Haw. Code R. § 17-1703.1-16 - Decisions pending over ninety days

(a) When a final decision has not been made and implemented within ninety (90) days of the request, the department shall reduce the premium-share amount or spenddown amount to what existed prior to the hearing request or restore or grant any service which was reduced or denied, if the individual is not already receiving aid paid pending. When the hearing decision is pending over ninety (90) days, aid paid shall be determined in accordance with subsections (d) and (e).

(b) The hearing officer shall notify the Med-QUEST Division orally on the ninety-first (91^st) day when a final decision is not reached within ninety (90) days. If the ninety-first (91^st) day falls on a weekend or holiday, the ninety-first (91^st) day shall then be the first working day following the weekend or holiday. A written confirmation shall be sent within three (3) working days.

(c) In situations where an individual has requested or is otherwise responsible for a delay in the hearing process, the time period shall be tolled only for the period of the delay.

(d) When a final decision is not made and implemented within ninety (90) days:

(1) The specific medical care denied the individual which is the issue on appeal shall be authorized from the ninety-first (91^st) day until the hearing decision is made and implemented; or

(2) The individual applying for medical assistance shall be made presumptively eligible to secure assistance from the ninety-first (91^st) day until the hearing decision is made and implemented.

(e) The department shall review current need and eligibility factors exclusive to the issue on appeal. If the individual is found to be currently eligible, the department shall reduce the premium-share amount or spenddown amount to what existed prior to the hearing request effective the ninety-first (91^st) day. The required action shall be taken within five (5) working days after the oral notice is received from the hearing officer. The amount of premium-share or spenddown amount shall be restored to the previous level until a final decision is made, provided the individual remains eligible and no other changes become necessary.

(f) If, for reasons exclusive to the issue pending hearing, the department determines that the individual is ineligible to receive assistance, the department shall terminate or deny the assistance on or after the ninety-first (91^st) day of the hearing request. The department shall send a notice indicating the reasons for not restoring assistance pending the final hearing decision.

Notes

Haw. Code R. § 17-1703.1-16

[Eff 09/30/13] (Auth: HRS § 346-14(9); 42 C.F.R. §431.244) (Imp: HRS § 346-12; 42 C.F.R. §431.244)