reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 40 - ELIGIBILITY CONDITIONS AND REQUIREMENTS › Part IV - Eligibility Requirements › Section 12VAC30-40-347 - Asset verification system

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  The agency is providing for the verification of assets for purposes of
				  determining or redetermining Medicaid eligibility for aged, blind, and disabled
				  Medicaid applicants and recipients using an asset verification system (AVS)
				  that meets the following minimum requirements:
1. The request and response system is
				  electronic.
a. Verification inquiries are
				  sent electronically via the Internet or similar means from the agency to the
				  financial institution.
b. The
				  system is not based on mailing paper-based requests.
c. The system has the capability to accept
				  responses electronically.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 40 - ELIGIBILITY CONDITIONS AND REQUIREMENTS › Part IV - Eligibility Requirements › Section 12VAC30-40-348 - Adult group individual income-based determinations

Current through Register Vol. 40, No. 24, July 15, 2024
A. Methodology for identification of
				  applicable federal medical assistance percentages (FMAP) rates. DMAS will
				  determine the appropriate FMAP rate for expenditures for individuals enrolled
				  in the adult group described in
				  42
				  CFR 435.119 and receiving benefits in
				  accordance with 42 CFR Part 440 Subpart C. The adult group FMAP methodology
				  consists of two parts: an individual-based determination related to enrolled
				  individuals and, as applicable, appropriate population-based
				  adjustments.
B. Adult group
				  individual income-based determinations. For individuals eligible in the adult
				  group, the Commonwealth will make an individual income-based determination for
				  purposes of the adult group FMAP methodology by comparing individual income to
				  the relevant converted income eligibility standards in effect on December 1,
				  2009, and included in the Modified Adjusted Gross Income (MAGI) Conversion Plan
				  (Part 2) approved by Centers for Medicare and Medicaid Services (CMS) on
				  February 11, 2014. In general, and subject to any adjustments described in this
				  section, under the adult group FMAP methodology, the expenditures of
				  individuals with incomes below the relevant converted income standards for the
				  applicable subgroup are considered as those for which the newly eligible FMAP
				  is not available.
C.
				  Population-based adjustments to the newly eligible population based on resource
				  test, enrollment cap, or special circumstances.
1. The Commonwealth does not apply a resource
				  proxy adjustment.
2. The
				  Commonwealth does not apply an enrollment cap.
3. The Commonwealth does not apply a special
				  circumstance adjustment.
4. The
				  Commonwealth does not apply any additional adjustment to the adult group FMAP
				  methodology.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 40 - ELIGIBILITY CONDITIONS AND REQUIREMENTS › Part IV - Eligibility Requirements › Section 12VAC30-40-370 - Variations from the basic personal needs allowance

Current through Register Vol. 40, No. 24, July 15, 2024
For victims of Virginia's eugenical program, the
					 Commonwealth shall, in addition to the basic personal needs allowance (PNA),
					 increase the basic PNA by amounts received as payments for involuntary
					 sterilization under the Virginia Eugenical Sterilization Act.
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 40 - ELIGIBILITY CONDITIONS AND REQUIREMENTS › Part V - State Supplementary Payments › Section 12VAC30-40-350 - Standards for optional state supplementary payments

Current through Register Vol. 40, No. 24, July 15, 2024
A. Aged, blind, and disabled recipients of
				  optional state supplementary payments are eligible for medical assistance as
				  categorically needy under this plan. The payments meet the four conditions
				  specified in 45 CFR 248.2(d), that is, they are:
1. Regular, in cash, and based on
				  need;
2. Available on a statewide
				  basis;
3. Made to reasonable
				  classifications of individuals who, except for the level of their income, would
				  be eligible for an SSI payment; and
4. Equal to the difference between income and
				  financial standards used to determine eligibility for the supplement.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 40 - ELIGIBILITY CONDITIONS AND REQUIREMENTS › Part V - State Supplementary Payments › Section 12VAC30-40-360 - Treatment of entrance fees of individuals residing in continuing care retirement communities

