11-174

§11-174-1
§11-174-2
§11-174-3
§11-174-4
§11-174-5
§11-174-6
§11-174-7
§11-174-8
TITLE 	11
DEPARTMENT 	OF 	HEALTH
CHAPTER 	174
PAYMENT 	FEES 	FOR 	HAWAII 	STATE 	HOSPITAL
Purpose
Definitions
Inclusive 	rate
Patient 	monthly 	maintenance 	standard
Liability 	for 	hospitalization 	fees
Procedure 	for 	requesting 	adjustment 	of
liability
Indigent 	and 	medically 	indigent 	patients
Right 	to 	appeal
§11-174-1 	Purpose. 	The 	purpose 	of 	this 	chapter 	is
to 	~establish 	a· 	payment 	fee 	for 	care 	and 	treatment 	of
patients 	at 	Hawaii 	State 	Hospital 	and 	to 	establish
billing 	and 	collection 	procedures 	related 	to 	the
hospital 	fee. 	[Eff. 	4 IHI 	]
(Auth: 	HRS 	§334-9) 	(Imp: 	HRS 	§334-6)
§11-174-2 	Definitions. 	As 	used 	in 	this 	chapter:
"Hospital" 	means 	Hawaii 	State 	Hospital.
"Indigent 	patient" 	means 	a 	person 	without 	adequate
and 	proper 	means 	of 	subsistence 	as 	defined 	in 	Title 	17,
Administrative 	Rules 	Subtitle 	6, 	Chapter 	742 	definition
of 	"categorically 	needy."
"Medically 	indigent 	patient" 	means 	a 	person
otherwise 	able 	to 	subsist 	himself, 	but 	who 	in 	the
emergency 	of 	sickness 	is 	not 	able 	to 	care 	for 	the 	extra
expenses 	necessary 	to 	maintain 	or 	restore 	health, 	as
defined 	in 	Title 	17, 	Administrative 	Rules 	Subtitle 	6,
Chapter 	finition 	of 	"medically 	needy."
[Eff. 	(Auth: 	HRS 	§334-9)
(Imp: 	HRS 	§334-6)
"Patient" 	means 	a
and/or 	treatment 	at
5, 	1981] 	(Auth: 	HRS
person 	under 	observation, 	care,
Hawaii 	State 	Hospital. 	[Eff. 	Nov.
§334-9) 	(Imp: 	HRS 	§334-6)
§11-174-3 	Inclusive 	rate. 	The 	inclusive 	rate 	for
the 	routine 	and 	ancillary 	services 	per 	patient 	shall 	be
$133 	per 	day. 	The 	routine 	and 	ancillary 	services 	shall
include 	room 	and 	board, 	standard 	items 	of 	clothing 	and
toilet 	articles, 	food 	and 	nutrition 	services, 	laundry
service, 	basic 	nursing 	and 	treatment 	supplies,
174-1
7

§11-174-3
psychiatric 	and 	psychological 	services, 	medical 	and
related 	services, 	nursing 	services, 	neurological
services, 	pharmacy 	services, 	occupational 	therapy
services, 	industrial 	therapy 	services, 	recreational
services 	and 	social 	services. 	All 	such 	services 	shall
be 	those 	which 	are 	regularly 	available 	and 	provided
within 	the 	usual 	resources 	of 	Hawaii 	state 	Hospital.
(Eff. 	Nov. 	5, 	1981] 	(Auth: 	HRS 	§334-9) 	(Imp: 	HRS
§ 3 3 4 - 6 ) 	J 	1 4 1986
§11-174-4 	Patient 	monthly 	maintenance 	standard.
The 	maximum 	monthly 	maintenance 	allowance 	for 	each
patient 	in 	the 	hospital 	is 	$60. 	This 	allowance 	shall
be 	deducted 	from 	patient 	and 	family 	income 	prior 	to
final 	determination 	of 	patient 	and 	family 	liability 	for
hospital 	fees. 	This 	allowance 	may 	be 	used 	by 	the
patient 	for 	the 	purchase 	of 	transportation, 	clothing,
entertainment 	in 	the 	community 	and 	other 	personal
incidental 	expenses 	not 	normally 	provided 	within 	the
hospital's 	daily 	fee. 	(Eff. 	]
(Auth: 	HRS 	§334-9) 	(Imp: 	HRS 	§334-6)
§11-174-5 	Liability 	for 	hospitalization 	fees.
(a) 	Every 	person 	hospitalized 	at 	Hawaii 	State
Hospital, 	who 	is 	not 	an 	indigent 	patient 	or 	medically
indigent 	patient, 	shall 	be 	liable 	for 	payment 	of 	the
inclusive 	rate 	per 	day 	established 	in 	section 	11-174-3.
(b) 	The 	amount 	of 	liability 	may 	be 	adjusted
provided 	the 	patient 	and 	his 	family's 	verified 	personal
assets 	and 	monthly 	income, 	after 	deduction 	of
allowances 	pursuant 	to 	Title 	17, 	Administrative 	Rules
Subtitle 	6, 	Chapter 	744, 	Subchapters 	6 	and 	7, 	exceed
the 	sum 	of:
( 1)
( 2)
( 3 )
The 	family's 	monthly 	maintenance 	standard
and 	patient 	family 	reserve 	established 	in
Title 	17, 	Administrative 	Rules 	Subtitle
6, 	Chapter 	744, 	Subchapters 	6 	and 	7;
The 	patient's 	and 	his 	family's 	medical
expenses 	incurred 	and 	unpaid 	prior 	to 	the
patient's 	hospital 	admission 	date; 	and
The 	patient's 	monthly 	maintenance
standard 	pursuant 	to 	section 	11-174-4.
174-2

