Section 17-1735.2-6 - Enforcement of contracts with participating health plan(a) The department may monitor a participating health plan's performance during any contract period.(b) The department may impose civil or administrative monetary penalties not to exceed the maximum amount established by federal and state statutes and regulations if the health plan: (1) Fails to provide medically necessary items and services that are required under law or under contract;(2) Imposes upon beneficiaries excess premiums and charges;(3) Acts to discriminate among an eligible individual;(4) Misrepresents or falsifies information;(5) Violates marketing guidelines established by the department;(6) Violates other contract provisions and requirements; or(7) Violates federal or state statutes or regulations.(c) If a health plan violates the contract conditions between the health plan and the department, federal or State statutes or regulations, the Hawaii Administrative Rules, or if there is a substantial risk to the health of an eligible individual, the department may: (1) Notify the affected individual of the violations;(2) Allow the affected individual to change plans without cause;(3) Suspend enrollment; or(4) Suspend payment. The department may also impose financial sanctions as described under the provisions of the contract between the respective plan and the department for inaccurate, incomplete, and untimely data and reports submitted to the department.
(d) If a health plan continues to violate the contract conditions between the health plan and the department, federal or state statutes and regulations, or the Hawaii Administrative Rules, regardless of any other penalty that may be imposed, the department shall: (1) Appoint temporary management to oversee compliance efforts;(2) Notify the affected eligible individual of the violations; or(3) Allow the affected eligible individual to change plans without cause.(e) Temporary management may continue until the department determines that the health plan can ensure that the behavior that caused the penalty will not recur.(f) Before imposing a sanction, with the exception of appointing temporary management to oversee compliance efforts, the department shall give the health plan timely written notice, as specified in the contract with the participating health plans.Haw. Code R. § 17-1735.2-6
[Eff 09/30/13] (Auth: HRS § 346-59.5) (Imp: HRS § 346-14; 42 C.F.R. §§430.25; 438.700, 438.702; 438.706; 438.710)