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Virginia Administrative Code


Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Chapter 5PUBLIC PARTICIPATION GUIDELINES
Chapter 10STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS
Chapter 20ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES
Chapter 30GROUPS COVERED AND AGENCIES RESPONSIBLE FOR ELIGIBILITY DETERMINATION
Chapter 40ELIGIBILITY CONDITIONS AND REQUIREMENTS
Chapter 50AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES
Chapter 60STANDARDS ESTABLISHED AND METHODS USED TO ASSURE HIGH QUALITY CARE
Chapter 70METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES - INPATIENT HOSPITAL SERVICES
Chapter 80METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES; OTHER TYPES OF CARE
Chapter 90METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE
Chapter 95STANDARDS ESTABLISHED AND METHODS USED FOR FEE-FOR-SERVICE REIMBURSEMENT
Chapter 100STATE PROGRAMS
Chapter 110ELIGIBILITY AND APPEALS
Chapter 120WAIVERED SERVICES
Chapter 129[RESERVED]
Chapter 130AMOUNT, DURATION AND SCOPE OF SELECTED SERVICES
Chapter 135DEMONSTRATION WAIVER SERVICES
Chapter 140VIRGINIA CHILDREN'S MEDICAL SECURITY INSURANCE PLAN [REPEALED]
Chapter 141FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN
Chapter 150UNINSURED MEDICAL CATASTROPHE FUND



Chapter 5PUBLIC PARTICIPATION GUIDELINES (create report)
Section 10Purpose
Section 20Definitions
Section 30Notification list
Section 40Information to be sent to persons on the notification list
Section 50Public comment
Section 60Petition for rulemaking
Section 70Appointment of regulatory advisory panel
Section 80Appointment of negotiated rulemaking panel
Section 90Meetings
Section 100Public hearings on regulations
Section 110Periodic review of regulations



Chapter 10STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS (create report)
Section 10Designation and authority
Section 20Organization for administration
Section 30Statewide operation
Section 40State Medical Care Advisory Committee
Section 50Pediatric immunization program
Section 60Application; determination of eligibility and furnishing Medicaid
Section 70Coverage and conditions of eligibility
Section 80Residence
Section 90Blindness
Section 100Disability
Section 110Financial eligibility
Section 120Medicaid furnished out of state
Section 130Requirements for advance directives
Section 140Amount, duration, and scope of services: Categorically needy
Section 150Amount, duration, and scope of services: Medically needy
Section 160Amount, duration, and scope of services: Other required special groups
Section 170Amount, duration, and scope of services: Limited coverage for certain aliens
Section 180Amount, duration, and scope of services: Homeless individuals
Section 190Amount, duration, and scope of services: Presumptively eligible pregnant women
Section 200Amount, duration, and scope of services: EPSDT services
Section 210Amount, duration, and scope of services: Comparability of services
Section 220Amount, duration, and scope of services: home health services
Section 230Amount, duration, and scope of services: Assurance of transportation
Section 240Amount, duration, and scope of services: Payment for nursing facility services
Section 250Amount, duration, and scope of services: Methods and standards to assure quality of services
Section 260Amount, duration, and scope of services: Family planning services
Section 270Amount, duration, and scope of services: Optometric services
Section 280Amount, duration, and scope of services: Organ transplant procedures
Section 290Amount, duration, and scope of services: Participation by Indian Health Service facilities
Section 300Amount, duration, and scope of services: Respiratory care services for ventilator-dependent individuals
Section 310Coordination of Medicaid with Medicare and other insurance: Premiums
Section 320Coordination of Medicaid with Medicare and other insurance: Deductibles/coinsurance
Section 325Premiums, deductibles, coinsurance and other cost sharing obligations
Section 330Medicaid for individuals age 65 or over in institutions for mental diseases
Section 340Special requirements applicable to sterilization procedures
Section 350Families receiving extended Medicaid benefits
Section 360[Reserved]
Section 400Methods of administration
Section 410Hearings for applicants and recipients
Section 420Safeguarding information on applicants and recipients
Section 430Medicaid quality control
Section 435Medicaid prohibition on payments to institutions or entities located outside of the United States
Section 440Medicaid Agency Fraud Detection and Investigation Program
Section 441Medicaid agency fraud detection and investigation program
Section 445Recovery audit contractors
Section 450Reports
Section 460Maintenance of records
Section 470Availability of agency program manuals
Section 480Reporting provider payments to Internal Revenue Service
Section 490Free choice of providers
Section 500Relations with standard-setting and survey agencies
Section 510Consultation to medical facilities
Section 520Required provider agreement
Section 530Utilization and quality control
Section 540Inspection of care in intermediate care facilities for the mentally retarded, facilities providing inpatient psychiatric services for individuals ...
Section 550Relations with state health and vocational rehabilitation agencies and Title V grantees
Section 560Liens and recoveries
Section 570Recipient cost sharing and similar charges
Section 580Payment for services
Section 590Direct payments to certain recipients for physicians' or dentists' services
Section 600Prohibition against reassignment of provider claims
Section 610Third party liability
Section 620Use of contracts
Section 630[Repealed]
Section 631Standards for payment for nursing facility and intermediate care facility for the mentally retarded services
Section 640Program for licensing administrators of nursing homes
Section 650Drug Utilization Review Program
Section 660Disclosure of survey information and provider or contractor evaluation
Section 670Appeals process
Section 680Conflict of interest provisions
Section 690Exclusion of providers and suspension of practitioners and other individuals
Section 700Disclosure of information by providers and fiscal agents
Section 710Income and eligibility verification system
Section 720Medicaid eligibility cards for homeless individuals
Section 730Systematic alien verification for entitlements
Section 740[Repealed]
Section 750[Repealed]
Section 751Enforcement of compliance for nursing facilities
Section 760Pharmacy services rebate agreement terms
Section 770Required coordination between the Medicaid and WIC Programs
Section 780Nurse aide training and competency evaluation for nursing facilities
Section 790Preadmission screening and annual resident review in nursing facilities
Section 800Survey and certification process
Section 810Resident assessment for nursing facilities
Section 815Cooperation with Medicaid Integrity Program efforts
Section 820Employee education about false claims recoveries
Section 850Standards of personnel administration
Section 860[Reserved]
Section 870Training programs; subprofessional and volunteer programs
Section 880[Reserved]
Section 900Fiscal policies and administration
Section 910Cost allocation
Section 920State financial participation
Section 930Hospital credit balance reporting
Section 940[Reserved]
Section 960Plan amendments
Section 970Nondiscrimination
Section 980[Repealed]
Section 990State Governor's review
Section 1000General provider appeals



