Adults Group

HAWAII ADMINISTRATIVE RULES

TITLE 17

DEPARTMENT OF HUMAN SERVICES

SUBTITLE 12

MED-QUEST DIVISION

CHAPTER 1718

ADULTS GROUP

Subchapter 1 General Provisions

§17-1718-1 Purpose §17-1718-2 General requirements §§17-1718-3 to 17-1718-7 (Reserved)

Subchapter 2 Eligibility Requirements

§17-1718-8 Purpose §17-1718-9 Basic requirements §17-1718-10 Categorical requirements §17-1718-11 Income requirements §17-1718-12 Asset requirements §17-1718-13 Eligibility review requirements §§17-1718-14 to 17-1718-18 (Reserved)

Subchapter 3 Freedom of Choice, Enrollment, Benefits and Disenrollment

§17-1718-19 Purpose §17-1718-20 Freedom of choice §17-1718-21 Enrollment into a participating health plan §17-1718-22 Benefits §17-1718-23 Disenrollment from a health plan

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§17-1718-1

§§17-1718-24 to 17-1718-28 (Reserved)

Historical Note: This chapter is based substantially upon repealed chapters 17-1727, 17-1728 and 17-1728.1. [Eff 08/01/94; am 07/20/95; am 01/29/96; am 03/30/96; am 11/25/96; am 12/27/97; am 07/06/99; am 06/19/00; am 10/26/01; am 12/03/01; am 02/16/02; am 05/10/03; am 09/17/07; am 09/10/09; am 04/30/10; am 08/19/11; am 06/25/12; R 09/30/13]

SUBCHAPTER 1

GENERAL PROVISIONS

§17-1718-1 Purpose. This chapter establishes the Adults Group. The eligibility group for individuals age nineteen years or older and under age sixty-five years, an option created through the enactment of the Affordable Care Act and commonly referred to as the Adults Group, provides coverage to eligible adults. [Eff 09/30/13; am and comp NOV I 0 2016 ] (Auth: HRS §346-14, 42 C.F.R. §435.119) (Imp: HRS §346-14, 42 C.F.R. §435.119)

§17-1718-2 General requirements. The confidentiality, administrative appeal, fraud, medical assistance recovery, application processing, eligibility review, and adverse action provisions described in subtitle 12 shall pertain to an individual who applies or is eligible under this chapter. [Eff 09/30/13; am and comp (Auth: HRS §§346-14, 346-29, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.119, 435.201, 435.907, 435.916, 455.1) (Imp: HRS §§346-14, 346-29, 346-44; 42 C.F.R. §§431.200, 431.206, 431.221, 431.230, 431.300, 435.119, 435.201, 435.907, 435.916, 455.1)

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§17-1718-10

§§17-1718-3 to 17-1718-7 (Reserved) .

SUBCHAPTER 2

ELIGIBILITY REQUIREMENTS

§17-1718-8 Purpose. This subchapter describes the eligibility requirements for participation in the Adults Group. [Eff 09/30/13; comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §435.119) (Imp: HRS §346-14; 42 C.F.R. §435.119)

§17-1718-9 Basic requirements. An individual whose eligibility is being determined under this chapter shall meet the basic eligibility requirements which include, but are not limited to, citizenship, qualified non-citizen or lawfully present non-citizen status, State residency, verification of identity, not residing in a public institution, and the provision of a social security number, as described in chapter 17- 1714 .1. [Eff 09/30/13; am and comp NOV 1 0 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.119, 435.400, 435.910) (Imp: HRS §346-14; 42 C.F.R. §§435.119, 435.400, 435.910)

§17-1718-10 Categorical requirements. (a) To be eligible under the Adults Group, an individual shall meet the following requirements: (1) Be age nineteen years or older, but under sixty-five years of age; (2) Not entitled to or enrolled for Medicare; (3) Not in receipt of Supplemental Security Income (SS!); and (4) Not eligible under any of the following chapters: (A) 17-1715, Children Group;

