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Virginia Administrative Code
Title 12. Health
Agency 5. Department Of Health
Chapter 200. Regulations Governing Eligibility Standards and Charges for Medical Care Services to Individuals
4/22/2021

12VAC5-200-10. Definitions.

The following words and terms when used in this chapter have the following meanings unless the context clearly indicates otherwise:

"Applicant" means the person requesting medical care services for himself or on whose behalf a request is made.

"Board" means the State Board of Health.

"Child" means a person under 18 years of age and includes any biological or adopted child, and any child placed for adoption or foster care unless otherwise treated as a separate unit for the purposes of determining eligibility and charges under these regulations.

"Commissioner" means the Commissioner of Health.

"Department" means the state Department of Health and includes the central office, regional offices, health districts, and local health departments.

"Eligibility determination" means the process of obtaining required information regarding family size, income, and other related data in order to establish charges to the applicant.

"Extraordinary financial hardship" includes hardship due to such events as natural disasters, damage to or the loss of uninsured real or personal property, unpaid legal liabilities, and obligatory and unavoidable expenditures for close relatives outside the family unit.

"Family" or "family unit" means the applicant and other such household members who together constitute one economic unit. An economic unit is one or more individuals who generally reside together and share income. The economic unit shall count in its income any contributions to the unit from persons not necessarily living with the unit.

A parent may be a biological, adoptive, or stepparent.

A woman who is pregnant may be counted as a multiple beneficiary when the pregnancy has been verified by a physician or a nurse practitioner working under the supervision of a physician.

A husband and wife who are separated and are not living together shall be considered to be separate family units.

"Flat rate charges" means charges for specified goods or services that are to be charged to all clients regardless of income and with no eligibility determination.

"Gross income" means total cash receipts before taxes from all sources. These include money wages and salaries before any deductions, but do not include food or rent in lieu of wages. These receipts include net receipts from nonfarm or farm self-employment (e.g., receipts from an applicant's own business or farm expenses) income, plus any depreciation shown on income tax forms. They include regular payments from social security or railroad retirement, unemployment and workers' compensation, strike benefits from union funds, veterans' benefits, training stipends, alimony, child support, and military family allotments or other regular support from an absent family member or someone not living in the household; private pensions, government employee pensions (including military retirement pay), and regular insurance or annuity payments; and income from dividends, interest, net rental income, net royalties, or periodic receipts from estates or trusts, lump sum settlements, and net gambling or lottery winnings.

"Gross income" does not include the value of food stamps, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) checks, fuel assistance payments, housing assistance, money borrowed, tax refunds, gifts, withdrawal of bank deposits from earned income, earnings of minor children, money received from the sale of property, general relief from the Department of Social Services, or college or university scholarships, grants, fellowships, and assistantships when provided to pay for, or in the form of, tuition, fees, other direct educational expenses, housing, or meals.

"Income scales" means scales based on individual or family gross income. They shall be based on the official federal poverty guidelines updated annually by the U.S. Department of Health and Human Services in accordance with §§ 652 and 6763(2) of the Omnibus Reconciliation Act of 1981 (Public Law 97-35). There shall be two income scales: one for Northern Virginia and one for the remainder of the Commonwealth as follows:

Income Level A – those clients with incomes up to and including 100% of the federal poverty income guidelines will qualify as Income Level A clients, except for Northern Virginia where the Income Level A will be up to and including 110% of the federal poverty income guidelines.

Income Level B – those clients with incomes above 100% and no more than 110% of the federal poverty guidelines will qualify as Income Level B clients, except for Northern Virginia where the Income Level B will be above 110% and no more than 133.3% of the federal poverty income guidelines.

Income Level C – those clients with incomes above 110% and no more than 133.3% of the federal poverty income guidelines will qualify as Income Level C clients, except for Northern Virginia where the Income Level C will be above 133.3% and no more than 166.6% of the federal poverty income guidelines.

Income Level D – those clients with incomes above 133.3% and no more than 166.6% of the federal poverty income guidelines will qualify as Income Level D clients, except for Northern Virginia where the Income Level D will be above 166.6% and no more than 200% of the federal poverty income guidelines.

Income Level E – those clients with incomes above 166.6% and less than 200% of the federal poverty income guidelines will qualify as Income Level E clients, except for Northern Virginia where the Income Level E will be above 200% and less than 233.3% of the federal poverty income guidelines.

Income Level F – those clients with incomes equal to or above 200% and less than 250% of the federal poverty income guidelines will qualify as Income Level F clients, except for Northern Virginia where the Income Level F will be equal to or above 233.3% and less than 283.3% of the federal poverty income guidelines.

Income Level G – those clients with incomes equal to or above 250% of the federal poverty level guidelines will qualify as Income Level G clients, except for Northern Virginia where income level G will be equal to or above 283.3% of the federal poverty income guidelines.

"Medical care services" means clinical medical, dental, and nursing services provided to patients by physicians, dentists, nurses, and other health care providers employed by health districts or contracted by health districts to provide these services. It does not include laboratory tests, pharmaceutical and biological products, radiological or other imaging studies, other goods or products, or other medical services that a health district does not directly provide.

"Medically indigent" means applicants whose individual or family gross income is defined as Income Level A.

"Minor" means a person less than 18 years of age whose parents are responsible for his care. A minor will be considered a separate family unit when married or not living with any relative or deemed an adult.

A minor shall be deemed an adult for the purposes of consenting to:

1. Medical or health services needed to determine the presence of or to treat venereal disease or any infectious or contagious disease which the State Board of Health requires to be reported.

2. Medical and health services required for birth control, pregnancy, or family planning except for the purposes of sexual sterilization.

"Nonchargeable services" means the medical care and related goods and services that the department has determined will be provided without charge and without an eligibility determination to all citizens regardless of income.

"Northern Virginia" means the area which includes the cities of Alexandria, Fairfax, Falls Church, Manassas, Manassas Park, and the counties of Arlington, Fairfax, Loudoun, and Prince William.

"Venereal disease" is synonymous with "sexually transmitted infection."

Statutory Authority

§§ 32.1-11 and 32.1-12 of the Code of Virginia.

Historical Notes

Derived from VR355-39-100 § 1.1, eff. December 1, 1993; amended, Virginia Register Volume 19, Issue 22, eff. August 13, 2003; Volume 20, Issue 22, eff. August 11, 2004.

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