LIS

Virginia Law

Administrative Code

Virginia Administrative Code
Title 12. Health
11/21/2024

Agency 30. Department of Medical Assistance Services

Preface

VAC AGENCY NO. 30

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

AGENCY SUMMARY

The Department of Medical Assistance Services (DMAS) is designated as the single state agency to administer the federal Medicaid program under Title XIX of the Social Security Act (42 USC Chapter 7 § 301 et seq.) and the Virginia Children’s Health Insurance Program, known as Family Access to Medical Insurance Security (FAMIS), under Title XXI of the Social Security Act. DMAS plays a critical role in improving the health and well-being of Virginians through access to high-quality health care coverage.

DMAS operates under the supervision of the Secretary of Health and Human Resources.

DMAS regulations are available on the Virginia Regulatory Town Hall at http://townhall.virginia.gov.

Rev. 07/2024

Chapter 5
Public Participation GuidelinesRead all
Part I
Purpose and Definitions
Section 10
Purpose
Section 20
Definitions
Part II
Notification of Interested Persons
Section 30
Notification List
Section 40
Information to Be Sent to Persons on the Notification List
Part III
Public Participation Procedures
Section 50
Public Comment
Section 60
Petition for Rulemaking
Section 70
Appointment of Regulatory Advisory Panel
Section 80
Appointment of Negotiated Rulemaking Panel
Section 90
Meetings
Section 100
Public Hearings on Regulations
Section 110
Periodic Review of Regulations
Chapter 10
State Plan under Title XIX of the Social Security Act Medical Assistance Program; General ProvisionsRead all
Part I
Single State Agency Organization
Section 10
Designation and Authority
Section 20
[Repealed]
Section 30
Statewide Operation
Section 40
State Medical Care Advisory Committee
Section 50
Pediatric Immunization Program
Part II
Coverage and Eligibility
Section 60
Application; Determination of Eligibility and Furnishing Medicaid
Section 70
Coverage and Conditions of Eligibility
Section 80
Residence
Section 90
Blindness
Section 100
Disability
Section 110
Financial Eligibility
Section 120
Medicaid Furnished Out of State
Section 130
Requirements for Advance Directives
Part III
Services; General Provisions
Section 140
Amount, Duration, and Scope of Services: Categorically Needy
Section 150
Amount, Duration, and Scope of Services: Medically Needy
Section 160
Amount, Duration, and Scope of Services: Other Required Special Groups
Section 170
Amount, Duration, and Scope of Services: Limited Coverage for Certain Aliens
Section 180
Amount, Duration, and Scope of Services: Homeless Individuals
Section 190
Amount, Duration, and Scope of Services: Presumptively Eligible Pregnant Women
Section 200
Amount, Duration, and Scope of Services: Epsdt Services
Section 210
Amount, Duration, and Scope of Services: Comparability of Services
Section 220
Amount, Duration, and Scope of Services: Home Health Services
Section 230
Amount, Duration, and Scope of Services: Assurance of Transportation
Section 240
Amount, Duration, and Scope of Services: Payment for Nursing Facility Services
Section 250
Amount, Duration, and Scope of Services: Methods and Standards to Assure Quality of Services
Section 260
Amount, Duration, and Scope of Services: Family Planning Services
Section 270
Amount, Duration, and Scope of Services: Optometric Services
Section 280
Amount, Duration, and Scope of Services: Organ Transplant Procedures
Section 290
Amount, Duration, and Scope of Services: Participation by Indian Health Service Facilities
Section 300
Amount, Duration, and Scope of Services: Respiratory Care Services for Ventilator-Dependent Individuals
Section 310
Coordination of Medicaid with Medicare and Other Insurance: Premiums
Section 320
Coordination of Medicaid with Medicare and Other Insurance: Deductibles/Coinsurance
Section 325
Premiums, Deductibles, Coinsurance and Other Cost Sharing Obligations
Section 330
Medicaid for Individuals Age 65 or over in Institutions for Mental Diseases
Section 340
Special Requirements Applicable to Sterilization Procedures
Section 350
Families Receiving Extended Medicaid Benefits
Section 360
[Reserved]
Part IV
General Program Administration
Section 400
Methods of Administration
Section 410
Hearings for Applicants and Recipients
Section 420
Safeguarding Information on Applicants and Recipients
Section 430
Medicaid Quality Control
Section 435
Medicaid Prohibition on Payments to Institutions or Entities Located Outside of the United States
Section 440
Medicaid Agency Fraud Detection and Investigation Program
Section 441
Medicaid Agency Fraud Detection and Investigation Program
Section 445
Recovery Audit Contractors
Section 450
Reports
Section 460
Maintenance of Records
Section 470
Availability of Agency Program Manuals
Section 480
Reporting Provider Payments to Internal Revenue Service
Section 490
Free Choice of Providers
Section 500
Relations with Standard-Setting and Survey Agencies
Section 510
Consultation to Medical Facilities
Section 520
Required Provider Agreement
Section 530
Utilization and Quality Control
Section 540
Inspection of Care in Intermediate Care Facilities for Persons with Intellectual and Developmental Disabilities, Facilities Providing Inpatient...
Section 550
Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees
Section 560
Liens and Recoveries
Section 570
Recipient Cost Sharing and Similar Charges
Section 580
Payment for Services
Section 590
Direct Payments to Certain Recipients for Physicians' or Dentists' Services
Section 600
Prohibition Against Reassignment of Provider Claims
Section 610
Third Party Liability
Section 620
Use of Contracts
Section 630
[Repealed]
Section 631
Standards for Payment for Nursing Facility and Intermediate Care Facility for the Mentally Retarded Services
Section 640
Program for Licensing Administrators of Nursing Homes
Section 650
Drug Utilization Review Program
Section 660
Disclosure of Survey Information and Provider or Contractor Evaluation
Section 670
Appeals Process
Section 680
Conflict of Interest Provisions
Section 690
Exclusion of Providers and Suspension of Practitioners and Other Individuals
Section 700
Disclosure of Information by Providers and Fiscal Agents
Section 710
Income and Eligibility Verification System
Section 720
Medicaid Eligibility Cards for Homeless Individuals
Section 730
Systematic Alien Verification for Entitlements
Section 740
[Repealed]
Section 750
[Repealed]
Section 751
Enforcement of Compliance for Nursing Facilities
Section 760
Pharmacy Services Rebate Agreement Terms
Section 770
Required Coordination Between the Medicaid and WIC Programs
Section 780
Nurse Aide Training and Competency Evaluation for Nursing Facilities
Section 790
Preadmission Screening and Annual Resident Review in Nursing Facilities
Section 800
Survey and Certification Process
Section 810
Resident Assessment for Nursing Facilities
Section 815
Cooperation with Medicaid Integrity Program Efforts
Section 820
Employee Education About False Claims Recoveries
Part V
Personnel Administration
Section 850
Standards of Personnel Administration
Section 860
[Reserved]
Section 870
Training Programs; Subprofessional and Volunteer Programs
Section 880
[Reserved]
Part VI
Financial Administration
Section 900
Fiscal Policies and Administration
Section 910
Cost Allocation
Section 920
State Financial Participation
Section 930
Hospital Credit Balance Reporting
Section 940
[Reserved]
Part VII
General Provisions
Section 960
Plan Amendments
Section 970
Nondiscrimination
Section 980
[Repealed]
Section 990
State Governor's Review
Section 1000
General Provider Appeals
Chapter 20
Administration of Medical Assistance ServicesRead all
Part I
Miscellaneous Provisions
Section 10
Attorney General's Certification
Section 20
[Repealed]
Section 60
Definition of Medicaid State Plan Health Maintenance Organizations (Hmos)
Section 70
[Repealed]
Section 80
Coordination of Title XIX with Part a and Part B of Title Xviii
Section 90
Confidentiality and Disclosure of Information Concerning Medicaid Applicants and Recipients
Section 100
Standards Governing General and Special Hospitals and Convalescent and Nursing Homes
Section 110
Nursing Facility Resident Drug Utilization Review
Section 120
Cooperative Arrangements with the State Vocational Rehabilitation Agency and with Title V Programs and Grantees
Part II
Liens/Estate Recoveries
Section 130
Lien Recoveries
Section 140
[Repealed]
Section 141
Estate Recoveries
Part III
Recipient Cost Sharing
Section 150
Copayments and Deductibles for Categorically Needy and Qmbs for Services Other Than under 42 CFR 447.53
Section 160
Copayments and Deductibles for Medically Needy and Qmbs for Services Other Than under 42 CFR 447.53
Section 170
