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. 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.