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VA Medicaid Covered Services

For a list of services that are not covered by Medicaid in Virginia, see Non-Covered Services below.

Covered Services

The following services are generally provided by Medicaid:

1. Inpatient hospital services other than those provided in an institution for mental diseases.

2. Outpatient hospital services. (See Outpatient Services below)

3. Rural health clinic services and other ambulatory services furnished by a rural health clinic.

4. 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).

5. Early and periodic screening and diagnosis of individuals under 21 years of age, and treatment of conditions found.

6. Family planning services and supplies for individuals of child-bearing 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 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.

10. 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.

11. Clinic services.

12. Dental services.

13. 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.

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

15. Other rehabilitative services, screening services, preventive services.

16. Reserved.

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.

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.

2. Reimbursement for induced abortions is provided in only those cases in which there would be substantial endangerment of health or life to the mother if the fetus was carried to term.

3. The following limits and requirements shall apply to DMAS coverage of outpatient observation beds.

a. Observation bed services shall be covered when they are reasonable and necessary to evaluate a medical condition to determine appropriate level of treatment.

b. Non-routine observation for underlying medical complications, as explained in documentation attached to the provider's claim for payment, after surgery or diagnostic services shall be covered. Routine use of an observation bed shall not be covered. Non-covered routine use shall be:

(1) Routine preparatory services and routine recovery time for outpatient surgical or diagnostic testing services (e.g., services for routine post-operative monitoring during a normal recovery period (four to six hours)).

(2) Observation services provided in conjunction with emergency room services, unless, following the emergency treatment, there are clear medical complications which must be managed by a physician other than the original emergency physician.

(3) Any substitution of an outpatient observation service for a medically appropriate inpatient admission.

c. These services must be billed as outpatient care and may be provided for up to 23 hours. A patient stay of 24 hours or more shall require inpatient pre-certification, where applicable.

d. When inpatient admission is required following observation services and prior approval has been obtained for the inpatient stay, observation charges must be combined with the appropriate inpatient admission and be shown on the inpatient claim for payment. Observation bed charges and inpatient hospital charges shall not be reimbursed for the same day.

Non-Covered Services

·             Abortions, unless the pregnancy is life-threatening or health-threatening;

·             Acupuncture;

·             Alcohol and drug abuse therapy (except as provided through the Community Services Boards)

·             Artificial insemination, in-vitro fertilization or other services to promote fertility;

·             Broken appointments;

·             Certain drugs not proven effective and those offered by non-participating manufacturers (enrolled doctors, drugstores, and health departments have lists of these drugs);

·             Certain experimental surgical and diagnostic procedures;

·             Chiropractic services;

·             Cosmetic treatment or surgery;

·             Day care;

·             Dentures;

·             Doctor services during non-covered hospital days;

·             Drugs prescribed to treat hair loss or to bleach skin;

·             Eyeglasses or their repair if you are age 21 or older;

·             Friday or Saturday hospital admission for non-emergency reasons or admission for more than one day prior to surgery unless the admission on those days is preauthorized;

·             Hospital charges for days of care not authorized for coverage;

·             Inpatient hospital care in an institution for the treatment of mental disease for recipients under age 65, unless they are under age 22 and receiving inpatient psychiatric services.

·             Medical care received from providers not enrolled in Virginia Medicaid or who will not accept payment from Virginia Medicaid as payment in full;

·             Private duty nursing (except under Waiver programs);

·             Psychological testing done for school purposes, educational diagnosis, school or institution admission and/or placement or upon court order;

·             Remedial education;

·             Routine dental care if you are age 21 or older;

·             Routine physicals and immunizations if you are age 21 or older;

·             Sterilization of recipients younger than age 21;

·             Telephone consultation; and,

·             Weight loss clinic programs.

If you receive a service not covered by Medicaid or you receive more services than the Medicaid limit for that service, you will have to pay those bills.

Back to:

VA Medicaid Eligibility

VA Medicaid Covered Groups

VA Medicaid Overview

VA Benefit Information System Welcome and Introduction

Source:

Information for this topic was drawn from Section M1850.100 of the Department of Social Services (DSS) Medicaid Manual.

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