Basis of Payment for Reserving Beds During a Recipient's Absence from an Inpatient Facility
Section 180
Definition of a Claim by Service
Part IV
Third Party Liability
Section 190
Requirements for Third Party Liability; Identifying Liable Resources
Section 200
Requirements for Third Party Liability; Payment of Claims
Section 205
Health Insurance Premium Payment for Kids
Section 210
State Method on Cost Effectiveness of Qualified Employer-Sponsored Insurance Plans
Part V
Sanctions, Advance Directives
Section 215
Sanctions for Psychiatric Hospitals
Section 220
Income and Eligibility Verification System Procedures; Requests to Other State Agencies
Section 230
Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals
Section 240
Requirements for Advance Directives under State Plans for Medical Assistance
Section 249
[Repealed]
Part VI
Nursing Facility Enforcement
Section 251
Termination of Provider Agreement
Section 252
Temporary Management
Section 253
Denial of Payment for New Admissions
Section 254
Civil Money Penalty
Section 255
State Monitoring
Section 256
Transfer of Residents; Transfer of Residents with Closure of Facility
Section 257
Required Plan of Correction
Section 258
Appeals
Section 259
Repeated Substandard Quality of Care
Part VII
Specialized Services; Categorical Determinations
Section 260
Definition of Specialized Services
Section 270
Categorical Determinations
Part VIII
Nursing Facilities Survey/Certification
Section 272
Survey and Certification Education Program
Section 274
Process for the Investigation of Allegations of Resident Neglect and Abuse and Misappropriation of Resident Property
Section 275
Procedures for Scheduling and Conduct of Standards Surveys
Section 277
Programs to Measure and Reduce Inconsistency
Section 278
Process for Investigations of Complaints and Monitoring
Part IX
Administration, Civil Rights
Section 280
Methods of Administration; Civil Rights
Part X
[Reserved]
Part XI
[Reserved]
Section 290
[Reserved]
Part XII
Provider Appeals
Section 500
Definitions
Section 510
[Reserved]
Section 520
Provider Appeals: General Provisions
Section 530
[Reserved]
Section 540
Informal Appeals
Section 550
Settlement Agreements
Section 560
Formal Appeals
Section 570
Reconsideration of Final Agency Decision
FORMS
Forms (12VAC30-20)
Chapter 30
Groups Covered and Agencies Responsible for Eligibility DeterminationRead all
Section 5
Definitions
Section 10
Mandatory Coverage: Categorically Needy and Other Required Special Groups
Section 20
Optional Groups Other Than the Medically Needy
Section 30
Optional Coverage of the Medically Needy
Section 40
Reasonable Classifications of Individuals Younger Than Age of 21, 20, 19, or 18 Years
Section 50
More Restrictive Categorical Eligibility Criteria
Section 60
Requirements Relating to Determining Eligibility for Medicare Prescription Drug Low-Income Subsidy
Section 70
Hospital Presumptive Eligibility
Chapter 40
Eligibility Conditions and RequirementsRead all
Part I
General Conditions of Eligibility
Section 10
General Conditions of Eligibility
Part II
Post-Eligibility Treatment of Institutionalized Individuals
Section 20
Post-Eligibility Treatment of Institutionalized Individuals
Section 30
Maintenance Needs of Non-Institutionalized Spouse
Section 40
Children
Section 50
Medical Expenses
Section 60
Maintenance of Residence
Section 70
Ssi Benefits
Section 80
Maintenance Standards
Part III
Financial Eligibility
Section 90
Income and Resource Levels and Methods
Section 100
Methods of Determining Income
Section 105
Financial Eligibility
Section 110
Medicaid Qualifying Trusts
Section 120
Medically Needy Income Levels (Mnils) Based on Family Size
Section 130
Handling of Excess Income; Spend-Down
Section 140
Methods for Determining Resources
Section 150
Resource Standard; Categorically Needy
Section 160
Resource Standard; Medically Needy
Section 170
Resource Standard; Qualified Medicare Beneficiaries and Specified Low-Income Medicare Beneficiaries
Section 180
Qualified Disabled and Working Individuals
Section 190
Excess Resources
Section 200
Effective Date of Eligibility
Section 210
Transfer of Resources - Categorically and Medically Needy, Qualified Medicare Beneficiaries, and Qualified Disabled and Working Individuals
Part IV
Eligibility Requirements
Section 220
Income Eligibility Levels
Section 230
Resource Levels
Section 235
Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered under Medicaid
Section 240
More Restrictive Methods of Treating Resources Than Those of the Ssi Program: § 1902(F) States Only
Section 250
Standards for Optional State Supplementary Payments
Section 260
Income Levels for 1902(F) States; Categorically Needy Who Are Covered under Requirements More Restrictive Than Ssi
Section 270
Resource Standards for 1902(F) States; Categorically Needy
Section 280
More Liberal Income Disregards
Section 290
More Liberal Methods of Treating Resources under §1902(R)(2) of the Act: §1902(F) States
Section 300
Transfer of Resources
Section 310
[Reserved]
Section 320
Consideration of Medicaid Qualifying Trust; Undue Hardship
Section 330
Cost Effectiveness Methodology for Cobra Continuation Beneficiaries
Section 340
Compliance with § 1924 and Obra 90
Section 345
[Repealed]
Section 347
Asset Verification System
Section 348
Adult Group Individual Income-Based Determinations
Part V
State Supplementary Payments
Section 350
Standards for Optional State Supplementary Payments
Section 360
Treatment of Entrance Fees of Individuals Residing in Continuing Care Retirement Communities
Section 370
Variations from the Basic Personal Needs Allowance
Chapter 50
Amount, Duration, and Scope of Medical and Remedial Care ServicesRead all
Part I
Categorically Needy
Section 10
Services Provided to the Categorically Needy with Limitations
Section 20
Services Provided to the Categorically Needy without Limitation
Section 30
Services Not Provided to the Categorically Needy
Section 35
Requirements Relating to Payment for Covered Outpatient Drugs for the Categorically Needy
Part II
Ambulatory Services; Medically Needy
Section 40
Ambulatory Services
Section 50
Services Provided to the Medically Needy with Limitations
Section 60
Services Provided to All Medically Needy Groups without Limitations
Section 70
Services or Devices Not Provided to the Medically Needy
Section 75
Requirements Relating to Payment for Covered Outpatient Drugs for the Medically Needy
Section 80
[Reserved]
Section 95
Reimbursement of Services; in General
Part III
Amount, Duration, and Scope of Services
Section 100
Inpatient Hospital Services Provided at General Acute Care Hospitals and Freestanding Psychiatric Hospitals; Enrolled Providers
Section 105
Inpatient Hospital Services Provided at General Acute Care Hospitals and Freestanding Psychiatric Hospitals; Nonenrolled Providers (Nonparticipating/Out of State)
Section 110
Outpatient Hospital and Rural Health Clinic Services
Section 120
Other Laboratory and X-Ray Services
Section 130
Nursing Facility Services, Epsdt, Including School Health Services and Family Planning
Section 131
Services Provided by Certified Early Intervention Practitioners under Epsdt
Section 140
Physician's Services Whether Furnished in the Office, the Patient's Home, a Hospital, a Skilled Nursing Facility, or Elsewhere
Section 150
Medical Care by Other Licensed Practitioners within the Scope of Their Practice As Defined by State Law
Section 160
Home Health Services
Section 165
Durable Medical Equipment Suitable for Use in the Home
Section 170
Private Duty Nursing Services
Section 180
Clinic Services
Section 190
Dental Services
Section 200
Physical Therapy, Occupational Therapy, and Services for Individuals with Speech, Hearing, and Language Disorders
Section 210
Prescribed Drugs, Dentures, and Prosthetic Devices, and Eyeglasses Prescribed by a Physician Skilled in Diseases of the Eye or by an Optometrist
Section 220
Diagnostic, Screening, Preventive, and Rehabilitative Services Other Than Those Provided Elsewhere in This Plan
Section 225
Rehabilitative Services; Intensive Physical Rehabilitation, and Corf Services
Section 226
Community Mental Health Services
Section 227
Lead Contamination
Section 228
[Repealed]
Section 229
[Reserved]
Section 229.1
[Repealed]
Section 230
Services for Individuals Age 65 or Older in Institutions for Mental Diseases
Section 240
Intermediate Care Services and Intermediate Care Services for Institutions for Mental Disease and Mental Retardation
Section 250
Inpatient Psychiatric Facility Services for Individuals under 21 Years of Age
Section 260
Nurse-Midwife Services
Section 270
Hospice Services (In Accordance with § 1905 (O) of the Act)
Section 280
Case Management Services for High-Risk Pregnant Women and Children Up to Age 1, As Defined in 12VAC30-50-410, in Accordance with § 1915 (G)(1) of ...
