Current through November, 2024
(a) A participating
health plan shall be required to provide the benefits defined in this
subchapter.
(b) Within a benefit
year, a participating health plan shall provide each enrollee no more than ten
days of medically necessary inpatient hospital care related to medical care,
surgery, psychiatric care, and substance abuse treatment. The following
hospital services shall be made available to each enrollee:
(1) Semi-private room and board and general
nursing care for inpatient stays related to medical care, surgery, psychiatric
care, and substance abuse treatment;
(2) Intensive care room and board and general
nursing care for medical care and surgery;
(3) Use of an operating room and related
facilities, inpatient anesthesia, radiology, laboratory and other diagnostic
services agreed upon by the participating health plan medical director for
medical care and surgery;
(4)
Drugs, dressings, blood derivatives and their administration, general medical
supplies, and diagnostic and therapeutic procedures as prescribed by the
attending physician;
(5) Other
ancillary services associated with hospital care except private duty nursing;
and
(6) Ten inpatient physician
visits within a benefit year.
(c) Within a benefit year, a participating
health plan shall provide each enrollee with coverage for the following
outpatient services:
(1) A maximum of twelve
outpatient visits including adult health assessments, family planning services,
diagnosis, treatment, consultations, to include substance abuse treatment, and
second opinions. The maximum of twelve outpatient visits shall not apply to:
(A) Emergency services as described in
section 17-1722.3-20;
(B) An
enrollee's first six mental health visits within a benefit year. After the
first six mental health visits, an enrollee may choose to apply a maximum of
six additional mental health visits toward the maximum of twelve physician
outpatient visits; or
(C)
Diagnostic testing, including laboratory and x-ray, directly related to a
covered outpatient visit.
(2) Coverage of medically necessary
ambulatory surgical care shall be limited to three procedures per benefit
year;
(3) Maternity care coverage
shall be limited to one routine visit to confirm pregnancy and any visits for
the diagnosis and treatment of conditions related to medically indicated or
elective termination of pregnancy such as ectopic pregnancy, hydatidiform mole,
and missed, incomplete, threatened, or elective abortions. Each of these visits
shall count toward the twelve maximum outpatient visits, ten maximum inpatient
days, or three maximum ambulatory surgeries.
(d) An enrollee shall be provided the
following health assessments which shall be counted toward the maximum of
twelve outpatient physician visits.
(1) An
enrollee age nineteen to thirty-five years old, inclusive, shall be allowed one
examination within a period of five benefit years.
(2) An enrollee thirty-six to fifty-five
years old, inclusive, shall be allowed one examination within a period of two
benefit years.
(3) An enrollee over
fifty-five years old shall be allowed one examination within each benefit
year.
(4) An annual pap smear for a
woman of child bearing age shall be included in the health assessment for an
enrollee age nineteen years or older.
(e) Within each benefit year, each enrollee
shall be provided a maximum coverage of six mental health visits, limited to
one treatment per day.
(1) After exhausting
the coverage of six mental health visits, an enrollee may use coverage of up to
six of the enrollee's twelve outpatient physician visits per benefit year, as
available, for additional mental health visits.
(2) Services for alcohol abuse conditions
shall be covered as mental health visits. The following restrictions on alcohol
and substance abuse treatment apply:
(A)
Outpatient alcohol abuse services shall be considered toward the maximum
coverage of six mental health visits and six annual outpatient physician office
visits if used for additional mental health visits;
(B) Inpatient alcohol abuse services shall be
considered toward an enrollee's maximum coverage of ten hospital days;
and
(C) All alcohol abuse services
shall be provided under an individualized treatment plan approved by the
participating health plan.
(f) Coverage shall be provided for a maximum
of four medication prescriptions per calendar month. Each prescription shall
not exceed a one-month supply of a medication included in a participating
health plan's formulary that consists of at least one prescription medication
per therapeutic class. A participating health plan shall not be required to
cover a brand name medication if a comparatively effective generic medication
within the therapeutic class is available, with the exception of statutory
requirements.
(g) Coverage shall be
provided for diabetic supplies, including syringes, test strips and
lancets.
(h) Coverage shall be
provided for 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) A participating health plan may, at the
plan's option and expense, provide benefits which exceed those defined in this
subchapter, with the exception of non-covered services identified in section
17-1722.3-19
(j) The Basic Health
Hawaii benefits defined in this section are based on a twelve-month period.
Benefits shall be pro-rated for any period other than a twelve month
period.
