If you do not agree with the foregoing determination, you may call, write, use other commonly available electronic means, or visit the Med-QUEST Eligibility Branch to request an informal review meeting with the eligibility worker and/or his/her supervisor or you may request an administrative hearing with a Hearing Officer.  You will be given the opportunity to present evidence in support of your position that the intended action is incorrect.  You do not need to first have an informal review meeting in order to request an administrative hearing.

You must make your request for either an informal review or an administrative hearing in-person, by telephone, mail, or through other commonly available electronic means.  If you wish to submit a written request, you may use the Department’s form or write your request on any paper.  Your request must be received by our office within 90 calendar days from the date of this notice.

You may have someone else request, or speak, for you at the informal review or administrative hearing.  This person is called an authorized representative.  If you did not designate an authorized representative on your application, please provide written authorization for the person to represent you or you may use the Department’s Request for a Hearing form.  The written authorization must be received by the Med-QUEST Eligibility Office in order to acknowledge any actions taken by your authorized representative.  An authorized representative must agree to maintain, or be legally bound to the confidentiality of any information regarding the applicant or beneficiary that is provided by the department.  An authorized representative who is a provider, staff member or volunteer of an organization must agree to sign an agreement to comply with regulations relating to confidentiality of information, prohibition against reassignment of provider claims as appropriate for a health facility or an organization acting on the facility’s behalf; must meet the authentication and data security standards required under State and Federal law or otherwise specified by the department.  If you choose to have an authorized representative, you may withdraw his or her name or replace the person with another authorized representative at any time.

At the informal review meeting or at the administrative hearing, you and/or your authorized representative will have the opportunity to explain why you do not agree with the decision.  At your request, our office will provide you with information about a Legal Aid Office that may be able to advise or represent you at no cost.  Please let us know if you need an interpreter or other aid to help you communicate with us at the informal review or administrative hearing.

H.A.R. 1703.1-2 & 1703.1-3

WHEN BENEFITS STOP

If your assistance continues pending a hearing decision, medical services will be covered and you may still use your Medicaid Identification (ID) card.  If the Administrative Appeals Office decision is not in your favor, you will need to repay the amounts you were not entitled to receive.

If your medical benefits are terminated, you will be responsible for your medical and dental expenses, including Medicare premiums, from the effective date medical benefits are terminated.  Do not use the plastic Medicaid ID card after medical benefits are terminated.  Doing so may subject you to investigation of fraud and possible legal prosecution.

A Certificate of Medical Coverage will be sent to you after your medical benefits terminate that may shorten or satisfy restrictions on the coverage of pre-existing conditions under a health plan.

I will not be treated differently because of my race, color, age, sex, sexual orientation, gender identity, national origin, physical or mental disability, or religious or political beliefs.  If I am not satisfied with the way I am treated, I can call the Department of Human Services, Civil Rights Compliance Unit, at (808) 586-4955 or send a letter immediately to their office at DHS/PCRCU, P.O. Box 339, Honolulu, HI 96809-0339 or write to the U.S. Department of Health and Human Services (US DHHS), Office of Civil Rights/Region IX, 90 7th Street, Suite 4-100, San Francisco, CA 94103-6705, Attention:  Regional Manager.  I may also call the US DHHS at 1-800-368-1019 (toll free) or 1-415-437-8311 (TDD) or file a complaint via www.hhs.gov/ocr/office/file.  I can also get a Discrimination Complaint Form, Consent/Release Form, and joint Nondiscrimination Notices at http://hawaii.gov/dhs in the Civil Rights Corner.

To make it easier to determine my eligibility for help paying for health coverage, I understand that if I do not qualify for Medicaid the Department of Human Services, Med-QUEST Division, may send my information to the Hawaii Health Connector so they can see if I qualify other health coverage.

You must report changes to your household size, including marital and pregnancy status, income, assets (if the amount of assets is an eligibility criterion), residence, mailing address, phone number, or any other pertinent information.  Call, write, use other commonly available electronic means or visit our office within 10 calendar days from the time you learn of the change.

It is a crime punishable under State and Federal law to lie, misrepresent facts, withhold information, or arrange for someone to knowingly lie or misrepresent facts on your behalf, in order to receive medical assistance or benefits.  You may be held liable for repaying the value of benefits you received and be subject to penalties under the law.