Virginia
In Virginia:
- Medicaid services are delivered primarily through several Managed Care Plans that contract with Virginia’s Medicaid program (administered by the Virginia Department of Medical Assistance Services or DMAS). The different Managed Care Plans in Virginia help beneficiaries choose a primary care provider, and provide a standard list of benefits.
- There were a total of 915,038 beneficiaries enrolled in Virginia’s Medicaid program as of July 2011. Of these, 532,292 were enrolled in managed care. 363,181 beneficiaries were enrolled in one of three commercial managed care organizations (MCOs), 169,111 were enrolled in one of two Medicaid-only MCOs, and 54,019 beneficiaries participated in a primary care case management program. Virginia also has a transportation Prepaid Ambulatory Health Plan that served 318,184 beneficiaries as of July 2011.
- The Virginia Department of Medical Assistance provides EPSDT services including behavioral health, substance abuse, and dental services to all children who receive Medicaid through either fee-for-service, or a Managed Care Organization (MCO).
As of 2013, 706,192 individuals were eligible for EPSDT through Virginia’s Medicaid program. According to CMS data from 2013, Virginia achieved an EPSDT screening ratio of 83% and a participation ratio of 73%. 323,771 children received dental services of any kind, with 302,341 receiving preventive dental services.
Last updated May 2014
| Medical Necessity |
Virginia uses the federal definition of medical necessity for EPSDT in the “What is EPSDT?” section of the Managed Care Resource Guide.
Virginia’s EPSDT program goals are to keep children as healthy as possible by:
The guide adds that “all requests for EPSDT treatment services must:
Services that are considered experimental or investigational are not covered.
EPSDT Specialized Services are medically necessary treatment services that are not a routinely covered service through Virginia Medicaid. All EPSDT “specialized services” must be a service that is allowed by the Centers for Medicare and Medicaid Services (CMS). The allowable treatment services are defined in the United States Code in 42 U.S.C. sec 1396d (r) (5).”
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| Initiatives to Improve Access |
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| Reporting & Data Collection | Virginia is one of only 12 states that require MCOs to be accredited by the National Committee for Quality Assurance (NCQA). This includes the reporting of Health Care Effectiveness Data and Information Set (HEDIS) data, from which several measures in the CHIPRA core set of measures for children are drawn including, adolescent well-care visits and well child visits in the first 15 months of life. |
| Behavioral Health |
While children enrolled in managed care organizations (MCOs) receive assessments, evaluations, and outpatient psychiatric and substance abuse therapy services through managed care, several services are carved out of managed care and offered on a fee-for-service basis, including:
Under the Children’s Mental Health Program in Virginia, Case Management and Home and Community-Based services are available to Medicaid-enrolled children who have been in a Psychiatric Residential Treatment Facility for more than 90 days. These provide team-based services in the community for children with a serious emotional disturbance.
Virginia Medicaid also covers two kinds of EPSDT Behavioral Therapy: Intensive In-Home Services, and Outpatient Programs – Applied Behavioral Analysis. Additionally, Targeted case management may be reimbursed while an individual is authorized for EPSDT Behavioral Therapy in the home environment. Covered services include, but are not limited to: services and methods used to validate the child’s treatment progress as included in the Individual Service Plan (ISP) as approved by the State’s Medicaid agency, family training, counseling, and home visits; clinical supervision and behavioral modification services.
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| Support to Providers and Families |
Support to Providers
Virginia Medicaid’s EPSDT Page has information for providers, including screening information, well child visit schedules, dental visit schedules and more. Virginia also offers providers a number of EPSDT manuals, including Nursing, Personal Care Services, Hearing and Audiology, Inpatient Services, and Behavioral Therapy.
Support to Families
Virginia Medicaid provides a number of EPSDT Birthday Newsletters that include information relevant to the child’s age; such as milestones and what to expect at a check up. The Newsletters are available in both English and Spanish and cover: Infant and Toddler, Early Childhood, Middle Childhood, Adolescents, and Teens. .
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| Care Coordination |
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| Oral Health |
Virginia covers the comprehensive set of pediatric dental services as recommended by the American Academy of Pediatric Dentistry (AAPD). |
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