Administrative Code

Virginia Administrative Code
10/24/2021

Part III. Recipient Cost Sharing

12VAC30-20-150. Copayments and deductibles for categorically needy and QMBs for services other than under 42 CFR 447.53.

A. The following charges are imposed on the categorically needy and Qualified Medicare Beneficiaries for services other than those provided under 42 CFR 447.53.

Service*

Type Charge

Amount and Basis for Determination

Deduct

Coins

Copay

Inpatient Hospital

-0-

‑0‑

$75

State's average daily payment of $594 is used as basis.

Outpatient Hospital Clinic

‑0‑

‑0‑

$3.00

State's average payment of $136 is used as basis.

Clinic Visit

‑0‑

‑0‑

$1.00

State's average payment of $29 is used as basis.

Physician Office Visit

‑0‑

‑0‑

$1.00

State's average payment of $23 is used as basis.

Eye Examination

‑0‑

‑0‑

$1.00

State's payment of $30 is used as basis.

Prescriptions:

--Generic

‑0‑

‑0‑

$1.00

State's average per generic script of $25 is used as payment basis.

--Brand Name

‑0‑

‑0‑

$3.00

State's average per brand-name script of $97 is used as payment basis.

Home Health Visit

‑0‑

‑0‑

$3.00

State's average payment of $56 is used as basis.

Other Physician Services

‑0‑

‑0‑

$3.00

State's average payment of $56 is used as basis.

Rehab Therapy Services (PT, OT, Sp/Lang.)

‑0‑

‑0‑

$3.00

State's average payment $78 is used as basis.

*NOTE: The applicability of copays to emergency services is discussed further in this section.

B. The method used to collect cost sharing charges for categorically needy individuals requires that providers be responsible for collecting the cost sharing charges from individuals.

C. The basis for determining whether an individual is unable to pay the charge, and the means by which such an individual is identified to providers, is described in this subsection:

Providers will, based on information available to them, make a determination of the recipient's ability to pay the copayment. In the absence of knowledge or indications to the contrary, providers may accept the recipient's assertion that he or she is unable to pay the required copayment.

Recipients have been notified that inability to meet a copayment at a particular time does not relieve them of that responsibility.

D. The procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b) are described in this subsection:

The application and exclusion of cost sharing is administered through the program's Medicaid Management Information System. Documentation of the certified computer system delineates, for each type of provider invoice used, protected eligible groups, protected services and applicable eligible groups and services.

Providers have been informed about: copay exclusions; applicable services and amounts; prohibition of service denial if recipient is unable to meet cost-sharing changes.

E. State policy does not provide for cumulative maximums on charges.

F. Emergency Services. No recipient copayment shall be collected for the following services:

1. Services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:

a. Placing the patient's health in serious jeopardy;

b. Serious impairment to bodily functions; or

c. Serious dysfunction of any bodily organ or part; and

2. All services delivered in emergency rooms.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Historical Notes

Derived from VR460-02-4.1810, eff. July 1, 1993; amended, Virginia Register Volume 19, Issue 18, eff. July 1, 2003; Volume 34, Issue 25, eff. September 5, 2018.

12VAC30-20-160. Copayments and deductibles for medically needy and QMBs for services other than under 42 CFR 447.53.

A. The following charges are imposed on the medically needy and Qualified Medicare Beneficiaries for services other than those provided under 42 CFR 447.53.

Service*

Type Charge

Amount and Basis for Determination

Deduct

Coins

Copay

Inpatient Hospital

-0-

‑0‑

$75

State's average daily payment of $594 is used as basis.

Outpatient Hospital Clinic

‑0‑

‑0‑

$3.00

State's average payment of $136 is used as basis.

Clinic Visit

‑0‑

‑0‑

$1.00

State's average payment of $29 is used as basis.

Physician Office Visit

‑0‑

‑0‑

$1.00

State's average payment of $23 is used as basis.

Eye Examination

‑0‑

‑0‑

$1.00

State's payment of $30 is used as basis.

Prescriptions:

--Generic

‑0‑

‑0‑

$1.00

State's average per generic script of $25 is used as payment basis.

--Brand Name

‑0‑

‑0‑

$3.00

State's average per brand-name script of $97 is used as payment basis.

Home Health Visit

‑0‑

‑0‑

$3.00

State's average payment of $56 is used as basis.