Current through Register Vol. 40, No. 24, July 15, 2024
When determining eligibility for medical assistance, an
					 individual's entrance fee in a continuing care retirement community or life
					 care community that collects an entrance fee on admission from such individuals
					 shall be considered a resource available to the individual to the extent
					 that:
1. The individual has the
				  ability to use the entrance fee, or the contract provides that the entrance fee
				  may be used, to pay for care should other resources or income of the individual
				  be insufficient to pay for such care;
2. The individual is eligible for a refund of
				  any remaining entrance fee when the individual dies or terminates the
				  continuing care retirement community or life care community contract and leaves
				  the community; and
3. The entrance
				  fee does not confer an ownership interest in the continuing care retirement
				  community or life care community.
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 I - Categorically Needy › Section 12VAC30-50-30 - Services not provided to the categorically needy

Current through Register Vol. 40, No. 24, July 15, 2024
The following services and devices are not provided to the
					 categorically needy:
1. Chiropractor
				  services.
2. Private duty nursing
				  services unless an individual receives services under an Early and Periodic
				  Screening, Diagnosis, and Treatment Services or a § 1915(c)
				  Waiver.
3. Dentures.
4. Other diagnostic and preventive services
				  other than those provided elsewhere in this plan: diagnostic services
				  (12VAC30-50-95).
5. (Reserved.)
6. Special tuberculosis related services
				  under § 1902(z)(2)(F) of the Social Security Act (the Act).
7. Respiratory care services (in accordance
				  with § 1920(e)(9)(A) through (C) of the Act).
8. Ambulatory prenatal care for pregnant
				  women furnished during a presumptive eligibility period by a qualified provider
				  (in accordance with § 1920 of the Act).
9. Any other medical care and any type of
				  remedial care recognized under state law specified by the U.S. Secretary of
				  Health and Human Services: 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.
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 I - Categorically Needy › Section 12VAC30-50-30 - Services not provided to the categorically needy

Current through Register Vol. 40, No. 24, July 15, 2024
The following services and devices are not provided to the
					 categorically needy:
1. Chiropractor
				  services.
2. Private duty nursing
				  services.
3. Dentures.
4. Other diagnostic and preventive services
				  other than those provided elsewhere in this plan: diagnostic services
				  (12VAC30-50-95
				  ) .
5. (Reserved.)
6. Special tuberculosis related services
				  under § 1902(z)(2)(F) of the Social Security Act (the Act).
7. Respiratory care services (in accordance
				  with § 1920(e)(9)(A) through (C) of the Act).
8. Ambulatory prenatal care for pregnant
				  women furnished during a presumptive eligibility period by a qualified provider
				  (in accordance with § 1920 of the Act).
9. Any other medical care and any type of
				  remedial care recognized under state law specified by the U.S. Secretary of
				  Health and Human Services: 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.
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 I - Categorically Needy › Section 12VAC30-50-35 - Requirements relating to payment for covered outpatient drugs for the categorically needy

Current through Register Vol. 40, No. 24, July 15, 2024
A. Effective
				  January 1, 2006, the Medicaid agency will not cover any Part D drug for
				  full-benefit dual eligible individuals who are entitled to receive Medicare
				  benefits under Part A or Part B.
The Medicaid agency provides coverage for the following
					 excluded or otherwise restricted drugs or classes of drugs, or their medical
					 uses to all Medicaid recipients, including full benefit dual eligible
					 beneficiaries under the Medicare Prescription Drug Benefit-Part D. The
					 following excluded drugs are covered:
1. Agents when used for anorexia, weight
				  loss, or weight gain (see specific drug categories in subsection B of this
				  section);
2. Agents when used for
				  the symptomatic relief of cough and colds (see specific drug categories in
				  subsection B of this section);
3.
				  Prescription vitamins and mineral products, except prenatal vitamins and
				  fluoride (see specific drug categories in subsection B of this section);
				  and
4. Nonprescription drugs (see
				  specific drug categories in subsection B of this section).
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 II - Ambulatory Services; Medically Needy › Section 12VAC30-50-40 - Ambulatory services

Current through Register Vol. 40, No. 24, July 15, 2024
The following ambulatory services are provided:
Physicians Services
Outpatient Hospital Services
Clinic Services
Laboratory and X-Ray Services
EPSDT Services
Family Planning Services
Optometrist Services
Home Health Services
Dental Services for those under age 21
Physical Therapy and Related Services
Prescribed Drugs
Eyeglass Services
Nurse Midwives
Outpatient Rehabilitation
Extended Services to Pregnant Women
Also provided are private health insurance premiums,
					 coinsurance, and deductibles when cost-effective (pursuant to
					 P.L.
					 101-508
										§ 4402).
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 II - Ambulatory Services; Medically Needy › Section 12VAC30-50-50 - Services provided to the medically needy with limitations

