17-1735.1

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1735.1-1
HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1735.1
GENERAL PROVISIONS FOR FEE-FOR-SERVICE MEDICAL ASSISTANCE
§17-1735.1-1 	Purpose
§17-1735.1-2 	An individual covered under fee-for-
service medical assistance
§17-1735.1-3 	Effective date of authorization
§§17-1735.1-4 to 17-1735.1-8 	(Reserved)
Historical Note: 	This chapter is based substantially
upon repealed chapter 17-1735. 	[Eff 08/01/94; am
07/20/95; am 02/10/97; am 07/06/99; am 02/16/02; am
05/10/03; 01/31/09; am 06/11/09; am 06/25/12;
R 09/30/13]
§17-1735.1-1 	Purpose. 	This chapter describes an
individual covered under the State's fee-for-service
component of the medical assistance program. 	The fee-
for-service program is discussed in the following
chapters: 	17-1722, special medical assistance
coverages and programs; 17-1736, provider provisions;
17-1737, scope and contents of the fee-for-service
medical assistance program; 17-1738, targeted case
management services; 17-1739, authorization, payment,
and claims in the fee-for-service medical assistance
program; 17-1740.1, reimbursement of federally
qualified health centers and rural health clinics; and
17-1741, utilization control.
[Eff 	09/30/13] 	(Auth: 	HRS §346-14) (Imp: 	HRS §346-
14)

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1735.1-2
§17-1735.1-2 	An individual covered under fee-for-
service medical assistance. 	(a) 	An individual
eligible for fee-for-service coverage under the medical
assistance program includes, but is not limited to:
(1) 	A child in receipt of foster care, kinship
guardianship or adoption assistance, under
age twenty-one who is a resident of the
State, and placed in another state as
described in chapter 17-1715;
(2) 	A non-citizen ineligible for Medicaid
assistance who receives emergency medical
services as described in chapter 17-1723.1;
(3) 	An individual who enters the State of Hawaii
Organ and Tissue Transplant (SHOTT) program
as described in chapter 17-1737;
(4) 	An incarcerated individual who is admitted as
an inpatient in a medical institution not on
the grounds of the incarceration facility;
(5) 	An individual who receives a determination of
eligibility on or after the start date of a
new health plan contract period that is
retroactive to a date prior to the start of
the new health plan contract period with
incurred services during the period from the
effective date of coverage up to the start
date of the new health plan contract period;
(6) 	A medically needy individual who is not aged,
blind or disabled as described in chapter 17-
1730.1; or
(7) 	An individual who is eligible for the
Qualified Medicare Beneficiaries (QMB),
Specified Low Income Medicare Beneficiaries
(SLMB), Qualified Disabled and Working
Individuals (QDWI), or Qualifying Individuals
(QI) program described in chapter 17-1722.
(b) 	While enrolled in a participating health
plan, an individual is excluded from the fee-for-
service program, except for the following additional
services that may be provided on a fee-for-service
basis, subject to approval by the department:
(1) 	Services provided through the Medicaid
waiver program for an individual with
developmental disabilities or intellectual
disabilities (DD-ID);

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1735.1-3
(2) 	ICF-ID institutional services;
(3) 	School-based health related services;
(4) 	Early intervention program services;
(5) 	Specialized behavioral health services; and
(6) 	Dental services as described in section 17-
1737-75.
(c) 	The department shall determine on a case-by-
case basis, whether an individual enrolled in a managed
care program may have additional services covered on a
fee-for-service basis. 	[Eff 	09/30/13] 	(Auth: 	HRS
§§88-4, 346-14; 42 C.F.R. §§430.25, 435.1009, 435.1010,
440.150; 42 U.S.C.§1396d(a)(28)(A)) (Imp: 	HRS §§88-4,
346-14; 42 C.F.R. §§430.25, 435.1009, 435.1010,
440.150; 42 U.S.C.§1396d(a)(28)(A))
§17-1735.1-3 	Effective date of authorization.
(a) 	The effective date for payments to be made for
covered services under the fee-for-service program for
an individual described in section 17-1735.1-2 shall
be:
(1) 	The date the application is received by the
department as described in chapter 17-1711.1;
(2) 	Any date specified by the individual on
which appropriate Medicaid eligible services
were incurred and is no earlier than the
first day of the third month prior to the
month the application is received by the
department for an individual applying for the
coverage of long-term care services, or the
immediate ten calendar days prior to the date
the application is received by the department
for all other individuals; or
(3) 	The date when all eligibility requirements
are met by the applicant.
(b) 	An applicant's eligibility for medical
assistance within a retroactive period is established
when:
(1) 	A submittal of a signed application is
received from an applicant, an individual or
department’s representative on behalf of a
deceased individual.
(2) 	Part or all of the individual’s medical bills
remain unpaid;

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1735.1-4
(3) 	The expenses incurred by the individual were
for medical care and services within the
scope of services covered under the fee-for-
service program as described in chapter 17-
1737 and authorization for medically
necessary services approved as described in
chapter 17-1739.1; and
(4) 	The care and services were provided by an
eligible participating provider.
[Eff 	09/30/13] 	(Auth: 	HRS §346-14; 42
C.F.R. §431.10) (Imp: 	HRS §346-14; 42 C.F.R.
§§435.914, 440.10, 440.20, 440.30, 440.40,
440.50, 440.60, 440.70, 440.80, 440.90,
440.100, 440.110, 440.120, 440.130, 440.140,
440.150, 440.155, 440.160, 440.165, 440.166,
440.167, 440.168, 440.169, 440.170, 440.180,
440.181, 440.185)
§§17-1735.1-4 to 17-1735.1-8 	(Reserved).