§11-174-5
( c) 	Any 	adjustment 	of 	liability 	as 	determined
in 	this 	chapter 	shall 	be 	calculated 	at 	the 	end 	of
the 	month 	or 	of 	hospitalization, 	whichever 	occurs
first. 	It 	shall 	be 	the 	responsibility 	of 	the 	patient
to 	provide 	verification 	of 	income 	and 	assets 	for
each 	billing 	period. 	[Eff. 	] 	(Auth:
HRS 	§339-9) 	(Imp: 	HRS 	§334-6)
§11-174-6 	Procedure 	for 	requesting 	adjustment
of 	liability. 	(a) 	Every 	patient 	shall 	be 	responsible
for 	submitting 	a 	completed 	Patient 	and 	Family
Questionnaire; 	Monthly 	Income 	of 	Patient 	and 	Family;
and 	Assets 	of 	Patient 	and 	Family 	forms 	attached
hereto 	as 	Exhibit 	A.
(b) 	The 	hospital 	shall 	determine 	the 	adjustment,
if 	any, 	using 	the 	Determination 	of 	Total 	of 	Available
Monthly 	Excess 	Income 	and 	Excess 	Assets 	and
Computation 	of 	Hospital 	Fee 	To 	Be 	Charged 	forms
attached 	hereto 	as 	Exhibit 	B.
[Eff. 	JUL 	] 	(Auth: 	HRS 	§334-9)
(Imp: 	HRS 	§336-6)
§11-174-7 	Indigent 	and 	medically 	indigent
patients. 	(a) 	An 	indigent 	patient 	who 	is 	eligible
for 	public 	assistance 	during 	hospitalization 	and
for 	whom 	no 	other 	person 	is 	liable 	for 	the 	patient's
hospitalization 	fees, 	shall 	not 	be 	liable 	for 	any
cost 	related 	to 	his 	hospitalization.
( b) 	A 	medically 	indigent 	patient 	whose 	income
level 	and 	other 	assets 	would 	qualify 	him 	for 	medical
assistance 	only 	under 	Title 	17, 	Administrative 	Rules
Subtitle 	6, 	Chapters 	742 	and 	744, 	and 	for 	whom 	no
other 	person 	is 	liable 	for 	the 	patient's
hospitalization 	fees, 	shall 	not 	be 	liable 	for 	any
cost 	related 	to 	his 	hospitalization.
[Eff. 	JUL1 	] 	(Auth: 	HRS 	§334-9) 	(Imp:
HRS: 	§334-6)
§11-174-8 	Right 	to 	appeal. 	Any 	patient
may 	request 	in 	writing 	reconsideration 	of 	his 	hospital
bill 	by 	the 	Hospital 	Administrator, 	the 	Chief 	of
the 	Mental 	Health 	Division, 	or 	the 	Director 	of 	Health
or 	may 	file 	an 	appeal 	in 	accordance 	with 	the
provisions 	Chapter 	91 	of 	the 	Hawaii 	Revised 	Statutes.
174-3
il7