Chapter 20ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES (create report)
Section 10Attorney General's certification
Section 20[Repealed]
Section 60Definition of Medicaid state plan health maintenance organizations (HMOs)
Section 70[Repealed]
Section 80Coordination of Title XIX with Part A and Part B of Title XVIII
Section 90Confidentiality and disclosure of information concerning Medicaid applicants and recipients
Section 100Standards governing general and special hospitals and convalescent and nursing homes
Section 110Nursing facility resident drug utilization review
Section 120Cooperative arrangements with the state vocational rehabilitation agency and with Title V programs and grantees
Section 130Lien recoveries
Section 140[Repealed]
Section 141Estate recoveries
Section 150Copayments and deductibles for categorically needy and QMBs for services other than under 42 CFR 447.53
Section 160Copayments and deductibles for medically needy and QMBs for services other than under 42 CFR 447.53
Section 170Basis of payment for reserving beds during a recipient's absence from an inpatient facility
Section 180Definition of a claim by service
Section 190Requirements for third party liability; identifying liable resources
Section 200Requirements for third party liability; payment of claims
Section 205Health Insurance Premium Payment (HIPP) for Kids
Section 210State method on cost effectiveness of employer-based group health plans
Section 215Sanctions for psychiatric hospitals
Section 220Income and eligibility verification system procedures; requests to other state agencies
Section 230Method for issuance of medicaid eligibility cards to homeless individuals
Section 240Requirements for advance directives under state plans for medical assistance
Section 249[Repealed]
Section 251Termination of provider agreement
Section 252Temporary management
Section 253Denial of payment for new admissions
Section 254Civil money penalty
Section 255State monitoring
Section 256Transfer of residents; transfer of residents with closure of facility
Section 257Required plan of correction
Section 258Appeals
Section 259Repeated substandard quality of care
Section 260Definition of specialized services
Section 270Categorical determinations
Section 272Survey and certification education program
Section 274Process for the investigation of allegations of resident neglect and abuse and misappropriation of resident property
Section 275Procedures for scheduling and conduct of standards surveys
Section 277Programs to measure and reduce inconsistency
Section 278Process for investigations of complaints and monitoring
Section 280Methods of administration; civil rights
Section 290[Reserved]
Section 500Definitions
Section 520Provider appeals: general provisions
Section 540Informal appeals
Section 560Formal appeals
FORMSFORMS (12VAC30-20)



