Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-570 - Recipient cost sharing and similar charges

Current through Register Vol. 40, No. 24, July 15, 2024
A. Unless a waiver under
				  42 CFR
				  431.55(g) applies,
				  deductibles, coinsurance rates, and copayments do not exceed the maximum
				  allowable charges under 42
				  CFR 447.54.
B. With respect to individuals covered as
				  categorically needy or as qualified Medicare beneficiaries (as defined in
				  § 1905(p)(1) of the Act) under the plan:
1. No enrollment fee, premium, or similar
				  charge is imposed under the plan.
2. No deductible, coinsurance, copayment, or
				  similar charge is imposed under the plan for the following:
a. Services to individuals under age 21.
				  Reasonable categories of individuals who are age 18 or older, but under age 21,
				  to whom charges apply are listed below, if applicable.
b. Services to pregnant women related to the
				  pregnancy or any other medical condition that may complicate the
				  pregnancy.
c. Charges apply for
				  services to pregnant women unrelated to the pregnancy.
d. Services furnished to any individual who
				  is an inpatient in a hospital, long-term care facility, or other medical
				  institution, if the individual is required, as a condition of receiving medical
				  services in the institution, to spend for medical care costs all but a minimal
				  amount of his or her income required for personal needs.
e. Emergency services if the services meet
				  the requirements in 42 CFR
				  447.53(b)(4).
f. Family planning services and supplies
				  furnished to individuals of childbearing age.
g. Services furnished by a health maintenance
				  organization in which the individual is enrolled.
h. Services furnished to an individual
				  receiving hospice care, as defined in § 1905(o) of the Act.
3. Unless a waiver under
				  42 CFR
				  431.55(g) applies, nominal
				  deductible, coinsurance, copayment, or similar charges are imposed for services
				  that are not excluded from such charges under item B 2 above:
a. For any service, no more than one type of
				  charge is imposed.
b. Charges apply
				  to services furnished to persons 21 or older.
c. For the categorically needy and qualified
				  Medicare beneficiaries,
				  12VAC30-20-150 specifies the:
(1) Service(s) for which a charge is
				  applied;
(2) Nature of the charge
				  imposed on each service;
(3)
				  Amount(s) of and basis for determining the charge(s);
(4) Method used to collect the
				  charge(s);
(5) Basis for
				  determining whether an individual is unable to pay the charge and the means by
				  which such an individual is identified to providers; and
(6) Procedures for implementing and enforcing
				  the exclusions from cost sharing contained in
				  42 CFR
				  447.53(b).
No cumulative maximum applies to deductible, coinsurance,
					 or copayment charges imposed on a specified time period.