Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1722.3 - BASIC HEALTH HAWAII › Subchapter 2 - BASIC HEALTH HAWAII › Section 17-1722.3-19 - Medical services and items not available in Basic Health Hawaii

Current through June, 2024
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;
(20) Hospice services;
(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.