Virginia Regulatory Town Hall View Chapter

Department of Medical Assistance Services

Board of Medical Assistance Services

Methods and Standards for Establishing Payment Rate; Other Types of Care [12 VAC 30 ‑ 80]

Chapter Information

Description	This chapter contains the reimbursement methodologies for other types of care (i.e., outpatient hospital, rural health clinics, rehabilitive providers, CORFs, physicians, dentists, local health departments, local school districts, pharmacies, transportation, and home health agencies). This chapter also contains provisions for payment of Medicare Parts A/B coinsurance and deductibles, and dispute resolution procedures for state-operated providers.
State Authority	COV 32.1-325 et seq .
Federal Authority	Title XIX of the Social Security Act (42 U.S.C. 1396)
Text of Regulation	Link to Virginia Administrative Code
Goals of Regulation	None entered
Meetings

Contact Information

Name / Title:	Emily McClellan / Regulatory Supervisor
Address:	600 E. Broad Street Suite 1300 Richmond, VA 23219
Email Address:	Emily.McClellan@DMAS.Virginia.gov
Telephone:	(804)371-4300 FAX: (804)786-1680 TDD: ()-

Action Title	Latest Stage	Status
Current Actions
Brain Injury Services Targeted Case Management	NOIRA	Comment period is underway and will end on 05/21/2025.
Private Duty Nursing Services Under EPSDT	Fast-Track	Returned to agency requesting additional information.
School Services	Fast-Track	Attorney General review in progress.
Emergency Room Charges	Final	Attorney General review in progress.
Pharmacy Updates	Fast-Track	Attorney General review in progress.

