reglab/statecodes huggingface dataset:
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 12VAC30-70-381 - DRG relative weights and hospital case-mix indices

Current through Register Vol. 40, No. 24, July 15, 2024
A. For the purposes
					 of calculating DRG relative weights and hospital case-mix indices, base year
					 claims data for all groupable cases shall be used. Base year claims data for
					 ungroupable cases and per diem cases shall not be used. In calculating the DRG
					 relative weights, 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 DRG relative weights:
1. The operating costs for each groupable
					 case shall be calculated by multiplying the per diems and ancillary
					 cost-to-charge ratios from each hospital's cost report ending in the state
					 fiscal year used as the base year to the corresponding days and ancillary
					 charges by revenue code for each hospital's groupable cases.
2. The standardized operating costs for each
					 groupable 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 the standardized operating costs.
3. The average standardized cost per DRG
					 shall be calculated by dividing the standardized operating costs for all
					 groupable cases in the DRG by the number of groupable cases classified in the
					 DRG.
4. The average standardized
					 cost per case shall be calculated by dividing the standardized operating costs
					 for all groupable cases by the total number of groupable cases.
5. The average standardized cost per DRG
					 shall be divided by the average standardized cost per case to determine the DRG
					 relative weight.
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 12VAC30-70-390

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 12VAC30-70-391 - Recalibration and rebasing policy

Current through Register Vol. 40, No. 24, July 15, 2024
A.
					 The department recognizes that claims experience or modifications in federal
					 policies may require adjustment to the DRG payment system policies provided in
					 this part. The state agency shall recalibrate (evaluate and adjust the DRG
					 relative weights and hospital case-mix indices) and rebase (review and update
					 the base year standardized operating costs per case and the base year
					 standardized operating costs per day) the DRG payment system at least every
					 three years. Recalibration and rebasing shall be done in consultation with the
					 Medicaid Hospital Payment Policy Advisory Council noted in
					 12VAC30-70-490. When rebasing is
					 carried out, if new rates are not calculated before their required effective
					 date, hospitals required to file cost reports and freestanding psychiatric
					 facilities licensed as hospitals shall be settled at the new rates, for
					 discharges on and after the effective date of those rates, at the time the
					 hospitals' cost reports for the year in which the rates become effective are
					 settled.
B. Effective July 1, 2009,
					 rates for freestanding psychiatric facilities shall be rebased using 2005 cost
					 data as the base year. Future rebasings shall be consistent with rebasing for
					 all other hospitals.
C. Effective
					 July 1, 2010, rates for freestanding psychiatric facilities shall not be
					 rebased.
Statutory Authority
§ 32.1-325 of the Code of Virginia; Title XIX of
						  the Social Security Act ( 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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-400 - Determination of per diem rates

Current through Register Vol. 40, No. 24, July 15, 2024
This section shall be applicable to only those claims for
						discharges prior to July 1, 1999. Each hospital's revised per diem rate or
						rates to be used during the transition period (SFY 1997 and SFY 1998) shall be
						based on the hospital's previous peer group ceiling or ceilings that were
						established under the provisions of
						12VAC30-70-10 through
						12VAC30-70-130, with the following
						adjustments:
1. All operating ceilings
					 will be increased by the same proportion to effect an aggregate increase in
					 reimbursement of $40 million in SFY 1997. This adjustment incorporates in per
					 diem rates the systemwide aggregate value of payment that otherwise would be
					 made through the payment adjustment fund. This adjustment will be calculated
					 using estimated 1997 rates and 1994 days.
2. Starting July 1, 1996, operating ceilings
					 will be increased for inflation to the midpoint of the state fiscal year, not
					 the hospital fiscal year. Inflation shall be based on the DRI-Virginia moving
					 average value as compiled and published by DRI/McGraw-Hill under contract with
					 DMAS, increased by two percentage points per year. The most current table
					 available prior to the effective date of the new rates shall be used.
For services to be paid at SFY 1998 rates, per diem rates
						shall be adjusted consistent with the methodology for updating rates under the
						DRG methodology (12VAC30-70-351 ).
3. There will be no
					 disproportionate share hospital (DSH) per diem.
4. To pay capital cost through claims, a
					 hospital specific adjustment to the per diem rate will be made. At settlement
					 of each hospital fiscal year, this per diem adjustment will be eliminated and
					 capital shall be paid as a pass-through.
5. This methodology shall be used after the
					 transition period to reimburse days of hospital stays with admission dates
					 before July 1, 1996.
6. This
					 methodology shall be used after the transition period to make interim payments
					 until such time as the DRG payment methodology is operational.
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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-410 - State university teaching hospitals