Chapter 30GROUPS COVERED AND AGENCIES RESPONSIBLE FOR ELIGIBILITY DETERMINATION (create report)
Section 10Mandatory coverage: Categorically needy and other required special groups
Section 20Optional groups other than the medically needy
Section 30Optional coverage of the medically needy
Section 40Reasonable classifications of individuals under the age of 21, 20, 19, and 18
Section 50More restrictive categorical eligibility criteria
Section 60Requirements relating to determining eligibility for Medicare Prescription Drug Low-Income Subsidy



Chapter 40ELIGIBILITY CONDITIONS AND REQUIREMENTS (create report)
Section 10General conditions of eligibility
Section 20Post-eligibility treatment of institutionalized individuals
Section 30Maintenance needs of non-institutionalized spouse
Section 40Children
Section 50Medical expenses
Section 60Maintenance of residence
Section 70SSI benefits
Section 80Maintenance standards
Section 90Income and resource levels and methods
Section 100Methods of determining income
Section 105Financial eligibility
Section 110Medicaid qualifying trusts
Section 120Medically needy income levels (MNILs) based on family size
Section 130Handling of excess income; spend-down
Section 140Methods for determining resources
Section 150Resource standard; categorically needy
Section 160Resource standard; medically needy
Section 170Resource standard; qualified Medicare beneficiaries and specified low-income Medicare beneficiaries
Section 180Qualified disabled and working individuals
Section 190Excess resources
Section 200Effective date of eligibility
Section 210Transfer of resources - categorically and medically needy, qualified Medicare beneficiaries, and qualified disabled and working individuals
Section 220Income eligibility levels
Section 230Resource levels
Section 235Reasonable limits on amounts for necessary medical or remedial care not covered under Medicaid
Section 240More restrictive methods of treating resources than those of the SSI program: § 1902(f) states only
Section 250Standards for optional state supplementary payments
Section 260Income levels for 1902(f) states; categorically needy who are covered under requirements more restrictive than SSI
Section 270Resource standards for 1902(f) states; categorically needy
Section 280More liberal income disregards
Section 290More liberal methods of treating resources under §1902(r)(2) of the Act: §1902(f) states
Section 300Transfer of resources
Section 310[Reserved]
Section 320Consideration of Medicaid qualifying trust; undue hardship
Section 330Cost effectiveness methodology for COBRA continuation beneficiaries
Section 340Compliance with § 1924 and OBRA 90
Section 345Eligibility under § 1931 of the Act
Section 347Asset verification system
Section 350Standards for optional state supplementary payments
Section 360Treatment of entrance fees of individuals residing in continuing care retirement communities



