Out-Patient Services

(a)The following out-patient medical services shall be covered when medically necessary and as otherwise stipulated:

(1)Physician Evaluation and Management Services;

(2)Laboratory Diagnostic Services;

(3)Diagnostic Radiology, Ultrasound and Mammography Screening Services, to include annual mammograms for women forty

(40)years of age and older, or as recommended by the American Medical Association (AMA), and patients shall be advised about the benefits, limitations, and potential harms linked with regular screening;

(A)CT Scan or MRI services must be authorized by the MIP Program prior to the rendering of services;

(4)Prescription Drugs;

(5)Ambulatory Surgical Services;

(6)Renal Dialysis;

(7)Physical and Occupational Therapy;

(8)Respiratory Therapy; CH. 2 DIVISION OF PUBLIC WELFARE

(9)Emergency Room Services. The use of the Guam Memorial Hospital Emergency Room shall be limited to urgent and life threatening situations as diagnosed by the emergency physician, and a Five Dollar ($5.00) co-payment is required.

(b)Services Not Covered. The following out-patient medical services shall not be covered:

(1)Non-emergency use of the Emergency Room of the hospital shall not be covered. Nonemergency use of the Emergency Room for the purposes of this exclusion shall be defined as the use of the Emergency Room for non-urgent or non-life threatening medical problems. All Program recipients seeking care at the hospital Emergency Room for purposes other than the treatment of urgent or life-threatening medical problems shall be fully responsible for the cost of all care and services rendered.

(2)Over-the-counter drugs not listed in the established MIP Formulary.

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