17-1720.1

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1720.1-1
HAWAII ADMINISTRATIVE RULES
TITLE 17
DEPARTMENT OF HUMAN SERVICES
SUBTITLE 12
MED-QUEST DIVISION
CHAPTER 1720.1
FREEDOM OF CHOICE, ENROLLMENT AND DISENROLLMENT
Subchapter 1 	General Provisions
§17-1720.1-1 	Purpose
§§17-1720.1-2 to 17-1720.1-6 	(Reserved)
Subchapter 2 	Freedom of Choice
§17-1720.1-7 	Purpose
§17-1720.1-8 	Choice of health plans
§17-1720.1-9 	Choice of primary care providers
§§17-1720.1-10 to 17-1720.1-14 	(Reserved)
Subchapter 3 	Enrollment
§17-1720.1-15 	Purpose
§17-1720.1-16 	Selection of a health plan for a
newly eligible individual
§17-1720.1-17 	Assignment to a health plan for a
newly eligible individual
§17-1720.1-18 	Change of health plan for an
individual prior to the annual
plan change period
§17-1720.1-19 	Exemptions to a health plan’s
enrollment limit
§17-1720.1-20 	Annual plan change period

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1720.1-2
§17-1720.1-21 	Effective date of enrollment
§§17-1720.1-22 to 17-1720.1-26 	(Reserved)
Subchapter 4 	Disenrollment
§17-1720.1-27 	Purpose
§17-1720.1-28 	Authority to disenroll
§17-1720.1-29 	Disenrollment
§§17-1720.1-30 to 17-1720.1-34 	(Reserved)
Historical Note: 	This chapter is based substantially
upon repealed subchapters 2, 3 and 4 of chapter 17-
1721.1 and subchapters 2, 4 and 5 of chapter 17-1727.
The source note for subchapters 2, 3 and 4 of chapter
17-1721.1 is: 	[Eff 01/31/09; am 06/11/09; am
06/25/12; R 09/30/13].
The source note for subchapters 2, 4 and 5 of chapter
17-1727 is: 	[Eff 08/01/94; am 01/29/96; am 11/25/96;
am 12/27/97; am 10/26/01; 02/16/02; am 05/10/03; am
09/17/07; am 08/19/11; am 06/25/12; R 09/30/13].
SUBCHAPTER 1
GENERAL PROVISIONS
§17-1720.1-1 	Purpose. 	This chapter describes
the freedom of choice, enrollment and disenrollment
provisions for individuals participating in the
demonstration project authorized by Section 1115 of
the Social Security Act. 	[Eff 	09/30/13] 	(Auth: HRS
§346-14) (Imp: HRS §346-14; 42 C.F.R. §§430.25,
438.50)
§§17-1720.1-2 to 17-1720.1-6 	(Reserved).

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1720.1-3
SUBCHAPTER 2
FREEDOM OF CHOICE
§17-1720.1-7 	Purpose. 	This subchapter describes
the provisions regarding an eligible individual’s
freedom of choice in the selection of a participating
health plan and a primary care provider.
[Eff 	09/30/13] 	(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)
§17-1720.1-8 	Choice of health plans. 	(a)
Except for the conditions in section 17-1720.1-13, an
eligible individual shall be allowed to select from
among the participating health plans, of which the
individual is not subject to an enrollment limit,
servicing the geographic area in which the individual
resides. 	This provision shall not apply to an
enrolled individual identified in subsection (c).
(b) 	If a health plan has reached its maximum
enrollment, the eligible individual shall select
another participating health plan that is available.
If only one other participating health plan is
available, subsection (c) shall apply.
(c) 	In the absence of a choice of health plans
in a service area, an eligible individual shall be
enrolled in the participating health plan accepting
new members. 	[Eff 	09/30/13] 	(Auth: HRS §346-14; 42
C.F.R. §§430.25, 438.52) (Imp: HRS §346-14; 42 C.F.R.
§§430.25, 438.52)
§17-1720.1-9 	Choice of primary care providers.
(a) 	In accordance with the procedures established by
the participating health plan, an eligible individual
shall be allowed to select a primary care provider
from among those available within the health plan’s
provider network.