Current through Register Vol. 40, No. 24, July 15, 2024
Services as described in Part III (12VAC30-50-100 et seq.) of this
					 chapter are provided to the medically needy with limitations.
1. Inpatient hospital services other than
				  those provided in an institution for mental diseases.
2. Outpatient hospital services.
3. Other laboratory and x-ray services;
				  nonemergency outpatient Magnetic Resonance Imaging (MRI), Computer Axial
				  Tomography (CAT) scans, and Positron Emission Tomography (PET) scans require
				  prior authorization.
4. Rural
				  health clinic services and other ambulatory services furnished by a rural
				  health clinic.
5. Federally
				  qualified health center (FQHC) services and other ambulatory services that are
				  covered under the plan and furnished by an FQHC in accordance with § 4231
				  of the State Medicaid Manual (HCFA, Pub. 45-4).
6. Family planning services and supplies for
				  individuals of childbearing age.
7.
				  Physicians' services whether furnished in the office, the patient's home, a
				  hospital, a skilled nursing facility, or elsewhere.
8. Medical and surgical services furnished by
				  a dentist (in accordance with § 1905(a)(5)(B) of the Act).
9. Medical care and any other type of
				  remedial care recognized under state law, furnished by licensed practitioners
				  within the scope of their practice as defined by state law, including:
a. Podiatrists' services;
b. Optometrists' services; and
c. Other practitioners' 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 II - Ambulatory Services; Medically Needy › Section 12VAC30-50-60 - Services provided to all medically needy groups without limitations

Current through Register Vol. 40, No. 24, July 15, 2024
Services as described in Part III (12VAC30-50-100
					 et seq.) of this chapter are provided to all medically needy groups without
					 limitations.
1. Nursing facility
				  services (other than services in an institution for mental diseases) for
				  individuals 21 years of age or older.
2. Early and periodic screening and diagnosis
				  of individuals younger than 21 years of age, and treatment of conditions
				  found.
3. Pursuant to P.L. No.
				  111-148 § 4107, counseling and pharmacotherapy for cessation of tobacco
				  use by pregnant women shall be covered.
a.
				  Counseling and pharmacotherapy for cessation of tobacco use by pregnant women
				  means diagnostic, therapy, and counseling services and pharmacotherapy
				  (including the coverage of prescription and nonprescription tobacco cessation
				  agents approved by the U.S. Food and Drug Administration) for cessation of
				  tobacco use by pregnant women who use tobacco products or who are being treated
				  for tobacco use that is furnished (i) by or under the supervision of a
				  physician, (ii) by any other health care professional who is legally authorized
				  to provide tobacco cessation services under state law and is authorized to
				  provide Medicaid coverable services other than tobacco cessation services, or
				  (iii) by any other health care professional who is legally authorized to
				  provide tobacco cessation services under state law and who is specifically
				  designated by the U.S. Secretary of Health and Human Services in federal
				  regulations for this purpose.
b. No
				  cost sharing shall be applied to these services. In addition to other services
				  that are covered for pregnant women,
				  12VAC30-50-510
				  also provides for other smoking cessation services that are covered for
				  pregnant women.
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 II - Ambulatory Services; Medically Needy › Section 12VAC30-50-70 - Services or devices not provided to the medically needy

