The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Applicant" means the person requesting medical care services for himself or on whose behalf a request is made.

"Board" means the State Board of Health.

"Child" means a person under 18 years of age and includes any a biological or adopted child, and any a child placed for adoption or foster care unless otherwise treated as a separate unit for the purposes of determining eligibility and charges under these regulations.

"Commissioner" means the Commissioner of Health.

"Department" means the state Department of Health and includes the central office, regional offices, health districts, and local health departments.

"Eligibility determination" means the process of obtaining required information regarding family size, income, and other related data in order to establish charges to the applicant.

"Extraordinary financial hardship" includes hardship due to such events as natural disasters, damage to or the loss of uninsured real or personal property, unpaid legal liabilities, and obligatory and unavoidable expenditures for close relatives outside the family unit.

"Family" or "family unit" means the applicant and other such household members who together constitute one economic unit. An economic unit is one or more individuals who generally reside together and share income. The economic unit shall count in its income any contributions to the unit from persons not necessarily living with the unit.

A parent may be a biological, adoptive, or stepparent.

A woman who is pregnant may be counted as a multiple beneficiary. when the pregnancy has been verified by a physician or a nurse practitioner working under the supervision of a physician.

A husband and wife Spouses who are separated and are not living together shall be considered to be separate family units.

"Flat rate charges" means charges for specified goods or services that are to be charged to all clients regardless of income and with no eligibility determination.

"Gross income" means total cash receipts before taxes from all sources. These include money wages and salaries before any deductions, but do not include food or rent in lieu of wages. These receipts include net receipts from nonfarm or farm self-employment (e.g., receipts from an applicant's own business or farm expenses) income, plus any depreciation shown on income tax forms. They include regular payments from social security or railroad retirement, unemployment and workers' compensation, strike benefits from union funds, veterans' benefits, training stipends, alimony, child support, and military family allotments or other regular support from an absent family member or someone not living in the household; private pensions, government employee pensions (including military retirement pay), and regular insurance or annuity payments; and income from dividends, interest, net rental income, net royalties, or periodic receipts from estates or trusts, lump sum settlements, and net gambling or lottery winnings.

"Gross income" does not include the value of food stamps, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) checks, fuel assistance payments, housing assistance, money borrowed, tax refunds, gifts, withdrawal of bank deposits from earned income, earnings of minor children, money received from the sale of property, general relief from the Department of Social Services, or college or university scholarships, grants, fellowships, and assistantships when provided to pay for, or in the form of, tuition, fees, other direct educational expenses, housing, or meals.

"Income scales" means scales based on individual or family gross income. They shall be based on the official federal poverty guidelines updated annually by the U.S. Department of Health and Human Services in accordance with §§ 652 and 6763(2) § 673(2) of the Omnibus Reconciliation Act of 1981 (Public Law 97-35). There shall be two income scales: one for Northern Virginia and one for the remainder of the Commonwealth. as follows:

Income Level A – those clients with incomes up to and including 100% of the federal poverty income guidelines will qualify as Income Level A clients, except for Northern Virginia where the Income Level A will be up to and including 110% of the federal poverty income guidelines.

Income Level B – those clients with incomes above 100% and no more than 110% of the federal poverty guidelines will qualify as Income Level B clients, except for Northern Virginia where the Income Level B will be above 110% and no more than 133.3% of the federal poverty income guidelines.

Income Level C – those clients with incomes above 110% and no more than 133.3% of the federal poverty income guidelines will qualify as Income Level C clients, except for Northern Virginia where the Income Level C will be above 133.3% and no more than 166.6% of the federal poverty income guidelines.

Income Level D – those clients with incomes above 133.3% and no more than 166.6% of the federal poverty income guidelines will qualify as Income Level D clients, except for Northern Virginia where the Income Level D will be above 166.6% and no more than 200% of the federal poverty income guidelines.

Income Level E – those clients with incomes above 166.6% and less than 200% of the federal poverty income guidelines will qualify as Income Level E clients, except for Northern Virginia where the Income Level E will be above 200% and less than 233.3% of the federal poverty income guidelines.

Income Level F – those clients with incomes equal to or above 200% and less than 250% of the federal poverty income guidelines will qualify as Income Level F clients, except for Northern Virginia where the Income Level F will be equal to or above 233.3% and less than 283.3% of the federal poverty income guidelines.

