HAR §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; 1720-17 §17-1720-31 3206 ,~ (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. [Eff 09/30/13; am and comp NOV 1 0 2016 (Auth: HRS §346-14; 42 C.F.R. §438.210) (Imp: HRS §346-14; 42 C.F.R. §438.210) §§17-1720-32 to 17-1720-34 (Reserved) . 1720-18