17-1737

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HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1737
SCOPE AND CONTENTS OF THE FEE FOR SERVICE MEDICAL
ASSISTANCE PROGRAM
Subchapter 1 	General Provisions
§17-1737-1 	Purpose
§17-1737-2 	Definitions
Subchapter 2 	Inpatient and Outpatient Hospital
Services, Physicians Services
§17-1737-3 	Inpatient hospital care
§17-1737-4 	Length of inpatient hospital care and
extension of stay
§17-1737-5 	Physician services
§17-1737-5.1 	Physician assistant services
§17-1737-6 	Outpatient hospital services
§§17-1737-7 to 17-1737-10 	(Reserved)
Subchapter 3 	Psychiatric Care
§17-1737-11 	Definitions
§17-1737-12 	Authorized providers of psychiatric
services
§17-1737-13 	Psychiatric consultation
§17-1737-14 	Diagnostic and evaluative procedures
for psychiatric care
§17-1737-15 	Repealed 	[Eff 08/01/94;
R 09/14/98 	]
§17-1737-15.1 	Examination for, determination, and
certification of mental disability
§17-1737-16 	Medical evaluation
§17-1737-17 	Psychiatric service and treatment
§17-1737-18 	Inpatient psychiatric care
§17-1737-18.1 	Inpatient psychiatric Services for

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individuals under age twenty-one in
psychiatric facilities or programs
§17-1737-19 	Licensed general hospital
§17-1737-20 	Inpatient care for substance abusers
§17-1737-21 	Outpatient psychiatric care
§17-1737-22 	Exclusion to the psychiatric program
§§17-1737-23 to 17-1737-25 (Reserved)
Subchapter 4 	Long Term Institutional
Services
§17-1737-26 	Scope and purpose
§17-1737-27 	Definitions
§17-1737-28 	Eligibility requirements
§17-1737-29 	Content of NF services
§17-1737-30 	Content of ICF-MR services
§17-1737-31 	Determining the applicant's or
recipient's need for long-term
institutional services
§17-1737-32 	Authorization for admission to a NF or
ICF-MR
§17-1737-33 	Preadmission screening and annual
resident review (PASRR)
§17-1737-34 	Utilization control for NFs
§17-1737-35 	Utilization control for ICF-MRs
§17-1737-36 	Inspection of care (IOC) reviews in
ICF-MR facilities
§17-1737-37 	Other service requirements
§17-1737-38 	Termination of long-term institutional
services
§17-1737-39 	Sharing of federal financial
participation payment penalty
assessment
§17-1737-40 	Remedies for nursing facilities that do
not meet the requirements for
participation
§17-1737-41 	State-approved feeding assistant
training program
§§ 17-1737-42 	(Reserved)
Subchapter 5 	Preventive and Rehabilitative
Services
§17-1737-43 	Preventive services
§17-1737-44 	Rehabilitative services
§17-1737-44.1 	Community mental health rehabilitative
services
§17-1737-45 	Home health services

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§17-1737-46 	Family planning services
§17-1737-47 	Hysterectomy
§17-1737-48 	Sterilization
§17-1737-49 	Respiratory care services
§17-1737-50 	Home pharmacy services
§17-1737-51 	Sleep services
§17-1737-51.1 	Telehealth services
§§17-1737-52 	(Reserved)
Subchapter 6 	Early and Periodic Screening,
Diagnosis, and Treatment (EPSDT)
§17-1737-53 	Early and periodic screening, diagnosis,
and treatment (EPSDT)
§17-1737-54 	Recipient eligibility requirements
§17-1737-55 	Informing
§17-1737-56 	Periodicity schedule
§17-1737-57 	Screening
§17-1737-58 	Diagnosis and treatment
§17-1737-59 	EPSDT providers
§17-1737-60 	Continuing care provider
§17-1737-61 	Provider requirements for participation
in the medical assistance program
§17-1737-62 	Appeal and hearing
§§17-1737-63 to 17-1737-70 	(Reserved)
Subchapter 7 	Ancillary Medical Services
§17-1737-71 	Drugs
§17-1737-71.1 	Supplemental rebate agreement for a drug
§17-1737-72 	Durable medical equipment
§17-1737-73 	Medical supplies
§17-1737-74 	Prosthetic and orthotic appliances
§17-1737-75 	Dental services
§17-1737-75.1 	Repealed 	[Eff 12/07/06; R 	08/10/09]
§17-1737-76 	Visual services
§17-1737-77 	Speech, hearing and language disorders
§17-1737-78 	Hearing evaluations and devices
§17-1737-79 	Physical therapy and occupational
therapy services
§17-1737-80 	Podiatry services
§17-1737-81 	Pediatric or family nurse practitioner
Services
§17-1737-81.1 	Nurse-midwife services
§17-1737-82 	Intra-state transportation
§17-1737-83 	Out-of-state transportation
§17-1737-83.1 	Out-of-state medical services
§17-1737-84 	Exclusions and limitations

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§§17-1737-85 to 17-1737-89 	(Reserved)
Subchapter 8 	Tissue and Organ Transplantation
§17-1737-90 	Definitions
§17-1737-91 	General provisions
§17-1737-92 	Corneal transplant (keratoplasty)
§17-1737-93 	Allogenic bone marrow transplant
§17-1737-94 	Kidney transplant
§§17-1737-95 to 17-1737-99 	(Reserved)
Subchapter 9 	Hospice Service
§17-1737-100 	Definitions
§17-1737-101 	Hospice care
§17-1737-102 	Plan of care
§17-1737-103 	Eligibility for hospice care
§17-1737-104 	Election of hospice care
§17-1737-105 	Waiver of other Medicaid benefits
§17-1737-106 	Revoking the election of hospice
§17-1737-107 	Payment for hospice care
§17-1737-108 	Providers of hospice service
§17-1737-109 	Appeals and hearings
§§17-1737-110 to 17-1737-114 	(Reserved)
Subchapter 10 	Subacute Care
§17-1737-115 	Purpose
§17-1737-116 	Definitions
§17-1737-117 	General provisions
§17-1737-118 	Staff standards
§17-1737-119 	Physician services
§17-1737-120 	Subacute patient care characteristics
§17-1737-121 	Exclusions
Historical Note: 	This chapter is based substantially
upon chapter 17-1370. [Eff 6/29/92; am 11/12/93; am
2/22/94; R 08/01/94 	]
SUBCHAPTER 1
GENERAL PROVISIONS

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§17-1737-1 	Purpose. 	This chapter shall set
forth:
(1) 	Medical care and services provided to
eligible persons under the fee for service
component of the medical assistance program;
(2) 	Excluded services; and
(3) 	Conditions for payment.
[Eff 08/01/94 	] 	(Auth: 	HRS §346-14)
(Imp: 	HRS §346-14)
§17-1737-2 	REPEALED. 	[R 09/30/13]
SUBCHAPTER 2
INPATIENT AND OUTPATIENT HOSPITAL
SERVICES, PHYSICIANS SERVICES
§17-1737-3 	Inpatient hospital care. 	(a)
Inpatient hospital care means services that are
ordinarily furnished in a hospital for the care and
treatment of inpatients under the direction of a
physician, podiatrist, or dentist and which is
furnished by an institution meeting the following
requirements:
(1) 	Is not maintained primarily for the treatment
of tuberculosis, mental diseases, or Hansen's
disease;
(2) 	Is licensed as a hospital by the State;
(3) 	Meets the requirements for medicare
participation; and
(4) 	Has in effect a utilization review plan
approved by the department.
(b) 	Inpatient hospital care shall include the
following:
(1) 	Ward or semiprivate accommodations including
bed and meals, or a private room when
medically indicated;
(2) 	Nursing care;
(3) 	Drugs, dressings, and diagnostic and
therapeutic procedures as prescribed by the
attending physician; and
(4) 	Other ancillary services associated with
hospital care except private duty nursing.
(c) 	The department shall not pay for inpatient
hospital care in the following instances:
(1) 	Patients whose medical needs do not require
admission for acute inpatient care;

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(2) 	Diagnostic procedure which may be performed
on an outpatient basis;
(3) 	Personal comfort items furnished by the
hospital; and 	(4) 	Partial hospitalization,
day, evening, or night care, except for a
patient receiving a surgical procedure or
test which would permit return to the
patient's home on the same
day.[Eff 08/01/94 	] (Auth: 	HRS §346-14)
(Imp: 	42 C.F.R. §440.10)
§17-1737-4 	Length of inpatient hospital care and
extension of stay. 	(a) 	The UCC of an acute hospital
facility shall determine the medical necessity for
admission and continued stay for all recipients.
(b) 	The length of stay for the service category
maternity after the delivery of a live newborn shall be
limited to two days after delivery for a normal
delivery and four days after delivery for a Cesarean
section delivery. 	Stays exceeding these limitations
must be authorized for medical necessity by the DHS's
medical consultant or its authorized representative.
(c) 	A request for the extension of hospital stay
shall be requested only when a patient is awaiting
placement in a long term care facility. 	[Eff 08/01/94]
(Auth: 	HRS §346-14) (Imp: 	42 C.F.R. §440.230)
§17-1737-5 	Physician services. 	(a) 	Physician
services means services provided within the scope of
practice of medicine or osteopathy as defined by state
law. (b) 	Medicaid payments shall be made for medically
necessary services when the services are provided by a
physician authorized by the department at locations
including, but not limited to:
(1) 	The physician's office;
(2) 	A clinic;
(3) 	A private home;
(4) 	An approved hospital;
(5) 	An approved skilled nursing or intermediate
care facility; or
(6) 	A licensed care home or adult family boarding
home.
(c) 	For the purpose of this program, the
following physicians' services shall be non-
reimbursable:

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(1) 	Hospital visits to a patient in an
institution for tuberculosis, Hansen's
disease, or mental disease; and
(2) 	Professional services rendered to an inmate
of a public institution, including visits to
a hospital where the inmate is confined
temporarily. 	[Eff 08/01/94 	] (Auth:
HRS 	§346-14) (Imp: 	42 C.F.R. §§440.50,
441.13)
§17-1737-5.1 	Physician assistant services. 	(a)
A physician assistant is an individual who is an
employee of a supervising physician and has been
certified by the board of medical examiners, State of
Hawaii, with the department of commerce and consumer
affairs, to practice medicine under a physician
supervision. 	The supervising physician must be a
Hawaii Medicaid provider.
(b) 	Physician assistant services can only be
provided to patients who have established a physician
patient relationship with the supervising physician.
The physician assistant shall only render services that
are in the physician assistant’s scope of practice in
the State of Hawaii.
(c) 	Physician supervision:
(1) 	Means overseeing the activities of, an
accepting responsibility for, the medical
services rendered by a physician assistant.
The supervising physician also is responsible
for assuring that the physician assistant’s
services are medically appropriate for the
patient.
(2) 	Supervision may be direct. 	Direct
supervision shall require the physical
presence of the supervising physician to be
at the same location the services are
rendered and only for those services the
supervising physician is authorized to
provide that are within the scope of practice
of a physician assistant.
(3) 	If supervision by the physician is other than
direct, the physician must be in the State of
Hawaii and available at all times by two way
radio, telephone, fax machine, modem, or
other telecommunication devices. 	The
physician assistant’s progress note must
indicate that the physician was not
physically present. 	The physician must
review the progress note written by the

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physician assistant and sign and date it.
The date must be the date he or she actually
reviewed the progress note.
(4) 	A supervising physician can be a physician or
group of physicians or an osteopathic
physician and surgeon licensed to practice
medicine and surgery in the State who in
writing accepts the responsibility for
the supervision of services rendered by a
physician assistant.
(5) 	The physician assistant notes for services
shall be personally acknowledged by the
supervising physician (no personal stamps
allowed as acknowledgement) within seven
working days of service even if services are
not claimed for payment.
(d) 	The supervising physician shall report to the
department the name of any physician assistants under
their supervision. 	Any changes shall be reported by
the supervising physician.
(e) 	The physician assistant must be an employee
of the supervising physician and cannot be the owner of
or stock holder in the supervising physician’s office,
clinic, or corporation.
(f) 	A physician assistant shall meet all the
requirements in accordance with chapter 453, Section
453-5.3, HRS.
(g) 	Medical services rendered by a physician
assistant may include, but are not limited to:
(1) 	Obtaining patient histories and performing
physical examinations;
(2) 	Ordering, interpreting, or performing
diagnostic and therapeutic procedures;
(3) 	Formulating a diagnosis;
(4) 	Developing and implementing a treatment plan;
(5) 	Monitoring the effectiveness of therapeutic
interventions;
(6) 	Assist at surgery;
(7) 	Offering counseling and education to meet
patient needs; and
(8) 	Making appropriate referrals.
(h) 	The physician assistant shall introduce
themselves as physician assistant to all patients for
whom the physician assistant may provide services.
They may not advertise in any manner without the name
or names of the supervising physician or physicians,
as the case may be, or in any manner that implies that
the physician assistant is an independent
practitioner.

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(i) 	Hawaii Medicaid will reimburse physician
assistant services if services are provided at the
supervising physician’s place of business. 	All claims
for physician assistant services must be submitted by
the employing physician.
(1) 	If the degree of supervision is not met
pursuant to section 16-85-49, Hawaii
Administrative Rules, the services provided
by the physician assistant will not be
covered by Medicaid;
(2) 	Payment for physician assistant services
cannot be made directly to the physician
assistant. 	They must be made to the actual
qualified physician employer;
(3) 	Physician assistant claims are not payable
when the service is not covered by Medicaid;
(4) 	Physician assistant claims are not payable if
the service requires prior authorization and
no authorization was obtained; and
(5) 	If none of the above requirements are met,
then the service is not reimbursable under
the State Medicaid program.
[Eff 06/26/09; 	] [Auth: 	HRS
§§346-14, 453-5.3, 453-5.4) 	(Imp: 	42 C.F.R.
§§440.50, 441.13; HRS §§346-14, 	453-5.3,
453.5-4)
§17-1737-6 	Outpatient hospital services. 	Out-
patient hospital services means preventive, diagnostic,
therapeutic, rehabilitative, or palliative services
provided to an outpatient by or under the direction of
a physician or dentist and which are furnished by an
institution meeting the following requirements:
(1) 	Is licensed or formally approved as a
hospital by the State; and
(2) 	Meets the requirements for medicare
participation. 	[Eff 08/01/94 	] 	(Auth:
HRS §346-14) (Imp: 	42 C.F.R. §440.20)
§§17-1737-7 to 17-1737-10 	(Reserved).
SUBCHAPTER 3
PSYCHIATRIC CARE
§17-1737-11 	REPEALED. 	[R 09/30/13]

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§17-1737-12 Authorized providers of psychiatric
services. 	Individuals and facilities authorized to
participate under the Medicaid program shall meet the
provisions of chapter 17-1736. 	In addition the
authorized provider shall meet the following
requirements:
(1) 	Psychiatrists shall be:
(A) 	Licensed to practice in the state;
(B) 	Have completed an approved three year
residency training program or
"Certified" by the American Board of
Psychiatry and Neurology; and
(C) 	In active clinical practice;
(2) 	Psychologists shall:
(A) 	Be licensed to practice in the State;
(B) 	Have earned a doctoral degree in
clinical, educational, or counseling
psychology;
(C) 	Be in active clinical practice;
(3) 	An advanced practice registered nurse (APRN)
in behavioral health shall be:
(A) 	Licensed to practice as a registered
professional nurse in the State;
Successfully completed an accredited
advanced training program in behavioral
health;
(B) 	Have a masters in nursing with emphasis
in psychiatric nursing and currently
certified by the American Nurses
Association to practice as an advanced
(C) 	practice registered nurse in behavioral
health;
(D) 	Limited to the scope of practice a
behavioral health advanced practice
registered nurse is legally authorized
to perform under State law; and
(E) 	Initially and biennially licensed with
the department of commerce and consumer
affairs as an advanced practice
registered nurse (APRN) in mental
health.
(4) 	A licensed clinical social worker (LCSW) in
behavioral health shall:
(A) 	Be licensed to practice in the
State as a licensed clinical social
worker and meets all of the requirements
in accordance with chapter 467E, HRS;
(B) 	Be currently licensed by the department
of commerce and consumer affairs and

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uses the designation of licensed
clinical social worker; and
(C) 	Be limited to the scope of practice of a
qualified licensed clinical social
worker in behavioral health as
authorized under State law;
(5) 	General hospitals with a separate license as
a psychiatric facility under Hawaii
Administrative Rules, Title 11, chapter 93,
shall have:
(A) 	Qualified professional, technical, and
consultant personnel available to
evaluate each patient at the time of
admission;
(B) 	Qualified, professional, technical, and
supporting personnel to carry out an
intensive and comprehensive treatment
program;
(C) 	A seclusion room;
(D) 	Psychiatric services available at all
times; and
(E) 	The capability to admit voluntary and
involuntary commitments; and
(6) 	State community mental health centers
and psychiatric outpatient clinics attached
to a general hospital with a separate license
as a psychiatric facility may provide
psychiatric care through the centers'
therapeutic teams. 	A therapeutic team shall:
(A) 	Be under the direct supervision of a
psychiatrist; or
(B) 	For patients who are not prescribed
medications, be under the supervision of
a psychologist; and
(C) 	Provide care that meets the patient's
specified needs. 	[Eff 08/01/94,
am 10/26/01; am 01/06/05] 	(Auth: 	HRS
§§346-14, 467E-7, 467E-9; 42 C.F.R.
§431.10) (Imp: 	HRS §§346E-7, 346E-9;
42 C.F.R. §§405.232(a), 440.60)
§17-1737-13 	Psychiatric consultation. 	(a) 	A
psychiatrist's or psychologist's consultation shall
be for diagnostic evaluation and treatment planning of
a patient.
(1) 	Consultation shall be limited to a total of
two hours, in one or two visits, for
interview and documentation.
(2) 	Prior authorization is not required.

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(3) 	A copy of the report shall be provided to the
department's medical or psychiatric
consultant upon the department's request.
(b) 	Restrictions on psychiatric consultations are
requests by:
(1) 	Friends;
(2) 	Relatives; or
(3) 	Other interested persons. [Eff 08/01/94 	]
(Auth: 	HRS §346-14; 42 C.F.R. §431.10) (Imp:
42 C.F.R. §405.231)
§17-1737-14 	Diagnostic and evaluative procedures
for psychiatric care. 	(a) 	Psychological testing
shall be authorized as a diagnostic or evaluative
procedure.
(b) 	Prior authorization is required for all
psychological testing except when given in an inpatient
facility or when requested by the department's
professional staff.
(1) 	The request for prior authorization shall be
completed, signed, and dated by the
psychiatrist or psychologist;
(2) 	The request for prior authorization shall be
received in the medical assistance program
(medicaid) office within five working days
from the date of testing. 	The postmarked
date shall be accepted provided it is within
the five working days requirement;
(3) 	Reimbursement to the psychiatrist or
psychologist shall be denied when forms are
not received within the specified time.
(c) 	Authorization shall be for a maximum of six
hours per twelve month period.
(d) 	The number of hours authorized includes time
for interview, appraisal, and concluding documentation.
(e) 	Only time spent by a qualified psychiatrist
or psychologist in administering, monitoring, and
evaluating tests shall be reimbursable. 	Time spent by
a technician is not reimbursable.
(f) 	A copy of the testing report shall be
provided to the department's psychiatric or medical
consultant upon request.
(g) 	Testing requested by the following agencies
and individuals for their use shall not be authorized:
(1) 	Friends;
(2) 	Relatives; or
(3) 	Other interested persons.
(h) 	Evaluation to determine mental impairment for
general assistance applicants and recipients between

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eighteen and sixty-five years of age shall be completed
by designated providers. 	No prior authorization is
required. 	[Eff 08/01/94 	] 	(Auth: 	HRS §346-14;
42 C.F.R. §431.10) 	(Imp: 	42 C.F.R. §405.231)
§17-1737-15 	REPEALED. 	[Eff 08/01/94;
R 09/14/98 	] 	(Auth: 	HRS §346-14, 346-71; 42
C.F.R. §430.10) (Imp: 42 C.F.R. §405.231)
§17-1737-15.1 	Examination for, determination, and
certification of mental disability. 	(a) 	The
department shall designate providers to conduct the
mental examinations.
(1) 	Selection of the providers shall be based on
the following:
(A) 	Past history of conducting and reporting
on mental examinations that meet the
department’s standards.
(B) 	An understanding of the purpose,
pertinent issues and potential problems
of the new examination and the services
that the department expects it to
provide.
(C) 	Responsiveness and responsibility to
assist the department in achieving its
goals.
(b) 	For a determination and certification of
mental disability, the department shall designate a
board to determine and certify mental disability. 	The
following shall apply to the board to determine and
certify mental disability:
(1) 	The board shall consist of licensed
physicians who are actively engaged in
the practice of psychiatry in the State
and a licensed psychologist actively
engaged in the practice of psychology in
the State; and
(2) 	The duties of the board shall be to
determine and certify mental disability
of applicants and recipients for general
assistance. 	[Eff 09/14/98 	]
(Auth: 	HRS §§346-14,
346-71; 42 C.F.R. §430.10) 	(Imp: 	42
C.F.R. §405.231)
§17-1737-16 	Medical Evaluation. (a) 	Applicants
who have been determined eligible for medicaid due to

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mental impairment shall be required to enter into
outpatient treatment. They shall also be required to be
medically evaluated by a physician to eliminate the
possibility that their mental impairment is due to a
physical illness.
(b) 	The medical evaluation may include and shall
be limited to:
(1) 	History and physical examination;
(2) 	Complete blood count (CBC), urinalysis, and
SMAC 20 or its equivalent; and
(3) 	Additional tests or further studies may be
done if they are medically indicated.
Justification for further studies shall be
provided to the department's medical or
psychiatric consultant upon the department's
request.
(c) 	The medical evaluation shall be completed no
later than four weeks from the date of approved
benefits. The result of the medical evaluation shall be
submitted to the branch or unit requesting the
information. 	The medical evaluation shall indicate
whether the mental impairment was or was not due to a
physical illness. 	[Eff 08/01/94 	] (Auth: 	HRS
§364-14; 42 C.F.R. §430.10) (Imp: 42 C.F.R. §405.231)
§17-1737-17 	Psychiatric service and treatment.
(a) Psychiatric service shall be allowed where:
(1) 	It is provided under an individualized
treatment or diagnostic plan which may be
revised during treatment if necessary.
(2) 	Psychiatric service furnished without a
planned program of therapy does not
constitute treatment and is not reimbursable;
and
(3) 	There is a reasonable expectation that
service will improve the patient's condition.
If the patient's condition is not altered
after the authorized outpatient visits in the
authorized period of treatment the frequency
and number of subsequent outpatient visits
requested may be reduced.
(b) 	A psychiatrist shall serve as a source of
information and guidance when psychiatric service is
provided by authorized mental health therapeutic teams;
(c) 	Drug management alone shall not be considered
psychiatric care but shall be considered general
medical care. 	Payments for drug management shall be
made to:

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(1) 	Authorized outpatient clinics for the cost of
the drugs; or
(2) 	Psychiatrists at a general medical visit rate
when accepting referrals for the purpose of
prescribing psychiatric medications or
evaluation of psychiatric medications.
(d) 	Psychiatric treatment shall be authorized
for: (1) 	Individual therapy, in a behavioral or
analytic framework;
(2) 	New but non-experimental modes of therapy
with prior authorization. 	The prior
authorization will be granted if the provider
can demonstrate adequate training and
experience in that particular mode of
therapy;
(3) 	Group therapy or its variant, including
family therapy, which can provide dimensions
of treatment not available by other modes of
treatment;
(4) 	Combined therapy, a combination of group and
individual psychotherapy, except that:
(A) 	Visits shall be either for group or
individual therapy, but not for both, on
the same day;
(B) 	The patient may have different
therapists for group and individual
psychotherapy; but
(C) 	The involved therapists must be
co-jointly responsible for coordinating
the care and treatment of the patient;
(5) 	Maintenance therapy, provided by physicians
other than psychiatrists where:
(A) 	The physician shall prescribe
psychiatric medication and observe the
patient for any changes in the patient's
condition or behavior;
(B) 	The physician shall provide supportive
care, however, justification and prior
authorization shall be required on the
designated form requesting outpatient
care if supportive care visits are made
more frequently than monthly;
(C) 	Psychiatric consultation by a
psychiatrist shall be readily available
to the physician providing maintenance
therapy; and
(D) 	Reimbursement for maintenance therapy
shall be equivalent to that of a general
medical office visit; and

