reglab/statecodes huggingface dataset:
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 12VAC30-80-60 - Reimbursement audit

Current through Register Vol. 40, No. 24, July 15, 2024
The single state agency will take whatever measures are
				  necessary to assure appropriate audit of records whenever reimbursement is
				  based on costs of providing care and services, or on a fee-for-service plus
				  cost of materials.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 12VAC30-80-70 - Fee-for-service providers: Transportation

Current through Register Vol. 40, No. 24, July 15, 2024
Payment for transportation services shall be according to the
				  following table:
TYPE OF SERVICE
PAYMENT METHODOLOGY
Taxi services
Rate set by the single state agency
Wheelchair van
Rate set by the single state agency
Nonemergency ambulance
Rate set by the single state agency
Emergency ambulance
Rate set by the single state agency
Volunteer drivers
Rate set by the single state agency
Air ambulance
Rate set by the single state agency
Mass transit
Rate charged to the public
Transportation agreements
Rate set by the single state agency
Special emergency transportation
Rate set by the single state agency
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 12VAC30-80-75 - Local Education Agency (LEA) providers

Current through Register Vol. 40, No. 24, July 15, 2024
A. Definitions. The following words are terms
				when used in this section shall have the following meanings unless the context
				clearly indicates otherwise:
"CMS" means Centers for Medicare and Medicaid
				  Services.
"DMAS" means Department of Medical Assistance
				  Services.
"FAMIS" means Family Access to Medical Insurance Security
				  Plan.
"FFP" means Federal Financial Participation.
"IDEA" means Individuals with Disabilities Education
				  Act.
"IEP" means Individual Education Plan.
"LEA" means Local Education Agency.
"MMIS" means Medicaid Management Information System.
B. Effective for services on or
				after July 1, 2006, the following methodology will determine the reimbursement
				for Local Education Agency (LEA) providers. The methodology described below
				applies to reimbursement for the following services delivered by LEA providers.
				These services are described in 12VAC30-50-135.
1. Speech therapy;
2. Audiology and hearing services;
3. Physician services for medical evaluation
				services;
4. Occupational
				therapy;
5. Physical
				therapy;
6. Psychiatric and
				psychological services;
7. Personal
				care services;
8. Skilled nursing
				services; and
9. Special
				transportation.
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 12VAC30-80-80 - Fee-for-service: Medicare coinsurance and deductibles

Current through Register Vol. 40, No. 24, July 15, 2024
Payments for Medicare coinsurance and deductibles for
				  noninstitutional services shall not exceed the allowed charges determined by
				  Medicare in accordance with 42 CFR 447.304(b)
				  less the portion paid by Medicare, other third party payors, and recipient
				  copayment requirements of this Plan. See
				  12VAC30-80-170.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 12VAC30-80-90 - Fee-for-service: Eyeglasses

Current through Register Vol. 40, No. 24, July 15, 2024
Payment for eyeglasses shall be the actual cost of the
				  frames and lenses not to exceed limits set by the single state agency, plus a
				  dispensing fee not to exceed limits set by the single state
				  agency.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 12VAC30-80-95 - Fee-for-service: hearing aids (under EPSDT)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Effective January 1, 2008, payment for
				hearing aids for individuals younger than 21 years of age shall be the actual
				cost of the device not to exceed limits set by the single state agency, plus a
				fixed dispensing and fitting fee not to exceed limits set by the single state
				agency.
B. All private and
				governmental providers are reimbursed according to the same methodology.
				Limitations set by the state agency are effective January 1, 2008, and for
				services provided on and after that date. The limitations are published at the
				following address (state agency website):
http://www.dmas.virginia.gov/pr-fee_files.htm
.
Statutory Authority
§ 32.1-325 of the Code of Virginia; Title XIX of the
					 Social Security Act ( 42 USC § 1396
					 ).
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 12VAC30-80-96 - Fee-for-service: Early Intervention (under EPSDT)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Payment for Early Intervention services
				pursuant to Part C of the Individuals with Disabilities Education Act (IDEA) of
				2004, as set forth in
				12VAC30-50-131 for individuals
				younger than 21 years of age, shall be the lower of the state agency fee
				schedule or actual charge (charge to the general public). All private and
				governmental fee-for-service providers are reimbursed according to the same
				methodology. The agency's rates were set as of October 1, 2009, and are
				effective for services on or after that date. Rates are published on the
				agency's website at ###www.dmas.virginia.gov.
B. There shall be separate fees for:
1. Certified Early Intervention professionals
				who are also licensed as either a physical therapist, occupational therapist,
				speech pathologist, or registered nurse and certified Early Intervention
				specialists who are also licensed as either a physical therapy assistant or
				occupational therapy assistant; and
2. All other certified Early Intervention
				professionals and certified Early Intervention specialists.
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 12VAC30-80-97 - Fee-for-service: behavioral therapy services under EPSDT