Chapter 50AMOUNT, DURATION, AND SCOPE OF MEDICAL AND REMEDIAL CARE SERVICES (create report)
Section 10Services provided to the categorically needy with limitations
Section 20Services provided to the categorically needy without limitation
Section 30Services not provided to the categorically needy
Section 35Requirements relating to payment for covered outpatient drugs for the categorically needy
Section 40Ambulatory services
Section 50Services provided to the medically needy with limitations
Section 60Services provided to all medically needy groups without limitations
Section 70Services or devices not provided to the medically needy
Section 75Requirements relating to payment for covered outpatient drugs for the medically needy
Section 80[Reserved]
Section 95Reimbursement of services; in general
Section 100Inpatient hospital services provided at general acute care hospitals and freestanding psychiatric hospitals; enrolled providers
Section 105Inpatient hospital services provided at general acute care hospitals and freestanding psychiatric hospitals; nonenrolled providers ...
Section 110Outpatient hospital and rural health clinic services
Section 120Other laboratory and x-ray services
Section 130Skilled nursing facility services, EPSDT, school health services and family planning
Section 131Services provided by certified Early Intervention practitioners under EPSDT
Section 140Physician's services whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere
Section 150Medical care by other licensed practitioners within the scope of their practice as defined by state law
Section 160Home health services
Section 165Durable medical equipment (DME) and supplies suitable for use in the home
Section 170Private duty nursing services
Section 180Clinic services
Section 190Dental services
Section 200Physical therapy and related services
Section 210Prescribed drugs, dentures, and prosthetic devices; and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist
Section 220Other diagnostic, screening, preventive, and rehabilitative services, i.e., other than those provided elsewhere in this plan
Section 225Rehabilitative services; intensive physical rehabilitation
Section 226Community mental health services
Section 227Lead contamination
Section 228Community substance abuse treatment services
Section 229[Reserved]
Section 229.1[Repealed]
Section 230Services for individuals age 65 or older in institutions for mental diseases
Section 240Intermediate care services and intermediate care services for institutions for mental disease and mental retardation
Section 250Inpatient psychiatric facility services for individuals under 21 years of age
Section 260Nurse-midwife services
Section 270Hospice services (in accordance with § 1905 (o) of the Act)
Section 280Case 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 290Extended services to pregnant women
Section 300Any other medical care and any other type of remedial care recognized under state law, specified by the Secretary of Health and Human Services
Section 310Emergency services for aliens
Section 320Program of All-Inclusive Care for the Elderly (PACE)
Section 321Eligibility for PACE enrollees
Section 325Rates and payments
Section 328PACE enrollment and disenrollment
Section 330PACE definitions
Section 335General PACE plan requirements
Section 340Criteria for PACE enrollment
Section 345PACE enrollee rights
Section 350PACE enrollee responsibilities
Section 355PACE plan contract requirements and standards
Section 360PACE sanctions
Section 410Case management services for high risk pregnant women and children
Section 420Case management services for seriously mentally ill adults and emotionally disturbed children
Section 430Case management services for youth at risk of serious emotional disturbance
Section 440Case management services for individuals with mental retardation
Section 450Case management services for individuals with mental retardation and related conditions who are participants in the Home and Community-Based Care ...
Section 460[Repealed]
Section 470Case management for recipients of auxiliary grants
Section 480Case management for foster care children
Section 490Case management for individuals with developmental disabilities, including autism
Section 491Case management services for individuals who have an Axis 1 substance-related disorder
Section 510Requirements and limits applicable to specific services: expanded prenatal care services
Section 520Drugs or drug categories which are not covered
Section 530Methods of providing transportation
Section 540Kidney transplantation (KT)
Section 550Corneal transplantation
Section 560Liver, heart, lung, allogeneic and autologous bone marrow transplantation
Section 570High dose chemotherapy and bone marrow/stem cell transplantation (coverage for persons over 21 years of age)
Section 580Other medically necessary transplantation procedures that are determined to not be experimental or investigational (coverage for persons younger ...
FORMSFORMS (12VAC30-50)
DIBRDOCUMENTS INCORPORATED BY REFERENCE (12VAC30-50)



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



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



Chapter 80METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES; OTHER TYPES OF CARE (create report)
Section 10General
Section 20Services that are reimbursed on a cost basis
Section 21Inpatient psychiatric services in residential treatment facilities (under EPSDT)
Section 25Reimbursement for federally qualified health centers (FQHCs) and rural health clinics (RHCs)
Section 30Fee-for-service providers
Section 32Reimbursement for substance abuse services
Section 35Fee for service: ambulatory surgery centers
Section 40Fee-for-service providers: pharmacy
Section 50Third party liability
Section 60Reimbursement audit
Section 70Fee-for-service providers: Transportation
Section 75Local Education Agency (LEA) providers
Section 80Fee-for-service: Medicare coinsurance and deductibles
Section 90Fee-for-service: Eyeglasses
Section 95Fee-for-service: hearing aids (under EPSDT)
Section 96Fee-for-service: Early Intervention (under EPSDT)
Section 100Fee-for-service: Expanded Prenatal Care
Section 110Fee-for-service: Case Management
Section 111Treatment foster care (TFC) case management
Section 115Fee-for-service: Early Discharge Follow-up Visit for Mothers and Newborns
Section 120Reimbursement for all other nonenrolled institutional and noninstitutional providers
Section 130Refund of overpayments
Section 140[Repealed]
Section 150Dispute resolution for state-operated providers
Section 160[Repealed]
Section 170Payment of Medicare Part A and Part B Deductible/Coinsurance
Section 180Establishment of rate per visit
Section 190State agency fee schedule for RBRVS
Section 200Prospective reimbursement for rehabilitation agencies or comprehensive outpatient rehabilitation facilities
FORMSFORMS (12VAC30-80)
DIBRDOCUMENTS INCORPORATED BY REFERENCE (12VAC30-80)



