Administrative Code

Virginia Administrative Code
12/3/2021

Part II. Ambulatory Services; Medically Needy

12VAC30-50-40. Ambulatory services.

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.

Historical Notes

Derived from VR460-03-3.1200, eff. June 16, 1993.

12VAC30-50-50. Services provided to the medically needy with limitations.

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.

10. Home health services' medical supplies, equipment, and appliances suitable for use in the home; 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; physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility.

11. Clinic services.

12. Dental services.

13. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders provided by or under supervision of a speech pathologist or audiologist.

14. Prescribed drugs, prosthetic devices, and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

15. Rehabilitative services.

16. Nurse-midwife services.

17. Case management services as defined in, and to the group specified in, 12VAC30-50-410 (in accordance with § 1905(a)(19) or § 1915(g) of the Act).

18. Extended services for pregnant women including pregnancy-related and post-partum services for 60 days after the pregnancy ends.

19. Certified pediatric or family nurse practitioners' services.

20. Any other medical care and any other type of remedial care recognized under state law, specified by the secretary, specifically transportation.

Statutory Authority

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

Historical Notes

Derived from VR460-03-3.1200, eff. June 16, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995; Volume 12, Issue 3, eff. November 29, 1995; Volume 14, Issue 4, eff. December 15, 1997; Volume 20, Issue 1, eff. October 22, 2003.

12VAC30-50-60. Services provided to all medically needy groups without limitations.

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.

4. 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.

5. Hospice care (in accordance with § 1905(o) of the Act).

6. Any other medical care or any other type of remedial care recognized under state law, specified by the U.S. Secretary of Health and Human Services, including: care and services provided in religious nonmedical health care institutions, skilled nursing facility services for patients younger than 21 years of age, and emergency hospital services.

7. Private health insurance premiums, coinsurance and deductibles when cost effective (pursuant to P.L. No. 101-508 § 4402).

8. Program of All-Inclusive Care for the Elderly (PACE) services are provided for eligible individuals as an optional State Plan service for medically needy individuals without limitation.

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.

Statutory Authority

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

Historical Notes

Derived from VR460-03-3.1200, eff. June 16, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995; Volume 14, Issue 4, eff. December 15, 1997; 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.

12VAC30-50-70. Services or devices not provided to the medically needy.

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.

Historical Notes

Derived from VR460-03-3.1200, eff. June 16, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995; Volume 12, Issue 3, eff. November 29, 1995; 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.

12VAC30-50-75. Requirements relating to payment for covered outpatient drugs for the medically 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.

12VAC30-50-80. [Reserved]. (Reserved)

12VAC30-50-95. Reimbursement of services; in general.

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.

Historical Notes

Derived from Virginia Register Volume 12, Issue 3, eff. November 29, 1995; amended, Virginia Register Volume 14, Issue 7, eff. January 21, 1998.

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