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

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

The appropriation act shall indicate thepercentage of the medicare fee schedule for the year 2000 to be used as thebasis for establishing the Hawaii medicaid fee schedule.  For any subsequentadjustments to the fee schedule, the legislature shall specify the extent ofthe adjustment in the appropriation act.

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

(d)  Payments to health maintenanceorganizations and prepaid health plans with which the department executes riskcontracts for the provision of medical care to eligible public assistancerecipients may be made on a prepaid basis.  The rate of payment perparticipating recipient shall be fixed by contract, as determined by thedepartment and the health maintenance organization or the prepaid health plan,but shall not exceed the maximum permitted by federal rules and shall be lessthan the federal maximum when funds appropriated by the legislature for suchcontracts require a lesser rate.  For purposes of this subsection, "healthmaintenance organizations" are entities approved as such, and"prepaid health plans" are entities designated as such by theDepartment of Health and Human Services; and "risk" means thepossibility that the health maintenance organization or the prepaid health planmay incur a loss because the cost of providing services may exceed the paymentsmade by the department for services covered under the contract.

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

The director shall submit a report to thelegislature on or before January 1 of each year indicating an estimate of theamount of money required to be appropriated to pay providers at the maximumrates permitted by federal and state rules in the upcoming fiscal year. [L1976, 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 L2000, 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.  L1991, c 306, §2.

 

Cross References

 

  Medicaid fraud unit, see §28-91.

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