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Virginia Administrative Code

Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Chapter 5	PUBLIC PARTICIPATION GUIDELINES
Chapter 10	STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS
Chapter 20	ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES
Chapter 30	GROUPS COVERED AND AGENCIES RESPONSIBLE FOR ELIGIBILITY DETERMINATION
Chapter 40	ELIGIBILITY CONDITIONS AND REQUIREMENTS
Chapter 50	AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES
Chapter 60	STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE
Chapter 70	METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES
Chapter 80	METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES; OTHER TYPES OF CARE
Chapter 90	METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE
Chapter 100	STATE PROGRAMS
Chapter 110	ELIGIBILITY AND APPEALS
Chapter 120	WAIVERED SERVICES
Chapter 129	[RESERVED]
Chapter 130	AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES
Chapter 135	DEMONSTRATION WAIVER SERVICES
Chapter 140	VIRGINIA CHILDREN'S MEDICAL SECURITY INSURANCE PLAN [REPEALED]
Chapter 141	FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN
Chapter 150	UNINSURED MEDICAL CATASTROPHE FUND

Chapter 5

PUBLIC PARTICIPATION GUIDELINES (create report)

Section 10	Purpose
Section 20	Definitions
Section 30	Notification list
Section 40	Information to be sent to persons on the notification list
Section 50	Public comment
Section 60	Petition for rulemaking
Section 70	Appointment of regulatory advisory panel
Section 80	Appointment of negotiated rulemaking panel
Section 90	Meetings
Section 100	Public hearings on regulations
Section 110	Periodic review of regulations

Chapter 10

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS (create report)

Section 10	Designation and authority
Section 20	Organization for administration
Section 30	Statewide operation
Section 40	State Medical Care Advisory Committee
Section 50	Pediatric immunization program
Section 60	Application; determination of eligibility and furnishing Medicaid
Section 70	Coverage and conditions of eligibility
Section 80	Residence
Section 90	Blindness
Section 100	Disability
Section 110	Financial eligibility
Section 120	Medicaid furnished out of state
Section 130	Requirements for advance directives
Section 140	Amount, duration, and scope of services: Categorically needy
Section 150	Amount, duration, and scope of services: Medically needy
Section 160	Amount, duration, and scope of services: Other required special groups
Section 170	Amount, duration, and scope of services: Limited coverage for certain aliens
Section 180	Amount, duration, and scope of services: Homeless individuals
Section 190	Amount, duration, and scope of services: Presumptively eligible pregnant women
Section 200	Amount, duration, and scope of services: EPSDT services
Section 210	Amount, duration, and scope of services: Comparability of services
Section 220	Amount, duration, and scope of services: home health services
Section 230	Amount, duration, and scope of services: Assurance of transportation
Section 240	Amount, duration, and scope of services: Payment for nursing facility services
Section 250	Amount, duration, and scope of services: Methods and standards to assure quality of services
Section 260	Amount, duration, and scope of services: Family planning services
Section 270	Amount, duration, and scope of services: Optometric services
Section 280	Amount, duration, and scope of services: Organ transplant procedures
Section 290	Amount, duration, and scope of services: Participation by Indian Health Service facilities
Section 300	Amount, duration, and scope of services: Respiratory care services for ventilator-dependent individuals
Section 310	Coordination of Medicaid with Medicare and other insurance: Premiums
Section 320	Coordination of Medicaid with Medicare and other insurance: Deductibles/coinsurance
Section 325	Premiums, deductibles, coinsurance and other cost sharing obligations
Section 330	Medicaid for individuals age 65 or over in institutions for mental diseases
Section 340	Special requirements applicable to sterilization procedures
Section 350	Families receiving extended Medicaid benefits
Section 360	[Reserved]
Section 400	Methods of administration
Section 410	Hearings for applicants and recipients
Section 420	Safeguarding information on applicants and recipients
Section 430	Medicaid quality control
Section 440	Medicaid Agency Fraud Detection and Investigation Program
Section 441	Medicaid agency fraud detection and investigation program
Section 450	Reports
Section 460	Maintenance of records
Section 470	Availability of agency program manuals
Section 480	Reporting provider payments to Internal Revenue Service
Section 490	Free choice of providers
Section 500	Relations with standard-setting and survey agencies
Section 510	Consultation to medical facilities
Section 520	Required provider agreement
Section 530	Utilization and quality control
Section 540	Inspection of care in intermediate care facilities for the mentally retarded, facilities providing inpatient psychiatric services for individuals ...
Section 550	Relations with state health and vocational rehabilitation agencies and Title V grantees
Section 560	Liens and recoveries
Section 570	Recipient cost sharing and similar charges
Section 580	Payment for services
Section 590	Direct payments to certain recipients for physicians' or dentists' services
Section 600	Prohibition against reassignment of provider claims
Section 610	Third party liability
Section 620	Use of contracts
Section 630	[Repealed]
Section 631	Standards for payment for nursing facility and intermediate care facility for the mentally retarded services
Section 640	Program for licensing administrators of nursing homes
Section 650	Drug Utilization Review Program
Section 660	Disclosure of survey information and provider or contractor evaluation
Section 670	Appeals process
Section 680	Conflict of interest provisions
Section 690	Exclusion of providers and suspension of practitioners and other individuals
Section 700	Disclosure of information by providers and fiscal agents
Section 710	Income and eligibility verification system
Section 720	Medicaid eligibility cards for homeless individuals
Section 730	Systematic alien verification for entitlements
Section 740	[Repealed]
Section 750	[Repealed]
Section 751	Enforcement of compliance for nursing facilities
Section 760	Pharmacy services rebate agreement terms
Section 770	Required coordination between the Medicaid and WIC Programs
Section 780	Nurse aide training and competency evaluation for nursing facilities
Section 790	Preadmission screening and annual resident review in nursing facilities
Section 800	Survey and certification process
Section 810	Resident assessment for nursing facilities
Section 815	Cooperation with Medicaid Integrity Program efforts
Section 820	Employee education about false claims recoveries
Section 850	Standards of personnel administration
Section 860	[Reserved]
Section 870	Training programs; subprofessional and volunteer programs
Section 880	[Reserved]
Section 900	Fiscal policies and administration
Section 910	Cost allocation
Section 920	State financial participation
Section 930	Hospital credit balance reporting
Section 940	[Reserved]
Section 960	Plan amendments
Section 970	Nondiscrimination
Section 980	[Repealed]
Section 990	State Governor's review
Section 1000	General provider appeals

