Chapter 200. Regulations Governing Eligibility Standards and Charges for Medical Care Services to Individuals
Part I
Definitions
12VAC5-200-10. Definitions.
The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:
"Applicant" means the person requesting medical care services for himself or on whose behalf a request is made.
"Board" means the State Board of Health.
"Child" means a person younger than 18 years of age and includes a biological or adopted child and a child placed for adoption or foster care unless otherwise treated as a separate unit for the purposes of determining eligibility and charges under this chapter.
"Commissioner" means the Commissioner of Health.
"Department" means the Virginia Department of Health and includes the central office, regional offices, health districts, and local health departments.
"Eligibility determination" means the process of obtaining required information regarding family size, income, and other related data in order to establish charges to the applicant.
"Extraordinary financial hardship" includes hardship due to natural disasters, damage to or the loss of uninsured real or personal property, unpaid legal liabilities, and obligatory and unavoidable expenditures for close relatives outside the family unit.
"Family" or "family unit" means the applicant and other household members who together constitute one economic unit. An economic unit is one or more individuals who generally reside together and share income. The economic unit shall count in its income any contributions to the unit from persons not necessarily living with the unit.
A parent may be a biological, adoptive, or stepparent.
A woman who is pregnant may be counted as a multiple beneficiary.
Spouses who are separated and are not living together shall be considered to be separate family units.
"Flat rate charges" means charges for specified goods or services that are to be charged to clients regardless of income and with no eligibility determination.
"Gross income" means total cash receipts before taxes from all sources. These include money wages and salaries before any deductions, but do not include food or rent in lieu of wages. These receipts include net receipts from nonfarm or farm self-employment (e.g., receipts from an applicant's own business or farm expenses) income, plus any depreciation shown on income tax forms. They include regular payments from social security or railroad retirement, unemployment and workers' compensation, strike benefits from union funds, veterans' benefits, training stipends, alimony, child support, and military family allotments or other regular support from an absent family member or someone not living in the household; private pensions, government employee pensions (including military retirement pay), and regular insurance or annuity payments; and income from dividends, interest, net rental income, net royalties, or periodic receipts from estates or trusts, lump sum settlements, and net gambling or lottery winnings.
"Gross income" does not include the value of food stamps, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) checks, fuel assistance payments, housing assistance, money borrowed, tax refunds, gifts, withdrawal of bank deposits from earned income, earnings of minor children, money received from the sale of property, general relief from the Department of Social Services, or college or university scholarships, grants, fellowships, and assistantships when provided to pay for, or in the form of, tuition, fees, other direct educational expenses, housing, or meals.
"Income scales" means scales based on individual or family gross income. They shall be based on the official federal poverty guidelines updated annually by the U.S. Department of Health and Human Services in accordance with § 673(2) of the Omnibus Reconciliation Act of 1981 (Public Law 97-35). There shall be two income scales: one for Northern Virginia and one for the remainder of the Commonwealth.
"Medical care services" means clinical medical, dental, and nursing services provided to patients by physicians, dentists, nurses, and other health care providers employed by health districts or contracted by health districts to provide these services. It does not include laboratory tests, pharmaceutical and biological products, radiological or other imaging studies, other goods or products, or other medical services that a health district does not directly provide.
"Medically indigent" means applicants whose individual or family gross income is defined as Income Level A.
"Minor" means a person younger than 18 years of age whose parents are responsible for the minor's care. A minor will be considered a separate family unit when married or not living with any relative or deemed an adult.
A minor shall be deemed an adult for the purposes of consenting to:
1. Medical or health services needed to determine the presence of or to treat venereal disease or any infectious or contagious disease that the State Board of Health requires to be reported.
2. Medical and health services required for birth control, pregnancy, or family planning except for the purposes of sexual sterilization.
"Nonchargeable services" means the medical care and related goods and services that the department has determined will be provided without charge and without an eligibility determination pursuant to 12VAC5-200-150 to individuals regardless of income.
"Northern Virginia" means the area which includes the cities of Alexandria, Fairfax, Falls Church, Manassas, Manassas Park, and the counties of Arlington, Fairfax, Loudoun, and Prince William.
