Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part V - Benefits and Reimbursement › Section 12VAC30-141-500 - Benefits reimbursement

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Reimbursement for the services covered under FAMIS fee-for-service and MCHIPs
				  shall be as specified in this section.
B. Reimbursement for physician services,
				  surgical services, clinic services, prescription drugs, laboratory and
				  radiological services, outpatient mental health services, early intervention
				  services, emergency services, home health services, immunizations, mammograms,
				  medical transportation, organ transplants, skilled nursing services, well baby
				  and well child care, vision services, durable medical equipment, disposable
				  medical supplies, dental services, case management services, physical therapy,
				  occupational therapy, or speech-language therapy services, hospice services,
				  school-based health services, behavioral therapy services including applied
				  behavior analysis, and certain community-based mental health services shall be
				  based on the Title XIX rates.
C.
				  Reimbursement to MCHIPs shall be determined on the basis of the estimated cost
				  of providing the MCHIP benefit package and services to an actuarially
				  equivalent population. MCHIP rates will be determined annually and published 30
				  days prior to the effective date.
D. Exceptions.
1. Prior authorization is required after five
				  visits in a fiscal year for physical therapy, occupational therapy, and
				  speech-language therapy provided by home health providers and outpatient
				  rehabilitation facilities and for home health skilled nursing visits. Prior
				  authorization is required for the following nonemergency outpatient procedures:
				  Magnetic Resonance Imaging, including Magnetic Resonance Angiography (MRA),
				  Computerized Axial Tomography (CAT) scans, including Computed Tomography
				  Angiography (CTA), or Positron Emission Tomography (PET) scans performed for
				  the purpose of diagnosing a disease process or physical injury. Prior
				  authorization for dental services will be based on the Title XIX prior
				  authorization requirements for dental services.
2. Reimbursement for inpatient hospital
				  services will be based on the Title XIX rates in effect for each hospital.
				  Reimbursement shall not include payments for disproportionate share or graduate
				  medical education payments made to hospitals. Payments made shall be final and
				  there shall be no retrospective cost settlements.
3. Reimbursement for outpatient hospital
				  services shall be based on the Title XIX rates in effect for each hospital.
				  Payments made will be final and there will be no retrospective cost
				  settlements.
4. Reimbursement for
				  inpatient mental health services other than by free standing psychiatric
				  hospitals will be based on the Title XIX rates in effect for each hospital.
				  Reimbursement will not include payments for disproportionate share or graduate
				  medical education payments made to hospitals. Payments made will be final and
				  there will be no retrospective cost settlements.
5. Reimbursement for outpatient
				  rehabilitation services will be based on the Title XIX rates in effect for each
				  rehabilitation agency. Payments made will be final and there will be no
				  retrospective cost settlements.
6.
				  Reimbursement for outpatient substance abuse treatment services will be based
				  on rates determined by DMAS for children ages six through 18 years. Payments
				  made will be final and there will be no retrospective cost
				  settlements.
7. Reimbursement for
				  prescription drugs will be based on the Title XIX rates in effect.
				  Reimbursements for Title XXI do not receive drug rebates as under Title
				  XIX.
8. Reimbursement for covered
				  prescription drugs for noninstitutionalized FAMIS recipients receiving the
				  fee-for-service benefits will be subject to review and prior authorization when
				  their current number of prescriptions exceeds nine unique prescriptions within
				  180 calendar days, and as may be further defined by the agency's guidance
				  documents for pharmacy utilization review and the prior authorization program.
				  The prior authorization process shall be applied consistent with the process
				  set forth in
				  12VAC30-50-210
				  A 7.