Current through Register Vol. 40, No. 24, July 15, 2024
1. Chiropractor
				  services.
2. Private duty nursing
				  services unless an individual receives services under an Early and Periodic
				  Screening, Diagnosis, and Treatment Services or a § 1915(c)
				  Waiver.
3. Dentures.
4. Diagnostic or preventive services other
				  than those provided elsewhere in the State Plan.
5. Inpatient hospital services, skilled
				  nursing facility services, and intermediate care facility services for
				  individuals 65 years of age or older in institutions for mental
				  diseases.
6. Intermediate care
				  facility services (other than such services in an institution for mental
				  diseases) for persons determined in accordance with § 1905(a)(4)(A) of the
				  Social Security Act (the Act), to be in need of such care in a public
				  institution, or a distinct part thereof, for persons with intellectual or
				  developmental disability or related conditions.
7. (Reserved.)
8. Special tuberculosis services under §
				  1902(z)(2)(F) of the Act.
9.
				  Respiratory care services (in accordance with § 1920(e)(9)(A) through (C)
				  of the Act).
10. Ambulatory
				  prenatal care for pregnant women furnished during a presumptive eligibility
				  period by a qualified provider (in accordance with § 1920 of the
				  Act).
11. Personal care services in
				  a recipient's home, prescribed in accordance with a plan of treatment and
				  provided by a qualified person under supervision of a registered
				  nurse.
12. Home and community care
				  for functionally disabled elderly individuals, as defined, described and
				  limited in
				  12VAC30-50-470.
13. Personal care services furnished to an
				  individual who is not an inpatient or resident of a hospital, nursing facility,
				  intermediate care facility for intellectually or developmentally disabled
				  persons, or institution for mental disease that are (i) authorized for the
				  individual by a physician in accordance with a plan of treatment, (ii) provided
				  by an individual who is qualified to provide such services and who is not a
				  member of the individual's family, and (iii) furnished in a home.
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 II - Ambulatory Services; Medically Needy › Section 12VAC30-50-70 - Services or devices not provided to the medically needy

Current through Register Vol. 40, No. 24, July 15, 2024
1. Chiropractor
				  services.
2. Private duty nursing
				  services.
3. Dentures.
4. Diagnostic or preventive services other
				  than those provided elsewhere in the State Plan.
5. Inpatient hospital services, skilled
				  nursing facility services, and intermediate care facility services for
				  individuals 65 years of age or older in institutions for mental
				  diseases.
6. Intermediate care
				  facility services (other than such services in an institution for mental
				  diseases) for persons determined in accordance with § 1905(a)(4)(A) of the
				  Social Security Act (the Act), to be in need of such care in a public
				  institution, or a distinct part thereof, for persons with intellectual or
				  developmental disability or related conditions.
7. (Reserved.)
8. Special tuberculosis services under §
				  1902(z)(2)(F) of the Act.
9.
				  Respiratory care services (in accordance with § 1920(e)(9)(A) through (C)
				  of the Act).
10. Ambulatory
				  prenatal care for pregnant women furnished during a presumptive eligibility
				  period by a qualified provider (in accordance with § 1920 of the
				  Act).
11. Personal care services in
				  a recipient's home, prescribed in accordance with a plan of treatment and
				  provided by a qualified person under supervision of a registered
				  nurse.
12. Home and community care
				  for functionally disabled elderly individuals, as defined, described and
				  limited in
				  12VAC30-50-470.
13. Personal care services furnished to an
				  individual who is not an inpatient or resident of a hospital, nursing facility,
				  intermediate care facility for intellectually or developmentally disabled
				  persons, or institution for mental disease that are (i) authorized for the
				  individual by a physician in accordance with a plan of treatment, (ii) provided
				  by an individual who is qualified to provide such services and who is not a
				  member of the individual's family, and (iii) furnished in a home.
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 II - Ambulatory Services; Medically Needy › Section 12VAC30-50-75 - Requirements relating to payment for covered outpatient drugs for the medically needy

Current through Register Vol. 40, No. 24, July 15, 2024
A. Effective
				  January 1, 2006, the Medicaid agency will not cover any Part D drug for
				  full-benefit dual eligible individuals who are entitled to receive Medicare
				  benefits under Part A or Part B.
The Medicaid agency provides coverage for the following
					 excluded or otherwise restricted drugs or classes of drugs, or their medical
					 uses to all Medicaid recipients, including full benefit dual eligible
					 beneficiaries under the Medicare Prescription Drug Benefit Part D. The
					 following excluded drugs are covered:
1. Agents when used for anorexia, weight
				  loss, or weight gain (see specific drug categories in subsection B of this
				  section);
2. Agents when used for
				  the symptomatic relief of cough and colds (see specific drug categories in
				  subsection B of this section);
3.
				  Prescription vitamins and mineral products, except prenatal vitamins and
				  fluoride (see specific drug categories in subsection B of this section);
				  and
4. Nonprescription drugs (see
				  specific drug categories in subsection B of this section).
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 II - Ambulatory Services; Medically Needy › Section 12VAC30-50-80 - Reserved

