reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Form - FORMS (12VAC30-60)

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia
				  Individual Developmental Disabilities Eligibility Survey - Infants' Version,
				  P235 (eff. 3/2016)
Virginia
				  Individual Developmental Disabilities Eligibility Survey - Children's Version,
				  P236 (eff. 3/2016)
Virginia
				  Individual Developmental Disabilities Eligibility Survey - Adults' Version,
				  P237 (eff. 3/2016)
Statutory Authority: §
											32.1-325
					 of the Code of Virginia;
					 42 USC §
												1396 et
					 seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 60 - STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE › Section - DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-60)

Current through Register Vol. 40, No. 24, July 15, 2024
Department of Medical Assistance Services Provider Manuals
				  (
https://www.virginiamedicaid.dmas.virginia.gov/wps/portal/ProviderManuals
):
Virginia Medicaid Nursing Home Manual
Virginia Medicaid Rehabilitation Manual
Virginia Medicaid Hospice Manual
Virginia Medicaid School Division Manual
Development of Special Criteria for the Purposes of
				  Pre-Admission Screening, Medicaid Memo, October 3, 2012, Department of Medical
				  Assistance Services [File Link Not Available]
Diagnostic and Statistical Manual of Mental Disorders, Fourth
				  Edition (DSM-IV-TR), copyright 2000, American Psychiatric Association
Patient Placement Criteria for the Treatment of
				  Substance-Related Disorders (ASAM PPC-2R), Second Edition, copyright 2001,
				  American Society on Addiction Medicine, Inc.
Medicaid Memo, Reissuance of the Pre-Admission Screening
				  (PAS) Provider Manual, Chapter IV, November 22, 2016, Department of Medical
				  Assistance Services [File Link Not Available]
Medicaid Special Memo, Subject: New Service Authorization
				  Requirement for an Independent Clinical Assessment for Medicaid and FAMIS
				  Children's Community Mental Health Rehabilitative Services, dated June 16,
				  2011, Department of Medical Assistance Services [File Link Not
				  Available]
Medicaid Special Memo, Subject: Changes to Children Community
				  Mental Health Rehabilitative Services - Children's Services, July 1, 2010 &
				  September 1, 2010, dated July 23, 2010, Department of Medical Assistance
				  Services [File Link Not Available]
Medicaid Special Memo, Subject: Changes to Community Mental
				  Health Rehabilitative Services - Adult-Oriented Services, July 1, 2010 &
				  September 1, 2010, dated July 23, 2010, Department of Medical Assistance
				  Services [File Link Not Available]
Approved Degrees in Human Services and Related Fields for
				  QMHP Registration, adopted November 3, 2017, revised February 9, 2018 [File
				  Link Not Available]
Part XIV Residential Psychiatric Treatment for Children and
				  Adolescents (Repealed)
Statutory Authority: §
											32.1-325
					 of the Code of Virginia,
					 42 USC §
												1396 et
					 seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part I - Per Diem Methodology › Section 12VAC30-70-10 - Effect of participation in Health Insurance for the Aged program

Current through Register Vol. 40, No. 24, July 15, 2024
For each hospital also participating in the Health
					 Insurance for the Aged program under Title XVIII of the Social Security Act,
					 the state agency will apply the standards, cost reporting period, cost
					 reimbursement principles, and method of cost apportionment currently used in
					 computing reimbursement to such a hospital under Title XVIII of the Act, except
					 that the inpatient routine service costs for medical assistance recipients will
					 be determined subsequent to the application of the Title XVIII method of
					 apportionment, and the calculation will exclude the applicable Title XVIII
					 inpatient routine service charges or patient days as well as Title XVIII
					 inpatient routine service cost.
Statutory Authority
Social Security Act Title XIX; 42 CFR Part 430 to end;
						all other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part I - Per Diem Methodology › Section 12VAC30-70-20 - Standards applied to non-participants in Title XVIII programs

Current through Register Vol. 40, No. 24, July 15, 2024
For each hospital not participating in the Program under
					 Title XVIII of the Act, the state agency will apply the standards and
					 principles described in 42
					 CFR 447.250 and either (a) one of the
					 available alternative cost apportionment methods in
					 42 CFR
					 447.250, or (b) the "Gross RCCAC method" of
					 cost apportionment applied as follows: For a reporting period, the total
					 allowable hospital inpatient charges; the resulting percentage is applied to
					 the bill of each inpatient under the Medical Assistance
					 Program.
Statutory Authority
Social Security Act Title XIX; 42 CFR Part 430 to end;
						all other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part I - Per Diem Methodology › Section 12VAC30-70-30 - Limitations of Medical Assistance Program payment; Medicare reimbursement principles