Other Physician Services

‑0‑

‑0‑

$3.00

State's average payment of $56 is used as basis.

Rehab Therapy Services (PT, OT, Sp/Lang.)

‑0‑

‑0‑

$3.00

State's average payment $78 is used as basis.

*NOTE: The applicability of copays to emergency services is discussed further in this section.

B. The method used to collect cost sharing charges for medically needy individuals requires that providers be responsible for collecting the cost sharing charges from individuals.

C. The basis for determining whether an individual is unable to pay the charge, and the means by which such an individual is identified to providers, is described in this subsection:

Providers will, based on information available to them, make a determination of the recipient's ability to pay the copayment. In the absence of knowledge or indications to the contrary, providers may accept the recipient's assertion that he or she is unable to pay the required copayment.

Recipients have been notified that inability to meet a copayment at a particular time does not relieve them of that responsibility.

D. The procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b) are described in this subsection:

The application and exclusion of cost sharing is administered through the program's Medicaid Management Information System. Documentation of the certified computer system delineates, for each type of provider invoice used, protected eligible groups, protected services and applicable eligible groups and services.

Providers have been informed about: copay exclusions; applicable services and amounts; and prohibition of service denial if recipient is unable to meet cost-sharing changes.

E. State policy does not provide for cumulative maximums.

F. Emergency Services. No recipient copayment shall be collected for the following services:

1. Services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:

a. Placing the patient's health in serious jeopardy;

b. Serious impairment to bodily functions; or

c. Serious dysfunction of any bodily organ or part; and

2. All services delivered in emergency rooms.

Statutory Authority

§32.1-324 and 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Historical Notes

Derived from VR460-02-4.1830, eff. July 1, 1993; amended, Virginia Register Volume 19, Issue 18, eff. July 1, 2003; Volume 34, Issue 25, eff. September 5, 2018.

12VAC30-20-170. Basis of payment for reserving beds during a recipient's absence from an inpatient facility.

1. Payment is made for reserving beds in long-term care facilities for recipients during their temporary absence for the following purpose: For leaves of absence up to 18 days per year for any reason other than inpatient hospital admissions.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-02-4.1930, eff. March 1, 1992.

12VAC30-20-180. Definition of a claim by service.

A. Claims.

SERVICE

CLAIM

A) Inpatient Hospital

A Bill for Service

B) Outpatient Hospital

A Bill for Service

C) Rural Health Clinic

A Line Item for Service

D) Laboratory and X-Ray

A Line Item of Service

E) Skilled Nursing

A Bill for Service

F) EPSDT

A Bill for Service

G) Family Planning

A Bill for Service or Line Item depending on provider type

H) Physician

A Line Item of Service

I) Other Medical

A Bill for Service or Line Item depending on provider type

J) Home Health

A Bill for Service

K) Clinic

A Line Item for Service

L) Dental

A Line Item of Service

M) Pharmacy

A Line Item of Service

N) Intermediate Care

A Bill for Service

O) Transportation

A Line Item of Service

P) Physical Therapy

A Bill for Service or Line Item depending on provider type

Q) Nurse Midwife

A Line Item of Service

R) Eyeglasses

A Line Item of Service

B. All providers that enroll with Medicaid on or after October 1, 2011, shall submit electronically all claims for covered services they render in the fee-for-service program under the State Plans for Title XIX and XXI of the Social Security Act, and any waivers thereof, and enroll to receive electronic funds transfer (EFT) for payment of those services. All other providers shall comply with this electronic submission requirement by July 1, 2012.

1. Any provider who cannot comply with this electronic claims submission or EFT requirement may request an exception from DMAS for good cause shown.

2. Good cause may include, but is not limited to, (i) the unavailability of the infrastructure necessary to support electronic claims submission in the provider's geographic region; (ii) the absence of a mechanism for electronic submission for the particular claim type, such as in the case of a temporary detention order; (iii) the provider's inability to transact business through a banking institution capable of EFT; or (iv) financial hardship.

Statutory Authority

§ 32.1-325 of the Code of Virginia; Title XIX, 42 USC § 1396 et seq.

Historical Notes

Derived from VR460-02-4.1950, eff. July 1, 1987; amended, Virginia Register Volume 31, Issue 3, eff. November 6, 2014.

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