"Venereal disease" is synonymous with "sexually transmitted infection."
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from VR355-39-100 § 1.1, eff. December 1, 1993; amended, Virginia Register Volume 19, Issue 22, eff. August 13, 2003; Volume 20, Issue 22, eff. August 11, 2004; Volume 42, Issue 9, eff. January 29, 2026.
Part II
General Information
12VAC5-200-20. (Repealed.)
Historical Notes
Derived from VR355-39-100 § 2.1, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; repealed, Virginia Register Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-30. (Repealed.)
Historical Notes
Derived from VR355-39-100 § 2.2, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; repealed, Virginia Register Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-40. (Repealed.)
Historical Notes
Derived from VR355-39-100 § 2.3, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; repealed, Virginia Register Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-50. Recipients of services.
This chapter shall apply to a person seeking medical care services provided by the department, except where other eligibility criteria are required for programs administered under federal statute.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from VR355-39-100 § 2.4, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-60. (Repealed.)
Historical Notes
Derived from VR355-39-100 § 2.5, eff. December 1, 1993; repealed, Virginia Register Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-70. (Repealed.)
Historical Notes
Derived from VR355-39-100 § 2.6, eff. December 1, 1993; repealed, Virginia Register Volume 20, Issue 22, eff. August 11, 2004.
Part III
Application and Charges
12VAC5-200-80. Application process and termination of services.
A. Upon an applicant's request for medical care services, except the services described in 12VAC5-200-150 and 12VAC5-200-160, the applicant or the applicant's authorized representative shall provide to the department accurate information and documentation regarding the applicant's family size, financial status, and other data needed to register the applicant as a patient and classify the applicant into the appropriate income level.
B. The department shall record the applicant's eligibility date as the date on which the applicant signs the Patient Application and Consent for Health Care.
C. If an applicant needs emergency medical services, the district director or the district director's designee shall waive this application process for that individual until the individual is able to participate in the interviewing process.
D. The district director may terminate medical care services to a patient if the patient fails to make a payment for medical care services or other goods or services received from the department within 90 days after receiving the goods or services. The district director may not terminate services without (i) giving notice to the patient or patient's authorized representative of the intent to terminate, (ii) determining that terminating services would not be detrimental to the patient's health, and (iii) for individuals receiving ongoing care, making a good faith effort to secure alternative care.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from VR355-39-100 § 3.1, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-90. Charges for services.
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.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from VR355-39-100 § 3.2, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-100. (Repealed.)
Historical Notes
Derived from VR355-39-100 § 3.3, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; repealed, Virginia Register Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-105. Charges for services and goods provided by contract.
The department, health districts, and local health departments may enter into contracts with agencies external to the department whereby the department, health district, or local health department provides medical services and goods. Charges for services and goods will be determined by the contract. If a patient copayment is required in the contract, the patient shall pay the full copayment to the department, district, or local health department regardless of the patient's income status. The patient shall not be required to pay if state or federal law precludes a copayment.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 20, Issue 22, eff. August 11, 2004; amended, Virginia Register Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-110. Income levels for charges.
A. The department shall annually publish specific income levels expressed in dollar amounts for determining eligibility for discounts to the charges for medical care services. The income levels established by the department shall be as follows:
1. Income Level A - those clients with individual or family incomes up to and including 100% of the federal poverty income guidelines will qualify as Income Level A clients, except for Northern Virginia, where the Income Level A will be up to and including 110% of the federal poverty income guidelines. These clients will be considered medically indigent.
2. Income Level B - those clients with individual or family incomes above 100% and no more than 110% of the federal poverty guidelines will qualify as Income Level B clients, except for Northern Virginia, where the Income Level B will be above 110% and no more than 133.3% of the federal poverty income guidelines.
3. Income Level C - those clients with individual or family incomes above 110% and no more than 133.3% of the federal poverty income guidelines will qualify as Income Level C clients, except for Northern Virginia, where the Income Level C will be above 133.3% and no more than 166.6% of the federal poverty income guidelines.
4. Income Level D - those clients with individual or family incomes above 133.3% and no more than 166.6% of the federal poverty income guidelines will qualify as Income Level D clients, except for Northern Virginia, where the Income Level D will be above 166.6% and no more than 200% of the federal poverty income guidelines.
