Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 80. Methods and Standards for Establishing Payment Rate; Other Types of Care

12VAC30-80-26. Reimbursement for Indian Health Service tribal 638 facilities.

A. Reimbursement for tribal health clinics.

1. Services provided by or through facilities of the Indian Health Services (IHS), including at the option of the tribe, facilities operated by a tribe or tribal organization, and funded by Title I or Title V of the Indian Self Determination and Education Assistance Act of 1975 (25 USC § 5301 et seq.), also known as tribal 638 facilities, are paid at the applicable IHS U.S. Office of Management & Budget (OMB) rate published annually in the Federal Register of Regulations by IHS.

2. The most current published IHS OMB outpatient per visit rate, also known as the outpatient all-inclusive rate, is paid for up to five outpatient visits per beneficiary per calendar day for professional services. An outpatient visit is defined as a face-to-face or telemedicine contact between any health care professional at or through the IHS facility authorized to provide services under the State Plan and a beneficiary for the provision of Title XIX defined services, as documented in the beneficiary's medical record.

3. Included in the outpatient per visit rate are Medicaid-covered pharmaceuticals or drugs, dental services, rehabilitative services, behavioral health services, ancillary services, and emergency room services provided on-site, and medical supplies incidental to the services provided to the beneficiary.

B. Virginia Medicaid reimburses tribal 638 facilities in accordance with the most recently published annual update of reimbursement rates for Indian Health Services, which is published in the Federal Register of Regulations and on the Indian Health Services website at on the page for reimbursement rates. Encounters or visits are limited to health care professionals as approved under the Virginia Medicaid State Plan. A tribal health program selecting to enroll as a federally qualified health center (FQHC) and agreeing to an alternate payment methodology (APM) will be paid using the APM.

C. Alternative payment methodology for tribal facilities recognized as FQHCs

1. Outpatient health programs or facilities operated by a tribe or tribal organization that choose to be recognized as FQHCs in accordance with § 1905 (I)(2)(B) of the Social Security Act and the Indian Self-Determination and Education Assistance Act of 1975 (25 USC § 5301 et seq.) will be paid using an APM for services, that is the published, all-inclusive rate (AIR). The APM/AIR rate is paid for up to five face-to-face encounters or visits per recipient per day.

2. The individual FQHC must agree to receive the APM. If a tribal FQHC does not agree to accept the APM, the Department of Medical Assistance Services shall seek accommodation with the FQHC, which may include submitting a State Plan amendment to authorize an alternative means of reimbursement for the FQHC.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Historical Notes

Derived from Virginia Register Volume 38, Issue 11, eff. March 3, 2022.

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