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(6) 	Patients with alcohol and drug problems may
require monitoring by pertinent laboratory
data. 	Such decisions regarding the
monitoring of data will be decided after
consultation and approval of the treating
physician.
(e) 	Exclusions for psychiatric care and treatment
are those for:
(1) 	Sex;
(2) 	Marriage;
(3) 	Diet;
(4) 	Employment counseling;
(5) 	Primal therapy; (
(6) 	Long term character analysis;
(7) 	Marathon group therapy;
(8) 	Consortiums; and
(9) 	Other modalities as determined by the
department. 	[Eff 08/01/94 	] (Auth:
HRS §346-14; 42 C.F.R. §431.10) (Imp: 	42
C.F.R. §405.231)
§17-1737-18 	Inpatient psychiatric care. 	(a)
Inpatient psychiatric care shall be provided only in an
authorized psychiatric facility and by authorized
psychiatric providers.
(b) 	Admission to a psychiatric facility shall be
by: (1) 	A psychiatrist; or
(2) 	A non-psychiatrist physician with a
psychiatrist concurring that admission is
needed.
(c) 	Authorization for inpatient psychiatric care
is required for:
(1) 	All application or pending cases; and
(2) 	Medicaid patients with third party coverage
or any other available resources except for
medicare.
(d) 	The department of human services form for
medical authorization shall be used to request
authorization for inpatient psychiatric care. 	The
following procedures shall be taken:
(1) 	The form shall be completed by the inpatient
psychiatric facility and shall be signed and
dated by a psychiatrist or countersigned and
dated by a psychiatrist when the patient is
admitted by non-psychiatrist physician;
(2) 	The psychiatric facility and the physician
shall both be responsible for submitting the

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form to the medical assistance program
(medicaid) office;
(3) 	The form shall be received in the medical
assistance program (medicaid) office of the
department within five working days from the
time of the patient's admission. 	The
postmarked date shall be accepted provided it
is within the five working days requirement
from the time of patient's admission;
(4) 	Reimbursements to the physician and
psychiatric facility is subject to denial
when forms are not received within the
specified time;
(5) 	A form shall be submitted for each admission;
and
(6) 	An extension form will not be required
regardless of length of stay.
(e) 	The length of hospital stay is applicable to
all categories and the following shall be followed:
(1) 	No more than thirty days per calendar year
shall be authorized. 	Inpatient days not used
in the authorized calendar year shall not be
added to the inpatient days allowed for the
following calendar year;
(2) 	The number of inpatient days available
through a third party coverage shall be
counted as part of the authorized number of
days under Medicaid. 	The psychiatric
facility shall apply the number of
inpatient days that are available from the
third party resource to the authorized number
of days under Medicaid; and
(3) 	One inpatient day can be exchanged for two
outpatient hours.
(f) 	Emergency inpatient psychiatric care shall be
provided as follows:
(1) 	In communities where a psychiatric facility
is not readily available, emergency inpatient
psychiatric service may be provided for up to
forty-eight hours at the closest licensed
general hospital; and
(2) 	A patient shall be transferred to an
authorized psychiatric facility or to a
long-term psychiatric facility if the
attending physician determines that the
patient requires inpatient psychiatric
service beyond the forty-eight hour period.
(g) 	Voluntary patients may obtain psychiatric
inpatient hospital passes only as needed for discharge

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1737-18
planning purposes. 	Involuntary patients will be
regulated according to legal requirements.
(1) 	A patient is authorized eight hours to assist
in his discharge preparation. 	The hours may
be used in a flexible and judicious manner
throughout the duration of admission.
(2) 	Exceptions may be made for patients who will
benefit from program under the auspices of
the treating hospital.
(3) 	All other types of hospital passes are not
reimbursable. 	[Eff 08/01/94;
am 06/19/00 	] 	(Auth: 	HRS §346-14; 42
C.F.R. §431.10) (Imp: 	HRS §431M-4; 42 C.F.R.
§§440.10, 440.160)
§17-1737-18.1 	Inpatient psychiatric Services for
individuals under age twenty-one in psychiatric
facilities or programs. 	(a) 	Inpatient psychiatric
services for recipients under age twenty-one shall be
provided:
(1) 	Under the direction of a physician;
(2) 	By:
(A) 	A psychiatric hospital or an inpatient
psychiatric program that is accredited
by the joint commission on accreditation
of healthcare organizations; or
(B) 	A psychiatric facility which is
accredited by the joint commission on
accreditation of healthcare
organizations, the commission on
accreditation of rehabilitation
facilities, the council on accreditation
of services for families and children,
or by any other accrediting
organization, with comparable standards
that is recognized by the State; and
(C) 	Is authorized to practice under the
Medicaid program and meets the
provisions of chapter 17-1736.
(3) 	Before the individual reaches the age
twenty-one or, if the individual was
receiving the services immediately before he
or she reached age twenty-one, services will
continue until the earlier of the following:
(A) 	The date the individual no longer
requires the services; or
(B) 	The date the individual reaches age
twenty-two.

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1737-19
(4) 	To an individual certified to be in need of
the services.
(A) 	Ambulatory care resources available in
the community do not meet the treatment
needs of the recipient; and
(B) 	The services can reasonably be expected
to improve the recipient’s condition or
prevent further regression so that the
services will no longer be needed.
(b) 	The individual shall receive active treatment
which involves a developed and supervised individual
plan of care to improve the individual’s condition to
the extent that inpatient care is no longer necessary.
The plan of care shall:
(1) 	Be based on a diagnostic evaluation that
includes examination of the medical,
psychological, social, behavioral and
developmental aspect of the recipient’s
situation and reflects the need for inpatient
psychiatric care;
(2) 	Be developed by a team of professionals in
consultation with the recipient, and his
parents, legal guardians, or others in whose
care he will be released after discharge;
(3) 	State treatment objectives;
(4) 	Prescribe an integrated program of therapies,
activities, and experiences designed to meet
the objectives;
(5) 	Include, at an appropriate time,
post-discharge plans and coordination of
inpatient services with partial discharge
plans and related community services to
ensure continuity of care with the
recipient’s family, school, and community
upon discharge;
(6) 	The plan shall be reviewed every thirty days
to:
(A) 	Determine that services being provided
are or were required on an inpatient
basis; and
(B) 	Recommend changes in the plan as
indicated by the recipient’s overall
adjustment as an inpatient.
(c) 	The individual plan of care must be developed
by an interdisciplinary team of physicians and other
personnel who are employed by, or provide services to
patients in, the facility.
(1) 	The interdisciplinary team shall be capable
of:

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(A) 	Assessing the recipient’s immediate and
long-range therapeutic needs,
developmental priorities, and personal
strengths and liabilities;
(B) 	Assessing the potential resources of the
recipient’s family;
(C) 	Setting treatment objectives; and
(D) 	Prescribing therapeutic modalities to
achieve the plan’s objectives.
(2) 	The team shall include, as a minimum, either:
(A) 	A board-eligible or board-certified
psychiatrist; or
(B) 	A clinical psychologist who has a
doctoral degree and a physician licensed
to practice medicine or osteopathy;
(3) 	The team shall also include one of the
following:
(A) 	A psychiatric social worker;
(B) 	A registered nurse with specialized
training or one year’s experience in
treating mentally ill individuals; or
(C) 	An occupational therapist who is
licensed, if required by the State, and
who has specialized training or one year
of experience in treating mentally ill
individuals;
(d) 	Prior authorization is required before
inpatient psychiatric services for recipients under age
twenty-one are provided. 	[Eff 02/16/02 	]
(Auth: 	HRS §346-14; 42 C.F.R. §431.10) 	(Imp: 	42
C.F.R. §§441.150 through 441.156)
§17-1737-19 	Licensed general hospital. 	(a) 	A
patient admitted to a licensed general hospital for a
medical condition may be provided psychiatric care on
the medical unit only when it is determined through
psychiatric consultation that the patient's condition
does not require the patient to be admitted to a
psychiatric facility.
(1) 	A maximum of four visits for psychiatric care
shall be allowed.
(A) 	Prior authorization is required before
inpatient psychiatric services for
recipients under age twenty-one are
provided.
(2) 	Prior authorization shall be required through
the designated outpatient request form if the
patient requires more treatment than the
authorized four hours. 	It shall be noted in

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the required form that the patient is in a
licensed general hospital.
(b) 	Prior authorization is required to admit a
patient to a psychiatric facility from a medical unit
for all applications and pending cases.
(1) 	The appropriate department of human services
form for prior medical authorization shall be
used to request authorization for inpatient
psychiatric care.
(2) 	All other appropriate policies for inpatient
psychiatric care shall apply.
[Eff 08/01/94 	] 	(Auth: 	HRS §346-14;
42 	C.F.R. §§431.10, 405.1020) 	(Imp: 	42
C.F.R. §§405.116, 405.1020)
§17-1737-20 	Inpatient care for substance abusers.
(a) 	Prior authorization for medical pensioners plan
cases are required for inpatient care for alcohol and
non-alcohol substance abuse regardless of whether the
patient is admitted to a medical unit of the hospital
or to the psychiatric unit of the hospital.
(b) 	Inpatient care for alcohol substance abuse
shall be as follows:
(1) 	Patients requiring only detoxification shall
be referred to a detoxification facility for
treatment;
(2) 	If a detoxification facility is not
available, the attending physician may admit
the patient to a licensed general hospital;
and
(3) 	Patients requiring detoxification in addition
to psychiatric or medical care shall be
referred to an authorized inpatient
psychiatric facility for psychiatric care or
to a licensed general hospital for medical
care.
(c) 	Inpatient care for non-alcohol substance
abuse shall be as follows:
(1) 	Patients requiring only detoxification for
substance abuse shall be referred by the
attending physician to an appropriate
facility for detoxification; and
(2) 	Patients requiring detoxification in addition
to psychiatric or medical care shall be
referred by the attending physician to an
appropriate facility for treatment.
(d) 	Prior authorization shall not be required for
the initial forty-eight hours of emergency care. 	If
the attending physician determines that the patient

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requires further inpatient care the patient shall be
transferred to an appropriate facility.
(e) 	Maximum hospital stay for patients requiring
only detoxification shall be ten days.
(f) 	Hospital stay for patients requiring more
than ten days for detoxification may be allowed
provided that there is a justification that patient
requires more than ten days for inpatient care.
[Eff 08/01/94 	] 	(Auth: 	HRS §346-14; 42 C.F.R.
§§431.10, 405.1020) (Imp: 	42 C.F.R. §§405.116,
405.1020)
§17-1737-21 	Outpatient psychiatric care. (a)
Outpatient psychiatric care shall be provided by
authorized psychiatric providers.
(b) 	Prior authorization is required for
outpatient psychiatric care for:
(1) 	All eligible recipients in need of outpatient
psychiatric care;
(2) 	Non-Medicaid patients who become eligible for
medical assistance and whose outpatient
visits may be covered retroactively. 	The
prior authorization form shall be submitted
by the provider immediately upon learning
that the patient became eligible for
retroactive coverage; and
(3) 	Medicaid patients with third party coverage
or any other available resources except for
Medicare.
(c) 	The appropriate department of human services
form for prior medical authorization shall be used to
request authorization for outpatient psychiatric care.
The following procedure shall be taken:
(1) 	The form shall be completed, signed, and
dated by the psychiatrist or psychologist;
(2) 	The form shall be received in the medical
assistance program (Medicaid) office of the
department within five working days from the
time of the patient's first visit. 	The
postmarked date shall be accepted provided it
is within the five working days requirement
from the time of patient's first visit;
(3) 	Subsequent requests shall be submitted to the
medical assistance program (Medicaid) office
within five working days from the date of the
last visit authorized. 	The postmarked date
shall be accepted provided it is within the
five working days requirement; and

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(4) 	Reimbursements to the physician or
psychologist shall be denied when forms are
not received within the specified time.
(d) 	Outpatient visits for psychiatric care shall
be as follows:
(1) 	Emergency room service in a licensed general
hospital may be provided to patients with
psychiatric problems. 	Services shall consist
of examination for clinical impression and
treatment; and Office or clinic visits shall
be a face to face, personal contact between
the patient and the authorized therapist for
therapy or for a diagnostic purpose.
(e) 	Outpatient visits shall not be reimbursed for
time spent beyond one hour for individual therapy; or
two hours for group therapy.
(f) 	The number of visits shall be as follows:
(1) 	The maximum number of visits for the primary
mode of therapy is twenty-four one hour
individual visits or twenty-four one and one-
half to two hour group visits within a twelve
month period;
(2) 	For a combination of group and individual
psychotherapy, the maximum for the primary
modality is twenty-four visits and the
maximum for the secondary modality (when
twenty-four of the primary modality is
approved) is six visits within a twelve month
period;
(3) 	Any combination of group and individual
psychotherapy is allowed, provided the total
of thirty visits and the maximum for the
primary modality are not exceeded;
(4) 	One-half hour (twenty to thirty minutes), or
one quarter hour (ten to fifteen minutes), as
well as one hour (forty-five to fifty
minutes) individual psychotherapy visits are
allowed. 	Any combination of visits is
allowed, provided the total does not exceed
twenty-four one hour visits within a twelve
month period; and
(5) 	One inpatient day can be exchanged for two
outpatient hours.
(g) 	Approval of a second request and subsequent
requests shall be based on the severity of the
patient's illness.
(1) 	Severe cases shall be allowed a maximum of
twenty-four visits within a twelve month
period;

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1737-24
(2) 	Moderate cases shall be allowed a maximum of
eighteen visits within a twelve month period;
(3) 	Maintenance cases shall be allowed a maximum
of twelve visits within a twelve month
period; and
(4) 	Personality disorders without acute crisis
shall be eligible for extension after one
year of treatment, with sufficient
justification.
(h) 	Visits not used in the authorized twelve
month period shall not be added to the outpatient
visits allowed for the following twelve month period.
(i) 	A summary of the patient-therapist
relationship may be requested at any interval after the
onset of treatment:
(1) 	The summary should include such information
as a justification for said diagnosis, a
logical expressed treatment plan and observed
changes since the onset of patient-therapist
relationship; and
(2) 	The summary shall be utilized by the
department's psychiatric consultant or by the
department's established peer review
committee to determine the number of
subsequent out-patient visits that shall be
authorized.
(j) 	Patients who have been under continuous
psychiatric treatment for longer than a year may have
their records reviewed by the department's psychiatric
consultant for progress towards rehabilitation and
general productivity of therapy before further
outpatient visits are approved. 	If the provider is in
disagreement with the department's psychiatric
consultant's determination, the case shall be referred
to the department's established peer review committee
for review.
(k) 	Psychiatric outpatient visits available
through third party coverage shall be counted as part
of a patient's authorized visits under Medicaid. 	It
shall be the provider's responsibility to apply the
number of visits available from the third party
coverage to the authorized number of visits under
Medicaid. 	[Eff 08/01/94; am 06/19/00;
am 02/16/02 	] 	(Auth: 	HRS §346-14; 42 C.F.R.
§431.10) (Imp: 	42 C.F.R. §440.20)
§17-1737-22 	Exclusions to the psychiatric
program. 	Excluded from the psychiatric program are:
Partial hospitalization, day, evening, and night care;

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(1) 	Residential treatment centers;
(2) 	Skilled nursing facilities;
(3) 	Intermediate care facilities;
(4) 	Consortiums; and
(5) 	Home visits to a residence, care home,
boarding home, or other living arrangement,
except in an emergency situation.
[Eff 02/16/02 	] 	(Auth: 	HRS §346-14; 42
C.F.R. §431.10) (Imp: 	42 C.F.R. §456.3)
§§17-1737-23 to 17-1737-25 	(Reserved).
SUBCHAPTER 4
LONG TERM INSTITUTIONAL SERVICES
§17-1737-26 	Scope and purpose. 	(a) 	This
subchapter governs the standard for payment which
providers of long-term institutional services shall
meet to qualify for medical payments for services
provided to medicaid recipients.
(b) 	This subchapter shall ensure provision of
effective and appropriate long-term institutional
services and the on-going evaluation of the quality,
appropriateness and timeliness of such services to
medicaid recipients. 	[Eff 08/01/94 	] 	(Auth:
HRS §346-14; 42 C.F.R. §§430.10, 431.10; Pub. L. No.
100-203) 	(Imp: 	42 C.F.R. §§440.40, 440.150, 440.260,
483.1)
§17-1737-27 	REPEALED. 	[R 09/30/13]
§17-1737-28 	Eligibility requirements. 	(a) 	The
individual applicant shall meet the basic eligibility
requirements of the medicaid program in order to
qualify for medicaid assistance.
(b) 	Long-term institutional services shall be
available to recipients who have been approved by the
department to receive these services.
[Eff 08/01/94 	] (Auth: 	HRS §346-14; 42 C.F.R.
§§430.10, 431.10, 442.1) (Imp: 	42 C.F.R. §§431.10,
442.1)

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1737-26
§17-1737-29 	Content of NF services. 	(a) Long-
term institutional services shall be provided by
free-standing or distinct part NFs that shall meet the
eligibility requirements specified in chapters 17-1736
and 17-1739.
(b) 	NFs shall provide:
(1) 	Skilled nursing care and related services for
residents who require medical or nursing
care;
(2) 	Rehabilitation services for the
rehabilitation of injured, disabled, or sick
persons; or
(3) 	On a regular basis, health-related care and
services to individuals who because of their
mental or physical condition require care and
services (above the level of room and board)
which can be made available to them only
through institutional facilities, and is not
primarily for the care and treatment of
mental diseases.
(c) 	NF services shall be provided either directly
by or under the general supervision of licensed
practical nurses or registered professional nurses.
(d) 	NF services shall include, but shall not be
limited to:
(1) 	Room and board;
(2) 	Administration of medication and treatment;
(3) 	Development, management, and evaluation of
the written resident care plan based on
physician orders that necessitate the
involvement of skilled technical or
professional personnel to meet the resident's
care needs, promote recovery, and ensure the
resident's health and safety;
(4) 	Observation and assessment of the resident's
unstable condition that requires the skills
and knowledge of skilled technical or
professional personnel to identify and
evaluate the resident's need for possible
medical intervention, modification of
treatment, or both, to stabilize the
resident's condition;
(5) 	Health education services provided by skilled
technical or professional personnel to teach
the recipient self care, such as gait
training and self administration of
medications;
(6) 	Provision of therapeutic diet and dietary
supplement as ordered by the attending
physician;

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1737-27
(7) 	Laundry service, including items of
recipient's washable personal clothing;
(8) 	Basic nursing and treatment supplies, such as
soap, skin lotion, alcohol, powder,
applicator, tongue depressor, cotton ball,
gauze, adhesive tape, band aids, incontinent
pad, V-pad, thermometer, blood pressure
apparatus, plastic or rubber sheet, enema
equipment, and douche equipment;
(9) 	Durable medical equipment and supplies used
by residents but which are reusable, such as
ice bag, hot water bottle, urinal, bedpan,
commode, cane, crutch, walker, wheelchair,
and siderail and traction equipment;
(10) 	Activities of the resident's choice
(including religious activities) that are
designed to provide normal pursuits for
physical and psychosocial well-being;
(11) 	Social services provided by qualified
personnel;
(12) 	A review of the drug regimen of each resident
at least once a month by a licensed
pharmacist, as required for a nursing
facility to participate in Medicaid;
(13) 	Nonrestorative or nonrehabilitative therapy,
or both, provided by nursing staff; and
(14) 	Provision of and payment for, through
contractual agreements with appropriate
skilled technical or professional personnel,
other medical and remedial services ordered
by the attending physician which are not
regularly provided by the provider. Other
services that may be needed, such as
transportation to realize the provision of
services ordered by the attending physician,
shall also be arranged through contractual
agreements. The contractual agreement shall
stipulate the responsibilities, functions,
objectives, service fee, and other terms
agreed to by the NF and the person or entity
that contracts to provide the service.
(15) 	Feeding assistance performed by a feeding
assistant, nurse aide, or nurse. 	The feeding
assistant must work under the supervision of
a registered nurse or licensed practical
nurse who is licensed to practice in Hawaii.
[Eff 08/01/94; am 02/10/97; am 05/05/05; am
05/24/07] 	(Auth: 	HRS §346-14; 42 C.F.R.
§§430.10, 431.10, 483.1) 	(Imp: 42 C.F.R.

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§§440.40, 483.1, 483.20, 483.30, 483.35,
483.160)
§17-1737-30 	Content of ICF-MR services. 	(a)
Long-term institutional services shall be provided by
freestanding or distinct part ICF-MR facilities that
shall meet the eligibility requirements specified in
chapters 17-1736 and 17-1739.
(b) 	ICF-MR facilities shall provide inpatient or
authorized community-based services designed primarily
for the treatment and rehabilitation of the mentally
retarded or persons with related conditions.
(c) 	ICF-MR services shall include but not be
limited to:
(1) 	Twenty-four hour supervision of mentally
retarded individuals or persons with related
conditions in a protected residential
setting;
(2) 	A continuous active treatment program which
includes aggressive, consistent
implementation of a program of specialized
and generic training, treatment health
services and related services described in
this subsection, that is directed towards:
(A) 	The acquisition of the behaviors
necessary for the client to function
with as much self-determination and
independence as possible; and
(B) 	The prevention or deceleration of
regression or loss of current optimal
functional status.
Active treatment does not include services to
maintain generally independent clients who
are able to function with little supervision
or in the absence of a continuous active
treatment program;
(3) 	Interventions to manage inappropriate client
behavior that are employed with sufficient
safeguards and supervision to ensure that the
safety, welfare and civil and human rights of
clients are adequately protected;
(4) 	Sufficient direct care staff to manage and
supervise clients in accordance with their
individual program plans, to respond to
injuries and symptom of illness and to handle
emergencies in each defined residential
living unit;

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(5) 	Preventive and general medical care as well
as annual physical exams of each client that
include:
(A) 	Evaluation of vision and hearing;
(B) 	Immunizations, using as a guide the
recommendations of the Public Health
Service Advisory Committee on
Immunization Practices or of the
Committee on the Control of Infectious
Diseases of the American Academy of
Pediatrics;
(C) 	Routine screening lab exams and special
studies; and
(D) 	TB control, appropriate to the
facility's population, and in accordance
with the recommendations of the American
College of Chest Physicians or the
section of diseases of the American
Academy of Pediatrics, or both;
(6) 	Licensed nursing services sufficient to care
for clients health needs, including those
clients with medical care plans;
(7) 	Provision of or arrangements for
comprehensive dental diagnostic services and
comprehensive dental treatment services that
include:
(A) 	The availability of emergency dental
treatment on a twenty-four hours a day
basis by a licensed dentist; and
(B) 	Dental care needed for relief of pain
and infections, restoration of teeth,
and maintenance of dental health;
(8) 	Provision of or arrangements for routine and
emergency drugs and biologicals that are
administered in compliance with physician's
orders;
(9) 	At least three meals a day that comprise a
nourishing, well-balanced diet including
modified and specially prescribed diets;
(10) Physician services available twenty-four
hours a day to:
(A) 	Develop and maintain, in coordination
with licensed nursing personnel, a
medical care plan of treatment for a
client if the physician determines that
an individual client requires
twenty-four hours licensed nursing care;
and

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1737-30
(B) 	Participate in establishing an initial
individual program plan for a newly
admitted client; and
(11) 	Provision of necessary services, including
emergency and other health care through
contractual agreements which shall:
(A) 	Stipulate the responsibilities,
functions, objectives, service fee, and
other terms agreed to by the ICF-MR and
the provider; and
(B) 	Provide that the ICF-MR is responsible
for assuring that the outside services
meet the standards for quality of
services. 	[Eff 08/01/94;
am 02/10/97 	] 	(Auth: 	HRS §346-
14; Pub. L. No. 100-203; 42 C.F.R.
§§430.10, 431.10, 483.400) 	(Imp: 	Pub.
L. No. 100-203; 42 C.F.R. §§483.400;
483.480)
§17-1737-31 	Determining the applicant's or
recipient's need for long-term institutional services.
(a) 	The provision for the determination of need for
admission to a long-term institution are based on a
physician's and other appropriate health care
professional's assessment of the applicant's or
recipient's condition and recommendation of the
applicant's or recipient's need for a specific acuity
level (or level of medical care).
(b) 	Their recommendation of the applicant's or
recipient's need for a specific acuity level (or level
of medical care) shall be based on the following
criteria:
(1) 	Acuity Level A recipient requires licensed
nursing and ancillary nursing personnel
services on a regular and long-term basis to
maintain, improve, or safeguard health, or to
minimize disability or pain. 	The services
provided shall be beyond room, board, and
personal care services available in personal
care home, and shall:
(A) 	Be available to recipients who require
assistance with the normal activities of
daily living twenty-four hours a day;
(B) 	Be ordered by a physician and shall be
provided under the direction of the
attending physician or staff physician;
(C) 	Be planned, provided, and maintained by
licensed and ancillary nursing personnel

