enrollment from one medical plan to another outside of the annual open enrollment period for that reason.
5. §17-1728-26, Financial responsibility of adult enrollees. This section is amended by amending subsections (c) and (e) to exempt from the premium-share requirement: 1) a Grant Diversion (GD) program participant for up to four months; and 2) a Supporting Employment Empowerment (SEE) program participant for up to six months. Any month in which the GD or SEE participant received medical assistance coverage shall count as one of the four or six months, respectively.
6. §17-1728-27, Disenrollment from QUEST-Net plans. New subsection (d) is added to require the Department to decide within a specified timeframe whether to allow disenrollment; otherwise the request to disenroll is considered approved. This amendment allows the State to be in compliance with the Balanced Budget Act of 1997 that revised various areas of the Medicaid law as it applies to managed care programs. The Medicaid law allows an enrollee to request disenrollment from a health plan and also requires the State to decide within a specific timeframe.
7. §17-1728-30, Enforcement and termination of contract with participating health plan. This section is added to allow provisions for the enforcement and termination of contract with participating health plan. This section states that the enforcement and termination of contract provisions described in chapter 17-1727 shall apply to health plan participating in QUEST-Net. The amendment allows the State to be in compliance with the Balanced Budget Act of 1997 that revised various areas of the Medicaid law as it applies to managed care programs.
8. §17-1728-32, Purpose. This section is amended to delete the provision that limits QUEST-Net participation to certain children who were formerly eligible under QUEST related programs.
9. §17-1728-33, Children who are not disabled or blind. This section is repealed.
10. §17-1728-34, QUEST-Net coverage for children who are not blind or disabled. Subsections (b) through (1) are repealed, as these subsections will be addressed in new section 17-1728-34.1.
11. §17-1728-34.1, Initial enrollment in QUEST-Net for children who are not blind or disabled. This section is added to address and describe the enrollment requirements for a child who is not blind or disabled. These requirements were originally addressed under §17-1728-34; the new provisions include: 1) child was not enrolled in a QUEST plan and will not be assessed a premium-share; 2) child was not enrolled in a QUEST plan and will be assessed a premium-share; 3) child was enrolled in a QUEST plan and will not be assessed a premium-share; 4) child was enrolled in a QUEST plan and is assessed a premium-share; 5) in the absence of choice of plan in a rural service area, a child who resides in that particular service area and will not be assessed a premium-share shall be enrolled in the participating plan; 6) requirements for a child who resides in an area that has one participating plan and will be assessed a premium-share; 7) allowing as an exception, violations by health plan as specified in sections 17-1727-61 and 17-1727-62 to comply with the Balanced Budget Act of 1997 that revised various areas of the Medicaid law as it applies to managed care programs. The Medicaid law allows an enrollee to change enrollment from one medical plan to another outside of the annual open enrollment period for that reason; and 8) allowing for flexibility as unanticipated circumstances may affect when the change in enrollment as a result of an open application period will be effective.
12. §17-1728-34.2, Effective date of enrollment in QUEST-Net for children who are not blind or disabled. This section is added to address the effective date of enrollment for applicants newly approved for coverage and the effective date of enrollment resulting from a change from one plan to another.
13. §17-1728-34.3, Coverage of QUEST-Net children who are not blind or disabled prior to the date of enrollment. This section is added to allow coverage of health care costs by the Department on a fee for service basis as of the date of coverage through the date of enrollment for a child-applicant who is initially determined eligible under QUEST-Net.
14. §17-1728-36, Financial responsibility of child enrollees. Adding subsection (c) to state that a child enrollee whose countable family income does not exceed two hundred fifty per cent FPL for a family of applicable size shall not be assessed a premium-share amends this section. Subsection (c) is renumbered (d) and amended to address the premium-share requirements for a child whose countable family income is greater than: two hundred fifty per cent, but does not exceed two hundred sixty-five per cent FPL; two hundred sixty-five per cent, but does not exceed two hundred eighty per cent FPL; and two hundred eighty per cent FPL.
15. §17-1728-37, Disenrollment from QUEST-Net plans. New subsection (d) is added to require the Department to decide within a specified timeframe whether to allow disenrollment; otherwise the request to disenroll is considered approved. This amendment allows the State to be in compliance with the Balanced Budget Act of 1997 that revised various areas of the Medicaid law as it applies to managed care programs. The Medicaid law allows an enrollee to request disenrollment from a health plan and also requires the State to decide within a specific timeframe.
16. §17-1728-38, Enforcement and termination of contract with participating health plan. This section is added to allow provisions for the enforcement and termination of contract with participating health plan. This section states that the enforcement and termination of contract provisions described in chapter 17-1727 shall apply to health plans participating in QUEST-Net. The amendment allows the State to be in compliance with the Balanced Budget Act of 1997 that revised various areas of the Medicaid law as it applies to managed care programs.
17. §17-1728-41, Purpose. This section is amended to delete the provision that limits QUEST-Net participation to certain blind and disabled children formerly eligible under the fee-for-service coverage for blind and disabled recipients or under QUEST-related programs.
18. §17-1728-42, Blind or disabled children who become ineligible for fee for service coverage. This section is repealed.