Section 290
Extended Services to Pregnant Women
Section 300
Any Other Medical Care and Any Other Type of Remedial Care Recognized under State Law, Specified by the Secretary of Health and Human Services
Section 310
Emergency Services for Aliens
Section 320
Program of All-Inclusive Care for the Elderly (PACE)
Part IV
Case Management Services
Section 321
Eligibility for PACE Enrollees
Section 325
Rates and Payments
Section 328
PACE Enrollment and Disenrollment
Section 330
PACE Definitions
Section 335
General PACE Plan Requirements
Section 340
Criteria for PACE Enrollment
Section 345
PACE Enrollee Rights
Section 350
PACE Enrollee Responsibilities
Section 355
PACE Plan Contract Requirements and Standards
Section 360
PACE Sanctions
Section 410
Case Management Services for High Risk Pregnant Women and Children
Section 415
Case Management for Individuals Receiving Early Intervention (Part C) Services
Section 420
Case Management Services for Seriously Mentally Ill Adults and Emotionally Disturbed Children
Section 430
Case Management Services for Youth at Risk of Serious Emotional Disturbance
Section 440
Support Coordination/Case Management Services for Individuals with Intellectual Disability
Section 450
[Repealed]
Section 460
[Repealed]
Section 470
Case Management for Recipients of Auxiliary Grants
Section 480
Case Management for Foster Care Children
Section 490
Support Coordination/Case Management for Individuals with Developmental Disabilities
Section 491
Substance Use Case Management Services for Individuals Who Have a Primary Diagnosis of Substance Use Disorder
Part V
Expanded Prenatal Care Services
Section 510
Requirements and Limits Applicable to Specific Services: Expanded Prenatal Care Services
Part VI
Drugs or Drug Categories
Section 520
Drugs or Drug Categories Which Are Not Covered
Part VII
Transportation
Section 530
Methods of Providing Transportation
Part VIII
Organ Transplant Services
Section 540
Kidney Transplantation (Kt)
Section 550
Corneal Transplantation
Section 560
Liver, Heart, Lung, Allogeneic and Autologous Bone Marrow Transplantation
Section 570
High Dose Chemotherapy and Bone Marrow/Stem Cell Transplantation (Coverage for Persons over 21 Years of Age)
Section 580
Other Medically Necessary Transplantation Procedures That Are Determined to Not Be Experimental or Investigational (Coverage for Persons Younger ...
Part IX
Commonwealth Coordinated Care Program [Repealed]
Section 600
[Repealed]
Part X
Alternative Benefit Plan
Section 610
Alternative Benefit Plan: Medicaid Expansion
FORMS
Forms (12VAC30-50)
DIBR
Documents Incorporated by Reference (12VAC30-50)
Chapter 60
Standards Established and Methods Used to Assure High Quality CareRead all
Section 5
Applicability of Utilization Review Requirements.
Section 10
Institutional Care
Section 20
Utilization Control: General Acute Care Hospitals; Enrolled Providers
Section 21
Utilization Control of Nonparticipating Out-of-State Inpatient Hospitals
Section 25
Utilization Control: Freestanding Psychiatric Hospitals
Section 30
Utilization Control: Long-Stay Acute Care Hospitals (Nonmental Hospitals)
Section 40
Utilization Control: Nursing Facilities
Section 50
Utilization Control: Intermediate Care Facilities for Persons with Intellectual and Developmental Disabilities and Institutions for Mental Disease
Section 60
[Repealed]
Section 61
Services Related to the Early and Periodic Screening, Diagnosis and Treatment Program (Epsdt); Community Mental Health and Behavioral Therapy Services for Youth
Section 65
Electronic Visit Verification
Section 70
Utilization Control: Home Health Services
Section 75
Durable Medical Equipment (Dme) and Supplies
Section 80
Utilization Control: Optometrists' Services
Section 90
[Repealed]
Section 100
Utilization Control: Incorporation of Specialized Quality Standards
Section 110
Utilization Control: Effect of Geographic Boundaries on Provision of Care
Section 120
Quality Management: Intensive Physical Rehabilitative Services and Comprehensive Outpatient Rehabilitation Facility Services
Section 130
Hospice Services
Section 140
Community Mental Health Services
Section 143
Mental Health Services Utilization Criteria; Definitions
Section 145
Mental Retardation Utilization Criteria
Section 147
[Repealed]
Section 150
Quality Management Review of Outpatient Rehabilitation Therapy Services
Section 160
Utilization Review of Case Management for Recipients of Auxiliary Grants
Section 170
Utilization Review of Treatment Foster Care Case Management Services
Section 180
[Repealed]
Section 181
Utilization Review of Addiction and Recovery Treatment Services
Section 185
Utilization Review of Substance Use Case Management
Section 200
Ticket to Work and Work Incentives Improvement Act (Twwiia) Basic Coverage Group: Alternative Benefits for Medicaid Buy-In Program
Section 300
[Repealed]
Section 301
Definitions
Section 302
Access to Medicaid-Funded Long-Term Services and Supports
Section 303
Screening Criteria for Medicaid-Funded Long-Term Services and Supports
Section 304
Requests and Referrals for Ltss Screening for Adults and Children Living in the Community; Adults and Children in Hospitals; and Adults and Children in Nursing Facilities
Section 305
Screenings in the Community and Hospitals and Nursing Facilities for Medicaid-Funded Long-Term Services and Supports
Section 306
Submission of Ltss Screenings
Section 307
[Repealed]
Section 308
Nursing Facility Admission for Ltss and Level of Care Determination Requirements
Section 310
Competency Training and Testing Requirements
Section 312
[Repealed]
Section 313
Individuals Determined to Not Meet Criteria for Medicaid-Funded Long-Term Services and Supports
Section 315
Periodic Evaluations for Individuals Receiving Medicaid-Funded Long-Term Services and Supports
Section 316
Criteria for Continued Nursing Facility Care Using the Minimum Data Set (Mds)
Section 318
Definitions to Be Applied When Completing the Mds
Section 320
Adult Ventilation/Tracheostomy Specialized Care Criteria
Section 330
[Reserved]
Section 340
Pediatric and Adolescent Specialized Care Criteria
Section 350
Criteria for Coverage of Specialized Treatment Beds
Section 360
[Repealed]
Section 361
Criteria for Supports and Services in Intermediate Care Facilities for Individuals with Intellectual Disabilities
Section 500
[Repealed]
FORMS
Forms (12VAC30-60)
DIBR
[Repealed]
Chapter 70
Methods and Standards for Establishing Payment Rates; in-Patient Hospital CareRead all
Part I
Per Diem Methodology
Section 10
Effect of Participation in Health Insurance for the Aged Program
Section 20
Standards Applied to Non-Participants in Title Xviii Programs
Section 30
Limitations of Medical Assistance Program Payment; Medicare Reimbursement Principles
Section 40
Payment of Reasonable Costs Based on Other Methods
Section 50
Hospital Reimbursement System
Section 60
Establishment of Reasonable and Adequate Payment Rates; Cost Reporting
Section 70
Revaluation of Assets
Section 80
Refund of Overpayments
Section 90
Reimbursement of Certified Hospitals Exempt from Medicare Prospective Payment System
Section 100
Reimbursement of Return on Equity Capital to Proprietary Providers
Section 110
Group Ceiling for State-Owned University Teaching Hospitals
Section 120
[Repealed]
Section 130
Payment Adjustment Fund
Part II
Hospital Appeals of Reimbursement Rates [Repealed]
Section 140
[Repealed]
Part III
Dispute Resolution for State-Operated Facilities
Section 150
Methods and Standards for Establishing Payment Rates - Inpatient Hospital Care: Dispute Resolution for State-Operated Providers
Part IV
[Reserved]
Section 160
[Reserved]
Section 200
[Repealed]
Part V
Inpatient Hospital Payment System
Article 1
Application of Payment Methodologies
Section 201
Application of Payment Methodologies
Section 210
[Repealed]
Section 220
[Repealed]
Article 2
Prospective (DRG-Based) Payment Methodology
Section 221
General
Section 230
[Repealed]
Section 231
Operating Payment for Drg Cases
Section 240
[Repealed]
Section 241
Operating Payment for Per Diem Cases
Section 250
[Repealed]
Section 251
Operating Payment for Transfer Cases
Section 260
[Repealed]
Section 261
Outlier Operating Payment
Section 270
[Repealed]
Section 271
Payment for Capital Costs
Section 280
[Repealed]
Section 281
Payment for Direct Medical Education Costs of Nursing Schools, Paramedical Programs, and Graduate Medical Education for Interns and Residents
Section 290
[Repealed]