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and other professional personnel, in
accordance with a written resident care
plan;
(D) 	Be provided on an inpatient basis only
after consideration of the recipient's
condition and the feasibility and
availability of utilizing more
economical alternative facilities and
services have been ruled out; and
(E) 	Be less than twenty-four hours of
skilled nursing or regular
rehabilitation services;
(2) 	Acuity Level B recipient shall:
(A) 	Be evaluated by an interdisciplinary
professional team, who shall recommend
admission based on their evaluation,
which shall be completed not more than
three months prior to admission, or
before the ICF-MR requests payment for a
client applying for medicaid after
admission;
(B) 	Be diagnosed as mentally retarded or
with other related conditions; and
(C) 	Require the medical care and special
services that are appropriately obtained
from an ICF-MR as described in section
17-1737-30; and
(3) 	Acuity Level C recipient requires skilled
nursing services provided directly or under
the general supervision of registered
professional nurses on a twenty-four hour
basis, rehabilitation services, or both and
shall:
(A) 	Be provided on a seven-days a week
basis, except rehabilitation services
may be needed by the recipient and
provided on a five-days a week basis;
and
(B) 	Include subparagraphs (1)(A),(B),(C),
and (D). [Eff 08/01/94 	] 	(Auth:
HRS §§346-14, 346-49; Pub. L. No. 100-
203; 42 C.F.R. §§430.10, 431.10) 	(Imp:
Pub. L. No. 100-203; 42 C.F.R.
§§435.1009, 440.40, 440.150, 456.270,
456.271, 456.370, 483.30, 483.440)
§17-1737-32 	Authorization for admission to a NF
or ICF-MR. 	(a) 	Authorization by the department for
the recommended acuity level (or level of medical care)

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1737-32
required by an applicant or recipient shall be in
accordance with the provisions of chapter 1739 and
section 17-1737-31.
(b) 	Authorization granted by the department for
admission to a NF or ICF-MR shall be based on the
determination that the applicant or recipient requires
the services stipulated in sections 17-1737-29 and 17-
1737-30. 	[Eff 08/01/94; am 02/10/97 	] 	(Auth:
HRS §§346-14, 346-49; 42 C.F.R. §§430.10, 431.10,
435.1009) 	(Imp: 	42 C.F.R. §§435.1009, 440.150,
456.271, 456.370, 483.440)
§17-1737-33 	Preadmission screening and resident
review (PASRR). 	The state PASRR program shall require
that:(1) 	NFs shall not admit, on or after January 1,
1989, any new resident with:
(A) 	"Mental illness" as defined in section
17-1737-27 unless the state mental
health authority has determined, based
on an independent physical and mental
evaluation performed by a person or
entity other than the state mental
health authority, prior to admission,
whether:
(i) 	Because of the physical and mental
condition of the individual, the
individual requires the level of
services provided by a NF; and
(ii) If the individual requires such
level of services, the individual
requires active treatment for
mental illness; or
(B) 	"Mental retardation" or "persons with
related conditions" as defined in
section 17-1737-27 unless the state
mental retardation/developmental
disability authority has determined
prior to admission whether:
(i) 	Because of the physical and mental
condition of the individual, the
individual requires the level of
services provided by a NF; and
(ii) If the individual requires such
level of services, the individual
requires active treatment for
mental retardation;

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(2) 	For those residents who entered the NF prior
to January 1, 1989, and were identified with
a diagnosis of:
(A) 	"Mental illness" as defined in section
17-1737-27, the state mental health
authority shall determine whether,
because of the resident's physical and
mental condition, the resident requires:
(i) 	The level of services provided by a
NF; and
(ii) Active treatment for mental
illness; or
(B) 	"Mental retardation" or identified as
"persons with related conditions" as
defined in section 17-1737-27, the state
mental retardation/developmental
disability authority shall determine
whether because of the resident's
physical and mental condition, the
resident requires:
(i) 	The level of services provided by a
NF; and
(ii) Specialized services for mental
retardation or related conditions
in an ICF-MR;
(3) 	The nursing facility shall notify the State
mental health authority or the State mental
retardation or developmental disabilities
authority within twenty-one days after a
significant change in the physical or mental
condition of a resident who meets criteria
for mental illness or mental retardation. For
an individual with mental illness, if their
condition worsens notification must be made
to the State mental health authority within
twenty-one days. 	For individuals with mental
retardation, if their condition improves
where the individual may benefit from
specialized services, notification to the
State mental retardation or developmental
disabilities authority must be made within
twenty-one days. 	[Eff 08/01/94; am
08/25/07 	] 	(Auth: 	HRS §346-14; 42
C.F.R. §§430.10, 431.10; Pub. L. No. 100-203)
(Imp: 	Pub. L. No. 100-203; 42 C.F.R.
§483.20)
§17-1737-34 	Utilization control for NFs. 	(a)
This section defines the utilization control process

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which shall be administered in accordance with state
and federal regulations to achieve optimal quality
control of the utilization of services provided under
the state plan.
(b) 	The provisions for utilization control are as
follows:
(1) 	Providers of NF services shall admit only
those recipients whose health care needs may
be met by the facility;
(2) 	Each resident shall receive the necessary
nursing, medical and psychosocial services to
attain and maintain the highest possible
mental and physical functional status, as
defined by the comprehensive resident
assessment and plan of care;
(3) 	The NF shall operate and provide services in
compliance with all state, federal, and local
laws, regulations, and codes and with
accepted professional standards and
principles that apply to professionals
providing services in the NF;
(4) 	The services provided by or arranged by the
NF shall meet professional standards of
quality and be provided by qualified persons
in accordance with each resident's written
plan of care; and
(5) 	The following requirements regarding nurse
aides shall be met:
(A) 	A nursing facility shall not use any
individual working in the facility as a
nurse aide for more than four months
unless the individual:
(i) 	Has completed a nurse aide training
and competency evaluation program
certified by the State; and
(ii) Is competent to provide such
services;
(B) 	A nursing facility shall provide for
individuals used as nurse aides a nurse
aide training competency and evaluation
program certified by the State and such
preparation as may be necessary to
complete such a program;
(C) 	A nursing facility shall not permit an
individual to serve as a nurse aide or
provide services of a type for which the
individual has not demonstrated
competency. 	A nursing facility shall
not use such an individual as a nurse
aide unless the facility has inquired of

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1737-35
the state registry as to information in
the registry concerning the individual;
(D) 	A nursing facility shall not use any
individual as a nurse aide if there has
been a period of twenty-four consecutive
months during which no nursing or
nursing-related services were performed
by the individual for monetary
compensation. 	Such individual will need
to complete a new training and
competency evaluation program;
(E) 	A nursing facility shall provide regular
performance reviews and regular in-
service education to assure that
individuals used as nurse aides are
competent to perform services as nurse
aides, including training for
individuals providing nursing and
nursing-related services to residents
with cognitive impairments;
(F) 	Any findings of abuse or neglect of
residents or misappropriations of
residents' property by nurse aides shall
be reported to the state department of
health; and
(G) 	The State shall:
(i) 	Establish and maintain a registry
of all individuals who have
satisfactorily completed a nurse
aide training and competency
evaluation program certified by the
State;
(ii) 	The registry shall include specific
documented findings by the State of
resident neglect or abuse or
misappropriation of resident
property as well as any brief
statement of the individual
disputing the findings; and
(iii) When inquiries to the registry are
made concerning an individual
listed in the registry, any
information disclosed concerning
such a finding shall also include
disclosure of any such statement in
the registry relating to the
finding or a clear and accurate
summary of such a statement.
[Eff 08/01/94, am 08/25/07 	]
(Auth: 	HRS §346-14; 42 U.S.C.

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§§1395, 1396; Pub. L. No. 100-203;
42 C.F.R. §§431.10, 435.1009,
456.1, 483.1) 	(Imp: 	Pub. L. No.
100-203; 42 C.F.R. §§435.1009,
442.1, 456.1, 456.250, 483.1,
483.20, 483.25, 483.75)
§17-1737-35 	Utilization control for ICF-MRs. 	(a)
This section defines the utilization control process
which shall be administered in accordance with state
and federal regulations to achieve optimal quality
control of the utilization of services provided under
the state plan.
(b) 	The provisions for the utilization control
for ICF-MRs are as follows:
(1) 	A written certification or recertification
statement that the client require a specific
level of care is required as follows:
(A) 	Admission certification shall be
provided by a physician or a nurse
practitioner or a clinical nurse
specialist who is not an employee of the
facility but is working in collaboration
with a physician, on admission or not
more than sixty days prior to
authorization of medicaid payment for
the provision of long-term institutional
services to the client;
(B) 	A recertification statement shall be
provided by a physician or a physician
assistant under the supervision of a
physician or a nurse practitioner or a
clinical nurse specialist who is not an
employee of the facility but is working
in collaboration with a physician, no
more than twelve months following
certification and thereafter no more
than twelve months intervals until
discharge from the ICF-MR;
(C) 	The written certification and
recertification statements shall be
placed on a form designed either by the
facility or the department specifically
for certification and recertification
documentations, and said form shall be
placed in each client's active medical
record; and
(D) 	The written certification and
recertification statements shall clearly

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indicate the client's need for a
specific level of care, and shall
include:
(i) 	A physician's 	signature or
initials clearly identified with
the acronym "M.D." for medical
doctor, or "D.O." for doctor of
osteopathy;
(ii) 	A physician assistant's signature
or initials, clearly identified
with the acronym "P.A." for
physician assistant;
(iii) 	A nurse practitioner's signature or
initials, clearly identified with
the acronym "R.N.C."or "R.N."
whichever is appropriate; or
(iv) 	A clinical nurse specialist's
signature or initials clearly
identified with the acronym
"R.N.M.S." or "R.N.C.S." whichever
is appropriate; and
(v) 	The date of certification or
recertification statement is signed
or initialed by a physician or a
physician assistant or a nurse
practitioner or a clinical nurse
specialist;
(2) 	The facility shall have in effect a written
utilization review plan approved by the
department which shall include the following
methods and procedures:
(A) 	Use of cross reference file numbers in
all UR related documentation to assure
the anonymity of the medicaid client;
(B) 	Identification of the administrative
entity and sub-group of the entity
responsible for the performance of UR
and the medical staff of a medical
institution;
(C) 	Development and selection and adoption
of forms utilized for the UR process;
(D) 	Review of documentation necessary to
verify justification for continued stay
cases. 	The information shall be an
integral part of the client's medical
record and shall include the following:
(i) 	Name of the attending physician;
(ii) 	Date of admission to the facility;
(iii) 	Date of application if made after
admission to the facility;

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1737-38
(iv) 	The written plan of care;
(v) 	The reasons for and the plan for
continued stay when deemed
necessary by the attending
physician; and
(vi) 	As necessary, other documented
material to support the utilization
review committee's decision;
(E) 	Utilization review committee members
shall not be involved in the care of a
client whose case is being reviewed and
shall not be employed by, or have a
financial interest in any facility in
which the URC functions;
(F) 	URC members must include at least one
physician and one other professional
responsible for review of continued stay
cases and at least one member shall be a
QMRP;
(G) 	Development and adoption of inhouse
criteria by which continued stay cases
shall be reviewed at least once in a six
month period;
(H) 	Review by a physician member of the URC
of cases not meeting the applicable
in-house ICF-MR criteria for continued
stay; and
(I) 	Notification of continued stay denial to
the affected client shall be as follows:
(i) 	The client's QMRP shall be notified
within one working day, and an
allowance of two working days shall
be afforded to the QMRP to respond
to the URC's continued stay denial
before it becomes final; and
(ii) 	Written notification of continued
stay denial by the URC within two
working days after the final URC
determination shall be given to the
facility administrator, the client,
and the client's next of kin; and
(3) 	The facility shall operate and provide
services in compliance with all state,
federal and local laws, regulations, and
codes and with accepted professional
standards and principles that apply to
professionals providing services in the
facility. 	[Eff 08/01/94 	] 	(Auth: 	HRS
§346-14; 42 C.F.R. §§430.10, 431.10, 456.1,
483.410; 42 U.S.C. §§1395, 1396) 	(Imp: 	42

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C.F.R. §§456.350, 456.351, 456.360, 456.370,
456.380, 456.381, 456.400, 456.401, 456.405 -
456.407, 456.411 - 456.413, 456.431 -
456.438)
§17-1737-36 	Inspection of care (IOC) reviews in
ICF-MR facilities. 	The department shall be
responsible for conducting periodic inspection of care
review in ICF-MRs to evaluate the utilization of care
and services provided to the client:
(1) 	Inspection of care team members shall be
employees of the department, and may consist
of a physician or a registered nurse, and a
social worker. One of the team members shall
be a QMRP. 	If a physician is not on the
team, a physician shall be available to
provide consultation to the team;
(2) 	Frequency of inspection shall be based on the
quality of care and services provided by the
facility, and on the condition of clients in
the facility. 	However, at the minimum, each
client shall be evaluated once annually;
(3) 	No facility shall be notified of the time of
inspection more than forty-eight hours before
the scheduled arrival of the team;
(4) 	Method of inspection shall be by personal
contact with and observation of each client,
and review of each client's medical record to
determine the following:
(A) 	Whether the facility services are
adequate to meet the health needs of
each client, the rehabilitative and
social needs of each client and to
promote maximum physical, mental, and
psychosocial functioning;
(B) 	Whether continued stay in the facility
is necessary and desirable;
(C) 	Whether it is feasible to meet the
client's health needs, and in an ICF-MR
the client's rehabilitative needs
through alternative institutional or
noninstitutional services; and
(D) 	Whether each client is receiving active
treatment in accordance with the
provisions of section 17-1737-30;
(5) 	The determinations on adequacy of services
and related matters stipulated in paragraph
(4) shall be based on, but not limited to,
such items as whether:

UNOFFICIAL
1737-40
(A) 	The medical evaluation, any required
social and psychological evaluations,
and the Individual Program Plans, where
required, are followed; and all ordered
services, including dietary orders, are
provided and properly recorded;
(B) 	The attending physician reviews
prescribed medications at least
quarterly;
(C) 	Tests or observations of each client
indicated by his medication regimen are
made at appropriate times and are
properly recorded;
(D) 	The individual program plan must be
reviewed at least every ninety days by
the QMRP and revised as necessary;
(E) 	For those clients certified as not
needing a medical care plan, a review of
their health status must be a direct
physical examination by a licensed nurse
on a quarterly or more frequent basis
depending on client need and the result
of any action (including referral to a
physician to address client health
problems) shall be recorded in the
client's record;
(F) 	Progress notes by physicians, nurses,
social workers, and other professionals
are made as indicated and are reflective
of the need for the specific
professional's intervention consistent
with the observed condition of the
client, and support the need for
continued stay at the ICF-MR;
(G) 	Progress notes shall be dated and signed
followed by the professional's
professional acronym;
(H) 	The client receives adequate services,
based on such observations as
cleanliness, absence of bedsores,
absence of signs of malnutrition or
dehydration, and apparent maintenance of
maximum physical, mental, and
psychosocial function;
(I) 	The client receives active treatment as
defined in section 17-1737-30;
(J) 	The client needs any service that is not
furnished by the facility through
arrangements with others; and

UNOFFICIAL
1737-41
(K) 	The client needs continued placement in
the facility or there is an appropriate
plan to transfer the patient to an
alternate method of care;
(6) 	The inspection of care team shall prepare a
report promptly after each inspection. 	The
report shall contain:
(A) 	The observations, conclusions, and
recommendations of the team concerning
the adequacy, appropriateness, and
quality of all services provided in the
facility or through other arrangements,
including physician services to
client's, and specific findings about
individual clients in the facility; and
(B) 	The dates of the inspection and the
names and qualifications of the members
of the team; and
(7) 	The department shall send a copy of each
inspection report to the facility inspected,
the facility's utilization review committee,
and the state department of health.
[Eff 08/01/94 	] 	(Auth: HRS §346-14; 42
C.F.R. §§430.10, 431.10) 	(Imp: 	42 C.F.R.
§§456.600 - 456.613)
§17-1737-37 	Other service requirements. 	(a)
Providers of long-term institutional services shall
establish and implement written policies and procedures
that govern access to, duplication of, and
dissemination of information from applicants' or
recipients' records:
(1) 	The following information about applicants
and recipients shall not be released:
(A) 	Names and addresses;
(B) 	Eligibility status, the amount of
assistance, or both;
(C) 	Medical services provided;
(D) 	Social and economic conditions or
circumstances;
(E) 	The department's evaluation of personal
information; and
(F) 	Medical data, including diagnosis and
past history of disease or disability;
and
(2) 	The conditions for release of information by
the department shall be in accordance with
the provisions of chapter 17-1702.

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1737-42
(b) 	Recipients shall have freedom in the
selection of any qualified medicaid provider from whom
the recipient may obtain services, in accordance with
the provisions of chapter 17-1736.
(c) 	Providers of long-term institutional services
shall submit to the department a written incident
report for each incident that result in harm to the
medicaid recipient. 	These reportable incidents
include, reaction to a drug or therapy, all bodily
injuries that require medical intervention, and absence
without leave for one or more nights. 	An incident
report shall be in writing and shall be submitted to
the department within seventy-two hours of a reportable
incident. 	Written reports shall include the following:
(1) 	Name of the NF or ICF-MR;
(2) 	Name, age, and birthdate of the recipient;
(3) 	Resident's diagnosis;
(4) 	Resident's acuity level at time of incident;
(5) 	Date, time, and place of the incident;
(6) 	Description of how the incident occurred;
(7) 	Description of the kind and extent of medical
intervention; and
(8) 	Date incident report was written, and
signature and title of the reporting
individual.
(d) 	Providers of long-term institutional services
shall admit and provide NF or ICF-MR levels of care,
treatment, and services to medicaid recipients without
discrimination, separation, or any other distinction on
the basis of race, color, national origin, or mental or
physical handicap in accordance with the provisions of
chapter 17-1736.
(e) 	For NFs and ICF-MRs, medical records shall be
retained three years from the date of a resident's
discharge from the provider's care.
[Eff 08/01/94 	] 	(Auth: 	HRS §346-14; 42 C.F.R.
§431.10; Pub. L. No. 100-203) 	(Imp: 	HRS §346-40; 42
C.F.R. §§431.51, 431.115, 431.301, 431.305; 29 U.S.C.
§794; 42 U.S.C. §2000d; Pub. L. No. 100-203)
§17-1737-38 	Termination of long-term
institutional services. 	(a) 	Medicaid payments for
long-term institutional services shall be terminated
when a recipient is deemed to no longer require a
specific level of care in accordance with the
provisions of section 17-1737-31 and the recipient
refuses to transfer to an available appropriate
placement.

UNOFFICIAL
1737-43
(b) 	The provider agreement shall be terminated
when the provider fails to provide long-term
institutional services in accordance with the terms
stipulated in the provider agreement.
(c) 	The appeal and hearing provisions of chapter
17-1736 shall apply. 	[Eff 08/01/94 	] 	(Auth: 	HRS
§346-14; 42 C.F.R. §431.10) (Imp: 	42 C.F.R. §§431.152,
431.202)
§17-1737-39 	Sharing of federal financial
participation payment penalty assessment. 	(a) 	The
department shall allocate to the provider any or all
federal financial participation payment penalties which
are assessed the department by the Health Care
Financing Administration of the Department of Health
and Human Services for provider's failure to meet the
utilization control requirements in accordance with the
provisions of sections 17-1737-34 and 17-1737-35.
(b) 	The amount shall be determined by a committee
composed of representatives from the department and
other interested 	private and public agencies.
(c) 	The appeal and hearing provisions of chapter
17-1736 shall apply. 	[Eff 08/01/94 	] 	(Auth: HRS
§346-14; 42 C.F.R. §431.10) (Imp: 	42 C.F.R. §§431.152,
431.202)
§17-1737-40 	Remedies for nursing facilities that
do not meet the requirements for participation. 	(a)
The department shall impose one or more of the
following remedies when a nursing facility does not
meet one or more of the requirements of participation
and its deficiencies constitute immediate jeopardy or
widespread actual harm that does not constitute
immediate jeopardy to the health and safety of its
residents:
(1) 	Remove the jeopardy and appoint temporary
management to oversee correction of the
deficiencies and assure the health and safety
of the facility's residents while corrections
are being made to bring the facility into
compliance with all of the requirements of
participation, or to oversee orderly closure
of a facility.
(A) 	Temporary management shall be state
personnel, private individuals, or a
team with education and requisite work
experience in nursing home
administration that qualifies the

UNOFFICIAL
1737-44
individual(s) to correct the
deficiencies in the facility to be
managed; and be licensed in accordance
with state law. 	The following
individuals are not eligible to serve as
temporary managers:
(i) 	Any individual who has been found
guilty of misconduct by any
licensing board or professional
society in any state;
(ii) 	Has or whose immediate family
members have any financial interest
in the facility managed; or
(iii) 	Any individual who currently serves
or, within the past two years, has
served as a member of the staff of
the facility;
(B) 	Facility management must agree to
relinquish control to the temporary
manager and to pay his or her salary
before the temporary manager can be
installed in the facility. 	The facility
cannot retain final authority to approve
changes of personnel or expenditures of
facility funds and be considered to have
relinquished control to the temporary
manager;
(C) 	If the facility refuses to relinquish
control to the temporary manager, the
facility shall be terminated;
(D) 	A temporary manager has the authority to
hire, terminate, or reassign staff,
obligate facility funds, alter facility
procedures, and otherwise manage a
facility to correct deficiencies
identified in the facility operation.
The temporary manager must be given
access to facility bank accounts that
include receipts;
(E) 	A temporary manager may be imposed
fifteen days after the facility receives
notice, in non-immediate jeopardy
situations; and two days after the
facility receives notice, in immediate
jeopardy situations; and
(F) 	Temporary management shall continue
until a facility is terminated, achieves
substantial compliance and is capable of
remaining in substantial compliance, or
decides to discontinue the remedy and

UNOFFICIAL
1737-45
reassumes management control before it
has achieved substantial compliance, in
which case the facility faces
termination;
(2) 	Assess civil money penalty, with interest,
and impose civil money penalty for the number
of days that a facility is not in substantial
compliance with one or more participation
requirements, regardless of whether or not
the deficiencies constitute immediate
jeopardy and for the number of days of past
noncompliance since the last standard survey,
including the number of days of immediate
jeopardy.
(A) 	Civil money penalties may be imposed as
a remedy for past noncompliance that is
corrected at the time of the current
survey. 	Situations for consideration of
a civil money penalty may include, but
may not be limited to, facilities that
cannot consistently sustain substantial
compliance with the requirements as
noted in the facility-specified reports,
substantiated complaints, or situations
which indicate that the facility did not
act to prevent a situation of
noncompliance from occurring;
(B) 	The amount of the civil money penalty
shall be on the lower range of $50 to
$3,000 per day or on the upper range of
$3,050 to $10,000 per day. 	A civil
money penalty shall not be less than
$50;
(C) 	Factors to be considered in determining
the amount of the civil money penalty
are:
(i) 	The facility's history of
noncompliance, including repeated
deficiencies;
(ii) 	The facility's financial condition;
(iii) 	Seriousness and scope of the
deficiencies;
(iv) 	Likelihood that the civil money
penalty will achieve correction and
continued compliance;
(v) 	The facility's degree of
culpability; and
(vi) 	Any other remedies being imposed in
addition to the civil money
penalty;

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(D) 	All funds collected as a result of these
civil money penalties shall be applied
to the protection of the health and
property of the residents of the
facility;
(E) 	The funds shall be used for:
(i) 	Payment for the cost of relocating
residents to other facilities;
(ii) 	State costs related to the
maintenance or operation of a
facility pending correction of
deficiencies or closure;
(iii) 	Reimbursement of residents for
personal funds or property lost as
a result of actions by the facility
or by individuals used by the
facility to provide services to
residents; and
(iv) 	Other costs related to the health
and property of the residents, such
as, the cost of having resident
medical records sealed, secured,
and stored; the cost of picking up
and transferring or delivering
resident medications or drugs; the
cost of using ambulance service;
and etc.;
(F) 	The civil money penalty may start
accruing as early as the date the
facility was first out of compliance, as
determined by HCFA or the State. 	A
civil money penalty cannot be collected
until a provider requests a hearing.
When no hearing is requested, payment of
a civil money penalty will be due
fifteen days after the time period for
requesting a hearing has expired and a
hearing request was not received or
after the final administrative decision
which includes a hearing and review; and
(G) 	A notice of imposition of civil money
penalty shall be sent to the facility
and shall include the following
information:
(i) 	Nature of the noncompliance
(regulatory requirements not met);
(ii) 	Statutory basis for the penalty;
(iii) 	Amount of penalty per day of
noncompliance;