Action Title	Latest Stage	Status
Past Actions
Tribal Health Clinic	Fast-Track	Stage complete. This regulation became effective on 03/03/2022.
Fee For Service Supplemental Payments and Hospital Assessment	Final	Stage complete. This regulation became effective on 01/01/2025.
Hospital Readmissions and Emergency Room Visits	Final	Stage complete. This regulation became effective on 01/20/2021.
2020 Provider Reimbursement Changes	Final	Stage complete. This regulation became effective on 12/23/2020.
Incontinence Supplies	Fast-Track	Stage complete. This regulation became effective on 04/15/2021.
2019 Provider Reimbursement Changes	Final	Stage complete. This regulation became effective on 01/08/2020.
2018 Institutional Provider Reimbursement Updates - Fast Track	Fast-Track	Stage complete. This regulation became effective on 03/05/2020.
ARTS Updates	Fast-Track	Stage complete. This regulation became effective on 03/05/2020.
Update of Average Commercial Rate for Eastern Virginia Medical School	Fast-Track	Stage complete. This regulation became effective on 12/27/2019.
Pharmacy Fee-for-Service Reimbursement	Final	Stage complete. This regulation became effective on 09/05/2019.
Sunset Supplemental Payments	Fast-Track	Stage complete. This regulation became effective on 11/15/2018.
CH 0080 CHKD Hospital Inflation, FFS Providers, & Reimbursement Services on a Cost Basis	Final	Stage complete. This regulation became effective on 08/08/2018.
Dental Services & Community Mental Health Services	Fast-Track	Stage complete. This regulation became effective on 11/29/2018.
EPSDT Behavioral Therapy Services	Final	Stage complete. This regulation became effective on 12/12/2018.
Supplemental Payments to State Owned or Operated Clinics	Fast-Track	Stage complete. This regulation became effective on 10/18/2018.
Supplemental Payments for Type One Physicians	Fast-Track	Stage complete. This regulation became effective on 10/18/2018.
2016 and 2017 Provider Reimbursement Changes	Final	Stage complete. This regulation became effective on 02/21/2018.
Institutions for Mental Disease Reimbursement Changes	Final	Stage complete. This regulation became effective on 03/08/2017.
Reimbursement for Targeted Case Management	Fast-Track	Stage complete. This regulation became effective on 09/22/2016.
Type One Physician Supplemental Payments	Fast-Track	Stage complete. This regulation became effective on 01/29/2016.
Enhanced Ambulatory Patient Group Out Patient Hospital Reimbursement Methodology	Final	Stage complete. This regulation became effective on 08/10/2016.
No Inflation Adjustment for Provider Reimbursement	Final	Stage complete. This regulation became effective on 04/22/2015.
Supplemental Payments for Various Provider Types (Hospitals, EVMS Physicians, NFs)	Fast-Track	Stage complete. This regulation became effective on 11/17/2016.
Supplemental Payments for Institutional/Non-Institutional Providers	Fast-Track	Stage complete. This regulation became effective on 02/13/2015.
Early Intervention (Part C) Case Management	Fast-Track	Stage complete. This regulation became effective on 02/13/2015.
2012 Reimbursement Methodology Changes	Final	Stage complete. This regulation became effective on 08/14/2013.
2010 Durable Medical Equipment (DME) Changes	Final	Stage complete. This regulation became effective on 07/01/2012.
CH 0080 Pharmacy Supplemental Rebate/Unit Dose Fee/Drug Threshold	Fast-Track	Stage complete. This regulation became effective on 01/16/2014.
Provider Preventable Conditions	Final	Stage complete. This regulation became effective on 04/25/2012.
2011 Incontinence Supplies by Contract	Final	Stage complete. This regulation became effective on 01/01/2012.
Outpatient Rehabilitation Agency and Long Stay Hospital Reimbursement	Final	Stage complete. This regulation became effective on 08/16/2012.
Coverage and Reimbursement of Early Intervention Services under Part C of IDEA	Final	Stage complete. This regulation became effective on 10/25/2012.
2011 Budget Reimbursement Changes	Final	Stage complete. This regulation became effective on 07/01/2011.
2011 Pharmacy Reimbursement Update	Final	Stage complete. This regulation became effective on 07/01/2011.
2011 Technical Corrections for Reimbursment Regulations	Final	Stage complete. This regulation became effective on 04/27/2011.
Prospective APG Outpatient Hospital Reimbursement	NOIRA	Stage withdrawn on 05/23/2011 after the comment period had ended.
2010 Pharmacy Reimbursement Change (ARRA)	Final	Stage complete. This regulation became effective on 12/08/2010.
2010 Pharmacy Reimbursement Change	Final	Stage complete. This regulation became effective on 07/01/2010.
2010 Reimbursement and Provider Termination Changes	Final	Stage complete. This regulation became effective on 07/01/2010.
2009 Hospital, Home Health, and Nursing Facility Reimbursement Changes	Final	Stage complete. This regulation became effective on 03/17/2010.
Ambulatory Surgery Center and Outpatient Rehabilitation Facility Reimbursement	Final	Stage complete. This regulation became effective on 04/05/2010.
Recalibrate Physician Services by Implementing Site of Service	Final	Stage complete. This regulation became effective on 12/23/2009.
MAC Reimbursement for Specialty Drugs	Final	Stage complete. This regulation became effective on 12/23/2009.
Substance Abuse Treatment Services	Final	Stage complete. This regulation became effective on 01/21/2010.
Reduction of Pharmacy Dispensing Fee	Final	Stage complete. This regulation became effective on 07/01/2009.
Assurance of Public/Private Reimbursement for Hearing Aid Services	Fast-Track	Stage complete. This regulation became effective on 04/02/2009.
2008 Reimbursement Changes	Final	Stage complete. This regulation became effective on 10/15/2008.
School Health Services; Modified Reimbursement for School Divisions	Final	Stage complete. This regulation became effective on 12/10/2008.
School Division reimbursement	Final	Stage complete. This regulation became effective on 07/23/2008.
Tamper Resistant Rx Pads	Emergency/NOIRA	Stage complete. Emergency regulation expired on 03/31/2009.
Hearing Aid Services for Children	Final	Stage complete. This regulation became effective on 01/01/2008.
2007 Reimbursement Changes	Final	Stage complete. This regulation became effective on 07/01/2007.
Physician Fee Increases	Final	Stage complete. This regulation became effective on 07/11/2007.
Supplemental payments for services provided by Type I physicians	Final	Stage complete. This regulation became effective on 07/11/2007.
Increase Reimbursement for Hospitals, Certain Physicians and Nursing Facilities	Fast-Track	Stage complete. This regulation became effective on 08/25/2007.
Long Term Care Partnership Insurance	Fast-Track	Stage complete. This regulation became effective on 09/01/2007.
Modifications to Supplemental Payment Methods for Medicaid Public Providers.	Final	Stage complete. This regulation became effective on 08/23/2006.
Supplemental Payment Method for Faculty in Dental Pediatric Residency Programs	Proposed	Stage withdrawn on 06/20/2006 before Attorney General's office completed its review.
Increase Dispensing Fees for Brand Name Drugs from $3.75 to $4.00	Final	Stage complete. This regulation became effective on 05/01/2006.
Emergency Room Physician Reimbursement Increase	Final	Stage complete. This regulation became effective on 05/01/2006.
Virginia Maximum Allowable Cost (VMAC)	Final	Governor's office has completed its review - Next step is Submission to the Registrar.
State Agency Fee Schedule for RBRVS (OB Increase)	Final	Stage complete. This regulation became effective on 09/01/2005.
Increase Dispensing Fee for Generic Pharmaceuticals to $4.00	Final	Stage complete. This regulation became effective on 07/01/2005.
DMERC Reimbursement for Durable Medical Equipment	Final	Stage complete. This regulation became effective on 01/01/2005.
PDL, P&T Com, Drug Rebates, UR of High Drug Thresholds	Final	Stage complete. This regulation became effective on 01/03/2005.
Physician Fee Increase for ER Services	Emergency/NOIRA	Stage complete. Emergency regulation expired on 08/31/2004.
Limit Outpatient Hosp Reimbursement to 80% of Allowable Cost; Establish Prospective Reimbursement for Rehab Agencies	Final	Stage withdrawn on 02/27/2004 prior to submission to DPB.
Pharmacy Services Unit Dose	Final	Stage complete. This regulation became effective on 11/06/2003.
Reduce Pharmacy Dispensing Fee	Final	Stage complete. This regulation became effective on 07/01/2003.
Modify AWP and re-define VMAC	Final	Stage complete. This regulation became effective on 07/01/2003.
Supplemental Payments for Inpatient and Outpatient Services	Final	Stage complete. This regulation became effective on 01/28/2004.
Reimbursement for Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC)	Final	Stage complete. This regulation became effective on 08/01/2002.
Outpatient Hospital Reimbursement	NOIRA	Stage withdrawn on 06/13/2002 prior to submission to DPB.
Residential Psychiatric Treatment under EPSDT	Final	Stage complete. This regulation became effective on 01/01/2001.
Case Management for Treatment Foster Care	Final	Stage complete. This regulation became effective on 01/01/2001.
Repeal Obstetric/Pediatric Fees	Final	Stage withdrawn on 08/09/2007 prior to submission to DPB.
Hospice Services and Payment Methodology	Final	Stage complete. This regulation became effective on 01/05/2000.

