MIP Program Benefit Limitations

The benefits provided for under the Medically Indigent Program shall be subject to the following annual limitations, unless otherwise specified:

(a)There will be a ten percent (10%) co-insurance for the following services:

(1)Radiation Therapy;

(2)Cardiac Related Services; CH. 2 DIVISION OF PUBLIC WELFARE

(3)Orthopedic Services and Appliances,

(4)Radiology.

(b)Renal Dialysis. Limited coverage to first twelve

(12)months and payment of Medicare Part B Premiums and co-insurance. Prior to the expiration of the twelve

(12)month limited coverage period, the Administrator shall facilitate the application of each Program recipient for Medicare coverage of renal dialysis. The twelve

(12)month limited coverage period shall not apply to recipients who do not qualify for Medicare coverage of renal dialysis.

(c)Physical Therapy. Therapy must be to restore a bodily function that once existed or has been lost or damaged due to disease or accidental injury. Coverage is only to the extent that it restores function to the status of function prior to the disease or accidental injury. Therapy must result in significant and demonstrable improvement in patient ability to function independently, limited to treatment by a physical therapist. The first twenty

(20)visits shall be covered. Fifty percent (50%) co insurance is required thereafter.

(d)Off Guam Medical Care. Off Guam medical care shall be a maximum of One Hundred Seventy-Five Thousand Dollars ($175,000.00) per year, including airfare and escort fees.

(e)Blood and Blood Products. Blood and blood products shall be a maximum of Fifty Thousand Dollars ($50,000.00). This limitation shall not apply to any person with hemophilia or any hemophiliarelated condition requiring the administration of blood and blood products.

(f)Hospice Care. Hospice care shall be limited to the comparable Medicare payment rate per day maximum of with a maximum of one hundred eighty

(180)days. This benefit shall only be eligible for services using Medicare criteria rendered on Guam.

(g)Eye Exam. Eye exam shall be limited to Fifty Dollars ($50.00) per visit.

(h)Corrective Lenses. Corrective lenses shall be limited to One Hundred Dollars ($100.00).

(i)Hearing Aids. Hearing aids as are medically necessary shall be covered; provided, that all available community resources for such hearing aids have been exhausted. Benefit is limited to a maximum of Five Hundred Dollars ($500.00) per hearing aid.

(j)Physical Examination. There shall be a Five Dollar ($5.00) co-payment for each physical exam related service per year.

(k)Well Child Care. Well Child Care shall be limited to six

(6)visits per year up to age two (2), excluding visits for immunizations.

(l)Pharmaceutical Prescriptions. Pharmaceutical prescriptions shall be limited to a maximum of thirty

(30)days supply at one

(1)time, with the exception of birth control pills dispensed with a ninety

(90)day supply.

(m)Occupational Therapy. Coverage limited to medically necessary services where an expectation exists that the therapy will result in significant practical improvement in the individual’s level of functioning within a reasonable period of time.

(1)Coverage is excluded if related solely to specific employment opportunities, work skills or work settings.

(2)The first twenty

(20)visits shall be covered up to the maximum provided herein. CH. 2 DIVISION OF PUBLIC WELFARE

(3)Additional treatments subject to re-certification for continuing treatment after initial twenty

(20)visits subject to medical review of further significant practical improvement to be attained.

(n)Acupuncture Care. Acupuncture care shall be limited to ten

(10)visits per contract period, maximum of Fifty Dollars ($50.00) per visit.

(o)Chiropractic Care. Chiropractic care shall be limited to ten

(10)visits per contract period, maximum of Twenty-Five Dollars ($25.00) per visit.

(p)Autism Spectrum Disorder (ASD). A Seventy-five Thousand Dollars ($75,000) maximum benefit per year for an eligible person up to the age of fifteen (15). The treatment of an autism spectrum disorder shall be limited to a Twenty-five Thousand Dollars ($25,000) maximum benefit per year for an eligible person who is between the ages of sixteen

(16)and twenty-one (21).