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



Chapter 95STANDARDS ESTABLISHED AND METHODS USED FOR FEE-FOR-SERVICE REIMBURSEMENT (create report)
Section 5General definitions



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



Chapter 110ELIGIBILITY AND APPEALS (create report)
Section 10Definitions
Section 20Division of Client Appeals
Section 30Time limitation for appeals
Section 40Judicial review
Section 50Right to representation
Section 60Designation of representative
Section 70Notification of adverse agency action
Section 80Advance notice
Section 90Right to appeal
Section 100Maintaining services
Section 110Division records
Section 120Computation of time limits
Section 130Request for appeal
Section 140Place of filing a Request for Appeal
Section 150Filing date
Section 160Time limit for filing
Section 170Extension of time for filing
Section 180Provision of information
Section 190Review
Section 200Medical assessment
Section 210Prehearing action
Section 220Evidentiary hearings
Section 230Scheduling and rescheduling
Section 240[Repealed]
Section 250Notification
Section 260Postponement
Section 270Location
Section 280Client access to records
Section 290Subpoenas
Section 300Role of the hearing officer
Section 310Informality of hearings
Section 320Evidence
Section 330Record of hearing
Section 340Oath or affirmation
Section 350Dismissal of Request for Appeal
Section 360Post-hearing supplementation of the record
Section 370Final decision and transmission of the hearing record
Section 380[Repealed]
Section 390[Repealed]
Section 610Definitions
Section 620Availability of real or personal property
Section 630Income-producing real property other than the home for aged, blind and disabled individuals
Section 640Income
Section 650Deeming of income and resources; responsibility of spouses
Section 660Deeming of income and resources; responsibility of parents for blind or disabled children
Section 670Aid to Dependent Children (ADC) Related Medically Needy Individuals
Section 680SSI
Section 690Imposition of lien
Section 700Transfer of assets
Section 710Undue hardship; transfer of resources
Section 720Definitions
Section 730Applicability
Section 740[Repealed]
Section 741Resource assessment required
Section 744Resource assessment initiated
Section 747Total resources
Section 750Notification of documentation required
Section 751Spousal share
Section 760Failure to provide documentation
Section 770Notification of assessment and appeal rights
Section 780Appeal of resource assessment
Section 790Applicability
Section 800Initial eligibility determinations
Section 810Initial determinations of ineligibility
Section 813Attribution of resources at the time of initial eligibility determination
Section 815Spousal protected resource amounts
Section 820[Repealed]
Section 830Additional resource exclusions
Section 831Undue hardship
Section 840Separate treatment of resources after eligibility for benefits established
Section 850Post-eligibility resource transfers
Section 853Community spouse resource allowance
Section 856Revisions to the community spouse resource allowance
Section 860Protected periods of eligibility
Section 870Exception to protected period of eligibility
Section 880Additional resources acquired during protected period of eligibility
Section 890[Repealed]
Section 900Resource eligibility determinations in retroactive months
Section 910Eligibility for community spouses and other family members
Section 920Applicability
Section 921Treatment of income
Section 930Determining income
Section 940Applicability
Section 950Mandatory deductions from institutionalized spouse's income
Section 960Community spouse income allowance
Section 970Family members maintenance needs allowance
Section 980Applicability, notices and regulatory authority
Section 990[Repealed]
Section 1000[Repealed]
Section 1010Hearing officer authority
Section 1011Appealable issues
Section 1020Definitions
Section 1030Income eligibility
Section 1040Spenddown calculation
Section 1050Required deductions based on kinds of services
Section 1060Required deductions based on the age of bills
Section 1070Projection of expenses
Section 1080Projection of institutional care expenses
Section 1090[Reserved]
Section 1100Individuals and families with income below the MNIL
Section 1110[Reserved]
Section 1120Reconciliation
Section 1130Eligibility
Section 1140Spenddown entitlement
Section 1150Qualified Medicaid Beneficiaries
Section 1160Retroactive spenddown; countable income; entitlement date
Section 1170[Reserved]
Section 1200Definitions
Section 1210[Repealed]
Section 1220Scope of coverage
Section 1230Written notice and reporting requirements
Section 1240Appeals
Section 1300[Repealed]
Section 1350Definitions
Section 1360Right to apply
Section 1370Applicant's signature
Section 1380Authorized representative for individual age 18 or older
Section 1390Authorized representative for children under 18 years of age
Section 1400Authorized representative for a deceased applicant
Section 1410Persons prohibited from signing an application
Section 1500Working individuals with disabilities; basic coverage group (Ticket to Work and Work Incentive Improvement Act (TWWIIA))
Section 1600Definitions (Reserved).
Section 1610Deemed newborn eligibility under FAMIS.
Section 1620Special eligible groups (Reserved).