Income Level G – those clients with incomes equal to or above 250% of the federal poverty level guidelines will qualify as Income Level G clients, except for Northern Virginia where income level G will be equal to or above 283.3% of the federal poverty income guidelines.

"Medical care services" means clinical medical, dental, and nursing services provided to patients by physicians, dentists, nurses, and other health care providers employed by health districts or contracted by health districts to provide these services. It does not include laboratory tests, pharmaceutical and biological products, radiological or other imaging studies, other goods or products, or other medical services that a health district does not directly provide.

"Medically indigent" means applicants whose individual or family gross income is defined as Income Level A.

"Minor" means a person less than 18 years of age whose parents are responsible for his care. A minor will be considered a separate family unit when married or not living with any relative or deemed an adult.

A minor shall be deemed an adult for the purposes of consenting to:

1. Medical or health services needed to determine the presence of or to treat venereal disease or any infectious or contagious disease which the State Board of Health requires to be reported.

2. Medical and health services required for birth control, pregnancy, or family planning except for the purposes of sexual sterilization.

"Nonchargeable services" means the medical care and related goods and services that the department has determined will be provided without charge and without an eligibility determination , pursuant to 12VAC5-200-150 to all citizens individuals regardless of income.

"Northern Virginia" means the area which includes the cities of Alexandria, Fairfax, Falls Church, Manassas, Manassas Park, and the counties of Arlington, Fairfax, Loudoun, and Prince William.

"Venereal disease" is synonymous with "sexually transmitted infection."

Section 32.1-11 of the Code of Virginia establishes the responsibility of the board as follows: "The board may formulate a program of environmental health services, laboratory services and preventive, curative and restorative medical care services, including home and clinic health services described in Titles V, XVIII and XIX of the United States Social Security Act and amendments thereto, to be provided by the department on a district or local basis. The board shall define the income limitations within which a person shall be deemed to be medically indigent. Persons so deemed to be medically indigent shall receive the medical care services of the department without charge. The board may also prescribe the charges to be paid for the medical care services of the department by persons who are not deemed to be medically indigent and may, in its discretion and within the limitations of available funds, prescribe a scale of such charges based upon ability to pay. Funds received in payment of such charges are hereby appropriated to the board for the purpose of carrying out the provisions of this title. The board shall review periodically the program and charges adopted pursuant to this section."

The board has promulgated this chapter to: (i) establish financial eligibility criteria to determine if a person is medically indigent and therefore qualified to receive medical care services from the department without charge; (ii) establish income scales and a mechanism for determining charges for medical care provided by the department to individuals who are not medically indigent, based upon their ability to pay; (iii) establish a mechanism for handling appeals and waivers; and (iv) establish continuity of eligibility among state agencies. The regulations are constructed to assure that eligibility criteria remain appropriate for changing economic conditions.

This chapter is administered by the commissioner.

The commissioner shall assure uniformity and consistency by interpreting and implementing the rules of the department for the provision of medical care and related goods and services. The commissioner may issue a guidance document that interprets these regulations and provides guidance for their implementation. Such a document shall be reviewed and revised whenever the regulations of this chapter are reviewed, and may also be amended or revised as needed to meet changing circumstances.

Whenever possible, charges for services shall use the most appropriate current Medicaid charges (and matching Medicaid codes). If there is no Medicaid code for a particular service, the most appropriate current Medicare charge (and matching code) shall be used. If both Medicaid and Medicare charges (and codes) exist for the same service, the Medicaid charge (and code) will be used. If neither a Medicaid nor a Medicare code exists for a particular service, the commissioner, or a designee, shall determine an appropriate charge and develop a matching code. A guidance document shall include procedures for determining the costs and establishing the charges for medical care and related goods and services when any of these are not otherwise addressed in these regulations or the Code of Virginia.

The commissioner shall publish specific income levels expressed in dollar amounts for determining eligibility for medical care services of the department in accordance with the income scales defined in 12VAC5-200-10.

This chapter shall apply to all persons a person seeking medical care services provided by the department, except where other eligibility criteria are required for programs administered under federal statute.

The provisions of the Virginia Administrative Process Act govern the adoption of these regulations and any subsequent amendments.