Current through Register Vol. 40, No. 24, July 15, 2024
For hospitals that were state owned teaching hospitals
						on January 1, 1996, all the calculations which support the determination of
						hospital specific rate per case and rate per day amounts under the prospective
						payment methodology shall be carried out separately from other hospitals, using
						cost data taken only from state university teaching hospitals. Rates to be used
						shall be determined on the basis of cost report and other applicable data from
						the most recent year for which reliable data are available at the time of
						rebasing.
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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-411 - Supplemental payments for certain teaching hospitals

Current through Register Vol. 40, No. 24, July 15, 2024
A. Effective for dates of service on or after
					 July 1, 2017, quarterly supplemental payments will be issued to qualifying
					 private hospitals for inpatient services rendered during the quarter.
B. Qualifying criteria. The primary teaching
					 hospitals affiliated with a Liaison Committee on Medical Education (LCME)
					 accredited medical school located in Planning District 23 that is a political
					 subdivision of the Commonwealth and an LCME accredited medical school located
					 in Planning District 5 that has a partnership with a public
					 university.
C. Reimbursement
					 methodology. Each qualifying hospital shall receive quarterly supplemental
					 payments for the inpatient services rendered during the quarter equal to the
					 difference between the hospital's Medicaid payments and the hospital's
					 disproportionate share limit (Omnibus Budget Reconciliation Act 93
					 disproportionate share hospital limit) for the most recent year for which the
					 disproportionate share limit has been calculated divided by four. The
					 supplemental payment amount will be determined prior to the beginning of the
					 fiscal year.
D. Limit. Maximum
					 aggregate payments to all qualifying hospitals shall not exceed the available
					 upper payment limit per state fiscal year.
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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-415 - Reimbursement for freestanding psychiatric hospital services under EPSDT

Current through Register Vol. 40, No. 24, July 15, 2024
A. The freestanding
					 psychiatric hospital specific rate per day for psychiatric cases shall be equal
					 to the hospital specific operating rate per day, as determined in subsection A
					 of 12VAC30-70-321 plus the hospital
					 specific capital rate per day for freestanding psychiatric cases.
B. The freestanding psychiatric hospital
					 specific capital rate per day for psychiatric cases shall be equal to the
					 Medicare geographic adjustment factor (GAF) for the hospital's geographic area
					 times the statewide capital rate per day for freestanding psychiatric cases
					 times the percentage of allowable cost specified in
					 12VAC30-70-271.
C. The statewide capital rate per day for
					 psychiatric cases shall be equal to the weighted average of the
					 GAF-standardized capital cost per day of facilities licensed as freestanding
					 psychiatric hospitals.
D. The
					 capital cost per day of facilities licensed as freestanding psychiatric
					 hospitals shall be the average charges per day of psychiatric cases times the
					 ratio total of capital cost to total charges of the hospital, using data
					 available from Medicare cost report.
E. Effective July 1, 2014, services provided
					 under arrangement, as defined in subdivisions B 6 a and B 6 b of
					 12VAC30-50-130, shall be
					 reimbursed directly by DMAS, according to the reimbursement methodology
					 prescribed for each provider in 12VAC30-80 or elsewhere in the State Plan, to a
					 provider of services under arrangement if all of the following are met:
1. The services are included in the active
					 treatment plan of care developed and signed as described in subdivision C 4 of
					 12VAC30-60-25; and
2. The services are arranged and overseen by
					 the freestanding psychiatric hospital treatment team through a written referral
					 to a Medicaid enrolled provider that is either an employee of the freestanding
					 psychiatric hospital or under contract for services provided under
					 arrangement.
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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-418 - Reimbursement for residential and inpatient substance use treatment services