Current through Register Vol. 40, No. 24, July 15, 2024
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 II - Ambulatory Services; Medically Needy › Section 12VAC30-50-95 - Reimbursement of services; in general

Current through Register Vol. 40, No. 24, July 15, 2024
The provision of the following medically necessary services
					 cannot be reimbursed except when they are ordered or prescribed, and directed
					 or performed within the scope of the license of a practitioner of the healing
					 arts: laboratory and x-ray services, family planning services, and home health
					 services. Physical therapy services will be reimbursed only when prescribed by
					 a physician. Inpatient acute hospitalizations will be reimbursed only if the
					 stay has been authorized.
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 12VAC30-50-100 - Inpatient hospital services provided at general acute care hospitals and freestanding psychiatric hospitals; enrolled providers

Current through Register Vol. 40, No. 24, July 15, 2024
A. Service authorization of all inpatient
				  hospital services will be performed. This applies to both general acute care
				  hospitals and freestanding psychiatric hospitals. Nonauthorized inpatient
				  services will not be covered or reimbursed by the Department of Medical
				  Assistance Services (DMAS) or its contractor. Service authorization shall be
				  based on criteria specified by DMAS.
1.
				  Admission review.
a. Planned/scheduled
				  admissions. Review shall be done prior to admission to determine that inpatient
				  hospitalization is medically justified. An initial length of stay shall be
				  assigned at the time of this review. Adverse authorization decisions shall have
				  available a reconsideration process as set out in subdivision 4 of this
				  subsection.
b. Unplanned/urgent or
				  emergency admissions. These admissions will be permitted before any service
				  authorization procedures. Review shall be performed within one working day to
				  determine that inpatient hospitalization is medically justified. An initial
				  length of stay shall be assigned for those admissions which have been
				  determined to be appropriate. Adverse authorization decisions shall have
				  available a reconsideration process as set out in subdivision 4 of this
				  subsection.
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 12VAC30-50-105 - Inpatient hospital services provided at general acute care hospitals and freestanding psychiatric hospitals; nonenrolled providers (nonparticipating/out of state)

Current through Register Vol. 40, No. 24, July 15, 2024
A. The full DRG
				  inpatient reimbursement methodology shall become effective July 1, 1998, for
				  general acute care hospitals and freestanding psychiatric hospitals which are
				  nonenrolled providers (nonparticipating/out of state) and the same reviews,
				  criteria, and requirements shall apply as are applied to enrolled, in-state,
				  participating hospitals in
				  12VAC30-50-100.
B. Inpatient hospital services rendered by
				  nonenrolled providers shall not require service authorization with the
				  exception of transplants as described in subsection I of this section and this
				  subsection. However, these inpatient hospital services claims will be suspended
				  from automated computer payment and will be manually reviewed for medical
				  necessity as described in subsections B through I of this section using
				  criteria specified by DMAS. Inpatient hospital services provided out of state
				  to a Medicaid recipient who is a resident of the Commonwealth of Virginia shall
				  only be reimbursed under at least one of the following conditions. It shall be
				  the responsibility of the hospital, when requesting service authorization for
				  the admission, to demonstrate that one of the following conditions exists in
				  order to obtain authorization.
1. The medical
				  services must be needed because of a medical emergency;
2. Medical services must be needed and the
				  recipient's health would be endangered if he were required to travel to his
				  state of residence;
3. The state
				  determines, on the basis of medical advice, that the needed medical services,
				  or necessary supplementary resources, are more readily available in the other
				  state;
4. It is the general
				  practice for recipients in a particular locality to use medical resources in
				  another state.
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 12VAC30-50-110 - Outpatient hospital and rural health clinic services

Current through Register Vol. 40, No. 24, July 15, 2024
A. Outpatient hospital services.
1. Outpatient hospital services means
				  preventive, diagnostic, therapeutic, rehabilitative, or palliative services
				  that:
a. Are furnished to
				  outpatients;
b. Except in the case
				  of nurse-midwife services, as specified in
				  42 CFR
				  440.165, are furnished by or under the
				  direction of a physician or dentist; and
c. Are furnished by an institution that:
(1) Is licensed or formally approved as a
				  hospital by an officially designated authority for state standard-setting;
				  and
(2) Except in the case of
				  medical supervision of nurse-midwife services, as specified in
				  42 CFR
				  440.165, meets the requirements for
				  participation in Medicare.
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 12VAC30-50-120 - Other laboratory and x-ray services

