Hawaii - I/DD Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-09

In Hawaii, services for individuals with intellectual and developmental disabilities are funded through the Medicaid I/DD Waiver (also known as the 1915(c) HCBS Waiver for Individuals with Intellectual and Developmental Disabilities), which is operated by the Department of Health, Developmental Disabilities Division (DOH-DDD) and overseen by the Department of Human Services, Med-QUEST Division (DHS-MQD). Prospective providers must first submit a DOH-DDD Medicaid I/DD Waiver Proposal Application and be recommended by DOH-DDD before they can enroll as a Medicaid provider with DHS-MQD.

The most critical structural prerequisite for new applicants is strict, upfront compliance with the CMS Home and Community-Based Services (HCBS) Final Rule. Hawaii does not allow a transition period for new providers; all prospective provider applicants and existing providers seeking to add a new service or setting must demonstrate full compliance with the HCBS Final Rule on community integration before DOH-DDD will recommend the applicant to DHS-MQD for enrollment. There are no exceptions to this rule.

1. Service Definition and Scope

The Hawaii Medicaid I/DD Waiver provides a comprehensive array of home and community-based services designed to support individuals with intellectual and developmental disabilities to live fully integrated lives in their communities. Services range from habilitation and supported employment to personal assistance, respite, and supported living.

Services are authorized based on an Individualized Service Plan (ISP) developed by the DOH-DDD Case Manager in collaboration with the participant. Providers must deliver services exactly as authorized in the ISP and adhere to the service-specific performance standards outlined in the Waiver Provider Standards Manual.

• Target Population: Individuals with intellectual and/or developmental disabilities who meet ICF/IID level of care.
• Operating Agency: Department of Health, Developmental Disabilities Division (DOH-DDD).
• Funding Authority: 1915(c) HCBS Medicaid I/DD Waiver.
• Service Array: Includes habilitation, supported employment, personal assistance, respite, and various residential supports.
• Authorization: Services must be explicitly authorized in the participant's Individualized Service Plan (ISP).

2. Regulatory and Oversight Agencies

The Medicaid I/DD Waiver is jointly managed by two state departments. The Department of Human Services, Med-QUEST Division (DHS-MQD) is the single State Medicaid Agency responsible for ultimate administrative authority, financial management, and provider enrollment.

The Department of Health, Developmental Disabilities Division (DOH-DDD) is the operating agency responsible for day-to-day waiver management, participant intake, level of care evaluations, ISP development, and initial provider application review and recommendation.

• State Medicaid Agency: Department of Human Services, Med-QUEST Division (DHS-MQD) (https://medquest.hawaii.gov).
• Operating Agency: Department of Health, Developmental Disabilities Division (DOH-DDD) (https://health.hawaii.gov/ddd/).
• Licensing Agency (Residential): DOH Office of Health Care Assurance (OHCA) (https://health.hawaii.gov/ohca/).
• Federal Oversight: Centers for Medicare & Medicaid Services (CMS) (https://www.cms.gov).

3. Gatekeeping Prerequisites: Who Can Even Apply

Before a provider can even apply to DHS-MQD for Medicaid enrollment, they must pass a rigorous proposal and validation process with DOH-DDD. The most significant structural barrier is the CMS HCBS Final Rule compliance requirement.

All new provider applicants, and existing providers adding new services or settings, must demonstrate full compliance with the HCBS Final Rule prior to approval. DOH-DDD conducts a "My Choice My Way" validation, which may include site visits, to ensure the applicant's settings and services meet community integration standards. If compliance is not demonstrated upfront, DOH-DDD will not recommend the applicant to DHS-MQD.

• HCBS Final Rule Compliance: Mandatory upfront compliance with no transition period for new applicants.
• DOH-DDD Recommendation: Required before submitting a Medicaid enrollment application to DHS-MQD.
• My Choice My Way Validation: DOH-DDD review process to verify HCBS Final Rule compliance.
• Site Visits: DOH-DDD may conduct site visits to applicant settings prior to approval.

4. Licensure and Certification Requirements

Hawaii does not have a single, universal "I/DD Provider License." Instead, licensure and certification depend on the specific services provided and the setting in which they are delivered. Professional staff must hold current Hawaii state licenses appropriate to their scope of practice.

For residential services, specific certifications or licenses are required. DOH-DDD certifies Adult Foster Homes, while the DOH Office of Health Care Assurance (OHCA) licenses Developmental Disabilities Domiciliary Homes, Adult Residential Care Homes, and other specialized residential facilities.

• Professional Licensure: Required for licensed practitioners (e.g., RNs, PTs, OTs) practicing within their scope.
• Adult Foster Homes: Certified directly by DOH-DDD.
• Domiciliary/Care Homes: Licensed by DOH Office of Health Care Assurance (OHCA).
• Temporary Licenses: Permits or temporary licenses requiring supervision do not qualify for Medicaid reimbursement.

5. Medicaid Provider Enrollment

Once an applicant successfully completes the DOH-DDD proposal process and receives a recommendation, they must formally enroll as a Medicaid provider with DHS-MQD. This involves submitting the Medicaid Application/Change Request Form (DHS 1139) and executing a Provider Services Agreement.

