reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part III - Amount, Duration, and Scope of Services › Section 12VAC30-50-260 - Nurse-midwife services

Current through Register Vol. 40, No. 24, July 15, 2024
Covered services for nurse midwives are defined as those
					 services allowed under the licensure requirements of the state statute and as
					 specified in 42 CFR
					 440.165.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part III - Amount, Duration, and Scope of Services › Section 12VAC30-50-270 - Hospice services (in accordance with section 1905 (o) of the Act)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Covered hospice
				  services shall be defined as those services allowed under the provisions of
				  Medicare law and regulations as they relate to hospice benefits and as
				  specified in 42 CFR Part 418.
B.
				  Categories of care. As described for Medicare and applicable to Medicaid,
				  hospice services shall entail the following four categories of daily care:
1. Routine home care is at-home care that is
				  not continuous.
2. Continuous home
				  care consists of at-home care that is predominantly nursing care and is
				  provided as short-term crisis care. A registered or licensed practical nurse
				  must provide care for more than half of the period of the care. Home health
				  aide or homemaker services may be provided in addition to nursing care. A
				  minimum of eight hours of care per day must be provided to qualify as
				  continuous home care.
3. Inpatient
				  respite care is short-term inpatient care provided in an approved facility
				  (freestanding hospice, hospital, or nursing facility) to relieve the primary
				  caregiver or caregivers providing at-home care for the recipient. Respite care
				  is limited to not more than five consecutive days.
4. General inpatient care may be provided in
				  an approved freestanding hospice, hospital, or nursing facility. This care is
				  usually for pain control or acute or chronic symptom management which cannot be
				  successfully treated in another setting.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part III - Amount, Duration, and Scope of Services › Section 12VAC30-50-280 - Case management services for high-risk pregnant women and children up to age 1, as defined in 12VAC30-50-410, in accordance with section 1915 (g)(1) of the Act

Current through Register Vol. 40, No. 24, July 15, 2024
Case management services for high-risk pregnant women and
					 children up to age 1 are provided, with limitations. See
					 12VAC30-50-410 for
					 details.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part III - Amount, Duration, and Scope of Services › Section 12VAC30-50-290 - Extended services to pregnant women

Current through Register Vol. 40, No. 24, July 15, 2024
A. Pregnancy-related and postpartum services
				  for 60 days after the pregnancy ends. The same limitations on all covered
				  services apply to this group as to all other recipient groups.
B. Services for any other medical conditions
				  that may complicate pregnancy. The same limitations on all covered services
				  apply to this group as to all other recipient groups.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part III - Amount, Duration, and Scope of Services › Section 12VAC30-50-300 - Any other medical care and any other type of remedial care recognized under state law, specified by the Secretary of Health and Human Services

Current through Register Vol. 40, No. 24, July 15, 2024
A. Emergency
				  transportation services shall be provided to Virginia Medicaid recipients to
				  ensure that they have necessary access to and from providers of all emergency
				  medical services. Emergency transport services shall be covered and
				  nonemergency transport services shall be covered as medical services. The
				  single state agency may enter into contracts with friends of recipients, public
				  agencies, nonprofit private agencies, for-profit private agencies, and public
				  carriers to provide transportation to Medicaid recipients.
B. Services of Christian Science nurses are
				  not provided.
C. Care and services
				  provided in Christian Science sanitoria are provided with no
				  limitations.
D. Skilled nursing
				  facility services for patients under 21 years of age are provided with no
				  limitations.
E. Emergency hospital
				  services are provided with no limitations.
F. Personal care services in recipient's
				  home, prescribed in accordance with a plan of treatment and provided by a
				  qualified person under supervision of a registered nurse are not
				  provided.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part III - Amount, Duration, and Scope of Services › Section 12VAC30-50-310 - Emergency services for aliens

