Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 130 - AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES › Part IX - DMAS-225 Adjustment Process › Section 12VAC30-130-620 - Limitations

Current through Register Vol. 40, No. 24, July 15, 2024
A. A DMAS-225
				  adjustment request shall always be used as the last source of payment. If a
				  recipient has other sources of possible payment (i.e., Medicare, major medical
				  insurance, prescription insurance, dental insurance, etc.), payment must be
				  sought first from those other sources.
B. The maximum amount for noncovered
				  medically necessary items or services that can be allowed as adjustments to the
				  patient pay amount for nursing facility residents shall be the amount specified
				  in
				  12VAC30-40-235.
C. Only the cost of medically necessary,
				  resident-specific, customized, noncovered items or services may be deducted
				  from patient pay. This shall include, but not necessarily be limited to,
				  electric, motorized, or customized wheelchairs and other equipment not
				  regularly supplied to residents by the facility as part of the cost of care.
				  Supplies, equipment, or services used in the direct care and treatment of
				  residents are covered services and must be provided by the facility. Covered
				  items and services include, but are not necessarily limited to, standard
				  wheelchairs, recliners, geriatric chairs, special mattresses, humidifiers,
				  cots, and routine podiatry care (e.g., trimming nails for onychauxis, cleaning
				  and soaking the feet, and other services performed in the absence of localized
				  illness, injury, or symptoms involving the foot). Expenses incurred by the
				  facility for covered items and services are considered "allowable expenses" and
				  are covered by Medicaid as part of reimbursement to the facility for the
				  resident's care; these costs cannot be deducted from patient pay.
D. Extenuating circumstances shall be
				  considered for the provision of podiatry care when corrective trimming is
				  performed to prevent further complications in a patient who has a systemic
				  condition that has resulted in severe circulation deficits or areas of
				  desensitization in the legs or feet. Trimming of nails for a systemic condition
				  is limited to once every 60 days and must be medically necessary. In such
				  cases, the facility is not responsible for routine podiatry care.
E. DMAS-225 adjustments shall be allowed for
				  the cost of medically or remedially necessary services provided prior to
				  Medicaid eligibility or prior to admission. Any decision made by DMAS or DSS to
				  deny a service may be appealed to DMAS. Appeals must be made in writing by the
				  resident or his legally appointed representative, as provided for in DMAS
				  Client Appeals Regulations (12VAC30-110).
F. The facility shall monitor the proper care
				  of the resident's medical supplies and equipment. Requests for adjustment made
				  because an item is lost or broken by facility staff must include documentation
				  on the resident's interdisciplinary plan of care regarding proper care and
				  treatment of the item. When loss or breakage is incurred as a result of
				  facility staff following improper practices, the facility must replace the
				  item.
G. All requests for DMAS-225
				  adjustments submitted by providers to either DMAS or DSS shall include:
1. The recipient's correct Medicaid
				  identification number;
2. The
				  current physician's orders for the noncovered service (not required for
				  replacement of hearing aid batteries or eyeglass frames or for repair to
				  hearing aids or eyeglasses);
3.
				  Medical justification for the service being requested (see subsection H of this
				  section);
4. The service
				  description;
5. Actual cost
				  information;
6. Documentation that
				  the recipient continues to need the equipment for which a repair, replacement,
				  or battery is requested;
7. A
				  statement of proof of denial or noncoverage by other insurance; and
8. A copy of the most current, fully
				  completed Minimum Data Set (MDS) and quarterly review.