Administrative Code

Virginia Administrative Code
1/24/2022

Part III. Services; General Provisions

12VAC30-10-140. Amount, duration, and scope of services: Categorically needy.

Medicaid is provided in accordance with the requirements of 42 CFR 440, Subpart B and § 1902(a), 1902(e), 1905(a), 1905(p), 1915, 1920, and 1925 of the Act.

Services for the categorically needy are described below and in 12VAC30-50-10 et seq. These services include:

1. Each item or service listed in § 1905(a)(1) through (5) and (21) of the Act, is provided as defined in 42 CFR Part 440, Subpart A, or, for EPSDT services, § 1905(r) and 42 CFR Part 411, Subpart B.

2. Nurse-midwife services listed in § 1905(a)(17) of the Act, are provided to the extent that nurse-midwives are authorized to practice under state law or regulation and without regard to whether the services are furnished in the area of management of the care of mothers and babies throughout the maternity cycle. Nurse-midwives are permitted to enter into independent provider agreements with the Medicaid agency without regard to whether the nurse-midwife is under the supervision of, or associated with, a physician or other health care provider.

3. Pregnancy-related, including family planning service, and postpartum services for a 60-day period (beginning on the day pregnancy ends) and any remaining days in the month in which the 60th day falls are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

4. Services for medical conditions that may complicate the pregnancy (other than pregnancy-related or postpartum services) are provided to pregnant women.

5. Services related to pregnancy (including prenatal, delivery, postpartum, and family planning services) and to other conditions that may complicate pregnancy are the same services provided to poverty level pregnant women eligible under the provision of § 1902(a)(10)(A)(i)(IV) and 1902(a)(10)(A)(ii)(IX) of the Act.

6. Home health services are provided to individuals entitled to nursing facility services as indicated in 12VAC30-10-220 of this plan.

7. Inpatient services that are being furnished to infants and children described in § 1902(l)(1)(B) through (D), or § 1905(n)(2) of the Act, on the date the infant or child attains the maximum age for coverage under the approved State plan will continue until the end of the stay for which the inpatient services are furnished.

8. Respiratory care services are not provided to ventilator dependent individuals as indicated in 12VAC30-10-300 of this plan.

9. Services are provided to families eligible under § 1925 of the Act as indicated in 12VAC30-10-350 of this plan.

10. Home and community care for functionally disabled elderly individuals is not covered.

11. Program of All-Inclusive Care for the Elderly (PACE) services as described and limited in Supplement 6 to Attachment 3.1-A (12VAC30-50-320, 12VAC30-50-321, 12VAC30-50-325, and 12VAC30-50-328).

12VAC30-50-10 et seq. identifies the medical and remedial services provided to the categorically needy, specifies all limitations on the amount, duration, and scope of those service, and lists the additional coverage (that is in excess of established service limits) for pregnancy-related services and services for conditions that may complicate the pregnancy.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-19, VR460-01-19.1, VR460-01-19.2, eff. June 16, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995; Volume 12, Issue 3, eff. November 29, 1995; Volume 16, Issue 18, eff. July 1, 2000; Volume 23, Issue 16, eff. July 1, 2007.

12VAC30-10-150. Amount, duration, and scope of services: Medically needy.

A. This State Plan covers the medically needy. The services described in this section and in Part II (12VAC30-50-40 et seq.) of 12VAC30-50 are provided. Services for medically needy include:

1. If services in an institution for mental diseases (42 CFR 440.140 and 440.160) or an intermediate care facility for the mentally retarded (or both) are provided to any medically needy group, then each medically needy group is provided either the services listed in § 1905(a)(1) through (5) and (17) of the Act, or seven of the services listed in § 1902(a)(1) through (20). The services are provided as defined in 42 CFR 440, Subpart A and in §§ 1902, 1905, and 1915 of the Act.

Subdivision 1 of this subsection is applicable with respect to nurse-midwife services under § 1902(a)(17).