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(b) 	In the absence of a timely selection among
the available primary care providers within the health
plan’s provider network, the enrolled individual shall
be assigned to a primary care provider by the health
plan.
(c) 	An enrolled individual may change their
primary care provider as frequently as, and for
whatever reason, they choose. 	Exceptions to this
provision shall be determined by the department.
[Eff 	09/30/13] 	(Auth: HRS §346-14; 42 C.F.R.
§§430.25, 431.51) (Imp: HRS §346-14; 42 C.F.R.
§§430.25, 431.51)
§§17-1720.1-10 to 17-1720.1-14 	(Reserved).
SUBCHAPTER 3
ENROLLMENT
§17-1720.1-15 	Purpose. 	The purpose of this
subchapter is to describe the selection and subsequent
enrollment provisions into a participating health
plan. 	An eligible individual described in section
17-1735.1-2(a) shall be provided fee-for-service
coverage and will not have the freedom to choose and
be enrolled in a participating health plan.
[Eff 	09/30/13] 	(Auth: HRS §346-14; 42 C.F.R.
§§430.25, 438.50) (Imp: HRS §346-14; 42 C.F.R.
§§430.25, 438.50)
§17-1720.1-16 	Selection of a health plan for a
newly eligible individual. 	(a) 	With the exception of
conditions in section 17-1720.1-17, at the time of
notification of application approval, an eligible
individual shall be provided the opportunity to select
a participating health plan to provide the covered
services effective the applicable date described in
section 17-1720.1-21.

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1720.1-5
(b) 	In the absence of a choice of health plan
open to new members in a service area, an individual
who resides in that particular service area shall be
auto-assigned to the participating health plan open to
new members.
(c) 	If the individual selects a health plan at
the time of notification of application approval, the
department shall send an enrollment notice identifying
the selected health plan and informing the enrolled
individual of the sixty (60) calendar days grace
period from the date of enrollment to select a
different health plan available in the service area in
which the individual resides and which is open to new
members.
(d) 	If the individual does not select a health
plan at the time of notification of application
approval, the individual shall be auto-assigned to a
health plan by the department to provide the covered
services effective the applicable date described in
section 17-1720.1-21. 	[Eff 	09/30/13] 	(Auth: HRS
§346-14; 42 C.F.R. §§430.25, 438.50) (Imp: HRS §346-
14; 42 C.F.R. §§430.25, 438.50)
§17-1720.1-17 	Assignment to a health plan for a
newly eligible individual. 	(a) 	An individual meeting
one of the following conditions will be auto-assigned
to a health plan at the time of determination of
eligibility.
(1) 	A newborn of an enrolled individual shall be
enrolled into the health plan of the mother,
retroactive to the date of birth. 	The
newborn auto-assignment shall be effective
for at least the first (1st) thirty (30)
calendar days following the birth;
(2) 	An individual who lost eligibility for a
period of six (6) months or less shall be
re-enrolled into their previous health plan;
(3) 	An enrolled individual who enters into the
child welfare system shall remain in their
current health plan;

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(b) 	Following the enrollment of a newly eligible
individual into an auto-assigned health plan by the
department, the individual shall be sent an enrollment
notice that identifies the auto-assigned health plan
and provides the individual the opportunity to select
a different health plan, which is available in the
service area in which the individual resides and open
to new members, within the fifteen (15) calendar days
grace period from the date of enrollment into an auto-
assigned health plan.
(1) 	If an individual does not select a different
health plan within the fifteen (15) calendar
days grace period, enrollment shall continue
in the health plan to which auto-assigned,
and the individual will be informed of the
sixty (60) calendar days grace period from
the date of initial enrollment to change
health plans.
(2) 	If the individual selects a different health
plan during the fifteen (15) calendar days
grace period, the date of enrollment into
the selected health plan shall be the first
of the next month following the month in
which the selection occurred, and the
department shall send an enrollment notice
identifying the selected health plan and
inform the individual of the sixty (60)
calendar days grace period from the date of
enrollment to select a different health plan
available in the service area in which the
individual resides open to new members.
(3) 	If during the sixty (60) calendar days grace
period an individual selects to change
health plans, the date of enrollment into
the selected health plan shall be the first
(1st) of the next month following the month
in which the selection occurred, and the
department shall send a new enrollment
notice identifying the selected health plan.
[Eff 	09/30/13] 	(Auth: HRS §346-14; 42
C.F.R. §§430.25, 438.50) (Imp: HRS §346-14;
42 C.F.R. §§430.25, 438.50)