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(iv) 	Factors that were considered in
determining the amount of the
penalty;
(v) 	Date on which the penalty begins to
accrue;
(vi) 	Statement that the penalty will
stop accruing on the date on which
that facility comes into
substantial compliance or is
terminated from participation in
the program;
(vii) 	When the penalty shall be
collected; and
(viii) 	Statement of the facility's right
to a hearing and information
regarding how to request a hearing,
implications of waiving the right
to a hearing, and information
regarding how to waive the right to
a hearing;
(3) 	Close the nursing facility or transfer the
residents to other facilities or both, to
minimize the period of time during which
residents are receiving less than adequate
care.
(A) 	A finding of immediate jeopardy will not
require the State to close a facility
and transfer residents. 	It may result
in the immediate termination of provider
agreement and the subsequent transfer of
residents;
(B) 	During an emergency which relates to the
facility's gross inability to provide
care and related services because of
fire, natural disaster, epidemic, or
other conditions endangering the health
and safety of the residents, the State
may permanently or temporarily transfer
residents to another facility until the
original facility is again able to care
for its residents; and
(C) 	Transfer requirements shall apply to
only Medicare and Medicaid residents and
not to private pay residents;
(4) 	Terminate the nursing facility's Medicaid
participation.
(A) 	When there is immediate jeopardy to
residents' health and safety,
termination procedures shall be
completed within twenty-three days from

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the last day of the survey which found
the immediate jeopardy, if the jeopardy
is not removed before then;
(B) 	When there is no immediate jeopardy,
HCFA or the State may terminate a
facility if the facility does not come
into substantial compliance within six
months of the date of the survey that
found it to be out of substantial
compliance; and
(C) 	Termination may be imposed by the State
at any time when appropriate for any
noncompliance. 	The facility's
compliance history shall be taken into
account when considering whether or not
to terminate a facility's provider
agreement;
(5) 	Impose denial of payment for new admissions
when a facility has been found to have
provided substandard quality of care on the
last three consecutive standard surveys,
regardless of other remedies imposed.
(A) 	Deny payment for all new admissions
within the third month from the last day
of the third consecutive survey.
(B) 	Facility shall be given written notice
at least two days before the effective
date in immediate jeopardy cases and at
least fifteen days before the effective
date in all others;
(C) 	Optional denial of payment for all new
admissions shall be imposed only when
the facility makes little or no effort
to come into substantial compliance,
e.g., when it fails to adhere to its
plan of correction;
(D) 	Mandatory denial of payment for all new
admissions shall be imposed when the
facility is not in substantial
compliance by the third month after the
last day of the survey identifying the
deficiency or when a provider has been
found to have furnished substandard care
on the last three consecutive standard
surveys;
(E) 	The denial of payment remedy may be
imposed at other times singly or in
conjunction with other remedies, when a
facility is not in substantial
compliance;

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(F) 	The denial of payments shall continue
until the State has verified that the
facility has achieved substantial
compliance. 	Payment resumes
prospectively from the date the State
has determined that substantial
compliance is achieved.
(i) 	When payment is denied for repeated
instances of substandard quality of
care, the remedy shall not be
lifted until the facility is in
substantial compliance and the
State or HCFA believes that the
facility will remain in substantial
compliance; and
(ii) 	If payment is denied for any other
reason and, if a survey team finds
written credible evidence that the
facility corrected deficiencies or
was in substantial compliance
before the date the survey agency
received the credible evidence, the
remedy shall be lifted as of that
date;
(G) 	No payments shall be made for the period
between the date the remedy was imposed
and the date that substantial compliance
was achieved; and
(H) 	Residents admitted before and discharged
before the effective date of the denial
of payment are considered new
admissions, if readmitted, and are
subject to the denial of payment; and
(6) 	State monitoring shall be imposed when a
facility has been found on three consecutive
standard surveys to have provided substandard
quality of care.
(A) 	State monitoring shall oversee the
correction of cited deficiencies in the
facility as a safeguard against further
harm to residents when harm or a
situation with a potential for harm has
occurred. 	State monitoring shall
include:
(i) 	Providing special consultative
services to a facility for
obtaining the type of training and
basic knowledge needed to achieve
and remain in compliance with
federal regulations or to attend an

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in-service training program likely
to correct the deficiencies; and
(ii) 	Assisting in the development of an
acceptable plan of correction;
(B) 	Situations when state monitoring may be
appropriate include, but are not limited
to, the following:
(i) 	Poor facility history, i.e., a
pattern of poor quality of care,
many complaints, etc.;
(ii) 	State agency concern that the
situation in the facility has the
potential to worsen;
(iii) 	Immediate jeopardy exists and
no temporary manager can be
appointed or the facility refuses
to relinquish control to a
temporary manager. 	A monitor shall
be imposed to oversee termination
procedures and transfer of
residents; or
(iv) 	The facility seems unable or
unwilling to take corrective action
for cited substandard quality of
care;
(C) 	Monitoring may occur anytime in a
facility, i.e., twenty-four hours a day,
seven days a week, if necessary. 	In all
instances, monitors shall have complete
access to all areas of the facility as
necessary for performance of the
monitoring task; and
(D) 	State monitoring shall be discontinued
when:
(i) 	The facility's provider agreement
is terminated; or
(ii) 	The facility is terminated; or the
facility has demonstrated to the
satisfaction of HCFA or the State
Agency, that the facility is in
substantial compliance with the
requirements and (if imposed for
repeated substandard quality of
care) that the facility will remain
in substantial compliance.
(b) 	The appeal and hearing provisions of chapter
17-1736 shall be available to providers subject to
state imposed remedies. 	[Eff 08/01/94; am 01/29/96;
am 11/25/96; am 09/14/98 	] 	(Auth: 	HRS §346-14;
42 C.F.R. §§442.118, 442.119; Pub. L. No. 100-203)

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(Imp: 	Pub. L. No. 100-203; 42 C.F.R. §§431.152,
431.202, 442.118, 442.119)
§17-1737-41 	State-approved feeding assistant
training program. 	(a) 	A state-approved feeding
assistant training program shall include a minimum of
ten clock hours of training, provided by Medicaid or
Medicare and Medicaid certified nursing facilities,
with a minimum of four clock hours of practical
training directly supervised by a registered nurse
licensed in Hawaii.
(b) 	A state-approved feeding assistant training
program shall include, but not be limited to, the
following:
(1) 	Feeding techniques;
(2) 	Assistance with feeding and hydration;
(3) 	Communication and interpersonal skills;
(4) 	Appropriate responses to resident behavior;
(5) 	Safety and emergency procedures, including
the Heimlich maneuver;
(6) 	Infection control;
(7) 	Resident rights; and
(8) 	Recognizing changes in residents that are
inconsistent with their normal behavior and
the importance of reporting those changes to
the supervisory nurse.
(c) 	Individuals being trained must be at least
eighteen years of age at the commencement of the
feeding assistant training program.
(d) 	The Office of Health Care Assurance (the
State survey agency), as part of the federally mandated
surveys that it conducts of Medicaid or Medicare and
Medicaid certified nursing facilities in the State,
determines whether the feeding assistance training
program requirements established by the Medicaid agency
are met by any such facility that operates a state-
approved feeding assistant training program under this
section.
(e) 	Proof of completion of a state-approved
feeding assistant training program by a Medicaid or
Medicare and Medicaid certified nursing facility may be
accepted as sufficient training for a feeding assistant
to provide this service in a Medicaid or Medicare and
Medicaid certified nursing facility in the State that
did not provide the actual training. 	Eff 08/01/94;
am 02/10/97; am 	] 	(Auth: 	HRS §346-14;

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42 C.F.R. §§430.10, 431.10, 483.1) 	(Imp: 	42 C.F.R.
§§440.40, 483.1, 483.20, 483.30, 483.35, 483.160)
§17-1737-42 	(Reserved)
SUBCHAPTER 5
PREVENTIVE AND REHABILITATIVE SERVICES
§17-1737-43 	Preventive services. 	(a) 	Preventive
services means services provided by a physician or
other licensed practitioner of the healing arts within
the scope of a practice under state law to:
(1) 	Prevent disease, disability, and other health
problems or their progress;
(2) 	Prolong life; and
(3) 	Promote physical and mental health and
efficiency.
(b) 	Medical payments to providers may be made on
behalf of recipients for the following services:
(1) 	Physical examinations for the following
purposes:
(A) 	School health clearances;
(B) 	Pre-admissions and periodic physicals
required by Public Health Regulation
12-B for care homes;
(C) 	Pre-placement physicals for adults
entering family boarding homes;
(D) 	Premarital examinations;
(E) 	Examinations to determine the extent of
mental or physical disability or
incapacity;
(F) 	Pre-placement and annual examinations
for children in foster care;
(G) 	Pre-adoption pediatric examinations;
(H) 	Employability determinations and WIN
pre-referral examinations;
(I) 	Examinations when indicated is suspected
child abuse cases, if eligible for
medical assistance;
(J) 	Pre-placement examinations for day care;
and
(K) 	Other health examinations limited to not
more than once in a two year period.

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(2) 	Routine laboratory examinations necessary to
complete the physicals, as well as diagnostic
screening; and
(3) 	Immunizations and vaccinations, with the
exception of pediatric vaccines covered under
the Vaccines for Children (VFC) program and
immunizations for travel to foreign
countries. 	[Eff 08/01/94; am 01/29/96 	]
(Auth: 	HRS §346-14) 	(Imp: 	42 C.F.R.
§440.130)
§17-1737-44 	Rehabilitative services. 	(a)
Rehabilitative services means those medical and
remedial items or services which are prescribed by a
licensed physician for the purpose of maximum reduction
of a patient's physical or mental disability and
restoration of the patient to the patient's best
possible functional level.
(b) 	Rehabilitative services shall be directed to
restoring a disabled person toward the following goals:
(1) 	Self-care and possible independent living; or
(2) 	Substantial gainful employment.
(c) 	Children through six years of age shall meet
the following conditions to show rehabilitative
services are reasonable and necessary:
(1) 	The services shall be considered under
accepted standards of medical practice to be
a specific and effective treatment for the
patient's condition. 	Experimental therapies
are excluded from coverage;
(2) 	An expectation that the condition will
improve significantly in a reasonable and
generally predictable period of time based on
the assessment made by the physician of the
patient's rehabilitative potential after any
needed consultation with the qualified
therapist or, services are necessary to
establish a safe and effective maintenance
program required in connection with a
specific developmental or disease state;
(3) 	The services required can be safely and
effectively performed only by a qualified
therapist/pathologist or under the immediate
supervision of a therapist because the
services are complex or because of the
child's medical or physical condition;
(4) 	The amount, frequency, and duration of the
services shall be reasonable and subject to
authorization by the department.

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Additionally, the provisions and limitations
pertaining to the specific rehabilitation
service such as physical therapy, speech
therapy, etc. addressed in this chapter and
chapter 17-1739 shall apply;
(5) 	Referrals for therapeutic services shall be
made by a physician. 	The physician is
expected to 	employ clinical judgment, the
history and physical, testing, etc. in
determining the medical necessity of
rehabilitative services; and
(6) 	Evaluation of the patient's developmental or
therapeutic status shall be measured and
expressed in objective, unambiguous concise
language. 	The results of tests as well as
goals, and therapeutic results shall be
recorded on appropriate forms and may be
reviewed by the department.
(d) 	Medical vendor payments may be made for the
following types of services whether provided on an
inpatient or an outpatient basis:
(1) 	Corrective surgery;
(2) 	Physical therapy;
(3) 	Speech therapy;
(4) 	Occupational therapy;
(5) 	Drugs, prosthetics, and durable medical
equipment and supplies; and
(6) 	Other related restorative services.
[Eff 08/01/94; am 02/10/97 	] (Auth:
HRS §346-14) (Imp: 	42 C.F.R. §440.130)
§17-1737-44.1 	Community mental health
rehabilitative services. 	(a) 	Medical payments to
eligible providers may be made for the following types
of community mental health rehabilitative services:
(1) 	Crisis management: 	This service provides
mobile assessment for individuals in active
state of crisis (twenty-four hours per day,
seven days a week). 	Immediate response is
required. 	Crisis management services include
referral to licensed psychiatrist, licensed
psychologist, or to an inpatient acute care
hospital. 	The presenting crisis situation
may necessitate that the services be provided
in the consumer’s home or natural environment
setting, such as the home, school, work
environment, or other community setting as
well as in a health care setting. 	These

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services are provided through agencies
accredited by a national accreditation
organization. 	These agencies must have staff
that includes one or more qualified mental
health professionals. 	If the services are
provided by staff other than a qualified
mental health professional, the staff shall
be supervised at a minimum by a qualified
mental health professional.
(1) 	Crisis Residential Services: 	Crisis
Residential Services are short-term
interventions provided to individuals
experiencing crisis, to address the cause of
the crisis and to avert or delay the need for
acute psychiatric inpatient hospitalization
or inpatient hospital-based psychiatric care
at levels of care below acute psychiatric
inpatient. 	Crisis Residential Services are
for individuals who are experiencing a period
of acute stress that significantly impairs
the capacity to cope with normal life
circumstances. 	The program provides
psychiatric services that address the
psychiatric, psychological, and behavioral
health needs of the individuals. 	Specific
services are:
(A) 	Psychiatric medical assessment;
(B) 	Crisis stabilization and intervention;
(C) 	Medication management and monitoring;
(D) 	Individual, group or family counseling
or all if necessary; and
(E) 	Daily living skills training.
Services are provided in a licensed
residential program, licensed therapeutic
group home or foster home setting. 	All
crisis residential programs shall have less
than sixteen beds. 	The services do not
include payment for room and board. 	Staff
providing crisis residential services shall
be qualified mental health professionals. 	If
the services are provided by staff other than
a qualified mental health professional, the
staff must be supervised at a minimum by a
qualified mental health professional.
(3) 	Biopsychosocial Rehabilitative Programs:
This is a therapeutic day rehabilitative
social skill building service which allows
individuals with serious mental illness to

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gain the necessary social and communication
skills necessary to allow them to remain in
or return to naturally occurring community
programs. Services include group skill
building activities that focus on the
development of problem-solving techniques,
social skills and medication education and
symptom management. 	All services provided
must be part of the individual’s plan of
care. 	A plan of care must identify the
treatment goals and the scope, amount and
duration of services that will assist the
individual to achieve the goals. 	A plan of
care must be approved by a licensed
physician, licensed psychologist, advanced
practice registered nurse or licensed
clinical social worker in behavioral health.
Plans of care must be reviewed and approved
every ninety calendar days. 	The therapeutic
value of the specific therapeutic
recreational activities must be clearly
described and justified in the plan of care.
At a minimum, the plan of care must:
(A) 	Define the goals and objectives for the
individual;
(B) 	Educate the individual about his or her
mental illness;
(C) 	How to avoid complications and relapse;
and
(D) 	Provide opportunities for him or her to
learn basic living skills and improve
interpersonal skills.
Services are provided by qualified mental
health professionals or staff that are under
the supervision of a qualified mental health
professional. 	Provider qualifications to
provide these services are ensured by
provider compliance with requirements and
standards of a national accreditation
organization.
(4) 	Intensive Family Intervention: 	These are
time limited intensive interventions intended
to stabilize the living arrangement, promote
reunification or prevent the utilization of
out of home therapeutic resources (i.e.
psychiatric hospital, therapeutic foster

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care, residential treatment facility) for
children with serious emotional or behavioral
disturbances or adults with serious mental
illness. 	These services:
(A) 	Diffuse the current crisis, evaluate its
nature and intervene to reduce the
likelihood of a recurrence;
(B) 	Assess and monitor the service needs of
the identified individual so that he or
she can be safely maintained in the
family;
(C) 	Ensure the clinical appropriateness of
services provided; and
(D) 	Improve the individual’s ability to care
for self and the family’s capacity to
care for the individual.
This service includes focused evaluations and
assessments, crisis case management, behavior
management, counseling, and other therapeutic
rehabilitative mental health services toward
improving the individual’s ability to
function in the family. 	Services are
directed towards the identified individual
within the family. 	Services can be provided
in-home, school or other natural environment.
Services are provided by a multidisciplinary
team comprised of qualified mental health
professionals. 	If the services are provided
by staff other than a qualified mental health
professional, the staff shall be supervised
at a minimum by a qualified mental health
professional. 	Additionally, provider
qualifications must be in compliance with
requirements and standards of a national
accreditation organization.
(5) 	Therapeutic Living Supports and Therapeutic
Foster Care Supports: 	These are services
covered in settings such as group living
arrangements or therapeutic foster homes.
Group living arrangements usually provide
services for three to six individuals, but
not more than fifteen individuals, per home.
Therapeutic foster homes provide services for
a maximum of fifteen individuals per home.
Although these group living arrangements and
therapeutic foster homes may provide
twenty-four hour per day of residential care,
only the therapeutic services provided are

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covered. 	There is no reimbursement of room
and board charges. 	Covered therapeutic
supports are only available when the
identified individual resides in a licensed
group living arrangement or licensed
therapeutic foster home. 	The identified
individual must be either a child with
serious emotional or behavioral disturbance
or an adult with a serious mental illness.
Services provided in therapeutic group homes
and therapeutic foster homes include
supervision, monitoring and developing
independence of activities of daily living
and behavioral management, medication
monitoring, counseling and training, directed
at the amelioration of functional and
behavioral deficits and based on the
individual’s plan of care developed by a team
of licensed and qualified mental health
professionals. 	Services shall be provided in
a licensed facility and provided by a
qualified mental health professional or staff
under the supervision of a qualified mental
health professional with twenty-four hour on-
call coverage by a licensed psychiatrist or
psychologist.
(6) 	Intensive outpatient hospital services:
These are outpatient hospital services for
the purpose of providing stabilization of
psychiatric impairments as well as enabling
the individual to reside in the community or
to return to the community from a more
restrictive setting. 	Services are provided
to an individual who is either a child with
serious emotional or behavioral disturbance
or an adult with a serious mental illness.
In addition, the adult or child shall meet at
least two of the following criteria:
(A) 	Is at high risk for acute inpatient
hospitalization, homelessness or (for
children) out-of-home placement because
of their behavioral health condition;
(B) 	Exhibits inappropriate behavior that
generates repeated encounters with
mental health professionals, educational
and social agencies, or the police; or

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(C) 	Are unable to recognize personal danger,
inappropriate social behavior, or
recognize and control behavior that
presents a danger to others.
The goals of service are clearly
identified in an individualized plan of
care. 	The short term and long term
goals and continuing care plan are
established prior to admission through a
comprehensive assessment of the consumer
to include a severity-adjusted rating of
each clinical issue and strength.
Treatment is time-limited, ambulatory
and active offering intensive,
coordinated clinical services provided
by a multi-disciplinary team. 	This
service includes medication
administration and a medication
management plan. 	Services are available
at least twenty hours per week. 	All
services are provided by qualified
mental health professionals, or by
individuals under the supervision of a
qualified mental health professional.
Additionally, provider qualifications
must be in compliance with requirements
and standards of a national
accreditation organization. 	Registered
nurses or licensed practical nurses must
be available for nursing interventions
and administration of medications.
Licensed psychiatrists or psychologists
must be actively involved in the
development, monitoring, and
modification of the plan of care. 	The
services must be provided in the
outpatient area or clinic of a licensed
hospital certified by a national
accreditation organization or other
licensed facility that is Medicare
certified for coverage of partial
hospitalization/day treatment. 	These
services are not provided to individuals
in the inpatient hospital setting and do
not include acute inpatient hospital
stays.

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(7) 	Assertive Community Treatment (ACT):
This is an intensive community
rehabilitation service for individuals
who are either children with serious
emotional or behavioral disturbance or
adults with a serious mental illness.
In addition, the adult or child must
meet at least two of the following
criteria:
(A) 	At high risk for acute inpatient
hospitalization, homelessness or (for
children) out-of-home placement because
of their behavioral health condition;
(B) 	Exhibits inappropriate behavior that
generates repeated encounters with
mental health professionals, educational
and social agencies, or the police; or
(C) 	Is unable to recognize personal danger,
inappropriate social behavior, and
recognize and control behavior that
presents a danger to others.
The ACT rehabilitative treatment services are
to restore and rehabilitate the individual to
his or her maximum functional level.
Treatment interventions include:
(A) 	Crisis management (crisis assessment,
intervention and stabilization);
(B) 	Individual restorative interventions for
the development of interpersonal,
community coping and independent living
skills;
(C) 	Services to assist the individual
develop symptom monitoring and
management skills;
(D) 	Medication prescription, administration
and monitoring medication and self
medication; and
(E) 	Treatment for substance abuse or other
co-occurring disorders.
Services include twenty-four hours a day,
seven days a week coverage, crisis
stabilization, treatment, and counseling.
Also, individuals included in ACT receive
case management to assist them in obtaining
needed medical and rehabilitative treatment
services within their ACT treatment plan.

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Services can be provided to individuals in
their home, work or other community settings.
ACT services are provided by agencies whose
staffs include one or more licensed qualified
mental health professionals. 	If the services
are provided by staff other than a licensed
qualified mental health professional, the
staff shall be supervised by a licensed
qualified mental health professional.
Provider qualifications to provide these
services are ensured by provider compliance
with requirements and standards of a national
accreditation organization. 	Case management
is an integral part of this service and
reimbursement for case management as a
separate service is not allowed. 	If
biopsychosocial rehabilitation is part of the
individual’s plan of care under intensive
case management, reimbursement for
biopyschosocial rehabilitation as a separate
service is not allowed.
(b) 	Community mental health rehabilitative
services are available to individuals eligible for
medical assistance and who are medically determined to
need mental health, drug abuse, or alcohol services or
all three. 	These services must be recommended by a
licensed physician, licensed psychologist, advanced
practice registered nurse or a licensed clinical social
worker in behavioral health to promote the maximum
reduction or restoration, or both, of a recipient to
their best possible functional level relevant to their
diagnosis of mental illness, abuse of drugs or alcohol.
(c) 	Individuals who are mentally retarded (MR) or
developmentally disabled are not eligible for these
services, including mentally retarded and
developmentally disabled individuals who are in Home
and Community Based Waiver programs.
(d) 	Community mental health rehabilitative
services shall be provided by the agencies certified by
the department of Health, adult mental health division
and child and adolescent mental health division.
(e) 	The covered services are available only to
Medicaid eligible recipients with a written plan of
care developed with the participation of a licensed
psychiatrist or psychologist. 	Services must be
medically necessary.

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1737-62
(f) 	The statewide reimbursement rate shall be the
rate negotiated by the department. 	The final rate will
be based on the following factors:
(1) 	Cost to provide the service;
(2) 	Comparison to comparable Medicaid provider
types;
(3) 	Relative value to other services within the
established fee schedule;
(4) 	Rate will not exceed Medicare’s upper limit
of reimbursement; and
(5) 	Rate will be reevaluated at a minimum of once
every two years for its cost basis and
allowability.
(g) 	Reimbursement shall be based of the following
units of service:
(1) 	Per contact (Crisis management services);
(2) 	Daily (crisis residential, therapeutic
support, intensive outpatient hospital
services), or
(2) 	Fifteen minute increments (assertive
community treatment (ACT), biopsychosocial
rehabilitative programs and intensive family
intervention). 	[Eff 02/07/05] 	(Auth: 	HRS
§346-14) 	(Imp: 	42 C.F.R. §440.130)
§17-1737-45 	Home health services. 	(a) 	Home
health services means services provided to a recipient
by a home health agency or under a home or
community-based waiver:
(1) 	At the recipient's place of residence or at a
location other than a hospital, skilled
nursing facility, intermediate care
facility - mental retardation, or
intermediate care facility;
(2) 	On a physician's orders as part of a written
plan of care that the physician reviews every
sixty days; and
(3) 	Medical authorization as specified in section
17-1739-4 is needed for all home health
services, medical supplies, equipment and
appliances unless otherwise specified under
this section.
(b) 	Home health services shall include:
(1) 	Nursing service, as defined in chapter 457,
HRS provided on a part-time or intermittent
basis;
(2) 	Home health aide services;

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(3) 	Medical supplies, equipment, and appliances
suitable for use in the home, subject to
prior authorization as specified in section
17-1739-4;
(4) 	Physical therapy, occupational therapy,
speech pathology and audiology services
subject to prior authorization as specified
in section 17-1739-4; and
(5) 	Medical social services and other services
not specifically listed in this section are
not covered.
(c) 	Reimbursement for home health services shall
be limited to the following:
(1) 	Home health services shall be reimbursable on
the basis of "per visit". 	A visit shall
encompass approximately one or two hours of
service;
(2) 	One visit per day only;
(3) 	Daily home visits without medical
authorization are permitted for home health
aide and nursing services in the first two
weeks of care if part of the written plan of
care;
(4) 	Initial physical therapy and occupational
therapy evaluations only without medical
authorization are permitted if part of a
written plan of care;
(5) 	No more than three visits a week for each
service shall be reimbursed for the third
week to the seventh week of patient care;
(6) 	No more than one visit a week for each
service shall be reimbursed from the eighth
week to the fifteenth week of patient care;
(7) 	No more than one visit every other month for
each service shall be reimbursed from the
sixteenth week of patient care; and
(8) 	Services exceeding the parameters of this
section shall be prior authorized by the
department's medical consultant or its
authorized representative. 	[Eff 08/01/94;
am 02/10/97 	] 	(Auth: 	HRS §346-14)
(Imp: 	42 C.F.R. §§440.70, 441.15)
§17-1737-46 	Family planning services. 	(a) 	All
fee for service medicaid recipients, male or female,
including minors, who are sexually active or of child-
bearing age, shall be eligible for family planning
services and supplies.

