Virginia Administrative Code
Title 12 - HEALTH
Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Chapter 80 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATE; OTHER TYPES OF CARE
Section 12VAC30-80-20 - Services that are reimbursed on a cost basis
Universal Citation: 2 VA Admin Code 30-80-20
Current through Register Vol. 41, No. 3, September 23, 2024
A. Payments for services listed in this section shall be on the basis of reasonable cost following the standards and principles applicable to the Title XVIII Program with the exception provided for in subdivision D 1 e of this section. The upper limit for reimbursement shall be no higher than payments for Medicare patients in accordance with 42 CFR 447.321. In no instance, however, shall charges for beneficiaries of the program be in excess of charges for private patients receiving services from the provider. The professional component for emergency room physicians shall continue to be uncovered as a component of the payment to the facility.
B. Reasonable costs will be determined from the filing of a uniform Centers for Medicare and Medicaid Services-approved cost report by participating providers. The cost reports are due not later than 150 days after the provider's fiscal year end. If a complete cost report is not received within 150 days after the end of the provider's fiscal year, DMAS or its designee shall take action in accordance with its policies to assure that an overpayment is not being made. All cost reports shall be reviewed and reconciled to final costs within 180 days of the receipt of a completed cost report. The cost report will be judged complete when DMAS has all of the following:
1. Completed cost reporting form provided by
DMAS, with signed certification;
2.
The provider's trial balance showing adjusted journal entries;
3. The provider's financial statements
including a balance sheet, a statement of income and expenses, a statement of
retained earnings (or fund balance), and a statement of changes in financial
position;
4. Schedules that
reconcile financial statements and trial balance to expenses claimed in the
cost report;
5. Depreciation
schedule or summary;
6. Home office
cost report, if applicable; and
7.
Such other analytical information or supporting documents requested by DMAS
when the cost reporting forms are sent to the provider.
C. Item 398 D of the 1987 Appropriation Act (as amended), effective April 8, 1987, eliminated reimbursement of return on equity capital to proprietary providers.
D. The services that are cost reimbursed are:
1. For dates of service prior to January 1,
2014, outpatient hospital services, including rehabilitation hospital
outpatient services and excluding laboratory services.
a. Definitions. The following words and terms
when used in this section shall have the following meanings when applied to
emergency services unless the context clearly indicates otherwise:
"All-inclusive" means all emergency department and ancillary service charges claimed in association with the emergency room visit, with the exception of laboratory services.
"DMAS" means the Department of Medical Assistance Services consistent with Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia.
"Emergency hospital services" means services that are necessary to prevent the death or serious impairment of the health of the recipient. The threat to the life or health of the recipient necessitates the use of the most accessible hospital available that is equipped to furnish the services.
"Recent injury" means an injury that has occurred less than 72 hours prior to the emergency department visit.
b. Scope. DMAS shall differentiate, as
determined by the attending physician's diagnosis, the kinds of care routinely
rendered in emergency departments and reimburse for nonemergency care rendered
in emergency departments at a reduced rate.
(1) With the exception of laboratory
services, DMAS shall reimburse at a reduced and all-inclusive reimbursement
rate for all services rendered in emergency departments that DMAS determines
were nonemergency care.
(2)
Services determined by the attending physician to be emergencies shall be
reimbursed under the existing methodologies and at the existing
rates.
(3) Services performed by
the attending physician that may be emergencies shall be manually reviewed. If
such services meet certain criteria, they shall be paid under the methodology
for subdivision 1 b (2) of this subsection. Services not meeting certain
criteria shall be paid under the methodology of subdivision 1 b (1) of this
subsection. Such criteria shall include:
(a)
The initial treatment following a recent obvious injury.
(b) Treatment related to an injury sustained
more than 72 hours prior to the visit with the deterioration of the symptoms to
the point of requiring medical treatment for stabilization.
(c) The initial treatment for medical
emergencies including indications of severe chest pain, dyspnea,
gastrointestinal hemorrhage, spontaneous abortion, loss of consciousness,
status epilepticus, or other conditions considered life threatening.
(d) A visit in which the recipient's
condition requires immediate hospital admission or the transfer to another
facility for further treatment or a visit in which the recipient
dies.
(e) Services provided for
acute vital sign changes as specified in the provider manual.