The enrollment process includes a mandatory application fee and requires the provider to obtain a temporary identification number for fingerprinting and background check purposes.

• Enrollment Form: Medicaid Application/Change Request Form (DHS 1139).
• Application Fee: $500 fee submitted to DOH-DDD, which forwards it to DHS-MQD.
• Provider Agreement: Must execute a written Provider Agreement with DHS-MQD.
• Fingerprinting: Required for high-risk providers; DHS-MQD issues a temporary ID for this process.

6. Staffing, Training and Background Checks

Providers must ensure all direct support workers possess satisfactory skills as defined in the participant's ISP prior to service delivery. Staff qualifications and training requirements are detailed in the Waiver Provider Standards Manual.

Comprehensive background checks are mandatory. This includes criminal history record checks, registry screenings, and verification that individuals are not on the OIG List of Excluded Individuals/Entities (LEIE). Additionally, all staff must have a DOH-approved Tuberculosis (TB) clearance.

• Background Checks: Criminal history record checks and registry screens required.
• OIG Exclusion List: Staff must not be on the federal OIG List of Excluded Individuals/Entities.
• TB Clearance: DOH-approved form documenting freedom from communicable TB required for all staff.
• Training: Mandatory New Employee Orientation and continuing education on state/agency policies.
• Family Members: Family members employed as staff must meet all requirements, including CPR/First Aid and TB screening.

7. Documentation, Policies and Records

Providers must maintain comprehensive, confidential case files for each participant. These records must include emergency contacts, ISPs, progress reports, and detailed service delivery logs.

Agencies must also maintain written Policies and Procedures (P&Ps) that align with DOH-DDD P&Ps. Required policies include emergency protocols, an alcohol and drug-free workplace, protection of participant rights, and confidentiality.

• Participant Records: Must include emergency info, ISPs, and service delivery documentation.
• Required Policies: Emergency protocols, drug-free workplace, participant rights, and confidentiality.
• Language Access: Must comply with Limited English Proficiency requirements and provide interpreter services.
• Audit Requirement: Providers receiving $750,000+ in Medicaid funds annually must submit an independent CPA audit.

8. Billing, Rates and Claims

Reimbursement is strictly tied to authorized services delivered to eligible, enrolled waiver participants. Providers cannot bill for services provided prior to a participant's official admission to the Medicaid I/DD Waiver.

All claims must be fully traceable to documented service delivery. Required documentation includes the participant's name, dates of service, type of service (including staff ratios), exact duration (time in/out), and signatures of the direct support worker and supervisor.

• Prior Authorization: Services must be authorized in the ISP prior to delivery and billing.
• Claim Traceability: Claims must match documented service delivery logs.
• Required Log Elements: Date, service type, time in/out, staff name, and supervisor signature.
• Cost Share: Some adult participants may have a Medicaid "Cost Share" obligation based on income.

9. Approval Sequence and Timeline

The approval process is sequential and begins with DOH-DDD. Applicants submit a DOH-DDD Medicaid I/DD Waiver Proposal Application. DOH-DDD reviews the application, verifies HCBS Final Rule compliance (often via site visits), and makes a recommendation.

If recommended, the applicant submits the DHS 1139 form and $500 fee to DOH-DDD, which forwards it to DHS-MQD. DHS-MQD then processes the enrollment, requires fingerprinting, and executes the Provider Agreement. The entire process can take several months depending on application completeness and site visit scheduling.

• Step 1: Submit DOH-DDD Medicaid I/DD Waiver Proposal Application.
• Step 2: DOH-DDD review and HCBS Final Rule validation (My Choice My Way).
• Step 3: DOH-DDD recommendation to DHS-MQD.
• Step 4: Submit DHS 1139 form and $500 fee.
• Step 5: DHS-MQD processing, fingerprinting, and Provider Agreement execution.

10. Common Denials and Survey Findings

Applications are frequently delayed or denied due to a failure to demonstrate upfront compliance with the CMS HCBS Final Rule. Because there is no transition period for new applicants, any setting that isolates or fails to integrate participants will result in a denial.

During ongoing operations, common survey findings include inadequate documentation of service delivery (missing time in/out or signatures), failure to maintain current TB clearances or background checks for staff, and failure to respond timely to DOH-DDD or DHS-MQD requests for information.

• HCBS Non-Compliance: Failure to prove community integration upfront blocks approval.
• Documentation Errors: Missing time in/out or signatures on service logs leads to recouped claims.
• Staff Clearances: Lapsed TB clearances or delayed background checks.
• Responsiveness: Failure to respond to state agency requests within specified timelines.

11. Key Contacts and Resources

Prospective providers should thoroughly review the Waiver Provider Standards Manual and the DOH-DDD website for the most current application materials and policy updates.

For questions regarding the initial proposal process, contact DOH-DDD. For questions regarding final Medicaid enrollment and billing, contact DHS-MQD.

• DOH-DDD Waiver Providers Page: https://health.hawaii.gov/ddd/waiver-providers
• DOH-DDD Main Page: https://health.hawaii.gov/ddd/
• DHS Med-QUEST Division (MQD): https://medquest.hawaii.gov
• DOH Office of Health Care Assurance (OHCA): https://health.hawaii.gov/ohca/

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