Chapter 20

ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES (create report)

Section 10	Attorney General's certification
Section 20	[Repealed]
Section 60	Definition of Medicaid state plan health maintenance organizations (HMOs)
Section 70	[Repealed]
Section 80	Coordination of Title XIX with Part A and Part B of Title XVIII
Section 90	Confidentiality and disclosure of information concerning Medicaid applicants and recipients
Section 100	Standards governing general and special hospitals and convalescent and nursing homes
Section 110	Nursing facility resident drug utilization review
Section 120	Cooperative arrangements with the state vocational rehabilitation agency and with Title V programs and grantees
Section 130	Lien recoveries
Section 140	[Repealed]
Section 141	Estate recoveries
Section 150	Copayments and deductibles for categorically needy and QMBs for services other than under 42 CFR 447.53
Section 160	Copayments and deductibles for medically needy and QMBs for services other than under 42 CFR 447.53
Section 170	Basis of payment for reserving beds during a recipient's absence from an inpatient facility
Section 180	Definition of a claim by service
Section 190	Requirements for third party liability; identifying liable resources
Section 200	Requirements for third party liability; payment of claims
Section 210	State method on cost effectiveness of employer-based group health plans
Section 215	Sanctions for psychiatric hospitals
Section 220	Income and eligibility verification system procedures; requests to other state agencies
Section 230	Method for issuance of medicaid eligibility cards to homeless individuals
Section 240	Requirements for advance directives under state plans for medical assistance
Section 249	[Repealed]
Section 251	Termination of provider agreement
Section 252	Temporary management
Section 253	Denial of payment for new admissions
Section 254	Civil money penalty
Section 255	State monitoring
Section 256	Transfer of residents; transfer of residents with closure of facility
Section 257	Required plan of correction
Section 258	Appeals
Section 259	Repeated substandard quality of care
Section 260	Definition of specialized services
Section 270	Categorical determinations
Section 272	Survey and certification education program
Section 274	Process for the investigation of allegations of resident neglect and abuse and misappropriation of resident property
Section 275	Procedures for scheduling and conduct of standards surveys
Section 277	Programs to measure and reduce inconsistency
Section 278	Process for investigations of complaints and monitoring
Section 280	Methods of administration; civil rights
Section 290	[Reserved]
Section 500	Definitions
Section 520	Provider appeals: general provisions
Section 540	Informal appeals
Section 560	Formal appeals

Chapter 30

GROUPS COVERED AND AGENCIES RESPONSIBLE FOR ELIGIBILITY DETERMINATION (create report)

Section 10	Mandatory coverage: Categorically needy and other required special groups
Section 20	Optional groups other than the medically needy
Section 30	Optional coverage of the medically needy
Section 40	Reasonable classifications of individuals under the age of 21, 20, 19, and 18
Section 50	More restrictive categorical eligibility criteria
Section 60	Requirements relating to determining eligibility for Medicare Prescription Drug Low-Income Subsidy

Chapter 40

ELIGIBILITY CONDITIONS AND REQUIREMENTS (create report)

Section 10	General conditions of eligibility
Section 20	Post-eligibility treatment of institutionalized individuals
Section 30	Maintenance needs of non-institutionalized spouse
Section 40	Children
Section 50	Medical expenses
Section 60	Maintenance of residence
Section 70	SSI benefits
Section 80	Maintenance standards
Section 90	Income and resource levels and methods
Section 100	Methods of determining income
Section 105	Financial eligibility
Section 110	Medicaid qualifying trusts
Section 120	Medically needy income levels (MNILs) based on family size
Section 130	Handling of excess income; spend-down
Section 140	Methods for determining resources
Section 150	Resource standard; categorically needy
Section 160	Resource standard; medically needy
Section 170	Resource standard; qualified Medicare beneficiaries and specified low-income Medicare beneficiaries
Section 180	Qualified disabled and working individuals
Section 190	Excess resources
Section 200	Effective date of eligibility
Section 210	Transfer of resources - categorically and medically needy, qualified Medicare beneficiaries, and qualified disabled and working individuals
Section 220	Income eligibility levels
Section 230	Resource levels
Section 235	Reasonable limits on amounts for necessary medical or remedial care not covered under Medicaid
Section 240	More restrictive methods of treating resources than those of the SSI program: � 1902(f) states only
Section 250	Standards for optional state supplementary payments
Section 260	Income levels for 1902(f) states; categorically needy who are covered under requirements more restrictive than SSI
Section 270	Resource standards for 1902(f) states; categorically needy
Section 280	More liberal income disregards
Section 290	More liberal methods of treating resources under �1902(r)(2) of the Act: �1902(f) states
Section 300	Transfer of resources
Section 310	[Reserved]
Section 320	Consideration of Medicaid qualifying trust; undue hardship
Section 330	Cost effectiveness methodology for COBRA continuation beneficiaries
Section 340	Compliance with � 1924 and OBRA 90
Section 345	Eligibility under � 1931 of the Act
Section 350	Standards for optional state supplementary payments
Section 360	Treatment of entrance fees of individuals residing in continuing care retirement communities