2. Prenatal care and delivery services for pregnant women.

3. Pregnancy-related, including family planning services, and postpartum services for a 60-day period (beginning on the day the pregnancy ends) and any remaining days in the month in which the sixtieth day falls are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

4. Services for any other medical condition that may complicate the pregnancy (other than pregnancy-related and postpartum services) are provided to pregnant women.

5. Ambulatory services as defined in 12VAC30-50-40 for recipients under age 18 and recipients entitled to institutional services.

6. Home health services to recipients entitled to nursing facility services as indicated in 12VAC30-10-220.

7. Services for the medically needy do not include services in an institution for mental diseases for individuals over age 65.

8. Services for the medically needy do not include services in an intermediate care facility for the mentally retarded.

9. Services for the medically needy do not include inpatient psychiatric services for individuals under age 21, other than those covered under early and periodic screening, diagnosis, and treatment (at 12VAC30-50-130).

10. Services for the medically needy do not include respiratory care services provided to ventilator dependent individuals. See 12VAC30-10-300.

11. Home and community care for functionally disabled elderly individuals is not covered.

12. Program of All-Inclusive Care for the Elderly (PACE) services as described and limited in Supplement 6 to Attachment 3.1-A (12VAC30-50-320, 12VAC30-50-321, 12VAC30-50-325, and 12VAC30-50-328) are covered.

B. Part II (12VAC30-50-40 et seq.) of 12VAC30-50 identifies services provided to each covered group of the medically needy. (Note: Other programs to be offered to medically needy beneficiaries would specify all limitations on the amount, duration and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. In addition, other programs to be offered to medically needy beneficiaries would also list the additional coverage that is in excess of established service limits for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population, this also is not applicable for this program.)

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-20, VR460-01-20.1, VR460-01-20.2, eff. June 16, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995; Volume 17, Issue 5, eff. January 1, 2001; Volume 25, Issue 14, eff. April 15, 2009.

12VAC30-10-160. Amount, duration, and scope of services: Other required special groups.

A. Qualified Medicare beneficiaries. Medicare cost sharing for qualified Medicare beneficiaries described in § 1905(p) of the Act is provided only as indicated in 12VAC30-10-310.

B. Qualified disabled and working individuals. Medicare Part A premiums for qualified disabled and working individuals described in § 1902(a)(10)(E)(ii) of the Act are provided as indicated in 12VAC30-10-310.

C. Specified low-income Medicare beneficiaries. Medicare Part B premiums for specified low-income Medicare beneficiaries described in § 1902(a)(10)(E)(iii) of the Act are provided as indicated in 12VAC30-10-310.

D. Qualifying Individuals-1. Medicare Part B premiums for qualifying individuals described in § 1902(a)(10)(E)(iv)(I) and subject to § 1933 of the Act are provided as indicated in 12VAC30-10-310.

E. Qualifying Individuals-2. The portion of the amount of increase to the Medicare Part B premium attributable to the home health provisions for qualifying individuals described in § 1902(a)(10)(E)(iv)(II) and subject to § 1933 of the Act are provided as indicated in 12VAC30-10-310.

F. Families receiving extended Medicaid benefits. Extended Medicaid benefits for families described in § 1925 of the Act are provided as indicated in 12VAC30-10-300.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-21, eff. January 1, 1993; amended, Virginia Register Volume 17, Issue 13, eff. April 11, 2001.

12VAC30-10-170. Amount, duration, and scope of services: Limited coverage for certain aliens.

A. Aliens granted lawful temporary resident status under § 245A of the Immigration and Nationality Act who meet the financial and categorical eligibility requirements under the approved State Medicaid plan are provided the services covered under the plan if they--

1. Are aged, blind, or disabled individuals as defined in § 1614(a)(1) of the Act;

2. Are children under 18 years of age; or

3. Are Cuban or Haitian entrants as defined in § 501(e)(1) and (2)(A) of P.L. 96-422 in effect on April 1, 1983.

B. Except for emergency services and pregnancy-related services, as described in 42 CFR 447.53(b), aliens granted lawful temporary resident status under § 245A of the Immigration and Nationality Act who are not identified in subdivisions A 1 through A 3 of this section, and who meet the financial and categorical eligibility requirements under the approved State plan are provided services under the plan no earlier than five years from the date the alien is granted temporary resident status.