Current through Register Vol. 40, No. 24, July 15, 2024
A. Services must be ordered or prescribed and
				  directed or performed within the scope of a license of the practitioner of the
				  healing arts.
B. Prior
				  authorization is required for the following nonemergency outpatient procedures:
				  Magnetic Resonance Imaging (MRI), including Magnetic Resonance Angiography
				  (MRA), Computerized Axial Tomography (CAT) scans, including Computed Tomography
				  Angiography (CTA), or Positron Emission Tomography (PET) scans performed for
				  the purpose of diagnosing a disease process or physical injury. The referring
				  physician ordering the scan must obtain the prior authorization in order for
				  the servicing provider to be reimbursed for the scan. Nonemergency outpatient
				  MRI, CAT and PET scans that are not prior authorized will not be covered or
				  reimbursed by the Department of Medical Assistance Services (DMAS).
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 12VAC30-50-130 - Nursing facility services, EPSDT, including school health services and family planning

Current through Register Vol. 40, No. 24, July 15, 2024
A. Nursing
				  facility services (other than services in an institution for mental diseases)
				  for individuals 21 years of age or older. Service must be ordered or prescribed
				  and directed or performed within the scope of a license of the practitioner of
				  the healing arts.
B. General
				  provisions for early and periodic screening, diagnosis, and treatment (EPSDT)
				  of individuals younger than 21 years of age, and treatment of conditions found.
1. Payment of medical assistance services
				  shall be made on behalf of individuals younger than 21 years of age who are
				  Medicaid eligible for medically necessary stays in acute care facilities and
				  the accompanying attendant physician care in excess of 21 days per admission
				  when such services are rendered for the purpose of diagnosis and treatment of
				  health conditions identified through a physical examination.
2. Reserved.
3. Orthoptics services shall only be
				  reimbursed if medically necessary to correct a visual defect identified by an
				  EPSDT examination or evaluation. DMAS shall place appropriate utilization
				  controls upon this service.
4.
				  Consistent with § 6403 of the Omnibus Budget Reconciliation Act of 1989,
				  early and periodic screening, diagnostic, and treatment services means the
				  following services: screening services, vision services, dental services,
				  hearing services, and such other necessary health care, diagnostic services,
				  treatment, and other measures described in Social Security Act § 1905(a)
				  to correct or ameliorate defects and physical and mental illnesses and
				  conditions discovered by the screening services and that are medically
				  necessary, whether or not such services are covered under the State Plan and
				  notwithstanding the limitations, applicable to recipients 21 years of age and
				  older, provided for by § 1905(a) of the Social Security Act.
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 12VAC30-50-140 - Physician's services whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere

Current through Register Vol. 40, No. 24, July 15, 2024
A. Elective
				  surgery as defined by the Program is surgery that is not medically necessary to
				  restore or materially improve a body function.
B. Cosmetic surgical procedures are not
				  covered unless performed for physiological reasons and require Program prior
				  approval.
C. Routine physicals and
				  immunizations are not covered except when the services are provided under the
				  Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program and when
				  a well-child examination is performed in a private physician's office for a
				  foster child of the local social services department on specific referral from
				  those departments.
D. Outpatient
				  psychiatric services.
1. Psychiatric services
				  can be provided by or under the supervision of an individual licensed under
				  state law to practice medicine or osteopathy. Only the following licensed
				  providers are permitted to provide psychiatric services under the supervision
				  of an individual licensed under state law to practice medicine or osteopathy:
				  an LMHP, LMHP-R, LMHP-RP, or LMHP-S as defined in
				  12VAC30-50-130,
				  or a licensed school psychologist as defined in § 54.1-3600 of the Code of
				  Virginia. Medically necessary psychiatric services shall be covered by the
				  Department of Medical Assistance Services (DMAS) or its designee and shall be
				  directly and specifically related to an active written plan designed and
				  signature dated by one of the health care professionals listed in this
				  subdivision.
2. Psychiatric
				  services shall be considered appropriate when an individual meets the following
				  criteria:
a. Requires treatment in order to
				  sustain behavioral or emotional gains or to restore cognitive functional levels
				  that have been impaired;
b.
				  Exhibits deficits in peer relations, dealing with authority; is hyperactive;
				  has poor impulse control; is clinically depressed or demonstrates other
				  dysfunctional clinical symptoms having an adverse impact on attention and
				  concentration, ability to learn, or ability to participate in employment,
				  educational, or social activities;
c. Is at risk for developing or requires
				  treatment for maladaptive coping strategies; and
d. Presents a reduction in individual
				  adaptive and coping mechanisms or demonstrates extreme increase in personal
				  distress.
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 12VAC30-50-150 - Medical care by other licensed practitioners within the scope of their practice as defined by state law

