Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 195. Virginia WIC Program
10/19/2020

12VAC5-195-590. Reimbursement and Payments.

A. For each processed food instrument, the state agency shall do one of the following:

1. Pay as submitted;

2. Make a price adjustment, if applicable; or

3. Deny payment of the redeemed food instrument.

B. The state agency's reimbursement responsibilities include:

1. Ensuring payments are made to authorized retailers that have a signed retailer agreement with the Virginia WIC Program. Unauthorized retailers will not be paid for any mistakenly accepted and deposited food instruments;

2. Ensuring the maximum reimbursement levels used by its banking contractor, based upon peer groups, are reasonable for the food and formula items prescribed for purchase by participants;

3. Making price adjustments to the reimbursement amount paid to retailers in order to ensure individual retailer's reimbursement levels remain eligible for authorization, based upon competitive prices charged by similar retailers;

4. Collecting bank account and routing numbers from applicants and authorized retailers in order to process direct deposit automated clearinghouse (ACH) payments;

5. Ensuring prompt ACH credits are made to the retailer's bank account when appropriate;

6. Collecting retailer's prices using an electronic, Internet-based application;

7. Identifying retailers whose prices are noncompetitive and take administrative actions including possible termination of the retailer's authorization;

8. Complying with all federal regulations and guidelines that require administrative approval by USDA prior to making payments, as applicable;

9. Providing written communications to all authorized retailers containing the procedures used by the program to pay or deny payments for all redeemed food instruments; and

10. Recouping overpayments due to banking or procedural errors, if applicable, from authorized retailers.

C. A not to exceed (NTE) amount for each peer group and UPC is established using sales data (7 CFR 246.12).

D. For cash value food benefits only, the retailer must offer one of the following options to the participant if the total dollar amount being purchased exceeds the printed cash value:

1. The participant shall be allowed to pay the amount over the printed cash value; or

2. The participant shall be allowed to reduce the quantity of eligible fruits and vegetables being purchased.

Retailers must notify the state agency in writing which of these options they provide to WIC participants.

E. The peer group and UPC NTE may be adjusted weekly by the state agency, depending upon external factors including wholesale price increases. The NTE used for the various peer group combinations is not distributed to authorized retailers prior to being used by the banking contractor.

F. The state agency shall use a post-payment review process to prospectively evaluate the reimbursement amount paid against redeemed food instruments in order to identify excessive or improperly redeemed food instruments in accordance with federal regulations (7 CFR 246.12). From the post-payment review process, the state agency may determine that one or more payments already made to a retailer were ineligible for payment as a result of a retailer failing to provide the cardholder with foods that were taken off the eWIC card. The state agency reserves the right to bill and recoup payments of these ineligible payments, which will be referred to as a retailer claim (7 CFR 246.12). The state agency shall not bill an authorized retailer if the retailer claim amount is less than $10.

G. A retailer that is not authorized to participate in the Virginia WIC Program that accepts a food instrument will not be reimbursed for any food instruments redeemed by a WIC participant.

H. A retailer must submit a direct deposit ACH form to the state agency that identifies any bank changes to its routing or account number. A direct deposit ACH form must be submitted at least 14 days prior to the change effective date. If the state agency's banking contractor identifies that the retailer's bank account or routing number is not valid, then the retailer will receive one written notice from the state agency. Failure by the retailer to resolve any reported discrepancies within 30 days after a written notice has been sent by the state agency may lead to the retailer being ineligible to receive payments for rejected food instruments.

I. Retailers are responsible for all bank handling fees and charges associated with doing business with the WIC Program.

Statutory Authority

§ 32.1-12 of the Code of Virginia; 7 CFR Part 246.

Historical Notes

Derived from Volume 24, Issue 19, eff. May 26, 2008; amended, Virginia Register Volume 25, Issue 22, eff. July 6, 2009; Volume 26, Issue 10, eff. January 18, 2010; Volume 29, Issue 12, eff. March 13, 2013; Volume 35, Issue 22, eff. July 24, 2019.

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