(a) A state plan may not provide benefits for charges for the following:
(1) care for an injury or disease either
(A) arising out of and in the course of an employment subject to a workers' compensation or similar law or where the benefit is available to be provided under a workers' compensation policy or equivalent self-insurance to a sole proprietor, business partner, or corporation officer; or
(B) to the extent benefits are payable without regard to fault under a coverage statutorily required to be contained in a motor vehicle or other liability insurance policy or equivalent self-insurance;
(2) treatment for cosmetic purposes other than surgery for the prompt repair of an accidental injury sustained while covered or for replacement of an anatomic structure removed during treatment of tumors;
(3) travel, other than transportation covered under AS 21.55.110 (17);
(4) private room accommodations to the extent it is in excess of the institution's most common charge for a semiprivate room;
(5) services or articles to the extent that the charge exceeds the reasonable charge in the locality for the service;
(6) services or articles that are determined not to be medically necessary, except for the fabrication or placement of the prosthesis as specified in AS 21.55.110 (12) and (2) of this subsection;
(7) services or articles that are not within the scope of the license or certificate of the institution or individual rendering the services or articles;
(8) services or articles furnished, paid for, or reimbursed directly by or under any law of a government, except as otherwise provided in this chapter;
(9) services or articles for custodial care or designed primarily to assist an individual in the activities of daily living;
(10) service charges that would not have been made if no insurance existed or that the covered individual is not legally obligated to pay;
(11) eyeglasses, contact lenses, or hearing aids or the fitting of them;
(12) dental care not specifically covered by this chapter;
(13) services of a registered nurse who ordinarily resides in the covered individual's home, or who is a member of the covered individual's family or the family of the covered individual's spouse;
(14) experimental procedures, except during an approved clinical trial; in this paragraph, "approved clinical trial" has the meaning given in AS 21.42.415 ; and
(15) services and supplies for which the patient was not charged.
(b) [Repealed, Sec. 8 ch 102 SLA 2003].
Section: Previous 21.55.100 21.55.110 21.55.120 21.55.130 21.55.140 21.55.150 NextLast modified: November 15, 2016