Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 80 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATE; OTHER TYPES OF CARE › Section 12VAC30-80-30 - Fee-for-service providers

Current through Register Vol. 40, No. 24, July 15, 2024
A. Payment for the
				following services, except for physician services, shall be the lower of the
				state agency fee schedule (12VAC30-80-190 has
				information about the state agency fee schedule) or actual charge (charge to
				the general public). Except as otherwise noted in this section, state developed
				fee schedule rates are the same for both governmental and private individual
				practitioners. The state agency fee schedule is published on the Department of
				Medical Assistance Services (DMAS) website at
http://www.dmas.virginia.gov/#/searchcptcodes
.
1. Physicians' services. Payment for
				physician services shall be the lower of the state agency fee schedule or
				actual charge (charge to the general public) except that emergency room
				services 99282-99284 with a principal diagnosis on the Preventable Emergency
				Room Diagnosis List shall be reimbursed the rate for 99281. The Preventable
				Emergency Room Diagnosis List shall be based on the list used for managed care
				organization clinical efficiency rate adjustments.
2. Dentists' services. Dental services,
				dental provider qualifications, and dental service limits are identified in
				12VAC30-50-190. Dental services
				are paid based on procedure codes, which are listed in the agency's fee
				schedule. Except as otherwise noted, state-developed fee schedule rates are the
				same for both governmental and private individual practitioners.
3. Mental health services.
a. Professional services furnished by
				nonphysicians as described in
				12VAC30-50-150. These services are
				reimbursed using current procedural technology (CPT) codes. The agency's fee
				schedule rate is based on the methodology as described in subsection A of this
				section.
(1) Services provided by licensed
				clinical psychologists shall be reimbursed at 90% of the reimbursement rate for
				psychiatrists in subdivision A 1 of this section.
(2) Services provided by independently
				enrolled licensed clinical social workers, licensed professional counselors,
				licensed clinical nurse specialists-psychiatric, or licensed marriage and
				family therapists shall be reimbursed at 75% of the reimbursement rate for
				licensed clinical psychologists.
b. Intensive in-home services are reimbursed
				on an hourly unit of service. The agency's rates are set as of July 1, 2011,
				and are effective for services on or after that date.
c. Therapeutic day treatment services are
				reimbursed based on the following units of service: one unit equals two to 2.99
				hours per day; two units equals three to 4.99 hours per day; three units equals
				five or more hours per day. No room and board is included in the rates for
				therapeutic day treatment. The agency's rates are set as of July 1, 2011, and
				are effective for services on or after that date.
d. Therapeutic group home services (formerly
				called level A and level B group home services) shall be reimbursed based on a
				daily unit of service. The agency's rates are set as of July 1, 2011, and are
				effective for services on or after that date.
e. Therapeutic day treatment or partial
				hospitalization services shall be reimbursed based on the following units of
				service: one unit equals two to three hours per day; two units equals four to
				6.99 hours per day; three units equals seven or more hours per day. The
				agency's rates are set as of July 1, 2011, and are effective for services on or
				after that date.
f. Psychosocial
				rehabilitation services shall be reimbursed based on the following units of
				service: one unit equals two to 3.99 hours per day; two units equals four to
				6.99 hours per day; three units equals seven or more hours per day. The
				agency's rates are set as of July 1, 2011, and are effective for services on or
				after that date.
g. Crisis
				intervention services shall be reimbursed on the following units of service:
				one unit equals two to 3.99 hours per day; two units equals four to 6.99 hours
				per day; three units equals seven or more hours per day. The agency's rates are
				set as of July 1, 2011, and are effective for services on or after that
				date.
h. Intensive community
				treatment services shall be reimbursed on an hourly unit of service. The
				agency's rates are set as of July 1, 2011, and are effective for services on or
				after that date.
i. Crisis
				stabilization services shall be reimbursed on an hourly unit of service. The
				agency's rates are set as of July 1, 2011, and are effective for services on or
				after that date.
j. Independent
				living and recovery services (previously called mental health skill building
				services) shall be reimbursed based on the following units of service: one unit
				equals one to 2.99 hours per day; two units equals three to 4.99 hours per day.
				The agency's rates are set as of July 1, 2011, and are effective for services
				on or after that date.
4.
				Podiatry.
5. Nurse-midwife
				services.
6. Durable medical
				equipment (DME) and supplies.