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  No payment shall be made for medical assistance furnished to qualified aliens
				  who entered the United States on or after August 22, 1996, who are not eligible
				  for Medicaid for five years after their entry, and nonqualified aliens,
				  including illegal aliens and legal nonimmigrants who are otherwise eligible,
				  unless such services are necessary for the treatment of an emergency medical
				  condition of the alien.
B.
				  Emergency services are defined as:
Emergency treatment of accidental injury or medical
					 condition (including emergency labor and delivery) manifested by acute symptoms
					 of sufficient severity (including severe pain) such that the absence of
					 immediate medical/surgical attention could reasonably be expected to result
					 in:
1. Placing the patient's health in
				  serious jeopardy;
2. Serious
				  impairment of bodily functions; or
3. Serious dysfunction of any bodily organ or
				  part.
For purposes of this definition, emergency treatment of a
					 medical condition does not include care and services related to either an organ
					 transplant procedure or routing prenatal or postpartum care.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part III - Amount, Duration, and Scope of Services › Section 12VAC30-50-320 - Program of All-Inclusive Care for the Elderly (PACE)

Current through Register Vol. 40, No. 24, July 15, 2024
The Commonwealth of Virginia has entered into a valid
					 program agreement or agreements with a PACE provider or providers and the
					 Secretary of the U.S. Department of Health and Human
					 Services.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC §
						1396.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-321 - Eligibility for PACE enrollees

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  The Commonwealth determines eligibility for PACE enrollees under rules applying
				  to institutional groups, and applies posteligibility treatment of income rules
				  to those individuals as specified in subsection B of this section. The
				  posteligibility treatment of income rules specified in this section are the
				  same as those that apply to the Commonwealth's approved Home and Community
				  Based Services waivers.
B. Regular
				  Post Eligibility. As a 209(b) state, the Commonwealth is using more restrictive
				  eligibility requirements than those for Supplemental Security Income (SSI). The
				  Commonwealth is using the posteligibility rules at
				  42 CFR
				  435.735. Payment for PACE services is reduced
				  by the amount remaining after deducting the following amounts from the PACE
				  enrollee's income.
1.
											42 CFR
				  435.735: States using more restrictive
				  requirements than SSI.
a. Allowances for the
				  needs of the individual shall be 165% of SSI.
b. Allowance for the needs of the spouse
				  shall not apply.
c. Allowance for
				  the needs of the family shall be the medically needy income standard.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-325 - Rates and payments

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  Commonwealth assures that the capitated rates will be equal to or less than the
				  cost to the agency of providing those same fee-for-service State Plan approved
				  services on a fee-for-service basis, to an equivalent nonenrolled population
				  group based upon the following methodology rates are set at a percent of
				  fee-for-service costs. Rates are set at a percentage of fee-for-service
				  costs.
B. The State Medicaid Agency
				  assures that the rates were set in a reasonable and predictable
				  manner.
C. The Commonwealth will
				  submit all capitated rates to the Centers for Medicare and Medicaid Services
				  (CMS) regional office for prior approval.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-328 - PACE enrollment and disenrollment

Current through Register Vol. 40, No. 24, July 15, 2024
The Commonwealth assures that there is a process in place
					 to provide for dissemination of PACE enrollment and disenrollment data. The
					 Commonwealth assures that it has developed and will implement procedures for
					 the enrollment and disenrollment of PACE participants via the Virginia Medicaid
					 management information system, including procedures for any adjustment to
					 account for the difference between the estimated number of PACE participants on
					 which the prospective monthly payment was based and the actual number of PACE
					 participants in that month.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-335 - General PACE plan requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A. DMAS, the state agency responsible for
				  administering Virginia's Medicaid program, shall only enter into PACE plan
				  contracts with approved PACE plan providers. The PACE provider must have an
				  agreement with CMS and DMAS for the operation of a PACE program. The agreement
				  must include:
1. Designation of the program's
				  service area;
2. The program's
				  commitment to meet all applicable federal, state, and local
				  requirements;
3. The effective date
				  and term of the agreement;
4. The
				  description of the organizational structure;
5. Participant bill of rights;
6. Description of grievance and appeals
				  processes;
7. Policies on
				  eligibility, enrollment, and disenrollment;
8. Description of services
				  available;
9. Description of the
				  organization's quality improvement program;
10. A statement of levels of performance
				  required on standard quality measures;
11. CMS and DMAS data requirements;
12. The Medicaid capitation rate or Medicaid
				  payment rate methodology and the methodology used to calculate the Medicare
				  capitation rate;
13. Procedures for
				  program termination; and
14. A
				  statement to hold harmless CMS, the state, and PACE participants if the PACE
				  organization does not pay for services performed by the provider in accordance
				  with the contract.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-340 - Criteria for PACE enrollment