C. Aliens who are not lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law who meet the eligibility conditions under the State's approved Medicaid plan, except for the requirement for receipt of AFDC, SSI or a State supplementary payment are provided, Medicaid only for care and services necessary for the treatment of an emergency medical condition (including emergency labor and delivery) as defined in § 1903(v)(3) of the Act.

Statutory Authority

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

Historical Notes

Derived from VR460-01-21.1, VR460-01-21.2, eff. June 16, 1993.

12VAC30-10-180. Amount, duration, and scope of services: Homeless individuals.

Clinic services furnished to eligible individuals who do not reside in a permanent dwelling or do not have a fixed home or mailing address are provided without restrictions regarding the site at which the services are furnished.

Statutory Authority

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

Historical Notes

Derived from VR460-01-21.2, eff. June 16, 1993.

12VAC30-10-190. Amount, duration, and scope of services: Presumptively eligible pregnant women.

Ambulatory prenatal care for pregnant women is not provided during a presumptive eligibility period.

Statutory Authority

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

Historical Notes

Derived from VR460-01-21.2, eff. June 16, 1993.

12VAC30-10-200. Amount, duration, and scope of services: EPSDT services.

The Medicaid agency meets the requirements of § 1902(a)(43), 1905(a)(4)(B), and 1905(r) of the Act with respect to early and periodic screening, diagnostic, and treatment (EPSDT) services.

The Medicaid agency does not have in effect agreements with continuing care providers.

Statutory Authority

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

Historical Notes

Derived from VR460-01-21.2, eff. June 16, 1993.

12VAC30-10-210. Amount, duration, and scope of services: Comparability of services.

Except for those items or services for which § 1902(a), 1902(a)(10), 1903(v), 1915 and 1925 of the Act, 42 CFR 440.250, and § 245A of the Immigration and Naturalization Act, permit exceptions:

A. Services made available to the categorically needy are equal in amount, duration, and scope for each categorically needy person.

B. The amount, duration, and scope of services made available to the categorically needy are equal to or greater than those made available to the medically needy.

C. Services made available to the medically needy are equal in amount, duration, and scope for each person in a medically needy coverage group.

D. Additional coverage for pregnancy-related services and services for conditions that may complicate the pregnancy are equal for categorically and medically needy.

Statutory Authority

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

Historical Notes

Derived from VR460-01-22, eff. June 16, 1993.

12VAC30-10-220. Amount, duration, and scope of services: home health services.

Home health services are provided in accordance with the requirements of 42 CFR 441.15.

A. Home health services are provided to all categorically needy individuals 21 years of age or over.

B. Home health services are provided to all categorically needy individuals under 21 years of age.

C. Home health services are provided to all the medically needy whether the individuals are under or over 21 years of age.

Statutory Authority

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

Historical Notes

Derived from VR460-01-23, eff. October 1, 1979.

12VAC30-10-230. Amount, duration, and scope of services: Assurance of transportation.

Provision is made for assuring necessary transportation of recipients to and from providers. Methods used to assure such transportation are described in 12VAC30-50-530.

Statutory Authority

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

Historical Notes

Derived from VR460-01-24, eff. April 20, 1994.

12VAC30-10-240. Amount, duration, and scope of services: payment for nursing facility services.

The state includes in nursing facility services at least the items and services specified in 42 CFR 483.10(f)(11).

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Historical Notes

Derived from VR460-01-24, eff. April 20, 1994; amended, Virginia Register Volume 34, Issue 1, eff. October 19, 2017.

12VAC30-10-250. Amount, duration, and scope of services: Methods and standards to assure quality of services.

The standards established and the methods used to assure high quality care are described in 12VAC30-60-10 et seq.

Statutory Authority

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

Historical Notes

Derived from VR460-01-25, eff. October 1, 1976.

12VAC30-10-260. Amount, duration, and scope of services: Family planning services.

The requirements of 42 CFR 441.20 are met regarding freedom from coercion or pressure of mind and conscience, and freedom of choice of method to be used for family planning.