19. §17-1728-43, Children who become ineligible for QUEST-related program and the fee for service coverage for the blind or disabled. This section is repealed.
20. §17-1728-44, QUEST-Net coverage for blind and disabled children. New sub- section (c) is added to state that the provisions for the effective date of authorization for disabled children under age nineteen are described in chapter 17-1735.
21. §17-1728-45, Financial responsibilities of blind and disabled children in QUEST-Net. This section is amended by amending subsection (a) to state that a blind or disabled child enrollee whose countable family income does not exceed two hundred fifty per cent FPL for a family of applicable size shall not be responsible for a share of the childs monthly medical expenses. Adding subsection (b) to address a blind or disabled child whose countable family income exceeds two hundred fifty per cent FPL for a family of applicable size shall be responsible for a share of the childs monthly medical expenses. Subsection (b) (e) were renumbered (c) (f), respectively.
Renumbered subsections (d) and (e) are amended to address the spenddown requirements for a blind or disabled child whose countable family income is greater than: two hundred fifty per cent, but does not exceed two hundred sixty-five per cent FPL; two hundred sixty-five per cent, but does not exceed two hundred eighty per cent FPL; and two hundred eighty per cent FPL.
CHAPTER 17-1732 COVERAGE OF BLIND OR DISABLED PREGNANT WOMEN AND CHILDREN:
§17-1732-15, Method of coverage. Subsection (b) is deleted as a medical assistance identification card or coupon is no longer proof of eligibility for coverage. Effective 11/02, providers must use the information on the plastic identification card to verify the eligibility of a recipient by contacting the Automated Voice Response System. Subsection (c) is renumbered to subsection (b) and the word coupons is replaced with a coupon.
CHAPTER 17-1737 SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL ASSISTANCE PROGRAM
1. §17-1737-72, Durable medical equipment. A new subsection (d) is added to state that not more than one wheelchair of any kind is allowed, unless there is a significant change in the recipients condition that justifies another wheelchair. Subsections (d) through (k) is renumbered (e) through (l), respectively. The newly renumbered subsection (j) is amended by adding the following as items not covered by the medical assistance program:
a) Air filters;
b) DME modifications to the house including, but not limited to, ceiling lifts, wheelchair lifts, elevators, and stair climbers;
c) Feeder chairs when the recipient has another seating system, such as a wheelchair;
d) Car seats and booster seats for individuals of all ages;
e) Infant or child strollers; and
f) High chairs or chairs used for feeding.
A new subsection (m) is added to state that Medicares criteria is followed for the coverage of durable medical equipment unless specifically stated elsewhere. This provision also applies to the maintenance, replacement, and repair of durable medical equipment.
2. §17-1737-73, Medical supplies. Subsection (d) is amended to state that bowel and bladder incontinence care supplies are not covered with the exception of diapers, underpads and gloves for a recipient age three or older. A new subsection (e) is added to state that Medicares criteria is followed for the coverage of medical supplies unless specifically stated elsewhere. This provision also applies to the maintenance, replacement, and repair of medical supplies.
3. §17-1737-74, Prosthetic and orthotic appliances. Subsection (c) paragraph (2) is amended by replacing the phrase stock conventional and stock orthopedic with Orthopedic and therapeutic. It is also amended to state that if an individual is diabetic, orthopedic and therapeutic shoes may be covered when prescribed by a physician and provided by a prosthetist or an orthotist.
4. §17-1737-84, Exclusions and limitations. Subsection (b) is amended as follows: (a) Paragraph (12) is amended to correct a typographical error; (b) Paragraphs (26) and (27) is deleted. The reference to infant or child car seats and infant or child strollers were placed in section 17-1737-72; (c) Paragraph (28) is renumbered to (26); and (d) New paragraphs (27) and (28) were added to exclude modifications to motor vehicles and equipment to access motor vehicles as services that the medical assistance program will not pay for. A new subsection (d) is added to state that a medical service, supply, or durable medical equipment excluded from coverage may be approved on a case by case basis by the department if there is sufficient justification to support the medical necessity, as determined by its medical consultant. Subsections (d) and (e) is renumbered (e) and (f), respectively.
5. §17-1737-101, Hospice care. Subsection (d) is amended as a housekeeping measure. In addition to the two periods of ninety days each, subsequent periods of sixty days will be allowed unless Medicare requirements for continuing services are not met. Previously, one subsequent period of thirty-days was allowed during the individuals lifetime.
A public hearing will be held at the following time and place:
Monday, June 4, 2007, 1:30 p.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
88 Kanoelehua Avenue, Room 107
Hilo, Hawaii 96720 (933-0339)
West Hawaii Section
Lanihau Professional Center
75-5591 Palani Road, Ste. 3004
Kailua-Kona, Hawaii 96740 (327-4970)
Kauai Section
4473 Pahee Street, Suite A
Lihue, Hawaii 96766 (241-3575)
Maui Section
210 Imi Kala Street, Suite 101
Wailuku, Hawaii 96793 (243-5780)
Molokai Section
State Civic Center
65 Makaena Street, Room 110
Kaunakakai, Hawaii 96748 (553-1758)
Lanai Unit
Call toll free 1-800-894-5755
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, 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
(SB05529050 5/4/07) LILLIAN B. KOLLER, DIRECTOR
