12 Va. Admin. Code § 30-150-70 - Contracts with providers
A. It
shall be the responsibility of the applicant to find a qualified provider
willing to contract with DMAS under the terms in this section.
B. Reimbursement for covered services shall
be a global fee based on existing Medicaid or Medicare rates (whichever is
higher) or Medicaid reimbursement methodology to cover all services in the
approved treatment plan. The global fee will cover: procurement costs for
transplants; any hospital costs from admission to discharge; total physician
costs for all physicians providing services during the course of treatment; and
any other medical or drug costs associated with the treatment plan approved by
DMAS.
C. A provider may agree to
less than the full global fee as long as the provider agrees to complete the
treatment plan with no additional payment by the applicant or on behalf of the
applicant subject to subsection D of this section.
D. A provider may accept private funds raised
on behalf of the applicant. The sum of private funds plus UMCF commitment may
not exceed the global fee determined in subsection B of this section. Private
funding must be fully disclosed in the contract, and the contract cannot be
contingent on funds to be raised in the future. Private funds are not
considered part of the applicant's income for purposes of determining
eligibility. Private funds are not a factor in determining access to the UMCF
or its waiting list.
E. A contract
shall commit Uninsured Medical Catastrophe Funds to a course of treatment for
up to one year from the date the contract is signed.
F. Reimbursement agreed to in the contract
pursuant to this section shall constitute payment in full.
G. An application shall be denied if no
provider is willing to sign a contract pursuant to this section within 30 days
after the date all of the following are in place: a favorable determination of
eligibility, approval of the treatment plan, and the availability of
funds.
H. Facilities providing
transplant procedures must be recognized as being capable of providing high
quality care in the performance of the transplant by meeting the selection
criteria outlined in
12VAC30-50-540,
12VAC30-50-560, and
12VAC30-50-570 under the Virginia
Title XIX State Plan for Medical Assistance.
Notes
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
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