Current through Register Vol. 40, No. 24, July 15, 2024
A. Payment for behavioral therapy services
				for individuals younger than 21 years of age shall be the lower of the state
				agency fee schedule or actual charge (charge to the general public). All
				private and governmental fee-for-service providers shall be reimbursed
				according to the same methodology. The agency's rates were set as of October 1,
				2011, and are effective for services on or after that date until rates are
				revised. Rates are published on the agency's website at
http://www.dmas.virginia.gov/
.
B. Providers shall be required to refund
				payments made by Medicaid if they fail to maintain adequate documentation to
				support billed activities.
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 80 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATE; OTHER TYPES OF CARE › Section 12VAC30-80-100 - Fee-for-service: Expanded Prenatal Care

Current through Register Vol. 40, No. 24, July 15, 2024
Expanded prenatal care services to include patient
				  education, homemaker, and nutritional services shall be reimbursed at the
				  lowest of: state agency fee schedule, actual charge, or Medicare (Title XVIII)
				  allowances.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 12VAC30-80-110 - Fee-for-service: case management

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				Targeted case management for early intervention (Part C) children.
1. Targeted case management for children from
				birth to three years of age who have developmental delay and who are in need of
				early intervention is reimbursed at the lower of the state agency fee schedule
				or the actual charge (charge to the general public). The unit of service is one
				month. All private and governmental fee-for-service providers are reimbursed
				according to the same methodology. The agency's rates are effective for
				services on or after October 11, 2011. Rates are published on the agency's
				website at
www.dmas.virginia.gov
.
2. Case management defined for another target
				group shall not be billed concurrently with this case management service except
				for case management services for high risk infants provided under
				12VAC30-50-410. Providers of early
				intervention case management shall coordinate services with providers of case
				management services for high risk infants, pursuant to
				12VAC30-50-410, to ensure that
				services are not duplicated.
3.
				Each entity receiving payment for services as defined in
				12VAC30-50-415 shall be required
				to furnish the following to DMAS, upon request:
a. Data, by practitioner, on the utilization
				by Medicaid beneficiaries of the services included in the unit rate;
				and
b. Cost information used by
				practitioner.
4. Future
				rate updates will be based on information obtained from the providers. DMAS
				monitors the provision of targeted case management through post-payment review
				(PPR). PPRs ensure that paid services were rendered appropriately, in
				accordance with state and federal policies and program requirements, provided
				in a timely manner, and paid correctly.
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 12VAC30-80-111 - Treatment foster care (TFC) case management

Current through Register Vol. 40, No. 24, July 15, 2024
The Medicaid agency will reimburse providers for the covered
				  services for TFC case management for each eligible child at the daily rate
				  agreed upon between the local Community Policy and Management Team (CPMT) in
				  the locality that is responsible for the child's care and the TFC case
				  management provider. This daily rate shall be based upon the intensity of the
				  case management needed by the child and be subject to an upper limit set by the
				  Medicaid agency. DMAS shall pay the lesser of the rate negotiated by the CPMT
				  or the maximum rate established by the department.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 12VAC30-80-115 - Fee-for-service: Early Discharge Follow-up Visit for Mothers and Newborns

Current through Register Vol. 40, No. 24, July 15, 2024
The early discharge follow-up visit for mothers and newborns
				  covered under the provisions of
				  12VAC30-50-220 C shall be
				  reimbursed at the lower of the state agency fee schedule or actual charges.
				  Providers qualified for reimbursement of this service are those hospitals,
				  physicians, nurse midwives, nurse practitioners, federally qualified health
				  clinics, rural health clinics, and health department clinics that are enrolled
				  as Medicaid providers and are qualified by the appropriate state authority for
				  delivery of the service. The service shall be delivered either by the
				  appropriate professional who is an employee of the participating provider or is
				  under contract with the participating billing providers listed in this section.
				  The staff providing the follow-up visit, at a minimum, shall be a registered
				  nurse having training and experience in maternal and child
				  health.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 12VAC30-80-120 - Reimbursement for all other nonenrolled institutional and noninstitutional providers

