Section 17-1722.3-18 - Basic Health Hawaii benefits(a) A participating health plan shall be required to provide the benefits defined in this subchapter.(b) Within a benefit year, a participating health plan shall provide each enrollee no more than ten days of medically necessary inpatient hospital care related to medical care, surgery, psychiatric care, and substance abuse treatment. The following hospital services shall be made available to each enrollee: (1) Semi-private room and board and general nursing care for inpatient stays related to medical care, surgery, psychiatric care, and substance abuse treatment;(2) Intensive care room and board and general nursing care for medical care and surgery;(3) Use of an operating room and related facilities, inpatient anesthesia, radiology, laboratory and other diagnostic services agreed upon by the participating health plan medical director for medical care and surgery;(4) Drugs, dressings, blood derivatives and their administration, general medical supplies, and diagnostic and therapeutic procedures as prescribed by the attending physician;(5) Other ancillary services associated with hospital care except private duty nursing; and(6) Ten inpatient physician visits within a benefit year.(c) Within a benefit year, a participating health plan shall provide each enrollee with coverage for the following outpatient services: (1) A maximum of twelve outpatient visits including adult health assessments, family planning services, diagnosis, treatment, consultations, to include substance abuse treatment, and second opinions. The maximum of twelve outpatient visits shall not apply to: (A) Emergency services as described in section 17-1722.3-20;(B) An enrollee's first six mental health visits within a benefit year. After the first six mental health visits, an enrollee may choose to apply a maximum of six additional mental health visits toward the maximum of twelve physician outpatient visits; or(C) Diagnostic testing, including laboratory and x-ray, directly related to a covered outpatient visit.(2) Coverage of medically necessary ambulatory surgical care shall be limited to three procedures per benefit year;(3) Maternity care coverage shall be limited to one routine visit to confirm pregnancy and any visits for the diagnosis and treatment of conditions related to medically indicated or elective termination of pregnancy such as ectopic pregnancy, hydatidiform mole, and missed, incomplete, threatened, or elective abortions. Each of these visits shall count toward the twelve maximum outpatient visits, ten maximum inpatient days, or three maximum ambulatory surgeries.(d) An enrollee shall be provided the following health assessments which shall be counted toward the maximum of twelve outpatient physician visits. (1) An enrollee age nineteen to thirty-five years old, inclusive, shall be allowed one examination within a period of five benefit years.(2) An enrollee thirty-six to fifty-five years old, inclusive, shall be allowed one examination within a period of two benefit years.(3) An enrollee over fifty-five years old shall be allowed one examination within each benefit year.(4) An annual pap smear for a woman of child bearing age shall be included in the health assessment for an enrollee age nineteen years or older.(e) Within each benefit year, each enrollee shall be provided a maximum coverage of six mental health visits, limited to one treatment per day. (1) After exhausting the coverage of six mental health visits, an enrollee may use coverage of up to six of the enrollee's twelve outpatient physician visits per benefit year, as available, for additional mental health visits.(2) Services for alcohol abuse conditions shall be covered as mental health visits. The following restrictions on alcohol and substance abuse treatment apply:(A) Outpatient alcohol abuse services shall be considered toward the maximum coverage of six mental health visits and six annual outpatient physician office visits if used for additional mental health visits;(B) Inpatient alcohol abuse services shall be considered toward an enrollee's maximum coverage of ten hospital days; and(C) All alcohol abuse services shall be provided under an individualized treatment plan approved by the participating health plan.(f) Coverage shall be provided for a maximum of four medication prescriptions per calendar month. Each prescription shall not exceed a one-month supply of a medication included in a participating health plan's formulary that consists of at least one prescription medication per therapeutic class. A participating health plan shall not be required to cover a brand name medication if a comparatively effective generic medication within the therapeutic class is available, with the exception of statutory requirements.(g) Coverage shall be provided for diabetic supplies, including syringes, test strips and lancets.(h) Coverage shall be provided for family planning services to include family planning services rendered by a physician or nurse midwife, and family planning drugs, supplies and devices approved by the federal Food and Drug Administration.(i) A participating health plan may, at the plan's option and expense, provide benefits which exceed those defined in this subchapter, with the exception of non-covered services identified in section 17-1722.3-19 (j) The Basic Health Hawaii benefits defined in this section are based on a twelve-month period. Benefits shall be pro-rated for any period other than a twelve month period.Haw. Code R. § 17-1722.3-18
[Eff 04/01/10; am 04/12/13 ] (Auth: HRS § 346-14) (Imp: HRS § 346-14