Current through Register Vol. 40, No. 24, July 15, 2024
A. The following
					 substance use disorder treatment services for adults and adolescents are
					 provided in a residential or inpatient setting:
(i) clinically managed population-specific
					 high intensity residential service (ASAM Level 3.3);
(ii) clinically managed high intensity
					 residential services (adult) and clinically managed medium intensity
					 residential services (adolescent) (ASAM Level 3.5);
(iii) medically monitored intensive inpatient
					 services (adult) and medically monitored high intensity inpatient services
					 (adolescent) (ASAM Level 3.7); and
(iv) medically managed intensive inpatient
					 services (ASAM Level 4.0).
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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-417 - Reimbursement for inpatient psychiatric services in residential treatment facilities (Level C) under EPSDT

Current through Register Vol. 40, No. 24, July 15, 2024
A.
					 Effective January 1, 2000, DMAS shall pay for inpatient psychiatric services in
					 residential treatment facilities provided by participating providers under the
					 terms and payment methodology described in this section.
B. Effective January 1, 2000, payment shall
					 be made for inpatient psychiatric services in residential treatment facilities
					 using a per diem payment rate as determined by DMAS based on information
					 submitted by enrolled residential psychiatric treatment facilities. This rate
					 shall constitute direct payment for all residential psychiatric treatment
					 facility services, excluding all services provided under arrangement that are
					 reimbursed in the manner described in subsection D of this section.
C. Enrolled residential treatment facilities
					 shall submit cost reports on uniform reporting forms provided by DMAS at such
					 time as required by DMAS. Such cost reports shall cover a 12-month period. If a
					 complete cost report is not submitted by a provider, DMAS shall take action in
					 accordance with its policies to assure that an overpayment is not being
					 made.
D. Effective July 1, 2014,
					 services provided under arrangement, as defined in subdivisions B 6 a and B 6 b
					 of 12VAC30-50-130, shall be
					 reimbursed directly by DMAS to a provider of services provided under
					 arrangement according to the reimbursement methodology prescribed for that
					 provider type elsewhere in the State Plan if all of the following are met:
1. The services provided under arrangement
					 are included in the active written treatment plan of care developed and signed
					 as described in section
					 12VAC30-130-890; and
2. The services provided under arrangement
					 are arranged and overseen by the residential treatment facility treatment team
					 through a written referral to a Medicaid enrolled provider that is either an
					 employee of the residential treatment facility or under contract for services
					 provided under arrangement.
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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-420 - Reimbursement of noncost-reporting general acute care hospital providers

Current through Register Vol. 40, No. 24, July 15, 2024
A. Effective July
					 1, 2000, noncost-reporting hospitals shall be paid based on the in-state
					 average DRG rates increased by the average capital percentage among hospitals
					 filing cost reports in a recent year.
B. Effective July 1, 2011, out-of-state
					 hospitals shall be reimbursed the lesser of the amount reimbursed by the
					 Medicaid program in the facility's home state or the rate defined in the
					 subsection A of this section.
C.
					 Prior approval must be received from DMAS when a referral has been made for
					 treatment to be received from a nonparticipating acute care facility (in-state
					 or out-of-state). Prior approval will be granted for inpatient hospital
					 services provided out of state to a Medicaid recipient who is a resident of the
					 Commonwealth of Virginia under any one of the following conditions. It shall be
					 the responsibility of the nonparticipating hospital, when requesting prior
					 authorization for the admission of the Virginia resident, to demonstrate that
					 one of the following conditions exists in order to obtain authorization.
					 Services provided out of state for circumstances other than these specified
					 reasons shall not be covered.
1. The medical
					 services must be needed because of a medical emergency;
2. Medical services must be needed and the
					 recipient's health would be endangered if he were required to travel to his
					 state of residence;
3. The state
					 determines, on the basis of medical advice, that the needed medical services,
					 or necessary supplementary resources, are more readily available in the other
					 state;
4. It is general practice
					 for recipients in a particular locality to use medical resources in another
					 state.
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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-425 - Supplemental payments for non-state-government-owned hospitals for inpatient services

