Page 32

STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 6-32

Effective Date: 07/01/05

32 Approval Date: _____________/06 Coverage offered for Secretary-approved coverage through the fee-for-service program and the PCCM program is summarized in the checklist below.

6.2.1.A ⌧ Inpatient services (Section 2110(a)(1))

A. Payment based upon DRG shall be made for medically necessary stays in acute general care facilities within the limits of coverage prescribed with the Title XIX State Plan and state regulations. B. Medically necessary inpatient psychiatric care rendered in a psychiatric unit of a general acute care hospital shall be covered for all children within the limits of coverage prescribed in the Title XIX State Plan and state regulations. C. Payment will not be made for inpatient hospitalization for those surgical and diagnostic procedures listed on the mandatory outpatient surgery list unless the inpatient stay is medically justified or meets one of the exceptions. D. For purposes of organ transplantation, all similarly situated individuals will be treated alike. Transplant services shall be limited to procedures that are not experimental. Transplants are covered when determined medically necessary and preauthorized. E. Coverage for a normal, uncomplicated vaginal delivery shall be limited to the day of delivery plus an additional two days unless additional days are medically justified. Coverage for cesarean births shall be limited to the day of delivery plus an additional four days unless additional days are medically justified. F. Coverage for a radical or modified radical mastectomy for treatment of disease or trauma of the breast shall be limited to 48 hours unless additional days are medically justified. Coverage for a total or partial mastectomy with lymph node dissection for treatment of disease or trauma of the breast shall be limited to 24 hours unless additional days are medically justified.

6.2.2.A ⌧ Outpatient services (Section 2110(a)(2)) A. Outpatient hospital means preventive, diagnostic, therapeutic, rehabilitative or palliative services that are furnished to outpatients, by or under the direction of a physician or dentist, except in the case of nurse mid-wife services.