Section 291
Payment for Indirect Medical Education Costs
Section 300
[Repealed]
Section 301
Payment to Disproportionate Share Hospitals
Section 310
[Repealed]
Section 311
Hospital Specific Operating Rate Per Case
Section 320
[Repealed]
Section 321
Hospital Specific Operating Rate Per Day
Section 330
[Repealed]
Section 331
Statewide Operating Rate Per Case
Section 340
[Repealed]
Section 341
Statewide Operating Rate Per Day
Section 350
[Repealed]
Section 351
Updating Rates for Inflation
Section 360
[Repealed]
Section 361
Base Year Standardized Operating Costs Per Case
Section 370
[Repealed]
Section 371
Base Year Standardized Operating Costs Per Day
Section 380
[Repealed]
Section 381
Drg Relative Weights and Hospital Case-Mix Indices
Section 390
[Repealed]
Section 391
Recalibration and Rebasing Policy
Article 3
Other Provisions for Payment of Inpatient Hospital Services
Section 400
Determination of Per Diem Rates
Section 410
State University Teaching Hospitals
Section 415
Reimbursement for Freestanding Psychiatric Hospital Services under Epsdt
Section 417
Reimbursement for Inpatient Psychiatric Services in Residential Treatment Facilities (Level C) under Epsdt
Section 418
Reimbursement for Residential and Inpatient Substance Use Treatment Services
Section 420
Reimbursement of Noncost-Reporting General Acute Care Hospital Providers
Section 425
Supplemental Payments for Non-State-Government-Owned Hospitals for Inpatient Services
Section 426
[Repealed]
Section 428
Supplemental Payments for Private Hosptial Partners of Type One Hospitals
Section 430
Medicare Upper Limit
Section 435
Lump Sum Payment
Section 440
[Repealed]
Section 441
Public Comment Process
Section 450
Cost Reporting Requirements
Section 460
Hospital Settlement
Section 470
Underpayments
Section 480
Refund of Overpayments
Section 490
Medicaid Hospital Payment Policy Advisory Council
Section 500
Outlier Methodology Illustration
FORMS
Forms (12VAC30-70)
DIBR
Documents Incorporated by Reference (12VAC30-70)
Chapter 80
Methods and Standards for Establishing Payment Rate; Other Types of CareRead all
Section 10
General
Section 20
Services That Are Reimbursed on a Cost Basis
Section 21
Reimbursement for Services Furnished Individuals Residing in a Freestanding Psychiatric Hospital or Residential Treatment Center (Level C)
Section 25
Reimbursement for Federally Qualified Health Centers (Fqhcs) and Rural Health Clinics (Rhcs)
Section 26
Reimbursement for Indian Health Service Tribal 638 Facilities
Section 30
Fee-For-Service Providers
Section 32
Reimbursement for Substance Use Disorder Services
Section 35
Fee for Service: Ambulatory Surgery Centers
Section 36
Fee-For-Service Providers: Outpatient Hospitals
Section 40
Fee-For-Service Providers: Pharmacy
Section 50
Third Party Liability
Section 60
Reimbursement Audit
Section 70
Fee-For-Service Providers: Transportation
Section 75
Local Education Agency (Lea) Providers
Section 80
Fee-For-Service: Medicare Coinsurance and Deductibles
Section 90
Fee-For-Service: Eyeglasses
Section 95
Fee-For-Service: Hearing Aids (Under Epsdt)
Section 96
Fee-For-Service: Early Intervention (Under Epsdt)
Section 97
Fee-For-Service: Behavioral Therapy Services under Epsdt
Section 100
Fee-For-Service: Expanded Prenatal Care
Section 110
Fee-For-Service: Case Management
Section 111
Treatment Foster Care (Tfc) Case Management
Section 115
Fee-For-Service: Early Discharge Follow-Up Visit for Mothers and Newborns
Section 120
Reimbursement for All Other Nonenrolled Institutional and Noninstitutional Providers
Section 130
Refund of Overpayments
Section 140
[Repealed]
Section 150
Dispute Resolution for State-Operated Providers
Section 160
[Repealed]
Section 170
Payment of Medicare Part a and Part B Deductible/Coinsurance
Section 180
Establishment of Rate Per Visit for Home Health Services
Section 190
State Agency Fee Schedule for Rbrvs
Section 200
Prospective Reimbursement for Rehabilitation Agencies or Comprehensive Outpatient Rehabilitation Facilities
Section 300
Medicare Equivalent of Average Commercial Rate
FORMS
Forms (12VAC30-80)
DIBR
Documents Incorporated by Reference (12VAC30-80)
Chapter 90
Methods and Standards for Establishing Payment Rates for Long-Term CareRead all
Part I
Methods and Standards for Establishing Payment Rates for Long-Term Care
Section 10
Methods and Standards for Establishing Payment Rates for Long-Term Care
Section 11
Public Comment Process
Part II
Nursing Home Payment System
Subpart I
General
Section 19
Supplemental Payments for Government-Owned Nursing Facilities
Section 20
[Repealed]
Section 21
Reimbursement for Individuals in a Disaster Struck Nursing Facility
Section 28
Mid-Year Fair Rental Value Rate Determination
Article 1
Transition to New Capital Payment Methodology
Section 29
Transition to New Capital Payment Methodology
Article 2
Plant Cost Component
Section 30
Plant Cost
Section 31
New Nursing Facilities and Bed Additions
Section 32
Major Capital Expenditures
Section 33
Financing
Section 34
Purchases of Nursing Facilities (Nf)
Article 3
Fair Rental Value Capital Payment System
Section 35
General Applicability
Section 36
Nursing Facility Capital Payment Methodology
Section 37
Calculation of Frv Per Diem Rate for Capital; Calculation of Frv Rental Amount; Change of Ownership
Section 38
Schedule of Assets Reporting
Section 39
Purchases of Nursing Facilities (Nf)
Article 4
Operating Cost Component
Section 40
Operating Cost
Section 41
Nursing Facility Reimbursement Formula
Section 42
[Repealed]
Section 44
Nursing Facility Price-Based Reimbursement Methodology
Section 45
Supplemental Payments for State-Owned Nursing Facilities
Section 46
[Reserved]
Section 47
[Reserved]
Section 48
[Reserved]
Section 49
[Reserved]
Article 5
Allowable Cost Identification
Section 50
Allowable Costs
Section 51
Purchases/Related Organizations
Section 52
Administrator/Owner Compensation
Section 53
Depreciation
Section 54
Rent/Leases
Section 55
Provider Payments
Section 56
Legal Fees/Accounting
Section 57
Documentation
Section 58
Fraud and Abuse
Section 59
[Reserved]
Article 6
New Nursing Facilities
Section 60
Interim Rate
Section 65
Final Rate and Effective for Dates of Services Beginning July 1, 2001, Through June 30, 2014
Article 7
Cost Reports
Section 70
Cost Report Submission
Section 75
Reporting Form; Accounting Method; Cost Report Extensions; Fiscal Year Changes
Article 8
Prospective Rates
Section 80
Time Frames
Article 9
Retrospective Rates
Section 90
Retrospective Rates
Section 100
[Reserved]
Article 10
Record Retention
Section 110
Record Retention
Article 11
Audits
Section 120
Audit Overview; Scope of Audit
Section 121
Field Audit Requirements
Section 122
Provider Notification
Section 123
Field Audit Exit Conference
Section 124
Audit Delay
Section 125
Field Audit Time Frames
Section 126
[Reserved]
Section 130
[Repealed]
Section 136
Elements of Capital Payment Methodology Not Subject to Appeal
Section 137
[Reserved]
Section 140
Individual Expense Limitation
Section 150
Cost Report Preparation Instructions
Article 1
Plant Cost Applicable
Section 160
Stock Acquisition; Merger of Unrelated and Related Parties
Article 2
Capital Cost Applicable
Section 165
Stock Acquisition; Merger of Unrelated and Related Parties
Section 170
Natceps Costs
Section 180
Criminal Records Checks
Section 190
Use of Mmr-240
Section 200
Commingled Investment Income
Section 210
Provider Notification
Section 220
Start-Up Costs
Section 221
Time Frames
Section 222
Organizational Costs
Section 223
[Reserved]
Section 230
Access to Records
Section 240
Home Office Operating Costs
Section 250
Lump Sum Payment
Section 251
Offset
Section 252
Payment Schedule
Section 253
Extension Request Documentation
Section 254
Interest Charge on Extended Repayment
Section 255
[Reserved]
Section 257
Credit Balance Reporting
Section 258
[Reserved]
Section 260
[Repealed]
Section 264
Specialized Care Services
Section 266
Traumatic Brain Injury (Tbi) Payment
Section 267
Private Room Differential
Part III
Nursing Home Payment System Appendices
Appendix I
Uniform Expense Classification
Section 270
Uniform Expense Classification
Section 271
Direct Patient Care Operating
Section 272
Indirect Patient Care Operating Costs
Section 273
Plant Costs
Section 274
Nonallowable Expenses
Section 275
Nurse Aide Training and Competency Evaluation Programs (Natceps) Costs
Section 276
Criminal Records Background Checks
Section 280
Leasing of Facilities
Section 290