Chapter 50

AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES (create report)

Section 10	Services provided to the categorically needy with limitations
Section 20	Services provided to the categorically needy without limitation
Section 30	Services not provided to the categorically needy
Section 35	Requirements relating to payment for covered outpatient drugs for the categorically needy
Section 40	Ambulatory services
Section 50	Services provided to the medically needy with limitations
Section 60	Services provided to all medically needy groups without limitations
Section 70	Services or devices not provided to the medically needy
Section 75	Requirements relating to payment for covered outpatient drugs for the medically needy
Section 80	[Reserved]
Section 95	Reimbursement of services; in general
Section 100	Inpatient hospital services provided at general acute care hospitals and freestanding psychiatric hospitals; enrolled providers
Section 105	Inpatient hospital services provided at general acute care hospitals and freestanding psychiatric hospitals; nonenrolled providers ...
Section 110	Outpatient hospital and rural health clinic services
Section 120	Other laboratory and x-ray services
Section 130	Skilled nursing facility services, EPSDT, school health services and family planning.
Section 140	Physician's services whether furnished in the office, the patient's home, a hospital, a skilled nursing facility or elsewhere
Section 150	Medical care by other licensed practitioners within the scope of their practice as defined by state law
Section 160	Home health services
Section 165	Durable medical equipment (DME) and supplies suitable for use in the home
Section 170	Private duty nursing services
Section 180	Clinic services
Section 190	Dental services
Section 200	Physical therapy and related services
Section 210	Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist
Section 220	Other diagnostic, screening, preventive, and rehabilitative services, i.e., other than those provided elsewhere in this plan
Section 225	Rehabilitative services; intensive physical rehabilitation
Section 226	Community mental health services
Section 227	Lead contamination
Section 228	Community substance abuse treatment services
Section 229	[Reserved]
Section 229.1	[Repealed]
Section 230	Services for individuals age 65 or older in institutions for mental diseases
Section 240	Intermediate care services and intermediate care services for institutions for mental disease and mental retardation
Section 250	Inpatient psychiatric facility services for individuals under 21 years of age
Section 260	Nurse-midwife services
Section 270	Hospice services (in accordance with � 1905 (o) of the Act)
Section 280	Case management services for high-risk pregnant women and children up to age 1, as defined in 12VAC30-50-410, in accordance with � 1915 (g)(1) of ...
Section 290	Extended services to pregnant women
Section 300	Any other medical care and any other type of remedial care recognized under state law, specified by the Secretary of Health and Human Services
Section 310	Emergency services for aliens
Section 320	Program of All-Inclusive Care for the Elderly (PACE)
Section 321	Eligibility for PACE enrollees
Section 325	Rates and payments
Section 328	PACE enrollment and disenrollment
Section 330	PACE definitions
Section 335	General PACE plan requirements
Section 340	Criteria for PACE enrollment
Section 345	PACE enrollee rights
Section 350	PACE enrollee responsibilities
Section 355	PACE plan contract requirements and standards
Section 360	PACE sanctions
Section 410	Case management services for high risk pregnant women and children
Section 420	Case management services for seriously mentally ill adults and emotionally disturbed children
Section 430	Case management services for youth at risk of serious emotional disturbance
Section 440	Case management services for individuals with mental retardation
Section 450	Case management services for individuals with mental retardation and related conditions who are participants in the Home and Community-Based Care ...
Section 460	[Repealed]
Section 470	Case management for recipients of auxiliary grants
Section 480	Case management for foster care children
Section 490	Case management for individuals with developmental disabilities, including autism
Section 491	Case management services for individuals who have an Axis 1 substance-related disorder
Section 510	Requirements and limits applicable to specific services: expanded prenatal care services
Section 520	Drugs or drug categories which are not covered
Section 530	Methods of providing transportation
Section 540	Kidney transplantation (KT)
Section 550	Corneal transplantation
Section 560	Liver, heart, lung, allogeneic and autologous bone marrow transplantation
Section 570	High dose chemotherapy and bone marrow/stem cell transplantation (coverage for persons over 21 years of age)
Section 580	Other medically necessary transplantation procedures that are determined to not be experimental or investigational (coverage for persons younger ...
FORMS	FORMS (12VAC30-50)
DIBR	DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-50)

Chapter 60

STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE (create report)

