Section 17-1703.1-5 - Payment status of medical assistance or coverage pending hearing(a) The beneficiary is entitled to timely notice as to the status of medical assistance or coverage pending hearing.(b) Adequate notice that medical assistance shall be reinstated and continued shall be provided where: (1) Pertaining to eligibility or the fee-forservice program coverage denial, the beneficiary requests a hearing within fifteen (15) calendar days of the date of the adequate notice for adverse action.(2) Pertaining to a managed care health plan's coverage denial, the beneficiary requests a hearing from the department within ten (10) calendar days of the date of the managed care health plan's notice for adverse action, for continuation of benefits, which were ordered by an authorized provider, and the original period covered by the original authorization has not expired.(3) If the fifteenth (15th) day or tenth (10th) day as applicable falls on a weekend or holiday, the fifteenth (15th) day or tenth (10th) day as applicable shall be the first working day following the weekend or holiday.(4) If the last day of the month falls on a weekend or holiday, the last day shall be the first working day following the weekend or holiday.(c) The medical assistance or coverage reinstated under (b) shall continue until a hearing decision is rendered unless: (1) The beneficiary withdraws or abandons the request for hearing as specified in section 17-1703.1-9;(2) Action was due to the application or a change in state or federal law or policy;(3) Another change affecting the beneficiary's eligibility occurs during the hearing process and the beneficiary fails to request a hearing after notice of the change;(4) The beneficiary does not request continued benefits pending a hearing decision.(5) In the case of a managed care health plan appeal, the time period or service limits of a previously authorized service has been met.(d) The department shall promptly send a notice to the beneficiary if benefits are to be reduced or discontinued pending the hearing decision for reasons other than withdrawal or abandonment of the request by the beneficiary.(e) If, while receiving aid paid pending hearing, the beneficiary: (1) Becomes eligible for a reduction of spenddown amount, or premium-share amount, the change shall be made; or(2) Sends a written request for and is denied a medical service, aid paid pending shall continue and a notice of the denial shall be sent to the beneficiary. The notice shall include a statement of the denial, reason for the denial, specific rule supporting the denial, and the person's right to appeal the decision. Haw. Code R. § 17-1703.1-5
[Eff 09/30/13] (Auth: HRS § 346-14; 42 C.F.R. §§431.223, 431.223, 431.230, 431.231, 431, 250) (Imp: HRS § 346-12; 42 C.F.R. §§431.223, 431.223, 431.230, 431.231, 431, 250)