Administrative Code

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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

12VAC30-50-410. Case management services for high risk pregnant women and children.

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.

E. Qualifications of Providers: Any duly enrolled provider which the Department determines is qualified who has signed an agreement with Department of Medical Assistance Services to deliver Maternity Care Coordination services. Qualified service providers will provide case management regardless of their capacity to provide any other services under the Plan. A Maternity Care Coordinator is the Registered Nurse or Social Worker employed by a qualified service provider who provides care coordination services to eligible clients. The RN must be licensed in Virginia and should have a minimum of one year of experience in community health nursing and experience in working with pregnant women. The Social Worker (MSW, BSW) must have a minimum of one year of experience in health and human services, and have experience in working with pregnant women and their families. The Maternity Care Coordinator assists clients in accessing the health care and social service system in order that outcomes which contribute to physical and emotional health and wellness can be obtained.

F. The State assures that the provision of case management services will not restrict an individual's free choice of providers in violation of § 1902(a)(23) of the Act.

1. Eligible recipients will have free choice of the providers of case management services.

2. Eligible recipients will have free choice of the providers of other medical care under the plan.

G. Payment for case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-03-3.1102 § 1, eff. May 1, 1994.

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