In-Patient Services

(a)The Medically Indigent Program shall cover only the following medically necessary in-patient services:

(1)maximum of sixty

(60)days inpatient hospitalization per illness. If confinement is medically necessary after the sixty

(60)days, prior authorization is required from MIP;

(2)semi-private room and board, or private room when medically necessary;

(3)coronary and intensive care;

(4)neonatal intensive care, intermediate nursery care and wellborn nursery care;

(5)surgery and anesthesia;

(6)operating room, delivery room and licensed birthing center services;

(7)diagnostic laboratory services;

(8)diagnostic radiology, ultrasound and mammography screening services;

(9)renal dialysis treatment; CH. 2 DIVISION OF PUBLIC WELFARE

(10)physician services;

(11)emergency room services;

(12)acute physical and occupational therapy when prescribed by physician and provided by a qualified licensed and registered therapist, subject to limitations stated below;

(13)respiratory therapy;

(14)prescribed drugs in accordance with the established MIP formulary;

(15)podiatry services; care in an intermediate care facility; and ambulance services.

(b)In-Patient Services Not Covered. The Medically Indigent Program shall not cover the following in-patient services:

(1)elective cosmetic surgery, except as provided for in the Women’s Health Act;

(2)custodial care, domiciliary care, private duty nursing or rest cures, except as provided for in hospices;

(3)personal comfort or convenience items;

(4)any diagnostic service requiring prior authorization which has not been obtained or has been denied;

(5)any specialized elective surgical service requiring prior authorization, which has not been obtained or has been denied; or

(6)non-emergency use of the Emergency Room.

(c)Limitations and Exclusions. All in-patient services are subject to the stated benefit limitations and exclusions outlined in § 2912 through § 2913.