Current through Register Vol. 40, No. 24, July 15, 2024
A. All
				other nonenrolled providers shall be reimbursed the lesser of the charges
				submitted, the DMAS cost to charge ratio, or the Medicare limits for the
				services provided.
B. Outpatient
				hospitals that are not enrolled as providers with the Department of Medical
				Assistance Services (DMAS) which submit claims shall be paid based on the DMAS
				average reimbursable outpatient cost-to-charge ratio, updated annually, for
				enrolled outpatient hospitals less five percent. The five percent is for the
				cost of the additional manual processing of the claims. Outpatient hospitals
				that are nonenrolled shall submit claims on DMAS invoices.
C. Nonenrolled providers of noninstitutional
				services shall be paid on the same basis as enrolled in-state providers of
				noninstitutional services. Nonenrolled providers of physician, dental,
				podiatry, optometry, and clinical psychology services, etc., shall be
				reimbursed the lesser of the charges submitted, or the DMAS rates for the
				services.
D. All nonenrolled
				noninstitutional providers shall be reviewed every two years for the number of
				Medicaid recipients they have served. Those providers who have had no claims
				submitted in the past 12 months shall be declared inactive.
E. Nothing in this regulation is intended to
				preclude DMAS from reimbursing for special services, such as rehabilitation,
				ventilator, and transplantation, on an exception basis and reimbursing for
				these services on an individually, negotiated rate basis.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 12VAC30-80-150 - Dispute resolution for state-operated providers

Current through Register Vol. 40, No. 24, July 15, 2024
A. Definitions.
"DMAS" means the Department of Medical Assistance
				  Services.
"Division director" means the director of a division of
				  DMAS.
"State-operated provider" means a provider of Medicaid
				  services which is enrolled in the Medicaid program and operated by the
				  Commonwealth of Virginia.
B. Right to request reconsideration. A
				state-operated provider shall have the right to request a reconsideration for
				any issue which would be otherwise administratively appealable under the State
				Plan by a nonstate operated provider. This shall be the sole procedure
				available to state-operated providers. The appropriate DMAS division must
				receive the reconsideration request within 30 calendar days after the provider
				receives its Notice of Amount of Program Reimbursement, notice of proposed
				action, findings letter, or other DMAS notice giving rise to a
				dispute.
C. Informal review. The
				state-operated provider shall submit to the appropriate DMAS division written
				information specifying the nature of the dispute and the relief sought. If a
				reimbursement adjustment is sought, the written information must include the
				nature of the adjustment sought, the amount of the adjustment sought, and the
				reasons for seeking the adjustment. The division director or his designee shall
				review this information, requesting additional information as necessary. If
				either party so requests, they may meet to discuss a resolution. Any designee
				shall then recommend to the division director whether relief is appropriate in
				accordance with applicable law and regulations.
D. Division director action. The division
				director shall consider any recommendation of his designee and shall render a
				decision.
E. DMAS director review.
				A state-operated provider may, within 30 days after receiving the informal
				review decision of the division director, request that the DMAS director or his
				designee review the decision of the division director. The DMAS director shall
				have the authority to take whatever measures he deems appropriate to resolve
				the dispute.
F. Secretarial review.
				If the preceding steps do not resolve the dispute to the satisfaction of the
				state-operated provider, within 30 days after the receipt of the decision of
				the DMAS director, the provider may request the DMAS director to refer the
				matter to the Secretary of Health and Human Resources and any other Cabinet
				Secretary as appropriate. Any determination by such Secretary or Secretaries
				shall be final.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 12VAC30-80-170 - Payment of Medicare Part A and Part B Deductible/Coinsurance