(f) Services provided for severe pain when
combined with one or more of the other guidelines.
(4) Payment shall be determined based on ICD
diagnosis codes and necessary supporting documentation. As used here, the term
"ICD" is defined in
12VAC30-95-5.
(5) DMAS shall review on an ongoing basis the
effectiveness of this program in achieving its objectives and for its effect on
recipients, physicians, and hospitals. Program components may be revised
subject to achieving program intent, the accuracy and effectiveness of the ICD
code designations, and the impact on recipients and providers. As used here,
the term "ICD" is defined in 12VAC30-95-5.
c. Limitation of allowable cost. Effective
for services on and after July 1, 2003, reimbursement of Type Two hospitals for
outpatient services shall be at various percentages as noted in subdivisions 1
c (1) and 1 c (2) of this subsection of allowable cost, with cost to be
determined as provided in subsections A, B, and C of this section. For
hospitals with fiscal years that do not begin on July 1, outpatient costs, both
operating and capital, for the fiscal year in progress on that date shall be
apportioned between the time period before and the time period after that date,
based on the number of calendar months in the cost reporting period, falling
before and after that date.
(1) Type One
hospitals.
(a) Effective July 1, 2003,
through June 30, 2010, hospital outpatient operating reimbursement shall be at
94.2% of allowable cost and capital reimbursement shall be at 90% of allowable
cost.
(b) Effective July 1, 2010,
through September 30, 2010, hospital outpatient operating reimbursement shall
be at 91.2% of allowable cost and capital reimbursement shall be at 87% of
allowable cost.
(c) Effective
October 1, 2010, through June 30, 2011, hospital outpatient operating
reimbursement shall be at 94.2% of allowable cost and capital reimbursement
shall be at 90% of allowable cost.
(d) Effective July 1, 2011, hospital
outpatient operating reimbursement shall be at 90.2% of allowable cost and
capital reimbursement shall be at 86% of allowable cost.
(2) Type Two hospitals.
(a) Effective July 1, 2003, through June 30,
2010, hospital outpatient operating and capital reimbursement shall be 80% of
allowable cost.
(b) Effective July
1, 2010, through September 30, 2010, hospital outpatient operating and capital
reimbursement shall be 77% of allowable cost.
(c) Effective October 1, 2010, through June
30, 2011, hospital outpatient operating and capital reimbursement shall be 80%
of allowable cost.
(d) Effective
July 1, 2011, hospital outpatient operating and capital reimbursement shall be
76% of allowable cost.
d. The last cost report with a fiscal year
end on or after December 31, 2013, shall be used for reimbursement for dates of
service through December 31, 2013, based on this section. Reimbursement shall
be based on charges reported for dates of service prior to January 1, 2014.
Settlement will be based on four months of runout from the end of the
provider's fiscal year. Claims for services paid after the cost report runout
period will not be settled.
e.
Payment for direct medical education costs of nursing schools, paramedical
programs, and graduate medical education for interns and residents.
(1) Direct medical education costs of nursing
schools and paramedical programs shall continue to be paid on an allowable cost
basis.
(2) Effective with cost
reporting periods beginning on or after July 1, 2002, direct graduate medical
education (GME) costs for interns and residents shall be reimbursed on a
per-resident prospective basis. See
12VAC30-70-281
for prospective payment methodology for graduate medical education for interns
and residents.
2. Rehabilitation agencies or comprehensive
outpatient rehabilitation.
a. Effective July
1, 2009, rehabilitation agencies or comprehensive outpatient rehabilitation
facilities that are operated by community services boards or state agencies
shall be reimbursed their costs. For reimbursement methodology applicable to
all other rehabilitation agencies, see
12VAC30-80-200.
b. Effective October 1, 2009, rehabilitation
agencies or comprehensive outpatient rehabilitation facilities operated by
state agencies shall be reimbursed their costs. For reimbursement methodology
applicable to all other rehabilitation agencies, see
12VAC30-80-200.
3. Supplement payments to Type One
hospitals for outpatient services.
a. In
addition to payments for services set forth elsewhere in the State Plan, DMAS
makes supplemental payments to qualifying state government owned or operated
hospitals for outpatient services furnished to Medicare members on or after
July 1, 2010. To qualify for a supplement payment, the hospital must be part of
the state academic health system or part of an academic health system that
operates under a state authority.
b. The amount of the supplemental payment
made to each qualifying hospital shall be equal to the difference between the
total allowable cost and the amount otherwise actually paid for the services by
the Medicaid program based on cost settlement.
c. Payment for furnished services under this
section shall be paid at settlement of the cost report.
