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) |
Exempt from APA | No, changes to this chapter are subject to the Administrative Process Act. |
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: ()- |
Current Actions | ||
Action Title | Latest Stage | Status |
---|---|---|
Fee For Service Supplemental Payments and Hospital Assessment | Final | Secretary of Health and Human Resources review in progress. |
Pharmacy Updates | - | |
Emergency Room Charges
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- | |
Outpatient Hospital Reimbursement | - |
Past Actions | ||
Action Title | Latest Stage | Status |
---|---|---|
Private Duty Nursing Services Under EPSDT | Emergency/NOIRA | Stage complete. This regulation became effective on 10/06/2023 and expires on 04/05/2025. |
Tribal Health Clinic | Fast-Track | Stage complete. This regulation became effective on 03/03/2022. |
Hospital Readmissions and Emergency Room Visits
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Final | Stage complete. This regulation became effective on 01/20/2021. |
2020 Provider Reimbursement Changes
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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
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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
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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
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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
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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
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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
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Final | Stage complete. This regulation became effective on 04/25/2012. |
2011 Incontinence Supplies by Contract
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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
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Final | Stage complete. This regulation became effective on 07/01/2011. |
2011 Pharmacy Reimbursement Update
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Final | Stage complete. This regulation became effective on 07/01/2011. |
2011 Technical Corrections for Reimbursment Regulations
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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)
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Final | Stage complete. This regulation became effective on 12/08/2010. |
2010 Pharmacy Reimbursement Change
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Final | Stage complete. This regulation became effective on 07/01/2010. |
2010 Reimbursement and Provider Termination Changes
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Final | Stage complete. This regulation became effective on 07/01/2010. |
2009 Hospital, Home Health, and Nursing Facility Reimbursement Changes
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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
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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
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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
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Final | Stage complete. This regulation became effective on 01/01/2008. |
2007 Reimbursement Changes
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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. |
Increase Dispensing Fees for Brand Name Drugs from $3.75 to $4.00
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Final | Stage complete. This regulation became effective on 05/01/2006. |
Emergency Room Physician Reimbursement Increase
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Final | Stage complete. This regulation became effective on 05/01/2006. |
Supplemental Payment Method for Faculty in Dental Pediatric Residency Programs | Emergency/NOIRA | Stage complete. Emergency regulation expired on 12/01/2006. |
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
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Final | Stage complete. This regulation became effective on 07/01/2005. |
DMERC Reimbursement for Durable Medical Equipment
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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 complete. This regulation became effective on 07/01/2004. |
Pharmacy Services Unit Dose | Final | Stage complete. This regulation became effective on 11/06/2003. |
Reduce Pharmacy Dispensing Fee
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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)
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Final | Stage complete. This regulation became effective on 08/01/2002. |
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 complete. This regulation became effective on 07/05/2000. |
Hospice Services and Payment Methodology | Final | Stage complete. This regulation became effective on 01/05/2000. |