Current through Register Vol. 40, No. 24, July 15, 2024
For either participating or nonparticipating facilities,
					 the Medical Assistance Program will pay no more in the aggregate for inpatient
					 hospital services that the amount it is estimated would be paid for the
					 services under the Medicare principles of reimbursement, as set forth in
					 42 CFR
					 447.253(b)(2), and/or lesser
					 of reasonable cost or customary charges in
					 42 CFR
					 447.250.
Statutory Authority
Social Security Act Title XIX; 42 CFR Part 430 to end;
						all other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part I - Per Diem Methodology › Section 12VAC30-70-40 - Payment of reasonable costs based on other methods

Current through Register Vol. 40, No. 24, July 15, 2024
The state agency will apply the standards and principles
					 as described in the state's reimbursement plan approved by the Secretary, HHS
					 on a demonstration or experimental basis for the payment of reasonable costs by
					 methods other than those described in
					 12VAC30-70-10 and
					 12VAC30-70-20.
Statutory Authority
Social Security Act Title XIX; 42 CFR Part 430 to end;
						all other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part I - Per Diem Methodology › Section 12VAC30-70-60 - Establishment of reasonable and adequate payment rates; cost reporting

Current through Register Vol. 40, No. 24, July 15, 2024
In accordance with Title 42 §§ 447.250 through
					 447.272 of the Code of Federal Regulations which implements §
					 1902(a)(13)(A) of the Social Security Act, the Department of Medical Assistance
					 Services ("DMAS") establishes payment rates for services that are reasonable
					 and adequate to meet the costs that must be incurred by efficiently and
					 economically operated facilities to provide services in conformity with state
					 and federal laws, regulations, and quality and safety standards. To establish
					 these rates Virginia uses the Medicare principles of cost reimbursement in
					 determining the allowable costs for Virginia's prospective payment system.
					 Allowable costs will be determined from the filing of a uniform cost report by
					 participating providers. The cost reports are due not later than 90 days after
					 the provider's fiscal year end. If a complete cost report is not received
					 within 90 days after the end of the provider's fiscal year, the Program shall
					 take action in accordance with its policies to assure that an overpayment is
					 not being made. The cost report will be judged complete when DMAS has all of
					 the following:
A. Completed cost
				  reporting form(s) provided by DMAS, with signed certification(s);
B. The provider's trial balance showing
				  adjusting journal entries;
C. The
				  provider's financial statements including, but not limited to, a balance sheet,
				  a statement of income and expenses, a statement of retained earnings (or fund
				  balance), a statement of charges in financial position, and footnotes to the
				  financial statements;
D. Schedules
				  which reconcile financial statements and trial balance to expenses claimed in
				  the cost report;
E. Home office
				  cost report, if applicable; and
F.
				  Such other analytical information or supporting documents requested by DMAS
				  when the cost reporting forms are sent to the provider.
Although utilizing the cost apportionment and cost finding
					 methods of the Medicare Program, Virginia does not adopt the prospective
					 payment system of the Medicare Program enacted October 1,
					 1983.
Statutory Authority
Social Security Act Title XIX; 42 CFR Part 430 to end;
						all other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part I - Per Diem Methodology › Section 12VAC30-70-70 - Revaluation of assets

