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

(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.