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(b) 	The department shall furnish assistance to
any eligible person by:
(1) 	Locating and referring to a recognized
provider those persons encountering
difficulties in obtaining family planning
services; and
(2) 	Prompt attention so that the eligible person
shall be assured of receiving family planning
service within thirty days from the time of
the request.
(c) 	The use of family planning services or
practices shall be entirely on a voluntary basis. 	At
no time shall any member of the department's staff
place a recipient under any obligation, duress,
compulsion, or use any other form of coercion on the
recipient to accept or reject family planning services.
(d) 	Family planning information shall be
disseminated by:
(1) 	Promptly informing new recipients of medical
assistance of the availability of family
planning services under the department's
program, Title IV-A of the Social Security
Act, and medicaid; and
(2) 	The branch worker hand issuing or mailing the
department's information brochure entitled
"Family Planning Services" to newly approved
medical assistance recipients.
(e) 	Family planning services shall include:
(1) 	Consultation, counseling, examination
including breast and pelvic examination, and
treatment by or under the supervision of a
physician or prescribed by a physician;
(2) 	Laboratory examinations and tests;
(3) 	Medically approved methods, procedures,
pharmaceutical supplies and devices to
prevent conception;
(4) 	Natural family planning methods;
(5) 	Diagnosis for infertility; and
(6) 	Voluntary sterilization procedures.
[Eff 08/01/94; am 06/19/00 	] (Auth: 	HRS
§346-14) (Imp: 	42 C.F.R. §§441.20, 440.250,
440.40)
§17-1737-47 	Hysterectomy. 	(a) 	Hysterectomy
means a medical procedure or operation for the purpose
of removing the uterus.
(b) 	Hysterectomies shall be covered under the
medicaid program when medically necessary except when
performed:

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(1) 	Solely for the purpose of rendering an
individual permanently incapable of
reproducing; or
(2) 	Primarily for the purpose of rendering the
individual permanently incapable of
reproducing when there is more than one
reason for the hysterectomy.
(c) 	Reimbursement for hysterectomies shall be
made only if the following conditions have been met,
regardless of the age of the patient or the medical
condition for which the hysterectomy was performed:
(1) 	The physician authorized to perform the
hysterectomy informs the individual or her
representative, if any, orally and in
writing, prior to the procedure that the
hysterectomy will render the individual
permanently incapable of reproducing; and
(2) 	The individual or her representative, if any,
signs a written acknowledgement of receipt of
that information; or
(3) 	If the individual is already sterile prior to
a hysterectomy, the physician who performed
the hysterectomy shall:
(A) 	Certify in writing that the person was
sterile; and
(B) 	State the cause of the sterility; or
(4) 	If the individual required a hysterectomy
because of a life threatening emergency, the
physician shall:
(A) 	Certify that prior acknowledgement was
not possible or practical; and
(B) 	Provide a description of the nature of
the emergency.
For the purpose of this subsection, "sterility" shall
be due to an established condition such as menopause,
successful prior sterilization procedure or
demonstrated bilateral tubal blockage due to disease.
Lack of conception without demonstrated tubal blockage
or endocrine dysfunction interfering with ovulation
shall not be acceptable in meeting the definition of
sterility. "Life threatening emergency" means actual
emergencies such as a ruptured uterus or uteroplacental
apoplexy or severe abdominal trauma. 	A hysterectomy
which becomes medically advised during an operative
procedure shall not be considered a life threatening
emergency. The possibility of an associated
hysterectomy shall be considered in all pelvic or lower
abdominal operative procedures and the proper tentative
warning provided.

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(d) 	The department shall obtain documentation,
showing the requirements of this section were met,
before making payments. 	[Eff 08/01/94 	] (Auth:
HRS §346-14) (Imp: 	42 C.F.R. §§441.255, 441.256)
§17-1737-48 	Sterilization. 	(a) 	Sterilization
means any medical procedure, treatment, or operation
for the purpose of rendering an individual permanently
incapable of reproducing. 	Sterilization shall be
neither a necessary part of the treatment of an
existing accompaniment of an operation. 	Sterilization
under this program shall not be authorized for any
individual who is:
(1) 	Mentally incompetent;
(2) 	Incompetent under applicable state law to
give informed and binding consent because of
mental incapacity;
(3) 	Under twenty-one years; or
(4) 	Institutionalized.
(b) 	Informed consent shall be obtained prior to
any sterilization procedure. 	For the purpose of this
program, the informed consent shall be valid only if
prior to obtaining the consent, the individual
requesting the service was furnished with the following
information:
(1) 	A thorough explanation of the procedure to be
performed;
(2) 	A full description of the attendant
discomforts and risks;
(3) 	A description of the benefits to be expected;
(4) 	Counseling concerning appropriate alternative
methods, and the effect and impact of the
proposed sterilization, including the fact
that the procedure shall be considered
irreversible;
(5) 	An offer to answer any inquiries concerning
the sterilization procedures;
(6) 	Advice that the individual is free to
withhold or withdraw the consent to the
procedure without affecting the right to
future medicaid benefits and without
prejudice to future care; and
(7) 	Advice that the sterilization will not be
performed for at least thirty days except
under conditions listed in subsection (e).
(c) 	The provider shall use the appropriate
departmental form to obtain written consent from a
medicaid recipient who is requesting the service. 	No
substitution of form shall be accepted.

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(d) 	Sterilization shall not be performed sooner
than thirty days but not more than one hundred eighty
days following the giving of informed consent in
writing, except as explained in subsection (e).
(e) 	Exceptions to subsections (b)(7) and (d) may
be made if more than seventy-two hours have passed
since informed consent was given and where there is:
(1) 	Premature delivery, when informed consent was
given at least thirty days before expected
date of delivery; or
(2) 	Emergency abdominal surgery.
(f) 	Consent for sterilization may not be obtained
if the person requesting sterilization is:
(1) 	In labor or childbirth;
(2) 	Seeking to obtain or is obtaining an
abortion; or
(3) 	Under the influence of alcohol or other
substances that affect the individual's state
of awareness.
(g) 	An operation for an ectopic pregnancy which
results in sterilization due to removal of a woman's
single remaining fallopian tube shall not be considered
either a primary sterilization or an abortion and
shall be a medically indicated procedure covered under
the program.
(h) 	A hysterectomy shall not be considered a
sterilization procedure. 	The provisions of section
17-1737-47 shall apply. 	[Eff 08/01/94 	] (Auth: 	HRS
§346-14) (Imp: 	42 C.F.R. §§441.250 - 441.258)
§17-1737-49 	Respiratory care services. 	(a)
Respiratory care services are services provided on a
part time basis in the home of the individual by a
respiratory therapist or other health care professional
trained in respiratory therapy as defined in section
17-1737-2.
(b) 	Respiratory care services may be provided for
medicaid eligible individuals who meet the following
criteria:
(1) 	Medically dependent on a ventilator support
for at least thirty consecutive days as an
inpatient in an acute or long term care
facility;
(2) 	Dependent on ventilator support for at least
six hours per day;
(3) 	If respiratory care services were not
available, would require inpatient care in a
hospital, or long-term care institution;

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(4) 	Eligible or would be eligible for medicaid
payments if institutional care were required;
(5) 	Has adequate support services to be cared for
at home; and
(6) 	Wishes to be cared for at home.
(c) 	Authorization by the department on form DHS
1144 shall be required for the provision of respiratory
care services.
(d) 	Medicaid payments for respiratory care
services shall be made only to providers meeting the
requirements of chapter 17-1736. 	[Eff 08/01/94 	]
(Auth: 	HRS §346-14, 42 C.F.R. §431.10) 	(Imp: 	Pub. L.
No. 99-509, Section 9408)
§17-1737-50 	Home pharmacy services. 	(a) 	Home
pharmacy services are services related to the
dispensing and clinical monitoring of enteral and
parenteral nutrition and therapeutic agents given
intravenously or by injection to recipients in their
homes.
(b) 	Home pharmacy services shall be ordered by a
physician and shall include clinical monitoring by
pharmacists and other skilled medical professionals,
such as registered nurses.
(c) 	Home pharmacy services may be provided to
Medicaid eligible individuals who:
(1) 	Require the use of therapeutic intravenous
or injectable agents including analgesics,
antibiotics, and fluids to treat their
medical condition;
(2) 	Do not require acute hospital or nursing
facility care, have adequate support in the
home, and can safely receive these services
in the home setting; and
(3) 	Wish to receive this care in the home.
(d) 	Authorization by the department for home
pharmacy services on form DHS 1144 shall be required
for the provision of home pharmacy services by
freestanding pharmacies and by acute care hospital
which provide home pharmacy services.
( e) 	Medicaid payments shall only be made when
freestanding home pharmacy services are furnished by
providers accredited by a nationally recognized
accreditation organization. 	[Eff 11/25/96;
am 02/16/02 	] 	(Auth: 	HRS §§346-14, 346-59)
(Imp: 	HRS §§346-14, 346-59; 42 C.F.R. §431.10)

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§17-1737-51 	Sleep services. 	(a) 	Sleep services
are services provided for the diagnosis and treatment
of sleep disorders and shall:
(1) 	Be performed by sleep laboratories or sleep
disorder centers; and
(2) 	Be provided to Medicaid eligible individuals
only when ordered by a physician and
authorized by the department on form DHS
1144.
(b) 	Medicaid payments shall only be made for
sleep services furnished by sleep laboratories or sleep
centers who are accredited by the American Sleep
Disorders Association by January 1, 1997.
[Eff 11/25/96 	] 	(Auth: 	HRS §§346-14, 346-59)
(Imp: 	HRS §§346-14, 346-59; 42 C.F.R. §431.10)
§17-1737-51.1 	Telehealth services. 	(a)
Telehealth services is the use of communication
equipment to link health care practitioners and
patients in different locations. 	It may be used in
place of a face-to-face, “hands on” encounter for
consultation, office visits, individual psychotherapy
and pharmacologic management. 	For purposes of this
section, the term “patient” refers to individuals
eligible for medical assistance.
(b) 	Telehealth services may be provided to
patients only if they are presented from an originating
site located in either a:
(1) 	Rural Health Professional Shortage Area
(HPSA) as defined by section 332(a)(1)(A) of
the Public Health Service Act;
(2) 	In a county outside of a Metropolitan
Statistical Area, as defined by Section
1886(d)(2)(D) of the Social Security Act; or
(3) 	From an entity that participates in a
Federal telemedicine demonstration project
that has been approved by the Secretary of
Health and Human Services as of December 31,
2000.
(c) 	Interactive audio and video telecommunication
systems must be used. 	Interactive telecommunications
systems must be multi-media communications that, at a
minimum, include audio and video equipment, permitting
real-time consultation among the patient, consulting
practitioner, and referring practitioner. 	Telephones,
facsimile machines, and electronic mail systems do not
meet the requirements of interactive
telecommunications system. 	As a condition of payment

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the patient must be present and participating in the
telehealth visit.
(d) 	An originating site is the location of a
patient at the time the service being furnished via a
telecommunications system occurs. 	Originating sites
authorized to furnish telehealth services are listed
below:
(1) 	The office of a physician or practitioner;
(2) 	A hospital;
(3) 	A critical access hospital;
(4) 	A rural health clinic; and
(5) 	A federally qualified health center.
An exception to this provision is an entity
participating in a Federal telehealth
demonstration project that is approved by or
is receiving funding from the Secretary of
Health and Human Services as of December 31,
2000. 	An entity participating in a Federal
telehealth demonstration project qualifies as
an originating site regardless of geographic
location.
(e) 	A distant site is the site at which the
physician or practitioner delivering the service is
located at the time the service is provided via a
telecommunications system.
(f) 	Coverage of telehealth services is based on
Medicare’s criteria. 	Each provider must bill the
appropriate CPT procedure code with the modifier code
“TM” indicating the services were provided via
telehealth. 	Only providers eligible to participate in
the medical assistance program will be reimbursed for
telehealth services. 	Reimbursements to an originating
site and distant site are based on the Hawaii Medicaid
fee schedule. 	[Eff 02/07/05] 	(Auth: 	HRS §346-59)
(Imp: 42 C.F.R. §410.78; Pub. L. 105-33)
§17-1737-52 	(Reserved).
SUBCHAPTER 6
EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT
(EPSDT)
§17-1737-53 	Early and periodic screening,
diagnosis, and treatment (EPSDT). 	(a) 	EPSDT means
early screening and diagnostic services to identify
physical or mental defects in recipients; and, to

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provide health care, treatment, and other measures to
correct or ameliorate any defects and chronic condition
discovered.
(b) 	EPSDT includes services to:
(1) 	Seek out recipients and their families and
inform them of the benefits of prevention and
the health services available;
(2) 	Help the recipient or family use health
resources, including their own talents,
effectively and efficiently; and
(3) 	Assure the problems identified are diagnosed
and treated early, before they become more
complex and their treatment more costly.
[Eff 08/01/94 	] 	(Auth: 	HRS §346-14)
(Imp: 	42 C.F.R. §441.50)
§17-1737-54 	Recipient eligibility requirements.
Early and Periodic Screening, Diagnosis, and Treatment
services shall be provided to eligible Medicaid
recipients under age twenty-one. 	[Eff 08/01/94;
am 06/19/00 	] 	(Auth: 	HRS §346-14) 	(Imp: 	42
C.F.R. §441.56)
§17-1737-55 	Informing. 	(a) 	The department
shall seek out individuals and their families and
inform them of the availability of EPSDT services by a
combination of written and oral methods to effectively
explain the benefits of prevention and the health
services available:
(1) 	Within sixty days of the recipient's initial
eligibility determination; and
(2) 	Annually thereafter in case of recipient or
family who have not utilized EPSDT services.
(b) 	Written and oral methods used to inform
recipients or their families shall be:
(1) 	Clear and nontechnical written materials; and
(2) 	Appropriate informing procedures for
recipients or their families who are deaf,
blind, or who cannot read or understand the
English language.
(c) 	Information provided to recipients or their
families shall include:
(1) 	Benefits of preventive health care;
(2) 	Services covered under the EPSDT program;
(3) 	Where and how to obtain EPSDT services;
(4) 	Availability of EPSDT services at no cost;

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(5) 	Upon request by recipient or family,
assistance with scheduling appointments for
EPSDT services; and
(6) 	Upon request by recipient or family,
assistance with transportation in accordance
with subsection 17-1737-82(h) to receive
EPSDT services.
(d) 	Newly eligible pregnant women shall be
informed about the availability of EPSDT services. 	A
positive response to an offer of EPSDT services during
pregnancy constitutes a request for EPSDT services for
the child at birth. 	[Eff 08/01/94 	] 	(Auth: 	HRS
§346-14) 	(Imp: 	42 C.F.R. §§441.56, 441.62; 42 U.S.C.
§1396d)
§17-1737-56 	Periodicity schedule. 	(a) 	The
scheduled frequency of medical screening services shall
be based on age:
(1) 	Infancy: by one month, at two, four, six,
nine, and twelve months;
(2) 	Early childhood: at fifteen, eighteen, and
twenty-four months and at three and four
years;
(3) 	Late childhood: at five, six, eight, ten, and
twelve years; and
(4) 	Adolescence: at fourteen, sixteen, eighteen,
and twenty years.
(b) 	The scheduled frequency of the dental
screening services shall be a maximum of one
screening/examination visit once every six months for
children six months to twenty years of age.
(c) 	Interperiodic screens which are medically
necessary to determine the existence of suspected
physical or mental illness or conditions, shall be
provided without regard to the schedules in subsections
(a) and (b). 	[Eff 08/01/94 	] 	(Auth: 	HRS §346-14)
(Imp: 	42 C.F.R. §§441.58, 441.59; 42 U.S.C. §1396d)
§17-1737-57 	Screening. 	(a) 	Upon request from
the recipient or family, the department shall assess
the recipient's health status and needs through initial
and periodic health examinations and evaluations of the
general physical and mental health, growth,
development, and nutritional status of infants,
children, and youth. 	Screening shall include, but not
be limited to:

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(1) 	Comprehensive health and developmental
history, including assessment of both
physical and mental health development;
(2) 	Comprehensive unclothed physical examination;
(3) 	Appropriate immunizations according to age
and health history;
(4) 	Appropriate vision testing;
(5) 	Appropriate hearing testing;
(6) 	Appropriate laboratory tests, including lead
blood level assessment appropriate for age and
risk factors;
(7) 	Routine dental examination furnished by direct
referral to a dentist which includes bitewing
x-ray, scaling and polishing, and topical
application of fluoride as deemed necessary in
accordance with section 17-1737-75; and
(8) 	Health education including anticipatory
guidance.
(b) 	The dental screening, to be completed by the
dentist, includes but is not limited to an oral
examination, diagnosis and assessment of any oral
disease or injuries, oral hygiene instructions, dietary
counseling relating to dental health, and injury
prevention counseling. 	Appropriate reading materials
and a toothbrush, at no charge to the patient, are
included in the screening fee. 	Preventive education
and assessment shall be included as follows, by age:
(1) 	Age twelve to twenty-four months - complete
the clinical oral exam and appropriate
diagnostic tests to assess oral growth and
development and/or pathology; provide oral
hygiene counseling for parents, guardians and
caregivers; remove supra-and subgingival
stains or deposits as indicated; assess the
child's systemic fluoride status and provide
fluoride supplementation if indicated,
following drinking water analysis; assess
appropriateness of feeding practices; provide
dietary counseling relating to oral health;
provide injury prevention counseling for
orofacial trauma (play objects, pacifiers,
car seats, etc.); provide counseling for oral
habits (digit, pacifiers, etc.); provide
diagnosis and required treatment for any oral
disease or injuries; provide anticipatory
guidance for parent/guardian; assess topical
fluoride status and give parental counseling;
provide injury prevention counseling for
orofacial trauma (learning to walk, run,
etc.);

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(2) 	Age two to six years - repeat twelve to
twenty-four month procedures every six
months or as indicated by individual
patient's needs/susceptibility to disease;
provide age-appropriate oral hygiene
instructions; complete a radiographic
assessment of pathology and/or abnormal
growth and development, as indicated for
individual patient's needs; scale and clean
the teeth every six months or as indicated by
the individual patient's needs; provide
topical fluoride treatments every six months
or as indicated by the individual patient's
needs; provide pit and fissure sealants for
permanent teeth as indicated by the
individual patient's needs; provide
counseling and services (athletic mouth
guards) as needed for orofacial trauma
prevention; provide assessment/treatment or
referral of developing malocclusion as
indicated by individual patient's needs;
treat any oral disease/habits/injuries as
indicated;
(3) 	Age six to twelve years - repeat two to
six year procedures every six months or as
indicated by individual patient's
needs/susceptibility to disease; provide
injury prevention counseling/services for
orofacial trauma (sports activities); provide
substance abuse counseling (smoking, smoke
less tobacco, etc.); and
(4) 	Age twelve to twenty years - repeat six
to twelve year procedure every six months or
as indicated by individual patient's
needs/susceptibility to disease.
[Eff 08/01/94; am 11/25/96 	] (Auth:
HRS §346-14) 	(Imp: 	42 C.F.R. §441.56; 42
U.S.C. §1396d)
§17-1737-58 	Diagnosis and treatment. 	(a)
Diagnostic and treatment services shall be provided for
problems identified during screening regardless of
whether the service is included in the department's
state plan. 	Provision of services that are not
included in the state plan shall be based on medical
necessity and require prior authorization, and shall be
limited to services permitted under medicaid.
(b) 	Assistance in referral shall be provided for
treatment services not covered by the medical

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assistance program (medicaid), but determined to be
needed as a result of problems identified during
screening and diagnosis. 	Assistance in referral only
shall include giving the recipient or family the names,
addresses, and telephone numbers of providers who are
able to furnish the needed treatment at little or no
cost to the recipient or family.
(c) 	Dental care, at as early an age as necessary
for relief of pain and infections, restoration of teeth
and maintenance of dental health in accordance with
section 17-1737-75. Dental diagnosis and treatment
shall be started within sixty days of the screening
date and the treatment plan shall be completed within
one hundred-twenty days from the date a procedure was
initiated, except under noted extenuating
circumstances.
(d) 	Diagnostic and treatment services shall be
started within six months from the request for
screening services by the recipient or family.
[Eff 08/01/94 	] 	(Auth: 	HRS §346-14) 	(Imp: 	42
C.F.R. §§441.56, 441.61; 42 U.S.C. §1396d)
§17-1737-59 	EPSDT providers. 	EPSDT providers
shall deliver either directly or indirectly through
referral EPSDT services as set out in sections
17-1737-53 to 17-1737-58. 	[Eff 08/01/94 	]
(Auth: 	HRS §346-14) 	(Imp: 	42 C.F.R. §§441.56,
441.58, 441.61)
§17-1737-60 	Continuing care provider. 	(a)
Continuing care means EPSDT services provided by a
medical professional familiar with the recipient's
episodes of acute illness; and who has an ongoing
relationship with the recipient or family as their
regular source of health care.
(b) 	Continuing care provider shall deliver EPSDT
services as set out in sections 17-1737-54 to
17-1737-59 with the exception of dental services, and
provide physician services as needed by the recipient
for acute, episodic, or chronic illnesses or
conditions.
(1) 	Recipient or family shall agree to use the
continuing care provider of their choice as
their regular source of continuing care
services.
(2) 	Provider and recipient or family shall sign
statements that reflect their respective
obligations under the continuing care

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arrangement. 	[Eff 08/01/94 	] 	(Auth:
HRS §346-14) 	(Imp: 	42 C.F.R. §441.60)
§17-1737-61 	Provider requirements for
participation in the medical assistance program. 	(a)
Participation in the program as an EPSDT or a
continuing care provider is open to public and
volunteer clinics and health agencies, health
maintenance organizations, prepaid health plans, group
practices, and solo practitioners. 	EPSDT provider and
continuing care provider shall meet all the
requirements as set out in chapter 17-1736.
(b) 	EPSDT provider and continuing care provider
approved by the department for program participation
shall enter into a contractual agreement with the
department. 	Contractual agreement shall include but
not be limited to:
(1) 	Provider responsibility to maintain
recipient's consolidated health history,
including information received from other
providers; and
(2) 	Department's responsibility to reimburse for:
(A) 	Medical screening services based on a
negotiated per patient rate; and
(B) 	Routine dental examinations in
accordance with the fee schedule
established for the fee for services
component of the medical assistance
program (medicaid). 	[Eff 08/01/94 	]
(Auth: 	HRS §346-14) 	(Imp: 	42 C.F.R.
§§431.10, 441.60)
§17-1737-62 	Appeal and hearing. 	An appeal and
hearing process in accordance with chapter 17-1736
shall be available to all EPSDT providers and
continuing care providers. 	[Eff 08/01/94 	]
(Auth: 	HRS §346-14) 	(Imp: 	42 C.F.R. §431.10)
§§17-1737-63 to 17-1737-70 	(Reserved).
SUBCHAPTER 7
ANCILLARY MEDICAL SERVICES

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§17-1737-71 Drugs. 	(a) 	Medical assistance
payments shall be made for drugs when dispensed to
eligible recipients within the following guidelines:
(1) 	When prescribed by a practitioner licensed in
the United States;
(2) 	The drug has been approved by the U.S. Food
and Drug Administration for the purpose for
which it is prescribed;
(3) 	The drug can be expected to be of therapeutic
value for the disease or condition under
treatment; and
(4) 	The drug complies with the Medicaid drug
formulary or prior authorization has been
obtained from the department's medical
consultant or designee or there is compliance
with the prior authorization requirements set
forth in section 17-1739.1-4.1.
(b) 	A drug formulary may be maintained as
follows:
(1) 	An advisory formulary committee shall be
appointed by the director of the department,
and shall consist of:
(A) 	A committee consisting of physicians,
pharmacists, and other individuals
deemed appropriate by the director; or
(B) 	At the option of the State, the State's
drug use review (DUR) board;
(2) 	The formulary committee's secretary or drug
use review coordinator shall be
representatives of the department and
selected by the director;
(3) 	The duties of the advisory drug formulary
committee shall be to:
(A) 	Meet when called by the chairperson;
(B) 	Develop and maintain a current and
effective drug formulary;
(C) 	Advise the department of suggested
changes; and
(D) 	Recommend the criteria under which prior
authorization may be appropriate;
(4) 	Actions of the advisory drug formulary
committee shall be:
(A) 	Subject to the approval of the
department;
(B) 	Circulated to appropriate providers; and
(C) 	Effective upon receipt by providers
unless otherwise stated; and
The term of each formulary committee
member shall be not more than two years