Statutory Authority

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

Historical Notes

Derived from VR460-01-26, eff. October 1, 1976.

12VAC30-10-270. Amount, duration, and scope of services: Optometric services.

Optometric services are provided. Services of the type an optometrist is legally authorized to perform are specifically included in the term "physicians' services" under this plan and are reimbursed whether furnished by a physician or an optometrist.

Statutory Authority

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

Historical Notes

Derived from VR460-01-27, eff. January 1, 1987.

12VAC30-10-280. Amount, duration, and scope of services: Organ transplant procedures.

Organ Transplant procedures are provided. Similarly situated individuals are treated alike and any restrictions on the facilities that may, or practitioners who may, provide those procedures is consistent with the accessibility of high quality care to individuals eligible for the procedures under this plan. Standards for the coverage of organ transplant procedures are described at 12VAC30-50-540.

Statutory Authority

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

Historical Notes

Derived from VR460-01-27, eff. January 1, 1987.

12VAC30-10-290. Amount, duration, and scope of services: Participation by Indian Health Service facilities.

Indian Health Service facilities are accepted as providers, in accordance with 42 CFR 431.110(b), on the same basis as other qualified providers.

Statutory Authority

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

Historical Notes

Derived from VR460-01-28, eff. July 1, 1987.

12VAC30-10-300. Amount, duration, and scope of services: Respiratory care services for ventilator-dependent individuals.

Respiratory care services, as defined in § 1902(e)(9)(C) of the Act, are not included in the plan.

Statutory Authority

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

Historical Notes

Derived from VR460-01-28, eff. July 1, 1987.

12VAC30-10-310. Coordination of Medicaid with Medicare and other insurance: Premiums.

A. Medicare Part A and Part B.

1. Qualified Medicare Beneficiary (QMB).

The Medicaid agency pays Medicare Part A premiums (if applicable) and Part B premiums for individuals in the QMB group defined in subsection 25 of 12VAC30-30-10 through the group premium payment arrangement, unless the agency has a buy-in agreement for such payment, as indicated in Part B.

The Medicaid agency does not pay premiums, for which the beneficiary would be liable, for enrollment in an HMO participating in Medicare.

2. Qualified Disabled and Working Individual (QDWI). The Medicaid agency pays Medicare Part A premiums under a group premium payment arrangement for individuals in the QDWI group defined in subsection 26 of 12VAC30-30-10 of this plan.

3. Specified Low-Income Medicare Beneficiary (SLMB). The Medicaid agency pays Medicare Part B premiums under the State buy-in process for individuals in the SLMB group defined in subsection 27 of 12VAC30-30-10 of this plan.

4. Other Medicaid Recipients.

The Medicaid agency pays Medicare Part B premiums to make Medicare Part B coverage available to all individuals who are a) receiving benefits under Titles I, IV-A, X, XIV, or XVI (AABD or SSI); b) receiving State supplements under Title XVI; or c) within a group listed at 42 CFR 431.625(d)(2).

The Medicaid agency does not pay Medicare Part B premiums for individuals receiving Title II or Railroad Retirement benefits.

The Medicaid agency does not pay Medicare Part B premiums for medically needy individuals (Federal Financial Participation is not available for this group).

B. Other Health Insurance. The Medicaid agency pays insurance premiums (through the Health Insurance Premium Payment Program (H.I.P.P.)) for medical or any other type of remedial care to maintain a third party resource for Medicaid covered services provided to eligible individuals (except those over 65 years of age and disabled individuals, entitled to Medicare Part A but not enrolled in Medicare Part B).

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-29, VR460-01-29.1, VR460-01-29.2, eff. January 1, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995.

12VAC30-10-320. Coordination of Medicaid with Medicare and other insurance: Deductibles/coinsurance.

A. Medicare Part A and B. 12VAC30-80-170 describes the methods and standards for establishing payment rates for services covered under Medicare, and/or the methodology for payment of Medicare deductible and coinsurance amounts, to the extent available for each of the following groups.