Action Title	Latest Stage	Status
Withdrawn Actions
Average Commercial Rate for Physicians Affiliated with Type One Hospitals	Fast-Track	Stage withdrawn on 09/29/2023 prior to submitting for AG review.
Doula Services	Fast-Track	Stage withdrawn on 04/28/2022 prior to submitting for AG review.
New Qualifying Hospitals	Fast-Track	Stage withdrawn on 08/09/2018 before the Governor's office completed its review.
Restore Emergency Dept. Physician Reimbursement	Final	Stage withdrawn on 01/11/2018 before submission to the Registrar.
CH 0080 Reimbursement - Hospitals	Fast-Track	Stage withdrawn on 03/10/2017 prior to submitting for AG review.
Reimbursement Effective Dates Companion Letters	Fast-Track	Stage withdrawn on 03/10/2017 prior to submitting for AG review.
2016 Non-Instituional Provider Reimbursement	Fast-Track	Stage withdrawn on 08/08/2017 before Attorney General's office completed its review.
New Pharmacy Reimbursement Methodology	Emergency/NOIRA	Stage withdrawn on 08/26/2016 prior to submitting for AG review.
No Inflation Adjustment for Provider Reimbursement
Amount, Duration, and Scope of Services Pharmacy Services: Pharmacy Infusion Services	Proposed	Stage withdrawn on 03/18/2016 after the comment period had ended.
2010 Reimbursment Changes (Stimulus)	Final	Stage withdrawn on 11/12/2013 before submission to the Registrar.
Project Description Goes Here
CH 0080 Discontinue Unit Dose Dispensing Fee	Final	Stage withdrawn on 06/12/2012 before Attorney General's office completed its review.
Supplemental Drug Rebate Agreements	Fast-Track	Stage withdrawn on 03/06/2012 prior to submitting for AG review.
Eliminate Dispensing Fee for NF Unit Dose Drugs	Final	Stage withdrawn on 03/06/2012 before Attorney General's office completed its review.
2011 DME Incontinence Supplies by Contract	Final	Stage withdrawn on 09/01/2011 prior to submitting for AG review.
Outpatient Rehabilitation Agency and Long Stay Hospital Reimbursement	Emergency/NOIRA	Stage withdrawn on 05/15/2009 before Attorney General's office completed its review.
Reimbursement of Hearing Aids Services for Children	Final	Stage withdrawn on 10/10/2008 before Attorney General's office completed its review.
Tamper-Resistant Rx Pads	Final	Stage withdrawn on 07/26/2007 before Attorney General's office completed its review.
Increase Pharmacy Dispensing Fee for Generic Drugs to $4.00	Final	Stage withdrawn on 03/03/2005 before submission to the Registrar.