A. Subject to the limits and exclusions specified in this section, contractors shall provide the following medically necessary health and medical services:

1. 1. Inpatient hospital services that are ordinarily furnished by a hospital to care for and treat inpatients and that are provided under the direction of a physician or a primary care practitioner. For the purposes of this section, inpatient hospital services exclude services in an institution for tuberculosis or mental diseases unless authorized under an approved section 1115 waiver.
2. 2. Outpatient health services that are ordinarily provided in hospitals, clinics, offices and other health care facilities by licensed health care providers. Outpatient health services include services provided by or under the direction of a physician or a primary care practitioner, including occupational therapy.
3. 3. Other laboratory and X-ray services ordered by a physician or a primary care practitioner.
4. 4. Medications that are ordered on prescription by a physician or a dentist who is licensed pursuant to title 32, chapter 11. Persons who are dually eligible for title XVIII and title XIX services must obtain available medications through a medicare licensed or certified medicare advantage prescription drug plan, a medicare prescription drug plan or any other entity authorized by medicare to provide a medicare part D prescription drug benefit.
5. 5. Medical supplies, durable medical equipment, insulin pumps and prosthetic devices ordered by a physician or a primary care practitioner. Suppliers of durable medical equipment shall provide the administration with complete information about the identity of each person who has an ownership or controlling interest in their business and shall comply with federal bonding requirements in a manner prescribed by the administration.
6. 6. For persons who are at least twenty-one years of age, treatment of medical conditions of the eye, excluding eye examinations for prescriptive lenses and the provision of prescriptive lenses.
7. 7. Early and periodic health screening and diagnostic services as required by section 1905(r) of title XIX of the social security act for members who are under twenty-one years of age.
8. 8. Family planning services that do not include abortion or abortion counseling. If a contractor elects not to provide family planning services, this election does not disqualify the contractor from delivering all other covered health and medical services under this chapter. In that event, the administration may contract directly with another contractor, including an outpatient surgical center or a noncontracting provider, to deliver family planning services to a member who is enrolled with the contractor that elects not to provide family planning services.
9. 9. Podiatry services that are performed by a podiatrist who is licensed pursuant to title 32, chapter 7 and ordered by a primary care physician or primary care practitioner.
10. 10. Nonexperimental transplants approved for title XIX reimbursement.

11. 11. Dental services as follows:

    1. (a) Except as provided in subdivision (b) of this paragraph, for persons who are at least twenty-one years of age, emergency dental care and extractions in an annual amount of not more than $1,000 per member.
    2. (b) Subject to approval by the centers for medicare and medicaid services, for persons treated at an Indian health service or tribal facility, adult dental services that are eligible for a federal medical assistance percentage of one hundred percent and that exceed the limit prescribed in subdivision (a) of this paragraph.
12. 12. Ambulance and nonambulance transportation, except as provided in subsection G of this section.
13. 13. Hospice care.

14. 14. Orthotics, if all of the following apply:

    1. (a) The use of the orthotic is medically necessary as the preferred treatment option consistent with medicare guidelines.
    2. (b) The orthotic is less expensive than all other treatment options or surgical procedures to treat the same diagnosed condition.
    3. (c) The orthotic is ordered by a physician or primary care practitioner.
15. 15. Subject to approval by the centers for medicare and medicaid services, medically necessary chiropractic services that are performed by a chiropractor who is licensed pursuant to title 32, chapter 8 and that are ordered by a primary care physician or primary care practitioner pursuant to rules adopted by the administration. The primary care physician or primary care practitioner may initially order up to twenty visits annually that include treatment and may request authorization for additional chiropractic services in that same year if additional chiropractic services are medically necessary.

16. 16. For up to ten program hours annually, diabetes outpatient self-management training services, as defined in 42 United States Code section 1395x, if prescribed by a primary care practitioner in either of the following circumstances:

    1. (a) The member is initially diagnosed with diabetes.

    2. (b) For a member who has previously been diagnosed with diabetes, either:

       1. (i) A change occurs in the member's diagnosis, medical condition or treatment regimen.
       2. (ii) The member is not meeting appropriate clinical outcomes.

17. 17. Pursuant to the terms and conditions that are approved by the centers for medicare and medicaid services and subject to available funding, traditional healing services, if both of the following apply:

    1. (a) The member qualifies for services through the Indian health service or a tribal facility pursuant to the conditions of participation outlined in 42 Code of Federal Regulations section 136.12.
    2. (b) The traditional healing service is delivered by or through the Indian health service or a tribal facility.

B. The limits and exclusions for health and medical services provided under this section are as follows:

1. 1. Circumcision of newborn males is not a covered health and medical service.

2. 2. For eligible persons who are at least twenty-one years of age:

   1. (a) Prosthetic devices do not include hearing aids, dentures or bone-anchored hearing aids. Prosthetic devices, except prosthetic implants, may be limited to $12,500 per contract year.
   2. (b) Percussive vests are not covered health and medical services.
   3. (c) Durable medical equipment is limited to items covered by medicare.
   4. (d) Nonexperimental transplants do not include pancreas-only transplants.
   5. (e) Bariatric surgery procedures, including laparoscopic and open gastric bypass and restrictive procedures, are not covered health and medical services.

J. All health and medical services provided under this article shall be provided in the geographic service area of the member, except:

1. 1. Emergency services and specialty services provided pursuant to section 36-2908.
2. 2. That the director may allow the delivery of health and medical services in other than the geographic service area in this state or in an adjoining state if the director determines that medical practice patterns justify the delivery of services or a net reduction in transportation costs can reasonably be expected. Notwithstanding the definition of physician as prescribed in section 36-2901, if services are procured from a physician or primary care practitioner in an adjoining state, the physician or primary care practitioner shall be licensed to practice in that state pursuant to licensing statutes in that state that are similar to title 32, chapter 13, 15, 17 or 25 and shall complete a provider agreement for this state.

N. Notwithstanding section 36-2901.08, monies from the hospital assessment fund established by section 36-2901.09 may not be used to provide any of the following:

1. 1. Chiropractic services as prescribed in subsection A, paragraph 15 of this section.
2. 2. Diabetes outpatient self-management training services as prescribed in subsection A, paragraph 16 of this section.
3. 3. Speech therapy provided in an outpatient setting to eligible persons who are at least twenty-one years of age.
4. 4. Cochlear implants to eligible persons who are at least twenty-one years of age.

O. For the purposes of this section:

1. 1. "Ambulance" has the same meaning prescribed in section 36-2201.
2. 2. "Tribal facility" has the same meaning prescribed in section 36-2981.