Section 10	Institutional care
Section 20	Utilization control: general acute care hospitals; enrolled providers
Section 21	Utilization control of nonparticipating out-of-state inpatient hospitals
Section 25	Utilization control: freestanding psychiatric hospitals
Section 30	Utilization control: Long-stay acute care hospitals (nonmental hospitals)
Section 40	Utilization control: Nursing facilities
Section 50	Utilization control: Intermediate Care Facilities for the Mentally Retarded (ICF/MR) and Institutions for Mental Disease (IMD)
Section 60	[Repealed]
Section 61	Services related to the Early and Periodic Screening, Diagnosis and Treatment Program (EPSDT); community mental health services for children
Section 70	Utilization control: Home health services
Section 75	Durable medical equipment (DME) and supplies
Section 80	Utilization control: Optometrists' services
Section 90	[Repealed]
Section 100	Utilization control: Incorporation of specialized quality standards
Section 110	Utilization control: Effect of geographic boundaries on provision of care
Section 120	Utilization control: Intensive physical rehabilitative services
Section 130	Hospice services
Section 140	Community mental health services
Section 143	Mental health services utilization criteria
Section 145	Mental retardation utilization criteria
Section 147	Substance abuse treatment services utilization review criteria
Section 150	General outpatient physical rehabilitation services
Section 160	Utilization review of case management for recipients of auxiliary grants
Section 170	Utilization review of treatment foster care (TFC) case management services
Section 180	Utilization review of community substance abuse treatment services
Section 185	Utilization review of case management
Section 200	Ticket to Work and Work Incentives Improvement Act (TWWIIA) basic coverage group: alternative benefits for Medicaid Buy-In program
Section 300	Nursing facility criteria
Section 303	Preadmission screening criteria for long-term care
Section 307	Summary of pre-admission nursing facility criteria
Section 310	[Reserved]
Section 312	Evaluation to determine eligibility for Medicaid payment of nursing facility or home and community-based care services
Section 316	Criteria for continued nursing facility care using the Minimum Data Set (MDS)
Section 318	Definitions to be applied when completing the MDS
Section 320	Adult ventilation/tracheostomy specialized care criteria
Section 330	[Reserved]
Section 340	Pediatric and adolescent specialized care criteria
Section 350	Criteria for coverage of specialized treatment beds
Section 360	Criteria for care in facilities for mentally retarded persons
Section 500	[Repealed]
FORMS	FORMS (12VAC30-60)
DIBR	DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-60)

Chapter 70

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES (create report)

Section 10	Effect of participation in Health Insurance for the Aged program
Section 20	Standards applied to non-participants in Title XVIII programs
Section 30	Limitations of Medical Assistance Program payment; Medicare reimbursement principles
Section 40	Payment of reasonable costs based on other methods
Section 50	Hospital reimbursement system
Section 60	Establishment of reasonable and adequate payment rates; cost reporting
Section 70	Revaluation of assets
Section 80	Refund of overpayments
Section 90	Reimbursement of certified hospitals exempt from Medicare Prospective Payment system
Section 100	Reimbursement of return on equity capital to proprietary providers
Section 110	Group ceiling for state-owned university teaching hospitals
Section 120	[Repealed]
Section 130	Payment adjustment fund
Section 140	[Repealed]
Section 150	Methods and standards for establishing payment rates - inpatient hospital care: Dispute resolution for state-operated providers
Section 160	[Reserved]
Section 200	[Repealed]
Section 201	Application of payment methodologies
Section 210	[Repealed]
Section 220	[Repealed]
Section 221	General
Section 230	[Repealed]
Section 231	Operating payment for DRG cases
Section 240	[Repealed]
Section 241	Operating payment for per diem cases
Section 250	[Repealed]
Section 251	Operating payment for transfer cases
Section 260	[Repealed]
Section 261	Outlier operating payment
Section 270	[Repealed]
Section 271	Payment for capital costs
Section 280	[Repealed]
Section 281	Payment for direct medical education costs of nursing schools, paramedical programs, and graduate medical education for interns and residents
Section 290	[Repealed]
Section 291	Payment for indirect medical education costs
Section 300	[Repealed]
Section 301	Payment to disproportionate share hospitals
Section 310	[Repealed]
Section 311	Hospital specific operating rate per case
Section 320	[Repealed]
Section 321	Hospital specific operating rate per day
Section 330	[Repealed]
Section 331	Statewide operating rate per case
Section 340	[Repealed]
Section 341	Statewide operating rate per day
Section 350	[Repealed]
Section 351	Updating rates for inflation
Section 360	[Repealed]
Section 361	Base year standardized operating costs per case
Section 370	[Repealed]
Section 371	Base year standardized operating costs per day
Section 380	[Repealed]
Section 381	DRG relative weights and hospital case-mix indices
Section 390	[Repealed]
Section 391	Recalibration and rebasing policy
Section 400	Determination of per diem rates
Section 410	State university teaching hospitals
Section 420	Reimbursement of noncost-reporting general acute care hospital providers
Section 425	Certified public expenditures for nonstate government-owned hospitals for inpatient services
Section 426	[Repealed]
Section 430	Medicare upper limit
Section 435	Lump sum payment
Section 440	[Repealed]
Section 441	Public comment process
Section 450	Cost reporting requirements
Section 460	Hospital settlement
Section 470	Underpayments
Section 480	Refund of overpayments
Section 490	Medicaid Hospital Payment Policy Advisory Council
Section 500	Outlier methodology illustration
FORMS	FORMS (12VAC30-70)
DIBR	DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-70)

Chapter 80

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES; OTHER TYPES OF CARE (create report)

Section 10	General
Section 20	Services that are reimbursed on a cost basis
Section 21	Inpatient psychiatric services in residential treatment facilities (under EPSDT)
Section 25	Reimbursement for federally qualified health centers (FQHCs) and rural health clinics (RHCs)
Section 30	Fee-for-service providers
Section 32	Reimbursement for substance abuse services
Section 40	Fee-for-service providers: pharmacy
Section 50	Third party liability
Section 60	Reimbursement audit
Section 70	Fee-for-service providers: Transportation
Section 75	Local Education Agency (LEA) providers
Section 80	Fee-for-service: Medicare coinsurance and deductibles
Section 90	Fee-for-service: Eyeglasses
Section 95	Fee-for-service: hearing aids (under EPSDT)
Section 100	Fee-for-service: Expanded Prenatal Care
Section 110	Fee-for-service: Case Management
Section 111	Treatment foster care (TFC) case management
Section 115	Fee-for-service: Early Discharge Follow-up Visit for Mothers and Newborns
Section 120	Reimbursement for all other nonenrolled institutional and noninstitutional providers
Section 130	Refund of overpayments
Section 140	[Repealed]
Section 150	Dispute resolution for state-operated providers
Section 160	[Repealed]
Section 170	Payment of Medicare Part A and Part B Deductible/Coinsurance
Section 180	Establishment of rate per visit
Section 190	State agency fee schedule for RBRVS
Section 200	Prospective reimbursement for rehabilitation agencies
FORMS	FORMS (12VAC30-80)
DIBR	DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-80)