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and overlapped in such a way that
expiration of term does not cause a
total membership change, or subject to
the bylaws of the drug use review board.
(c) 	The drug formulary shall contain:
(1) 	Drugs approved by the U.S. Food and Drug
Administration for human use and whose
manufacturers' have entered into rebate
agreement with the Centers for Medicare and
Medicaid Services;
(2) 	Drug products which are safe, economical, and
effective;
(3) 	Drugs that are not experimental; and
(4) 	The following categories of drugs, subject to
restriction under section 1927 of the Act,
are not covered:
(A) 	Used for cosmetic purposes or hair
growth;
(B) 	With associated tests or monitoring
purchased exclusively from the
manufacturer or designee as a condition
of sale;
(C) 	Which are classed as “less than
effective” as described in Section
107(c)(3) of the Drug Amendments of 1962
or are identical, similar or related;
and
(D) 	Used to promote fertility.
(d) 	A recipient eligible for medical assistance,
who is eligible for Medicare, shall not be covered for
prescription drugs that are covered under the Medicare
Part D Prescription Drug Program effective
January 1, 2006.
(e) 	Selected drugs that are excluded from the
Medicare Part D Prescription Drug Program or otherwise
restricted drugs or classes of drugs, may be covered
and available with prior authorization. 	They are as
follows:
(1) 	Agents when used for anorexia, weight loss,
weight gain;
(2) 	Agents when used for the symptomatic relief
cough and colds;
(3) 	Prescription vitamins and mineral products,
except prenatal vitamins and fluoride;
(4) 	Nonprescription drugs;
(5) 	Barbiturates; and
(6) 	Benzodiazepines. 	[Eff 08/01/94;
am 11/13/95; am 03/30/96; am 03/11/04;

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am 12/26/05 	] 	(Auth: 	HRS §346-14)
(Imp: 	42 C.F.R. §440.120; P. L. No. 103-66;
42 U.S.C. §§ 1396r(8)(d)(4) and (5),
1927(d)(2), 1935(d)(2))
§17-1737-71.1 	Supplemental rebate agreement for a
drug. 	(a) 	The department may enter into an agreement
with a pharmaceutical manufacturer to obtain a
rebate(s) in addition to the rebates pursuant to 42
U.S.C. Section 1396r-8(a).
(b) 	Participation by a pharmaceutical
manufacturer in a supplemental rebate agreement with
the department is voluntary.
(c) 	A supplemental rebate agreement may be a
factor in the placement of a drug on a preferred drug
list pursuant to section 17-1739.1-4.1(b).
[Eff 03/11/04 	] 	(Auth: 	HRS §346-14) (Imp: 	42
C.F.R. §440.120; 42 U.S.C. §1396r(8))
§17-1737-72 Durable medical equipment. 	(a)
Durable medical equipment means equipment prescribed by
a licensed physician to meet the medical equipment
needs of a patient. 	Durable medical equipment
includes, but is not limited to, wheelchairs, walkers,
crutches, canes, hospital beds, side rails,
respirators, and oxygen equipment.
(b) 	Durable medical equipment may be provided if
it is:
(1) 	A medically necessary modality in the
treatment of a medical condition;
(2) 	Necessary to assist the recipient in meeting
or improving activities of daily living;
(3) 	Recommended by the attending physician for
medical care of a patient; or
(4) 	Suitable for use in the recipient's place of
residence.
(c) 	Ramps for wheelchairs may be provided with
prior authorization when necessary to accomplish
activities of daily living.
(d) 	Not more than one wheelchair of any kind is
allowed, unless there is a significant change in the
recipient’s condition that justifies another
wheelchair.
(e) 	Medical equipment or appliances, when not
available in the department's inventory, may be
provided through rental or purchase, depending on the
physician's opinion about the length of time the
recipient will require use of the equipment.

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(f) 	Rental payment for durable medical equipment
or appliances shall cease and the item will have been
purchased by the state when rental payments become
equal to the purchase price.
(g) 	When an item is purchased during a rental
period but before the rental paid equals the purchase
price, all rental payments will be credited toward the
purchase price of that item.
(h) 	Durable medical equipment shall not be
provided to recipients who are patients in acute
hospitals or long-term care facilities.
(i) 	Medical authorization shall be required for
the purchase, cumulative rental, or repair of durable
medical equipment when the cost to the program exceeds
$50 per month.
(j) 	The following items shall not be covered by
the medical assistance program:
(1) 	Books;
(2) 	Air conditioners;
(3) 	Television sets;
(4) 	Massagers;
(4) 	Household items and furnishings including
standard, orthopedic, or water beds;
(5) 	Fans;
(7) 	Air purifiers or air filters;
(8) 	Computers;
(9) 	Telephones;
(10) 	DME modifications to the house, which may
include, but is not limited to, ceiling
lifts, wheelchair lifts, elevators, and
stair climbers;
(11) 	Feeder chairs when the recipient has another
seating system, such as a wheelchair;
(12) 	Car seats and booster seats for individuals
of all ages;
(13) 	Infant or child strollers;
(14) 	High chairs or chairs used for feeding; and
(15) 	Other items not generally used primarily for
health care.
(k) 	The medical consultant may change a request
for durable medical equipment to a less expensive make
or model when the basic functions of the desired
equipment are met.
(l) 	Durable medical equipment purchased by the
Medicaid program may be re-claimed by the department
when no longer useful to the client.
(m) 	Medicare’s criteria is followed for the
coverage of durable medical equipment unless
specifically stated elsewhere. 	This provision also

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applies to the maintenance, replacement, and repair of
durable medical equipment. 	[Eff 08/01/94;
am 10/26/01, am 05/10/03; am 09/17/07 	] 	(Auth:
HRS §346-14) (Imp: 42 C.F.R. §§440.110, 440.130)
§17-1737-73 	Medical supplies. (a) 	Medical
supplies means medical items prescribed by a licensed
physician that are medically necessary for the
treatment, care, or observation of a medical condition.
(b) 	Medical supplies include, but are not limited
to, insulin syringes and needles, ostomy appliances and
supplies, urine test materials, contraceptive devices,
incontinence pads or devices, catheters, urine bags and
tubing, ice bags, and hot water bottles or heating
pads.(c) 	Medical Authorization shall be required when
the line item billed cost of the items prescribed
exceeds $50 per month, except for intra-uterine devices
for family planning purposes for which the cost may
exceed $50 per month.
(d) 	The following items shall not be covered by
the program:
(1) 	Tooth brushes of any type, including standard
or mechanical, except when distributed
through the EPSDT program and included as
part of the oral screening visit, water
cleansing devices, toothpaste, denture
cleaners, and mouth washes;
(2) 	Baby oil and powder;
(3) 	Sanitary napkins;
(4) 	Health food and food supplements;
(5) 	Non-medicated shampoos;
(6) 	Soaps including medicated soaps;
(7) 	Lip balm;
(8) 	Band aids;
(9) 	Prepared food formula except when necessary
for nutrition due to inborn metabolic
abnormalities, abnormalities of digestion or
absorption, or when persons are being fed by
nasogastric, gastrostomy or jejunostomy tube.
Milk substitutes and related compounds may be
made available under this exception with
prior authorization;
(10) 	Bowel and bladder incontinence care supplies
with the exception of diapers, underpads and
gloves, for a recipient age three or older
and catheters, subject to medical necessity;
(11) 	For individuals over the age of twenty-
one, incontinence care supplies in excess of

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two hundred diapers per month, fifty
underpads per month, and fifty pairs of
gloves per month; and
(12) 	Other supplies not primarily medical in
nature.
(e) 	Medical supplies billed using a miscellaneous
Health Care Financing Procedure Coding System (HCPCS)
code are required to have a copy of the invoice
submitted for the equipment billed. 	Payment for
medical supplies will be based on the invoice amount
plus a negotiated percentage amount.
(f) 	Medicare’s 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. 	[Eff 08/01/94; am 02/16/02; am 05/10/03;
am 09/17/07 	] 	(Auth: 	HRS §346-14) 	(Imp: 	42
C.F.R. §§440.20, 440.90)
§17-1737-74 	Prosthetic and orthotic appliances.
(a) 	Prosthetic and orthotic appliances means those
appliances prescribed by a physician, dentist, or
podiatrist for the restoration of function or
replacement of functional body parts.
(b) 	Prior authorization shall be required when
the original or cumulative cost for purchase, repair,
or manufacture of the appliances exceeds $50, except
for dental prosthetic appliances which are covered
under section 17-1737-75.
(c) 	The following items may be covered by the
medical assistance program:
(1) 	Stock prosthetic eyes to prevent the
problems associated with an empty eye
socket;
(2) 	Orthopedic and therapeutic shoes when
prescribed by a physician and provided by a
prosthetist or an orthotist and when at
least one of the shoes will be attached to a
brace or prosthesis or the individual is
diabetic;
(3) 	Stock orthopedic shoes and high-topped shoes
for children under the age of six years;
(4) 	Modification of stock conventional or
orthopedic shoes when medically necessary;
(5) 	Custom-made orthopedic shoes when there is a
clearly established medical need that cannot
be satisfied by the modification of stock
conventional or orthopedic shoes; and

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(6) 	Implanted breast prosthesis provided the
surgical procedure of implantation is
approved by the department.
(d) 	Testicular prosthesis shall not be included
in the medical assistance program. [Eff 08/01/94;
am 09/17/07 	] 	(Auth: 	HRS §346-14) 	(Imp: 	42
C.F.R. §§440.120)
§17-1737-75 	Dental services. 	(a) 	Dental
services means diagnostic, preventive, and corrective
procedures administered because of a diseased
condition, injury, or impairment, by or under the
supervision of a dentist licensed under state law for
the treatment of teeth and the associated structures of
the oral cavity.
(b) 	Dental services for individuals under the age
of twenty-one are limited to the following services:
(1) 	Emergency treatment which includes services
to relieve dental pain, eliminate infection,
and treatment of acute injuries to the teeth
and supporting structures of the oro-facial
complex;
(2) 	X-ray with the limitations of one set of two
bitewing rediographs during a twelve-month
period and one set of full month rediographs
during a five-year period, including
bitewings;
(3) 	Preventive dental services:
(A) 	Topical application of fluoride;
(B) 	Sealants for occlusal surface of
permanent molar teeth only for children
ages six through fifteen; and
(C) 	Dental examination and prophylaxis
treatment, which shall be limited to not
more than once every six months, and
which shall not cover routine
examination of institutional patients;
(4) 	Periodontic treatment limited to cases of
medical necessity, includes in the procedure,
post operative care for six months following
treatment and recall treatment limited to
three times a year. Prior authorization and a
medical report is required: 	Osseous and
mucogingival surgeries, grafts, and implants
are considered elective and are not covered;
(5) 	Dental work done under conscious sedation
(inhalation or intravenous) or general
anesthesia shall be allowed only in cases of

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medical necessity and within program policy
guidelines. 	A medical report is required;
(6) 	Root canal therapy with the following
requirements:
(A) 	Root canal therapy shall be covered for
a maximum of once per tooth, except in
cases of poor prognosis, as in the case
of advanced decay or bone loss or prior
root canal failure. Completed root canal
x-rays shall be submitted with the claim
for payment;
(B) 	Root canal therapy shall not be covered
for the purpose of overdenture
fabrication except under special medical
circumstances which requires prior
authorization and a medical report;
(7) 	Extraction, whether done in the dentist's
office or in a hospital under general
anesthesia;
(8) 	Restorative dentistry with the following
limitations:
(A) 	Restorative dentistry shall be limited
to the use of amalgam, silicate, resin,
plastic, acrylic, or composite fillings;
(B) 	Non-duplicated restorative procedures
are allowed only once per tooth every
two years as needed in the treatment of
fractured or carious teeth;
(C) 	Acrylic jackets and acrylic veneer
crowns, if authorized, shall be limited
to anterior teeth for a maximum of once
per tooth;
(D) 	The department shall not allow a
separate charge for tooth preparation,
temporary restorations, pulp caps,
cement bases, impressions, or local
anesthesia;
(E) 	An amalgam or composite buildup shall be
considered a component part of the
preparation for the completed
restoration except in special
circumstances, and by report; and
(F) 	Amalgam restorations are allowed, but
composite resin or acrylic restorations
in posterior secondary teeth (except the
facial surface of permanent first
premolars) shall be considered purely
cosmetic dentistry and shall not be
covered;

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(9) 	Drugs administered by the dentist in the
dentist's office shall be covered at the rate
of fifty cents for each drug plus the cost of
the drug;
(10) 	Dental prosthesis limited to crowns, space
maintainers, partial or full dentures,
adjustments and repair, subject to the
following limitations:
(A) 	Partial dentures shall be limited to
fill the space due to the loss of one or
more anterior teeth and to fill the
space due to the loss of two or more
posterior teeth exclusive of third
molars;
(B) 	One partial or full denture shall be
allowed per arch per recipient in any
five year period. 	This is allowed when
existing dentures cannot be repaired or
adjusted;
(C) 	Temporary partial dentures shall be
allowed only when teeth have been
extracted recently and shall be subject
to the maximum benefits for dentures;
(D) 	Denture relines are limited to one per
denture every two years;
(E) 	Precious, semi-precious, and
non-precious metal cast crowns shall be
limited to permanent first and second
molars;
(F) 	Overdentures shall not be covered; and
(G) 	Space maintainers are limited to
children age fourteen and under to hold
the space for the eruption of the
permanent cuspids, pre-molars or first
molars due to premature loss of the
deciduous predecessor; and
(11) 	Consultation and dental surgery with the
following limitations:
(A) 	Routine postoperative visits shall be
considered part of the total surgical
procedure and shall not be separately
compensable; and
(B) 	Vestibuloplastys, skin grafts, bone
grafts, and implants shall not be
covered except when one or more is part
of the treatment for fractured jaws.
(c) 	Specific dental services not covered by the
department shall include the following:
(1) 	Orthodontic services except following repair
of a cleft palate or other severe

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developmental defect or injury in a child for
which the functions of speech, swallowing, or
chewing shall be restored;
(2) 	Fixed bridge work;
(3) 	Plaque control;
(4) 	Gold inlays;
(5) 	Gold crowns, except for permanent first and
second molars;
(6) 	Procedures, appliances, or restorations
solely for cosmetic purposes. 	Composite
resin or acrylic restoration in posterior
teeth and all primary teeth shall be
considered purely cosmetic; and
(7) 	Overdentures.
(d) 	Dental services for individuals twenty-one
years and older are limited to emergency treatment
which does not include services aimed at restoring and
replacing teeth and shall include services for the
following:
(1) Relief of dental pain;
(2) Elimination of infection; and
(3) Treatment of acute injuries to the teeth or
supporting structures of the oro-facial
complex. 	[Eff 08/01/94; am 01/29/96;
am 03/30/96; am 06/19/00; am 04/11/03;
am 12/07/06,am 08/10/09,am 	]
(Auth: 	HRS §346-14) (Imp: 	42 C.F.R. §440.100)
§17-1737-75.1
§17-1737-75.1 	REPEALED. 	[Eff 12/07/06; R
08/10/09]
§17-1737-76 	Visual services. 	(a) 	Visual or
optometric services means services provided by an
ophthalmologist or optometrist licensed to practice
under state law to correct visual problems within the
limits of their professional fields and includes the
dispensing of prescription eyeglasses on the written
prescription of a licensed practitioner.
(b) 	Visual services shall include:
(1) 	Professional services limited to:
(A) 	Eye examinations;
(B) 	Refraction, with coverage of a second
refraction for persons under the age of
eighteen years within twelve months, or
eighteen years or older within
twenty-four months only when indicated

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by symptoms. 	The provider shall make a
reasonable effort to determine the date
of any previous refraction; and
(C) 	Vision analysis;
(2) 	Prescription eyeglasses:
(A) 	When, for single vision lenses, the
refractive correction is at least:
(i) 	For an original prescription, (+)
or (-) 0.50 diopter, sphere or
cylinder, or 1 vertical or 5
horizontal prism diopters; or
(ii) 	For a change in prescription of (+)
or (-) 0.50 diopter, or sphere or
cylinder, or 6 degrees in cylinder
axis;
(B) 	Which may have single vision, bifocal,
or prism lenses made of glass or
plastic. Glass lenses shall conform to
standard Z-80 (National Bureau of
Standards) as it existed on
September 15, 1983;
(C) 	But, exclusions shall be that:
(i) 	Trifocal lenses shall be covered
only for those persons who are
currently wearing these lenses
satisfactorily and for specific job
requirements;
(ii) 	Tinted or coated corrective lenses
shall be included only for persons
with aphakia, albinism, glaucoma,
or other medical conditions of the
eyes exclusive of photophobia not
associated with such conditions.
Lights transmission shall be
adequate to permit use of the
lenses indoors and at night;
(iii) 	Oversize lenses shall not be
covered; and
(iv) 	Bilateral plano glasses shall be
covered as safety glasses for
persons with one remaining
functioning eye;
(D) 	Along with the case and frame, and
repair or replacement of any part;
(E) 	Individuals with presbyopia who require
no or minimal distance correction shall
be fitted with ready-made half glasses
instead of bifocals; and
(F) 	Where applicable following cataract
extraction with or without insertion

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of an intraocular prosthetic lens,
ready-made temporary glasses shall be
rented or purchased until healing has
occurred and change in refractive error
has stabilized;
(3) 	Related services which include:
(A) 	Verification of prescription and
dispensing of eyeglasses;
(B) 	Fitting to include facial measurements;
and
(C) 	Adjustment of glasses;
(4) 	Contact lenses of all types covered in
accordance with the following limitations:
(A) 	Keratoconus in one or both eyes where
corrected vision by glasses is less than
20/40 and the vision is further improved
by contact lenses;
(B) 	Corneal astigmatism in one or both eyes
greater than 4.00 diopter and the
astigmatism correctable by contact
lenses;
(C) 	Irregular astigmatism due to corneal
imperfection where corrected vision by
glasses is less than 20/40 and vision is
further improved by contact lenses;
(D) 	Anisometropia due to aphakia or other
causes where the vision corrected by
glasses in the non-affected eye is less
than 20/50, the problem either will last
for at least six months or is permanent,
and the person requires binocular vision
for educational or job purposes;
(E) 	Bilateral aphakia when a person becomes
ill using spectacle glasses or when the
person's occupation makes the wearing of
glasses hazardous;
(F) 	Certain inflammatory conditions of the
cornea for which therapeutic contact
lenses are indicated with the
recommendation of an ophthalmologist;
and
(G) 	Not where there are:
(i) 	Elderly persons beyond the working
age with aphakia where the
corrected vision in the non-aphakia
eye with glasses is 20/50 or
better, and the addition of a
contact lens will not make the
person economically productive; and

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(ii) 	Solely cosmetic purposes such as
obscuring an opaque pupil;
(5) 	Subnormal visual aids; and
(6) 	Replacement of glasses or contact lenses
limited to one pair or unit in a twenty-four
month period.
(c) 	Approval shall be required to obtain contact
lenses, subnormal visual aids costing more than $50,
and to replace glasses or contact lenses within two
years, and shall include one or more of the following
(1) 	The date and circumstances of loss;
(2) 	The date the previous glasses were made;
(3) 	The visual acuity without and with
correction; or
(4) 	The refractive prescription and the previous
prescription, if a change is being requested.
(d) 	Bifocal lenses do not require authorization
but claims for these lenses for persons under forty
years of age shall include adequate medical
justification.
(e) 	Excluded services and materials shall be:
(1) 	Visual training and exercise lessons;
(2) 	Tinted or absorptive lenses except as stated
in subsection (b)(2)(C)(ii);
(3) 	Oversize lenses except for replacement of
lenses only;
(4) 	Contact lenses for cosmetic purposes;
(5) 	Bifocal contact lenses;
(6) 	Blended bifocals; and
(7) 	All services or materials not in compliance
with the preceding restrictions.
[Eff 08/01/94 	] (Auth: HRS §346-14) (Imp:
42 C.F.R. §§440.120, 440.230, 441.30)
§17-1737-77 	Speech, hearing and language
disorders. 	(a) 	Services for individuals with speech,
hearing, and language disorders means diagnostic,
screening, preventive, or corrective services provided
by, or under the direction of, a speech pathologist or
audiologist, to whom a patient is referred by a
physician. 	Necessary supplies and equipment shall be
included.
(b) 	A physician may prescribe services for
patients with speech, hearing, or language disorders
who are expected to improve in a reasonable period of
time with therapy.
(c) 	All recommended speech, hearing, and language
evaluations shall require prior authorization by the

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department's medical consultants according to the
following procedures:
(1) 	For evaluation, information indicating
diagnosis, age, and duration of the clinical
condition; and
(2) 	For therapy, information indicating:
(A) 	The evaluation and results of
standardized objective tests; and
(B) 	A plan of therapy with goals and time
frames.
(d) 	If a reasonable doubt exists that an
individual requires therapy or continuation of therapy,
a board of experienced therapists may be asked to
review the medical consultants' findings and make
recommendations to the department's medical
consultants. 	[Eff 08/01/94 	] (Auth: 	HRS
§346-14) (Imp: 	42 C.F.R. §§440.110, 440.230)
§17-1737-78 	Hearing evaluations and devices. 	(a)
All hearing aid rentals, purchases, or repairs shall
require medical approval by the department.
(b) 	Persons requesting hearing aids shall have a
hearing evaluation by a physician who is an ear, nose,
and throat specialist who concurs with the need for a
hearing aid.
(c) 	The following conditions and limitations
shall apply:
(1) 	A hearing evaluation may be permissible every
twelve months;
(2) 	Hearing aids purchased by the medicaid
program shall be of the unilateral type.
Miniaturized or "all in the ear" hearing aids
are excluded. Special models or modifications
shall require justification with
documentation of medical necessity;
(3) 	Hearing aid purchase requests shall be
approved initially for one month of rental at
$25 per month to determine the
appropriateness of the hearing aid;
(4) 	Purchase of the hearing aid may be
recommended based on the evaluation of the
rental period of paragraph (1). 	A new
authorization form shall be submitted showing
the model and serial number of the hearing
aid;
(5) 	If the hearing aid purchase is not
recommended, a factory reconditioning charge
of no more than $50 may be paid when

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supported by a copy of the manufacturer's
invoice;
(6) 	Repair of hearing aids shall be itemized;
(7) 	Hearing aid replacements may be purchased
every two years with justification;
(8) 	Ear plugs may be purchased for individuals
with recurrent middle ear infections on
recommendation by a physician who is an ear,
nose and throat specialist. 	Only one set of
ear plugs every twelve months shall be
allowed; and
(9) 	Insurance premiums to cover hearing aid
losses or repair shall be a coverage only for
children under twelve years of age.
(d) 	Eligible children may be referred to the
department of health for hearing evaluations and
services. 	[Eff 08/01/94 	] 	(Auth: 	HRS §346-14)
(Imp: 	42 C.F.R. §§431.10, 440.110, 440.220)
§17-1737-79 	Physical therapy and occupational
therapy services. (a) 	Physical therapy means services
prescribed by a physician that are provided to a
recipient by a qualified physical therapist licensed by
the state and certified by the medicaid program to
provide services. 	Necessary supplies and equipment
shall be included as part of this service.
(b) 	Occupational therapy means services
prescribed by a physician provided to a recipient by a
qualified occupational therapist who has been certified
by the American Occupational Therapy Association and
approved by the medicaid program to provide services.
Necessary supplies and equipment shall be included as
part of the service.
(c) 	Physical and occupational therapy may be
prescribed by a physician when medically necessary and
when the following conditions are met:
(1) 	The services are considered under accepted
standards of medical practice, to be a
specific and effective treatment for the
patient's condition;
(2) 	The services or patient's condition is of a
level of complexity requiring services that
can be safely and effectively performed only
by a qualified therapist. 	Maintenance
therapy which does not require the
performance and supervision of a therapist
shall be considered as nursing rather than
therapy services for separate billing, even
if performed or supervised by a therapist;

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(3) 	There is an expectation that the patient's
condition will improve significantly in a
reasonable period of time based on the
assessment made by the physician of the
patient's restoration potential, or the
services are necessary to establish a safe
and effective maintenance program required in
connection with a specific disease state; and
(4) 	The amount, frequency, and duration of
services are reasonable.
(d) 	When physical therapy or occupational therapy
is requested for an acute symptomatic condition without
demonstrable musculoskeletal abnormality, the therapy
shall be provided for only a short period of time not
to exceed two weeks, except when extended by prior
approval.
(e) 	Where a neuro-musculoskeletal abnormality is
demonstrated, a definitive diagnosis shall be made
utilizing radiologic or appropriate diagnostic
procedures, and if necessary, specialty consultation.
(f) 	All recommended therapy for non-institutional
recipients shall require the approval of the medical
consultant and the request shall include the following
information:
(1) 	Diagnosis;
(2) 	Recommended therapy indicating the frequency
and estimated duration of therapy; and
(3) 	For chronic cases, long term goals and a plan
of care.
(g) 	Outpatient physical therapy services and
outpatient occupational therapy shall be limited to no
more than three-fourths of an hour or three modalities
of treatment per day although several treatment
modalities may be provided during this treatment
period. 	Physical therapy services exceeding three-
fourths of an hour or three modalities shall be
specifically approved by the department prior to the
provision of services. 	[Eff 08/01/94 	] (Auth:
HRS §346-14) (Imp: 	42 C.F.R. §§440.10, 440.230)
§17-1737-80 Podiatry services. 	(a) Podiatry
services means services directed toward the treatment
and care of feet ailments or disorders of the foot and
ankle that are provided by a podiatrist or a physician,
who is licensed to practice in the State of Hawaii.
(b) 	Podiatry services and appliances
(orthoses,prostheses) shall include, but are not
limited to, the treatment of conditions of the foot and
ankle such as:

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(1) 	Professional services, not involving surgery,
provided in the office and clinic;
professional services, not involving surgery,
related to diabetic foot care in the
outpatient and inpatient hospital, skilled
nursing facility, and intermediate care
facility under the following conditions:
(A) 	Podiatry services, not involving
surgery, in a hospital (inpatient or
outpatient), skilled nursing facility,
and intermediate care facility shall be
considered as adjuncts to general
medical care and limited to diabetic
foot care;
(B) 	In the case of a patient requiring
inpatient hospital care, podiatry
services shall be limited to diabetic
foot care only, must be ordered by the
attending physician as noted by the
physician in the medical chart, and may
be furnished after obtaining prior
authorization from the department's
medical consultant; and
(C) 	In the case of a patient requiring
podiatry services in a skilled nursing
or an intermediate care facility,
podiatry services shall be limited to
diabetic foot care only and must be
ordered by the attending physician as
noted by the physician in the medical
chart;
(2) 	Surgical procedures are limited to those
involving the ankle and below; surgical
procedures performed in the office, clinic,
and skilled nursing or intermediate care
facility with costs greater than $100 require
prior authorization from the department's
medical consultant or agent. All surgical
procedures performed in the outpatient
hospital require prior authorization from the
department's medical consultants;
(3) 	Diagnostic radiology procedures limited to
the ankle and below;
(4) 	Foot appliances (orthoses, prostheses);
(5) 	Orthopedic shoes and casts; and
(6) 	Orthodigital prostheses and casts.
(c) 	Foot and ankle care related to the treatment
of infection or injury is covered in the office or an
outpatient clinic setting.

