{"data":{"id":"us-va/12vac30-20-160","jurisdiction":"us-va","citation":"12VAC30-20-160","heading":"Copayments and deductibles for medically needy and QMBs for services other than under 42 CFR 447.53","body":"A. The following charges are imposed on the medically needy and Qualified Medicare Beneficiaries for services other than those provided under 42 CFR 447.53.\n\nService*\n\nType Charge\n\nAmount and Basis for Determination\n\nDeduct\n\nCoins\n\nCopay\n\nInpatient Hospital\n\n-0-\n\n‑0‑\n\n$75\n\nState's average daily payment of $594 is used as basis.\n\nOutpatient Hospital Clinic\n\n‑0‑\n\n‑0‑\n\n$3.00\n\nState's average payment of $136 is used as basis.\n\nClinic Visit\n\n‑0‑\n\n‑0‑\n\n$1.00\n\nState's average payment of $29 is used as basis.\n\nPhysician Office Visit\n\n‑0‑\n\n‑0‑\n\n$1.00\n\nState's average payment of $23 is used as basis.\n\nEye Examination\n\n‑0‑\n\n‑0‑\n\n$1.00\n\nState's payment of $30 is used as basis.\n\nPrescriptions:\n\n--Generic\n\n‑0‑\n\n‑0‑\n\n$1.00\n\nState's average per generic script of $25 is used as payment  basis.\n\n--Brand Name\n\n‑0‑\n\n‑0‑\n\n$3.00\n\nState's average per brand-name script of $97 is used as  payment basis.\n\nHome Health Visit\n\n‑0‑\n\n‑0‑\n\n$3.00\n\nState's average payment of $56 is used as basis.\n\nOther Physician Services\n\n‑0‑\n\n‑0‑\n\n$3.00\n\nState's average payment of $56 is used as basis.\n\nRehab Therapy Services (PT, OT, Sp/Lang.)\n\n‑0‑\n\n‑0‑\n\n$3.00\n\nState's average payment $78 is used as basis.\n\n*NOTE: The applicability of copays to emergency services is discussed further in this section.\n\nB. The method used to collect cost sharing charges for medically needy individuals requires that providers be responsible for collecting the cost sharing charges from individuals.\n\nC. The basis for determining whether an individual is unable to pay the charge, and the means by which such an individual is identified to providers, is described  in this subsection:\n\nProviders will, based on information available to them, make a determination of the recipient's ability to pay the copayment. In the absence of knowledge or indications to the contrary, providers may accept the recipient's assertion that he or she is unable to pay the required copayment.\n\nRecipients have been notified that inability to meet a copayment at a particular time does not relieve them of that responsibility.\n\nD. The procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b) are described  in this subsection:\n\nThe application and exclusion of cost sharing is administered through the program's  Medicaid Management Information System. Documentation of the certified computer system delineates, for each type of provider invoice used, protected eligible groups, protected services and applicable eligible groups and services.\n\nProviders have been informed about: copay exclusions; applicable services and amounts; and prohibition of service denial if recipient is unable to meet cost-sharing changes.\n\nE. State policy does not provide for cumulative maximums.\n\nF. Emergency Services. No recipient copayment shall be collected for the following services:\n\n1. Services provided in a hospital, clinic, office, or other facility that is equipped to furnish the required care, after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) that the absence of immediate medical attention could reasonably be expected to result in:\n\na. Placing the patient's health in serious jeopardy;\n\nb. Serious impairment to bodily functions; or\n\nc. Serious dysfunction of any bodily organ or part; and\n\n2. All services delivered in emergency rooms.","path":["Title 12. Health","Agency 30. Department of Medical Assistance Services","Chapter 20. Administration of Medical Assistance Services","Part III. Recipient Cost Sharing"],"source_url":"https://law.lis.virginia.gov/admincode/title12/agency30/chapter20/section160/","current_through":"2026 Regular Session (effective July 1, 2026)","vintage":"","retrieved_at":"2026-09-14T04:50:52Z","sha256":"941de9bf286b81f5858701aa3045db1a7ca9ea2b9a3fd1a31cf3feb529b42327","source_id":"us-va-vac","stale":false,"prev":"us-va/12vac30-20-150","next":"us-va/12vac30-20-170"},"notice":"GroundRules: Original legal text. Not legal advice."}