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Effective July 1, 2008, the valuation of an asset of a hospital or long-term
				  care facility which has undergone a change of ownership on or after July 18,
				  1984, shall be the lesser of the seller's allowable depreciated historical cost
				  (net book value) as determined for Medicaid reimbursement of the owner of
				  record as of July 18, 1984, or the acquisition cost to the new owner.
B. In the case of an asset not in existence
				  as of July 18, 1984, the valuation of an asset of a hospital or long-term care
				  facility shall be the lesser of the seller's allowable depreciated historical
				  cost (net book value) as determined for Medicaid reimbursement of the first
				  owner of record, or the acquisition cost to the new owner.
C. In establishing appropriate allowance for
				  depreciation, interest on capital indebtedness, and return on equity (if
				  applicable prior to July 1, 1986) the base to be used for such computations
				  shall be limited to subsection A or B of this section.
D. Costs (including legal fees, accounting
				  and administrative costs, travel costs, and feasibility studies) attributable
				  to the negotiation or settlement of the sale or purchase of any capital asset
				  (by acquisition or merger) shall be reimbursable only to the extent that they
				  have not been previously reimbursed by Medicaid.
E. Rental charges in sale and leaseback
				  agreements shall be restricted to the depreciation, mortgage interest and (if
				  applicable prior to July 1, 1986) return on equity based on cost of ownership
				  as determined in accordance with subsections A and B of this section.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part I - Per Diem Methodology › Section 12VAC30-70-90 - Reimbursement of certified hospitals exempt from Medicare Prospective Payment system

Current through Register Vol. 40, No. 24, July 15, 2024
Effective October 1, 1986, hospitals that have obtained
					 Medicare certification as inpatient rehabilitation hospitals or rehabilitation
					 units in acute care hospitals, which are exempted from the Medicare Prospective
					 Payment System (DRG), shall be reimbursed in accordance with the current
					 Medicaid Prospective Payment System as described in the
					 12VAC30-70-10 through
					 12VAC30-70-80, excluding
					 12VAC30-70-50(6).
					 Additionally, rehabilitation hospitals and rehabilitation units of acute care
					 hospitals which are exempt from the Medicare Prospective Payment System will be
					 required to maintain separate cost accounting records, and to file separate
					 cost reports annually utilizing the applicable Medicare cost reporting forms
					 (HCFA 2552 series) and the Medicaid forms (MAP-783 series).
A new facility shall have an interim rate determined using
					 a pro forma cost report or detailed budget prepared by the provider and
					 accepted by the DMAS, which represents its anticipated allowable cost for the
					 first cost reporting period of participation. For the first cost reporting
					 period, the provider will be held to the lesser of its actual operating cost or
					 its peer group ceiling. Subsequent rates will be determined in accordance with
					 the current Medicaid Prospective Payment System as noted in the preceding
					 paragraph.
Statutory Authority
Social Security Act Title XIX; 42 CFR Part 430 to end;
						all other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part I - Per Diem Methodology › Section 12VAC30-70-100 - Reimbursement of return on equity capital to proprietary providers

Current through Register Vol. 40, No. 24, July 15, 2024
Item 398D of the 1987 Appropriation Act (as amended),
					 effective April 8, 1987, eliminated reimbursement of return on equity capital
					 to proprietary providers.
Statutory Authority
Social Security Act Title XIX; 42 CFR Part 430 to end;
						all other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part I - Per Diem Methodology › Section 12VAC30-70-110 - Group ceiling for state-owned university teaching hospitals

Current through Register Vol. 40, No. 24, July 15, 2024
A. Pursuant to Item
				  389 E4 of the 1988 Appropriation Act (as amended), effective July 1, 1988, a
				  separate group ceiling for allowable operating cost shall be established for
				  state-owned university teaching hospitals.
B. Effective July 1, 1994, the separate group
				  ceiling for allowable operating costs for state-owned university teaching
				  hospitals shall be calculated using cost report and other applicable data
				  pertaining to facility fiscal year ending June 30, 1993.
Statutory Authority
Social Security Act Title XIX; 42 CFR Part 430 to end;
						all other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part II - Hospital Appeals of Reimbursement Rates [Repealed] › Section 12VAC30-70-140 to 12VAC30-70-145

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part IV - [Reserved] › Section 12VAC30-70-160 to 12VAC30-70-190 - Reserved

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 1 - Application of Payment Methodologies › Section 12VAC30-70-210

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 1 - Application of Payment Methodologies › Section 12VAC30-70-220

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-230

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-231 - Operating payment for DRG cases

Current through Register Vol. 40, No. 24, July 15, 2024
A. The operating payment for DRG cases that
					 are not transfer cases shall be equal to the hospital specific operating rate
					 per case, as determined in
					 12VAC30-70-311,
					 times the DRG relative weight, as determined in
					 12VAC30-70-381.
B. Exceptions.
1. Special provisions for calculating the
					 operating payment for transfer cases are provided in
					 12VAC30-70-251.
2. Readmissions within five days of discharge
					 shall be considered a continuation of the same stay and shall not be treated as
					 a new case.
3. Effective July 1,
					 2020, readmissions within six to 30 days of discharge shall be paid at 50% of
					 the normal rate unless it is a planned readmission, an obstetrical readmission,
					 an admission to critical access hospitals, or in any case where the patient was
					 originally discharged against medical advice.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-240

