Hawaii Administrative Rules
Title 17 - DEPARTMENT OF HUMAN SERVICES
Department of Human Services
Chapter 1720 - BENEFITS PACKAGE
Subchapter 8 - EXCLUSIONS AND LIMITATIONS
Section 17-1720-31 - Exclusions and limitations
Current through August, 2024
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;
(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.