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Eligibility shall be determined in the manner provided for in the State Plan
				  and these regulations. To the extent these regulations differ from other
				  provisions of the State Plan for purposes of PACE eligibility and enrollment,
				  these regulations shall control.
B.
				  Individuals meeting the following nonfinancial criteria shall be eligible to
				  enroll in PACE plans approved by DMAS:
1.
				  Individuals who are age 55 or older;
2. Individuals who require nursing facility
				  level of care and are at imminent risk of nursing facility placement as
				  determined by a LTSS screening team through a long-term services and supports
				  screening performed using the UAI and all required forms in the LTSS screening
				  packet pursuant to
				  12VAC30-60-306;
3. Individuals for whom PACE plan services
				  are medically appropriate and necessary because without the services the
				  individual is at imminent risk of nursing facility placement;
4. Individuals who reside in a PACE plan
				  catchment area;
5. Individuals who
				  meet other criteria specified in a PACE plan contract;
6. Individuals who participate in the
				  Medicaid or Medicare programs as specified in §
											32.1-330.3E
				  of the Code of Virginia; and
7.
				  Individuals who voluntarily enroll in a PACE plan and agree to the terms and
				  conditions of enrollment.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-345 - PACE enrollee rights

Current through Register Vol. 40, No. 24, July 15, 2024
A. PACE
				  providers shall ensure that enrollees are fully informed of their rights and
				  responsibilities in accordance with all state and federal requirements. These
				  rights and responsibilities shall include:
1.
				  The right to be fully informed at the time of enrollment that PACE plan
				  enrollment can only be guaranteed for a 30-day period pursuant to §
											32.1-330.3F
				  of the Code of Virginia;
2. The
				  right to receive PACE plan services directly from the provider or under
				  arrangements made by the provider; and
3. The right to be fully informed in writing
				  of any action to be taken affecting the receipt of PACE plan
				  services.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-350 - PACE enrollee responsibilities

Current through Register Vol. 40, No. 24, July 15, 2024
A. Enrollees shall access services through an
				  assigned PCP. Enrollees shall be given the opportunity to choose a PCP
				  affiliated with the applicable PACE provider. In the event an enrollee fails to
				  choose a PCP, one shall be assigned by the provider.
B. Enrollees shall be responsible for
				  copayments, if any.
C. Enrollees
				  shall raise complaints relating to PACE plan coverage and services directly
				  with the PACE provider. The provider shall have a DMAS-approved enrollee
				  complaint process in place at all times.
D. Enrollees shall raise complaints
				  pertaining to Medicaid eligibility and PACE plan eligibility directly to DMAS.
				  These complaints shall be considered under DMAS' Client Appeals regulations
				  (12VAC30-110).
E. The PACE provider
				  shall have a grievance process in place including procedures for filing an
				  enrollee's grievance, documenting the grievance, responding to and resolving
				  the grievance in a timely manner, and maintaining confidentiality of the
				  agreement pursuant to 42 CFR
				  460.120.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC §
						1396.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-355 - PACE plan contract requirements and standards

Current through Register Vol. 40, No. 24, July 15, 2024
A. Pursuant to 42 CFR Part 460 and §
				  32.1 - 330.3 of the Code of Virginia, DMAS shall establish contract
				  requirements and standards for PACE providers.
B. At the point of PACE plan contract
				  agreement, DMAS shall modify
				  12VAC30-50-320 accordingly and
				  submit it to CMS.
C. Any expansion
				  of PACE programs shall be on a schedule and within an area determined solely at
				  the discretion of DMAS through a Request for Applications (RFA) process. No
				  organization shall begin any new PACE program without going through the RFA
				  process as required by DMAS.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC §
						1396.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-360 - PACE sanctions