Please Print in Ink Exhibit A
Page 1 of 4
HAWAII STATE HOSPTIAL
PATIENT AND FAMILY Q.UESTIQNNAIRE
Name of Patient:__________________ Date:______
Hospital case No.: _____ Patient's Social Security No.: ________ _
Date of (re) Admission"'--_______ Ward Assigned____________
Medical Coverage for Patient, if any:
Name of Insuror:._____________________ _
Policy or other No.:.___________________ _
Includes Mental Illness? 	If yes, number days covered.
(Yes) 	(No)
Person(s) Responsible for Patient's Bill:._________________ _
Home Address_________________ Home Tel. No .._____ _
Employer__________________ Bus. Tel. No .._____ _
Business Address 	Occupation"-------
Number of Dependents Claimed on Federal Tax Return (Do Not include patient)__
Family Members Livinq in Home (Do Not include oatient)
Name 	Aae 	Relationship to Patient 	Social Security Number
l.
2.
3.
4.
5.
Note: 	If more than 5, please list other family members living in 	the 	home 	on 	a
separate piece of paper and provide the same information.
If 	the 	patient 	and/or 	patient's 	family 	is 	currently 	receiving 	DSSH 	Income
Maintenance and/or Medical Assistance, provide following information:
Name of Welfare Worker
--------------------Location of Welfare Worker
------------------Telephone Number of Welfare Worker______________ _
Date 	Signature(s) of Person(s) Responsible
For Hawaii State Hospital Use Only
Hospital Care to be provided at no charge to patient and/or family because
Patient and/or family received DSSH income maintenance and medical assistance
_immediately prior to patient's admission.
Verified with above listed DSSH Worker by _______________ _
Date
Hospital care to be provided at no charge to patient and/or family because
although eligible due to a total lack of any income or excess assets, patient
and/or family had not applied for DSSH maintenance or medical assistance
_ 	immediately prior to patient's hospital admission.
Patient or person(s) responsible for patient's medical expenses to be charged
the rate of$ 	per day based on patient and/or family income and
excess assets 1i sted on the attached pages.
Above Determination Made B.}'_________________________
Patients' Accounts Manager 	Date
(10/1/84)
,,,
'

Exhibit A
Page 2 of 4
MONTHLY INCOME of Patient and Family
Name of Patient 	Month of _______,, 19__
Note: 	Include all unearned and earned income received 	by 	family 	members 	living
in the home plus any income received by or for the patient.
Unearned Income
~ 	Amount 	~ 	Amount
1. 	Social Security Benefits$ 	10. 	Child Support 	$
2. 	Veterans Benefits 	$ 	11. 	Temporary disability 	$
3. 	Pension, retirement 	$ 	12. 	Legal Cash Settlement
or Inheritance 	$
4. 	Unemployment Insurance 	$ 13. 	Loans or Grants 	$
5. 	Workers Compensation 	$ 14. 	Regular living expense
6. 	Railroad Retirement 	$ 	Contributions of food,
Shelter, utilities,
7. 	Strike Benefits (Cash or 	Clothing, and other
In-kind cash value) 	$ 	provided to family or
patient 	$
8. 	Stock dividends and
Royalties 	$ 	15. 	Any other non-exempt
lump sum of cash 	$
9. 	Alimony 	$ Total monthly Unearned
Income
Note:
t~--
All 	unearned 	income 	reported 	above 	must be verified by copies of checks
received 	or 	letters/statements 	from 	payors 	verifying 	amounts 	paid
monthly. 	These must be provided by the patient or family.
Earned Income
~ 	Amount 	~ 	Amount
l . 	Wages (Net of Mandatory 	5. 	Federal &State tax
deductions for State, 	refund 	$
Federal income tax, FICA,
retirement and TOI 	$ 	6. 	Military allowance
for Quarters 	$
2. 	Cash value in-kind wages$ 	Subsistence 	$
Clothing 	$
3. 	Self-employment income 	$ Total monthly Earned
4. 	Federal earned income tax 	Income 	$
credit 	$
Note: 	All 	earned 	income 	reported 	above must be verified by copies of pay stubs
and/or income tax returns (in the case of self 	employed 	income). 	In-kind
wages 	are 	to 	be verified by Statement from the employer providing in-kind
wages.
Total Monthly Gross Income Recap
Total Monthly Unearned Income 	$..____ _
Total Monthly Earned Income 	+$___ _
Total Monthly Gross Income 	=$;...____
I certify that all unearned and earned income 	of 	the 	patient 	and 	family 	members
living 	in 	the patient's home is listed above and is true and correct to the best of
my knowledge.
Prepared by
----------------------	(Signature(s) Patient or Person Responsible 	Date
(10/1/84)
8 7 0