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§17-1720.1-18 	Change of a health plan for an
individual prior to the annual plan change period.
(a) 	Except for changes made by a newly eligible
individual during the fifteen (15) or sixty (60)
calendar days grace periods, an enrolled individual
shall only be allowed to change enrollment from one
health plan to another during the annual plan change
period.
(b) 	Exceptions to (a) can occur for cause, which
include the following circumstances:
(1) 	A decision from an administrative appeals
office allowing participating health plan
change;
(2) 	A court order allowing participating health
plan change;
(3) 	Provisions in federal or State statutes or
administrative rules;
(4) 	A non-returning plan or termination of the
individual’s health plan’s contract or the
start of a new contract;
(5) 	Mutual agreement by the participating health
plans involved, the enrolled individual and
the department;
(6) 	Violations by a participating health plan
specified in chapter 17-1735.2;
(7) 	Change in foster placement if necessary for
the best interest of the child;
(8) 	The individual’s PCP or long-term care
residential facility is not in the health
plan’s provider network and is in the
provider network of a different
participating health plan provided the
health plan is not at its maximum
enrollment;
(9) 	The individual is eligible to receive HCBS
or personal assistance services level I and
is enrolled in a health plan with a waiting
list for HCBS or personal assistance
services level I and another health plan
does not have a waiting list for the
necessary service(s);

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1720.1-8
(10) The participating health plan’s refusal,
because of moral or religious objections, to
cover the service the individual seeks as
allowed for in the department’s contract
with the participating health plan;
(11) The individual’s need for related
services(e.g., a cesarean section and a
tubal ligation) to be performed at the same
time and not all related services are
available within the network and the
individual’s primary care physician or
another provider determines that receiving
the services separately would subject the
individual’s to unnecessary risk;
(12) Lack of direct access to women’s health care
specialists for breast cancer screening, pap
smears and pelvic exams;
(13) Other reasons, including but not limited to,
poor quality of care, lack of access to
covered services, or lack of access to
providers experienced in dealing with the
individual’s health care needs, lack of
direct access to certified nurse midwives,
pediatric nurse practitioners, family nurse
practitioners, if available in the
geographic area in which the individual
resides;
(14) Relocation of the individual to a service
area where the health plan in which they
were enrolled does not provide services;
(15) The individual missed the annual plan change
period due to a temporary loss of Medicaid
eligibility and was re-enrolled in their
previous health plan; or
(16) Other special circumstances as determined by
the department.
(c) 	When changing health plans, an individual
shall select among health plans participating in the
service area in which the individual resides that are
open to new members except as described in section 17-
1720.1-19.

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1720.1-9
(d) 	In the absence of choice of health plans
participating in the service area in which the
individual resides and open to new members, except as
described in section 17-1720.1-19, the individual
shall be enrolled in the available health plan
accepting new members. 	[Eff 	09/30/13] 	(Auth: 	HRS
§346-14; 42 C.F.R. §§430.25, 438.50) (Imp: 	HRS §346-
14; 42 C.F.R. §§430.25, 438.50)
§17-1720.1-19 	Exemptions to a health plan’s
enrollment limit. 	(a) 	The department may implement
an enrollment limit on any health plan that has an
enrollment equal to or exceeding the maximum
enrollment allowed for the service area as determined
by the department and the enrollment limit shall be
effective at the start of and remain in effect for the
benefit year.
(b) 	Subject to approval by the department, a
health plan may self-impose an enrollment limit, and
the enrollment limit shall be effective when
enrollment has reached the self-imposed limit as
determined by the department.
(c) 	When a health plan has an enrollment limit,
the health plan may not be available for selection and
shall not be available for auto-assignment until the
restriction is lifted.
(d) 	The following eligible individuals shall be
exempt from a participating health plan’s enrollment
limit:
(1) 	A newborn born to an enrolled individual
shall be enrolled in the mother’s health
plan for a minimum of thirty (30) days, or
if the mother is not eligible, enrolled in
the health plan of the:
(A) 	Youngest enrolled household member; or
(B) 	Primary household member if there is no
sibling enrolled.
(2) 	An enrolled individual in a health plan with
a waiting list for HCBS or personal
assistance services–level I when another
health plan in the same service area open to