Chapter 90

METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE (create report)

Section 10	Methods and standards for establishing payment rates for long-term care
Section 11	Public comment process
Section 19	Certified public expenditures for locally-owned nursing facilities
Section 20	Nursing home payment system; generally
Section 29	Transition to new capital payment methodology
Section 30	Plant cost
Section 31	New nursing facilities and bed additions
Section 32	Major capital expenditures
Section 33	Financing
Section 34	Purchases of nursing facilities (NF)
Section 35	General applicability
Section 36	Nursing Facility Capital Payment Methodology
Section 37	Calculation of FRV per diem rate for capital; calculation of FRV rental amount; change of ownership
Section 38	Schedule of assets reporting
Section 39	Purchases of nursing facilities (NF)
Section 40	Operating cost
Section 41	Nursing facility reimbursement formula
Section 42	[Repealed]
Section 44	[Reserved]
Section 50	Allowable costs
Section 51	Purchases/related organizations
Section 52	Administrator/owner compensation
Section 53	Depreciation
Section 54	Rent/Leases
Section 55	Provider payments
Section 56	Legal fees/accounting
Section 57	Documentation
Section 58	Fraud and abuse
Section 59	[Reserved]
Section 60	Interim rate
Section 65	Final rate
Section 70	Cost report submission
Section 75	Reporting form; accounting method; cost report extensions; fiscal year changes
Section 80	Time frames
Section 90	Retrospective rates
Section 100	[Reserved]
Section 110	Record retention
Section 120	Audit overview; scope of audit
Section 121	Field audit requirements
Section 122	Provider notification
Section 123	Field audit exit conference
Section 124	Audit delay
Section 125	Field audit time frames
Section 126	[Reserved]
Section 130	[Repealed]
Section 136	Elements of capital payment methodology not subject to appeal
Section 137	[Reserved]
Section 140	Individual expense limitation
Section 150	Cost report preparation instructions
Section 160	Stock acquisition; merger of unrelated and related parties
Section 165	Stock acquisition; merger of unrelated and related parties
Section 170	NATCEPs costs
Section 180	Criminal records checks
Section 190	Use of MMR-240
Section 200	Commingled investment income
Section 210	Provider notification
Section 220	Start-up costs
Section 221	Time frames
Section 222	Organizational costs
Section 223	[Reserved]
Section 230	Access to records
Section 240	Home office operating costs
Section 250	Lump sum payment
Section 251	Offset
Section 252	Payment schedule
Section 253	Extension request documentation
Section 254	Interest charge on extended repayment
Section 255	[Reserved]
Section 257	Credit balance reporting
Section 258	[Reserved]
Section 260	[Repealed]
Section 264	Specialized care services
Section 266	Traumatic Brain Injury (TBI) payment
Section 270	Uniform Expense Classification
Section 271	Direct patient care operating
Section 272	Indirect patient care operating costs
Section 273	Plant costs
Section 274	Nonallowable expenses
Section 275	Nurse Aide Training and Competency Evaluation Programs (NATCEPs) costs
Section 276	Criminal records background checks
Section 280	Leasing of facilities
Section 290	Cost reimbursement limitations
Section 300	[Repealed]
Section 305	Resource Utilization Groups (RUGs)
Section 306	Case-mix index (CMI)
Section 307	Applicability of case-mix indices (CMI)
Section 310	Normalized Case Mix Index (NCMI)
Section 320	National RUG-III categories and weights
Section 330	Traumatic brain injury diagnoses
FORMS	FORMS (12VAC30-90)
DIBR	DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-90)

Chapter 100

STATE PROGRAMS (create report)

Section 10	[Repealed]
Section 20	[Repealed]
Section 30	[Repealed]
Section 40	[Repealed]
Section 50	[Repealed]
Section 60	[Repealed]
Section 70	Definitions
Section 80	Program established
Section 90	Allocation of funds
Section 100	Amount, duration, and scope of services covered
Section 110	Changes in amount, duration, and scope of services covered
Section 120	Inpatient hospital reimbursement rate
Section 130	Local health department and outpatient hospital clinics reimbursement
Section 140	Emergency services reimbursement
Section 150	Eligibility criteria
Section 155	Application not required
Section 160	Length of effective period of application
Section 170	Persons eligible for Title XIX services
Section 180	Appeal
Section 190	State funds remaining at the end of the fiscal year
Section 200	Determination of liability for excess payments
Section 250	Definitions
Section 260	Eligibility requirements
Section 270	Determination of countable income and liquid assets
Section 280	Program application and enrollment
Section 290	Changes in eligibility
Section 300	Enrollee openings
Section 310	Authorization for benefits
Section 320	Notification
Section 330	Appeals
Section 340	Health insurance premium payments
Section 350	Recovery
Section 360	Fraud
Section 370	Confidentiality
Section 400	Applicability
Section 410	Definitions
Section 420	[Withdrawn]
Section 430	Program contractors
Section 440	Subscribers' employers
Section 450	Program reimbursement
Section 460	Confidentiality
Section 470	Appeals process
Section 480	[Reserved]
Section 490	Sunset provision
FORMS	FORMS (12VAC30-100)

Chapter 110

ELIGIBILITY AND APPEALS (create report)