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 non-state-government-owned hospitals as certified by the provider
					 through cost reports.
B. A
					 non-state-government-owned hospital is owned or operated by a unit of
					 government other than a state.
C.
					 Effective July 1, 2018, additional supplemental payments will be issued to each
					 non-state-government-owned acute care hospital for inpatient services provided
					 to Medicaid patients.
1. The supplemental
					 payment shall equal inpatient hospital clam payments times the upper payment
					 limit (UPL) gap percentage.
a. The annual UPL
					 gap percentage is the percentage calculated where the numerator is the
					 difference for each non-state-government-owned acute care hospital between a
					 reasonable estimate of the amount that would be paid under Medicare payment
					 principles for inpatient hospital services provided to Medicaid patients, as
					 calculated in accordance with
					 42
					 CFR 447.272, and what Medicaid paid for such
					 services, and the denominator is Medicaid claim payments to each hospital for
					 inpatient hospital services provided to Medicaid patients in the same years
					 used in the numerator.
b. The UPL
					 gap percentage will be calculated annually for each hospital using data for the
					 most recent year for which comprehensive annual data are available and inflated
					 to the state fiscal year for which payments are to be made.
c. Maximum aggregate payments to all
					 qualifying hospitals shall not exceed the available upper payment limit. If
					 inpatient payments for non-state-government-owned hospitals would exceed the
					 upper payment limit, the numerator in the calculation of the UPL gap percentage
					 shall be reduced proportionately.
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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-426

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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-428 - Supplemental payments for private hospital partners of Type One hospitals

Current through Register Vol. 40, No. 24, July 15, 2024
A. Effective for
					 dates of service on or after October 25, 2011, quarterly supplemental payments
					 will be issued to qualifying private hospitals for inpatient services rendered
					 during the quarter. These quarterly supplemental payments will cease for dates
					 of service on or after the effective date of State Plan amendments authorizing
					 increased payments to qualifying hospitals from the Health Care Provider Rate
					 Assessment Fund established pursuant to § 32.1-331.02 of the Code of
					 Virginia and approved by the Centers for Medicare and Medicaid
					 Services.
B. Qualifying criteria.
					 In order to qualify for the supplemental payment, the hospital must be enrolled
					 currently as a Virginia Medicaid provider and must be owned or operated by a
					 private entity in which a Type One hospital has a nonmajority
					 interest.
C. Reimbursement
					 methodology.
1. Hospitals not participating
					 in the Medicaid disproportionate share hospital (DSH) program shall receive
					 quarterly supplemental payments for the inpatient services rendered during the
					 quarter. Each quarterly payment distribution shall occur not more than two
					 years after the year in which the qualifying hospital's entitlement arises. The
					 annual supplemental payments in any fiscal year shall be the lesser of:
a. The difference between each qualifying
					 hospital's inpatient Medicaid billed charges and Medicaid payments the hospital
					 receives for services processed for fee-for-service Medicaid recipients during
					 the fiscal year; or
b. $14,620 per
					 Medicaid discharge for state plan rate year 2012. For future state plan rate
					 years, this number shall be adjusted by inflation based on the Virginia moving
					 average values as compiled and published by Global Insight (or its successor)
					 under contract with the department.
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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-430 - Medicare upper limit

Current through Register Vol. 40, No. 24, July 15, 2024
For participating and nonparticipating facilities, the
						state agency will pay no more in the aggregate for inpatient hospital services
						than 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) or the lesser
						of reasonable cost or customary charges in
						42 CFR
						447.250.
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item 322 J
						  of Chapter 912 of the 1996 Virginia Acts of Assembly.
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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-435 - Lump sum payment