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1720.1-10
new members does not have a waitlist for
these services;
(3) 	An enrolled individual who lost eligibility
for a period of six (6) months or less shall
be re-enrolled into their previous health
plan;
(4) 	A child under Foster Care, previously under
Foster Care, Kinship Guardianship or
Subsidized Adoption; or
(5) 	A newly determined eligible individual who
has seen a PCP, exclusive to a capped health
plan, within the previous six (6) months or
longer as determined by the department.
[Eff 	09/30/13] 	(Auth: 	HRS §346-14; 42
C.F.R. §§430.25, 435.150, 438.50) (Imp: 	HRS
§346-14; 42 C.F.R. §§430.25, 435.150,
438.50)
§17-1720.1-20 	Annual plan change period. 	(a) An
individual shall be allowed to change enrollment from
one participating health plan to another participating
health plan within the service areas in which the
individual resides that is open to receiving new
members during the annual plan change period.
(b) 	The annual plan change period shall occur
each calendar year at a time designated by the
department.
(c) 	An individual who does not request to change
health plan enrollment during annual plan change shall
remain in their current health plan.
[Eff 	09/30/13] 	(Auth: 	HRS §346-14; 42 C.F.R.
§§430.25, 438.50) (Imp: 	HRS §346-14; 42 C.F.R.
§§430.25, 438.50)
§17-1720.1-21 	Effective date of enrollment. 	(a)
The effective date of enrollment for a newly eligible
individual shall be one of the following:
(1) 	The date a completed application is received
by the department;
(2) 	Any date specified by the applicant on which
appropriate Medicaid eligible services were

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1720.1-11
incurred in accordance with chapter 17-
1730.1 and is no earlier than the first (1st)
day of the third (3rd) month prior to the
month the application is received by the
department for individuals applying for the
coverage of long-term care services or the
tenth (10th) calendar day immediately prior
to the date the application is received by
the department for all other individuals;
(3) 	The start date of the participating health
plan contract period in which an eligibility
determination is made for retroactive
coverage; or
(4) 	The date when all eligibility requirements
were met.
(b) 	For an individual with cause as defined in
section 17-1720.1-18 who changes health plans, the
effective date of enrollment in the new health plan
shall be the first (1st) day of the month as designated
by the department.
(c) 	For an eligible individual disenrolled from
a health plan due to temporary loss of eligibility for
a period of six (6) months or less and as a result
missed the annual plan change period, the effective
date of enrollment shall be the same date as
subsection (a)(4).
(d) 	For an enrolled individual who relocates to
a service area where the health plan does not provide
service, the effective date of enrollment shall be the
date of the individual’s relocation.
(e) 	For a newborn born to an eligible
individual, the effective date of enrollment shall be
the date of birth.
(f) 	For an individual changing from one health
plan to another during the annual plan change period
the effective date of enrollment shall be the first
(1st) day of the second (2nd) month after the annual
plan change period ends or as determined by the
department.
(g) 	For all other changes from one health plan
to another, the effective date of enrollment shall be

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1720.1-12
the first (1st) day of the month following the date on
which the department authorizes the enrollment change.
[Eff 	09/30/13] 	(Auth: 	HRS §346-14; 42 C.F.R.
§§430.25, 438.50) (Imp: 	HRS §346-14; 42 C.F.R.
§§430.25, 438.50)
§§17-1720.1-22 to 17-1720.1-26 	(Reserved)
SUBCHAPTER 4
DISENROLLMENT
§17-1720.1-27 	Purpose. 	The purpose of this
subchapter is to describe the requirements for
disenrollment from a participating health plan.
[Eff 	09/30/13] 	(Auth: HRS §346-14; 42 C.F.R.
§§430.25, 438.56) (Imp: HRS §346-14; 42 C.F.R.
§§430.25, 438.56)
§17-1720.1-28 	Authority to disenroll. 	The
department shall have the sole authority to disenroll
an individual from a participating health plan.
[Eff 	09/30/13] 	(Auth: 	HRS §346-14; 42 C.F.R.
§§430.25, 438.56) (Imp: 	HRS §346-14; 42 C.F.R.
§§430.25, 438.56)
§17-1720.1-29 	Disenrollment. 	An individual may
be disenrolled for reasons that include, but are not
limited to, the following:
(1) 	A decision by an administrative appeals
office for disenrollment from a
participating health plan;
(2) 	A court order for disenrollment from a
participating health plan;
(3) 	Provisions in federal or State statutes or
administrative rules;

