Agencies | Governor
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
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
2019 Provider Reimbursement Changes
This action is exempt from the executive branch review process.
Final Returned to agency requesting additional information.
2018 Institutional Provider Reimbursement Updates - Fast Track Fast-Track Secretary of Health and Human Resources review in progress.
ARTS Updates Fast-Track DPB Fast-Track authorization in progress.
Update of Average Commercial Rate for Eastern Virginia Medical School Fast-Track Governor's office review in progress.
Fee For Service Supplemental Payments and Hospital Assessment Proposed DPB review in progress.

Past Actions
Action Title Latest Stage Status
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
This action is exempt from the executive branch review process.
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
This action is exempt from the executive branch review process.
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
This action is exempt from the executive branch review process.
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
This action is exempt from the executive branch review process.
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
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 04/25/2012.
2011 Incontinence Supplies by Contract
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 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
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 07/01/2011.
2011 Pharmacy Reimbursement Update
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 07/01/2011.
2011 Technical Corrections for Reimbursment Regulations
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 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)
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 12/08/2010.
2010 Pharmacy Reimbursement Change
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 07/01/2010.
2010 Reimbursement and Provider Termination Changes
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 07/01/2010.
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 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
This action is exempt from the executive branch review process.
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
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 07/23/2008.
Tamper Resistant Rx Pads Emergency/NOIRA Stage complete. Emergency regulation expired on 03/31/2009.
Hearing Aid Services for Children
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 01/01/2008.
2007 Reimbursement Changes
This action is exempt from the executive branch review process.
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
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 05/01/2006.
Emergency Room Physician Reimbursement Increase
This action is exempt from the executive branch review process.
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
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 07/01/2005.
DMERC Reimbursement for Durable Medical Equipment
This action is exempt from the executive branch review process.
Final Stage complete. This regulation became effective on 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
This action is exempt from the executive branch review process.
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)
This action is exempt from the executive branch review process.
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.
Outpatient Hospital Reimbursement
Incontinence Supplies

Withdrawn Actions
Action Title Latest Stage Status
New Qualifying Hospitals Fast-Track Stage withdrawn on 08/09/2018 before the Governor's office completed its review.
Restore Emergency Dept. Physician Reimbursement
This action is exempt from the executive branch review process.
Final Stage withdrawn on 01/11/2018 before submission to the Registrar.
CH 0080 Reimbursement - Hospitals
Reimbursement Effective Dates Companion Letters
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 03/18/2016 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 03/06/2012 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 09/01/2011 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 07/26/2007 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 03/03/2005 before submission to the Registrar.