4. Supplemental payments for private hospital
partners of Type One hospitals. Effective for dates of service on or after
October 25, 2011, quarterly supplemental payments shall be issued to qualifying
private hospitals for outpatient services rendered during the quarter. These
quarterly supplemental payments will cease for dates of service on or after the
effective date of State Plan amendments authorizing increased payments to
qualifying hospitals from the Health Care Provider Rate Assessment Fund
established pursuant to § 32.1-331.02 of the Code of Virginia and approved
by the Centers for Medicare and Medicaid Services.
a. In order to qualify for the supplemental
payment, the hospital shall be enrolled currently as a Virginia Medicaid
provider and shall be owned or operated by a private entity in which a Type One
hospital has a nonmajority interest.
b. Reimbursement methodology.
(1) Hospitals notparticipating in the
Medicaid disproportionate share hospital (DSH) program shall receive quarterly
supplemental payments for the outpatient services rendered during the quarter.
Each quarterly payment distribution shall occur not more than two years after
the year in which the qualifying hospital's entitlement arises. The annual
supplemental payments in a fiscal year shall be the lesser of:
(a) The difference between each qualifying
hospital's outpatient Medicaid billed charges and Medicaid payments the
hospital receives for services processed for fee-for-service Medicaid
individuals during the fiscal year; or
(b) $1,894 per Medicaid outpatient visit for
state plan rate year 2012. For future state plan rate years, this number shall
be adjusted by inflation based on the Virginia moving average values as
compiled and published by Global Insight (or its successor) under contract with
the department.
(2)
Hospitals participating in the DSH program shall receive quarterly supplemental
payments for the outpatient services rendered during the quarter. Each
quarterly payment distribution shall occur not more than two years after the
year in which the qualifying hospital's entitlement arises. The annual
supplemental payments in a fiscal year shall be the lesser of:
(a) The difference between each qualifying
hospital's outpatient Medicaid billed charges and Medicaid payments the
hospital receives for services processed for fee-for-service Medicaid
individuals during the fiscal year;
(b) $1,894 per Medicaid outpatient visit for
state plan rate year 2012. For future state plan rate years, this number shall
be adjusted by inflation based on the Virginia moving average values as
compiled and published by Global Insight (or its successor) under contract with
the department; or
(c) The
difference between the limit calculated under § 1923(g) of the Social
Security Act and the hospital's DSH payments for the applicable payment period.
c. Limit.
Maximum aggregate payments to all qualifying hospitals in this group shall not
exceed the available upper payment limit per state fiscal year.
5. Supplemental outpatient
payments for non-state-government-owned hospitals. Effective July 1, 2018,
supplemental payments will be issued to qualifying non-state-government-owned
hospitals for outpatient services provided to Medicaid patients.
a. Qualifying hospitals are all
non-state-government-owned acute care hospitals.
b. The supplemental payment shall equal
outpatient hospital claim payments times the upper payment limit (UPL) gap
percentage.
(1) The annual UPL gap percentage
is the percentage calculated where the numerator is the difference for each
qualifying hospital between a reasonable estimate of the amount that would be
paid under Medicare payment principles for outpatient hospital services
provided to Medicaid patients, as calculated in accordance with
42
CFR 447.321, and what Medicaid paid for such
services, and the denominator is Medicaid claim payments to all qualifying
hospitals for outpatient hospital services provided to Medicaid patients in the
same year used in the numerator.
(2) The annual UPL gap percentage will be
calculated annually for each hospital using the most recent year for which
comprehensive annual data are available and inflated to the state fiscal year
for which payments are to be made.
6. Quarterly payments. After the close of
each quarter, beginning with the July 1, 2018, to September 30, 2018, quarter,
each qualifying hospital shall receive supplemental payments for the outpatient
services paid during the prior quarter. The supplemental payments for each
qualifying hospital for each quarter shall be calculated by multiplying the
Medicaid outpatient hospital payments paid in that quarter by the annual UPL
gap percentage for each hospital.
Statutory Authority: § 32.1-325 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.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