Current through Register Vol. 40, No. 24, July 15, 2024
Except for a nominal recipient copayment (as specified in
				  12VAC30-20-150 and
				  12VAC30-20-160 ), if applicable,
				  the Medicaid agency uses the following general method for payment:
1. Payments are limited to state plan rates
				and payment methodologies for the groups and payments listed below and
				designated with the letters "SP."
For specific Medicare services which are not otherwise
				  covered by this state plan, the Medicaid agency uses Medicare payment rates
				  unless a special rate or method is set out.
Not applicable. There are no special rates or methods used
				  for specific Medicare services which are not otherwise covered by this state
				  plan.
2. Payments are up to
				the full amount of the Medicare rate for the groups and payments listed below
				and designated with the letters "MR."
3. Payments are up to the amount of a special
				rate, or according to a special method, for the groups and payments listed
				below and designated with the letters "NR."
4. Any exceptions to the general methods used
				for a particular group or payment are specified.
Payment of Medicare Part A and Part B
						  Deductible/Coinsurance
QMBs:
Part A
SP
Deductibles
SP
Coinsurance
Part B
SP
Deductibles
SP
Coinsurance
Other Medicaid Recipients (Other Dual
						  Eligibles)
Part A
SP
Deductibles
SP
Coinsurance
Part B
SP
Deductibles
SP
Coinsurance
Dual Eligible (QMB Plus)
Part A
SP
Deductibles
SP
Coinsurance
Part B
SP
Deductibles
SP
Coinsurance
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 12VAC30-80-180 - Establishment of rate per visit for home health services

Current through Register Vol. 40, No. 24, July 15, 2024
A. Effective for dates of services on and
				after July 1, 1991, the Department of Medical Assistance Services (DMAS) shall
				reimburse home health agencies (HHAs) at a flat rate per visit for each type of
				service rendered by HHAs (i.e., nursing, physical therapy, occupational
				therapy, speech-language pathology services, and home health aide services.) In
				addition, supplies left in the home and extraordinary transportation costs will
				be paid at specific rates.
B.
				Effective for dates of services on and after July 1, 1993, DMAS shall establish
				a flat rate for each level of service for HHAs by peer group. There shall be
				three peer groups:
(i) the Department of
				Health's HHAs,
(ii) non-Department
				of Health HHAs whose operating office is located in the Virginia portion of the
				Washington DC-MD-VA metropolitan statistical area, and
(iii) non-Department of Health HHAs whose
				operating office is located in the rest of Virginia. The use of the Health Care
				Financing Administration (HCFA) designation of urban metropolitan statistical
				areas (MSAs) shall be incorporated in determining the appropriate peer group
				for these classifications.
The Department of Health's agencies are being placed in a
				  separate peer group due to their unique cost characteristics (only one
				  consolidated cost report is filed for all Department of Health
				  agencies).
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 12VAC30-80-190 - State agency fee schedule for RBRVS

Current through Register Vol. 40, No. 24, July 15, 2024
A. Reimbursement of fee-for-service
				providers. Effective for dates of service on or after July 1, 1995, the
				Department of Medical Assistance Services (DMAS) shall reimburse
				fee-for-service providers, with the exception of home health services (see
				12VAC30-80-180
				) and durable medical equipment services (see
				12VAC30-80-30
				), using a fee schedule that is based on a Resource Based Relative Value Scale
				(RBRVS).
B. Fee schedule.
1. For those services or procedures that are
				included in the RBRVS published by the Centers for Medicare and Medicaid
				Services (CMS) as amended from time to time, the DMAS fee schedule shall employ
				the Relative Value Units (RVUs) developed by CMS as periodically updated.
a. Effective for dates of service on or after
				July 1, 2008, DMAS shall implement site of service differentials and employ
				both nonfacility and facility RVUs. The implementation shall be budget neutral
				using the methodology in subdivision 2 of this subsection.
b. The implementation of site of service
				shall be transitioned over a four-year period.
(1) Effective for dates of service on or
				after July 1, 2008, DMAS shall calculate the transitioned facility RVU by
				adding 75% of the difference between the nonfacility RVU and nonfacility RVU to
				the facility RVU.
(2) Effective for
				dates of service on or after July 1, 2009, DMAS shall calculate the
				transitioned facility RVU by adding 50% of the difference between the
				nonfacility RVU and nonfacility RVU to the facility RVU.
(3) Effective for dates of service on or
				after July 1, 2010, DMAS shall calculate the transitioned facility RVU by
				adding 25% of the difference between the nonfacility RVU and nonfacility RVU to
				the facility RVU.
(4) Effective for
				dates of service on or after July 1, 2011, DMAS shall use the unadjusted
				Medicare facility RVU.
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 12VAC30-80-200 - Prospective reimbursement for rehabilitation agencies or comprehensive outpatient rehabilitation facilities