1. Qualified Medicare Beneficiaries (QMBS). The Medicaid agency pays Medicare Part A and Part B deductibles and coinsurance amounts for QMBs (subject to any nominal Medicaid copayment) for all services available under Medicare.

2. Other Medicaid Recipients. The Medicaid agency pays Medicaid services also covered under Medicare and furnished to recipients entitled to Medicare (subject to any nominal Medicaid copayment). For services furnished to individuals who are described in 12VAC30-10-310 A 4, payment is only for the amount, duration, and scope of services otherwise available under this plan.

3. Dual Eligible--QMB plus. The Medicaid agency pays Medicare Part A and Part B deductible and coinsurance amounts for all services available under Medicare and pays for all Medicaid services furnished to individuals eligible both as QMBs and categorically or medically needy (subject to any nominal Medicaid copayment).

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-29.3, eff. January 1, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995.

12VAC30-10-325. Premiums, deductibles, coinsurance and other cost sharing obligations.

A. Pursuant to § 1906 of the Act, the Medicaid agency pays all premiums, deductibles, coinsurance, and other cost sharing obligations for items and services covered under the State plan (subject to any nominal Medicaid copayment) for eligible individuals in employer-based cost-effective group health plans.

B. When coverage for eligible family members is not possible unless ineligible family members enroll, the Medicaid agency pays premiums for enrollment of other family members when cost-effective. In addition, the eligible individual is entitled to services covered by the State plan which are not included in the group health plan. Guidelines for determining cost effectiveness are described in 12VAC30-10-610 H.

C. Pursuant to § 1906A of the Act, the Medicaid agency pays all premiums, deductibles, coinsurance, and other cost sharing obligations for items and services covered under the State Plan, as specified in the qualified employer-sponsored coverage, without regard to limitations specified in § 1916 or § 1916A of the Act, for eligible individuals under age 19 who have access to and elect to enroll in such coverage. The eligible individual is entitled to services covered by the State Plan that are not included in the employer-sponsored coverage. For qualified employer-sponsored coverage, the employer must contribute at least 40% of the premium cost.

When coverage for eligible family members under age 19 is not possible unless an ineligible family member enrolls, the Medicaid agency pays premiums for enrollment of the ineligible family member and, at the option of the parent or legal guardian, other family members that are eligible for coverage under the employer-sponsored plan. The agency also pays deductibles, coinsurance, and other cost-sharing obligations for items and services covered under the State Plan for the ineligible family member. 12VAC30-20-205 provides a detailed description of this program.

D. The Medicaid agency pays premiums for individuals described in subsection 19 of 12VAC30-30-10.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-29.4, eff. April 1, 1993; amended, Virginia Register Volume 29, Issue 2, eff. November 8, 2012.

12VAC30-10-330. Medicaid for individuals age 65 or over in institutions for mental diseases.

Medicaid is provided for individuals 65 years of age or older who are patients in institutions for mental diseases.

The requirements of 42 CFR 441, Subpart C, and 42 CFR 431.620(c) and (d) are met.

Statutory Authority

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

Historical Notes

Derived from VR460-01-30, eff. October 1, 1976.

12VAC30-10-340. Special requirements applicable to sterilization procedures.

All requirements of 42 CFR 441, Subpart F are met.

Statutory Authority

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

Historical Notes

Derived from VR460-01-31, eff. March 31, 1979.

12VAC30-10-350. Families receiving extended Medicaid benefits.

A. Services provided to families during the first 6-month period of extended Medicaid benefits under § 1925 of the Act are equal in amount, duration, and scope to services provided to categorically needy AFDC recipients as described in 12VAC30-50-10 (or may be greater if provided though a caretaker relative employer's health insurance plan).

B. Services provided to families during the second 6-month period of extended Medicaid benefits under § 1925 of the Act are equal in amount, duration and scope to services provided to categorically needy AFDC recipients as described in 12VAC30-50-10 et seq. (or may be greater if provided through a caretaker relative employer's health insurance plan).

Statutory Authority

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

Historical Notes

Derived from VR460-01-31.1, eff. June 16, 1993.

12VAC30-10-360. [Reserved]. (Reserved)

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