Administrative Code

Virginia Administrative Code
10/22/2021

Part II. State/Local Hospitalization Program

12VAC30-100-70. Definitions.

The following words and terms, when used in this part, shall have the following meaning unless the context clearly indicates otherwise:

"Allocation process" means the process described in § 32.1-345 B of the Code of Virginia, which is used annually to allocate funds appropriated by the General Assembly for this program to counties and cities of the Commonwealth.

"Board of Medical Assistance Services" or "BMAS" means that board established by § 32.1-324 et seq. of the Code of Virginia.

"Bona fide resident" means an individual who has been determined by the local department of social services to be residing in the city or county where making application at the time of or immediately prior to medical treatment with the intent of remaining permanently in that locality and who did not establish residency for the purposes of obtaining benefits.

"Covered ambulatory surgical center services" means those services which are provided by any distinct licensed and certified entity, established by 42 CFR 416.2, that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization, which do not exceed in amount, duration, and scope those available to recipients of medical assistance services as provided in the State Plan for Medical Assistance established by Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia; and which are rendered by providers who have signed agreements to participate in the SLH program and who are enrolled providers in the MAP.

"Covered inpatient services" means inpatient services that do not exceed in amount, duration, and scope those available to recipients of medical assistance services as provided in the State Plan for Medical Assistance established by Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia and that are rendered by providers who have signed agreements to participate in the SLH program and who are enrolled providers in the MAP.

"Covered local public health services" means services provided by local health departments that do not exceed in amount, duration and scope those available to recipients of medical assistance services as provided in the State Plan for Medical Assistance established by Chapter 10 of Title 32.1 of the Code of Virginia and that are rendered by providers who have signed agreements to participate in the SLH program and who are enrolled providers in the MAP.

"Covered outpatient services" means outpatient services, as performed in an outpatient hospital setting, that do not exceed in amount, duration and scope those available to recipients of medical assistance services as provided in the State Plan for Medical Assistance established by Chapter 10 of Title 32.1 of the Code of Virginia and that are rendered by providers who have signed agreements to participate in the SLH program and who are enrolled providers in the MAP.

"Claim" means a request for payment for services rendered.

"Department" or "DMAS" means the Department of Medical Assistance Services established by § 32.1-323 of the Code of Virginia.

"Director" means the Director of the Department of Medical Assistance Services established by § 32.1-323 of the Code of Virginia.

"DRG" means diagnostic related group of codes to define the severity or intensity of illness.

"Enrolled provider" or "providers" means inpatient or outpatient hospitals, free-standing ambulatory surgical centers and local public health departments which have signed agreements to participate in the SLH program and are enrolled providers in the MAP.

"Indigent person" means a person who is a bona fide resident of the county or city, whether gainfully employed or not and who, either by himself or by those upon whom he is dependent, is unable to pay for required hospitalization or treatment. Residence shall not be established for the purpose of obtaining the benefits of this program. Aliens illegally living in the United States and migrant workers shall not be considered bona fide residents of the county or city for purposes of the SLH program.

"Locality" means any city or county which is required by law to participate in the SLH program.

"MAP" or "Medicaid" means the Medical Assistance Program as administered by the Department of Medical Assistance Services.

"Medical emergency" means that a delay in obtaining treatment may cause death or serious impairment of the health of the patient. See 42 CFR 440.170(e).

"Net countable income" means the value of income using the current budget methodology of the Virginia Aid to Families with Dependent Children Program.

"Net countable resources" means the countable value of an applicant's resources using the current budget methodology of the Virginia Aid to Families with Dependent Children Program.

"Payable claim" means a claim for a covered service rendered to an eligible individual with a date of service in the current SLH payment year provided that the claim is submitted for payment before the last payment processing cycle in June and provided there are funds available in the allocation for the locality of residence of the eligible individual.

"SLH payment year" means a year beginning May 1 of any year and ending April 30 of the following year.

"SLH program" means the State/Local Hospitalization Program.

"State Plan" means the State Plan for Medical Assistance for the Commonwealth.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-05-1000.0000 § 1.1, eff. May 1, 1994; amended Virginia Register Volume 12, Issue 18, eff. July 1, 1996.

12VAC30-100-80. Program established.

