The term, "Medically Necessary" is a long-standing criteria for health insurance coverage, yet it is not appropriate for disabilities related serices such as community engagement, companion care, and supported employment. While managed care is a viable route for cost containment and to promote appropriate services, existing health insurance definitions and methods do not always fit. It seems that we're trying to fit a square peg into a round hole.

"Medical necessity” for payment implies that services must have a physician’s order and not be developed by the Person-Centered planning process.

Please strike the word, "medically" from the term "medically necessary" in the following sections.

12VAC30-122 B 1. - Legal Authority

12VAC30-122-20. Definitions. The term and definition: " 'Medically necessary' means an item or service provided for the diagnosis or treatment of an individual's condition consistent with community standards of medical practice as determined by DMAS"  don't fit with some waiver services that are not medical (e.g. community engagement, companion care, and supported employment).

Perhaps there is a need to add a definition for necessity that is not medical.

12VAC30-122-120. Provider requirements. A. 5.

12VAC30-122-410. In-home support service. C. 2.

Note: The term "medically necessary" does seem appropriate for private duty nursing and skilled nursing.