Current through Register Vol. 40, No. 24, July 15, 2024
A. Rehabilitation agencies or comprehensive
				outpatient rehabilitation facilities.
1.
				Effective for dates of service on and after July 1, 2009, rehabilitation
				agencies or comprehensive outpatient rehabilitation facilities, excluding those
				operated by community services boards or state agencies, shall be reimbursed a
				prospective rate equal to the lesser of the agency's fee schedule amount or
				billed charges per procedure. The agency shall develop a statewide fee schedule
				based on Current Procedural Terminology (CPT) codes to reimburse providers what
				the agency estimates they would have been paid in FY 2010 minus
				$371,800.
2. Effective for dates of
				service on and after October 1, 2009, rehabilitation agencies or comprehensive
				outpatient rehabilitation facilities, excluding those operated by state
				agencies shall be reimbursed a prospective rate equal to the lesser of the
				agency's fee schedule amount or billed charges per procedure. The agency shall
				develop a statewide fee schedule based on CPT codes to reimburse providers what
				the agency estimates they would have been paid in FY 2010 minus
				$371,800.
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 › Form - FORMS (12VAC30-80)

Current through Register Vol. 40, No. 24, July 15, 2024
Pharmacy Claim Form (3/96).
CMS Noninstitutional Services Cost Report Certification
				  Statement (10/07).
Compound Prescription Pharmacy Claim Form (3/96).
I.V. Therapy Implementation Form, DMAS-354 (eff. 6/98).
Questionnaire to Assess an Applicant's Ability to
				  Independently Manage Personal Attendant Services in the CD-PAS Waiver or DD
				  Waiver, DMAS-95 Addendum (eff. 8/00).
DD Waiver Enrollment Request, DMAS-453 (eff. 1/01).
DD Waiver Consumer Service Plan, DMAS-456 (eff. 1/01).
DD Medicaid Waiver -- Level of Functioning Survey -- Summary
				  Sheet, DMAS-458 (eff. 1/01).
Documentation of Recipient Choice between Institutional Care
				  or Home and Community-Based Services (eff. 8/00).
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 - DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-80)

Current through Register Vol. 40, No. 24, July 15, 2024
Approved Drug Products with Therapeutic Equivalence
				  Evaluations, 25th Edition, 2005, U.S. Department of Health and Human
				  Services
International Classification of Diseases, ICD-9-CM 2007
				  (effective for claims with dates of service through September 30, 2015),
				  Physician, Volumes 1 and 2, 9th Revision-Clinical Modification, American
				  Medical Association
Virginia Medicaid Durable Medical Equipment and Supplies
				  Provider Manual, Appendix B (rev. 1/11), Department of Medical Assistance
				  Services
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 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE › Part I - Methods and Standards for Establishing Payment Rates for Long-Term Care › Section 12VAC30-90-11 - Public comment process

Current through Register Vol. 40, No. 24, July 15, 2024
The state has in place a public process which complies with
					 the requirements of § 1902(a)(13)(A) of the Social Security
					 Act.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE › Part II - Nursing Home Payment System › Subpart I - General › Section 12VAC30-90-19 - Supplemental payments for nonstate government-owned nursing facilities

Current through Register Vol. 40, No. 24, July 15, 2024
A. In addition to
					 payments made elsewhere, effective July 1, 2005, DMAS shall draw down federal
					 funds to cover unreimbursed Medicaid costs for inpatient services provided by
					 nonstate government-owned nursing facilities as certified by the provider
					 through cost reports. A nonstate government-owned nursing facility is defined
					 as a provider owned or operated by a county, city, or other local government
					 agency, instrumentality, authority, or commission.
B. Effective July 1, 2014, DMAS shall make
					 additional supplemental payments to nonstate government-owned nursing
					 facilities that meet the requirements in subsection A of this section.
					 Quarterly supplemental payment for each facility shall be calculated in the
					 following manner:
1. Annually calculate for
					 each nursing facility what Medicare would have paid for Medicaid services in
					 the base year, which is the most recently available state fiscal year, using
					 the Medicare skilled nursing facility prospective payment system updated for
					 market basket adjustments and other rate changes to the rate year, which is the
					 upcoming state fiscal year.
2.
					 Annually calculate for each facility what Medicaid paid in the base year
					 including any supplemental payments resulting from subsection A of this section
					 updated for inflation and other rate changes to the rate year.
3. Calculate a per diem supplemental payment
					 for each facility by subtracting Medicaid expenditures calculated in
					 subdivision 2 of this subsection from what Medicare would have paid calculated
					 in subdivision 1 of this subsection and dividing the result by the number of
					 paid days for each facility in the base year.
4. At the end of each quarter of the rate
					 year, calculate the number of paid days in the quarter for each facility and
					 multiply it by the per diem supplemental payment for each facility.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE › Part II - Nursing Home Payment System › Subpart I - General › Section 12VAC30-90-20