5. Income Level E - those clients with individual or family incomes above 166.6% and less than 200% of the federal poverty income guidelines will qualify as Income Level E clients, except for Northern Virginia, where the Income Level E will be above 200% and less than 233.3% of the federal poverty income guidelines.
6. Income Level F - those clients with individual or family incomes equal to or above 200% and less than 250% of the federal poverty income guidelines will qualify as Income Level F clients, except for Northern Virginia, where the Income Level F will be equal to or above 233.3% and less than 283.3% of the federal poverty income guidelines.
7. Income Level G - those clients with individual or family incomes equal to or above 250% of the federal poverty level guidelines will qualify as Income Level G clients, except for Northern Virginia, where income level G will be equal to or above 283.3% of the federal poverty income guidelines.
B. Applicants for medical care services, including those in Northern Virginia as defined in Part I, whose family income exceeds Income Level A shall be assessed a charge as follows:
1. Income Level A – 100% discount of the established charge for the service.
2. Income Level B – 90% discount of the established charge for the service.
3. Income Level C – 75% discount of the established charge for the service.
4. Income Level D – 50% discount of the established charge for the service.
5. Income Level E – 25% discount of the established charge for the service.
6. Income Level F – 5.0% discount of the established charge for the service.
7. Income Level G – No discount will be given.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from VR355-39-100 § 3.4, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-120. Automatic eligibility.
The department shall provide services to an applicant receiving assistance from the following programs as Income Level A patients without additional income verification:
1. General Relief.
2. Title XIX-Medicaid.
3. National School Lunch Program for children receiving school meals at no cost. Only applicable to child dental services.
4. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Only applicable to dental varnish services under the Dental Varnish Program for children from six months to three years of age.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from VR355-39-100 § 3.5, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-130. Explanation of charges.
The department shall provide an explanation of the estimated charges, applicable discounts, and expected payment to the applicant before rendering services.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from VR355-39-100 § 3.6, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-140. Redetermination of eligibility.
Unless otherwise required by law or regulation, the department shall redetermine eligibility to receive discounts on established charges every 12 months and when income or family status changes.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from VR355-39-100 § 3.7, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; Volume 42, Issue 9, eff. January 29, 2026.
Part IV
Nonchargeable Services
12VAC5-200-150. Services provided at no charge to the patient.
A. The department shall provide the following services at no charge to the patient:
1. Those immunizations for all children as required by §§ 22.1-271.4 and 32.1-46 of the Code of Virginia.
2. Immunizations for a person up to 22 years of age who is enrolled in a public or private primary or secondary school and lacks evidence of complete and appropriate immunizations for the diseases covered by § 32.1-46 of the Code of Virginia.
3. Examination and testing of persons suspected of having or known to have tuberculosis as required by § 32.1-50 of the Code of Virginia.
4. Examination, testing, and treatment of persons for sexually transmitted diseases as required by § 32.1-57 of the Code of Virginia.
5. Anonymous or confidential testing for human immunodeficiency virus as required by § 32.1-55.1 of the Code of Virginia.
B. The department may provide other medical services at no charge to appropriate citizens of the Commonwealth if directed by the board, the commissioner, or a district health director.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from VR355-39-100 § 4.1, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-160. Immunization services.
The department may provide immunization services free of charge to appropriate individuals in the event of an epidemic or when declared necessary by the commissioner or district health director to protect the public health of all citizens of the Commonwealth.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from VR355-39-100 § 4.2, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004.
12VAC5-200-170. (Repealed.)
Historical Notes
Derived from VR355-39-100 § 4.3, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; repealed, Virginia Register Volume 42, Issue 9, eff. January 29, 2026.
Part V
Exceptions
12VAC5-200-180. (Repealed.)
Historical Notes
Derived from VR355-39-100 § 5.1, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; repealed, Virginia Register Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-190. Limitations.
A. The district director can limit the provision of medical care services based on an assessment of public need and available department resources.
B. The district director may establish policies to limit the provision of medical care services provided by the department based on legal residence and visa status except where federal funds are appropriated for the service.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from VR355-39-100 § 5.2 and § 5.3, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004.
