Section 17-1722.3-19 - Medical services and items not available in Basic Health Hawaii The following services and items shall not be covered by participating health plans or the department under Basic Health Hawaii:
(1) Custodial or domiciliary care;(2) Services received in skilled nursing facilities, intermediate care facilities, and intermediate care facilities for the mentally retarded;(3) Personal care items such as shampoos, toothpaste, mouthwashes, denture cleansers, shoes including orthopedic footwear, slippers, clothing, laundry services, baby oils and powders, sanitary napkins, soaps, lip balms, and bandages;(4) Non-medical items such as books, telephones, electronic transmitting and paging devices, radios, linens, clothing, television sets, computers, air conditioners, air purifiers, fans, household items and furnishings;(5) Emergency facility services for non-emergency services;(6) Out-of-state emergency and non-emergency services;(7) Experimental and investigational services, procedures, drugs, devices, and treatments;(8) Organ and tissue transplantation and transplantation services for either a recipient or a donor;(9) Blood, blood products, and blood storage on an outpatient basis;(10) Gender reassignment and related medical, surgical, and psychiatric services, drugs, and hormones;(11) In vitro fertilization, reversal of sterilization, artificial insemination, sperm banking procedures, and drugs to test fertility;(12) Eyeglasses, contact lenses, low vision aids, orthoptic training, and refractions;(13) Hearing aids and related supplies and services, including fitting for, purchase of, rental of, and insuring of hearing aids;(14) Durable medical equipment, prosthetic devices, orthotics, medical supplies, and related services including purchases, rental, repairs, and related services, except as supplied as part of an inpatient hospital stay;(15) Biofeedback, acupuncture, naturopathic services, faith healing, Christian Science services, hypnosis, and massage treatment;(16) Obesity treatment, weight loss programs, food, food supplements, health foods, and prepared formulas;(17) All services, procedures, equipment, and supplies not specifically listed which are not medically necessary;(18) Cosmetic surgery or treatment, cosmetic rhinoplasties, reconstructive or plastic surgery to improve appearance and not bodily function, piercing of ears and other body areas, electrolysis, hair transplantation, reduction and augmentation mammoplasties, paniculectomies and other body sculpturing procedures, excision or destruction of benign skin or subcutaneous lesions without medical justification;(19) Transportation, including air (fixed wing or helicopter) ambulances;(21) All home health agency services;(22) Home and community based services to include, but not limited to, adult day care, adult day health, assistive living, pediatric attendant care, community care management agency (CCMA) services, community care foster family home services, counseling and training activities, environmental accessibility adaptations, expanded adult residential care homes (E-ARCH) or residential care services, home delivered meals, home maintenance, medically fragile day care, moving assistance, non-medical transportation, personal assistance services, personal emergency response systems, private duty nursing, and respite care;(23) Personal care, chore services, social worker services, case management services, and targeted case management services;(24) Tuberculosis services when provided without cost to the general public;(25) Hansen's disease treatment or follow-up;(26) Treatment of persons confined to a public institution;(27) Penile and testicular prostheses and related services;(28) Chiropractic services;(29) Psychiatric care and treatment for sex and marriage problems, weight control, employment counseling, primal therapy, long term character analysis, marathon group therapy, and consortium;(30) Routine foot care and treatment of flat feet;(31) Swimming lessons, summer camp, gym membership, and weight control classes;(32) Cardiac and coronary artery surgery involving cardio-pulmonary by-pass, cataract surgery with or without intraocular lens implants, and refractive keratoplasty;(33) Physical therapy, occupational therapy, speech therapy, respiratory services, and sleep studies rendered on an outpatient basis;(34) Medical services provided without charge by any other federal, state, municipal, territorial, or other government agency, including the Veterans Administration;(35) Medical services for an injury or illness caused by another person or third party from whom the enrollee has or may have a right to recover damages;(36) Medical services that are payable under the terms of any other group or non-group health plan coverage;(37) Medical services that do not follow standard medical practice or are not medically necessary;(38) Stand-by services by a stand-by physician and telephone consultation;(39) Services provided for illness or injury caused by an act of war, whether or not a state of war legally exists, or required during a period of active duty that exceeds thirty days in any branch of the military;(40) Treatment of sexual dysfunction including medical and surgical procedures, supplies, drugs, and equipment;(41) All services excluded by the Hawaii Medicaid Program;(42) All services not provided by providers licensed or certified in the State of Hawaii to perform the service;(43) Medical services that are payable under terms of worker compensation, automobile medical and no-fault, underinsured or uninsured motorist, or similar contract of insurance;(44) Physical examination required for continuing employment, such as taxi driver's or truck driver's licensing, or as required by government or private businesses;(45) Physical examinations, psychological evaluations, and immunizations as a requirement for licenses or for purposes of securing insurance policies or plans;(46) Allergy testing and treatment;(47) Treatment of any complication resulting from previous cosmetic, experimental, or investigative procedures, or any other non-covered service;(48) Rehabilitation services, either on an inpatient or outpatient basis, including cardiac, alcohol or drug dependence rehabilitation;(49) All acne treatment, surgery, drugs for adults; removal or treatment of asymptomatic benign skin lesions or growth; and(50) Inpatient hospital care related to maternity, such as prenatal, postpartum, and delivery services including all laboratory testing in both inpatient and outpatient setting. An exception is one outpatient visit to confirm pregnancy, as identified as a covered service in this chapter.Haw. Code R. § 17-1722.3-19
[Eff 04/01/10] (Auth: HRS § 346-14) (Imp: HRS § 346-14)