§17-1731-7 - Appeal process.

§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:
(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 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)

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