Section 17-1720-31 - Exclusions and limitations A participating health plan shall not provide coverage for certain services, procedures, medications, supplies, equipment, or other items that are:
(1) Specifically excluded from coverage by State or federal requirements;(2) Provided by providers not licensed or certified in the State to perform the service;(3) Available without charge to the general public through a separate state or federally administered federally-funded program;(4) Covered by a third party medical or liability insurance, including Medicare;(5) Required to receive prior authorization but did not receive it;(6) Experimental in nature and have not been approved by the United States Food and Drug Administration, or both;(7) Elective and do not improve outcomes such as decreasing risk of morbidity or mortality;(8) Without sufficient evidence of effectiveness or net benefits as determined by the department and not covered under the currently approved Medicaid State Plan, Medicaid waivers, or both;(9) Comparatively effective to a tolerated lower cost alternative; or(10) Otherwise determined by the department to be non-covered, excluded, or limited.Haw. Code R. § 17-1720-31
[Eff 09/30/13] (Auth: HRS § 346-14; 42 C.F.R. §438.210 ) (Imp: HRS § 346-14; 42 C.F.R. §438.210 )