Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 40. Eligibility Conditions and Requirements

12VAC30-40-235. Reasonable limits on amounts for necessary medical or remedial care not covered under Medicaid.

A. The Medicaid agency meets the requirements of 42 CFR 435.725, 42 CFR 435.832, and § 1924 of the Social Security Act, in that the agency will deduct amounts for incurred expenses for medical or remedial care that are not subject to payment by a third party, including medically necessary or remedial care recognized under state law but not covered under the state's Medicaid plan, subject to reasonable limits as specified in subsection B of this section.

B. All medical or remedial goods and services not subject to payment by a third party and not covered by Medicaid but recognized under state law must be prescribed by a physician, dentist, podiatrist or other practitioner with prescribing authority pursuant to Virginia law. The maximum amount that may be deducted from the patient's income for nursing facility residents shall be the maximum amount reimbursed by the higher of either Medicare or Medicaid for the same noncovered items or services.

C. If neither Medicaid nor Medicare has an allowed amount for the service rendered, then DMAS will protect from the individual's income:

1. For services, the amount of the provider's usual and customary charge; or

2. For supplies and durable medical equipment, the actual invoice cost plus the lesser of either:

a. The labor charges; or

b. A 30% mark-up from the invoice.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 20, Issue 19, eff. August 1, 2004.

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