Current through Register Vol. 40, No. 24, July 15, 2024
A. Podiatrists'
				  services.
1. Covered podiatry services are
				  defined as reasonable and necessary diagnostic, medical, or surgical treatment
				  of disease, injury, or defects of the human foot. These services must be within
				  the scope of the license of the podiatrists' profession and defined by state
				  law.
2. The following services are
				  not covered: preventive health care, including routine foot care; treatment of
				  structural misalignment not requiring surgery; cutting or removal of corns,
				  warts, or calluses; experimental procedures; acupuncture.
3. The Program may place appropriate limits
				  on a service based on medical necessity or for utilization control, or
				  both.
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 12VAC30-50-160 - Home health services

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Service must be ordered or prescribed by a physician, nurse practitioner (NP),
				  clinical nurse specialist (CNS), or physician assistant (PA). Services shall be
				  directed or performed within the scope of a license of a practitioner of the
				  healing arts. Home health services shall be provided in accordance with
				  guidelines found in the Virginia Medicaid Home Health Manual.
B. Nursing services provided by a home health
				  agency.
1. Intermittent or part-time nursing
				  service provided by a home health agency or by a registered nurse when no home
				  health agency exists in the area.
2. Patients may receive up to five visits by
				  a licensed nurse annually. Limits are per recipient, regardless of the number
				  of providers rendering services. "Annually" shall be defined as July 1 through
				  June 30 for each recipient. If services beyond these limitations are determined
				  by a practitioner, as defined in subsection A of this section, to be required,
				  then the provider shall request prior authorization from DMAS for additional
				  services. Payment shall not be made for additional service unless authorized 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 III - Amount, Duration, and Scope of Services › Section 12VAC30-50-170 - Private duty nursing services

Current through Register Vol. 40, No. 24, July 15, 2024
Private duty nursing services are not provided unless an
					 individual receives services under an Early and Periodic Screening, Diagnostic
					 and Treatment Services or a § 1915(c) Waiver.
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 III - Amount, Duration, and Scope of Services › Section 12VAC30-50-170 - Private duty nursing services

Current through Register Vol. 40, No. 24, July 15, 2024
Private duty nursing services are not
					 provided.
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 12VAC30-50-180 - Clinic services

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Reimbursement for induced abortions is provided in only those cases in which
				  there would be a substantial endangerment of life to the mother if the fetus
				  were carried to term.
B. Clinic
				  services means preventive, diagnostic, therapeutic, rehabilitative, or
				  palliative items or services that:
1. Are
				  provided to outpatients;
2. Are
				  provided by a facility that is not part of a hospital but is organized and
				  operated to provide medical care to outpatients; and
3. Except in the case of nurse-midwife
				  services, as specified in
				  42 CFR
				  440.165, are furnished by or under the
				  direction of a physician or dentist.
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 12VAC30-50-190 - Dental services

