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.