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-241 - Operating payment for per diem cases

Current through Register Vol. 40, No. 24, July 15, 2024
A. The operating payment for acute care
					 psychiatric cases and rehabilitation cases shall be equal to the hospital
					 specific operating rate per day, as determined in subsection A of
					 12VAC30-70-321, times the covered
					 days for the case.
B. The payment
					 for freestanding psychiatric cases shall be equal to the hospital specific rate
					 per day for freestanding psychiatric cases, as determined in subsection B of
					 12VAC30-70-321, times the covered
					 days for the case.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-250

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-251 - Operating payment for transfer cases

Current through Register Vol. 40, No. 24, July 15, 2024
A. The operating payment for transfer cases
					 shall be determined as follows:
1. A
					 transferring hospital shall receive the lesser of (i) a per diem payment equal
					 to the hospital's DRG operating payment for the case, as determined in
					 12VAC30-70-231, divided by the
					 arithmetic mean length of stay for the DRG into which the case falls times the
					 length of stay for the case at the transferring hospital or (ii) the hospital's
					 full DRG operating payment for the case, as determined in
					 12VAC30-70-231. The transferring
					 hospital shall be eligible for an outlier operating payment, as specified in
					 12VAC30-70-261, if applicable
					 criteria are satisfied.
2. The
					 final discharging hospital shall receive the hospital's full DRG operating
					 payment, as determined in
					 12VAC30-70-231. The final
					 discharging hospital shall be eligible for an outlier operating payment, as
					 specified in
					 12VAC30-70-261, if applicable
					 criteria are satisfied.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-260

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-261 - Outlier operating payment

Current through Register Vol. 40, No. 24, July 15, 2024
A.
					 An outlier operating payment shall be made for outlier cases. This payment
					 shall be added to the operating payments determined in
					 12VAC30-70-231 and
					 12VAC30-70-251. Eligibility for
					 the outlier operating payment and the amount of the outlier operating payment
					 shall be determined as follows:
1. The
					 hospital's adjusted operating cost for the case shall be estimated. This shall
					 be equal to the hospital's total charges for the case times the hospital's
					 operating cost-to-charge ratio, as defined in subsection C of
					 12VAC30-70-221, times the
					 adjustment factor specified in
					 12VAC30-70-331 B.
2. The adjusted outlier operating fixed loss
					 threshold shall be calculated as follows:
a.
					 The outlier operating fixed loss threshold shall be multiplied by the statewide
					 average labor portion of operating costs, yielding the labor portion of the
					 outlier operating fixed loss threshold. Hence, the nonlabor portion of the
					 outlier operating fixed loss threshold shall constitute one minus the statewide
					 average labor portion of operating costs times the outlier operating fixed loss
					 threshold.
b. The labor portion of
					 the outlier operating fixed loss threshold shall be multiplied by the
					 hospital's Medicare wage index, yielding the wage adjusted labor portion of the
					 outlier operating fixed loss threshold.
c. The wage adjusted labor portion of the
					 outlier operating fixed loss threshold shall be added to the nonlabor portion
					 of the outlier operating fixed loss threshold, yielding the wage adjusted
					 outlier operating fixed loss threshold.
3. The hospital's outlier operating threshold
					 for the case shall be calculated. This shall be equal to the wage adjusted
					 outlier operating fixed loss threshold times the adjustment factor specified in
					 12VAC30-70-331 B plus the
					 hospital's operating payment for the case, as determined in
					 12VAC30-70-231 or
					 12VAC30-70-251.
4. The hospital's outlier operating payment
					 for the case shall be calculated. This shall be equal to the hospital's
					 adjusted operating cost for the case minus the hospital's outlier operating
					 threshold for the case. If the difference is less than or equal to zero, then
					 no outlier operating payment shall be made. If the difference is greater than
					 zero, then the outlier operating payment shall be equal to the difference times
					 the outlier adjustment factor.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-270

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-280

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-281 - Payment for direct medical education costs of nursing schools, paramedical programs, and graduate medical education for interns and residents