Cost Reimbursement Limitations
Section 300
[Repealed]
Section 305
Resource Utilization Groups (Rugs)
Section 306
Case-Mix Index (Cmi)
Section 307
Applicability of Case-Mix Indices (Cmi)
Section 310
Normalized Case Mix Index (Ncmi)
Section 320
National Rug-III Categories and Weights
Part IV
Traumatic Brain Injury Payment System
Section 330
Traumatic Brain Injury Diagnoses
FORMS
Forms (12VAC30-90)
DIBR
Documents Incorporated by Reference (12VAC30-90)
Chapter 95
Standards Established and Methods Used for Fee-For-Service ReimbursementRead all
Section 5
Applicability; General Definitions
Section 10
Timely Claims Filing
Chapter 100
State ProgramsRead all
Part I
(Repealed)
Section 10
[Repealed]
Section 20
[Repealed]
Section 30
[Repealed]
Section 40
[Repealed]
Section 50
[Repealed]
Section 60
[Repealed]
Part II
State/Local Hospitalization Program
Section 70
Definitions
Section 80
Program Established
Section 90
Allocation of Funds
Section 100
Amount, Duration, and Scope of Services Covered
Section 110
Changes in Amount, Duration, and Scope of Services Covered
Section 120
Inpatient Hospital Reimbursement Rate
Section 130
Local Health Department and Outpatient Hospital Clinics Reimbursement
Section 140
Emergency Services Reimbursement
Section 150
Eligibility Criteria
Section 155
Application Not Required
Section 160
Length of Effective Period of Application
Section 170
Persons Eligible for Title XIX Services
Section 180
Appeal
Section 190
State Funds Remaining at the End of the Fiscal Year
Section 200
Determination of Liability for Excess Payments
Part III
HIV Premium Assistance Program
Section 250
Definitions
Section 260
Eligibility Requirements
Section 270
Determination of Countable Income and Liquid Assets
Section 280
Program Application and Enrollment
Section 290
Changes in Eligibility
Section 300
Enrollee Openings
Section 310
Authorization for Benefits
Section 320
Notification
Section 330
Appeals
Section 340
Health Insurance Premium Payments
Section 350
Recovery
Section 360
Fraud
Section 370
Confidentiality
Part IV
Health Insurance for the Working Uninsured (Repealed)
Section 400
[Repealed]
Section 410
[Repealed]
Section 420
[Withdrawn]
Section 430
[Repealed]
Section 440
[Repealed]
Section 450
[Repealed]
Section 460
[Repealed]
Section 470
[Repealed]
Section 480
[Repealed]
Section 490
[Repealed]
FORMS
Forms (12VAC30-100)
Chapter 110
Eligibility and AppealsRead all
Part I
Client Appeals
Subpart I
General
Article 1
Definitions
Section 10
Definitions
Article 2
Appeal System
Section 20
Appeals Division
Section 30
Time Limitation for Appeals
Section 35
Expedited Appeals
Section 40
Judicial Review
Article 3
Representation
Section 50
Right to Representation
Section 60
Designation of Representative
Article 4
Notice and Appeal Rights
Section 70
Notification of Adverse Agency Action
Section 80
Advance Notice
Section 90
Right to Appeal
Section 100
Maintaining Services
Article 5
Miscellaneous Provisions
Section 110
Appeals Division Records
Section 120
Computation of Time Limits
Article 1
Commencement of Appeals
Section 130
Request for Appeal
Section 140
Place of Filing a Request for Appeal
Section 150
Filing Date
Section 160
Time Limit for Filing
Section 170
Extension of Time for Filing
Section 180
Provision of Information
Section 185
Appeal Summary
Article 2
Prehearing Review
Section 190
Review
Section 200
Medical Assessment
Section 210
Prehearing Action
Article 3
Hearing
Section 220
Evidentiary Hearings
Section 230
Scheduling and Rescheduling
Section 240
[Repealed]
Section 250
Notification
Section 260
Postponement
Section 270
Location
Section 280
Client Access to Records
Section 285
Appeals Division Access to Agency Records
Section 290
Subpoenas
Section 300
Role of the Hearing Officer
Section 310
Informality of Hearings
Section 320
Evidence
Section 330
Record of Hearing
Section 340
Oath or Affirmation
Section 350
Dismissal of Request for Appeal
Section 360
Post-Hearing Supplementation of the Record
Section 370
Final Decision and Transmission of the Hearing Record
Section 380
[Repealed]
Section 390
[Repealed]
Part II
Related Cash Assistance Property Rules
Section 610
Definitions
Section 620
Availability of Real or Personal Property
Section 630
Income-Producing Real Property Other Than the Home for Aged, Blind and Disabled Individuals
Section 640
Income
Section 650
Deeming of Income and Resources; Responsibility of Spouses
Section 660
Deeming of Income and Resources; Responsibility of Parents for Blind or Disabled Children
Section 670
Aid to Dependent Children (Adc) Related Medically Needy Individuals
Section 680
Ssi
Section 690
Imposition of Lien
Part III
Related More Liberal Methods of Treating Resources-Transfer of Assets
Section 700
Transfer of Assets
Part IV
Transfer of Resources
Section 710
Undue Hardship; Transfer of Resources
Part V
Married Institutionalized Individuals' Eligibility and Patient Pay
Subpart I
Definitions
Section 720
Definitions
Article 1
General
Section 730
Applicability
Section 740
[Repealed]
Article 2
Assessments of Couple's Resources
Section 741
Resource Assessment Required
Section 744
Resource Assessment Initiated
Section 747
Total Resources
Section 750
Notification of Documentation Required
Section 751
Spousal Share
Section 760
Failure to Provide Documentation
Section 770
Notification of Assessment and Appeal Rights
Section 780
Appeal of Resource Assessment
Article 3
Resource Eligibility Determinations for Institutionalized Spouses
Section 790
Applicability
Section 800
Initial Eligibility Determinations
Section 810
Initial Determinations of Ineligibility
Section 813
Attribution of Resources at the Time of Initial Eligibility Determination
Section 815
Spousal Protected Resource Amounts
Section 820
[Repealed]
Section 830
Additional Resource Exclusions
Section 831
Undue Hardship
Section 840
Separate Treatment of Resources After Eligibility for Benefits Established
Section 850
Post-Eligibility Resource Transfers
Section 853
Community Spouse Resource Allowance
Section 856
Revisions to the Community Spouse Resource Allowance
Section 860
Protected Periods of Eligibility
Section 870
Exception to Protected Period of Eligibility
Section 880
Additional Resources Acquired During Protected Period of Eligibility
Section 890
[Repealed]
Section 900
Resource Eligibility Determinations in Retroactive Months
Section 910
Eligibility for Community Spouses and Other Family Members
Article 4
Income
Section 920
Applicability
Section 921
Treatment of Income
Section 930
Determining Income
Section 940
Applicability
Section 950
Mandatory Deductions from Institutionalized Spouse's Income
Section 960
Community Spouse Income Allowance
Section 970
Family Members Maintenance Needs Allowance
Section 980
Applicability, Notices and Regulatory Authority
Section 990
[Repealed]
Section 1000
[Repealed]
Section 1010
Hearing Officer Authority
Section 1011
Appealable Issues
Part VI
Deduction of Incurred Medical Expenses in Determining Countable Income (Spenddown)
Section 1020
Definitions
Section 1030
Income Eligibility
Section 1040
Spenddown Calculation
Section 1050
Required Deductions Based on Kinds of Services
Section 1060
Required Deductions Based on the Age of Bills
Section 1070
Projection of Expenses
Section 1080
Projection of Institutional Care Expenses
Section 1090
[Reserved]
Section 1100
Individuals and Families with Income Below the Mnil
Section 1110
[Reserved]
Section 1120
Reconciliation
Section 1130
Eligibility
Section 1140
Spenddown Entitlement
Section 1150
Qualified Medicaid Beneficiaries
Section 1160
Retroactive Spenddown; Countable Income; Entitlement Date
Section 1170
[Reserved]
Part VII
Medical Assistance Eligibility Resulting from Welfare Reform
Section 1200
Definitions
Section 1210
[Repealed]
Section 1220
Scope of Coverage
Section 1230
Written Notice and Reporting Requirements
Section 1240
Appeals
Section 1300
[Repealed]
Part VIII
Applications for Medicaid
Section 1350
Definitions
Section 1360
Right to Apply
Section 1370
Applicant's Signature
Section 1380
Authorized Representative for Individual Age 18 or Older
Section 1390
Authorized Representative for Children under 18 Years of Age
Section 1400
Authorized Representative for a Deceased Applicant
Section 1410
Persons Prohibited from Signing an Application
Section 1500
Working Individuals with Disabilities; Basic Coverage Group (Ticket to Work and Work Incentive Improvement Act (Twwiia))
Section 1600
12VAC30-110-1600. (Reserved).