A. Upon an applicant's request for medical care services (excepting those except the services described in 12VAC5-200-150, and 12VAC5-200-160, and 12VAC5-200-170), the department will require applicant or the applicant's authorized representative shall provide to the department accurate information as to and documentation regarding the applicant's family size, financial status and other related data as described on the application for medical care needed to register the applicant as a patient and classify the applicant into the appropriate income level. The applicant must be informed during the interviewing process of the provisions as described in this section of the regulations.

An application date is established when the applicant completes and signs the application for medical care services. B. The department shall record the applicant's eligibility date as the date on which the applicant signs the Patient Application and Consent for Health Care.

When C. If an applicant is in need of needs emergency medical services, the district director, or his designee, shall waive this application process for that individual until such time as the individual is able to participate in the interviewing process.

It is the applicant's responsibility to furnish the department with proof of the applicant's financial data in order to be appropriately classified according to income level and family size so that eligibility for discounts for medical care services can be determined.

Any individual who is acting on behalf of an applicant will be responsible for the accuracy of all financial data provided to the department.

Individuals who have failed D. The district director may terminate medical care services to a patient if the patient fails to make any a payment for medical care services or other goods or services received from the department within the past 90 days for medical care services or other after receiving the goods or services.they have received may have their medical care services terminated. The district director may not terminate services only following without (i) giving notice to the individual patient or patient's authorized representative that such services will be terminated of the intent to terminate, (ii) and only after determining that terminating services would not be detrimental to the individual's patient's health. Medical care services cannot be terminated and (iii) for individuals receiving ongoing care without, making a good faith effort to secure alternative care.

A. Charges for services means the reasonable charges established by the board for medical care services. No charge shall be established outside the provisions of these regulations. The department may prescribe a scale of discounts for certain medical care services. The commissioner shall publish specific income levels expressed in dollar amounts for determining eligibility for medical care services of the department in accordance with the income scales defined in 12VAC5-200-110.

B. The commissioner shall use the most appropriate current Medicaid charges to establish the fee schedule for services provided by the department pursuant to this chapter. If there is no Medicaid charge for a particular service, the commissioner shall use the most appropriate current Medicare charge. If neither a Medicaid nor a Medicare charge exists for a particular service, the commissioner shall determine an appropriate charge based on the cost of providing the medical care service. Charges will be based on current published Medicaid reimbursement levels. In those instances where Medicaid does not reimburse for a service provided by the department, charges shall be based on the appropriate current Medicare reimbursement levels. Where neither Medicaid nor Medicare reimburse for a service, the commissioner shall establish charges based on the costs of providing the medical care services. Charges for goods and services not directly provided by the agency may be based on the agency's cost. Directors of health districts may request permission from the commissioner, or commissioner's designee, to round charges to a convenient value. the nearest whole dollar.

C. If the department provides a medical care service to a patient with private health insurance that covers the service provided, the department shall charge to the private health insurance carrier an amount equal to the allowable charge of the patient's private health insurance coverage. If the health insurance carrier denies a claim for the medical care service, the department may not charge the patient an amount greater than the amount the patient would have paid if the patient did not have private health insurance.

D. On selected occasions it may be desirable to provide certain medical services, e.g., influenza immunization, to large numbers of people quickly and conveniently and thereby promote their use by the public. In order to accomplish this, districts may charge a flat rate charge for these services under these circumstances. This provision includes services that are otherwise available at a discounted charge. No eligibility determination will be done, and all service recipients will be charged the same flat rate charge. However, the district must also provide convenient alternative times and venues where applicants can request an eligibility determination and obtain these services at a discounted rate if eligible. The commissioner or commissioner's designee must approve such flat rate charge arrangements in advance, including approval of the specific flat rate charge.

E. Except as otherwise set out in this chapter, charges for certain goods and medical care services may be set at a flat rate charge not subject to discounting. Flat rate charges must be expressly approved by the commissioner or commissioner's designee prior to their implementation.

Except as otherwise set out in this chapter, charges for certain goods and medical care services may be set at a flat rate charge not subject to discounting. All flat rate charges must be expressly approved by the commissioner or commissioner's designee prior to their implementation.

The department, health districts, and local health departments may enter into contracts with agencies external to the department whereby the department, health district, or local health department provides medical services and goods. Charges for such services and goods will be determined by the contract. If a patient copayment is required in the contract, the patient shall pay the full copayment to the department, district, or local health department regardless of the patient's income status. The patient shall not be required to pay if state or federal law precludes a copayment.