Current through Register Vol. 40, No. 24, July 15, 2024
A. DMAS
				  shall apply sanctions to providers for violations of PACE contract provisions
				  or federal or state law and regulation.
B. Permissible state sanctions shall include,
				  but need not be limited to, the following:
1.
				  A written warning to the provider;
2. Withholding all or part of the PACE
				  provider's capitation payments, or retracting all or part of any reimbursement
				  previously paid;
3. Suspension of
				  new enrollment in the PACE plan;
4.
				  Restriction of current enrollment in the PACE plan; and
5. Contract termination.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-410 - Case management services for high risk pregnant women and children

Current through Register Vol. 40, No. 24, July 15, 2024
A. Target Group: To
				  reimburse case management services for high-risk Medicaid eligible pregnant
				  women and children up to age 2.
B.
				  Services will be provided to the entire state.
C. Comparability of Services: Services are
				  not comparable in amount, duration, and scope. Authority of section 1915(g)(1)
				  of the Act is invoked to provide services without regard to the requirements of
				  section 1902(a)(10)(B) of the Act.
D. Definition of Services: The case
				  management services will provide maternal and child health coordination to
				  minimize fragmentation of care, reduce barriers, and link clients with
				  appropriate services to ensure comprehensive, continuous health care. The
				  Maternity Care Coordinator will provide:
1.
				  Assessment-Determining clients' service needs, which include psychosocial,
				  nutrition, medical, and educational factors.
2. Service Planning-Developing an
				  individualized description of what services and resources are needed to meet
				  the service needs of the client and help access those resources.
3. Coordination & Referral-Assisting the
				  client in arranging for appropriate services and ensuring continuity of
				  care.
4. Follow-up &
				  Monitoring-Assessing ongoing progress and ensuring services are
				  delivered.
5. Education &
				  Counseling-Guiding the client and developing a supportive relationship that
				  promotes the service plan.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-420 - Case management services for seriously mentally ill adults and emotionally disturbed children

Current through Register Vol. 40, No. 24, July 15, 2024
A. Target
				  Group: The Medicaid eligible individual shall meet the DBHDS definition for
				  "serious mental illness," or "serious emotional disturbance in children and
				  adolescents."
1. An active client for case
				  management shall mean an individual for whom there is a plan of care in effect
				  which requires regular direct or client-related contacts or communication or
				  activity with the client, family, service providers, significant others and
				  others including at least one face-to-face contact every 90 days. Billing can
				  be submitted for an active client only for months in which direct or
				  client-related contacts, activity or communications occur. Authorization is
				  required for Medicaid reimbursement.
2. There shall be no maximum service limits
				  for case management services. Case management shall not be billed for
				  individuals who are in institutions for mental disease.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-430 - Case management services for youth at risk of serious emotional disturbance

Current through Register Vol. 40, No. 24, July 15, 2024
A. Target
				  group: Medicaid eligible individuals who meet the DBHDS definition of youth at
				  risk of serious emotional disturbance.
1. An
				  active client shall mean an individual for whom there is a plan of care in
				  effect which requires regular direct or client-related contacts or
				  communication or activity with the client, family, service providers,
				  significant others and others including at least one face-to-face contact every
				  90-days. Billing can be submitted for an active client only for months in which
				  direct or client-related contacts, activity or communications occur.
				  Authorization is required for Medicaid reimbursement.
2. There shall be no maximum service limits
				  for case management services. Case management services must not be billed for
				  individuals who are in institutions for mental disease.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-440 - Support coordination/case management services for individuals with intellectual disability

Current through Register Vol. 40, No. 24, July 15, 2024
A. Target
				  Group. Medicaid eligible individuals who have an intellectual disability as
				  defined in §
										37.2-100 of the Code
				  of Virginia.
1. An active individual for
				  intellectual disability support coordination/case management shall mean a
				  person for whom there is an individual support plan (ISP) (as defined in
				  12VAC30-122-20 ) in effect that requires direct or individual-related contacts
				  or communication or activity with the individual, the individual's family or
				  caregiver, service providers, significant others, and others including at least
				  one face-to-face contact with the individual every 90 days. Billing can be
				  submitted for an active individual only for months in which direct or
				  individual-related contacts, activity, or communications occur, consistent with
				  the ISP.
2. The unit of service is
				  one month. There shall be no maximum service limits for support
				  coordination/case management services except as related to individuals residing
				  in institutions or medical facilities. For these individuals, reimbursement for
				  support coordination/case management shall be limited to 30 days immediately
				  preceding discharge. Support coordination/case management for individuals who
				  reside in an institution may be billed for no more than two predischarge
				  periods within 12 months.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IV - Eligibility Requirements › Section 12VAC30-50-450