Section 1610
Deemed Newborn Eligibility under Famis.
Section 1620
Coverage of Former Foster Care Youth
Chapter 120
Waivered ServicesRead all
Section 10
[Repealed]
Part I
(Repealed)
Section 61
[Repealed]
Section 62
[Repealed]
Section 63
[Repealed]
Section 64
[Repealed]
Section 65
[Repealed]
Section 66
[Repealed]
Section 67
[Repealed]
Section 68
[Repealed]
Part II
Home and Community-Based Services for Technology Assisted Individual (Repealed)
Section 70
[Repealed]
Section 80
[Repealed]
Section 90
[Repealed]
Section 100
[Repealed]
Section 110
[Repealed]
Section 115
[Repealed]
Section 120
[Repealed]
Section 130
[Repealed]
Part III
Home and Community-Based Services for Individuals with Acquired Immunodeficiency Syndrome (AIDS) and AIDS-Related Complex (Repealed)
Section 140
[Repealed]
Section 150
[Repealed]
Section 160
[Repealed]
Section 165
[Repealed]
Section 170
[Repealed]
Section 180
[Repealed]
Section 190
[Repealed]
Section 195
[Repealed]
Section 200
[Repealed]
Section 201
[Repealed]
Section 210
[Repealed]
Part IV
Mental Retardation Waiver (Repealed)
Section 211
[Repealed]
Section 213
[Repealed]
Section 215
[Repealed]
Section 217
[Repealed]
Section 219
[Repealed]
Section 220
[Repealed]
Section 221
[Repealed]
Section 223
[Repealed]
Section 225
[Repealed]
Section 227
[Repealed]
Section 229
[Repealed]
Section 230
[Repealed]
Section 231
[Repealed]
Section 233
[Repealed]
Section 235
[Repealed]
Section 237
[Repealed]
Section 240
[Repealed]
Section 241
[Repealed]
Section 243
[Repealed]
Section 245
[Repealed]
Section 247
[Repealed]
Section 249
[Repealed]
Section 250
[Repealed]
Part V
Medallion (Repealed)
Section 260
[Repealed]
Section 270
[Repealed]
Section 280
[Repealed]
Section 290
[Repealed]
Section 300
[Repealed]
Section 310
[Repealed]
Section 320
[Repealed]
Section 330
[Repealed]
Section 340
[Repealed]
Section 350
[Repealed]
Part VI
Medallion Mandatory Managed Care
Section 360
Definitions
Section 370
Medallion Mandatory Managed Care Members
Section 380
Medallion Mco Responsibilities
Section 385
[Repealed]
Section 390
Payment Rate for Mcos
Section 395
Preauthorized, Emergency, and Post-Stabilization Services and Payment Rate for Care Provided by Out-of-Network Providers
Section 400
Quality Control and Utilization Review
Section 410
Sanctions
Section 420
Member Grievances and Appeals
Section 430
Provider Grievances, Reconsiderations, and Appeals
Section 440
[Reserved]
Part VII
Commonwealth Coordinated Care Plus Program
Section 450
[Repealed]
Section 460
[Repealed]
Section 470
[Repealed]
Section 480
[Repealed]
Section 490
[Repealed]
Section 600
Definitions
Section 610
Ccc Plus Mandatory Managed Care Members Enrollment Process
Section 615
Ccc Plus Providers; Medicaid Enrollment Process
Section 620
Mco Responsibilities; Sanctions
Section 625
Continuity of Care
Section 630
Covered Services
Section 635
Payment Rates for Mcos
Section 640
State Fair Hearing Process
Section 650
Appeal Timeframes
Section 660
Pre State Fair Hearing Decisions
Section 670
State Fair Hearing Process and Final Decision
Section 680
Appeals Division Records
Section 690
Provider Appeals
Part VIII
Individual and Family Developmental Disabilities Support Waiver
Article 1
General Requirements [Repealed]
Section 700
[Repealed]
Section 710
[Repealed]
Section 720
[Repealed]
Section 730
[Repealed]
Section 740
[Repealed]
Article 2
Covered Services and Limitations and Related Provider Requirements
Section 750
[Repealed]
Section 751
[Repealed]
Section 752
[Repealed]
Section 753
[Repealed]
Section 754
[Repealed]
Section 755
[Repealed]
Section 756
[Repealed]
Section 757
[Repealed]
Section 758
[Repealed]
Section 759
[Repealed]
Section 760
[Repealed]
Section 761
[Repealed]
Section 762
[Repealed]
Section 763
[Repealed]
Section 764
[Repealed]
Section 765
[Repealed]
Section 766
[Repealed]
Section 767
[Repealed]
Section 768
[Repealed]
Section 769
[Repealed]
Section 770
[Repealed]
Section 771
[Repealed]
Section 772
[Repealed]
Section 773
[Repealed]
Section 774
[Repealed]
Section 775
[Repealed]
Section 776
[Repealed]
Section 777
[Repealed]
Section 780
[Repealed]
Section 790
[Repealed]
Part IX
Commonwealth Coordinated Care Plus Waiver
Section 900
Definitions
Section 905
Waiver Description and Legal Authority
Section 910
[Repealed]
Section 920
Individual Eligibility Requirements
Section 924
Covered Services; Limits on Covered Services
Section 925
Respite Coverage in Children's Residential Facilities
Section 927
Exception Criteria for Personal Care Services
Section 930
General Requirements for Home and Community-Based Participating Providers
Section 935
Participation Standards for Specific Covered Services
Section 940
[Repealed]
Section 945
Payment for Covered Services
Section 950
[Repealed]
Section 960
[Repealed]
Section 970
[Repealed]
Section 980
[Repealed]
Section 990
Quality Management Review; Utilization Review; Level of Care (Loc) Reviews.