Current through Register Vol. 40, No. 24, July 15, 2024
A. In
					 addition to the DRG payment, DMAS shall make a one-time, lump sum payment of
					 $12,243,204 to eligible Virginia hospitals participating in the Medicaid
					 program. This payment shall be made in two equal, semi-annual amounts during
					 fiscal year 2001. For purposes of distribution, each hospital's share of the
					 total amount shall be determined as follows:
1. DMAS shall determine the total operating
					 payments due each hospital for inpatient hospital services provided from
					 January 1, 2000, through June 30, 2000, using hospital claims data from
					 discharges in that period.
2. DMAS
					 shall determine the total operating payments that would have been due each
					 hospital for the same services had the inpatient hospital rates and weights
					 applicable in fiscal year 1998 been continued with inflation for fiscal years
					 1999 and 2000.
3. The difference
					 between the two values calculated in subdivisions 1 and 2 of this subsection,
					 summed across all hospitals, is the statewide difference. Each
					 hospital-specific difference divided by the statewide difference is the
					 hospital-specific percent share of the statewide difference.
4. The hospital-specific percent share of the
					 statewide difference, times the total funds provided by this appropriation, is
					 the hospital-specific lump sum payment to be paid in two equal semi-annual
					 payments during fiscal year 2001. This payment shall be made as an increase to
					 reimbursement for services provided to Medicaid recipients during state fiscal
					 year 2001. For each hospital, the hospital-specific lump sum payment amount
					 shall be divided by the number of DRG cases in the hospital discharged from
					 July 1, 2000, through December 31, 2000, on or before April 30, 2001. This per
					 case amount shall be paid to each hospital for each of the cases discharged by
					 the hospital during this specified time period, as determined by
					 DMAS.
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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-440

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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-441 - 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 70 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES › Part V - Inpatient Hospital Payment System › Article 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-470 - Underpayments

Current through Register Vol. 40, No. 24, July 15, 2024
When the settlement of a hospital fiscal year indicates
						that an underpayment has occurred, the state agency shall pay the additional
						amount to the hospital within 60 days of completion of the
						settlement.
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item 322 J
						  of Chapter 912 of the 1996 Virginia Acts of Assembly.
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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-490 - Medicaid Hospital Payment Policy Advisory Council

Current through Register Vol. 40, No. 24, July 15, 2024
In order to ensure the ongoing relevance and fairness of
						the prospective payment system for hospital services, the Director of the
						Department of Medical Assistance Services shall appoint a Medicaid Hospital
						Payment Policy Advisory Council. The council shall be composed of four hospital
						or health system representatives nominated by the Virginia Hospital and
						Healthcare Association, two senior department staff and one representative each
						from the Department of Planning and Budget and the Joint Commission on
						Healthcare. This council will be charged with evaluating and developing
						recommendations on payment policy changes in areas that include, but are not
						limited to, the following:
(i)
					 utilization reductions directly attributable to the 1995 Appropriations Act
					 utilization initiative and any necessary adjustments to SFY1997 and 1998 DRG
					 rates;
(ii) the update and
					 inflation factors to apply to the various components of the delivery system;
(iii) the treatment of capital and
					 medical education costs;
(iv) the
					 mechanisms and budget implications of recalibration and rebasing approaches;
(v) the disproportionate share
					 payment fund and allocation mechanisms; and
(vi) the timing and final design of an
					 outpatient payment methodology.
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item 322 J
						  of Chapter 912 of the 1996 Virginia Acts of Assembly.
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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section 12VAC30-70-500

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 3 - Other Provisions for Payment of Inpatient Hospital Services › Form - FORMS (12VAC30-70)