Current through Register Vol. 40, No. 24, July 15, 2024
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 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE › Part II - Nursing Home Payment System › Subpart I - General › Section 12VAC30-90-21 - Reimbursement for individuals in a disaster struck nursing facility

Current through Register Vol. 40, No. 24, July 15, 2024
Reimbursement to a disaster struck nursing facility for
						individuals who must be temporarily evacuated to another facility (resident
						accepting nursing facility) may continue for up to 30 days after the disaster
						event. Reimbursement will be the same as if the individual was residing in the
						disaster struck nursing facility. No other reimbursement will be made to either
						the disaster struck nursing facility or the resident accepting nursing
						facility. The disaster struck nursing facility must meet the following
						conditions:
1. The disaster struck
					 nursing facility must have a contract with the resident accepting nursing
					 facility. The contract must include (i) terms of reimbursement and mechanisms
					 to resolve any contract disputes, (ii) protocols for sharing care and treatment
					 information between the two facilities, and (iii) requirements that both
					 facilities meet all conditions of Medicaid participation determined by the
					 Virginia Department of Health. The Virginia Long-Term Mutual Aid Plan, which
					 includes a Memorandum of Understanding, is an acceptable contract.
2. The disaster struck nursing facility must
					 notify the Department of Medical Assistance Services (DMAS) of the disaster
					 event; maintain records of evacuated individuals with names, dates, and
					 destinations of evacuated residents; and update DMAS on the status of the
					 repairs.
3. The disaster struck
					 nursing facility must determine within 15 days of the event whether individuals
					 will be able to return to the facility within 30 days of the disaster event. If
					 the disaster struck nursing facility determines that it is not able to reopen
					 within 30 days, it must discharge the individuals and work with them to choose
					 admission to other facilities or alternative placements. Nothing shall preclude
					 an individual from asking to be discharged and admitted to another facility or
					 alternative placement. Reimbursement to the disaster struck nursing facility
					 shall cease when an individual is discharged.
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 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE › Part II - Nursing Home Payment System › Subpart II - Rate Determination Procedures › Article 1 - Transition to New Capital Payment Methodology › Section 12VAC30-90-28 - Mid-year fair rental value rate determination

Current through Register Vol. 40, No. 24, July 15, 2024
A. New facilities and facilities undergoing a
						major renovation may apply for a mid-year fair rental value (FRV) rate
						determination or change if putting into service a major renovation or new beds.
						Providers are allowed only one mid-year FRV rate change during a state fiscal
						year (SFY).
1. New facilities. A new nursing
						facility is defined as a facility that is required to obtain a certificate of
						occupancy prior to the admittance of a resident. New nursing facilities should
						file a mid-year FRV report when the facility's certificate of occupancy has
						been issued. The nursing facility shall submit complete pro forma documentation
						at least 60 days prior to the certificate of occupancy effective date, and the
						new FRV rate shall be effective at the beginning of the month following the end
						of the 60 days, subject to confirmation that the new beds are operational.
a. For any facility whose FRV report has less
						than 12 months of experience, the department shall develop an occupancy
						schedule as defined in the nursing facility capital payment methodology
						(12VAC30-90-36
						) that represents the average statewide occupancy by month of operation for use
						in calculating the per diem rate in lieu of a minimum occupancy requirement or
						actual occupancy. After the initial FRV report filing, actual occupancy data
						shall be used.
b. New facilities
						shall use the occupancy schedule developed by the Department of Medical
						Assistance Services (DMAS) to estimate patient days for their first FRV report
						until actual patient days are available. The occupancy percentage used to
						calculate estimated patient days shall be based on the number of months
						remaining within the calendar year from the month of receipt of the certificate
						of occupancy. For example, if the certificate of occupancy is received in
						February, then the number of months remaining in the calendar year would be 11,
						and the occupancy percentage to use would be 85.84% (see Table 1 in
						12VAC30-90-36
						). The estimated patient days would be equal to the occupancy percentage times
						the annualized bed days available for the report period.
c. DMAS shall have 15 days from the date of
						the provider's submission to determine if the filing is complete for purposes
						of setting a rate for a new facility. The facility shall have 15 days from the
						date the filing is deemed incomplete to submit the required information. The
						deadline for setting the rate shall be extended for 30 days after the filing is
						deemed complete.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE › Part II - Nursing Home Payment System › Subpart II - Rate Determination Procedures › Article 1 - Transition to New Capital Payment Methodology › Section 12VAC30-90-29 - Transition to new capital payment methodology