Definitions. The following words and terms when used in this
				  section shall have the following meanings unless the context clearly indicates
				  otherwise:
"DMERC" means the Durable Medical Equipment Regional Carrier
				  rate as published by the Centers for Medicare and Medicaid Services at
http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/DMEPOSFeeSched/DMEPOS-Fee-Schedule.html
.
"HCPCS" means the Healthcare Common Procedure Coding System,
				  Medicare's National Level II Codes, HCPCS 2006 (Eighteenth edition), as
				  published by Ingenix, as may be periodically updated.
a. Obtaining prior authorization shall not
				guarantee Medicaid reimbursement for DME.
b. The following shall be the reimbursement
				method used for DME services:
(1) If the DME
				item has a DMERC rate, the reimbursement rate shall be the DMERC rate minus
				10%. For dates of service on or after July 1, 2014, DME items subject to the
				Medicare competitive bidding program shall be reimbursed the lower of:
(a) The current DMERC rate minus 10%;
				or
(b) The average of the Medicare
				competitive bid rates in Virginia markets.
(2) For DME items with no DMERC rate, the
				agency shall use the agency fee schedule amount. The reimbursement rates for
				DME and supplies shall be listed in the DMAS Medicaid Durable Medical Equipment
				(DME) and Supplies Listing and updated periodically. The agency fee schedule
				shall be available on the agency website at
www.dmas.virginia.gov
.
(3) If a DME item has no DMERC rate or agency
				fee schedule rate, the reimbursement rate shall be the manufacturer's net
				charge to the provider, less shipping and handling, plus 30%. The
				manufacturer's net charge to the provider shall be the cost to the provider
				minus all available discounts to the provider. Additional information specific
				to how DME providers, including manufacturers who are enrolled as providers,
				establish and document their costs for DME codes that do not have established
				rates can be found in the relevant agency guidance
				document.
c. DMAS shall
				have the authority to amend the agency fee schedule as it deems appropriate and
				with notice to providers. DMAS shall have the authority to determine alternate
				pricing, based on agency research, for any code that does not have a
				rate.
d. Certain durable medical
				equipment used for intravenous therapy and oxygen therapy shall be bundled
				under specified procedure codes and reimbursed as determined by the agency.
				Certain services or durable medical equipment such as service maintenance
				agreements shall be bundled under specified procedure codes and reimbursed as
				determined by the agency.
(1) Intravenous
				therapies. The DME for a single therapy, administered in one day, shall be
				reimbursed at the established service day rate for the bundled durable medical
				equipment and the standard pharmacy payment, consistent with the ingredient
				cost as described in
				12VAC30-80-40, plus the pharmacy
				service day and dispensing fee. Multiple applications of the same therapy shall
				be included in one service day rate of reimbursement. Multiple applications of
				different therapies administered in one day shall be reimbursed for the bundled
				durable medical equipment service day rate as follows: the most expensive
				therapy shall be reimbursed at 100% of cost; the second and all subsequent most
				expensive therapies shall be reimbursed at 50% of cost. Multiple therapies
				administered in one day shall be reimbursed at the pharmacy service day rate
				plus 100% of every active therapeutic ingredient in the compound (at the lowest
				ingredient cost methodology) plus the appropriate pharmacy dispensing
				fee.
(2) Respiratory therapies. The
				DME for oxygen therapy shall have supplies or components bundled under a
				service day rate based on oxygen liter flow rate or blood gas levels. Equipment
				associated with respiratory therapy may have ancillary components bundled with
				the main component for reimbursement. The reimbursement shall be a service day
				per diem rate for rental of equipment or a total amount of purchase for the
				purchase of equipment. Such respiratory equipment shall include oxygen tanks
				and tubing, ventilators, noncontinuous ventilators, and suction machines.
				Ventilators, noncontinuous ventilators, and suction machines may be purchased
				based on the individual patient's medical necessity and length of
				need.
(3) Service maintenance
				agreements. Provision shall be made for a combination of services, routine
				maintenance, and supplies, to be known as agreements, under a single
				reimbursement code only for equipment that is recipient owned. Such bundled
				agreements shall be reimbursed either monthly or in units per year based on the
				individual agreement between the DME provider and DMAS. Such bundled agreements
				may apply to, but not necessarily be limited to, either respiratory equipment
				or apnea monitors.
7. Local health services.
8. Laboratory services (other than inpatient
				hospital). The agency's rates for clinical laboratory services were set as of
				July 1, 2014, and are effective for services on or after that date.
9. Payments to physicians who handle
				laboratory specimens, but do not perform laboratory analysis (limited to
				payment for handling).