Current through Register Vol. 40, No. 24, July 15, 2024
Computation of Inpatient Operating Cost, HCFA-2552-92 D-1
						(12/92).
Apportionment of Cost of Services Rendered by Interns and
						Residents, HCFA-2552-92 D-2 (12/92).
Cost Reporting Forms for Hospitals (Map 783 Series), eff.
						10/15/93
Certification by Officer or Administrator of
						Provider
Analysis of Interim Payments for Title XIX
						Services
Computation of Title XIX Ratio of Cost to Charges
Computation of Inpatient and Outpatient Ancillary Service
						Costs
Computation of Outpatient Capital Reduction
Computation of Title XIX Outpatient Costs
Computation of Charges for Lower of Cost or Charge
						Comparison
Computation of Title XIX Reimbursement Settlement
Computation of Net Medicaid Inpatient Operating Cost
						Adjustment
Calculation of Medicaid Inpatient Profit Incentive for
						Hospitals
Plant Costs
Education Costs
Obstetrical Care Requirements Certification
Computation for Separating the Allowable Plant and
						Education Cost (pass-throughs) from the Inpatient Medicaid Hospital
						Costs
Cost
						Reporting Form Residential Treatment Facilities, RTF-608 (undated, filed
						9/2016)
Graduate
						Medical Education Application (eff. 8/2019)
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 3 - Other Provisions for Payment of Inpatient Hospital Services › Section - DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-70)

Current through Register Vol. 40, No. 24, July 15, 2024
All Patient Diagnosis Related Groups (AP-DRG) Grouper,
						DRG and MDC Code Listings, Version 12, January 1995
Health Care Cost Review, Third Quarter 2009, IHS Global
						Insight
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 12VAC30-80-10 - General

Current through Register Vol. 40, No. 24, July 15, 2024
The policy and the method to be used in establishing payment
				  rates for each type of care or service (other than inpatient hospitalization,
				  skilled nursing and intermediate care facilities) listed in § 1905(a) of
				  the Social Security Act and included in this State Plan for Medical Assistance
				  are described in the following paragraphs:
1. Reimbursement and payment criteria will be
				established which are designed to enlist participation of a sufficient number
				of providers of services in the program so that eligible persons can receive
				the medical care and services included in the Plan at least to the extent these
				are available to the general population.
2. Participation in the program will be
				limited to providers of services who accept, as payment in full, the state's
				payment plus any copayment required under the State Plan.
3. Payment for care or service will not
				exceed the amounts indicated to be reimbursed in accord with the policy and
				methods described in this Plan and payments will not be made in excess of the
				upper limits described in 42
				CFR 447.304(a). The state
				agency has continuing access to data identifying the maximum charges allowed:
				such data will be made available to the Secretary, HHS, upon request.
4. Consistent with
				42 CFR
				447.26 and effective July 1, 2012, the
				Commonwealth shall not reimburse any other providers for (i) wrong surgical or
				other invasive procedure performed on a patient; (ii) surgical or other
				invasive procedure performed on the wrong body part; or (iii) surgical or other
				invasive procedure performed on the wrong patient.
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 12VAC30-80-20 - Services that are reimbursed on a cost basis

