12 Va. Admin. Code § 30-150-50 - Treatment plan
A. Except as
otherwise provided in this section, any medical services that are not
experimental or investigational may be covered under a treatment
plan.
B. Services provided for in
the treatment plan must be for a course of treatment approved by DMAS to
remediate, cure, or ameliorate the life-threatening illness or injury. The
course of treatment proposed in the plan may not exceed 12 months.
C. The treatment plan should reflect the
standard of practice for treating the life-threatening illness or injury given
the applicant's health status at the time the treatment plan is approved.
Treatment plans will not be approved for any illness or injury that is expected
to be terminal even with the treatment.
D. DMAS may approve the treatment plan as
submitted, modify the treatment plan, or deny the treatment plan. DMAS may
review and revise treatment plan decisions based on additional information up
until the time a contract is signed. A treatment plan may only be altered if,
during the course of treatment approved, the medical condition of the person
substantially changes and renders the original course of treatment no longer
appropriate, as determined by the contracting health provider. If any
alteration increases the established dollar amount, additional funds can be
approved if available. Any alteration cannot exceed the one-year time frame
from initial authorization.
E. The
UMCF is not responsible for maintenance medications or additional treatments
beyond the course of treatment approved by DMAS and contracted with a
provider.
F. The UMCF will not
commit funds or pay for services provided prior to the date the application is
approved.
G. Covered services
include specialized medical treatment, hospitalization, or both, to include the
following to the extent they are part of the approved treatment plan:
1. Inpatient hospital services;
2. Outpatient hospital services and
ambulatory surgical centers;
3.
Ambulatory care;
4. Laboratory and
x-ray services;
5. Physician's
services and other ambulatory care;
6. Medical care furnished by licensed
practitioners within the scope of their practice as defined by state
law;
7. Prescribed drugs;
and
8. Rehabilitative services to
the extent necessary to recover from medical treatment.
H. Noncovered services include:
1. Transportation services;
2. Mental health services;
3. Nursing facility services;
4. Case management;
5. Hospice care;
6. Private duty nursing services;
7. Prosthetic devices;
8. Eyeglasses, dentures, hearing aids and
other similar devices;
9.
Alternative medicine therapies such as homeopathic remedies, hypnosis, or
herbal remedies; and
10. Emergency
services.
I. Only the
following organ and tissue transplant procedures will be covered:
1. Kidney;
2. Liver;
3. Heart;
4. Lung; and
5. Bone marrow.
J. Patients receiving transplants must be
acceptable for coverage and treatment by meeting the same selection criteria
(except for the age limitation) outlined in
12VAC30-50-540,
12VAC30-50-560, and
12VAC30-50-570 of the Virginia
Title XIX State Plan for Medical Assistance.
Notes
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
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