The State/Local Hospitalization Program is hereby established, within the Department of Medical Assistance Services (DMAS), for indigent persons. The director of the department shall administer this program and expend state and local funds in accordance with the provisions of Chapter 12 (§ 32.1-343 et seq.) of Title 32.1 of the Code of Virginia.

Statutory Authority

§§ 32.1-344 and 32.1-346 of the Code of Virginia.

Historical Notes

Derived from VR460-05-1000.0000 § 2.1, eff. May 1, 1994.

12VAC30-100-90. Allocation of funds.

From the appropriation made by the General Assembly each state fiscal year, the director shall allocate funds to each locality in accordance with provisions of § 32.1-345 of the Code of Virginia. These allocations will be used for the sole purpose of processing payable claims for that SLH payment year.

Statutory Authority

§§ 32.1-344 and 32.1-346 of the Code of Virginia.

Historical Notes

Derived from VR460-05-1000.0000 § 2.2, eff. May 1, 1994.

12VAC30-100-100. Amount, duration, and scope of services covered.

The amount, duration, and scope of services covered by the SLH program shall be equal to the amount, duration, and scope of the same services covered by the MAP established by the State Plan. SLH services shall be limited to inpatient and outpatient hospital services; and to services rendered in free-standing ambulatory surgical centers and local public health departments.

Statutory Authority

§§ 32.1-344 and 32.1-346 of the Code of Virginia.

Historical Notes

Derived from VR460-05-1000.0000 § 3.1, eff. May 1, 1994.

12VAC30-100-110. Changes in amount, duration, and scope of services covered.

Changes in the amount, duration, and scope of services covered by the MAP shall, unless modified by the BMAS, automatically change the amount, duration, and scope of services covered by the SLH program.

Statutory Authority

§§ 32.1-344 and 32.1-346 of the Code of Virginia.

Historical Notes

Derived from VR460-05-1000.0000 § 3.2, eff. May 1, 1994.

12VAC30-100-120. Inpatient hospital reimbursement rate.

The inpatient hospital reimbursement rate shall be consistent with the Medicaid inpatient rate methodology. However, no disproportionate share or medical education adjustment for SLH inpatient hospital reimbursement shall be provided. For the two-year DRG phase-in period beginning July 1, 1996, the daily inpatient hospital reimbursement rate shall be the same as that per diem rate established and in effect on July 1 of each year by DMAS for the specific hospital established by § 32.1-346 B 2 of the Code of Virginia. Inpatient hospital reimbursement rates for SLH services shall not be subject to readjustment through the year-end cost reporting process.

The department shall delay implementation of the Diagnosis Related Groups reimbursement methodology for inpatient hospital services provided under this program until July 1, 1999. Until that time, the daily inpatient hospital reimbursement rate shall be the same as the per diem rate established by the department and in effect on June 30, 1998.

Statutory Authority

§ 32.1-325 of the Code of Virginia and Item 338 C of Chapter 464 of the 1998 Acts of Assembly.

Historical Notes

Derived from VR460-05-1000.0000 § 3.3, eff. May 1, 1994; amended Virginia Register Volume 12, Issue 18, eff. July 1, 1996; Volume 14, Issue 18, eff. July 1, 1998.

12VAC30-100-130. Local health department and outpatient hospital clinics reimbursement.

Reimbursement to local health departments and outpatient hospital clinics shall be an all inclusive fee per visit and at the rate established by § 32.1-346 B 1 of the Code of Virginia. Outpatient hospital clinics reimbursement rates shall not be subject to readjustment through the year-end cost reporting process.

Statutory Authority

§§ 32.1-344 and 32.1-346 of the Code of Virginia.

Historical Notes

Derived from VR460-05-1000.0000 § 3.4, eff. May 1, 1994.

12VAC30-100-140. Emergency services reimbursement.

Reimbursement for hospital emergency room services shall be an all inclusive fee per visit and shall be reimbursed at the rate established by § 32.1-346 B 4 of the Code of Virginia. Emergency room services reimbursement rates shall not be subject to readjustment through the year-end cost reporting process.

Statutory Authority

§§ 32.1-344 and 32.1-346 of the Code of Virginia.

Historical Notes

Derived from VR460-05-1000.0000 § 3.5, eff. May 1, 1994.

12VAC30-100-150. Eligibility criteria.