Current through Register Vol. 40, No. 24, July 15, 2024
A. Direct medical
					 education costs of nursing schools and paramedical programs shall continue to
					 be paid on an allowable cost basis.
1.
					 Payments for these direct medical education costs shall be made in estimated
					 quarterly lump sum amounts and settled at the hospital's fiscal year
					 end.
2. Final payment for these
					 direct medical education (DMedEd) costs shall be the sum of the fee-for-service
					 DMedEd payment and the managed care DMedEd payment. Fee-for-service DMedEd
					 payment is the ratio of Medicaid inpatient costs to total allowable costs,
					 times total DMedEd costs. Managed care DMedEd payment is equal to the managed
					 care days times the ratio of fee-for-service DMedEd payments to fee-for-service
					 days.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-290

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-291 - Payment for indirect medical education costs

Current through Register Vol. 40, No. 24, July 15, 2024
A. Hospitals shall be eligible to receive
					 payments for indirect medical education (IME). Out-of-state cost reporting
					 hospitals are eligible for this payment only if they have Virginia Medicaid
					 utilization in the base year of at least 12% of total Medicaid days. These
					 payments recognize the increased use of ancillary services associated with the
					 educational process and the higher case-mix intensity of teaching hospitals.
					 The payments for indirect medical education shall be made in estimated
					 quarterly lump sum amounts and settled at the hospital's fiscal year
					 end.
B. Final payment for IME shall
					 be determined as follows:
1. Type One
					 hospitals shall receive an IME payment equal to the hospital's Medicaid
					 operating reimbursement times an IME percentage determined as follows (this
					 formula also applies to Children's Hospital of the King's Daughters effective
					 July 1, 2013):
IME Percentage for Type One Hospitals = [1.89 X ((1 +
						r)0.405-1)] X (IME Factor)
An IME factor shall be calculated for each Type One
						hospital and shall equal a factor that, when used in the calculation of the IME
						percentage, shall cause the resulting IME payments to equal what the IME
						payments would be with an IME factor of one, plus an amount equal to the
						difference between operating payments using the adjustment factor specified in
						subdivision B 1 of
						12VAC30-70-331
						and operating payments using an adjustment factor of one in place of the
						adjustment factor specified in subdivision B 1 of
						12VAC30-70-331.
2. Type Two hospitals shall receive an IME
					 payment equal to the hospital's Medicaid operating reimbursement times an IME
					 percentage determined as follows (excluding Children's Hospital of the King's
					 Daughters):
IME Percentage for Type Two Hospitals = [1.89 X ((1 +
						r)0.405-1)] X 0.5695
In both equations, r is the ratio of full-time equivalent
						residents to staffed beds, excluding nursery beds. The IME payment shall be
						calculated each year using the most recent reliable data regarding the number
						of full-time equivalent residents and the number of staffed beds, excluding
						nursery beds.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-300

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-310

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-311 - Hospital specific operating rate per case

Current through Register Vol. 40, No. 24, July 15, 2024
A. The hospital specific operating rate per
					 case shall be equal to the labor portion of the statewide operating rate per
					 case, as determined in
					 12VAC30-70-331, times the
					 hospital's Medicare wage index plus the nonlabor portion of the statewide
					 operating rate per case.
B. For
					 rural hospitals, the hospital's Medicare wage index used in this section shall
					 be the Medicare wage index of the nearest metropolitan wage area or the
					 effective Medicare wage index, whichever is higher.
C. Effective July 1, 2008, and ending after
					 June 30, 2010, the hospital specific operating rate per case shall be reduced
					 by 2.683%.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						  Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-320

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-321 - Hospital specific operating rate per day

Current through Register Vol. 40, No. 24, July 15, 2024
A. The hospital specific operating rate per
					 day shall be equal to the labor portion of the statewide operating rate per
					 day, as determined in subsection A of
					 12VAC30-70-341, times the
					 hospital's Medicare wage index plus the nonlabor portion of the statewide
					 operating rate per day.
B. For
					 rural hospitals, the hospital's Medicare wage index used in this section shall
					 be the Medicare wage index of the nearest metropolitan wage area or the
					 effective Medicare wage index, whichever is higher.
C. Effective July 1, 2008, and ending after
					 June 30, 2010, the hospital specific operating rate per day shall be reduced by
					 2.683%.
Statutory Authority: § 32.1-325 of the Code of
						  Virginia; 42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-330