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1737-94
(d) 	Bunionectomies are covered only when the
bunion is present with overlying skin ulceration or
neuroma secondary to the bunion.
(e) 	The following services shall not be covered
under the program:
(1) 	Routine foot care, including debridement not
related to treatment of infection or injury,
with the exception of diabetic foot care in
the inpatient hospital or nursing facility
setting. 	Routine foot care, as defined for
this purpose, includes:
(A) 	The cutting or removal of corns or
calluses;
(B) 	The trimming of nails (including mycotic
nails); and
(C) 	Other hygienic and preventive
maintenance care in the realm of self-
care, such as cleaning and soaking the
feet, the use of shin creams to maintain
skin tone of both ambulatory and bedfast
patients;
(2) 	Treatment of flat feet;
(3) 	Any services performed in the absence of
localized illness, injury or symptoms
involving the foot and ankle are not covered;
(4) 	Bunionectomies are not covered if the sole
indications are pain and difficulty finding
appropriate shoes; and
(5) 	Services performed in, but not limited to,
the following settings:
(A) 	A home;
(B) 	A domiciliary care home;
(C) 	A residential drug treatment program;
(D) 	A mental health group home;
(E) 	A therapeutic home; or
(F) 	A foster home.
(f) 	All podiatry services to be provided to a
hospital inpatient or recommended appliances of a non-
emergency nature and costing more than $100 shall
require prior authorization by the department’s
medical consultant or agent. Requests for services or
appliances shall be submitted on the appropriate
departmental form by the patient's attending
physician. 	[Eff 08/01/94; am 01/29/96; am 10/26/01;
am 05/05/05] (Auth: HRS §346-14) (Imp: 42 C.F.R.
§440.60)
§17-1737-81 	Pediatric or family nurse
practitioner services. 	(a) 	Pediatric or family nurse

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practitioners are registered nurses who meet the
following conditions:
(1) 	Licensed to practice as a registered
professional nurse in the State;
(2) 	Successfully completed an accredited,
advanced training program in pediatrics or
family health;
(3) 	Currently certified by the American Nurses
Association or the National Board of
Pediatric Nurse Practitioners and Nurses to
practice in either specialty named above; and
(4) 	Initially and biennially licensed with the
department of commerce and consumer affairs
as an advanced practice registered nurse
(APRN) in their area of profession.
(b) 	Nurse practitioner services to medicaid
recipients shall be limited to the scope of practice a
nurse practitioner is legally authorized to perform
under state law at locations including, but not limited
to: (1) 	The practitioner's office;
(2) 	A private or public clinic;
(3) 	A private home;
(4) 	An approved hospital;
(5) 	An approved nursing facility; or
(6) 	A licensed care home or adult family boarding
home.
(c) 	Medicaid payments shall be made only to
pediatric and family nurse practitioners who meet the
requirements of this section and of chapter 17-1736.
[Eff 08/01/94; am 01/06/05] 	(Auth: 	HRS §346-14)
(Imp: 	Pub. L. No. 101-239, §6405)
§17-1737-81.1 	Nurse-midwife services. 	(a) 	A
nurse-midwife is a registered nurse who meets the
following conditions:
(1) 	Licensed to practice as a registered
professional nurse in the State;
(2) 	Initially and biennially licensed with the
department of commerce and consumer affairs
as an advanced practice registered
nurse(APRN)certified nurse-midwife; and
(3) 	Successfully completed a program of study and
clinical experience for nurse-midwives and is
currently certified as a nurse-midwife by the
American College of Nurse-Midwives as a
nurse-midwife.

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(b) 	Nurse-midwife services to Medicaid recipients
shall be limited to the scope of practice a
nurse-midwife is legally authorized to perform under
state law, including but not limited to, providing
independent management of women’s health care, focusing
particularly on pregnancy, childbirth, the postpartum
period, care of the newborn, and the family planning
and gynecological needs of women.
(c) 	Medicaid payments shall be made only to a
nurse-midwife who meets the requirements of this
section and of chapter 17-1736. 	[Eff 01/06/05] 	(Auth:
HRS §346-14) 	(Imp: 42 C.F.R. §440.165)
§17-1737-82 	Intra-state transportation. 	(a)
Transportation may be provided in order to enable a
recipient to secure needed medical care and related
services.
(b) 	Transportation shall be by the most
economical means which would not be hazardous or
injurious to the recipient's health.
(c) 	Air transportation may be allowable where the
attending physician or a hospital refers a recipient to
a specialist or medical facility for diagnostic and
treatment services not available or not accessible on
the recipient's island of residence. Air transportation
requests may be initiated by the department's social
worker when a physician is not available to refer an
individual for medical care in Honolulu.
(d) 	In emergency situations, air transportation:
(1) 	Shall be by regularly scheduled commercial
flight when:
(A) 	Available;
(B) 	Medical care will not be affected if
travel is delayed until the next
scheduled flight; and
(C) 	The patient can sit in a standard seat
and requires no oxygen or other life
support mechanisms enroute; or
(D) 	If the patient is unable to sit and a
stretcher is required, the airline may
accommodate the patient in lieu of four
passenger seats;
(2) 	Shall be by air ambulance service when:
(A) 	Regularly scheduled commercial flights
are inappropriate because of problems
with the recipient's condition, which
include:
(i) 	Head injuries with evidence of
increasing intracranial pressure;

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1737-97
(ii) 	Multiple system injuries;
(iii) 	Complications of labor or
prematurity of newborn children
with respiratory distress; or
(iv) 	Other acute injuries or illnesses
beyond local capabilities; and do
not allow for service or time
delays; or
(B) 	Recipients to be transported on an
arranged basis cannot travel by
regularly scheduled commercial flights
because the recipients are:
(i) 	In spica casts returning home to
another island; or
(ii) 	Long-term care patients who are
bed-bound and going to another
island;
(3) 	If by air ambulance:
(A) 	Shall be authorized for a one-way trip
only; and
(B) 	Shall have life support services and at
least one attendant on the flight;
(4) 	Shall be arranged by the recipient's
attending physician or hospital who shall
complete and sign the appropriate form
justifying the use of an air ambulance and
give the original and all copies of the form
to the air ambulance crew chief; and
(5) 	May be coordinated with surface ambulance
service by the referring physician to the
designated hospital on the island of
destination.
(e) 	In a non-emergency situation, air
transportation:
(1) 	Shall be subject to prior review and
authorization by the department's medical
consultant;
(2) 	May be provided in the form of a round-trip
ticket when medical services on another
island are recommended by the attending
physician and the recipient is expected to
return home in two weeks or less;
(3) 	May be provided in the form of a round-trip
ticket to a person accompanying the recipient
if an attendant's service is recommended by
the commercial carrier. 	Payment may be made
for an attendant's services when rendered by
a person other than a relative under section
17-1739-7; and (4) 	Shall be by regularly
scheduled commercial flights.

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(f) 	In both emergency and non-emergency
situations, the department shall allow other related
inter-island travel expenses, such as:
(1) 	Cost of outside meals and lodging, while
receiving necessary and authorized medical
services; and
(2) 	Vendor payments for meals and lodging made
only to designated providers of the services
who have been authorized to participate under
the department's medical assistance program.
(g) 	Ground ambulance service may be allowed as
follows:
(1) 	Emergency ambulance service for injuries
shall be available in each county to the
patient. 	Ambulance service may be used in an
emergency; and
(2) 	Ambulance transfer service for transporting a
recipient to, from, and between medical
facilities and other providers may be
utilized when recommended by the attending
physician.
(h) 	Taxi service may be allowed as follows:
(1) 	Transportation by taxi may be authorized by
the payment worker to assist a recipient to
obtain covered medical services where:
(A) 	A recipient resides in an area not
served by a bus system;
(B) 	A recipient has no means of
transportation;
(C) 	Transportation is available but the
recipient cannot be accommodated at a
suitable hour; or
(D) 	A recipient is acutely ill, injured or
has a physical or mental impairment
verified by a physician, and travel by
bus would be either hazardous to that
person's health or would cause physical
hardship; and
(2) 	For rural areas, available taxi service
nearest to the recipient's home shall be
utilized.
(3) 	The department shall not be required to
provide transportation beyond the closest
geographic area where appropriate health care
services are readily available.
(i) 	Handicab services may be used for recipients
who are confined to a wheelchair or who are physically
unable to take care of themselves.
(j) 	Transportation services shall be available
for those individuals eligible for medical assistance,

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1737-99
provided all the provisions in this section are met.
An individual who utilizes benefits for other than
their intended purpose, may be referred for potential
prosecution of fraud. 	A provider who knowingly and
willfully falsifies, misrepresents, conceals, or fails
to disclose material facts to obtain transportation
services for an individual, may be referred by the
department to the Medicaid fraud control unit for
investigation and potential prosecution of fraud. 	The
department may seek the recovery of monies associated
with the fraudulent act. 	[Eff 08/01/94; am 02/10/97;
am 02/07/05] 	(Auth: 	HRS §346-14) (Imp: 	42 C.F.R. §§
431.53, 440.170)
§17-1737-83 	Out-of-state transportation.
(a) 	Out-of-state transportation may be provided
to eligible recipients for covered medical services
which are unavailable in Hawaii and with prior
authorization by the department's medical consultant.
(b) 	Transportation shall be by the most
economical means which would not be hazardous or
injurious to the recipient's health.
(c) 	Transportation shall be limited to a United
States medical facility which is licensed to provide
such services and certified as a medicaid provider by
the state where the facility is located.
(d) 	Request for out-of-state transportation shall
be made by the attending physician or a medical
facility and shall include:
(1) 	All information requested in the department
designated forms; and
(2) 	A comprehensive clinical summary of the
patient's condition, need for out-of-state
medical facility service, the name and
address of the out-of-state facility and the
name and telephone number of the authorized
representative of that medical facility.
(e) 	Out-of-state transportation may be provided
in the form of a round trip ticket issued to:
(1) 	The recipient when the recipient is expected
to return home in thirty days or less as
determined by the attending physician or
medical facility. 	A one-way ticket may be
issued when the recipient is expected to
remain out-of-state for more than thirty
days.
(2) 	Any person accompanying the recipient without
regard to the person's relationship to the

UNOFFICIAL
1737-100
recipient, if an attendant is required by the
transportation carrier or recommended by the
attending physician or the medical facility
and authorized by the department's medical
consultant.
(f) 	Other related travel expenses may be allowed
with prior authorization by the department's medical
consultant and may include but not be limited to:
(1) 	Cost of meals and lodging for the recipient
and one attendant;
(2) 	Taxi or other non-emergency ground
transportation when such transportation is
related to the provision of authorized
medical coverage; and
(3) 	Services of an attendant provided the
attendant is unrelated to the recipient.
(g) 	Transportation services shall be available
for those individuals eligible for medical assistance,
provided all the provisions in this section are met.
An individual who utilizes benefits for other than
their intended purpose, may be referred for potential
prosecution of fraud. 	A provider who knowingly and
willfully falsifies, misrepresents, conceals, or fails
to disclose material facts to obtain transportation
services for an individual, may be referred by the
department to the Medicaid fraud control unit for
investigation and potential prosecution of fraud. 	The
department may seek the recovery of monies associated
with the fraudulent act. 	[Eff 08/01/94; am 02/07/05]
(Auth: 	HRS §346-14) 	(Imp: 	42 C.F.R. §§431.53,
440.170)
§17-1737-83.1 	Out-of-state medical services. 	(a)
Out-of-state medical services shall be covered for
eligible Hawaii residents visiting in another state.
Medical services incurred while visiting in another
state shall be covered only when the requirements of
temporary absence as stated in section 17-1714-22(d)
are met.
(1) 	To receive payment for services incurred out-
of-state, the provider shall meet the
requirements of section 17-1736-13. 	In
addition:
(A) 	The services were required as they were
an emergency;
(B) 	The services were needed and the
recipient's health would have been
endangered if the recipient had to
return to the State of residence; or

UNOFFICIAL
1737-101
(C) 	The State has determined that the
services sought are unavailable in
Hawaii or more readily available in
another state; or
(2) 	Out-of-state Services shall require prior
authorization by the department, with the
exception to the services indicated in
subsection (b), paragraphs (1) and (2).
(b) 	Children under the age of nineteen and
children under the age of twenty-one years who are in
foster care placement or are covered by subsidized
adoption agreements shall be eligible for out-of-state
medical services. 	[Eff 02/10/97 	] 	(Auth: 	HRS
§346-14) 	(Imp: 	42 C.F.R. §§430(a); 431.52)
§17-1737-84 	Exclusions and limitations. 	(a)
Medical assistance payments shall not be made for
certain health services or items for reasons
including, but not limited to the following:
(1) 	The procedure, service, or material is of
generally unproven benefit;
(2) 	It is of an experimental nature;
(3) 	It is excluded by federal regulations or
state rules;
(4) 	It is not considered by the department to be
medically necessary;
(5) 	The same or similar results may be obtained
by another method at a reduced cost;
(6) 	The procedure is frequently followed by
severe complications which may be in
themselves life-threatening or require
prolonged medical care or secondary
operations; or
(7) 	Prior authorization is required but has not
been obtained.
(b) 	Based on subsection (a), the following
procedures or services are excluded and the medical
assistance program shall not pay any services in
association with them:
(1) 	Drugs not approved by the U.S. Food and Drug
Administration;
(2) 	Long term psychiatric institutional
treatment;
(3) 	Treatment of a person confined to a public
institution regardless of where the
treatment is performed;
(4) 	The follow-up examination or treatment of
Hansen's disease after the diagnosis has
been established regardless of whether the

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patient is contagious except for surgical or
rehabilitative procedures to restore useful
function;
(5) 	Treatment for tuberculosis when such
treatment is available free to the general
public;
(6) 	Acupuncture;
(7) 	Naturopathic, chiropractic, or Christian
Science or faith healing services;
(8) 	Private duty nursing;
(9) 	Circumcision after twelve months of age
unless there is documentation of phimosis
severe enough to prevent retraction,
recurrent balanitis, severe verrucae of or
under the prepuce or severe adhesions
between glans and prepuce;
(10) 	Repair of umbilical or ventral herniae
unless they are painful or bowel is present
in the sac;
(11) 	Excision or destruction of benign skin or
subcutaneous lesions except hemangiomas,
plantar warts, molluscum contagiosum,
leukiplakia or milia without medical
justification;
(12) 	Hysterectomies and sterilization procedures
not complying with the restrictions under
sections 17-1737-47 and 17-1737-48;
(13) 	Reversal of elective sterilization
procedures;
(14) 	Rhinoplasties except following accidental
injury resulting in significant obstruction
of breathing;
(15) 	Gastroplasty or other surgical procedures on
the stomach or bowel, or both, when
performed for morbid obesity unless the
operation may logically be expected to
improve an established medical condition
such as cardiac or respiratory
decompensation or severe hypertension.
Guidelines issued by the department shall be
met;
(16) 	Orthodontic services except for the
provisions of section 17-1737-75(c)(1) and
fixed bridgework;
(17) 	Orthoptic training;
(18) 	Tinted and contact lenses except as
described under section 17-1737-76 (visual
services);

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(19) 	Personal comfort items such as radios,
televisions, telephones, fans, or air
conditioners;
(20) 	Standard household items such as beds,
linens, cooking utensils, or blenders;
(21) 	Cosmetic, reconstructive, or plastic surgery
performed primarily to improve or change
physical appearance, performed primarily for
psychological purposes, or to restore form
but which does not correct or materially
improve bodily function. 	However,
consideration may be given when the purpose
of the procedure is to:
(A) 	Correct a congenital anomaly;
(B) 	Restore body form following an
accidental injury; or
(C) 	Revise disfigurement or extensive
scars, or both, resulting from
neoplastic surgery;
(22) 	Specific cosmetic surgery procedures
including:
(A) 	Sex transformation treatments,
procedures, hormones, or other
medication for the establishment or
maintenance of gender reassignment
except that medication may be allowed
if the sex of the individual has been
changed by court order;
(B) 	Cosmetic, reconstructive, or plastic
surgery procedures performed primarily
for psychological reasons or as a
result of the aging process;
(C) 	Augmentation mammoplasties except
following medically indicated
mastectomies for carcinoma,
precancerous conditions, or extensive
fibrosis or traumatic amputation;
(D) 	Reduction mammoplasties unless there is
medical documentation of intractable
pain not amenable to other forms of
treatment as a result of increasingly
large pendulous breasts;
(E) 	Paniculectomies and other body
sculpturing procedures;
(F) 	Removal of tattoos;
(G) 	Hair transplants;
(H) 	Electrolysis;
(I) 	Insertion of testicular prostheses,
unilateral or bilateral;

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1737-104
(J) 	Jejuno-ileal by-pass procedures for
morbid obesity;
(K) 	Ear piercing;
(23) 	In vitro fertilization procedures;
(24) 	Medications, devices, or agents for the
treatment of erectile dysfuction in males;
(25) 	Swimming lessons, summer camp, gym
membership, weight control classes, or
smoking cessation classes;
(26) 	Personal use of physical therapy equipment
that is customarily used by a physical
therapist in a physical therapy treatment or
modality including, but not limited to, tilt
tables, whirlpools, mats, play equipment, or
exercise equipment;
(27) 	Modifications to motor vehicles; and
(28) 	Equipment to access motor vehicles or
modifications to access motor vehicles.
(c) 	The UCC shall apply these exclusions in
facilities and for recipients under its review. 	In
other cases authorization of the department shall be
obtained before performing any of the above procedures
where exclusions are allowed.
(d) 	A medical service, supply, or durable
medical equipment excluded from coverage may be
approved on a case by case basis by the deparment if
there is sufficient justification to support the
medical necessity, as determined by its medical
consultant.
(e) 	All other forms or types of health care
services and supplies not specifically mentioned in
this chapter shall not be included in the program.
Questions regarding a form or type of health care
service or supply shall be directed to the medical
consultant.
(f) 	New tests, procedures, equipment, supplies,
and other services for which payment has not been
claimed previously shall not be considered for
inclusion until information satisfactory and
acceptable to the program has been received and
approval given. 	This particularly applies to tests
and procedures not included in the HCPCS code, where
several procedures are being clumped under one
heading, or a single procedure is divided into several
components. 	[Eff 08/01/94; am 03/30/96; am 11/25/96;
am 02/10/97; am 07/06/99; am 06/19/00; am 10/26/01;
09/17/07 	] 	(Auth: 	HRS §346-14) 	(Imp: 	42
C.F.R. §456.3)

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1737-105
§§17-1737-85 to 17-1737-89 	(Reserved).
SUBCHAPTER 8
TISSUE AND ORGAN TRANSPLANTATION
§17-1737-90 	REPEALED. 	[R 09/30/13]
§17-1737-91 	General provisions. 	(a) 	Allogenic
bone marrow and cadaveric corneal transplants are
covered under this program.
(b) 	Kidney transplantations are covered under
this program.
(c) 	Other non-experimental, non-investigational
organ and tissue transplantations are covered when
performed in a facility certified by Medicare for the
specific transplantation and approved for medical
necessity by the department's medical consultant.
(d) 	Transplantation shall be performed by
experienced specialists with transplantation training
and with established success records in an approved
Medicare-certified facility with proper equipment and
adequate and appropriately trained support staff,
except as provided in subsection (i).
(e) 	Prior authorization shall be required from
the department's medical consultant for all
transplants.
(f) 	Immunosuppressive therapy shall be covered as
required.
(g) 	If a transplant should fail or be rejected
and the patient is still within the age limits for
transplantation, the program's medical consultant may
review the case for one additional transplantation for
that patient.
(h) 	The program shall cover costs of tissue
typing of potential donors and cost of acquisition of
the tissue or organ as well as other studies necessary
to determine the appropriateness of the procedure and
any post transplantation follow-up evaluations as
required.
(i) 	When approved by the department's medical
consultant, a patient may be treated at an appropriate
out-of-state Medicare-certified transplant center for
the authorized procedure. 	[Eff 08/01/94;
am 11/25/96 	] 	(Auth: HRS §346-14; 42 C.F.R. §431.10)
(Imp: 	42 C.F.R. §440.230; 42 U.S.C. §1396b(i))

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§17-1737-92 	Corneal transplant (keratoplasty).
(a) 	Indications of penetrating keratoplasty include:
(1) 	Corneal opacification that sufficiently
obscures visibility (vision) through the
anterior segment of the eye with at least
light perception present. 	Causes for this
problem include:
(A) 	Corneal injury and scarring;
(B) 	Corneal degeneration (from Fuch's or
other dystrophy or from previous
cataract or intraocular lens
implantation, or both);
(C) 	Corneal degeneration from keratoconus or
familial causes;
(D) 	Corneal infection (e.g., herpes); and
(2) 	Therapeutic graft for relief of pain with at
least light perception vision present, from
corneal degeneration because of inflammation
with pain in the eye and useful vision still
present.
(b) 	Indications of lemellar keratoplasty include:
(1) 	Superficial layer corneal scarring and
deformity due to:
(A) 	Trauma;
(B) 	Degeneration;
(C) 	Infection; or
(D) 	Congenital deformity (anterior);
(2) 	Aphakia;
(3) 	High myopia;
(4) 	High refractive error;
(5) 	Keratoconus; and
(6) 	Recurrent pterygium.
(c) 	Conditions and limitations affecting corneal
transplant include:
(1) 	A relative contraindication is intractable
glaucoma in the eye under consideration for
surgery;
(2) 	No active eye infection at the time of
surgery;
(3) 	No general medical contraindications to
surgery or anesthesia;
(4) 	Informed consent shall be obtained from the
patient or patient's representative; and
(5) 	No age restriction. 	[Eff 08/01/94 	]
(Auth: HRS §346-14; 42 C.F.R. §431.10) 	(Imp:
42 C.F.R. §440.230; 42 U.S.C. §1396b(i))
§17-1737-93 	Allogenic bone marrow transplant.