Section 995
Appeals
Part X
Intellectual Disability Waiver
Article 1
Definitions and General Requirements [Repealed]
Section 1000
[Repealed]
Section 1005
[Repealed]
Section 1010
[Repealed]
Section 1012
[Repealed]
Section 1020
[Repealed]
Section 1030
[Repealed]
Section 1040
[Repealed]
Section 1060
[Repealed]
Section 1062
[Repealed]
Section 1070
[Repealed]
Section 1072
[Repealed]
Section 1080
[Repealed]
Section 1082
[Repealed]
Section 1088
[Repealed]
Section 1090
[Repealed]
Part XV
Day Support Waiver for Individuals with Mental Retardation
Section 1500
[Repealed]
Section 1510
[Repealed]
Section 1520
[Repealed]
Section 1530
[Repealed]
Section 1540
[Repealed]
Section 1550
[Repealed]
Part XVI
Alzheimer's Waiver
Section 1600
[Repealed]
Section 1605
[Repealed]
Section 1610
[Repealed]
Section 1620
[Repealed]
Section 1630
[Repealed]
Section 1640
[Repealed]
Section 1650
[Repealed]
Section 1660
[Repealed]
Section 1670
[Repealed]
Section 1680
[Repealed]
Part XVII
Home and Community-Based Services for Technology Assisted Individuals Waiver [Repealed]
Section 1700
[Repealed]
Section 1705
[Repealed]
Section 1710
[Repealed]
Section 1720
[Repealed]
Section 1730
[Repealed]
Section 1740
[Repealed]
Section 1750
[Repealed]
Section 1760
[Repealed]
Section 1770
[Repealed]
Part XX
Money Follows the Person
Section 2000
Transition Coordinator
Section 2010
Transition Services
FORMS
Forms (12VAC30-120)
DIBR
Documents Incorporated by Reference (12VAC30-120)
Chapter 121
Commonwealth Coordinated Care Program [Repealed]Read all
Section 10
[Repealed]
Section 20
[Repealed]
Section 30
[Repealed]
Section 40
[Repealed]
Section 45
[Repealed]
Section 50
[Repealed]
Section 60
[Repealed]
Section 70
[Repealed]
Section 73
[Repealed]
Section 75
[Repealed]
Section 78
[Repealed]
Section 80
[Repealed]
Section 83
[Repealed]
Section 85
[Repealed]
Section 90
[Repealed]
Section 100
[Repealed]
Section 110
[Repealed]
Section 120
[Repealed]
Section 130
[Repealed]
Section 140
[Repealed]
Section 145
[Repealed]
Section 150
[Repealed]
Section 160
[Repealed]
Section 170
[Repealed]
Section 180
[Repealed]
Section 190
[Repealed]
Section 195
[Repealed]
Section 200
[Repealed]
Section 210
[Repealed]
Section 220
[Repealed]
Section 230
[Repealed]
Section 240
[Repealed]
Section 250
[Repealed]
FORMS
[Repealed]
DIBR
[Repealed]
Chapter 122
Community Waiver Services for Individuals with Developmental DisabilitiesRead all
Section 10
Purpose; Legal Authority; Covered Services; Aggregate Cost Effectiveness; Required Individual and Provider Enrollment; Individual Costs
Section 20
Definitions
Section 30
Waiver Populations; Single Waiver Enrollment; Waiver Termination Upon Loss of Eligibility
Section 40
Waiver Services; When Not Authorized
Section 45
Waiver Slot Allocation Process
Section 50
Criteria for All Individuals Seeking Developmental Disability Waivers Services
Section 60
Financial Eligibility Standards for Individuals
Section 70
Assessment and Enrollment; Virginia Individual Developmental Disabilities Eligibility Survey
Section 80
Waiver Approval Process; Authorizing and Accessing Services
Section 90
Waiting List; Criteria; Slot Assignment; Emergency Access; Reserve Slots
Section 100
Modifications to or Termination of Services
Section 110
Waiver Provider Enrollment
Section 120
Provider Requirements
Section 125
Electronic Visit Verification
Section 130
Provider Termination
Section 140
Provider Confidentiality; Change of Ownership; Completion of Assessment Instruments
Section 150
Requirements for Consumer-Directed Model of Service Delivery
Section 160
Voluntary or Involuntary Disenrollment of Consumer-Directed Services
Section 170
Fiscal Employer/Agent Requirements
Section 180
Orientation Testing; Professional Competency Requirements; Advanced Competency Requirements
Section 190
Individual Support Plan; Plans for Supports; Reevaluation of Service Need
Section 200
Supports Intensity Scale&Reg; Requirements; Virginia Supplemental Questions; Levels of Support; Supports Packages
Section 210
Payment for Covered Services (Tiers)
Section 220
Appeals
Section 230
Utilization Review and Quality Management Review
Section 240
Services Covered in the Building Independence Waiver
Section 250
Services Covered in the Community Living Waiver
Section 260
Services Covered in the Family and Individual Support Waiver
Section 270
Assistive Technology Service
Section 280
Benefits Planning Service
Section 290
Center-Based Crisis Support Service
Section 300
Community-Based Crisis Support Service
Section 310
Community Coaching Service
Section 320
Community Engagement Service
Section 330
Community Guide Service
Section 340
Companion Service
Section 350
Crisis Support Service
Section 360
Electronic Home-Based Support Service
Section 370
Environmental Modifications Service
Section 380
Group Day Service
Section 390
Group Home Residential Service
Section 400
Group and Individual Supported Employment Service
Section 410
In-Home Support Service
Section 420
Independent Living Support Service
Section 430
Individual and Family/Caregiver Training Service
Section 440
Employment and Community Transportation Service
Section 450
Peer Support Service
Section 460
Personal Assistance Service
Section 470
Personal Emergency Response System Service
Section 480
Private Duty Nursing Service
Section 490
Respite Service
Section 500
Services Facilitation Service
Section 510
Shared Living Service
Section 520
Skilled Nursing Service
Section 530
Sponsored Residential Service
Section 540
Supported Living Residential Service
Section 550
Therapeutic Consultation Service
Section 560
Transition Service
Section 570
Workplace Assistance Service
FORMS
Forms (12VAC30-122)
Chapter 129
[Reserved]Read all
Chapter 130
Amount, Duration and Scope of Selected ServicesRead all
Part I
Outpatient Physical Rehabilitative Services (Repealed)
Section 10
[Repealed]
Section 15
[Repealed]
Section 20
[Repealed]
Section 30
[Repealed]
Section 40
[Repealed]
Section 42
[Repealed]
Section 50
[Repealed]
Section 60
[Repealed]
Section 70
[Repealed]
Part II
Long-Stay Acute Care Hospitals
Section 80
Scope
Section 90
Authorization for Services
Section 100
Criteria for Long-Stay Acute Care Hospital Stays
Section 110
Documentation Requirements
Section 120
Long-Stay Acute Care Hospital Services
Section 130
Long-Stay Acute Care Hospital Requirements
Part III
Preadmission Screening and Annual Resident Review
Section 140
Definitions
Section 150
Persons Subject to Nursing Home Preadmission Screening and Identification of Conditions of Mental Illness and Mental Retardation (Level I)
Section 160
Level II Determination
Section 170
Categorical Determinations
Section 180
Annual Resident Review
Section 190
Determinations and Placement of Individuals with Mi or Mr/Rc
Section 200
Pasarr Evaluation Criteria
Section 210
Specialized Services
Section 220
Placement Options
Section 230
Evaluating the Need for Nf Services and Nf Level of Care (Pasarr/Nf)
Section 240
Evaluating Whether an Individual with Mi Requires Specialized Services (Pasarr/Mi)
Section 250
Evaluating Whether an Individual with Mr/Rc Requires Specialized Services (Pasarr/Mr)
Section 260
Appeals
Part IV
Drug Utilization Review Program
Section 270
Definitions
Section 280
Authority
Section 290
Scope and Purpose
Section 300
Retrospective Dur
Section 310
Prospective Dur
Section 320
Criteria and Standards for Dur
Section 330
Educational Program
Section 335
Other Interventions
Section 340
Dur Board
Section 350
Dur Committee
Section 360
Exemption of Organized Health Care Settings
Section 370
[Repealed]
Part V
Drug Utilization Review in Nursing Facilities
Section 380
Definitions
Section 390
Scope
Section 400
Utilization Review Process
Section 410
[Repealed]
Section 420
Medical Quality Assurance
Part VI
Criteria for Intermediate Care for Mentally Retarded Persons
Section 430
Introduction
Section 440
Definitions
Section 450
Patient Assessment Criteria
Section 460
Directions for Applying the Criteria
Part VII
Hospice Services [Repealed]
Section 470
[Repealed]
Part VIII
Community Mental Health and Mental Retardation Services
Section 540
[Repealed]
Section 550
[Repealed]
Section 560
[Repealed]
Section 565
[Repealed]
Section 570
[Repealed]
