Virginia Law

A. Charges for services means the reasonable charges established by the board for medical care services. No charge shall be established outside the provisions of this chapter. The department may prescribe a scale of discounts for certain medical care services. The commissioner shall publish specific income levels expressed in dollar amounts for determining eligibility for medical care services of the department in accordance with the income scales defined in 12VAC5-200-110.

B. The commissioner shall use the most appropriate current Medicaid charges to establish the fee schedule for services provided by the department pursuant to this chapter. If there is no Medicaid charge for a particular service, the commissioner shall use the most appropriate current Medicare charge. If neither a Medicaid nor a Medicare charge exists for a particular service, the commissioner shall determine an appropriate charge based on the cost of providing the medical care service. Charges for goods and services not directly provided by the agency may be based on the agency's cost. Directors of health districts may request permission from the commissioner or the commissioner's designee to round charges to the nearest whole dollar.

C. If the department provides a medical care service to a patient with private health insurance that covers the service provided, the department shall charge to the private health insurance carrier an amount equal to the allowable charge of the patient's private health insurance coverage. If the health insurance carrier denies a claim for the medical care service, the department may not charge the patient an amount greater than the amount the patient would have paid if the patient did not have private health insurance.

D. On selected occasions it may be desirable to provide certain medical services, such as influenza immunization, to large numbers of people quickly and conveniently and thereby promote their use by the public. In order to accomplish this, districts may charge a flat rate charge for these services under these circumstances. This provision includes services that are otherwise available at a discounted charge. No eligibility determination will be done, and service recipients will be charged the same flat rate charge. However, the district must also provide convenient alternative times and venues where applicants can request an eligibility determination and obtain these services at a discounted rate if eligible. The commissioner or commissioner's designee must approve flat rate charge arrangements in advance, including approval of the specific flat rate charge.

E. Except as otherwise set out in this chapter, charges for certain goods and medical care services may be set at a flat rate charge not subject to discounting. Flat rate charges must be expressly approved by the commissioner or commissioner's designee prior to implementation.