Section 10	Definitions
Section 20	Division of Client Appeals
Section 30	Time limitation for appeals
Section 40	Judicial review
Section 50	Right to representation
Section 60	Designation of representative
Section 70	Notification of adverse agency action
Section 80	Advance notice
Section 90	Right to appeal
Section 100	Maintaining services
Section 110	Division records
Section 120	Computation of time limits
Section 130	Request for appeal
Section 140	Place of filing a Request for Appeal
Section 150	Filing date
Section 160	Time limit for filing
Section 170	Extension of time for filing
Section 180	Provision of information
Section 190	Review
Section 200	Medical assessment
Section 210	Prehearing action
Section 220	Evidentiary hearings
Section 230	Scheduling and rescheduling
Section 240	[Repealed]
Section 250	Notification
Section 260	Postponement
Section 270	Location
Section 280	Client access to records
Section 290	Subpoenas
Section 300	Role of the hearing officer
Section 310	Informality of hearings
Section 320	Evidence
Section 330	Record of hearing
Section 340	Oath or affirmation
Section 350	Dismissal of Request for Appeal
Section 360	Post-hearing supplementation of the record
Section 370	Final decision and transmission of the hearing record
Section 380	[Repealed]
Section 390	[Repealed]
Section 610	Definitions
Section 620	Availability of real or personal property
Section 630	Income-producing real property other than the home for aged, blind and disabled individuals
Section 640	Income
Section 650	Deeming of income and resources; responsibility of spouses
Section 660	Deeming of income and resources; responsibility of parents for blind or disabled children
Section 670	Aid to Dependent Children (ADC) Related Medically Needy Individuals
Section 680	SSI
Section 690	Imposition of lien
Section 700	Transfer of assets
Section 710	Undue hardship; transfer of resources
Section 720	Definitions
Section 730	Applicability
Section 740	[Repealed]
Section 741	Resource assessment required
Section 744	Resource assessment initiated
Section 747	Total resources
Section 750	Notification of documentation required
Section 751	Spousal share
Section 760	Failure to provide documentation
Section 770	Notification of assessment and appeal rights
Section 780	Appeal of resource assessment
Section 790	Applicability
Section 800	Initial eligibility determinations
Section 810	Initial determinations of ineligibility
Section 813	Attribution of resources at the time of initial eligibility determination
Section 815	Spousal protected resource amounts
Section 820	[Repealed]
Section 830	Additional resource exclusions
Section 831	Undue hardship
Section 840	Separate treatment of resources after eligibility for benefits established
Section 850	Post-eligibility resource transfers
Section 853	Community spouse resource allowance
Section 856	Revisions to the community spouse resource allowance
Section 860	Protected periods of eligibility
Section 870	Exception to protected period of eligibility
Section 880	Additional resources acquired during protected period of eligibility
Section 890	[Repealed]
Section 900	Resource eligibility determinations in retroactive months
Section 910	Eligibility for community spouses and other family members
Section 920	Applicability
Section 921	Treatment of income
Section 930	Determining income
Section 940	Applicability
Section 950	Mandatory deductions from institutionalized spouse's income
Section 960	Community spouse income allowance
Section 970	Family members maintenance needs allowance
Section 980	Applicability, notices and regulatory authority
Section 990	[Repealed]
Section 1000	[Repealed]
Section 1010	Hearing officer authority
Section 1011	Appealable issues
Section 1020	Definitions
Section 1030	Income eligibility
Section 1040	Spenddown calculation
Section 1050	Required deductions based on kinds of services
Section 1060	Required deductions based on the age of bills
Section 1070	Projection of expenses
Section 1080	Projection of institutional care expenses
Section 1090	[Reserved]
Section 1100	Individuals and families with income below the MNIL
Section 1110	[Reserved]
Section 1120	Reconciliation
Section 1130	Eligibility
Section 1140	Spenddown entitlement
Section 1150	Qualified Medicaid Beneficiaries
Section 1160	Retroactive spenddown; countable income; entitlement date
Section 1170	[Reserved]
Section 1200	Definitions
Section 1210	[Repealed]
Section 1220	Scope of coverage
Section 1230	Written notice and reporting requirements
Section 1240	Appeals
Section 1300	Medicaid eligibility for certain aliens and immigrants
Section 1350	Definitions
Section 1360	Right to apply
Section 1370	Applicant's signature
Section 1380	Authorized representative for individual age 18 or older
Section 1390	Authorized representative for children under 18 years of age
Section 1400	Authorized representative for a deceased applicant
Section 1410	Persons prohibited from signing an application
Section 1500	Working individuals with disabilities; basic coverage group (Ticket to Work and Work Incentive Improvement Act (TWWIIA))

Chapter 120

WAIVERED SERVICES (create report)

