Section 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.

Historical Notes

Derived from Volume 18, Issue 17, eff. June 6, 2002; amended, Virginia Register Volume 22, Issue 25, eff. November 6, 2006.

Statutory Authority

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