Medicaid Benefits: Online Database

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Acute Care Services

Institutional and Clinic Services

Practitioner Services

Prescription Drugs

Physical Therapy and Other Services

Products and Devices

Transportation Services

Other Services

Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: Virginia (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes	$3/visit	Specified services	Limits vary by service	Fee for service	CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes	$1/visit	After initial 26 Mental Health treatment visits	Mental health service limits vary	Fee for service	CN & MN
Federally Qualified Health Center Services
Yes	$1/visit			Cost based payment	CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes	$100/non-emergency admission	Non-emergency admissions	Admissions for specified procedures safely rendered on outpatient basis, weekend admissions and days before elective surgery must be medically justified; psych admissions limited to 21 days in two months for same diagnosis	Prospective payment/discharge using DRG for acute care; prospective per diem for psych, rehab and other special hospitals/units	CN & MN
Outpatient Hospital Services
Yes	$3/visit	Specified services	Limits vary by service	Cost based payment with limits	CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes	$3/visit		Limits vary by service	Fee for service	CN & MN
Rural Health Clinic Services
Yes	$1/visit	Specified services	Limits vary by service	Cost based payment	CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
No
Chiropractor Services
No
Dental Services
Yes			Limited to medically necessary oral surgery and associated diagnostic services	Fee for service	CN & MN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes		Hospital-based care	Limited to medically necessary oral surgery and associated diagnostic services	Fee for service	CN & MN
Nurse Midwife Services
Yes			Limited to non-high risk pregnancies	Fee for service	CN & MN
Nurse Practitioner Services
Yes	$1/visit		Services limited by scope of practice, routine physical exams not covered	Fee for service	CN & MN
Optometrist Services
Yes	$1/visit		Refractive exams only	Fee for service	CN & MN
Physician Services
Yes	$1/visit including refractive eye exams, $3/service other than visits		Elective surgical procedures must restore body function, inpatient hospital admissions for specified surgical procedures normally rendered on outpatient basis must be medically justified, routine physical exams not covered	Fee for service	CN & MN
Podiatrist Services
Yes	$1/visit	Specified services	Preventive and routine foot care not covered	Fee for service	CN & MN
Psychologist Services
Yes		After initial 26 visits	52 visits in year one and 26 visits in subsequent years	Fee for service	CN & MN
Prescription Drugs
Prescription Drugs
Yes	$1/generic Rx, $3/brand Rx	Specified drugs	Rx must be generic unless DAW or brand has preferred status on drug list	AWP-10.25%, plus $4.00 dispensing fee to traditional pharmacies	CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
No
Physical Therapy Services
No
Services for Speech, Hearing and Language Disorders
Yes	$1/visit		Limited to audiology services	Fee for service	CN & MN
Products and Devices
Dentures
No
Eyeglasses
No
Hearing Aids
No
Medical Equipment and Supplies
Yes		Specified items	Limits vary by item	Fee for service, home infusion therapy paid per diem	CN & MN
Prosthetic and Orthotic Devices
Yes		Yes	Limits vary by service	Fee for service	CN & MN
Transportation Services
Ambulance Services
Yes		Non-emergency transports		Fee for service	CN & MN
Non-Emergency Medical Transportation Services
Yes		Yes		See service-specific FN	CN & MN
Other Services
Diagnostic, Screening and Preventive Services
Yes			Diagnostic services only covered as part of anothr service, specified coverage criteria for screening and preventive services	Fee for service	CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes		Non-emergent outpatient diagnostic scans	Limits vary by service	Fee for service	CN & MN
Targeted Case Management
Yes			Limits vary by population group served	Fee for service	CN & MN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes		Enrollment	Services for the following populations: 2, 3, 4, 5, 6 & 8 - See service-specific FN	Fee for service	CN & MN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes	$3/day including all therapy services	After initial 5 visits	32 home health aide visits/year	Fee for service using geographic adjustments, health departments have special rates	CN & MN
Hospice Care
Yes		Yes		Prospective rates based on Medicare methodology	CN & MN
Personal Care Services
No
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
Yes				Capitated payment	CN & MN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes		Admission	Hosp leave days not covered, 7 consecutive therapeutic leave days up to 18 days/year	Prospective per diem or cost based payment	CN
Inpatient Psychiatric Services, under age 21
Yes		Admission		Prospective per diem	CN
Intermediate Care Facility Services for the Mentally Retarded
Yes		Admission	Hosp leave days not covered, 7 consecutive therapeutic leave days up to 18 days/year	Cost based payment	CN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes		Admission	18 therapeutic leave days/year	Prospective per diem based on cost and acuity adjusted	CN & MN
Religious Non-Medical Health Care Institution and Practitioner Services
No

Notes: This State has added the optional Medicaid buy-in group of disabled adults permissible through the Ticket to Work and Work Incentives Improvement Act (TWWIIA) in a program called Medicaid Works. These beneficiaries are allowed to continue Medicaid coverage, and receive full benefits, if their income is at or below 80 percent of the FPL. No premiums are required.