Current through Register Vol. 40, No. 24, July 15, 2024
A. This section provides for a transition to
						a new capital payment methodology. The methodology that will be phased out for
						most facilities is described in Article 2 (12VAC30-90-30 et seq.) of this
						subpart. The methodology that will be phased in for most facilities is
						described in Article 3 (12VAC30-90-35 et
						seq.) of this subpart. The terms and timing of the transition are described in
						this section.
B. Nursing facilities
						enrolled in the Medicaid program prior to July 1, 2000, shall be paid for
						capital related costs under a transition policy from July 1, 2000, through June
						30, 2012. Facilities and beds paid under the transition policy shall receive
						payments as follows:
1. During SFY 2001, each
						facility's capital per diem shall be the facility's capital per diem on June
						30, 2000. The methodology under which this per diem is determined shall be the
						plant cost reimbursement methodology in effect as of June 30, 2000.
2. During SFY 2002, each facility subject to
						the transition policy shall be paid for capital costs under the methodology
						described in Article 2 (12VAC30-90-30 et
						seq.) of this subpart.
3. During
						SFY 2003 through SFY 2012, each facility subject to the transition policy shall
						have a capital per diem that is a percentage of the per diem described in
						Article 2 (12VAC30-90-30 et seq.) of this
						subpart plus a percentage of the per diem described in Article 3 (12VAC30-90-35 et seq.) of this
						subpart. The percentage associated with the per diem described in Article 2
						shall be 90% for services provided in SFY 2003, 80% for services in SFY 2004,
						70% for services in SFY 2005, and so on until the percentage is 0% for services
						in SFY 2012. The percentage associated with the per diem described in Article 3
						shall be equal to 100% minus the percentage associated with the per diem
						described in Article 2. In SFY 2012, the capital per diem shall be based
						entirely on the per diem described in Article 3.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE › Part II - Nursing Home Payment System › Subpart II - Rate Determination Procedures › Article 2 - Plant Cost Component › Section 12VAC30-90-30 - Plant cost

Current through Register Vol. 40, No. 24, July 15, 2024
A. This article
						describes a capital payment methodology that will be phased out for most
						nursing facilities by SFY 2012. The terms and timing of the transition to a
						different methodology are described in
						12VAC30-90-29.
						The methodology that will eventually replace this one for most facilities is
						described in Article 3 (12VAC30-90-35
						et seq.) of this subpart.
B. Plant
						cost shall include actual allowable depreciation, interest, rent or lease
						payments for buildings and equipment as well as property insurance, property
						taxes and debt financing costs allowable under Medicare principles of
						reimbursement or as defined herein.
C. Effective July 1, 2001, to calculate the
						reimbursement rate, plant cost shall be converted to a per diem amount by
						dividing plant cost by the greater of actual patient days or the number of
						patient days. Patient days shall be computed as the required occupancy
						percentage of the daily licensed bed complement during the applicable cost
						reporting period. The required occupancy percentage means the ratio of nursing
						facility total patient days to total potential patient days for all available
						licensed beds. The required occupancy percentage for dates of service on or
						before June 30, 2013, shall be 90%, and for dates of service on or after July
						1, 2013, the required occupancy percentage shall be 88%. For facilities with
						less than 12 months of occupancy experience, the required occupancy percentage
						shall be determined from the occupancy schedule in
						12VAC30-90-36.
						For facilities that also provide specialized care services, see subdivision 9
						of
						12VAC30-90-264
						for special procedures for computing the number of patient days required to
						meet the occupancy requirement.
D.
						Costs related to equipment and portions of a building or facility not available
						for patient care related activities are nonreimbursable plant costs.
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 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE › Part II - Nursing Home Payment System › Subpart II - Rate Determination Procedures › Article 2 - Plant Cost Component › Section 12VAC30-90-32 - Major capital expenditures