A. The department shall annually publish specific income levels expressed in dollar amounts for determining eligibility for discounts to the charges for medical care services. The income levels established by the department shall be as follows:

1. Income Level A – those clients with individual or family incomes up to and including 100% of the federal poverty income guidelines will qualify as Income Level A clients, except for Northern Virginia where the Income Level A will be up to and including 110% of the federal poverty income guidelines. These clients will be considered medically indigent.

2. Income Level B – those clients with individual or family incomes above 100% and no more than 110% of the federal poverty guidelines will qualify as Income Level B clients, except for Northern Virginia where the Income Level B will be above 110% and no more than 133.3% of the federal poverty income guidelines.

3. Income Level C – those clients with individual or family incomes above 110% and no more than 133.3% of the federal poverty income guidelines will qualify as Income Level C clients, except for Northern Virginia where the Income Level C will be above 133.3% and no more than 166.6% of the federal poverty income guidelines.

4. Income Level D – those clients with individual or family incomes above 133.3% and no more than 166.6% of the federal poverty income guidelines will qualify as Income Level D clients, except for Northern Virginia where the Income Level D will be above 166.6% and no more than 200% of the federal poverty income guidelines.

5. Income Level E – those clients with individual or family incomes above 166.6% and less than 200% of the federal poverty income guidelines will qualify as Income Level E clients, except for Northern Virginia where the Income Level E will be above 200% and less than 233.3% of the federal poverty income guidelines.

6. Income Level F – those clients with individual or family incomes equal to or above 200% and less than 250% of the federal poverty income guidelines will qualify as Income Level F clients, except for Northern Virginia where the Income Level F will be equal to or above 233.3% and less than 283.3% of the federal poverty income guidelines.

7. Income Level G – those clients with individual or family incomes equal to or above 250% of the federal poverty level guidelines will qualify as Income Level G clients, except for Northern Virginia where income level G will be equal to or above 283.3% of the federal poverty income guidelines.

The charges made to the applicant shall be subject to 100% discounting for those who are found to be medically indigent as defined in Part I.

B. Applicants for medical care services, including those in Northern Virginia as defined in Part I, whose family income exceeds Income Level A shall be assessed a charge as follows:

1. Income Level A – 100% discount of the established charge for the service.

2. Income Level B – 90% discount of the established charge for the service.

3. Income Level C – 75% discount of the established charge for the service.

4. Income Level D – 50% discount of the established charge for the service.

5. Income Level E – 25% discount of the established charge for the service.

6. Income Level F – 5.0% discount of the established charge for the service.

7. Income Level G – No discount will be given.

Applicants receiving The department shall provide services to an applicant receiving assistance from the following public assistance program will receive services programs as Income Level A patients without additional income verification:

1. General Relief

2. Title XIX-Medicaid

3. National School Lunch Program for children receiving school meals at no cost. Only used for applicable to child dental services.

4. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Only applicable to dental varnish services under the Dental Varnish Program for children from six months to three years of age.

Applicants who are eligible for services under this section, and are not participating in Medicaid or any other children's medical insurance program sponsored by the state, should apply for these programs. Applicants who do not apply for Medicaid or a children's medical insurance program within 60 days of receiving services may be assessed the undiscounted charge for the medical care and related goods and services provided.

Prior to services being rendered, an The department shall provide an explanation of the estimated charges, applicable discounts, and expected payment shall be provided to the applicant before rendering services.

Eligibility Unless otherwise required by law or regulation, the department shall redetermine eligibility to receive discounts from on established charges must be redetermined at least every 12 months, or and when income or family status changes, unless otherwise required by law or regulation.

A. The department shall provide the following services are provided at no charge to the patient:

1. Those immunizations for all children as required by § 32.1-46 and § 22.1-271.4 of the Code of Virginia , and of persons .

2. Immunizations for a person up to the age of 21 when the person 22 who is enrolled in a public or private primary or secondary school and lacks evidence of complete and appropriate immunizations for the diseases covered by that section § 32.1-46 of the Code of Virginia.

2. 3. Examination and testing of persons suspected of having or known to have tuberculosis as required by § 32.1-50 of the Code of Virginia.

3. 4. Examination, testing and treatment of persons for sexually transmitted diseases as required by § 32.1-57 of the Code of Virginia.

4. 5. Anonymous or confidential testing for human immunodeficiency virus as required by § 32.1-55.1 of the Code of Virginia.

