Hawaii Administrative Rules
Title 17 - DEPARTMENT OF HUMAN SERVICES
Department of Human Services
Chapter 1720 - BENEFITS PACKAGE
Subchapter 3 - STANDARD BENEFITS PACKAGE
Section 17-1720-10 - Standard benefits package

(A) Semi-private room and board and general nursing care for inpatient stays related to medical care, surgery, and psychiatric care;

(B) Intensive care room and board and general nursing care for medical care and surgery;

(C) Use of an operating room and related facilities, inpatient anesthesia, radiology, laboratory and other diagnostic services agreed upon by the plan medical director for medical care and surgery;

(D) Drugs, dressings, blood derivatives and their administration, general medical supplies, and diagnostic and therapeutic procedures as prescribed by the attending physician; and

(E) Other ancillary services associated with hospital care except private duty nursing.

(A) Ambulatory surgical center procedures or outpatient hospital services;

(B) Behavioral health services;

(C) Bona fide emergency services, coverage shall be provided for bona fide emergency services including ground and air (fixed wing and rotor) ambulance for emergency transportation, emergency room services, and physician services in conjunction with the emergency room visits. Bona fide emergency room visits shall be restricted to those requiring services for emergency medical conditions;

(D) Diagnostic testing, including laboratory and radiology;

(E) Dialysis;

(F) Durable medical equipment including visual appliances, prosthetic devices, orthotics and medical supplies;

(G) Early and Periodic Screening, Diagnosis and Treatment services as described in chapters 17-1715 and 17-1715.1, for an enrollee under age twenty-one years who requires services that have either been exhausted or not described under section 17-1720-10;

(H) Family planning services to include family planning services rendered by a physician or nurse midwife, and family planning drugs, supplies and devices approved by the federal Food and Drug Administration;

(I) Habilitation services;

(J) Home health services;

(K) Hospice services;

(L)

(M) Pregnancy related, maternity and newborn care services;

(N) Medical services related to dental needs;

(O) Methadone management;

(P) Non-emergency transportation;

(P) Prescription or over-the-counter drugs with a prescription limited by a strict formulary and defined in the contract negotiated between the health plan and the department;

(Q) Other practitioner services;

(R) Out-of-State services;

(S) Physician services;

(T) Podiatry services;

(U) Preventative services;

(V) Rehabilitation services including physical, occupational, speech, and cognitive rehabilitation therapy;

(W) Sterilization services;

(X) Smoking cessation services;

(Y) Substance abuse treatment services;

(Z) Urgent care services;

(AA) Vaccinations; and

(BB) Vision and hearing services.