Section 580
[Repealed]
Section 590
[Repealed]
Part IX
DMAS-225 Adjustment Process
Section 600
Definitions
Section 610
Purpose and Scope
Section 620
Limitations
Part X
New Drug Review Program Regulations [Repealed]
Section 630
[Repealed]
Part XI
New Drugs Not Covered by Medicaid [Repealed]
Section 730
[Repealed]
Part XII
Health Insurance Premium Payment Program (HIPP)
Section 740
General
Section 750
Time Frames for Determining Cost Effectiveness
Section 760
Notices
Section 770
[Reserved]
Section 780
[Repealed]
Section 790
Information Required of Applicants and Recipients
Part XIII
Client Medical Management Programs
Section 800
Definitions
Section 810
Client Medical Management Program for Individuals
Section 820
Client Medical Management Program for Providers
Part XIV
Residential Psychiatric Treatment for Children and Adolescents (Repealed)
Section 850
[Repealed]
Section 860
[Repealed]
Section 870
[Repealed]
Section 880
[Repealed]
Section 890
[Repealed]
Part XV
Case Management Treatment Foster Care Services
Section 900
Definitions
Section 910
Targeted Case Management for Foster Care Children in Treatment Foster Care (Tfc) Covered Services
Section 920
Provider Qualifications
Section 930
Organization and Administration Requirements
Section 940
Discharge from Care
Section 950
Entries in Case Records
Part XVI
Pharmacy Services Prior Authorization
Section 1000
Pharmacy Services Prior Authorization
Part XVII
Marketing of Provider Services
Section 2000
Marketing Requirements and Restrictions
Section 3000
[Repealed]
Section 3010
[Repealed]
Section 3020
[Repealed]
Section 3030
[Repealed]
Part XX
Addiction and Recovery Treatment Services
Section 5000
Addiction and Recovery Treatment Services
Section 5010
Addiction and Recovery Treatment Services; Purpose
Section 5020
Definitions
Section 5030
Eligible Individuals
Section 5040
Covered Services: Requirements; Limits; Standards
Section 5050
Covered Services: Clinic Services - Opioid Treatment Program Services
Section 5060
Covered Services: Clinic Services - Preferred Office-Based Addiction Treatment
Section 5070
Covered Services: Practitioner Services - Early Intervention/Screening Brief Intervention and Referral to Treatment (Asam Level 0.5)
Section 5080
Covered Services: Outpatient Services - Physician Services (Asam Level 1.0)
Section 5090
Covered Services: Community Based Services - Intensive Outpatient Services (Asam Level 2.1)
Section 5100
Covered Services: Community Based Care - Partial Hospitalization Services (Asam Level 2.5)
Section 5110
Covered Services: Clinically Managed Low Intensity Residential Services (Asam Level 3.1)
Section 5120
Covered Services: Clinically Managed Population - Specific High Intensity Residential Service (Asam Level 3.3)
Section 5130
Covered Services: Clinically Managed High Intensity Residential Services (Adult) and Clinically Managed Medium Intensity Residential Services(Adolescent) (Asam Level 3.5)
Section 5140
Covered Services: Medically Monitored Intensive Inpatient Services (Adult) and Medically Monitored High Intensity Inpatient Services (Adolescent) (Asam Level 3.7)
Section 5150
Covered Services: Medically Managed Intensive Inpatient Services (Asam Level 4.0)
Section 5160
Peer Support Services and Family Support Partners: Definitions
Section 5170
Peer Support Services and Family Support Partners: Service Definitions
Section 5180
Peer Support Services and Family Support Partners: Medical Necessity Criteria
Section 5190
Peer Support Services and Family Support Partners: Provider and Setting Requirements
Section 5200
Peer Support Services and Family Support Partners: Documentation of Required Activities
Section 5210
Peer Support Services and Family Support Partners: Limitations and Exclusions to Service Delivery
FORMS
Forms (12VAC30-130)
DIBR
Documents Incorporated by Reference (12VAC30-130)
Chapter 135
Demonstration Waivers (Repealed) [Repealed]Read all
Part I
(Repealed)
Section 10
[Repealed]
Section 20
[Repealed]
Section 30
[Repealed]
Section 40
[Repealed]
Section 50
[Repealed]
Section 60
[Repealed]
Section 70
[Repealed]
Section 80
[Repealed]
Section 90
[Repealed]
Section 100
[Repealed]
Section 110
[Repealed]
Section 120
[Repealed]
Section 130
[Repealed]
Section 140
[Repealed]
Section 150
[Repealed]
Section 160
[Repealed]
Section 170
[Repealed]
Section 180
[Repealed]
Section 190
[Repealed]
Section 200
[Repealed]
Section 210
[Repealed]
Section 220
[Repealed]
Section 230
[Repealed]
Section 240
[Repealed]
Section 250
[Repealed]
Section 260
[Repealed]
Section 270
[Repealed]
Section 280
[Repealed]
Section 290
[Repealed]
Section 300
[Repealed]
Section 310
[Repealed]
Section 320
[Repealed]
Section 330
(Reserved.)
Section 340
[Repealed]
Section 350
(Reserved.)
Section 360
[Repealed]
Part III
Governor's Access Plan Demonstration Waiver for Individuals with Serious Mental Illness
Section 400
[Repealed]
Section 410
[Repealed]
Section 420
[Repealed]
Section 430
[Repealed]
Section 440
[Repealed]
Section 450
[Repealed]
Section 460
[Repealed]
Section 470
[Repealed]
Section 475
[Repealed]
Section 480
[Repealed]
Section 485
[Repealed]
Section 487
[Repealed]
Section 489
[Repealed]
Section 491
[Repealed]
Section 494
[Repealed]
Section 495
[Repealed]
Section 496
[Repealed]
Section 498
[Repealed]
FORMS
[Repealed]
DIBR
[Repealed]
Chapter 140
Virginia Children's Medical Security Insurance Plan [Repealed]Read all
Section 10
[Repealed]
Chapter 141
Family Access to Medical Insurance Security PlanRead all
Part I
General Provisions
Section 10
Definitions
Section 20
Administration and General Background
Section 30
Outreach and Public Participation
Part II
Appeal of Adverse Actions
Section 40
Appeal of Adverse Actions or Adverse Benefit Determinations
Section 50
Notice of Adverse Action or Adverse Benefit Determination
Section 60
Request for Appeal
Section 70
Appeal Procedures
Section 80
[Reserved]
Part III
Eligibility Determination and Application Requirements
Section 100
General Conditions of Eligibility
Section 110
Duration of Eligibility and Renewal
Section 120
[Repealed]
Section 130
Nondiscriminatory Provisions
Section 140
No Entitlement
Section 150
Application Requirements
Part IV
Cost Sharing
Section 160
Copayments for Families Not Participating in Famis Select
Section 170
[Repealed]
Section 175
Famis Select
Section 180
Liability for Excess Benefits; Liability for Excess Benefits or Payments Obtained without Intent; Recovery of Famis Payments
Section 190
[Reserved]
Part V
Benefits and Reimbursement
Section 200
Benefit Packages
Section 210
[Reserved]
Section 500
Benefits Reimbursement
Section 510
[Reserved]
Part VI
Quality Assurance and Utilization Control
Section 560
Quality Assurance
Section 570
Utilization Control
Section 580
[Reserved]
Section 600
Recipient Audit Unit
Section 610
[Reserved]
Section 650
Provider Review
Section 660
Assignment to Managed Care
Part VII
FAMIS MOMS
Section 670
Definitions
Section 680
Administration and General Background
Section 690
Outreach and Public Participation
Section 700
Appeal of Adverse Actions or Adverse Benefit Determinations
Section 710
Notice of Adverse Action or Adverse Benefit Determination
Section 720
Request for Appeal
Section 730
Appeal Procedures
Section 740
General Conditions of Eligibility
Section 750
Duration of Eligibility
Section 760
Pregnant Women Ineligible for Famis Moms
Section 770
Nondiscriminatory Provisions
Section 780
No Entitlement
Section 790
Application Requirements
Section 800
Copayments
Section 810
Liability for Excess Benefits
Section 820
Benefit Packages
Section 830
Benefits Reimbursement
Section 840
Quality Assurance
Section 850
Utilization Control
Section 860
Recipient Audit Unit
Section 870
Provider Review
Section 880
Assignment to Managed Care
Chapter 150
Uninsured Medical Catastrophe FundRead all
Section 10
Definitions
Section 20
Umcf Program Established
Section 30
Criteria for Disbursements from the Umcf
Section 40
Eligibility Criteria
Section 50
Treatment Plan
Section 60
Availability of Funds; No Entitlement
Section 70
Contracts with Providers
Section 80
Payments
Section 90
Application Procedures and Waiting List
Section 100
Appeals

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