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part V - Expanded Prenatal Care Services › Section 12VAC30-50-510 - Requirements and limits applicable to specific services: expanded prenatal care services

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Comparability of services: Services are not comparable in amount, duration and
				  scope. Authority of § 9501(b) of COBRA 1985 allows an exception to provide
				  service to pregnant women without regard to the requirements of §
				  1902(a)(10)(B).
B. Definition of
				  services: Expanded prenatal care services will offer a more comprehensive
				  prenatal care services package to improve pregnancy outcome. The expanded
				  prenatal care services provider may perform the following services:
1. Patient education. Includes six classes of
				  education for pregnant women in a planned, organized teaching environment
				  including but not limited to topics such as body changes, danger signals,
				  substance abuse, labor and delivery information, and courses such as planned
				  parenthood, Lamaze, smoking cessation, and child rearing. Instruction must be
				  rendered by Medicaid certified providers who have appropriate education,
				  license, or certification.
2.
				  Homemaker. Includes those services necessary to maintain household routine for
				  pregnant women, primarily in third trimester, who need bed rest. Services
				  include, but are not limited to, light housekeeping, child care, laundry,
				  shopping, and meal preparation. Must be rendered by Medicaid certified
				  providers.
3. Nutrition. Includes
				  nutritional assessment of dietary habits, and nutritional counseling and
				  counseling follow-up. All pregnant women are expected to receive basic
				  nutrition information from their medical care providers or the WIC Program.
				  Must be provided by a Registered Dietitian (R.D.) or a person with a master's
				  degree in nutrition, maternal and child health, or clinical dietetics with
				  experience in public health, maternal and child nutrition, or clinical
				  dietetics.
4. Blood glucose meters.
				  Effective on and after July 1, 1993, blood glucose test products shall be
				  provided when they are determined by the physician to be medically necessary
				  for pregnant women suffering from a condition of diabetes which is likely to
				  negatively affect their pregnancy outcomes. The women authorized to receive a
				  blood glucose meter must also be referred for nutritional counseling. Such
				  products shall be provided by Medicaid enrolled durable medical equipment
				  providers.
5. Addiction and
				  recovery treatment services shall be covered in expanded prenatal care services
				  consistent with 12VAC30-130-5000 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part VI - Drugs or Drug Categories › Section 12VAC30-50-520 - Drugs or drug categories which are not covered

Current through Register Vol. 40, No. 24, July 15, 2024
A. Agents when used for anorexia or weight
				  gain. Coverage of anorexiants for other than weight loss requires medical
				  justification. FDA-approved drug therapies and agents for weight loss, when
				  preauthorized, will be covered for recipients who meet the strict disability
				  standards for obesity established by the Social Security Administration in
				  effect on April 7, 1999, and whose condition is certified as life threatening,
				  consistent with Department of Medical Assistance Services' medical necessity
				  requirements, by the treating physician.
B. Agents when used for cosmetic purposes or
				  hair growth.
1. Minoxidil shall not be
				  covered when prescribed for hair growth or other cosmetic purposes.
2. Agents containing hydroquinone or its
				  derivatives which are used solely for depigmentation of the skin.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part VII - Transportation › Section 12VAC30-50-530 - Methods of providing transportation

