Administrative Code

Virginia Administrative Code
6/25/2022

Part III. Application and Charges

12VAC5-200-80. Application process.

Upon an applicant's request for medical care services (excepting those services described in 12VAC5-200-150, 12VAC5-200-160, and 12VAC5-200-170) the department will require information as to the family size, financial status and other related data as described on the application for medical care. The applicant must be informed during the interviewing process of the provisions as described in this section of the regulations.

An application date is established when the applicant completes and signs the application for medical care services.

When an applicant is in need of emergency medical services, the district director, or his designee, shall waive this application process for that individual until such time as the individual is able to participate in the interviewing process.

It is the applicant's responsibility to furnish the department with proof of the applicant's financial data in order to be appropriately classified according to income level and family size so that eligibility for discounts for medical care services can be determined.

Any individual who is acting on behalf of an applicant will be responsible for the accuracy of all financial data provided to the department.

Individuals who have failed to make any payment within the past 90 days for medical care services or other goods or services they have received may have their medical care services terminated. The district director may terminate services only following notice to the individual that such services will be terminated and only after determining that terminating services would not be detrimental to the individual's health. Medical care services cannot be terminated for individuals receiving ongoing care without 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.

12VAC5-200-90. Charges for services.

Charges for services means the reasonable charges established by the board for medical care services. No charge shall be established outside the provisions of these regulations. The department may prescribe a scale of discounts for certain medical care services. Charges will be based on current published Medicaid reimbursement levels. In those instances where Medicaid does not reimburse for a service provided by the department, charges shall be based on the appropriate current Medicare reimbursement levels. Where neither Medicaid nor Medicare reimburse for a service, the commissioner shall establish charges based on the costs of providing the medical care services. 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 commissioner's designee, to round charges to a convenient value.

On selected occasions it may be desirable to provide certain medical services, e.g., 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 all 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 such flat rate charge arrangements in advance, including approval of the specific flat rate charge.

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.

12VAC5-200-100. Flat rate charges.

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. All flat rate charges must be expressly approved by the commissioner or commissioner's designee prior to their implementation.

Statutory Authority

§§ 32.1-11 and 32.1-12 of the Code of Virginia.

Historical Notes

Derived from VR355-39-100 § 3.3, eff. December 1, 1993; amended, Virginia Register Volume 20, Issue 22, eff. August 11, 2004.

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 such 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.

12VAC5-200-110. Income levels for charges.

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 charges made to the applicant shall be subject to 100% discounting for those who are found to be medically indigent as defined in Part I.

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.

12VAC5-200-120. Automatic eligibility.

Applicants receiving the following public assistance program will receive services as Income Level A patients without additional income verification.

General Relief

Title XIX—Medicaid

National School Lunch Program for children receiving school meals at no cost. Only used for child dental services.

Applicants who are eligible for services under this section, and are not participating in Medicaid or any other children's medical insurance program sponsored by the state, should apply for these programs. Applicants who do not apply for Medicaid or a children's medical insurance program within 60 days of receiving services may be assessed the undiscounted charge for the medical care and related goods and services provided.

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.

12VAC5-200-130. Explanation of charges.

Prior to services being rendered, an explanation of the estimated charges, applicable discounts, and expected payment shall be provided to the applicant.

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.

12VAC5-200-140. Redetermination of eligibility.

Eligibility to receive discounts from established charges must be redetermined at least every 12 months, or when income or family status changes, unless otherwise required by law or regulation.

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.

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