Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part III - Recipient Cost Sharing › Section 12VAC30-20-160 - Copayments and deductibles for medically needy and QMBs for services other than under 42 CFR 447.53

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  following charges are imposed on the medically needy and Qualified Medicare
				  Beneficiaries for services other than those provided under
				  42 CFR
				  447.53.
Service*
Type Charge
Amount and Basis for Determination
Deduct
Coins
Copay
Inpatient Hospital
-0-
-0-
$75
State's average daily payment of $594 is used as
								basis.
Outpatient Hospital Clinic
-0-
-0-
$3.00
State's average payment of $136 is used as
								basis.
Clinic Visit
-0-
-0-
$1.00
State's average payment of $29 is used as
								basis.
Physician Office Visit
-0-
-0-
$1.00
State's average payment of $23 is used as
								basis.
Eye Examination
-0-
-0-
$1.00
State's payment of $30 is used as
								basis.
Prescriptions:
--Generic
-0-
-0-
$1.00
State's average per generic script of $25 is used
								as payment basis.
--Brand Name
-0-
-0-
$3.00
State's average per brand-name script of $97 is
								used as payment basis.
Home Health Visit
-0-
-0-
$3.00
State's average payment of $56 is used as
								basis.
Other Physician Services
-0-
-0-
$3.00
State's average payment of $56 is used as
								basis.
Rehab Therapy Services (PT, OT,
								Sp/Lang.)
-0-
-0-
$3.00
State's average payment $78 is used as
								basis.
*NOTE: The applicability of copays to emergency services is
					 discussed further in this section.
B. The method used to collect cost sharing
				  charges for medically needy individuals requires that providers be responsible
				  for collecting the cost sharing charges from individuals.
C. The basis for determining whether an
				  individual is unable to pay the charge, and the means by which such an
				  individual is identified to providers, is described in this subsection:
Providers will, based on information available to them,
					 make a determination of the recipient's ability to pay the copayment. In the
					 absence of knowledge or indications to the contrary, providers may accept the
					 recipient's assertion that he or she is unable to pay the required
					 copayment.
Recipients have been notified that inability to meet a
					 copayment at a particular time does not relieve them of that
					 responsibility.
D. The
				  procedures for implementing and enforcing the exclusions from cost sharing
				  contained in
				  42 CFR
				  447.53(b) are described in
				  this subsection:
The application and exclusion of cost sharing is
					 administered through the program's Medicaid Management Information System.
					 Documentation of the certified computer system delineates, for each type of
					 provider invoice used, protected eligible groups, protected services and
					 applicable eligible groups and services.
Providers have been informed about: copay exclusions;
					 applicable services and amounts; and prohibition of service denial if recipient
					 is unable to meet cost-sharing changes.
E. State policy does not provide for
				  cumulative maximums.
F. Emergency
				  Services. No recipient copayment shall be collected for the following services:
1. Services provided in a hospital, clinic,
				  office, or other facility that is equipped to furnish the required care, after
				  the sudden onset of a medical condition manifesting itself by acute symptoms of
				  sufficient severity (including severe pain) that the absence of immediate
				  medical attention could reasonably be expected to result in:
a. Placing the patient's health in serious
				  jeopardy;
b. Serious impairment to
				  bodily functions; or
c. Serious
				  dysfunction of any bodily organ or part; and