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

STATE: Virginia Page 6-40

Effective Date: 07/01/05

40 Approval Date: _____________/06 appliances not defined as medical equipment; items that are only for the recipient’s comfort and convenience.

6.2.14.A ⌧ Home and community-based health care services (See instructions) (Section 2110(a)(14)) A. 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. Effective 08-01-2003, home health services are limited to five visits without prior authorization in each state fiscal year. Service extensions beyond the initial five visits must be prior-authorized. Limits are per recipient, regardless of the number of providers rendering services. If services beyond these limitations are determined by the physician to be required, then the provider shall request prior authorization from DMAS for additional services. B. Home Health Aide services provided by a home health agency. Home health aides must function under the supervision of a professional nurse. Home health aides must meet the federal certification requirements. Patient may receive up to 32 visits annually.

6.2.15.A ⌧ Nursing care services (See instructions) (Section 2110(a)(15))

Intermittent or part-time nursing service provided by a home health agency; Nurse mid-wife services allowed under licensure requirements of Virginia and federal law; skilled nursing services provided in schools to special education students.

Private duty nursing services are not covered.

6.2.16.A ⌧ Abortion only if necessary to save the life of the mother or if the pregnancy is the result of an act of rape or incest (Section 2110(a)(16) Abortion only if necessary to save the life of the mother.

6.2.17.A ⌧ Dental services (Section 2110(a)(17)) A. Routine diagnostic, preventive or restorative procedures necessary for oral health provided by or under the direct supervision of a dentist in accordance with the State Dental Practice Act. B. Initial, periodic and emergency examinations; required radiography necessary to develop a treatment plan; patient education; dental prophylaxis;