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-331 - Statewide operating rate per case

Current through Register Vol. 40, No. 24, July 15, 2024
A. The statewide operating rate per case
					 shall be equal to the base year standardized operating costs per case, as
					 determined in
					 12VAC30-70-361,
					 times the inflation values specified in
					 12VAC30-70-351
					 times the adjustment factor specified in subsection B of this
					 section.
B. The adjustment factor
					 shall be determined separately for Type One and Type Two hospitals:
1. For Type One hospitals the adjustment
					 factor shall be a calculated percentage that causes the Type One hospital
					 statewide operating rate per case to equal the Type Two hospital statewide
					 operating rate per case;
2. For
					 Type Two hospitals the adjustment factor shall be:
a. 0.7800 effective July 1, 2006, through
					 June 30, 2010.
b. 0.7500 effective
					 July 1, 2010, through September 30, 2010.
c. 0.7800 effective October 1,
					 2010.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-340

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-341 - Statewide operating rate per day

Current through Register Vol. 40, No. 24, July 15, 2024
A. The statewide operating rate per day shall
					 be equal to the base year standardized operating costs per day, as determined
					 in subsection B of
					 12VAC30-70-371,
					 times the inflation values specified in
					 12VAC30-70-351,
					 times the adjustment factor specified in subsection B or C of this
					 section.
B. The adjustment factor
					 for acute care rehabilitation cases shall be the one specified in subsection B
					 of
					 12VAC30-70-331.
C. The adjustment factor for acute care
					 psychiatric cases for:
1. Type One hospitals
					 shall be the one specified in subdivision B 1 of
					 12VAC30-70-331,
					 times the factor in subdivision 2 this subsection, divided by the factor in
					 subdivision B 2 of
					 12VAC30-70-331.
2. Type Two hospitals shall be:
a. 0.7800 effective July 1, 2006, through
					 June 30, 2007.
b. 0.8400 effective
					 July 1, 2007, through June 30, 2010.
c. 0.8100 effective July 1, 2010, through
					 September 30, 2010.
d. 0.8400
					 effective October 1, 2010.
3. For critical access hospitals, effective
					 July 1, 2019, the inpatient operating rate per day shall be based on an
					 adjustment factor equal to 100% of cost reimbursement.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-350

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-351 - Updating rates for inflation

Current through Register Vol. 40, No. 24, July 15, 2024
A.
					 Each July, the Virginia moving average values as compiled and published by
					 Global Insight (or its successor), under contract with the department shall be
					 used to update the base year standardized operating costs per case, as
					 determined in
					 12VAC30-70-361,
					 and the base year standardized operating costs per day, as determined in
					 12VAC30-70-371,
					 to the midpoint of the upcoming state fiscal year. The most current table
					 available prior to the effective date of the new rates shall be used to inflate
					 base year amounts to the upcoming rate year. Thus, corrections made by Global
					 Insight (or its successor), in the moving averages that were used to update
					 rates for previous state fiscal years shall be automatically incorporated into
					 the moving averages that are being used to update rates for the upcoming state
					 fiscal year.
B. The inflation
					 adjustment for hospital operating rates, disproportionate share hospitals (DSH)
					 payments, and graduate medical education payments shall be eliminated for
					 fiscal year (FY) 2010. The elimination of the inflation adjustments shall not
					 be applicable to rebasing in FY 2011.
C. In FY 2011, hospital operating rates shall
					 be rebased; however the 2008 base year costs shall only be increased 2.58% for
					 inflation. For FY 2011 there shall be no inflation adjustment for graduate
					 medical education (GME) or freestanding psychiatric facility rates. The
					 inflation adjustment shall be eliminated for hospital operating rates, GME
					 payments, and freestanding psychiatric facility rates for FY 2012. The
					 inflation adjustment shall be 2.6% for inpatient hospitals, including hospital
					 operating rates, GME payments, DSH payments, and freestanding psychiatric
					 facility rates for FY 2013, and 0.0% for the same facilities for FY 2014, FY
					 2015, and FY 2016. For FY 2017, the inflation adjustment for inpatient hospital
					 operating rates, GME, DSH, and freestanding psychiatric hospitals shall be 50%
					 of the adjustment calculated in subsection A of this section. In FY 2018, the
					 inflation adjustment for inpatient hospital operating rates, GME, DSH, and
					 freestanding psychiatric hospitals shall be eliminated for inpatient hospitals.
					 A full inflation adjustment payment shall be made in both FY 2017 and FY 2018
					 to Virginia freestanding children's hospitals with greater than 50% Medicaid
					 utilization in 2009.
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-360