Current through Register Vol. 40, No. 24, July 15, 2024
A. Payments for services listed in this
				section shall be on the basis of reasonable cost following the standards and
				principles applicable to the Title XVIII Program with the exception provided
				for in subdivision D 1 e of this section. The upper limit for reimbursement
				shall be no higher than payments for Medicare patients in accordance with
				42
				CFR 447.321. In no instance, however, shall
				charges for beneficiaries of the program be in excess of charges for private
				patients receiving services from the provider. The professional component for
				emergency room physicians shall continue to be uncovered as a component of the
				payment to the facility.
B.
				Reasonable costs will be determined from the filing of a uniform Centers for
				Medicare and Medicaid Services-approved cost report by participating providers.
				The cost reports are due not later than 150 days after the provider's fiscal
				year end. If a complete cost report is not received within 150 days after the
				end of the provider's fiscal year, DMAS or its designee shall take action in
				accordance with its policies to assure that an overpayment is not being made.
				All cost reports shall be reviewed and reconciled to final costs within 180
				days of the receipt of a completed cost report. The cost report will be judged
				complete when DMAS has all of the following:
1. Completed cost reporting form provided by
				DMAS, with signed certification;
2.
				The provider's trial balance showing adjusted journal entries;
3. The provider's financial statements
				including a balance sheet, a statement of income and expenses, a statement of
				retained earnings (or fund balance), and a statement of changes in financial
				position;
4. Schedules that
				reconcile financial statements and trial balance to expenses claimed in the
				cost report;
5. Depreciation
				schedule or summary;
6. Home office
				cost report, if applicable; and
7.
				Such other analytical information or supporting documents requested by DMAS
				when the cost reporting forms are sent to the provider.
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 12VAC30-80-21 - Reimbursement for services furnished individuals residing in a freestanding psychiatric hospital or residential treatment center (Level C)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Reimbursement
				for all services furnished to individuals younger than 21 years of age who are
				residing in a freestanding psychiatric hospital shall be based on the
				freestanding psychiatric hospital reimbursement described in 12VAC30-70-415 and
				the reimbursement of services provided under arrangement described in
				12VAC30-80.
B. Reimbursement for
				all services furnished to individuals younger than 21 years of age who are
				residing in a residential treatment center (Level C) shall be based on the
				residential treatment center (Level C) reimbursement described in
				12VAC30-70-417 and the reimbursement of services provided under arrangement
				described in 12VAC30-80.
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 12VAC30-80-25 - Reimbursement for federally qualified health centers (FQHCs) and rural health clinics (RHCs)

Current through Register Vol. 40, No. 24, July 15, 2024
A. Consistent
				with the Benefits Improvement and Protection Act (BIPA) of 2000, Section 702,
				DMAS adopts the alternative payment methodology. This alternative payment
				methodology continues established reasonable cost reimbursement using Medicare
				principles of reimbursement. The Commonwealth shall make interim payments on a
				per visit basis and shall reconcile to actual costs via the year-end cost
				report. The methodology used to determine the payment amount is:
(i) agreed to by the Commonwealth and the
				center or clinic and
(ii) results
				in payment to the center or clinic of an amount that is at least equal to the
				PPS payment rate.
1. Newly qualified
				FQHCs/RHCs adopting the alternative payment methodology after federal fiscal
				year 2000 will have initial payments established through pro forma cost
				reporting methods.
2. At the end of
				the cost reporting cycle, the Commonwealth shall compare the alternative per
				visit rate to the PPS rate and reimburse the center/clinic the higher of the
				alternative rate or the PPS rate for the number of visits recorded during the
				reporting period.
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 12VAC30-80-26 - Reimbursement for Indian Health Service tribal 638 facilities

Current through Register Vol. 40, No. 24, July 15, 2024
A. Reimbursement
				for tribal health clinics.
1. Services
				provided by or through facilities of the Indian Health Services (IHS),
				including at the option of the tribe, facilities operated by a tribe or tribal
				organization, and funded by Title I or Title V of the Indian Self Determination
				and Education Assistance Act of 1975 (25 USC §
											5301 et seq.), also known as tribal 638
				facilities, are paid at the applicable IHS U.S. Office of Management &
				Budget (OMB) rate published annually in the Federal Register of Regulations by
				IHS.
2. The most current published
				IHS OMB outpatient per visit rate, also known as the outpatient all-inclusive
				rate, is paid for up to five outpatient visits per beneficiary per calendar day
				for professional services. An outpatient visit is defined as a face-to-face or
				telemedicine contact between any health care professional at or through the IHS
				facility authorized to provide services under the State Plan and a beneficiary
				for the provision of Title XIX defined services, as documented in the
				beneficiary's medical record.
3.
				Included in the outpatient per visit rate are Medicaid-covered pharmaceuticals
				or drugs, dental services, rehabilitative services, behavioral health services,
				ancillary services, and emergency room services provided on-site, and medical
				supplies incidental to the services provided to the beneficiary.
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 12VAC30-80-32 - Reimbursement for substance use disorder services