Section 10	[Repealed]
Section 61	[Repealed]
Section 62	[Repealed]
Section 63	[Repealed]
Section 64	[Repealed]
Section 65	[Repealed]
Section 66	[Repealed]
Section 67	[Repealed]
Section 68	[Repealed]
Section 70	Definitions
Section 80	General coverage and requirements for technology assisted waiver services
Section 90	Covered services and provider requirements
Section 100	Provider reimbursement
Section 110	Assessment and plan of care requirements
Section 115	Reevaluation requirements and utilization review
Section 120	Appeal of denied coverage
Section 130	[Repealed]
Section 140	Definitions
Section 150	General coverage and requirements for home and community-based care services for individuals with AIDS
Section 160	General conditions and requirements for all providers for home and community-based care services participating providers
Section 165	Consumer-directed services: personal assistance and respite care services
Section 170	Case management services
Section 180	Agency-directed personal care services
Section 190	Agency-directed respite care services
Section 195	Enteral nutrition products
Section 200	[Repealed]
Section 201	Private duty nursing services
Section 210	[Repealed]
Section 211	Definitions
Section 213	General coverage and requirements for MR waiver services
Section 215	Individual eligibility requirements
Section 217	General requirements for home and community-based participating providers
Section 219	Participation standards for home and community-based waiver services participating providers
Section 220	[Repealed]
Section 221	Assistive technology
Section 223	Companion services
Section 225	Consumer-directed model of service delivery
Section 227	Crisis stabilization services
Section 229	Day support services
Section 230	[Repealed]
Section 231	Environmental modifications
Section 233	Personal assistance and respite services
Section 235	Personal Emergency Response System (PERS)
Section 237	Prevocational services
Section 240	[Repealed]
Section 241	Residential support services
Section 243	[Repealed]
Section 245	Skilled nursing services
Section 247	Supported employment services
Section 249	Therapeutic consultation
Section 250	[Repealed]
Section 260	Definitions
Section 270	Program purpose
Section 280	MEDALLION clients
Section 290	Providers of services
Section 300	MEDALLION provider requirements
Section 310	Services exempted from MEDALLION referral requirements
Section 320	PCP payments
Section 330	Utilization review
Section 340	Client and provider appeals
Section 350	Sanctions
Section 360	Definitions
Section 370	Medallion II enrollees
Section 380	Medallion II MCO responsibilities
Section 385	[Repealed]
Section 390	Payment rate for Medallion II MCOs
Section 395	Payment rate for preauthorized or emergency care provided by out-of-network providers
Section 400	Quality control and utilization review
Section 410	Sanctions
Section 420	Client grievances and appeals
Section 430	[Reserved]
Section 450	Definitions
Section 460	General coverage and requirements for assisted living services
Section 470	Conditions and requirements for participating assisted living facilities
Section 480	Reevaluation of service need and utilization review
Section 490	[Repealed]
Section 700	Definitions
Section 710	General coverage and requirements for all home and community-based waiver services
Section 720	Qualification and eligibility requirements; intake process
Section 730	General requirements for home and community-based participating providers
Section 740	Participation standards for home and community-based waiver services participating providers
Section 750	In-home residential support services
Section 751	[Reserved]
Section 752	Day support services
Section 753	Prevocational services
Section 754	Supported employment services
Section 755	[Reserved]
Section 756	Therapeutic consultation
Section 757	[Reserved]
Section 758	Environmental modifications
Section 759	[Reserved]
Section 760	Skilled nursing services
Section 761	[Reserved]
Section 762	Assistive technology
Section 763	[Reserved]
Section 764	Crisis stabilization services
Section 765	[Reserved]
Section 766	Personal care and respite care services
Section 767	[Reserved]
Section 768	[Repealed]
Section 769	[Reserved]
Section 770	Consumer-directed model of service delivery
Section 771	[Reserved]
Section 772	Family/caregiver training
Section 773	[Reserved]
Section 774	Personal Emergency Response System (PERS)
Section 775	[Reserved]
Section 776	Companion services
Section 777	[Reserved]
Section 780	[Repealed]
Section 790	[Repealed]
Section 900	Definitions
Section 910	General coverage and requirements for Elderly or Disabled with Consumer Direction Waiver services
Section 920	Individual eligibility requirements
Section 930	General requirements for home and community-based participating providers
Section 940	Adult day health care services
Section 950	Agency-directed personal care services
Section 960	Agency-directed respite care services
Section 970	Personal emergency response system (PERS)
Section 980	Consumer-directed services: personal care and respite services
Section 1500	Definitions
Section 1510	General coverage and requirements for Day Support Waiver services.
Section 1520	Individual eligibility requirements
Section 1530	General requirements for home and community-based participating providers
Section 1540	Participation standards for home and community-based waiver services participating providers
Section 1550	Services: day support services, prevocational services and supported employment services.
Section 1600	Definitions
Section 1610	Individual eligibility requirements
Section 1620	Covered services
Section 1630	General requirements for participating providers
Section 1640	Participation standards for provision of services
Section 1650	Payment for services
Section 1660	Utilization review
Section 2000	Transition coordinator
Section 2010	Transition services
FORMS	FORMS (12VAC30-120)
DIBR	DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-120)

Chapter 129

[RESERVED] (create report)

Chapter 130

AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES (create report)