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-361 - Base year standardized operating costs per case

Current through Register Vol. 40, No. 24, July 15, 2024
A. For the purposes of calculating the base
					 year standardized operating costs per case, base year claims data for all DRG
					 cases, including outlier cases, shall be used. Base year claims data for per
					 diem cases shall not be used. Separate base year standardized operating costs
					 per case shall be calculated for Type One and Type Two hospitals. In
					 calculating the base year standardized operating costs per case, a transfer
					 case shall be counted as a fraction of a case based on the ratio of its length
					 of stay to the arithmetic mean length of stay for cases assigned to the same
					 DRG as the transfer case.
B. Using
					 the data elements identified in subsection E of
					 12VAC30-70-221, the following
					 methodology shall be used to calculate the base year standardized operating
					 costs per case:
1. The operating costs for
					 each DRG case shall be calculated by multiplying the hospital's total charges
					 for the case by the hospital's operating cost-to-charge ratio, as defined in
					 subsection C of
					 12VAC30-70-221.
2. The standardized operating costs for each
					 DRG case shall be calculated as follows:
a.
					 The operating costs shall be multiplied by the statewide average labor portion
					 of operating costs, yielding the labor portion of operating costs. Hence, the
					 nonlabor portion of operating costs shall constitute one minus the statewide
					 average labor portion of operating costs times the operating costs.
b. The labor portion of operating costs shall
					 be divided by the hospital's Medicare wage index, yielding the standardized
					 labor portion of operating costs.
c. The standardized labor portion of
					 operating costs shall be added to the nonlabor portion of operating costs,
					 yielding standardized operating costs.
3. The case-mix neutral standardized
					 operating costs for each DRG case shall be calculated by dividing the
					 standardized operating costs for the case by the hospital's case-mix
					 index.
4. The base year
					 standardized operating costs per case shall be calculated by summing the
					 case-mix neutral standardized operating costs for all DRG cases and dividing by
					 the total number of DRG cases.
5.
					 The base year standardized operating costs per case shall be reduced by 5.1% to
					 create a pool for outlier operating payments. Eligibility for outlier operating
					 payments and the amount of the outlier operating payments shall be determined
					 in accordance with
					 12VAC30-70-261.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-370

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-371 - Base year standardized operating costs per day

Current through Register Vol. 40, No. 24, July 15, 2024
A. For the purpose of calculating the base
					 year standardized operating costs per day, base year claims data for per diem
					 cases shall be used. Base year claims data for DRG cases shall not be used.
					 Separate base year standardized operating costs per day shall be calculated for
					 Type One and Type Two hospitals.
B.
					 Using the data elements identified in subsection E of
					 12VAC30-70-221, the following
					 methodology shall be used to calculate the base year standardized operating
					 costs per day:
1. The operating costs for
					 each per diem case shall be calculated by multiplying the hospital's total
					 charges for the case by the hospital's operating cost-to-charge ratio, as
					 defined in subsection C of
					 12VAC30-70-221.
2. The standardized operating costs for each
					 per diem case shall be calculated as follows:
a. The operating costs shall be multiplied by
					 the statewide average labor portion of operating costs, yielding the labor
					 portion of operating costs. Hence, the nonlabor portion of operating costs
					 shall constitute one minus the statewide average labor portion of operating
					 costs times the operating costs.
b.
					 The labor portion of operating costs shall be divided by the hospital's
					 Medicare wage index, yielding the standardized labor portion of operating
					 costs.
c. The standardized labor
					 portion of operating costs shall be added to the nonlabor portion of operating
					 costs, yielding standardized operating costs.
3. The base year standardized operating costs
					 per day for acute care psychiatric cases shall be calculated by summing the
					 standardized operating costs for acute care psychiatric cases and dividing by
					 the total number of acute care psychiatric days. This calculation shall be
					 repeated separately for freestanding psychiatric cases and rehabilitation
					 cases.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 2 - Prospective (DRG-Based) Payment Methodology › Section 12VAC30-70-380

Current through Register Vol. 40, No. 24, July 15, 2024