HAR §17-1711.1-29. Purpose

This subchapter describes the process to determine eligibility for an individual who is applying for participation in a medical assistance program. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.907) (Imp: HRS §346-14, 42 C.F.R. §435.907) UNOFFICIAL 1711.1-14 §17-1711.1-30 Presumptive eligibility submitted by a qualified hospital. (a) The department shall provide Medicaid to certain individuals who are determined presumptively eligible by a qualified hospital. (b) Approval for presumptive eligibility shall be limited to the coverage groups as determined by the department. (c) The department shall establish standards, policies, and measures of quality outcomes to qualify, and as appropriate disqualify, hospitals approved to determine presumptive eligibility. (d) The applicant shall be subject to departmental fraud penalties or recovery requirements for false or withheld information. [Eff 09/30/13] (Auth: HRS §§346-l4, 346-29; 42 C.F.R. §§435.906, 435.907, 435.908, 435.1110) (Imp: HRS §346-29; 42 C.F.R. §§435.906, 435.907, 435.908, 435.1110) §17-1711.1-31 Expedited processing for emergency medical services. (a) An application shall be processed within two working days when: (1) The applicant is suffering from an emergency medical condition for which covered medical services are available; and (2) Failure to receive immediate treatment would result in any of the following consequences; (A) Serious risk of disease; (B) Threat to life or vital function; (C) Serious health complication; or (D) Serious irreparable harm. (b) The applicant shall be required to submit the following: (1) An application for medical assistance; and (2) The prescribed departmental form, signed by a licensed physician, advance practice registered nurse or dentist, certifying the need for immediate medical treatment based on any of the reasons in subsection (a) and that the individual will not be treated UNOFFICIAL 1711.1-15 unless the department determines eligibility for medical assistance. (c) The applicant shall be subject to departmental fraud penalties or recovery requirements for false or withheld information. [Eff 09/30/13] (Auth: HRS §346-14; 42 C.F.R. §435.911, 435.930, 435.945) (Imp: 42 C.F.R. §435.911, 435.930, 435.945) §17-1711.1-32 Determination of eligibility for Medicaid. (a) The department shall determine eligibility according to federal and State regulations and policies. The decision regarding eligibility or ineligibility shall be supported by facts in the applicant's record. Each application shall be determined as eligible or ineligible unless the application is withdrawn or discontinued under section 17-1711.1-22. (b) Timely dispositions of eligibility or ineligibility shall be made within: (1) Ninety days from the date of application for an applicant applying for medical assistance on the basis of disability including applications for long-term care; or (2) Forty-five days from the date of application for all other applicants. (c) A determination of eligibility or ineligibility shall be completed within the applicable time standards except in unusual circumstances such as: (1) A delay or failure of an applicant or appropriate required agency to take required action; or (2) An administrative or other type of emergency beyond the department's control. (d) The department shall not use the time standards specified in paragraph (b) of this section as a waiting period before determining eligibility or for a denial due to failure of the department to determine eligibility timely. UNOFFICIAL 1711.1-16 (e) A delay beyond the applicable time standard under paragraph (b) of this section attributed to the department shall not result in the withholding of medical assistance from the applicant. A presumption of eligibility for medical assistance shall be made: (1) Effective the ninety-first day for an applicant applying on the basis of disability including for long-term care, or on the forty-sixth day for any other applicant until a determination of eligibility is completed; and (2) The reason for the delay shall be documented in the applicant's record. (f) For an applicant subject to MAGI methodology who meets the financial requirements for eligibility and for whom the department is providing a reasonable opportunity to provide documentation of citizenship or immigration status, the department, consistent with the applicable timeliness standard, shall furnish medical assistance. (g) For an applicant who is applying for a MAGI- excepted group and for whom additional information is required to determine eligibility, eligibility shall be determined under a MAGI group until the determination of eligibility on any other basis is completed. (h) For an individual determined ineligible for Medicaid, the department shall transfer the individual's application information for other insurance affordability programs as appropriate pursuant to 42 C.F.R. §435.1200(e). [Eff 09/30/13] (Auth: HRS §§346-14, 346-29; 42 C.F.R. §§435.907, 435.911, 435.912, 435.914, 435.945, 435.1200) (Imp: HRS §346-29; 42 C.F.R. §§435.907, 435.911, 435.912, 435.914, 435.945, 435.1200)