12VAC5-200-200. [Reserved]. (Reserved)
12VAC5-200-210. (Repealed.)
Historical Notes
Derived from VR355-39-100 § 5.4, eff. December 1, 1993; repealed, Virginia Register Volume 20, issue 22, eff. August 11, 2004.
Part VI
Waiver of Charges
12VAC5-200-220. (Repealed.)
Historical Notes
Derived from VR355-39-100 § 6.1, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; repealed, Virginia Register Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-230. Waivers.
A. The commissioner is authorized, and may delegate the authority to a local health director, to grant or deny a waiver to all or a portion of a charge for reasons of unusually serious health problems or extraordinary financial hardship if a patient or the patient's guardian or legal representative applies for a waiver in writing. A resulting waived or partially waived charge shall be determined by the commissioner or designee and reviewed and revised as needed. The commissioner or designee shall also identify those expenses that are considered to be bills for medical care services and shall review and revise this determination as needed.
B. In the event of an adverse decision, the patient, guardian or other authorized person will be advised of their rights to appeal under Part VII (12VAC5-200-270) of this chapter.
C. An approved waiver shall only be effective for the duration of the health or financial hardship or 180 days, whichever is shorter. The commissioner or the commissioner's designee may grant an additional waiver related to the health or financial hardship if the patient or the patient's guardian or legal representative reapplies for the waiver.
D. No person believed to be eligible for Medicaid or any state-sponsored children's medical insurance program and who has failed to complete an application for these programs will be eligible for a waiver.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from VR355-39-100 § 6.2 through § 6.5, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; Volume 42, Issue 9, eff. January 29, 2026.
12VAC5-200-240. [Reserved]. (Reserved)
Part VII
Appeal Process
12VAC5-200-270. Rights.
A. If an applicant for or recipient of medical care services is denied services, has services terminated, wishes to contest the determined income level, or is denied a waiver as defined in Part VI (12VAC5-200-220 et seq.) of this chapter, the applicant or recipient is entitled to appeal that action as set forth under this part.
B. The district director shall notify the applicant or recipient in writing of the appeal process, including time limits, and the right to receive a written statement of the reasons for denial. If a person already receiving services is denied those services, a written notice of termination shall be given 30 days in advance of discontinuing services. The applicant or recipient has the right to confront any witnesses who may have testified against him.
C. An individual or the individual's representative may make a written or oral appeal to the district or program director within 30 days of the denial of service.
D. Upon receipt of the appeal, the district director shall review and make written recommendations to the commissioner or commissioner's designee within 15 days. Within 45 days following the date on which an appeal is filed, the commissioner or commissioner's designee shall make a final decision and notify the district director of the decision in writing.
E. The district director or the program director shall notify the individual or the individual's representative in writing of the final decision.
F. The department shall continue to provide medical care services to the applicant or recipient during the appeal process.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from VR355-39-100 § 7.1, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; Volume 42, Issue 9, eff. January 29, 2026.
Part VIII
Fraud
12VAC5-200-280. Fraud.
If an applicant for or recipient of medical care services is willfully misrepresenting himself or withholding or falsifying information in an attempt to obtain medical services free or at a reduced rate, the district director may discontinue services to the affected person 30 days after notifying the person that services will be discontinued. The affected person is entitled to the appeal process set forth in Part VII (12VAC5-200-270) of this chapter.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from VR355-39-100 § 8.1, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004; Volume 42, Issue 9, eff. January 29, 2026.
Part IX
Charges and Payment Requirements by Income Levels
12VAC5-200-290. Charges and payment requirements.
A. The commissioner shall establish a procedure for the ongoing development, maintenance, revision, and updating of the charges and payments schedules pursuant to this chapter. There shall be two sets of schedules, one for Northern Virginia as defined in 12VAC5-200-10 and one for the remainder of the Commonwealth.
B. The department shall make the charges for medical care services and the income schedules used to determine sliding scale discounts available to the public for inspection and copying at the headquarters, district, and local health department offices of the department.
Statutory Authority
§§ 32.1-11 and 32.1-12 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 20, Issue 22, eff. August 11, 2004; amended, Virginia Register Volume 42, Issue 9, eff. January 29, 2026.