REGULATIONS
Vol. 34 Iss. 25 - August 06, 2018

TITLE 12. HEALTH
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Chapter 20
Final Regulation

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Final Regulation

REGISTRAR'S NOTICE: The following regulatory action is exempt from Article 2 of the Administrative Process Act in accordance with § 2.2-4006 A 4 c of the Code of Virginia, which excludes regulations that are necessary to meet the requirements of federal law or regulations, provided such regulations do not differ materially from those required by federal law or regulation. The Department of Medical Assistance Services will receive, consider, and respond to petitions by any interested person at any time with respect to reconsideration or revision.

Title of Regulation: 12VAC30-20. Administration of Medical Assistance Services (amending 12VAC30-20-150, 12VAC30-20-160).

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Effective Date: September 5, 2018.

Agency Contact: Emily McClellan, Regulatory Supervisor, Policy Division, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371‑4300, FAX (804) 786‑1680, or email emily.mcclellan@dmas.virginia.gov.

Summary:

The amendments decrease the cost sharing amount charged per inpatient hospitalization from $100 to $75 to comply with 42 CFR 447.52(b)(2).

Part III
Recipient Cost Sharing

12VAC30-20-150. Copayments and deductibles for categorically needy and QMBs for services other than under 42 CFR 447.53.

A. The following charges are imposed on the categorically needy and Qualified Medicare Beneficiaries for services other than those provided under 42 CFR 447.53.

Service*

Type Charge

Amount and Basis for Determination

Deduct

Coins

Copay

Inpatient Hospital

$100.00 -0-

‑0‑

‑0‑ $75

State's average daily payment of $594 is used as basis.

Outpatient Hospital Clinic

‑0‑

‑0‑

$3.00

State's average payment of $136 is used as basis.

Clinic Visit

‑0‑

‑0‑

$1.00

State's average payment of $29 is used as basis.

Physician Office Visit

‑0‑

‑0‑

$1.00

State's average payment of $23 is used as basis.

Eye Examination

‑0‑

‑0‑

$1.00

State's payment of $30 is used as basis.

Prescriptions:

 

 

 

 

--Generic

‑0‑

‑0‑

$1.00

State's average per generic script of $25 is used as payment basis.

--Brand Name

‑0‑

‑0‑

$3.00

State's average per brand-name script of $97 is used as payment basis.

Home Health Visit

‑0‑

‑0‑

$3.00

State's average payment of $56 is used as basis.

Other Physician Services

‑0‑

‑0‑

$3.00

State's average payment of $56 is used as basis.

Rehab Therapy Services (PT, OT, Sp/Lang.)

‑0‑

‑0‑

$3.00

State's average payment $78 is used as basis.

*NOTE: The applicability of copays to emergency services is discussed further in this section.

B. The method used to collect cost sharing charges for categorically needy individuals requires that providers be responsible for collecting the cost sharing charges from individuals.

C. The basis for determining whether an individual is unable to pay the charge, and the means by which such an individual is identified to providers, is described below in this subsection:

Providers will, based on information available to them, make a determination of the recipient's ability to pay the copayment. In the absence of knowledge or indications to the contrary, providers may accept the recipient's assertion that he or she is unable to pay the required copayment.

Recipients have been notified that inability to meet a copayment at a particular time does not relieve them of that responsibility.

D. The procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b) are described below in this subsection:

The application and exclusion of cost sharing is administered through the program's MMIS Medicaid Management Information System. Documentation of the certified computer system delineates, for each type of provider invoice used, protected eligible groups, protected services and applicable eligible groups and services.

Providers have been informed about: copay exclusions; applicable services and amounts; prohibition of service denial if recipient is unable to meet cost-sharing changes.

E. State policy does not provide for cumulative maximums on charges.

F. Emergency Services. No recipient copayment shall be collected for the following services:

1. Services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:

a. Placing the patient's health in serious jeopardy;

b. Serious impairment to bodily functions; or

c. Serious dysfunction of any bodily organ or part; and

2. All services delivered in emergency rooms.

12VAC30-20-160. Copayments and deductibles for medically needy and QMBs for services other than under 42 CFR 447.53.

A. The following charges are imposed on the medically needy and Qualified Medicare Beneficiaries for services other than those provided under 42 CFR 447.53.

Service*

Type Charge

Amount and Basis for Determination

Deduct

Coins

Copay

Inpatient Hospital

$100.00 -0-

‑0‑

‑0‑ $75

State's average daily payment of $594 is used as basis.

Outpatient Hospital Clinic

‑0‑

‑0‑

$3.00

State's average payment of $136 is used as basis.

Clinic Visit

‑0‑

‑0‑

$1.00

State's average payment of $29 is used as basis.

Physician Office Visit

‑0‑

‑0‑

$1.00

State's average payment of $23 is used as basis.

Eye Examination

‑0‑

‑0‑

$1.00

State's payment of $30 is used as basis.

Prescriptions:

 

 

 

 

--Generic

‑0‑

‑0‑

$1.00

State's average per generic script of $25 is used as payment basis.

--Brand Name

‑0‑

‑0‑

$3.00

State's average per brand-name script of $97 is used as payment basis.

Home Health Visit

‑0‑

‑0‑

$3.00

State's average payment of $56 is used as basis.

Other Physician Services

‑0‑

‑0‑

$3.00

State's average payment of $56 is used as basis.

Rehab Therapy Services (PT, OT, Sp/Lang.)

‑0‑

‑0‑

$3.00

State's average payment $78 is used as basis.

*NOTE: The applicability of copays to emergency services is discussed further in this section.

B. The method used to collect cost sharing charges for medically needy individuals requires that providers be responsible for collecting the cost sharing charges from individuals.

C. The basis for determining whether an individual is unable to pay the charge, and the means by which such an individual is identified to providers, is described below in this subsection:

Providers will, based on information available to them, make a determination of the recipient's ability to pay the copayment. In the absence of knowledge or indications to the contrary, providers may accept the recipient's assertion that he or she is unable to pay the required copayment.

Recipients have been notified that inability to meet a copayment at a particular time does not relieve them of that responsibility.

D. The procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b) are described below in this subsection:

The application and exclusion of cost sharing is administered through the program's MMIS Medicaid Management Information System. Documentation of the certified computer system delineates, for each type of provider invoice used, protected eligible groups, protected services and applicable eligible groups and services.

Providers have been informed about: copay exclusions; applicable services and amounts; and prohibition of service denial if recipient is unable to meet cost-sharing changes.

E. State policy does not provide for cumulative maximums.

F. Emergency Services. No recipient copayment shall be collected for the following services:

1. Services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:

a. Placing the patient's health in serious jeopardy;

b. Serious impairment to bodily functions; or

c. Serious dysfunction of any bodily organ or part; and

2. All services delivered in emergency rooms.

VA.R. Doc. No. R18-5231; Filed July 16, 2018, 3:34 p.m.