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1737-107
(a) 	Indications for allogenic bone marrow
transplant include:
(1) 	Severe aplastic anemia unresponsive to usual
therapy;
(2) 	Acute myelogenous leukemia in first
remission;
(3) 	Acute lymphocytic leukemia in second
remission; and
(4) 	Chronic leukemia after first year.
(b) 	Conditions and limitations affecting
allogenic bone marrow transplant include:
(1) 	Human leukocyte group A (HLA) histocompatible
donor shall be available;
(2) 	Patient has no other major systemic disease
which would result in poor potential for
recovery (such as a heart condition, liver
disease, kidney damage, brain lesions, cancer
in other organs or lung disease);
(3) 	Patient shall have been properly evaluated by
a qualified authority in Hawaii and bone
marrow transplant is recommended as a
possible curative procedure or if palliative,
with reasonable likelihood for prolongation
of life and return to an active life;
(4) 	No active infection at the time of the
procedure;
(5) 	No general medical contraindication for the
procedure and anesthesia;
(6) 	Informed consent shall be obtained from the
patient or the patient's representative; and
(7) 	Age restricted to fifty or under except when
identical twin is histocompatible and then
age limit may be fifty-five.
[Eff 08/01/94 	] 	(Auth: HRS §346-14; 42
C.F.R. §431.10) 	(Imp: 	42 C.F.R. §440.230;
42 U.S.C. §1396b(i))
§17-1737-94 	Kidney transplant. 	(a) Indications
are irreversible kidney failure that has progressed to
a point that a useful, comfortable life can no longer
be sustained by conventional medical treatment. 	The
following conditions may deteriorate to the point when
kidney transplant may be required:
(1) 	Glomerulonephritis:
(A) 	Proliferative;
(B) 	Membranous;
(C) 	Mesangio-capilliary;
(2) 	Chronic pyelonephritis;
(3) 	Hereditary:

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(A) 	Polycystic disease;
(B) 	Medullary cystic disease;
(C) 	Nephritis (including Alport's syndrome);
(4) 	Hypertensive nephrosclerosis;
(5) 	Metabolic:
(A) 	Cystinosis;
(B) 	Amyloid;
(C) 	Gout;
(6) 	Congenital:
(A) 	Hyperplasia;
(B) 	Horseshoe kidney;
(7) 	Toxic:
(A) 	Analgesic nephropathy;
(B) 	Heavy metal poisoning;
(8) 	Irreversible acute renal failure:
(A) 	Cortical necrosis;
(B) 	Acute tubular necrosis; and
(9) 	Trauma.
(b) 	Conditions and limitations affecting kidney
transplant include:
(1) 	A living, related donor with major blood
group (ABO) and human leukocyte group A (HLA)
histocompatibility, or an appropriate
cadaveric kidney with major blood group (ABO)
and human leukocyte group A (HLA)
histocompatibility shall be available;
(2) 	Patient shall be in a stable emotional state;
(3) 	There is no active infection at the time of
transplant;
(4) 	There are no general medical
contraindications to major surgery and
anesthesia;
(5) 	Patient has a normal lower urinary tract;
(6) 	There are no other major systemic disease
which would preclude successful recovery
potential (such as cancer, polyarteritis,
systemic lupus erythematosis or heart, lung
or liver disease);
(7) 	Patient is evaluated by a qualified authority
in Hawaii and renal transplant is
recommended;
(8) 	Informed consent shall be obtained from the
patient or the patient's representative; and
(9) 	Age limits five through fifty.
[Eff 08/01/94 	] 	(Auth: HRS §346-14; 42
C.F.R. §431.10) 	(Imp: 	42 C.F.R. §440.230;
42 U.S.C. §1396b(i))
§§17-1737-95 to 17-1737-99 	(Reserved).

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1737-109
SUBCHAPTER 9
HOSPICE SERVICE
§17-1737-100 	REPEALED. 	[R 09/30/13]
§17-1737-101 	Hospice care. (a) 	Hospice care
means care and services provided to a terminally ill
individual by a hospice program in home, outpatient and
inpatient settings.
(b) 	The hospice shall retain professional
management responsibility for services related to the
terminal illness and shall ensure that they are
furnished in a safe and effective manner by persons
qualified to provide services, and in accordance with a
plan of care as specified in section 17-1737-102.
(c) 	Hospice services shall be provided by hospice
employees or by staff contracted by the hospice and
includes the following:
(1) 	Nursing care and services by or under the
supervision of a registered nurse;
(2) 	Medical social services provided by a
qualified social worker under the direction
of a physician;
(3) 	Physician services provided by physician
employees of the hospice including physician
members of the interdisciplinary team;
(4) 	Counseling services available to both the
individual and the family including the
following:
(A) 	Dietary, spiritual and any other
counseling services for the individual
and family while enrolled in the
hospice; and
(B) 	Bereavement counseling, provided after
the patient's death;
(5) 	Physical therapy services, occupational
therapy services, and speech-language
pathology services;
(6) 	Home health aide and homemaker services to
meet the needs of the patients;
(7) 	Medical supplies and appliances including
drugs and biologicals, provided as needed for
the palliation and management of the terminal
illness and related conditions; and
(8) 	Inpatient care for pain control and symptom
management provided in a participating
medicaid facility.

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1737-110
(d) 	Coverage for hospice care shall be
limited to two periods of ninety days each and
subsequent periods of sixty days unless Medicare
requirements for continuing services are not met.
[Eff 08/01/94; am 09/17/07 	] 	(Auth: HRS §346-14)
(Imp: 42 U.S.C. §1396(a) and (d))
§17-1737-102 	Plan of care. 	(a) 	A written plan
of care shall be established and maintained for each
individual admitted to a hospice program and the care
provided to an individual shall be in accordance with
the plan.
(b) 	The plan shall be established by the
attending physician, medical director or physician
designee and interdisciplinary group prior to providing
care.(c) 	The plan shall be reviewed and updated by the
attending physician, the medical director, and
interdisciplinary group at intervals, as specified in
the plan.
(d) 	The plan shall include all of the following:
(1) 	Assessment of the individual's needs;
(2) 	Identification of the services including the
management of discomfort and symptom relief;
and
(3) 	Statement in detail of the scope and
frequency of services needed to meet the
patient's and family's needs.
[Eff 08/01/94 	] 	(Auth: HRS §346-14)
(Imp: 42 U.S.C. §1396(a) and (d))
§17-1737-103 	Eligibility for hospice care. 	(a)
Hospice care shall be provided to eligible applicants
and recipients of medical assistance who voluntarily
elect hospice care. 	Medicaid will only cover services
that are unrelated to the hospice diagnosis except for
individuals under twenty-one years of age.
(b) 	Eligible applicants and recipients under
twenty-one years of age shall be provided hospice
service and curative treatment services related to the
individual’s terminal illness or associated condition.
(c) All of the following conditions shall be met:
(1) 	A written certification of terminal illness
is obtained by the hospice, signed by the
hospice physician and the individual's
attending physician;

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1737-111
(2) 	The recipient or a representative
voluntarily elects to participate in the
Medicaid hospice program and signs the
appropriate Medicaid form requesting this
service; and
(3) 	Approval is obtained from the department on a
designated form. [Eff 08/01/94;
am 06/25/12 	] 	(Auth: HRS §346-14) 	(Imp: 42
U.S.C. §1396(a) and (d))
§17-1737-104 	Election of hospice care. 	(a) 	An
eligible individual who elects to receive hospice care
shall file an election statement with the hospice. 	A
representative may also file an election statement.
(b) 	An election to receive hospice care shall be
considered to continue through the initial ninety day
period and subsequent ninety and thirty day election
periods without a break in care if the individual:
(1) 	Remains in the care of the hospice; and
(2) 	Does not revoke the election of hospice care.
(c) 	Additional days of hospice care beyond the
two hundred ten days stipulated in subsection (b) may
be allowed if the personal or hospice physician
recertifies the individual to be terminally ill.
(d) 	An individual or representative may designate
an effective date for the election of hospice care
beginning with the first day of hospice care but no
earlier than the date the election is made.
(e) 	Individuals electing hospice care who are
eligible for both medicare and medicaid shall have
their hospice election periods counted concurrently.
(f) 	Individuals who have private insurance
coverage for hospice care shall utilize that resource
before medicaid coverage. [Eff 08/01/94 	]
(Auth: HRS §346-14) 	(Imp: 42 U.S.C. §1396(a) and (d))
§17-1737-105 	Waiver of other Medicaid benefits.
(a) 	An individual who elects hospice services shall
waive all rights to Medicaid payments for services
related to the treatment of the terminal condition for
which hospice care was elected. 	This provision shall
not apply to individuals under twenty-one years of age.
(b) 	Medicaid payments may be made for hospice and
related services provided by:
(1) 	The designated hospice;
(2) 	Another hospice under arrangements made by
the designated hospice; and

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1737-112
(3) 	The individual's attending physician if that
physician is not an employee of the
designated hospice or receiving compensation
from the hospice for services to the
individual.
(c) 	Medicaid payments may be made for other
Medicaid covered services unrelated to the terminal
condition for which hospice care was elected.
[Eff 08/01/94; am 06/25/12 	] 	(Auth: 	HRS §346-14)
(Imp: 42 U.S.C. §1396(a) and (d))
§17-1737-106 	Revoking the election of hospice.
(a) 	An individual or representative may revoke an
election of hospice care at any time during an election
period.
(b) 	The individual or representative shall file a
signed statement with the hospice that revokes medicaid
coverage of hospice care and the effective date of the
revocation.
(c) 	The individual or representative may at any
time elect to again receive hospice care for any other
hospice election period the individual is eligible to
receive. 	[Eff 	08/01/94 	] 	(Auth: HRS §346-14)
(Imp: 42 U.S.C. §1396(a) and (d))
§17-1737-107 	Payment for hospice care. 	(a)
Payments shall be available to Medicaid providers
certified by Medicare to render hospice care as
provided for under this subchapter.
(b) 	Payment for hospice care shall be made using
the same methodology as Medicare and in the amounts
specified by CMS.
(c) 	Payment for services or items not related to
the terminal illness and billed by other Medicaid non-
hospice providers are allowed.
(d) 	For a Medicaid recipient who resides in a
nursing facility and meets the nursing facility level
of care requirements, but elects hospice, the Medicaid
program will pay the hospice provider:
(1) 	For routine hospice services; and
(2) 	Ninety-five percent of the facility specific
per diem rate for ICF services. The Medicaid
program shall not pay the NF.
(e) 	The following categories shall be utilized to
determine payment:

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(1) 	Routine home care day. 	A routine home care
day is a day on which an individual who has
elected to receive hospice care is at home
and is not receiving continuous care as
defined in paragraph (2);
(2) 	Continuous home care day. 	A continuous home
care day is a day on which an individual who
has elected to receive hospice care is not in
an inpatient facility and receives hospice
care consisting predominantly of nursing care
on a continuous basis at home. 	Home health
aide or homemaker services or both may also
be provided on a continuous basis.
Continuous home care is furnished during
periods of crisis and only as necessary to
maintain the terminally ill patient at home.
A minimum of eight hours of care shall be
required to qualify for the continuous home
care rate;
(3) 	Inpatient respite care day. 	An inpatient
respite care day is a day on which the
individual who has elected hospice care
receives care in an approved facility on a
short-term basis for respite. 	Respite care
may not be reimbursed for more than five
consecutive days at a time; and
(4) 	General inpatient care day. 	A general
inpatient care day is a day on which an
individual who has elected hospice care
receives general inpatient care in an
inpatient facility for pain control or acute
or chronic symptom management which cannot be
managed in other settings.
[Eff 08/01/94; am 02/07/05] 	(Auth:
HRS §§346-14, 346-59) 	(Imp: 42 U.S.C.
§1396(a) and (d); HRS §346-59)
§17-1737-108 	Providers of hospice service. (a)
Providers of hospice services shall meet applicable
state and federal licensing and the certification
requirements of chapter 17-1736 including certification
by medicare to provide hospice service.
(b) 	Providers of service shall enter into a
contractual agreement with the state medicaid agency.
[Eff 08/01/94 	] 	(Auth: 	HRS §346-14) 	(Imp: 	42
C.F.R. §431.107, 42 U.S.C. §1396(a) and (d))

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§17-1737-109 	Appeals and hearings. 	(a) 	An
appeal and hearing shall be available to providers of
hospice service in accordance with chapter 17-1736.
(b) 	An appeal and hearing for applicants and
recipients shall be available in accordance with
chapter 17-1703. 	[Eff 08/01/94 	] 	(Auth: 	HRS
§346-14) 	(Imp: 	42 U.S.C. §1396(a) and (d))
§§17-1737-110 to 17-1737-114 	(Reserved).
SUBCHAPTER 10
SUBACUTE CARE
§17-1737-115 	Purpose. 	The purpose of this
subchapter is to describe a level of care needed by a
patient not requiring inpatient acute care, but who
needs more intensive nursing care than is provided at
the skilled nursing level of care.
[Eff 11/25/96 	] 	(Auth: 	HRS §346-14; 42 C.F.R.
§431.10) 	(Imp: 	HRS 	§346-14)
§17-1737-116 	REPEALED. 	[R 09/30/13]
§17-1737-117 	General provisions. 	(a) 	Beds shall
be specifically certified for subacute care and costs
for providing subacute services shall be shown
separately on the facility's cost report. 	Each
participating 	facility shall be required to establish
a subacute unit (SACU) as follows:
(1) 	Freestanding SNF - A minimum of six to a
maximum of sixty beds; or
(2) 	Acute care hospital - A minimum of six to a
maximum of sixty beds or more with the
department's approval.
(b) 	The facility shall accept and retain only
those subacute patients for whom it can provide
adequate care.
(c) 	The facility shall maintain complete and
accurate patient information, in sufficient detail to
provide for continuity of care, for patients
transferred to a subacute unit.

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1737-115
(d) 	The freestanding SNF shall maintain written
agreements with one or more acute care hospitals to
ensure that the acute services are accessible in
emergency situations and to facilitate the transfer of
patients.
(e) 	The subacute unit shall have provisions for
twenty-four hour emergency services including but not
limited to laboratory, radiology, respiratory therapy,
and pharmacy services, and if necessary, ventilator
support by qualified respiratory technicians.
(f) 	The subacute unit shall make arrangements for
emergency medical care as needed and shall consult with
the attending physician or designee when available.
Pulmonologist consultant shall be available twenty-four
hours a day for telephone consultations and visits or
both whenever a facility has ventilator patients. 	The
telephone numbers of those physician(s) shall be posted
in a conspicuous area in the subacute unit.
(g) 	Freestanding subacute units shall be licensed
specifically as freestanding subacute units in the
State of Hawaii by the department of health.
(h) 	The facilities caring for group III and group
IV pediatric patients shall provide all mandated
developmental and educational services.
(i) 	The department through its medical
consultants will determine the medical necessity of the
subacute level of care for patients who do not have a
medically justified need for the acute level of care,
do not qualify for the skilled nursing facility (SNF)
level of care, or the intermediate care facility (ICF)
level of care, and who meet the criteria of the
subacute level of care and cannot be discharged from
the acute care facility. 	[Eff 11/25/96;
am 06/19/00 	] 	(Auth: 	HRS §346-14; 42 C.F.R
§431.10) 	(Imp: 	HRS §346-14)
§17-1737-118 	Staffing standards. 	(a) 	For the
purpose of this section, each licensed nursing staff
shall be counted as one. 	Each subacute unit shall be
under the supervision of a registered nurse twenty-four
hours a day.
(b) 	Subacute units authorized to provide care to
respirator or ventilator dependent patients shall
provide a minimum daily average of 9.0 nursing care
hours of which 5.0 hours shall be provided by the
nursing staff. 	Where there is a mix of ventilator-
dependent and other patients, the facility shall
provide no less than 5.0 licensed and certified hours
per patient per day. 	Subacute units without

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1737-116
ventilator patients shall employ sufficient licensed
staff to provide a minimum daily average of 5.0
licensed and certified nursing hours.
(c) 	The department may require a facility to
provide additional staff in accordance with subsection
(b). (d) 	Registered nurses and licensed practical
nurses shall have a minimum of six months experience
(within the past two years) in a direct participatory
general acute care facility where the caseload included
patients requiring intensive care and the use of
special equipment. 	Completion of a department of human
services approved subacute training course may be
substituted for this requirement.
(e) 	The experience stated in subsection (d) or
substitute clinical training for licensed nurses shall
include respirator and tracheostomy care, nasogastric
tube and gastrostomy care, administration of total
parenteral nutrition and traction care. 	In addition,
this requirement shall be completed prior to treating
subacute patients. 	Registered nurses shall be
certified by the facility to perform intravenous
procedures and cardiopulmonary resuscitation.
(f) 	The facility shall provide documentation that
all staff participating in direct patient care,
including the director of nursing, registered nurses,
licensed practical nurses, and nurse's aide staff have
continuing in-service training pertinent to the
subacute level of care and shall make documentation
available upon request by the department of human
services at the time of the facility inspection.
[Eff 11/25/96 	] 	(Auth: 	HRS §346-14; 42 C.F.R.
§431.10) 	(Imp: 	HRS §346-14)
§17-1737-119 	Physician services. 	Physician
services shall include, but not be limited to:
(1) 	The evaluation and completion of forms used
to establish and continue the subacute level
of care for a recipient;
(2) 	Physicians visits at least weekly during the
first month and a minimum of once every two
weeks thereafter until the stability of the
patient's condition allows for monthly
visits;
(3) 	A plan of care shall be entered into the
medical record and shall include:
(A) 	Medical history, physical findings, and
diagnosis indicating the need for
admission;

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1737-117
(B) 	A description of the functional level of
the patient;
(C) 	Objectives to be achieved by the plan of
care;
(D) 	Any orders for medications, treatments,
restorative, and rehabilitative
services, activities, therapies, social
services, therapeutic diet, and special
procedures recommended for the health
and safety of the patient;
(E) 	Plans for continuing care, including
review and modification to the plan of
care;
(F) 	Plans for discharge, including
responsible family member or care
givers; and
(G) 	The attending or staff physician and
other personnel involved in the
recipients care shall review each plan
of care at least every thirty days.
[Eff 11/25/96 	] 	(Auth: 	§346-14;
42 C.F.R. §431.10) 	(Imp: 	HRS§346-14;
42 C.F.R. 431.10, 440.50, 456.60,
456.80, 456.250)
§17-1737-120 	Subacute patient care
characteristics. 	(a) 	To qualify for subacute level of
care under group I, patients, age twenty-one years and
older, must be medically stable and require continuous
mechanical ventilation for at least fifty per cent of
each day.
(b) 	To qualify for subacute level of care under
group II, non-ventilator patients, age twenty-one years
and older, who require a higher level of service than
SNF, but who do not require acute hospital care, must
be medically stable and require the following services:
(1) 	Tracheostomy care with suctioning required at
least once an hour;
(2) 	Any combination of mechanical ventilation,
tracheostomy care with suctioning and
inhalation treatment with or without oxygen
at least once a shift;
(3) 	Total parenteral nutrition;
(4) 	Continuous intravenous therapy for the
administration of therapeutic agents or
hydration, or intermittent IV therapy for the
administration of therapeutic drugs at least
once a shift through a peripheral or central
line or both. 	Therapeutic agents are to

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include antibiotics, non-vescicant oncology
chemotherapy, and analgesics;
(5) 	Stable newborns or premature infants under
age one, who have been inpatients in the
acute hospital for at least a week and cannot
be discharged because they require any of the
following services:
(A) 	Monitoring episodes of bradycardia and
apnea which are resolved by manual
stimulation in infants for whom
discharge from a facility is medically
inappropriate; or
(B) 	Nasogastric tube or gastrostomy
feedings;
(6) 	Stable patients admitted to the acute care
hospital for infections, who are afebrile for
twenty-four hours on intravenous or
parenteral antibiotics and undergoing
twenty-four to forty-eight hour trials of
oral antibiotics or being trained to infuse
parenteral antibiotics in the home in
preparation for discharge to the home;
(7) 	Two or more of the following services:
(A) 	Tracheostomy care with suctioning
required at least once a shift;
(B) 	Traction and pin care for fractures
(Bucks Traction is not included);
(C) 	Medically necessary isolation
precautions as recommended by the
Centers for Disease Control. 	(Infection
control measures for the care of
decubitus ulcers do not apply in this
category);
(D) 	Debridement, packing, and medicated
irrigation with or without whirlpool
treatment, aseptic dressing changes,
management of extensive (stage III)
decubitus ulcers or wound infection, and
JP drains;
(E) 	Skilled nursing services including but
not limited to the monitoring,
observation, and care of patients with
HIV infection/AIDS, patients who have
terminal diseases, patients who require
chronic dialysis treatment, patients
receiving radiation therapy, patients
receiving treatment for dehydration or
monitoring of hydration, or patients
receiving treatment for pain control who

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have or are at high risk for significant
medical complications;
(F) 	Skilled nursing care including
observation, monitoring for the side
effects of treatment for patients
receiving radiation therapy, or the
monitoring of hydration and pain control
who have or are at high risk for
significant medical complications;
(H) 	At least daily ventilation or inhalation
therapy services or both with or without
oxygen;
(I) 	Treatment of patients with eating
disorders including bulimia and anorexia
nervosa who require skilled supervision
and monitoring of food intake and
psychiatric inpatient care and are
medically stable in the inpatient
facility, but who are at high risk of
medical complications if discharged to
outpatient care; or
(J) 	Treatment of psychiatric patients who
are not an immediate danger to
themselves or others, but who require
inpatient monitoring, supervision, and
psychiatric care because of high risk
for life-threatening complications to
themselves or others if discharged to
outpatient care; or
(c) 	Group III pediatric patients who no longer
require inpatient acute care, must be at baseline
status, and not at risk for rapid deterioration.
Requires dynamic care meeting the following:
(1) 	Weekly medical interventions and monitoring;
and
(2) 	Twenty-four hours a day skilled nursing;
(3) 	Types of interventions required in group III
pediatric subacute level of care are:
(A) 	Pediatric patients who are ventilator
dependent;
(B) 	Tracheostomy care with skilled
interventions (e.g. suctioning greater
than once in an eight hour shift.
(d) 	Group IV pediatric patients who no longer
requires acute care, must be at baseline state, and not
at risk for rapid deterioration. 	Requires chronic care
meeting the following:
(1) 	Medical interventions and monitoring at least
weekly; and

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(2) 	Skilled nursing intervention at least once
per shift.
(3) 	Types of interventions required in group IV
pediatric subacute level of care are:
(A) 	Continuous intravenous therapy for
administration of therapeutic agents or
hydration, or intermittent IV therapy
for the administration of therapeutic
drugs at least once a shift through a
peripheral of central line (antibiotics,
nonvesican oncology chemotherapy, and
analgesics, TPN).
(B) 	Two or more of the following services:
(i) 	Tracheostomy care with suctioning
not more than once in an eight hour
shift and does not require
continuous monitoring;
(ii) 	Debridement, packing, and medicated
irrigation, aseptic dressing
changes, extensive care of decubiti
(stage III), or wound infection and
drains.
(iii) 	Skilled supervision and monitoring
of nutritionally compromised
patients with eating disorders at
high risk of medical complications
if managed in an outpatient
setting;
(iv) 	At least daily inhalation therapy
by skilled staff; or
(v) 	Multiple (two or more modalities)
rehabilitative services required
daily with short and long term
attainable goals.
(e) 	Admission to the subacute level for
individuals who require other services shall be made on
a case-by-case basis. [Eff 11/25/96; am 06/19/00 	]
(Auth: 	HRS §346-14; 42 C.F.R. §431.10) 	(Imp: 	HRS
§346-14)
§17-1737-121 	Exclusions. 	Subacute payments shall
not be made for the following patients:
(1) 	Patients who are medically unstable and
require acute inpatient care in an acute care
hospital; or
(2) 	Patients whose level of care is appropriately
level C (SNF), level A (ICF), level B
(ICF-MR), or lower. 	Included in this group
are the following:

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1737-121
(A) 	Stable newborns or premature infants
under one year of age who require
training of the sucking reflex and
monitoring of weight and oral feeding to
gain weight sufficient for discharge to
the home setting;
(B) 	Stable children, newborns, or infants
under the care of the child protective
services awaiting placement; and
(C) 	Patients in terminal phases of disease
who request or whose legal guardians
have requested in writing the desire not
to be resuscitated and no subacute
services have been or will be rendered.
[Eff 11/25/96 	] 	(Auth: 	HRS
§346-14; 42 C.F.R. §431.10) 	(Imp: 	HRS
§§346-14, 346-59)