                                 CODE OF VIRGINIA

DIRECTOR TO ESTABLISH STANDARDS; REIMBURSEMENT OF SERVICES (§ 32.1-346)

A. The Director shall prescribe regulations setting forth the amount, duration
and scope of medical services covered by the Program which shall be uniform in
all localities. Such services shall consist only of inpatient and outpatient
hospital services, services rendered in free-standing ambulatory surgical
centers and local public health clinics by providers who have signed agreements
to participate in the State/Local Hospitalization Program and are enrolled
providers in the Medical Assistance Program. Services covered under the Program
shall not exceed in amount, duration or scope those available to recipients of
Medical Assistance Services as provided in the State Plan for Medical Assistance
pursuant to Chapter 10 (&#xA7; 32.1-323 et seq.) of this title. Subject to the
above, the Board may modify such coverage so long as uniformity of coverage is
maintained throughout the Commonwealth.

B. Reimbursement for services under this Program shall be equal to that of the
Medical Assistance Program pursuant to Chapter 10 of this title as follows:

   1. The reimbursement rate per visit for outpatient hospital services shall be
   the same as that established by the Department of Medical Assistance Services
   for an intermediate office visit for an established patient;

   2. The inpatient hospital reimbursement rate shall be consistent with the
   Medicaid inpatient rate methodology. However, no disproportionate share or
   medical education adjustment for SLH inpatient hospital reimbursement shall be
   provided;

   3. Inpatient hospital stays for adults shall be limited to twenty-one days of
   covered hospitalization within sixty days for the same or similar diagnosis.
   The sixty day period shall begin with the initial hospital admission. Only
   twenty-one total medically necessary days shall be covered whether incurred
   for one or more hospital stays, in the same or multiple hospitals, during the
   sixty day period. Inpatient hospital admissions on Friday and Saturday shall
   not be covered except in cases of medical emergencies. Reimbursement of
   inpatient hospital days on behalf of individuals up to the age of twenty-one
   shall be for medically necessary stays in excess of twenty-one days as
   provided in the State Plan for Medical Assistance Services;

   4. The hospital emergency room reimbursement rate per visit shall be the same
   as that rate established by the Department of Medical Assistance Services for
   an intermediate level, established patient emergency department visit; and

   5. The outpatient surgical rate for hospitals and ambulatory surgical centers
   shall be the same as the rates established by the Department of Medical
   Assistance Services for the facility component for ambulatory surgical
   centers.

C. Procedures identified by the Department of Medical Assistance Services as
outpatient surgical procedures shall be performed in an outpatient setting
unless the inpatient care was medically necessary and outpatient surgery could
not be safely performed, the surgical procedure was performed with other
surgical procedures requiring inpatient admission or adequate outpatient
facilities were not available.

D. Acceptance of payment for services by a provider under this Program shall
constitute payment in full.

HISTORY: 1989, cc. 657, 746; 1996, cc. 782, 792.