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§17-1718-10

(B)17-1715.1, Former Foster Care Children Group; (C) 17-1716, Pregnant Women Group; (D) 17-1717, Parents and Other Caretaker Relatives Group; and (E) 17-1717.1, Transitional Medical Assistance. (b) An individual whose household's modified adjusted gross income (MAGI) based income exceeds the income standard for participation under the Parents and Other Caretaker Relatives Group may participate in the Adults Group if the individual: (1) Resides with a child under nineteen years of age; (2) Assumes primary responsibility for the care of the child described in paragraph (1); and (3) The child described in paragraph (1) is enrolled in Medicaid. (c) An individual who is applying on the basis of blindness or disability shall be subject to the provisions of chapters 17-1719, 17-1724.1, and 17- 1725 .1 . [Eff 09/30/13; am and comp NOV-1 0 2016 (Auth: HRS §346-14; 42 C.F.R. §§430.25, 435.119, 435.150, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 435.119, 435.150, 435.603)

§17-1718-11 Income requirements. (a) The MAGI methodology described in chapter 17-1724.2 shall be used to determine the countable income for an individual subject to an income limit. (b) The income standard for participation in the Adults Group is one hundred thirty-three per cent of the federal poverty level for a household of applicable size. An income disregard of five per cent of the applicable federal poverty level is added to the highest income standard for an individual using MAGI-based methodology under the applicable title of the Social Security Act. (c) An individual who is determined ineligible under this chapter shall have eligibility determined for other applicable eligibility groups. [Eff

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§17-1718-19

09/30/13; am and comp NOV 1 O2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.119, 435.601, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§435.119, 435.601, 435.603)

§17-1718-12 Asset requirements. Assets shall not be considered in the determination of eligibility for participation in the Adults Group. [Eff 09/30/13; comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.119, 435.603) (Imp: HRS §346-14; 42 C.F.R. §§435.119, 435.603)

§17-1718-13 Eligibility review requirements. (a) An eligible individual shall receive an annual eligibility review every twelve months. (b) Eligibility shall be redetermined in accordance with chapter 17-1712.1 and subchapter 5 of chapter 17-1714.1. [Eff 09/30/13; am and comp NOV 10 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§435.119, 435.916, 435.940) (Imp: HRS §346-14; 42 C.F.R. §§435.119, 435.916, 435.940)

§§17-1718-14 to 17-1718-18 (Reserved) .

SUBCHAPTER 3

FREEDOM OF CHOICE, ENROLLMENT, BENEFITS AND DIS ENROLLMENT

§17-1718-19 Purpose. This subchapter addresses and refers to the provisions of freedom of choice, enrollment, benefits and disenrollment for an individual who is eligible in accordance with this chapter. [Eff 09/30/13; am and comp NOV I 0 2016 (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 4 31 . 4 0 ) ( I mp : HRS § 3 4 6 - 14 ; 4 2 C . F . R . § § 4 3 0 . 2 5 , 431.10, 431.40)

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§17-1718-20

§17-1718-20 Freedom of choice. (a) An individual eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735.1-2(a), shall be provided a choice of a health plan and a provider as described in chapter 17-1720.1. (b) An individual identified in section 17- 1735.1-2 (a) shall choose a department approved provider as described in section 17-1736-3. [Eff 09/30/13; am and comp NOV I 0 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 438.52) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.51, 438.52)

§17-1718-21 Enrollment into a participating health plan. (a) An individual eligible in accordance with this chapter, with the exception of an individual identified in section 17-1735.1-2(a), shall be enrolled in a health plan as described in chapter 17-1720.1. (b) An individual identified in section 17- 1735.1-2 (a) shall not be enrolled into a health plan and their healthcare services shall be provided on a fee-for-service basis. [Eff 09/30/13; am and comp NOV 10 2016] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40, 438.50) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.10, 431.40, 438.50)

§17-1718-22 Benefits. (a) An individual eligible in accordance with this chapter who is enrolled in a health plan shall be provided a standard benefits package by a participating health plan and other services when appropriate as described in chapter 17-1720. (b) An individual identified in section 17- 1735.1-2 (a) shall be provided coverage under the fee- for-service provisions as described in chapter 17- 1737. [Eff 09/30/13; am and comp NOV I 0 2016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.40,

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§17-1718-23

438.6) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.6)

§17-1718-23 Disenrollment from a health plan. An enrollee shall be disenrolled from a health plan under the provisions as described in chapter 17- 1720.1. [Eff 09/30/13; comp NOV102016 ] (Auth: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.56) (Imp: HRS §346-14; 42 C.F.R. §§430.25, 431.40, 438.56)

§§17-1718-24 to 17-1718-28 (Reserved) .

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320 6