Section 10	Scope
Section 15	Eligibility criteria for outpatient rehabilitative services
Section 20	Physical therapy
Section 30	Occupational therapy
Section 40	Services for individuals with speech, hearing, and language disorders
Section 42	Service limitations
Section 50	Authorization for services
Section 60	Documentation requirements
Section 70	[Repealed]
Section 80	Scope
Section 90	Authorization for services
Section 100	Criteria for long-stay acute care hospital stays
Section 110	Documentation requirements
Section 120	Long-stay acute care hospital services
Section 130	Long-stay acute care hospital requirements
Section 140	Definitions
Section 150	Persons subject to nursing home preadmission screening and identification of conditions of mental illness and mental retardation (Level I)
Section 160	Level II determination
Section 170	Categorical determinations
Section 180	Annual resident review
Section 190	Determinations and placement of individuals with MI or MR/RC
Section 200	PASARR evaluation criteria
Section 210	Specialized services
Section 220	Placement options
Section 230	Evaluating the need for NF services and NF level of care (PASARR/NF)
Section 240	Evaluating whether an individual with MI requires specialized services (PASARR/MI)
Section 250	Evaluating whether an individual with MR/RC requires specialized services (PASARR/MR)
Section 260	Appeals
Section 270	Definitions
Section 280	Authority
Section 290	Scope and purpose
Section 300	Retrospective DUR
Section 310	Prospective DUR
Section 320	Criteria and standards for DUR
Section 330	Educational program
Section 335	Other interventions
Section 340	DUR Board
Section 350	DUR Committee
Section 360	Exemption of organized health care settings
Section 370	[Repealed]
Section 380	Definitions
Section 390	Scope
Section 400	Utilization review process
Section 410	[Repealed]
Section 420	Medical quality assurance
Section 430	Introduction
Section 440	Definitions
Section 450	Patient assessment criteria
Section 460	Directions for applying the criteria
Section 470	[Repealed]
Section 540	Definitions
Section 550	[Repealed]
Section 560	[Repealed]
Section 565	Substance abuse treatment services
Section 570	[Repealed]
Section 580	Free choice of providers
Section 590	Nonduplication of payment
Section 600	Definitions
Section 610	Purpose and scope
Section 620	Limitations
Section 630	[Repealed]
Section 730	[Repealed]
Section 740	General
Section 750	Time frames for determining cost effectiveness
Section 760	Notices
Section 770	[Reserved]
Section 780	[Repealed]
Section 790	Information required of applicants and recipients
Section 800	Definitions
Section 810	Client Medical Management Program for recipients
Section 820	Client Medical Management Program for providers
Section 850	Definitions
Section 860	Service coverage; eligible individuals; service certification
Section 870	Preauthorization
Section 880	Provider qualifications
Section 890	Plans of care; review of plans of care
Section 900	Definitions
Section 910	Targeted case management for foster care children in treatment foster care (TFC) covered services
Section 920	Provider qualifications
Section 930	Organization and administration requirements
Section 940	Discharge from care
Section 950	Entries in case records
Section 1000	Pharmacy services prior authorization
FORMS	FORMS (12VAC30-130)
DIBR	DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-130)

Chapter 135

DEMONSTRATION WAIVER SERVICES (create report)

Section 10	Definitions
Section 20	Administration and eligibility determination
Section 30	Eligibility
Section 40	Covered services
Section 50	Provider qualifications
Section 60	Quality assurance
Section 70	Reimbursement
Section 80	Recipients' rights and right to appeal
Section 90	Sunset provision
Section 100	Definitions
Section 110	(Reserved.)
Section 120	General coverage and requirements for Children�s Mental Health Waiver services
Section 130	(Reserved.)
Section 140	Eligibility requirements and intake process
Section 150	(Reserved.)
Section 160	Participation standards for home and community-based waiver services participating providers
Section 170	(Reserved.)
Section 180	Agency-directed companion services
Section 190	(Reserved.)
Section 200	Agency-directed respite services.
Section 210	(Reserved.)
Section 220	Consumer-directed companion and respite services
Section 230	(Reserved.)
Section 240	Community Transition Services
Section 250	(Reserved.)
Section 260	Environmental modifications
Section 270	(Reserved.)
Section 280	Family/caregiver training
Section 290	(Reserved.)
Section 300	Service description, criteria, limitations, and provider requirements
Section 310	(Reserved.)
Section 320	Therapeutic consultation
Section 330	(Reserved.)
Section 340	Reevaluation of service need and quality management review
Section 350	(Reserved.)
Section 360	Sunset provision
DIBR	DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-135)

Chapter 140

VIRGINIA CHILDREN'S MEDICAL SECURITY INSURANCE PLAN [REPEALED] (create report)

Section 10

[Repealed]

Chapter 141

FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN (create report)

Section 10	Definitions
Section 20	Administration and general background
Section 30	Outreach and public participation
Section 40	Review of adverse actions
Section 50	Notice of adverse action
Section 60	Request for review
Section 70	Review procedures
Section 80	[Reserved]
Section 100	Eligibility requirements
Section 110	Duration of eligibility
Section 120	Children ineligible for FAMIS
Section 130	Nondiscriminatory provisions
Section 140	No entitlement
Section 150	Application requirements
Section 160	Copayments for families not participating in FAMIS Select
Section 170	[Repealed]
Section 175	FAMIS Select
Section 180	Liability for excess benefits; liability for excess benefits or payments obtained without intent; recovery of FAMIS payments
Section 190	[Reserved]
Section 200	Benefit packages
Section 210	[Reserved]
Section 500	Benefits reimbursement
Section 510	[Reserved]
Section 560	Quality assurance
Section 570	Utilization control
Section 580	[Reserved]
Section 600	Recipient audit unit
Section 610	[Reserved]
Section 650	Provider review
Section 660	Assignment to managed care
Section 670	Definitions
Section 680	Administration and general background
Section 690	Outreach and public participation
Section 700	Review of adverse actions
Section 710	Notice of adverse action
Section 720	Request for review
Section 730	Review procedures
Section 740	Eligibility requirements
Section 750	Duration of eligibility
Section 760	Pregnant women ineligible for FAMIS MOMS
Section 770	Nondiscriminatory provisions
Section 780	No entitlement
Section 790	Application requirements
Section 800	Copayments
Section 810	Liability for excess benefits
Section 820	Benefit packages
Section 830	Benefits reimbursement
Section 840	Quality assurance
Section 850	Utilization control
Section 860	Recipient audit unit
Section 870	Provider review
Section 880	Assignment to managed care

Chapter 150

UNINSURED MEDICAL CATASTROPHE FUND (create report)

Section 10	Definitions
Section 20	UMCF program established
Section 30	Criteria for disbursements from the UMCF
Section 40	Eligibility criteria
Section 50	Treatment plan
Section 60	Availability of funds; no entitlement
Section 70	Contracts with providers
Section 80	Payments
Section 90	Application procedures and waiting list
Section 100	Appeals