An individual is eligible to receive SLH program services if he:

1. Has filed an application with the locality where he resides within 30 days of discharge, in the case of inpatient services, or within 30 days of the date of service, in the case of outpatient services;

2. Is a bona fide resident of the locality to which he has applied;

3. Has a net countable income, using the current budget methodology of the Virginia Aid to Families with Dependent Children Program, equal to or less than 100% of the federal nonfarm poverty income guidelines as published for the then current year in the United States Code of Federal Regulations (CFR), except that localities which in fiscal year 1989 used a higher income level may continue to use the 1989 income level in subsequent years; and

4. Has net countable resources, using the current budget methodology of the Virginia Aid to Families with Dependent Children Program, equal to or less than the then current resource standards of the federal Supplemental Security Income Program (SSI).

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-05-1000.0000 § 4.1, eff. May 1, 1994; amended Virginia Register Volume 12, Issue 18, eff. July 1, 1996.

12VAC30-100-155. Application not required.

The locality where the applicant resides is not required to accept an application to receive SLH program services from an individual after SLH locality funds have been exhausted for the fiscal year.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 12, Issue 18, eff. July 1, 1996.

12VAC30-100-160. Length of effective period of application.

An eligibility decision favorable to the applicant shall remain in effect for a period of 180 days. If the recipient requires further medical treatment during the eligibility period, no new application shall be required. If the eligibility period has expired a new application shall be required.

Statutory Authority

§§ 32.1-344 and 32.1-346 of the Code of Virginia.

Historical Notes

Derived from VR460-05-1000.0000 § 4.2, eff. May 1, 1994.

12VAC30-100-170. Persons eligible for Title XIX services.

Persons who have been determined eligible for services as defined by and contained in the Social Security Act Title XIX shall not be eligible for SLH program benefits established by § 32.1-346 B 3 of the Code of Virginia. This exclusion does not apply to Medicaid-eligible individuals who are enrolled in the Family Planning Waiver described in 12VAC30-135-10 through 12VAC30-135-40, or those determined eligible as a Qualified Medicare Beneficiary (QMB). Individuals determined eligible for Medicare coverage as a QMB may be determined eligible for SLH program benefits for the months prior to their enrollment for services as a QMB.

Statutory Authority

§§ 32.1-324, 32.1-325, 32.1-344, 32.1-346 and 32.1-347 of the Code of Virginia.

Historical Notes

Derived from VR460-05-1000.0000 § 4.3, eff. May 1, 1994; amended, Virginia Register Volume 24, Issue 25, eff. October 2, 2008.

12VAC30-100-180. Appeal.

An applicant for SLH may appeal an appealable adverse determination regarding eligibility for services or liability for excess payments as defined in § 32.1-349 of the Code of Virginia. SLH appeals will follow the procedures established by Medicaid for client appeals. Exhaustion of appropriated funds in a given locality for payment of SLH services is not an appealable issue. Funds allocated for one fiscal year shall not be used to pay for provider claims in another fiscal year.

Statutory Authority

§§ 32.1-344 and 32.1-346 of the Code of Virginia.

Historical Notes

Derived from VR460-05-1000.0000 § 4.4, eff. May 1, 1994.

12VAC30-100-190. State funds remaining at the end of the fiscal year.

State funds remaining at the end of the fiscal year shall be used as an offset to the calculated local share for the following year. The funds shall be allocated among localities in accordance with a procedure established by DMAS to ensure that state funds remaining at the end of the fiscal year are used first to offset increases in calculated local shares, then to offset calculated local share for all localities. Remaining state funds shall be applied toward offsetting calculated local share only and shall not be added to a locality's base allocation. State funds remaining at the end of the state fiscal year shall not be used for other purposes including payment for claims rendered in a prior SLH payment year.

Statutory Authority

§§ 32.1-344 and 32.1-346 of the Code of Virginia.

Historical Notes

Derived from VR460-05-1000.0000 § 5.1, eff. May 1, 1994.

12VAC30-100-200. Determination of liability for excess payments.

The department shall be employed to recover excess SLH payments. Such disputes shall be heard in accordance with the Administrative Process Act. Potential fraud cases shall be referred to the appropriate law-enforcement agency.

Statutory Authority

§§ 32.1-344 and 32.1-346 of the Code of Virginia.

Historical Notes

Derived from VR460-05-1000.0000 § 6.1, eff. May 1, 1994.

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