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1720.1-13
(4) 	A non-returning plan or termination of the
health plan’s contract or the start of a new
contract;
(5) 	Mutual agreement by the participating health
plans involved, the individual and the
department;
(6) 	Violations by a participating health plan
specified in chapter 17-1735.2;
(7) 	Change in foster placement if necessary for
the best interest of the child;
(8) 	The individual selects a health plan that is
not capped during the annual plan change
period;
(9) 	The individual’s PCP or long-term care
residential facility is not in the health
plan’s provider network and is in the
provider network of a different health plan,
provided the health plan is not at its
maximum enrollment;
(10) 	The individual is eligible to receive HCBS
or personal assistance services level I and
is enrolled in a health plan with a waiting
list for HCBS or personal assistance
services level I and the other health plan
does not have a waiting list for the
necessary service(s);
(11) 	The participating health plan’s refusal,
because of moral or religious objections, to
cover the service the individual seeks as
allowed for in the contract with health
plan;
(12) 	The individual’s need for related services
(e.g., a cesarean section and a tubal
ligation) to be performed at the same time
and not all related services are available
within the network and the individual’s
primary care physician or another provider
determines that receiving the services
separately would subject the individual to
unnecessary risk;

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1720.1-14
(13) 	Lack of direct access to women’s health care
specialists for breast cancer screening, pap
smears and pelvic exams;
(14) 	Other reasons, including but not limited to,
poor quality of care, lack of access to
covered services, or lack of access to
providers experienced in dealing with the
individual’s health care needs, lack of
direct access to certified nurse midwives,
pediatric nurse practitioners, family nurse
practitioners, if available in the
geographic area in which the individual
resides;
(15) 	Relocation to a service area where the
health plan in which the individual was
enrolled does not provide services;
(16) 	The individual missed the annual plan change
period due to a temporary loss of Medicaid
eligibility and was re-enrolled in the
previous health plan;
(17) 	Voluntary withdrawal from participation in
the medical assistance program by the
individual or a authorized representative;
(18) 	Not meeting the eligibility requirements;
(19) 	Death of the enrolled individual;
(20) 	The enrolled individual is a medically needy
individual who is two full months in arrears
in the payment of the designated enrollment
fee, unless the failure to pay occurs
because:
(A) 	The individual is not in control of the
individual’s personal finances, and the
arrearage is caused by the party
responsible for the individual’s
finances, and action is being taken to
remediate the situation, including but
not limited to:
(i) Appointment of a new responsible
party for the individual’s
finances; or
(ii) Recovery of the individual’s funds
from the responsible party which

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1720.1-15
will be applied to the
individual’s enrollment fee
obligation.
(B) 	The individual is in control of the
individual’s finances, and the
arrearage is due to the unavailability
of the individual’s funds due to
documented theft or financial
exploitation, and action is being taken
to:
(i) 	Ensure that theft or exploitation
does not continue; or
(ii) Recover the individual’s funds to
pay the individual’s enrollment
fee obligation;
(21) Incarceration of an enrolled individual into
a public facility;
(22) Admission to the State hospital;
(23) Enrollment into the State of Hawaii Organ
and Tissue Transplantation (SHOTT) program;
(24) Relocation out-of-state by the State;
(25) Provision of false information with the
intent of enrolling in the medical
assistance program under false pretenses;
(26) Eligible for Medicare Special Savings
benefits;
(27) Other special circumstances as determined by
the department; or
(28) An individual disenrolled for cause.
[Eff 	09/30/13] 	(Auth: 	HRS §346-14; 42
C.F.R. §§430.25, 438.56) (Imp: 	HRS §346-14;
42 C.F.R. §§430.25, 438.56)
§§17-1720.1-30 to 17-1720.1-34 	(Reserved).