Assets of Patient and Family
Exhibit A
Page 3 of 4
Name of Patient _____________________ _
Note: 	Include all assets of family members living in 	the 	home 	plus 	any 	assets
held by or for the patient.
Tll!,e of Asset
1. 	cash on Hand
2. 	cash in Savings & Checking
Accounts
3. 	Stocks and Bonds
4. 	Time deposits, savings
certificates
5. 	Occasional cash gift
6. 	Equity value of life insurance
7. 	Government bonds, treasury
notes, municipal bonds
8. 	Mutual fund shares
9. 	Equity in additional burial plots,
funeral plans or vault in excess
of 1 exemption permitted.
(Funeral plan exemption limited
to i1,500.)
10. Retirement plan equity (only if
available for withdrawal)
11. Non-exempt value of motor
vehicle owned (over il,500)
12. Equity in non-exempt personal
property (e.g. jewelry)
13. Non-home real property equity
14. Monies or assets in trust funds
(See Title 17, Subtitle 6,
Chapter 744-17-(14) if Trust Fund
irrevocable or has other impediment
to use of funds)
15. Stocks or equity in any profit-
sharing plan, if available for
withdrawal
Dollar Value
t
t
t
t___
$.__ _
t
$.,__ _
t
t
$.__ _
t
t
t
t
t
16 	Money received from sale of assets 	$~-----
17. Investments in gemstones or
precious metals
18. Equity in a business
19. Value of any other non-exempt
assets
(10/1/84)
$.__ _
t
t
To Be Verified BJ!.
Financial Institution
where deposited
Stockbroker letter
Financial Institution
where deposited.
Person giving cash
Insurance 	Co. 	issuing
policy
Financial Institution
where deposited
Stockbroker letter
Seller of plot, plan or
vault
Company or agency
administering plan
Kelly's Blue Book
Professional appraisal
of fair market value
Real estate appraisal
or most recent tax
assessor's valuation,
less all recorded
encumbrances
Trustee valuation
Stockbroker or plan
administrator
Appraisal value or
sales slip
current liabilities
less current book value
of assets confirmed by
accountant or CPA
Appraisal of current
market value
8 7 O

20. State excise tax and
income tax credits due
or received
21. Federal or State income
tax refund due or received
Total Value of Assets
t
t
i___
Exhibit A
Page 4 of 4
Income tax return
Income tax return
I/we ceritfy that the above list of assets 	is 	true 	and 	correct 	to 	the 	best 	of
111Y/our 	knowledge 	and 	includes 	all assets of the patient and family members living
in the patient's home.
Signature(s) Patient or Person(s) Responsible 	Date
Note: 	Hospital fee of ll33 per day will be charged for patient's care 	until 	such
time 	as 	required 	verifications of assets are received and the correct fee
can be determined.
For Hospital Use Only
Total Assets
Less allowable reserve
Excess Assets
*Allowable reserve (17-744-44 (b))
No. of Eligible Persons
in Household
l
2
Maximum Personal
Reserve Allowable
1,500
2,250
;2so shall be added for each additional member of household.
(10/1 /84)
8 7

Exhibit B
Page l of 2
HAWAII STATE HOSPITAL
DETERMINATION OF TOTAL OF AVAILABLE MONTHLY EXCESS INCOME AND EXCESS ASSETS
Name of Patient'--------------------------
Aged (MA) or 	Families with 	Individual or Family
Disabled (MD) 	Dependent Children 	with no dependent
Individual 	(MF) 	Children (MG)
l. Monthly Gross Income 	$ 	$ 	$
2. Less Allowable
Deductions
A. 	Each full time
employed family
member in home
X $75 = 	-$ 	0 	-$ 	$
B. 	Each part-time or
unemployed family
member in home
x l70 = 	-$ 	0 	-$ 	..$
c. 	Allowable amount
paid for child
care or for care
for incapacitated
adult in same
household 	-$ 	0 	-$ 	-$
D. 	Patient monthly
maintenance
standard while in
hospital 	-$ 	60.00 	-$ 	60.00 	-$ 	60.00
E. 	Monthly main-
tenance standard
for total No. of
family members
living in home 	-$ 	0 	-$ 	-.$
3. Available Monthly
Excess Income 	=$ 	=$ 	=.$
4. Value excess Assets 	+$ 	+$ 	+$
5. Total 	=$ 	=$ 	=$
6. Deduct Family and
Patient Medical
Expenses incurred
and unpaid prior to
hospital admission 	-.$ 	-$ 	-$
7. Total to be applied
to hospital bill of
patient 	=$ 	=$ 	=$
Prepared by_______________________ _
Patients' Accounts Manager 	Date
(l0/1/84)
8 7

. .,. , .
HAWAII STATE HOSPITAL
COMPUTATION OF HOSPITAL FEE TO BE CHARGED
Name of Patient 	Month of
1. 	Total Available ( from Line 7, appendix 2).
2. 	Number of Patient Days
3. 	Hospital Fee Per Day 	x$
4. 	Total Due 	=
133.00
Exhibit B
Page 2 of 2
19__
Note: 	Fee 	to 	be 	charged is Jl33.00 per patient day if line 4 is equal to or less
than line 1. 	If line 4 is greater than line 1, compute reduced fee 	per 	day
below.
5. 	Total available (line 1)
6. 	Number of Patient Days 	.
7. 	Reduced Fee Per Day 	=
8. 	Amount Forgiven Per Day 	=
(Jl 33 - 1 i ne 7)
Fee Determined By: ___________________ _
Patients' Accounts Manager 	Date
Note: 	Hospital 	fee 	as 	determined 	above on either line 4 or line 7 will continue
in effect for future months 	unless 	there 	are 	reported 	to 	the 	Patients'
Accounts 	Manager 	changes 	in 	the 	patient's and/or patient's family income
and assets.
(10/1/84)
8 7 0