N.H. Admin. Code § He-W 530.05

Current through Register No. 50, December 12, 2024

Section He-W 530.05 - Non-Covered Services

(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.

N.H. Admin. Code § He-W 530.05

#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