10. X-ray
				services.
11. Optometry
				services.
12. Reserved.
13. Home health services. Effective June 30,
				1991, cost reimbursement for home health services is eliminated. A rate per
				visit by discipline shall be established as set forth by
				12VAC30-80-180.
14. Physical therapy; occupational therapy;
				and speech, hearing, language disorders services when rendered to
				noninstitutionalized recipients.
15. Clinic services, as defined under
				42 CFR
				440.90, except for services in ambulatory
				surgery clinics reimbursed under
				12VAC30-80-35.
16. Supplemental payments for services
				provided by Type I physicians.
a. In addition
				to payments for physician services specified elsewhere in this chapter, DMAS
				provides supplemental payments to Type I physicians for furnished services
				provided on or after July 2, 2002. A Type I physician is a member of a practice
				group organized by or under the control of a state academic health system or an
				academic health system that operates under a state authority and includes a
				hospital, who has entered into contractual agreements for the assignment of
				payments in accordance with 42 CFR 447.10.
b. The methodology for determining the
				Medicare equivalent of the average commercial rate is described in
				12VAC30-80-300.
c. Supplemental payments shall be made
				quarterly no later than 90 days after the end of the quarter.
d. Effective May 1, 2017, the supplemental
				payment amount for Type I physician services shall be the difference between
				the Medicaid payments otherwise made for physician services and 258% of
				Medicare rates.
17.
				Supplemental payments for services provided by physicians at Virginia
				freestanding children's hospitals.
a. In
				addition to payments for physician services specified elsewhere in this
				chapter, DMAS provides supplemental payments to Virginia freestanding
				children's hospital physicians providing services at freestanding children's
				hospitals with greater than 50% Medicaid inpatient utilization in state fiscal
				year 2009 for furnished services provided on or after July 1, 2011. A
				freestanding children's hospital physician is a member of a practice group (i)
				organized by or under control of a qualifying Virginia freestanding children's
				hospital, or (ii) who has entered into contractual agreements for provision of
				physician services at the qualifying Virginia freestanding children's hospital
				and that is designated in writing by the Virginia freestanding children's
				hospital as a practice plan for the quarter for which the supplemental payment
				is made subject to DMAS approval. The freestanding children's hospital
				physicians also must have entered into contractual agreements with the practice
				plan for the assignment of payments in accordance with
				42 CFR
				447.10.
b. Effective July 1, 2015, the supplemental
				payment amount for freestanding children's hospital physician services shall be
				the difference between the Medicaid payments otherwise made for freestanding
				children's hospital physician services and 178% of Medicare rates as defined in
				the supplemental payment calculation for Type I physician services. Payments
				shall be made on the same schedule as Type I physicians.
18. Supplemental payments for services
				provided by physicians affiliated with Eastern Virginia Medical Center.
a. In addition to payments for physician
				services specified elsewhere in this chapter, the Department of Medical
				Assistance Services provides supplemental payments to physicians affiliated
				with Eastern Virginia Medical Center for furnished services provided on or
				after October 1, 2012. A physician affiliated with Eastern Virginia Medical
				Center is a physician who is employed by a publicly funded medical school that
				is a political subdivision of the Commonwealth of Virginia, who provides
				clinical services through the faculty practice plan affiliated with the
				publicly funded medical school, and who has entered into contractual
				arrangements for the assignment of payments in accordance with
				42 CFR
				447.10.
b. Effective November 1, 2018, the
				supplemental payment amount shall be the difference between the Medicaid
				payments otherwise made for physician services and 145% of the Medicare rates.
				The methodology for determining the Medicare equivalent of the average
				commercial rate is described in
				12VAC30-80-300.
c. Supplemental payments shall be made
				quarterly, no later than 90 days after the end of the
				quarter.
19. Supplemental
				payments for services provided by physicians at freestanding children's
				hospitals serving children in Planning District 8.
a. In addition to payments for physician
				services specified elsewhere in this chapter, DMAS shall make supplemental
				payments for physicians employed at a freestanding children's hospital serving
				children in Planning District 8 with more than 50% Medicaid inpatient
				utilization in fiscal year 2014. This applies to physician practices affiliated
				with Children's National Health System.
b. The supplemental payment amount for
				qualifying physician services shall be the difference between the Medicaid
				payments otherwise made and 178% of Medicare rates but no more than $551,000
				for all qualifying physicians. The methodology for determining allowable
				percent of Medicare rates is based on the Medicare equivalent of the average
				commercial rate described in this chapter.
c. Supplemental payments shall be made
				quarterly no later than 90 days after the end of the quarter. Any quarterly
				payment that would have been due prior to the approval date shall be made no
				later than 90 days after the approval date.
