Virginia Administrative Code
Title 12 - HEALTH
Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN
Part IV - Cost Sharing
Section 12VAC30-141-160 - Copayments for families not participating in FAMIS Select
Universal Citation: 2 VA Admin Code 30-141-160
Current through Register Vol. 41, No. 3, September 23, 2024
A. Copayments shall apply to all enrollees in an MCHIP.
B. These cost-sharing provisions shall be implemented with the following restrictions:
1. Total cost sharing for each 12-month
eligibility period shall be limited to (i) for families with incomes equal to
or less than 150% of federal poverty level (FPL), the lesser of (a) $180 and
(b) 2.5% of the family's income for the year (or 12-month eligibility period);
and (ii) for families with incomes greater than 150% of FPL, the lesser of $350
and 5.0% of the family's income for the year (or 12-month eligibility
period).
2. DMAS or its designee
shall ensure that the annual aggregate cost sharing for all FAMIS enrollees in
a family does not exceed the aforementioned caps.
3. Families will be required to submit
documentation to DMAS or its designee showing that their maximum copayment
amounts are met for the year.
4.
Once the cap is met, DMAS or its designee will issue a new eligibility card
excluding such families from paying additional copays for the 12-month
enrollment period.
C. Exceptions to the above cost-sharing provisions:
1. Copayments shall not be required for well
child, well baby, and pregnancy-related services. This shall include:
a. All healthy newborn inpatient physician
visits, including routine screening (inpatient or outpatient);
b. Routine physical examinations, laboratory
tests, immunizations, and related office visits;
c. Routine preventive and diagnostic dental
services (i.e., oral examinations, prophylaxis and topical fluoride
applications, sealants, and x-rays);
d. Services to pregnant females related to
the pregnancy; and
e. Other
preventive services as defined by the department.
2. Enrollees are not held liable for any
additional costs, beyond the standard copayment amount, for emergency services
furnished outside of the individual's managed care network. Only one copayment
charge will be imposed for a single office visit.
3. No cost sharing will be charged to
American Indians and Alaska Natives.
Statutory Authority: § 32.1-351 of the Code of Virginia; 42 USC § 1396 et seq.
Disclaimer: These regulations may not be the most recent version. Virginia may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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