17-1731

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HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1731
PREMIUM ASSISTANCE PROGRAM
§17-1731-1 	Purpose
§17-1731-2 	Definitions
§17-1731-3 	Eligibility requirements
§17-1731-4 	Benefits
§17-1731-5 	Termination of premium assistance
§17-1731-6 	Administration of the premium
assistance program
§17-1731-7 	Appeal process
§§17-1731-8 to 17-1731-10 	(Reserved)
§17-1731-1 	Purpose. 	This chapter establishes,
subject to the availability of State funds, a premium
assistance program for a low-income individual who
purchases a silver level qualified health plan through
the Hawaii health insurance exchange and receives
advanced premium tax credit (APTC) and maximum cost-
sharing reduction (CSR). 	The department shall pay the
eligible individual’s share of the premium to the
qualified health plan in which the eligible individual
is enrolled. 	[Eff 	02/27/15 	] 	(Auth: 	HRS §346-
14) (Imp: 	HRS §346-14)
§17-1731-2 	Definitions. 	The following
definitions shall apply to this subchapter:
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“Exchange” means the Hawaii health insurance
exchange established under the Affordable Care Act.
“Qualified health plan” means a qualified health
plan or a qualified health plan issuer, as those terms
are defined in 45 C.F.R. §155.20, and as the context
may dictate. 	[Eff 	02/27/15 	] 	(Auth: 	HRS
§346.14) (Imp: 	HRS §346.14)
§17-1731-3 	Eligibility requirements. 	To be
eligible for the premium assistance described in this
chapter, an individual shall:
(1) 	Have selected or be enrolled in a 94%
actuarial value silver level qualified
health plan through the Exchange;
(2) 	Be determined eligible for advanced premium
tax credit (APTC), apply the maximum APTC
amount available towards their premium and
the maximum cost-sharing reduction (CSR) by
the Exchange;
(3) 	Have household income of less than one
hundred percent of the federal poverty level
for the applicable household size as
determined by the Exchange and communicated
by the Exchange to the qualified health plan
selected by the individual.
[Eff 	02/27/15 	] 	(Auth: 	HRS §346.14)
(Imp: 	HRS §346.14)
§17-1731-4 	Benefits. 	(a) 	The department shall,
upon presentation of an invoice by a qualified health
plan to the department, pay the share of premium that
the eligible individual is required to pay to the
qualified health plan to receive coverage.
(b) 	Benefit limitations:
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(1) 	The department shall pay an eligible
individual's share of premium to the
qualified health plan only upon receipt of
an invoice submitted by the qualified health
plan to the department;
(2) 	The department shall not make any payments
directly to eligible individuals; and
(3) 	The department shall not pay and the
eligible individual shall be responsible
for, any cost-sharing including, but not
limited to, deductibles, co-payments or co-
insurance.
(c) 	The department is not responsible for
ensuring that the qualified health plan timely submits
an invoice for an eligible individual's share of
premium to the department. 	[Eff 	02/27/15 	]
(Auth: 	HRS §346-14) (Imp: 	HRS §346-14)
§17-1731-5 	Termination of premium assistance.
Premium assistance payable under this chapter on
behalf of an eligible individual shall be terminated
at any time for any of the following reasons:
(1) 	The individual fails to meet the eligibility
requirements set forth in section 17-1731-3;
(2) 	The individual voluntarily terminates
participation in the premium assistance
program;
(3) 	The individual no longer resides in the
State;
(4) 	Death of the individual;
(5) 	The individual's whereabouts are unknown;
(6) 	Insufficient State funds; or
(7) 	The premium assistance program is
terminated. 	[Eff 	02/27/15 	] 	(Auth:
HRS §346-14) (Imp: 	HRS §346-14)
§17-1731-6 	Administration of the premium
assistance program. 	(a) 	The department may contract
with a third party or parties to administer any
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component of this program, including, but not limited
to, payment, auditing, and recovery.
(b) 	The department's provision of premium
assistance under this chapter shall be administered at
no cost to the eligible individual.
[Eff 	02/27/15 	] 	(Auth: 	HRS §346-14) (Imp: 	HRS
§346-14)
17-1731-7 	Appeal process. 	(a) 	An eligible
individual may appeal the department’s failure to pay
the benefit described in section 17-1731-4 only as
provided in this section.
(b) 	Issues relating to the determination of an
individual's household income by the Exchange under
section 17-1731-3(3) must be directed to the Exchange.
(c) 	Issues relating to a qualified health plan
requiring premium payment from an eligible individual
must be directed to the qualified health plan before
requesting informal review or an administrative
hearing under this section.
(d) 	Requests for an informal review or
administrative hearing under this chapter may be
submitted by an eligible individual or the
individual’s authorized representative only when:
(1) 	The qualified health plan is requiring
premium payment from the eligible individual;
and
(2) 	The qualified health plan states in writing
that the reason for requiring premium payment
is because the department did not timely pay
an invoice that was submitted by the
individual's health plan to the department.
(e) 	An eligible individual or the individual’s
authorized representative may request an informal
review.
(1) 	A request for an informal review must:
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(A) 	Be submitted in writing and received by
the department within thirty (30)
calendar days after the date of the
bill sent by the qualified health plan
to the individual.
(B) 	Include both a copy of the bill sent by
the qualified health plan to the
individual and a copy of the notice
from the qualified health plan stating
that the individual was sent a bill
because the department did not timely
pay the health plan’s invoice.
(2) 	The eligible individual is not required to
seek an informal review prior to filing a
request for an administrative hearing.
(3) 	The department shall respond in writing to
the request for an informal review and
provide notice to the eligible individual of
the right to request an administrative
hearing under subsection (f). 	An individual
shall have fifteen (15) calendar days from
the date of the informal review decision to
file a request for an administrative
hearing.
(f) 	An eligible individual or the individual’s
authorized representative may file a request for an
administrative hearing.
(1) 	A request for an administrative hearing
must:
(A) 	Be submitted in writing and received by
the department within thirty (30)
calendar days after the date of the
bill sent by the qualified health plan
to the individual, or within fifteen
(15) calendar days from the date of the
decision notice for an informal review.
(B) 	Include both a copy of the bill sent by
the qualified health plan to the
individual and a copy of the notice
from the health plan stating that the
individual was sent a bill because the
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department did not timely pay the
health plan’s invoice.
(2) 	The provisions of chapter 17-1703.1 shall
not apply to appeals under this chapter,
except for section 17-1703.1-6.
[Eff 	02/27/15 	] 	(Auth: 	HRS §346-14)
(Imp: 	HRS §346-12)
§§17-1731-8 to 17-1731-10 	(Reserved)
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