20. Supplemental payments to nonstate
				government-owned or operated clinics.
a. In
				addition to payments for clinic services specified elsewhere in this chapter,
				DMAS provides supplemental payments to qualifying nonstate government-owned or
				government-operated clinics for outpatient services provided to Medicaid
				patients on or after July 2, 2002. Clinic means a facility that is not part of
				a hospital but is organized and operated to provide medical care to
				outpatients. Outpatient services include those furnished by or under the
				direction of a physician, dentist, or other medical professional acting within
				the scope of his license to an eligible individual. Effective July 1, 2005, a
				qualifying clinic is a clinic operated by a community services board. The state
				share for supplemental clinic payments will be funded by general fund
				appropriations.
b. The amount of
				the supplemental payment made to each qualifying nonstate government-owned or
				government-operated clinic is determined by:
(1) Calculating for each clinic the annual
				difference between the upper payment limit attributed to each clinic according
				to subdivision 20 d of this subsection and the amount otherwise actually paid
				for the services by the Medicaid program;
(2) Dividing the difference determined in
				subdivision 20 b (1) of this subsection for each qualifying clinic by the
				aggregate difference for all such qualifying clinics; and
(3) Multiplying the proportion determined in
				subdivision 20 b (2) of this subsection by the aggregate upper payment limit
				amount for all such clinics as determined in accordance with
				42 CFR
				447.321 less all payments made to such
				clinics other than under this section.
c. Payments for furnished services made under
				this section will be made annually in a lump sum during the last quarter of the
				fiscal year.
d. To determine the
				aggregate upper payment limit referred to in subdivision 20 b (3) of this
				subsection, Medicaid payments to nonstate government-owned or
				government-operated clinics will be divided by the "additional factor" whose
				calculation is described in
				12VAC30-80-190 B 2 in regard to
				the state agency fee schedule for Resource Based Relative Value Scale. Medicaid
				payments will be estimated using payments for dates of service from the prior
				fiscal year adjusted for expected claim payments. Additional adjustments will
				be made for any program changes in Medicare or Medicaid
				payments.
21. Personal
				assistance services (PAS) or personal care services for individuals enrolled in
				the Medicaid Buy-In program described in
				12VAC30-60-200 or covered under
				Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), and respite
				services covered under EPSDT. These services are reimbursed in accordance with
				the state agency fee schedule described in
				12VAC30-80-190. The state agency
				fee schedule is published on the DMAS website at
http://www.dmas.virginia.gov
.
				The agency's rates, based upon one-hour increments, were set as of July 1,
				2020, and shall be effective for services on and after that date.
22. Private duty nursing services covered
				under EPSDT are reimbursed based on an hourly unit of service in accordance
				with the state agency fee schedule. The fee schedule is the same for both
				governmental and private providers and was set as of July 1, 2016, and shall be
				effective for services provided on and after that date. The state agency fee
				schedule is published on the DMAS website at
https://www.dmas.virginia.gov/for-providers/procedure-fee-files-cpt-codes/
.
23. Supplemental payments to state-owned or
				state-operated clinics.
a. Effective for
				dates of service on or after July 1, 2015, DMAS shall make supplemental
				payments to qualifying state-owned or state-operated clinics for outpatient
				services provided to Medicaid patients on or after July 1, 2015. Clinic means a
				facility that is not part of a hospital but is organized and operated to
				provide medical care to outpatients. Outpatient services include those
				furnished by or under the direction of a physician, dentist, or other medical
				professional acting within the scope of his license to an eligible
				individual.
b. The amount of the
				supplemental payment made to each qualifying state-owned or state-operated
				clinic is determined by calculating for each clinic the annual difference
				between the upper payment limit attributed to each clinic according to
				subdivision 19 b of this subsection and the amount otherwise actually paid for
				the services by the Medicaid program.
c. Payments for furnished services made under
				this section shall be made annually in lump sum payments to each
				clinic.
d. To determine the upper
				payment limit for each clinic referred to in subdivision 19 b of this
				subsection, the state payment rate schedule shall be compared to the Medicare
				resource-based relative value scale nonfacility fee schedule per Current
				Procedural Terminology code for a base period of claims. The base period claims
				shall be extracted from the Medical Management Information System and exclude
				crossover claims.