(2) Covered health services include:
(a) Physician services. Those services delivered by a physician licensed under chapter 458, chapter 459, chapter 460, chapter 461, or chapter 463 that are medically necessary for the treatment of an injury, illness, or disease. Physician services shall not include those services that are clinically unproven, experimental, or purely for cosmetic purposes. Each member is limited to 12 physician visits per calendar year, excluding those visits related to annual or periodic physical examinations for wellness pursuant to paragraph (g) or for immunizations.
(b) Hospital inpatient services. Those services provided for the treatment of a member who is admitted as an inpatient by a licensed physician or dentist to a hospital licensed under part I of chapter 395 up to a limit of 10 days per calendar year per member.
(c) Hospital outpatient services. Those services provided to a member in the outpatient portion of a hospital licensed under part I of chapter 395, up to a limit of $1,500 per calendar year per member, that are preventive, diagnostic, therapeutic, or palliative.
(d) Laboratory services. Professional laboratory services ordered by a licensed physician or other licensed practitioner of the healing arts and provided in a laboratory that meets the requirements for Medicare participation and is licensed under chapter 483.
(e) X-ray services. Radiological services ordered by a licensed physician or other licensed practitioner of the healing arts and that are provided by a licensed professional.
(f) Family planning services. Drugs and supplies that will enable a member to plan family size.
(g) Health appraisals, including physician examinations and related tests. Routine annual physical examinations conducted by or under the direction of a licensed physician, without regard to medical necessity, in order to detect disease, disability, or other physical or mental conditions. These services include well-baby and well-child screening and diagnostic services provided on a periodic basis to members under the age of 21.
(i) Advanced registered nurse practitioner services.
(j) Outpatient mental health visits and substance abuse treatment. Outpatient mental health visits provided by community mental health centers as provided in chapter 394 and by a mental health therapist licensed under chapter 490 or chapter 491 and substance abuse treatment provided by a center licensed under chapter 397, up to a total of five visits per calendar year per member.
(3) Covered health services do not include any of the following:
(a) Surgery solely for cosmetic purposes.
(b) Prescribed drugs.
(c) Nursing home services.
(d) Medical examinations conducted and medical reports prepared for either purchasing or renewing life insurance or participating as a plaintiff or defendant in a civil action for the recovery or settlement of damages.
(e) Clinically unproven or experimental procedures.