Current through Register Vol. 40, No. 24, July 15, 2024
A. Dental
				  services shall be covered for individuals younger than 21 years of age in
				  fulfillment of the treatment requirements under the Early and Periodic
				  Screening, Diagnosis, and Treatment (EPSDT) Program and defined as routine
				  diagnostic, preventive, or restorative procedures necessary for oral health
				  provided by or under the direct supervision of a dentist in accordance with
				  Chapter 27 (§
										54.1-2700 et seq.) of
				  Title 54.1 of the Code of Virginia.
1. The
				  Department of Medical Assistance Services (DMAS) will provide any medically
				  necessary dental service to individuals younger than 21 years of age.
2. Certain dental services, as described in
				  the DMAS Office Reference Manual (Smiles for Children, March 13, 2014),
				  prepared by DMAS's dental benefits administrator, require preauthorization or
				  prepayment review by DMAS or its designee.
3. Dental services for individuals younger
				  than the age of 21 years that do not require preauthorization or prepayment
				  review are initial, periodic, and emergency examinations; required radiography
				  necessary to develop a treatment plan; patient education; dental prophylaxis;
				  fluoride treatments; routine amalgam and composite restorations; stainless
				  steel crowns, prefabricated steel post and temporary (polycarbonate ) crowns,
				  and stainless steel bands; crown recementation; pulpotomies; emergency
				  endodontics for temporary relief of pain; pulp capping; sedative fillings;
				  therapeutic apical closure; topical palliative treatment for dental pain;
				  removal of foreign body; simple extractions; root recovery; incision and
				  drainage of abscess; surgical exposure of the tooth to aid eruption;
				  sequestrectomy for osteomyelitis; and oral antral fistula closure.
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 12VAC30-50-220 - Diagnostic, screening, preventive, and rehabilitative services other than those provided elsewhere in this plan

Current through Register Vol. 40, No. 24, July 15, 2024
A. Diagnostic services are provided but only
				  when necessary to confirm a diagnosis.
B. Screening services.
1. Screening mammograms for the female
				  recipient population aged 35 and over shall be covered, consistent with the
				  guidelines published by the American Cancer Society.
2. Screening PSA (prostate specific antigen)
				  and the related DRE (digital rectal examination) for males shall be covered,
				  consistent with the guidelines published by the American Cancer
				  Society.
3. Screening Pap smears
				  shall be covered annually for females, consistent with the guidelines published
				  by the American Cancer Society.
4.
				  Screening services for colorectal cancer, specifically screening with an annual
				  fecal occult blood test, flexible sigmoidoscopy or colonoscopy, or in
				  appropriate circumstances radiologic imaging, in accordance with the most
				  recently published recommendations established by the American College of
				  Gastroenterology, in consultation with the American Cancer Society, for the
				  ages, family histories, and frequencies referenced in such
				  recommendations.
5. Low-dose
				  computed tomography lung cancer screening shall be covered annually for
				  individuals between the ages of 55 years and 80 years who are current smokers,
				  have quit smoking within the last 15 years, or have a history of smoking at
				  least one pack of cigarettes per day for 30 or more years.
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 12VAC30-50-227 - Lead contamination

Current through Register Vol. 40, No. 24, July 15, 2024
Coverage shall be provided for investigations by local
					 health departments to determine the source of lead contamination in the home as
					 part of the management and treatment of Medicaid-eligible children who have
					 been diagnosed with elevated blood lead levels. Only costs that are eligible
					 for federal funding participation in accordance with current federal
					 regulations shall be covered. Payments for environmental investigations under
					 this section shall be limited to no more than two visits per
					 residence.
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 12VAC30-50-228

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 III - Amount, Duration, and Scope of Services › Section 12VAC30-50-229.1

Current through Register Vol. 40, No. 24, July 15, 2024
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 12VAC30-50-230 - Services for individuals age 65 or older in institutions for mental diseases

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Inpatient hospital services are provided with no limitations.
B. Skilled nursing facility services are
				  provided with no limitations.
C.
				  Intermediate care facility services are provided with no limitations.
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 12VAC30-50-240 - Intermediate care services and intermediate care services for institutions for mental disease and mental retardation

Current through Register Vol. 40, No. 24, July 15, 2024
A. Intermediate care facility services (other
				  than such services in an institution for mental diseases) for persons
				  determined, in accordance with § 1902 (a)(31)(A) of the Act, to be in need
				  of such care are provided with no limitations.
B. Including such services in a public
				  institution (or distinct part thereof) for the mentally retarded or persons
				  with related conditions are provided with no limitations.
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 12VAC30-50-250 - Inpatient psychiatric facility services for individuals under 21 years of age

Current through Register Vol. 40, No. 24, July 15, 2024
Inpatient psychiatric facility services for individuals
					 under 21 years of age are not provided, other than those provided under early
					 and periodic screening, diagnosis, and treatment (12VAC30-50-130
					 ).
Statutory Authority
§ 32.1-325 of the Code of Virginia.