Current through Register Vol. 40, No. 24, July 15, 2024
A. DMAS will ensure necessary transportation
				  for recipients to and from providers of covered medical services. DMAS shall
				  cover transportation to covered medical services under the following
				  circumstances:
1. Emergency air, ambulance
				  transportation, and all other modes of transportation, shall be covered as
				  medical services under 42
				  CFR 431.53 and any other applicable federal
				  Medicaid regulations. These modes include, but shall not be limited to,
				  nonemergency air travel, nonemergency ground ambulance, stretcher vans,
				  wheelchair vans, common user bus (intra-city and inter-city),
				  volunteer/registered drivers, and taxicabs. DMAS may contract directly with
				  providers of transportation or with brokers of transportation services, or
				  both. DMAS may require that brokers not have a financial interest in
				  transportation providers with whom they contract.
2. Medicaid provided transportation shall
				  only be available when recipients have no other means of transportation
				  available.
3. Recipients shall be
				  furnished transportation services that are the most economical to adequately
				  meet the recipients' medical needs.
4. Ambulances, wheelchair vans, taxicabs, and
				  other modes of transportation must be licensed to provide services in the
				  Commonwealth by the appropriate state or local licensing agency, or both.
				  Volunteer/registered drivers must be licensed to operate a motor vehicle in the
				  Commonwealth and must maintain automobile insurance.
5. DMAS-covered school transportation is
				  described at
				  12VAC30-50-130 C. Vehicles and
				  drivers providing the transportation shall be in compliance with applicable
				  laws and regulations.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part VIII - Organ Transplant Services › Section 12VAC30-50-540 - Kidney transplantation (KT)

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Patient selection criteria for provision of kidney transplantation.
				  Transplantation of the kidney is a surgical treatment whereby a diseased kidney
				  is replaced by a healthy organ. Pre-authorization is required. The following
				  patient selection criteria shall apply for the consideration of all approvals
				  for coverage and reimbursement for kidney transplantation.
1. Current medical therapy has failed and
				  patient has failed to respond to appropriate conservative management;
2. The patient does not have other systemic
				  disease including but not limited to the following:
a. Reversible renal conditions;
b. Major extra-renal complications
				  (malignancy, systemic disease, cerebral cardio-arterial disease);
c. Active infection;
d. Severe malnutrition; or
e. Pancytopenia.
3. The patient is not in both an irreversible
				  terminal state and on a life support system;
4. Adequate supervision will be provided to
				  assure there will be strict adherence to the medical regimen which is
				  required;
5. The KT is likely to
				  prolong life and restore a range of physical and social function suited to
				  activities of daily living;
6. A
				  facility with appropriate expertise has evaluated the patient, and has
				  indicated willingness to undertake the procedure;
7. The patient does not have multiple
				  uncorrectable severe major system congenital anomalies;
8. Failure to meet (1) through (7) above
				  shall result in denial of pre-authorization and coverage for the requested
				  kidney transplant procedures.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part VIII - Organ Transplant Services › Section 12VAC30-50-550 - Corneal transplantation

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Patient selection criteria for provision of corneal transplantation (CT).
				  Transplantation of the cornea is a surgical treatment whereby a diseased cornea
				  is replaced by a healthy organ. While pre-authorization is not required, the
				  following patient selection criteria shall apply for the consideration of all
				  approvals for reimbursement for cornea transplantation.
1. Current medical therapy has failed and
				  will not prevent progressive disability;
2. The patient is suffering from one of the
				  following conditions:
a. Post-cataract
				  surgical decompensation,
b. Corneal
				  dystrophy,
c. Post-traumatic
				  scarring,
d. Keratoconus,
				  or
e. Aphakia Bullous
				  Keratopathy;
3. Adequate
				  supervision will be provided to assure there will be strict adherence by the
				  patient to the long term medical regimen which is required;
4. The CT is likely to restore a range of
				  physical and social function suited to activities of daily living;
5. The patient is not in both an irreversible
				  terminal state and on a life support system;
6. The patient does not have untreatable
				  cancer, bacterial, fungal, or viral infection;
7. The patient does not have the following
				  eye conditions:
a. Trichiasis,
b. Abnormal lid brush and/or
				  function,
c. Tear film
				  deficiency,
d. Raised transocular
				  pressure,
e. Intensive
				  inflammation, and
f. Extensive
				  neo-vascularization.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part VIII - Organ Transplant Services › Section 12VAC30-50-560 - Liver, heart, lung, allogeneic and autologous bone marrow transplantation

