HAR §17-1735.2-5. Capitated payments

(a) Each participating health plan shall be paid on a capitated basis, as negotiated with the department, for an eligible individual enrolled in that health plan. (b) The department shall provide the capitated payment, as stipulated in the contract between the department and each health plan, in return for the health plan's provision of all contracted coverage for the health plan's eligible individuals. [Eff 09/30/13] (Auth: HRS §346-14) (Imp: HRS §346-14; 42 C.F.R. §430.25) §17-1735.2-6 Enforcement of contracts with participating health plan. (a) The department may monitor a participating health plan’s performance during any contract period. (b) The department may impose civil or administrative monetary penalties not to exceed the maximum amount established by federal and state statutes and regulations if the health plan: (1) Fails to provide medically necessary items and services that are required under law or under contract; (2) Imposes upon beneficiaries excess premiums and charges; (3) Acts to discriminate among an eligible individual; (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. UNOFFICIAL 1735.2-5 (c) If a health plan violates the contract conditions between the health plan and the department, federal or State statutes or regulations, the Hawaii Administrative Rules, or if there is a substantial risk to the health of an eligible individual, the department may: (1) Notify the affected individual of the violations; (2) Allow the affected individual to change plans without cause; (3) Suspend enrollment; or (4) Suspend payment. The department may also impose financial sanctions as described under the provisions of the contract between the respective plan and the department for inaccurate, incomplete, and untimely data and reports submitted to the department. (d) If a health plan continues to violate the contract conditions between the health plan and the department, federal or state statutes and regulations, or the Hawaii Administrative Rules, regardless of any other penalty that may be imposed, the department shall: (1) Appoint temporary management to oversee compliance efforts; (2) Notify the affected eligible individual of the violations; or (3) Allow the affected eligible individual to change plans without cause. (e) Temporary management may continue until the department determines that the health plan can ensure that the behavior that caused the penalty will not recur. (f) 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, as specified in the contract with the participating health plans. [Eff 09/30/13] (Auth: HRS §346-59.5) (Imp: HRS §346-14; 42 C.F.R. §§430.25; 438.700, 438.702; 438.706; 438.710) UNOFFICIAL 1735.2-6 §17-1735.2-7 Termination of contract with participating health plan. (a) The department shall have the authority to terminate the participating health plan’s contract for any or all of the following reasons: (1) Convenience; (2) Default by the health plan; (3) Expiration of the medical assistance program; (4) Failure by the health plan to abide by the contract conditions; (5) Insolvency of or declaration of bankruptcy by the health plan; (6) Failure to meet federal or state statutes, or both; or (7) Unavailability of funds. (b) When termination of contract is due to reasons identified under subsections (a)(2), (4) or (6), the department shall provide a hearing for the affected health plan prior to termination of the contract. (c) After the department notifies the health plan of its intent to terminate the contract due to reasons identified under subsections (a)(2), (4) or (6), the department may do the following: (1) Provide the affected eligible individual written notice of the department’s intent to terminate the contract; and (2) Allow the affected eligible individual to change health plans immediately without cause. [Eff 09/30/13] (Auth: HRS §346- 14) (Imp: HRS §346-14; 42 C.F.R. §§430.25; 438.708) §