Chapter 120WAIVERED 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[Repealed]
Section 80[Repealed]
Section 90[Repealed]
Section 100[Repealed]
Section 110[Repealed]
Section 115[Repealed]
Section 120[Repealed]
Section 130[Repealed]
Section 140[Repealed]
Section 150[Repealed]
Section 160[Repealed]
Section 165[Repealed]
Section 170[Repealed]
Section 180[Repealed]
Section 190[Repealed]
Section 195[Repealed]
Section 200[Repealed]
Section 201[Repealed]
Section 210[Repealed]
Section 211[Repealed]
Section 213[Repealed]
Section 215[Repealed]
Section 217[Repealed]
Section 219[Repealed]
Section 220[Repealed]
Section 221[Repealed]
Section 223[Repealed]
Section 225[Repealed]
Section 227[Repealed]
Section 229[Repealed]
Section 230[Repealed]
Section 231[Repealed]
Section 233[Repealed]
Section 235[Repealed]
Section 237[Repealed]
Section 240[Repealed]
Section 241[Repealed]
Section 243[Repealed]
Section 245[Repealed]
Section 247[Repealed]
Section 249[Repealed]
Section 250[Repealed]
Section 260[Repealed]
Section 270[Repealed]
Section 280[Repealed]
Section 290[Repealed]
Section 300[Repealed]
Section 310[Repealed]
Section 320[Repealed]
Section 330[Repealed]
Section 340[Repealed]
Section 350[Repealed]
Section 360Definitions
Section 370Medallion II enrollees
Section 380Medallion II MCO responsibilities
Section 385[Repealed]
Section 390Payment rate for Medallion II MCOs
Section 395Payment rate for preauthorized or emergency care provided by out-of-network providers
Section 400Quality control and utilization review
Section 410Sanctions
Section 420Client grievances and appeals
Section 430[Reserved]
Section 450[Repealed]
Section 460[Repealed]
Section 470[Repealed]
Section 480[Repealed]
Section 490[Repealed]
Section 700Definitions
Section 710General coverage and requirements for all home and community-based waiver services
Section 720Qualification and eligibility requirements; intake process
Section 730General requirements for home and community-based participating providers
Section 740Participation standards for home and community-based waiver services participating providers
Section 750In-home residential support services
Section 751[Reserved]
Section 752Day support services
Section 753Prevocational services
Section 754Supported employment services
Section 755[Reserved]
Section 756Therapeutic consultation
Section 757[Reserved]
Section 758Environmental modifications
Section 759[Reserved]
Section 760Skilled nursing services
Section 761[Reserved]
Section 762Assistive technology
Section 763[Reserved]
Section 764Crisis stabilization services
Section 765[Reserved]
Section 766Personal care and respite care services
Section 767[Reserved]
Section 768[Repealed]
Section 769[Reserved]
Section 770Consumer-directed model of service delivery
Section 771[Reserved]
Section 772Family/caregiver training
Section 773[Reserved]
Section 774Personal emergency response system (PERS)
Section 775[Reserved]
Section 776Companion services
Section 777[Reserved]
Section 780[Repealed]
Section 790[Repealed]
Section 900Definitions
Section 910General coverage and requirements for Elderly or Disabled with Consumer Direction Waiver services
Section 920Individual eligibility requirements
Section 925Respite coverage in children's residential facilities
Section 930General requirements for home and community-based participating providers
Section 940Adult day health care services
Section 950Agency-directed personal care services
Section 960Agency-directed respite care services
Section 970Personal emergency response system (PERS)
Section 980Consumer-directed services: personal care and respite services
Section 1000Definitions
Section 1005Waiver description and legal authority
Section 1010Individual eligibility requirements
Section 1020Covered services; limits on covered services
Section 1030[Reserved]
Section 1040General requirements for participating providers
Section 1060Participation standards for provision of services; providers' requirements
Section 1070Payment for services
Section 1080Utilization review; level of care reviews
Section 1088Waiver waiting list
Section 1090Appeals
Section 1500Definitions
Section 1510General coverage and requirements for Day Support Waiver services.
Section 1520Individual eligibility requirements
Section 1530General requirements for home and community-based participating providers
Section 1540Participation standards for home and community-based waiver services participating providers
Section 1550Services: day support services, prevocational services and supported employment services.
Section 1600Definitions
Section 1605Waiver description and legal authority
Section 1610Individual eligibility requirements
Section 1620Covered services
Section 1630General requirements for enrolled providers
Section 1640Participation standards for provision of services
Section 1650Payment for services
Section 1660Utilization review
Section 1670Waiver waiting list
Section 1680Appeals
Section 1700Definitions
Section 1705Waiver description and legal authority
Section 1710Individual eligibility requirements; preadmission screening
Section 1720Covered services; limits; changes to or termination of services
Section 1730General requirements for participating providers
Section 1740Participation standards for provision of services
Section 1750Payment for services
Section 1760Quality management review; utilization reviews; level of care (LOC) reviews
Section 1770Appeals; provider and recipient
Section 2000Transition coordinator
Section 2010Transition services
FORMSFORMS (12VAC30-120)
DIBRDOCUMENTS INCORPORATED BY REFERENCE (12VAC30-120)