Current through Register Vol. 40, No. 24, July 15, 2024
A.
						Major capital expenditures include, but are not limited to, major renovations
						(without bed increase), additions, modernization, other renovations, upgrading
						to new standards, and equipment purchases. Major capital expenditures shall be
						any capital expenditures costing $100,000 or more each, in aggregate for like
						items, or in aggregate for a particular project. These include purchases of
						similar type equipment or like items within a one calendar year period (not
						necessarily the provider's reporting period).
B. Providers (including related organizations
						as defined in
						12VAC30-90-51 ) shall be required
						to obtain three competitive bids and if applicable, a Certificate of Public
						Need before initiating any major capital expenditures. All bids must be
						obtained in an open competitive manner, and subject to disclosure to the DMAS
						prior to initial rate setting. (Related parties see
						12VAC30-90-51.)
C. Useful life shall be determined by the
						American Hospital Association's Estimated Useful Lives of Depreciable Hospital
						Assets (AHA). If the item is not included in the AHA guidelines, reasonableness
						shall be applied to determine useful life.
D. Major capital additions, modernization,
						renovations, and costs associated with upgrading the NF to new standards shall
						be subject to cost limitations based upon the applicable components of the
						construction cost limits determined in accordance with
						12VAC30-90-31 B.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE › Part II - Nursing Home Payment System › Subpart II - Rate Determination Procedures › Article 2 - Plant Cost Component › Section 12VAC30-90-34 - Purchases of nursing facilities (NF)

Current through Register Vol. 40, No. 24, July 15, 2024
A. In the event of a sale of a NF, the
						purchaser must have a current license and certification to receive DMAS
						reimbursement as a provider and must notify DMAS of the sale within 30 days of
						the date legal title passes to the purchaser. The notification shall include:
1. That a sale or transfer is about to be
						made or has already occurred;
2.
						The location and general description of the property; and
3. The names and addresses of the transferee
						and transferor and all such business names and addresses of the transferor for
						the last three years.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE › Part II - Nursing Home Payment System › Subpart II - Rate Determination Procedures › Article 3 - Fair Rental Value Capital Payment System › Section 12VAC30-90-35 - General applicability

Current through Register Vol. 40, No. 24, July 15, 2024
This article describes a capital payment methodology
						  that will be phased in for most nursing facilities by SFY 2012. The terms and
						  timing of the transition to a different methodology are described in
						  12VAC30-90-29. The methodology
						  that this one will replace for most facilities is described in Article 2
						  (12VAC30-90-30 et seq.) of this
						  subpart.
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item 319
							 (II) of Chapter 1073 of the 2000 Acts of Assembly.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE › Part II - Nursing Home Payment System › Subpart II - Rate Determination Procedures › Article 3 - Fair Rental Value Capital Payment System › Section 12VAC30-90-37 - Calculation of FRV per diem rate for capital; calculation of FRV rental amount; change of ownership

Current through Register Vol. 40, No. 24, July 15, 2024
A.
						Calculation of FRV per diem rate for capital.
1. The facility FRV per diem rate shall be
						equal to the sum of the facility FRV rental amount and the facility's allowable
						property tax and insurance cost from the most recent settled cost report,
						divided by the greater of actual patient days or the required occupancy
						percentage of the potential patient days for all licensed beds throughout the
						cost reporting period. For facilities that also provide specialized care
						services, see subdivision 9 of
						12VAC30-90-264
						for special procedures for computing the number of patient days required to
						meet the required occupancy percentage requirement.
2. Effective July 1, 2014, facilities shall
						be required to submit a calendar year FRV report covering both NF and
						specialized care beds to be used to set a prospective FRV rate effective the
						following July 1for both the NF and the specialized care facility. The calendar
						year FRV report shall be submitted by the end of February following the end of
						the calendar year. FRV reports shall be settled within 90 days of filing the
						FRV report. For late FRV reports, the prospective rate may be effective 90 days
						after the date of filing even if after July 1. No capital rate shall be paid
						between July 1 and the effective date of the prospective FRV rate for a late
						report.
3. New nursing facilities
						or major renovations that qualify for mid-year FRV rate adjustments must follow
						pro forma submission procedures as specified in 12VAC30-90-28.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE › Part II - Nursing Home Payment System › Subpart II - Rate Determination Procedures › Article 3 - Fair Rental Value Capital Payment System › Section 12VAC30-90-39 - Purchases of nursing facilities (NF)

Current through Register Vol. 40, No. 24, July 15, 2024
A. In the event of a sale of a NF, the
						purchaser must have a current license and certification to receive DMAS
						reimbursement as a provider and must notify DMAS of the sale within 30 days of
						the date legal title passes to the purchaser. The notification shall include:
1. That a sale or transfer is about to be
						made or has already occurred;
2.
						The location and general description of the property;
3. The names and addresses of the transferee
						and transferor and all such business names and addresses of the transferor for
						the last three years.