Current through Register Vol. 40, No. 24, July 15, 2024
A. Physician services described in
				12VAC30-50-140,
				other licensed practitioner services described in
				12VAC30-50-150,
				and clinic services described in
				12VAC30-50-180
				for assessment and evaluation or treatment of substance use disorders shall be
				reimbursed using the methodology in
				12VAC30-80-30
				and
				12VAC30-80-190
				subject to the following reductions for psychotherapy services for other
				licensed practitioners.
1. Psychotherapy and
				substance use disorder counseling services of licensed clinical psychologists
				shall be reimbursed at 90% of the reimbursement rate for
				psychiatrists.
2. Psychotherapy and
				substance use disorder counseling services provided by independently enrolled
				licensed clinical social workers, licensed professional counselors, licensed
				marriage and family therapists, licensed psychiatric nurse practitioners,
				licensed substance abuse treatment practitioners, or registered clinical nurse
				specialists-psychiatric shall be reimbursed at 75% of the reimbursement rate
				for licensed clinical psychologists.
3. The same rates shall be paid to
				governmental and private providers. These services are reimbursed based on the
				Common Procedural Terminology codes and Healthcare Common Procedure Coding
				System codes. The agency's rates were set as of July 1, 2007, and are updated
				as described in
				12VAC30-80-190.
				All rates are published on the Department of Medical Assistance Services (DMAS)
				website at
http://www.dmas.virginia.gov
.
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 12VAC30-80-35 - Fee for service: ambulatory surgery centers

Current through Register Vol. 40, No. 24, July 15, 2024
A. Definitions: The following words and terms
				when used in this part shall have the following meanings unless the context
				clearly indicates otherwise:
"Ambulatory Patient Group (APG)" means a defined group of
				  outpatient procedures, encounters, or ancillary services that incorporates
				  International Classification of Disease (ICD) diagnosis codes, Current
				  Procedural Terminology (CPT) codes, and Healthcare Common Procedure Coding
				  System (HCPCS) codes.
"APG relative weight" means the relative expected average
				  costs for each APG divided by the relative expected average costs for visits
				  assigned to all APGs.
B.
				Effective July 1, 2010, the prospective Ambulatory Patient Group (APG)-based
				payment system described as follows shall apply to Ambulatory Surgery Center
				(ASC) services:
1. The operating payments for
				ASC visits shall be determined on the basis of a base rate per visit times the
				relative weight of the APG to which the visit is assigned.
2. The APG relative weights shall be the
				weights determined and published periodically by DMAS. The weights shall be
				updated at least every three years.
3. The base rate shall be adjusted by the
				budget neutrality factor (BNF) to ensure that no increase in expenditures
				occurs as a result of updates to the relative weights. The base period used to
				adjust the base rate shall be a recent 12-month period prior to the fiscal year
				that the new base rates will be effective.
4. The operating payment shall represent
				total allowable amount for a visit including ancillary services.
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 12VAC30-80-40 - Fee-for-service providers: pharmacy

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				Payment for covered outpatient legend and nonlegend drugs dispensed by a retail
				community pharmacy will include the drug ingredient cost plus a $10.65
				professional dispensing fee. The drug ingredient cost reimbursement shall be
				the lowest of:
1. The national average drug
				acquisition cost (NADAC) of the drug, the federal upper limit (FUL), or the
				provider's usual and customary (U&C) charge to the public as identified by
				the claim charge; or
2. When no
				NADAC is available, DMAS shall reimburse at the lowest of the wholesale
				acquisition cost plus 0%, the FUL, or the provider's U&C charge to the
				public as identified by the claim charge.
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 12VAC30-80-50 - Third party liability

Current through Register Vol. 40, No. 24, July 15, 2024
All reasonable measures will be taken to ascertain the legal
				  liability of third parties to pay for authorized care and services provided to
				  eligible recipients including those measures specified under 42 USC §
				  1396(a)(25).
Statutory Authority
§ 32.1-325 of the Code of Virginia.