Chapter 129[RESERVED] (create report)



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



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



Chapter 140VIRGINIA CHILDREN'S MEDICAL SECURITY INSURANCE PLAN [REPEALED] (create report)
Section 10[Repealed]



Chapter 141FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN (create report)
Section 10Definitions
Section 20Administration and general background
Section 30Outreach and public participation
Section 40Review of adverse actions
Section 50Notice of adverse action
Section 60Request for review
Section 70Review procedures
Section 80[Reserved]
Section 100Eligibility requirements
Section 110Duration of eligibility
Section 120Children ineligible for FAMIS
Section 130Nondiscriminatory provisions
Section 140No entitlement
Section 150Application requirements
Section 160Copayments for families not participating in FAMIS Select
Section 170[Repealed]
Section 175FAMIS Select
Section 180Liability for excess benefits; liability for excess benefits or payments obtained without intent; recovery of FAMIS payments
Section 190[Reserved]
Section 200Benefit packages
Section 210[Reserved]
Section 500Benefits reimbursement
Section 510[Reserved]
Section 560Quality assurance
Section 570Utilization control
Section 580[Reserved]
Section 600Recipient audit unit
Section 610[Reserved]
Section 650Provider review
Section 660Assignment to managed care
Section 670Definitions
Section 680Administration and general background
Section 690Outreach and public participation
Section 700Review of adverse actions
Section 710Notice of adverse action
Section 720Request for review
Section 730Review procedures
Section 740Eligibility requirements
Section 750Duration of eligibility
Section 760Pregnant women ineligible for FAMIS MOMS
Section 770Nondiscriminatory provisions
Section 780No entitlement
Section 790Application requirements
Section 800Copayments
Section 810Liability for excess benefits
Section 820Benefit packages
Section 830Benefits reimbursement
Section 840Quality assurance
Section 850Utilization control
Section 860Recipient audit unit
Section 870Provider review
Section 880Assignment to managed care



Chapter 150UNINSURED MEDICAL CATASTROPHE FUND (create report)
Section 10Definitions
Section 20UMCF program established
Section 30Criteria for disbursements from the UMCF
Section 40Eligibility criteria
Section 50Treatment plan
Section 60Availability of funds; no entitlement
Section 70Contracts with providers
Section 80Payments
Section 90Application procedures and waiting list
Section 100Appeals