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Patient selection criteria for provision of liver, heart, allogeneic and
				  autologous bone marrow transplantation.
1.
				  The following general conditions shall apply to these services:
a. Coverage shall not be provided for
				  procedures that are provided on an investigational or experimental
				  basis.
b. There must be no
				  effective alternative medical or surgical therapies available with outcomes
				  that are at least comparable.
c.
				  The transplant procedure and application of the procedure in treatment of the
				  specific condition for which it is proposed have been clearly demonstrated to
				  be medically effective.
d. Prior
				  authorization by the Department of Medical Assistance Services (DMAS) is
				  required. The prior authorization request must contain the information and
				  documentation as required by DMAS.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part VIII - Organ Transplant Services › Section 12VAC30-50-570 - High dose chemotherapy and bone marrow/stem cell transplantation (coverage for persons over 21 years of age)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Patient selection criteria for high dose
				  chemotherapy and bone marrow/stem cell transplantation (coverage for persons
				  over 21 years of age).
1. The following
				  general conditions shall apply to these services:
a. This must be the most effective medical
				  therapy available yielding outcomes that are at least comparable to other
				  therapies.
b. The transplant
				  procedure and application of the procedure in treatment of the specific
				  condition for which it is proposed have been clearly demonstrated to be
				  medically effective.
c. Prior
				  authorization by the Department of Medical Assistance Services (DMAS) is
				  required. The prior authorization request must contain the information and
				  documentation as required by DMAS. The nearest approved and appropriate
				  facility will be considered.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part VIII - Organ Transplant Services › Section 12VAC30-50-580 - Other medically necessary transplantation procedures that are determined to not be experimental or investigational (coverage for persons younger than 21 years)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Patient
				  selection criteria for any other medically necessary transplantation procedures
				  that are determined to not be experimental or investigational.
1. The following general conditions shall
				  apply to these services:
a. Coverage shall not
				  be provided for procedures that are provided on an investigational or
				  experimental basis.
b. There must
				  be no effective alternative medical or surgical therapies available with
				  outcomes that are at least comparable.
c. The transplant procedure and application
				  of the procedure in treatment of the specific condition for which it is
				  proposed have been clearly demonstrated to be medically effective and not
				  experimental or investigational.
d.
				  Prior authorization by the Department of Medical Assistance Services is
				  required. The prior authorization request must contain the information and
				  documentation as required by DMAS.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part VIII - Organ Transplant Services › Form - FORMS (12VAC30-50)

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia
					 Uniform Assessment Instrument, UAI, Virginia Long-Term Care Council (rev.
					 11/2018)
I.V. Therapy Implementation Form, DMAS-354 (eff.
					 6/1998)
Health Insurance Claim Form, Form HCFA-1500 (eff.
					 12/1990)
Certificate
					 of Medical Necessity-Durable Medical Equipment and Supplies, DMAS-352 (rev.
					 7/2010)
Questionnaire
					 to Assess an Applicant's Ability to Independently Manage Personal Attendant
					 Services in the CD-PAS Waiver or DD Waiver, DMAS-95 Addendum (eff.
					 8/2005)
Comprehensive
					 Outpatient Rehab Facility Participation Agreement (undated; filed
					 11/2015)
Rehabilitation
					 Hospital Participation Agreement (undated; filed 11/2015)
Medical
					 Necessity Assessment and Private Duty Nursing Service Authorization Form (DMAS
					 62)
Statutory Authority: §
												32.1-325 of the Code of
						Virginia, 42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part VIII - Organ Transplant Services › Form - FORMS (12VAC30-50)

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Uniform Assessment Instrument, UAI, Virginia
					 Long-Term Care Council (1994)
I.V. Therapy Implementation Form, DMAS-354 (eff. 6/1998)
Health Insurance Claim Form, Form HCFA-1500 (eff.
					 12/1990)
Certificate
					 of Medical Necessity-Durable Medical Equipment and Supplies, DMAS-352 (rev.
					 7/2010)
Questionnaire to Assess an Applicant's Ability to
					 Independently Manage Personal Attendant Services in the CD-PAS Waiver or DD
					 Waiver, DMAS-95 Addendum (eff. 8/2000)
DD Waiver Enrollment Request, DMAS-453 (eff. 1/2001)
DD Waiver Consumer Service Plan, DMAS-456 (eff.
					 1/2001)
DD Medicaid Waiver -- Level of Functioning Survey --
					 Summary Sheet, DMAS-458 (eff. 1/2001)
Documentation of Recipient Choice between Institutional
					 Care or Home and Community-Based Services (eff. 8/2000)
Comprehensive
					 Outpatient Rehab Facility Participation Agreement (undated; filed
					 11/2015)
Rehabilitation
					 Hospital Participation Agreement (undated; filed 11/2015)
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part VIII - Organ Transplant Services › Section - DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-50)