B. The department may provide other medical services at no charge to appropriate citizens of the Commonwealth if directed by the board, the commissioner, or a district health director.

The department may elect to provide other medical services at no charge to appropriate citizens of the Commonwealth when directed by the board, the commissioner or a district health director.

A continuing exception to the above regulations for assessing charges for medical care services will exist for patients determined to be eligible for services provided under those programs of the department specified in the Code of Virginia or published in separate state plans.

In instances when patients have financial hardships and there are no other avenues of care, the patient, guardian or other authorized person may request a waiver of charges for up to 180 calendar days. A waiver shall be requested in writing to the district director. If a waiver is granted, it shall be for the duration of the financial hardship or 180 days, whichever is shorter.

If the waiver request is approved, the patient will receive a full discount for all charges while covered by the waiver. If the waiver request is denied, the charges will continue as before.

A. The commissioner is authorized , and may delegate the authority to a local health director, to grant or deny requested waivers and may delegate this authority to the district directors. A a waiver to all or a portion of a charge may be granted for reasons of unusually serious health problems or extraordinary financial hardship if a patient or the patient's guardian or legal representative applies for a waiver in writing. A resulting waived or partially waived charge shall be determined by the commissioner or designee and reviewed and revised as needed. The commissioner or designee shall also identify those expenses that are considered to be medical bills for medical care services and shall review and revise this determination as needed.

B. In the event of an adverse decision, the patient, guardian or other authorized person will be advised of their rights to appeal under Part VII of this chapter.

C. Waivers will not be continued past 180 days. Additional waivers may be granted, but the applicant must reapply at least every 180 days. An approved waiver shall only be effective for the duration of the health or financial hardship or 180 days, whichever is shorter. The commissioner or his designee may grant an additional waiver related to the health or financial hardship if the patient or the patient's guardian or legal representative reapplies for the waiver.

D. No person believed to be eligible for Medicaid or any state-sponsored children's medical insurance program and who has failed to complete an application for these programs will be eligible for a waiver.

A. If an applicant for or recipient of medical care services as defined in these regulations is denied such services, has services terminated, wishes to contest the determined income level, or is denied a waiver as defined in Part VI of these regulations this chapter, the applicant/recipient applicant or recipient is entitled to appeal that action as set forth under this part. There are no further rights of appeal except as set forth in this part.

B. The applicant/recipient has the right to be informed The district director shall notify the applicant or recipient in writing of the appeal process, including time limits, and the right to receive a written statement of the reasons for denial. If a person already receiving services is denied those services, a written notice of termination shall be given 30 days in advance of discontinuing services. The person The applicant or recipient has the right to confront any witnesses who may have testified against him.

C. An individual or his representative may make a written or oral appeal to the district or program director within 30 days of the denial of service.

D. Upon receipt of the appeal, the district director shall review and make written recommendations to the commissioner, or commissioner's designee, within 15 days. Within 45 days following the date on which an appeal is filed, the commissioner, or commissioner's designee, shall make a final decision and notify the district director of the decision in writing.

E. The district director or the program director shall notify the individual or his representative in writing of the final decision.

E. Services to applicants/recipients shall continue F. The department shall continue to provide medical care services to the applicant or recipient during the appeal process.

If the district director identifies a patient If an applicant for or recipient of medical care services is willfully misrepresenting himself, or withholding or falsifying information in an attempt to obtain medical services free or at a reduced rate, the district director may discontinue services to the affected person 30 days after notifying the person that services will be discontinued. Such recipient The affected person is entitled to the appeal process set forth in Part VII of this chapter.

This part shall be administered by the commissioner. A. The commissioner shall establish a procedure for the ongoing development; , maintenance, revision, and updating ; and promulgation of these of the charges and payments schedules pursuant to this chapter. There shall be two sets of schedules, one for Northern Virginia as defined in 12VAC5-200-10 and one for the remainder of the Commonwealth.

By the provisions of the "Regulations Governing Eligibility Standards and Charges for Medical Care Services to Individuals" (12VAC5-200) promulgated by the Board of Health in accordance with §§ 32.1-11 and 32.1-12 of the Code of Virginia, the B. The department shall make the charges for medical care services , stating the minimum required payments to be made by patients or other responsible persons toward their charges, according to income levels and the income schedules used to determine sliding scale discounts are available to the public for inspection and copying at the headquarters, district, and local health department offices of the department.