Hawaii Administrative Rules
Title 17 - DEPARTMENT OF HUMAN SERVICES
Department of Human Services
Chapter 1703.1 - ADMINISTRATIVE APPEALS
Section 17-1703.1-5 - Payment status of medical assistance or coverage pending hearing
Universal Citation: HI Admin Rules 17-1703.1-5
Current through August, 2024
(a) The beneficiary is entitled to timely notice as to the status of medical assistance or coverage pending hearing.
(b) Adequate notice that medical assistance shall be reinstated and continued shall be provided where:
(1) Pertaining to eligibility or the
fee-forservice program coverage denial, the beneficiary requests a hearing
within fifteen (15) calendar days of the date of the adequate notice for
adverse action.
(2) Pertaining to a
managed care health plan's coverage denial, the beneficiary requests a hearing
from the department within ten (10) calendar days of the date of the managed
care health plan's notice for adverse action, for continuation of benefits,
which were ordered by an authorized provider, and the original period covered
by the original authorization has not expired.
(3) If the fifteenth
(15th) day or tenth
(10th) day as applicable falls on a weekend or
holiday, the fifteenth (15th) day or tenth
(10th) day as applicable shall be the first working
day following the weekend or holiday.
(4) If the last day of the month falls on a
weekend or holiday, the last day shall be the first working day following the
weekend or holiday.
(c) The medical assistance or coverage reinstated under (b) shall continue until a hearing decision is rendered unless:
(1) The
beneficiary withdraws or abandons the request for hearing as specified in
section 17-1703.1-9;
(2) Action was
due to the application or a change in state or federal law or policy;
(3) Another change affecting the
beneficiary's eligibility occurs during the hearing process and the beneficiary
fails to request a hearing after notice of the change;
(4) The beneficiary does not request
continued benefits pending a hearing decision.
(5) In the case of a managed care health plan
appeal, the time period or service limits of a previously authorized service
has been met.
(d) The department shall promptly send a notice to the beneficiary if benefits are to be reduced or discontinued pending the hearing decision for reasons other than withdrawal or abandonment of the request by the beneficiary.
(e) If, while receiving aid paid pending hearing, the beneficiary:
(1) Becomes
eligible for a reduction of spenddown amount, or premium-share amount, the
change shall be made; or
(2) Sends
a written request for and is denied a medical service, aid paid pending shall
continue and a notice of the denial shall be sent to the beneficiary. The
notice shall include a statement of the denial, reason for the denial, specific
rule supporting the denial, and the person's right to appeal the decision.
Disclaimer: These regulations may not be the most recent version. Hawaii may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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