Current through Register Vol. 40, No. 24, July 15, 2024
Diagnostic and Statistical Manual of Mental Disorders,
					 Fifth Edition, DSM-5, 2013, American Psychiatric Association [File Link Not
					 Available]
Length of Stay by Diagnosis and Operation, Southern Region,
					 1996, HCIA, Inc.
Guidelines for Perinatal Care, 4th Edition, August 1997,
					 American Academy of Pediatrics and the American College of Obstetricians and
					 Gynecologists
Virginia Supplemental Drug Rebate Agreement Contract and
					 Addenda
Office Reference Manual (Smiles for Children), prepared by
					 DMAS' Dental Benefits Administrator, copyright 2010, dated March 13, 2014
					 (
http://www.dmas.virginia.gov/Content_atchs/dnt/VA_SFC_ORM_140313.pdf
)
Patient Placement Criteria for the Treatment of
					 Substance-Related Disorders ASAM PPC-2R, Second Edition, copyright 2001,
					 American Society of Addiction Medicine
Approved Degrees in Human Services and Related Fields for
					 QMHP Registration, adopted on November 3, 2017, revised on February 9, 2018
					 [File Link Not Available]
Statutory Authority: §
												32.1-325
						of the Code of Virginia,
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part IX - Commonwealth Coordinated Care Program › Section 12VAC30-50-600

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 50 - AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES › Part X - Alternative Benefit Plan › Section 12VAC30-50-610 - Alternative benefit plan: Medicaid expansion

Current through Register Vol. 40, No. 24, July 15, 2024
A. The Commonwealth provides alternative
				  benefits to the adult group (defined in § 1902(a)(10)(A)(i)(VIII) of the
				  Social Security Act) under the coverage option under § 1937 of the Social
				  Security Act (42 USC §
											301 et seq.) approved by the Secretary of
				  Health and Human Services. Enrollment is mandatory for individuals in the adult
				  group, and the alternative benefit package shall be available
				  statewide.
B. In developing the
				  benefit package for the alternative benefit plan, the Commonwealth reviewed:
1. Benefits in its approved State Plan as a
				  "benchmark benefit package";
2. The
				  largest plan by enrollment of the three largest small group insurance products
				  in the small-group market as the "base benchmark plan"; and
3. Essential health benefits.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-10 - Institutional care

Current through Register Vol. 40, No. 24, July 15, 2024
Institutional care will be provided by facilities qualified
				  to participate in Title XVIII and/or Title XIX.
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item 396 E 5
					 of the 1995 Appropriations Act.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section 12VAC30-60-20 - Utilization control: general acute care hospitals; enrolled providers

Current through Register Vol. 40, No. 24, July 15, 2024
A. The Department
				of Medical Assistance Services (DMAS) shall not reimburse for services which
				are not authorized as follows:
1. DMAS shall
				monitor, consistent with state law, the utilization of all inpatient hospital
				services. All inpatient hospital stays shall be service authorized prior to
				admission. Services rendered without such service authorization shall not be
				covered, except as stated in subdivision 2 of this subsection.
2. If a provider has rendered inpatient
				services to an individual who later is determined to be Medicaid eligible, the
				provider shall be responsible for obtaining the required authorization prior to
				billing DMAS for these services.
3.
				Regardless of service authorization, DMAS shall review all claims which are
				suspended for sterilization, hysterectomy, or abortion procedures for the
				presence of the required federal and state forms prior to reimbursement. If the
				forms are not attached to the bill and not properly completed, reimbursement
				for the services rendered will be denied or reduced according to DMAS
				policy.