HAR §17-1722-65. Covered services

(a) Inpatient hospital care shall be limited to five days per state fiscal year per individual for the following services: (1) Semi-private room and board and general nursing care; (2) Intensive care room and board and general nursing care; (3) Use of operating room and related facilities, labor and delivery room, inpatient anesthesia, radiology, laboratory and other diagnostic services agreed upon by the director; (4) Drugs and medications administered while an inpatient; (5) Medically necessary dressings, casts, blood derivatives and their administration, and general medical supplies; and (6) Five inpatient physician visits per fiscal year. (b) Physician office visits, including diagnosis and treatment, consultations, and second opinions are limited to twelve visits per fiscal year. Excluded from this limitation are adult health assessments and bona fide emergency room visits. (c) Maternity care is limited to the following: UNOFFICIAL 1722-18 (1) An all-inclusive fee that includes outpatient diagnostic tests, prenatal care, delivery, postpartum care, and complications of pregnancy; and (2) Two inpatient maternity days per fiscal year that will not count as an inpatient day in subsection (a) of this section. (d) Ambulatory surgical care is limited to three procedures per year and must be for medically necessary care and not excluded in sections 17-1722-66 and 17-1737-84. (e) Preventative services shall include: (1) Health assessments comprised of services and tests appropriate to the age and sex of the individual; and (2) Immunizations for diptheria, measles, mumps, rubella, whooping cough, polio, tetanus, influenza/pneumovex, hemophilus, influenza, cholera, typhoid and typhus. (f) Emergency care is restricted by the following guidelines: (1) Coverage is limited to those medical conditions manifesting in acute symptoms of such severity that the absence of medical attention could reasonably be expected to result in placing the enrollee's health in serious jeopardy, or serious impairment to bodily functions, or serious dysfunction of any body organ or part; and (2) The need for emergency service shall be substantiated with appropriate documentation from the enrollee's medical record or a report from a hospital or treating physician; (g) Three mental health visits, to include alcohol or drug dependency conditions, per fiscal year, with one treatment per day (h) The department shall not be responsible to pay for services that are not described in this section. (i) The department will only pay for services described in this section that are also allowable under chapter 17-1737. (j) Services to be provided by medicaid providers described in chapter 17-1736, and reimbursement for services will be based on the medicaid reimbursement schedule. UNOFFICIAL 1722-19 [Eff 11/13/95 ] (Auth: HRS §§346-14, 431N) (Imp: HRS §§346-14, 431N)