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Virginia Regulatory Town Hall
Agency
Department of Medical Assistance Services
Board
Board of Medical Assistance Services


chapter
Methods and Standards for Establishing Payment Rate; Other Types of Care [12 VAC 30 ‑ 80]
Guidance Documents   Periodic Reviews
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 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 and the standard executive branch review process.
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
Supplemental Payments to State Owned or Operated Clinics Fast-Track Governor's office review in progress.
Supplemental Payments for Type One Physicians Fast-Track DPB review in progress.
EPSDT Behavioral Therapy Services Proposed Stage complete. Comment period ended 9/22/2017.
Restore Emergency Dept. Physician Reimbursement
This action is exempt from the executive branch review process.
Final Exempt action can be submitted directly to the Registrar.

Past Actions
Action Title Latest Stage Status
Institutions for Mental Disease Reimbursement Changes Final Stage complete. This regulation became effective on 3/8/2017.
Reimbursement for Targeted Case Management Fast-Track Stage complete. This regulation became effective on 9/22/2016.
Pharmacy Fee-for-Service Reimbursement Emergency/NOIRA Stage complete. This regulation became effective on 6/16/2017 and expires on 12/15/2018.
Type One Physician Supplemental Payments Fast-Track Stage complete. This regulation became effective on 1/29/2016.
Enhanced Ambulatory Patient Group Out Patient Hospital Reimbursement Methodology Final Stage complete. This regulation became effective on 8/10/2016.
No Inflation Adjustment for Provider Reimbursement
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 4/22/2015.
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 2/13/2015.
Early Intervention (Part C) Case Management Fast-Track Stage complete. This regulation became effective on 2/13/2015.
2012 Reimbursement Methodology Changes
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 8/14/2013.
2010 Durable Medical Equipment (DME) Changes Final Stage complete. This regulation became effective on 7/1/2012.
CH 0080 Pharmacy Supplemental Rebate/Unit Dose Fee/Drug Threshold Fast-Track Stage complete. This regulation became effective on 1/16/2014.
Provider Preventable Conditions
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 4/25/2012.
2011 Incontinence Supplies by Contract
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 1/1/2012.
Outpatient Rehabilitation Agency and Long Stay Hospital Reimbursement Final Stage complete. This regulation became effective on 8/16/2012.
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
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 7/1/2011.
2011 Pharmacy Reimbursement Update
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 7/1/2011.
2011 Technical Corrections for Reimbursment Regulations
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 4/27/2011.
Prospective APG Outpatient Hospital Reimbursement NOIRA Stage withdrawn on 5/23/2011 after the comment period had ended.
2010 Pharmacy Reimbursement Change (ARRA)
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 12/8/2010.
2010 Pharmacy Reimbursement Change
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 7/1/2010.
2010 Reimbursement and Provider Termination Changes
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 7/1/2010.
2009 Hospital, Home Health, and Nursing Facility Reimbursement Changes
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 3/17/2010.
Ambulatory Surgery Center and Outpatient Rehabilitation Facility Reimbursement Final Stage complete. This regulation became effective on 4/5/2010.
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 1/21/2010.
Reduction of Pharmacy Dispensing Fee
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 7/1/2009.
Assurance of Public/Private Reimbursement for Hearing Aid Services Fast-Track Stage complete. This regulation became effective on 4/2/2009.
2008 Reimbursement Changes
This action is exempt from the executive branch review process.
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 7/23/2008.
Tamper Resistant Rx Pads Emergency/NOIRA Stage complete. Emergency regulation expired on 3/31/2009.
Hearing Aid Services for Children
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 1/1/2008.
2007 Reimbursement Changes
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 7/1/2007.
Physician Fee Increases Final Stage complete. This regulation became effective on 7/11/2007.
Supplemental payments for services provided by Type I physicians Final Stage complete. This regulation became effective on 7/11/2007.
Increase Reimbursement for Hospitals, Certain Physicians and Nursing Facilities Fast-Track Stage complete. This regulation became effective on 8/25/2007.
Long Term Care Partnership Insurance Fast-Track Stage complete. This regulation became effective on 9/1/2007.
Modifications to Supplemental Payment Methods for Medicaid Public Providers. Final Stage complete. This regulation became effective on 8/23/2006.
Increase Dispensing Fees for Brand Name Drugs from $3.75 to $4.00
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 5/1/2006.
Emergency Room Physician Reimbursement Increase
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 5/1/2006.
Supplemental Payment Method for Faculty in Dental Pediatric Residency Programs Emergency/NOIRA Stage complete. Emergency regulation expired on 12/1/2006.
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 9/1/2005.
Increase Dispensing Fee for Generic Pharmaceuticals to $4.00
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 7/1/2005.
DMERC Reimbursement for Durable Medical Equipment
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 1/1/2005.
PDL, P&T Com, Drug Rebates, UR of High Drug Thresholds Final Stage complete. This regulation became effective on 1/3/2005.
Physician Fee Increase for ER Services Emergency/NOIRA Stage complete. Emergency regulation expired on 8/31/2004.
Limit Outpatient Hosp Reimbursement to 80% of Allowable Cost; Establish Prospective Reimbursement for Rehab Agencies Final Stage complete. This regulation became effective on 7/1/2004.
Pharmacy Services Unit Dose Final Stage complete. This regulation became effective on 11/6/2003.
Reduce Pharmacy Dispensing Fee
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 7/1/2003.
Modify AWP and re-define VMAC Final Stage complete. This regulation became effective on 7/1/2003.
Supplemental Payments for Inpatient and Outpatient Services Final Stage complete. This regulation became effective on 1/28/2004.
Reimbursement for Federally Qualified Health Centers (FQHC) and Rural Health Clinics (RHC)
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 8/1/2002.
Residential Psychiatric Treatment under EPSDT Final Stage complete. This regulation became effective on 1/1/2001.
Case Management for Treatment Foster Care Final Stage complete. This regulation became effective on 1/1/2001.
Repeal Obstetric/Pediatric Fees Final Stage complete. This regulation became effective on 7/5/2000.
Hospice Services and Payment Methodology Final Stage complete. This regulation became effective on 1/5/2000.
CH 0080 CHKD Hospital Inflation -
Reimbursement Effective Dates Companion Letters -
Outpatient Hospital Reimbursement -
New Qualifying Hospitals -
CH 0080 Reimbursement - Hospitals -
2016 and 2017 Provider Reimbursement Changes -

