Current through Register No. 40, October 3, 2024
(a) Non-covered services shall be those
services for which the Medicaid program shall make no payment.
(b) Non-covered services shall include:
(1) Acupuncture;
(2) Services ancillary to, or directly
related to, a non-covered service or procedure;
(3) Biofeedback;
(4) Experimental or investigational
procedures described as such in the National Coverage Determinations (NCD)
found in the Centers for Medicare and Medicaid Services "Medicare Coverage
Database" at http://www.cms.gov/medicare-coverage-database/ (under the "Quick
Search" function, select "National Coverage Documents", optionally enter a
filter by entering a "keyword" to narrow the search results, and select the
"Search by Type" button, or, if a keyword is not entered, the entire list of
NCD titles will appear alphabetically and may be selected), including
thermogenic therapy, sex change operations, and electrosleep therapy;
(5) Reversal of voluntary
sterilization;
(6) Operations for
impotency;
(7) Operations, devices,
and procedures for the purpose of contributing to or enhancing fertility or
procreation;
(8) Plastic surgery,
to include cosmetic surgery, for the purpose of preserving or improving
appearance or disfigurement, except when required for the prompt repair of
accidental injury or for the improvement in functioning of a malformed body
part;
(9) Hypnosis, except when
performed by a psychiatrist as part of an established treatment plan;
(10) Routine foot care, except as described
in He-W 532;
(11) Services or items
that are free to the public;
(12)
Physician care in a non-medical government or public institution;
(13) Dietary services, including commercial
weight loss, nutritional counseling, and exercise programs, except as otherwise
allowed in He-W 500;
(14) Homemaker
services, except when provided as part of an authorized Choices for
Independence (CFI) program support plan to CFI recipients as described in He-E
801;
(15) Academic performance
testing not related to a medical condition;
(16) Detoxification services provided outside
an acute care facility or a medical services clinic;
(17) Services provided by halfway
houses;
(18) Hospital inpatient
care which is not medically necessary;
(19) Autopsies;
(20) Auditory training, except for auditory
trainer devices which are covered;
(21) Respite, except as a service under a
home and community based care waiver in accordance with 42 CFR 400.180 and
440.181;
(22) Child care;
(23) Chiropractor services;
(24) Institutions for Mental Diseases, in
accordance with Section 1905(a) (24) (B) of the Social Security Act;
(25) Duplicative services, which are services
that deliver the same functionality to the same recipient during the same
period of time, regardless of whether those services are provided solely under
medicaid or by medicaid in combination with another program or
entity;
(26) Services provided
outside the United States and its territories;
(27) Vaccinations for out of country
travel;
(28) Services provided by
individuals who are not licensed, certified or otherwise recognized by the
provisions of He-W 500 to provide such services;
(29) Personal clothing or footwear;
(30) Service and therapy animals;
(31) Equine-assisted psychotherapy;
(32) Any service which is not specifically
listed elsewhere in He-W 522 through He-W 589 as covered, or covered with prior
authorization, and which is not covered as follows:
a. The service is not covered by Medicare, as
indicated by the National Coverage Determinations (NCD) found in the Centers
for Medicare and Medicaid Services "Medicare Coverage Database" at
http://www.cms.gov/medicare-coverage-database/ (under the "Quick Search"
function, select "National Coverage Documents", optionally enter a filter by
entering a "keyword" to narrow the search results, and select the "Search by
Type" button, or, if a keyword is not entered, the entire list of NCD titles
will appear alphabetically and may be selected); or
b. The service is not covered by New
Hampshire or New England commercial insurance policies and coverage criteria as
follows:
1.Anthem Medical Policies and Clinical UM Guidelines,
http://www.anthem.com/wps/portal/ahpprovider?content_path=provider/wi/f5/s1/t4/pw_ad080065.htm&state=wi&rootLevel=0&label=Anthem%20Medical%20Policies
(select the "Continue" button to confirm that the page has been read and
proceed to the "Overview" page, then select the "Click Here to Search" button
in the middle of this page to continue to the search engine, enter search
criteria for the specific coverage policy, and then select the specific
coverage policy);
2.Cigna Coverage Policies,
https://cignaforhcp.cigna.com
(select "RESOURCES" at the top of the page, then select "Coverage Policies",
then select "Medical A-Z Index" for an alphabetical list of policies, and then
select the specific coverage policy); or
3.Aetna Clinical Policy Bulletins,
http://www.aetna.com/healthcare-professionals/policies-guidelines/cpb_alpha.html
(select specific bulletin from the alphabetical listing of clinical policy
bulletins); and
(33) Any service for which coverage is not
specified within the New Hampshire Medicaid State Plan, and as such the
department is unable to claim federal financial participation (FFP) for said
service.
#6745, eff 5-1-98, EXPIRED: 12-31-98; ss by #6925, eff
1-1-99; ss by #8780, INTERIM, eff 1-1-07, EXPIRES: 6-30-07; ss by #8929, eff
6-30-07; amd by #9103, eff 3-12-08; amd by #9366, eff 1-17-09; amd by #9622,
eff 1-1-10; amd by #9836, eff 12-18-10; ss by #10504, eff 1-9-14; amd by
#10561, eff 3-29-14
