Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722 - SPECIAL MEDICAL ASSISTANCE COVERAGES AND PROGRAMS › Subchapter 8 - SPECIAL GROUP FOR INDIVIDUALS FORMERLY COVERED BY SHIP › Section 17-1722-66 - Excluded services

Current through June, 2024
The department will not be responsible to pay for the
					 following medical services or conditions:
(1) Custodial or domiciliary care;
(2) Charges for care in intermediate care or
				  skilled nursing facilities or intermediate care facilities for the mentally
				  retarded;
(3) Personal or comfort
				  items as television, telephone, guest trays, or a private room in a hospital
				  unless deemed medically necessary by the treating physician;
(4) Emergency facility services for
				  non-emergency conditions;
(5)
				  Medical, surgical or other health care procedures, services, drugs or devices
				  that are considered experimental or investigational;
(6) Transplant and open heart surgery
				  procedures and coverage of organ donor services;
(7) Prescription and non-prescription drugs
				  and hormones and their administration, except those provided as an inpatient
				  hospital service;
(8) Sex change
				  operations, investigation of and Otreatment for infertility, reversal of
				  sterilization, artificial insemination, in vitro fertilization, and
				  contraceptive supplies and devices;
(9) Vision care services to include
				  eyeglasses, contact lenses, routine eye examinations, including eye refraction,
				  except as provided as part of routine health assessments;
(10) Hearing aids, prosthesis, orthopedic
				  shoes, routine foot care;
(11)
				  Purchase or rental of hearing aids or durable medical equipment, including, but
				  not limited to hospital beds, wheel chairs, walk-aids, or other medical
				  equipment not specifically listed as a covered service, except as used while in
				  the hospital;
(12) Dental services
				  for temporomandilar joint problems, except for repair necessitated by
				  accidental injury to sound natural teeth or jaw provided such repair commences
				  within ninety days of an accidental injury or as soon as medically feasible,
				  and provided that the individual is eligible for covered services at the time
				  services are provided and at the time of the accident;
(13) Orthopedic services and
				  supplies;
(14) Biofeedback and
				  acupuncture;
(15) Obesity treatment
				  and weight loss programs;
(16)
				  Medical services rendered outside the state;
(17) Services which are not medically
				  necessary to diagnose, treat, or to improve the functioning of a malformed body
				  member, even though such services are not specifically listed as
				  exclusions;
(18) Cosmetic surgery,
				  including treatment for complications of cosmetic surgery;
(19) Reconstructive surgery for congenital or
				  acquired conditions that do not involve severe functional impairment including
				  but not limited to keloids, mammoplasty except for radical mastectomy, deviated
				  septum for which psychological or psychiatric impairment alone shall not be a
				  sufficient basis for reconstructive surgery;
(20) Medical services received and paid for
				  by the Veterans Administration;
(21) Medical services that are payable under
				  the terms of worker compensation, automobile medical and no-fault, underinsured
				  or uninsured motorist, or similar contract of insurance;
(22) Conditions resulting from acts of war,
				  declared or not;
(23)
				  Transportation to medical providers to include ambulance services;
(24) Hospice services;
(25) Early and Periodic Screening Diagnostic
				  and Treatment (EPSDT) services;
(26) Outpatient renal services;
(27) Case management services;
(28) Personal care services;
(29) Private duty nursing and medical social
				  worker services;
(30) Services
				  provided by the community long term care branch;
(31) Home Health Agency (HHA)
				  services;
(32) Targeted case
				  management services;
(33) State
				  funeral payments services;
(34)
				  Adult day health services;
(35)
				  Chore services;
(36) Any service
				  excluded by medicaid under chapter 17-1737; or
(37) Services not provided by medicaid
				  providers.