Section 167:3-h Coverage of Services and Items Under the Medical Assistance Program.
I. It is the intent of the general court to support persons with special health care needs and disabilities with coverage of medically necessary services and items under the medical assistance program so that they may live in their homes and communities as independently as possible and with the maximum ability to be mobile and exercise self care.
II. For the purpose of providing medical assistance, the department shall develop a definition of ""medical necessity'' consistent with Title XIX of the Social Security Act and consistent with paragraph I.
III. The commissioner of the department of health and human services shall establish by rules adopted under RSA 541-A an independent coverage review process for any and all services and items allowable under Title XIX of the Social Security Act and not otherwise identified as a covered service or item under rules established by the department. The review process shall include consideration of extenuating circumstances unique to the medical assistance recipient that warrant coverage of the service or item. Criteria for coverage shall include all of the following:
(a) The service or item is medically necessary;
(b) The service or item does not meet the definition of medically necessary, but the department's clinical review finds that there are extenuating circumstances unique to the recipient that would make a denial for coverage clinically contraindicative;
(c) The service or item does not meet the definition of medically necessary, but the department's clinical review finds that new scientific evidence exists in the medical literature or by experts in the field about the efficacy or medical appropriateness of the requested item, and the department determines that the original basis for non-coverage was based on the previous lack of such evidence; or
(d) The service or item will prevent the need for a more costly covered service or item, including prevention of hospitalization or institutionalization.
IV. Medical assistance shall include coverage for disposable incontinence supplies under the Medicaid state plan for individuals who have a medical condition resulting in incontinence, as documented by a physician.
Source. 2007, 288:1, eff. Sept. 1, 2007.