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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 191. State Plan for the Children with Special Health Care Needs Program
11/23/2024

12VAC5-191-100. Contracts with providers.

A. The program may choose to administer a pool of funds for payment of direct health care services for the uninsured and underinsured clients subject to availability of funds and guidelines that govern its eligibility and coverage of services.

B. The program and its contractors are payors of last resort for direct health care services. All other payment sources, including Title XVIII (Medicare), Title XIX (Medicaid and its EPSDT Program), Title XXI (SCHIP), military health insurance, private health insurance, any other state and federal medical assistance program, or any entity that contracts to pay medical care costs for persons eligible for medical assistance in the Commonwealth shall be exhausted prior to program payment.

C. The program and its contractors will not pay any portion of the bill that is not covered by any insurer, state and federal medical assistance program, or any entity that contracts to pay medical care costs for persons eligible for medical assistance in the Commonwealth unless the service is totally nonreimbursable by them.

D. Providers of direct health care services are limited to those providers who:

1. Have credentials, licensure or certification in the clinical specialty to provide the approved services.

2. Accept the Medicaid fee-for-service rate of reimbursement for the specific service based upon the appropriate code set to identify procedures, services, and diagnoses as approved for use by the federal Centers for Medicare and Medicaid Services.

3. Accept the amounts as negotiated by the program, or a contractor on its behalf, as payment in full on behalf of the program, client, and his family or legal guardian.

E. Paraprofessional staff and volunteers may provide services under the direction of a provider who has credentials, licensure, or certification.

Statutory Authority

§§ 32.1-12 and 32.1-77 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 23, Issue 21, eff. July 25, 2007.

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