Part I. Categorically Needy
12VAC30-50-10. Services provided to the categorically needy with limitations.
The following services are provided with limitations as described in Part III (12VAC30-50-100 et seq.) of this chapter:
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), including Magnetic Resonance Angiography (MRA), Computerized Axial Tomography (CAT) scans, including Computed Tomography Angiography (CTA), and Positron Emission Tomography (PET) scans performed for the purpose of diagnosing a disease process or physical injury 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. Early and periodic screening and diagnosis of individuals under 21 years of age, and treatment of conditions found.
7. Family planning services and supplies for individuals of child-bearing age.
8. Physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere.
9. Medical and surgical services furnished by a dentist (in accordance with § 1905(a)(5)(B) of the Act).
10. Medical care or 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: podiatrists, optometrists and other practitioners.
11. Home health services: 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; home health aide services provided by a home health agency; and medical supplies, equipment, and appliances suitable for use in the home; physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility.
12. Clinic services.
13. Dental services.
14. Physical therapy and related services, including occupational therapy and services for individuals with speech, hearing, and language disorders (provided by or under supervision of a speech pathologist or audiologist).
15. Prescribed drugs, prosthetic devices, and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.
16. Other rehabilitative services, screening services, preventive services.
17. Nurse-midwife services.
18. Case management services as defined in, and to the group specified in, 12VAC30-50-95 et seq. (in accordance with § 1905(a)(19) or § 1915(g) of the Act).
19. Extended services to pregnant women: pregnancy-related and postpartum services for a 60-day period after the pregnancy ends and any remaining days in the month in which the 60th day falls (see 12VAC30-50-510). (Note: Additional coverage beyond limitations.)
20. Pediatric or family nurse practitioners' service.
21. Any other medical care and any other type of remedial care recognized by state law, specified by the Secretary: transportation.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from VR460-02-3.1100, eff. June 16, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995; Volume 14, Issue 4, eff. December 15, 1997; Volume 16, Issue 18, eff. July 1, 2000; Volume 20, Issue 1, eff. October 22, 2003; Volume 22, Issue 16, eff. July 3, 2006; Volume 25, Issue 14, eff. April 15, 2009.
12VAC30-50-20. Services provided to the categorically needy without limitation.
The following services as described in Part III (12VAC30-50-100 et seq.) of this chapter are provided to the categorically needy without limitation:
1. Nursing facility services (other than services in an institution for mental diseases) for individuals 21 years of age or older.
2. Services for individuals 65 years of age or older in institutions for mental diseases: inpatient hospital services; skilled nursing facility services; and services in an intermediate care facility.
3. 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 Social Security Act (the Act), to be in need of such care, including such services in a public institution (or distinct part thereof) for persons with intellectual or developmental disability or related conditions.
4. Hospice care (in accordance with § 1905(o) of the Act).
5. 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: care and services provided in religious nonmedical health care institutions, nursing facility services for patients younger than 21 years of age, or emergency hospital services.
6. Private health insurance premiums, coinsurance, and deductibles when cost effective (pursuant to P.L. No. 101-508 § 4402).
7. Program of All-Inclusive Care for the Elderly (PACE) services are provided for eligible individuals as an optional State Plan service for categorically needy individuals without limitation.
8. 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.
9. Inpatient psychiatric facility services and residential psychiatric treatment services (including therapeutic group homes and psychiatric residential treatment facilities) for individuals younger than 21 years of age.
10. Coverage of routine patient cost for items and services as defined in § 1905(gg) of the Social Security Act (42 USC § 1396 et seq.) that are furnished in connection with participation in a qualifying clinical trial.
Statutory Authority
§ 32.1-325 of the Code of Virginia, 42 USC § 1396 et seq.
Historical Notes
Derived from VR460-02-3.1100, eff. June 16, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995; Volume 18, Issue 7, eff. January 16, 2002; Volume 20, Issue 1, eff. October 22, 2003; Volume 23, Issue 16, eff. July 1, 2007; Volume 29, Issue 11, eff. February 27, 2013; Volume 35, Issue 24, eff. August 22, 2019; Volume 39, Issue 5, eff. November 23, 2022.
12VAC30-50-30. Services not provided to the categorically needy.
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.
Historical Notes
Derived from VR460-02-3.1100, eff. June 16, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995; Volume 14, Issue 4, eff. December 15, 1997; Volume 14, Issue 18, eff. July 1, 1998; Volume 17, Issue 5, eff. January 1, 2001; Volume 18, Issue 7, eff. January 16, 2002; Volume 35, Issue 24, eff. August 22, 2019.
12VAC30-50-35. Requirements relating to payment for covered outpatient drugs for the categorically needy.
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).
B. Coverage of specific categories of excluded drugs will be in accordance with existing Medicaid policy as described in 12VAC30-50-520.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC 1396 et seq.
Historical Notes
Derived from Virginia Register Volume 23, Issue 11, eff. March 7, 2007; amended, Virginia Register Volume 32, Issue 1, eff. October 22, 2015.