§346-59  Medical care payments.  (a) 
The department shall adopt rules under chapter 91 concerning payment to
providers of medical care.  The department shall determine the rates of payment
due to all providers of medical care, and pay such amounts in accordance with
the requirements of the appropriations act and the Social Security Act, as
amended.  Payments to critical access hospitals for services rendered to
medicaid beneficiaries shall be calculated on a cost basis using medicare
reasonable cost principles.



(b)  Rates of payment to providers of medical
care who are individual practitioners, including doctors of medicine, dentists,
podiatrists, psychologists, osteopaths, optometrists, and other individuals
providing services, shall be based upon the Hawaii medicaid fee schedule.  The
amounts paid shall not exceed the maximum permitted to be paid individual
practitioners or other individuals under federal law and regulation, the
medicare fee schedule for the current year, the state limits as provided in the
appropriation act, or the provider's billed amount.



The appropriation act shall indicate the
percentage of the medicare fee schedule for the year 2000 to be used as the
basis for establishing the Hawaii medicaid fee schedule.  For any subsequent
adjustments to the fee schedule, the legislature shall specify the extent of
the adjustment in the appropriation act.



(c)  In establishing the payment rates for
other noninstitutional items and services, the rates shall not exceed the
current medicare payment, the state limits as provided in the appropriation
act, the rate determined by the department, or the provider's billed amount.



(d)  Payments to health maintenance
organizations and prepaid health plans with which the department executes risk
contracts for the provision of medical care to eligible public assistance
recipients may be made on a prepaid basis.  The rate of payment per
participating recipient shall be fixed by contract, as determined by the
department and the health maintenance organization or the prepaid health plan,
but shall not exceed the maximum permitted by federal rules and shall be less
than the federal maximum when funds appropriated by the legislature for such
contracts require a lesser rate.  For purposes of this subsection, "health
maintenance organizations" are entities approved as such, and
"prepaid health plans" are entities designated as such by the
Department of Health and Human Services; and "risk" means the
possibility that the health maintenance organization or the prepaid health plan
may incur a loss because the cost of providing services may exceed the payments
made by the department for services covered under the contract.



(e)  The department shall prepare each biennial
budget request for a medical care appropriation based upon the most current
Hawaii medicaid fee schedule available at the time the request is prepared.



The director shall submit a report to the
legislature on or before January 1 of each year indicating an estimate of the
amount of money required to be appropriated to pay providers at the maximum
rates permitted by federal and state rules in the upcoming fiscal year. [L
1976, c 150, §2; am L 1979, c 220, §1; am L 1983, c 252, §1; am L 1986, c 107,
§1; am L 1987, c 290, §2; am L 1988, c 308, §1; am L 1990, c 263, §§2, 3; am L
2000, c 226, §§4, 9; am L 2001, c 29, §§2, 4; am L 2002, c 16, §28; am L 2004,
c 148, §2]



 



Note



 



  Increase in rate of payment to providers of medical care.  L
1991, c 306, §2.



 



Cross References



 



  Medicaid fraud unit, see §28-91.



  Medical assistance application information; annual report;
public disclosure, see §346-29.3.