Withdrawn Actions
Action Title Latest Stage Status
2016 Non-Instituional Provider Reimbursement -
New Pharmacy Reimbursement Methodology -
No Inflation Adjustment for Provider Reimbursement -
Amount, Duration, and Scope of Services Pharmacy Services: Pharmacy Infusion Services Proposed Stage withdrawn on 3/18/2016 after the comment period had ended.
2010 Reimbursment Changes (Stimulus)
This action is exempt from the executive branch review process.
Final Stage withdrawn on 11/12/2013 before submission to the Registrar.
Project Description Goes Here -
CH 0080 Discontinue Unit Dose Dispensing Fee -
Supplemental Drug Rebate Agreements -
Eliminate Dispensing Fee for NF Unit Dose Drugs
This action is exempt from the executive branch review process.
Final Stage withdrawn on 3/6/2012 before Attorney General's office completed its review.
2011 DME Incontinence Supplies by Contract
This action is exempt from the executive branch review process.
Final Stage withdrawn on 9/1/2011 prior to submitting for AG review.
Outpatient Rehabilitation Agency and Long Stay Hospital Reimbursement -
Reimbursement of Hearing Aids Services for Children
This action is exempt from the executive branch review process.
Final Stage withdrawn on 10/10/2008 before Attorney General's office completed its review.
Tamper-Resistant Rx Pads
This action is exempt from the executive branch review process.
Final Stage withdrawn on 7/26/2007 before Attorney General's office completed its review.
Increase Pharmacy Dispensing Fee for Generic Drugs to $4.00
This action is exempt from the executive branch review process.
Final Stage withdrawn on 3/3/2005 before submission to the Registrar.