§ 32.1-346. Director to establish standards; reimbursement of services.
A. The Director shall prescribe regulations setting forth the amount,duration and scope of medical services covered by the Program which shall beuniform in all localities. Such services shall consist only of inpatient andoutpatient hospital services, services rendered in free-standing ambulatorysurgical centers and local public health clinics by providers who have signedagreements to participate in the State/Local Hospitalization Program and areenrolled providers in the Medical Assistance Program. Services covered underthe Program shall not exceed in amount, duration or scope those available torecipients of Medical Assistance Services as provided in the State Plan forMedical Assistance pursuant to Chapter 10 (§ 32.1-323 et seq.) of this title.Subject to the above, the Board may modify such coverage so long asuniformity of coverage is maintained throughout the Commonwealth.
B. Reimbursement for services under this Program shall be equal to that ofthe Medical Assistance Program pursuant to Chapter 10 of this title asfollows:
1. The reimbursement rate per visit for outpatient hospital services shall bethe same as that established by the Department of Medical Assistance Servicesfor an intermediate office visit for an established patient;
2. The inpatient hospital reimbursement rate shall be consistent with theMedicaid inpatient rate methodology. However, no disproportionate share ormedical education adjustment for SLH inpatient hospital reimbursement shallbe provided;
3. Inpatient hospital stays for adults shall be limited to twenty-one days ofcovered hospitalization within sixty days for the same or similar diagnosis.The sixty day period shall begin with the initial hospital admission. Onlytwenty-one total medically necessary days shall be covered whether incurredfor one or more hospital stays, in the same or multiple hospitals, during thesixty day period. Inpatient hospital admissions on Friday and Saturday shallnot be covered except in cases of medical emergencies. Reimbursement ofinpatient hospital days on behalf of individuals up to the age of twenty-oneshall be for medically necessary stays in excess of twenty-one days asprovided in the State Plan for Medical Assistance Services;
4. The hospital emergency room reimbursement rate per visit shall be the sameas that rate established by the Department of Medical Assistance Services foran intermediate level, established patient emergency department visit; and
5. The outpatient surgical rate for hospitals and ambulatory surgical centersshall be the same as the rates established by the Department of MedicalAssistance Services for the facility component for ambulatory surgicalcenters.
C. Procedures identified by the Department of Medical Assistance Services asoutpatient surgical procedures shall be performed in an outpatient settingunless the inpatient care was medically necessary and outpatient surgerycould not be safely performed, the surgical procedure was performed withother surgical procedures requiring inpatient admission or adequateoutpatient facilities were not available.
D. Acceptance of payment for services by a provider under this Program shallconstitute payment in full.
§ 32.1-346. Director to establish standards; reimbursement of services.
A. The Director shall prescribe regulations setting forth the amount,duration and scope of medical services covered by the Program which shall beuniform in all localities. Such services shall consist only of inpatient andoutpatient hospital services, services rendered in free-standing ambulatorysurgical centers and local public health clinics by providers who have signedagreements to participate in the State/Local Hospitalization Program and areenrolled providers in the Medical Assistance Program. Services covered underthe Program shall not exceed in amount, duration or scope those available torecipients of Medical Assistance Services as provided in the State Plan forMedical Assistance pursuant to Chapter 10 (§ 32.1-323 et seq.) of this title.Subject to the above, the Board may modify such coverage so long asuniformity of coverage is maintained throughout the Commonwealth.
B. Reimbursement for services under this Program shall be equal to that ofthe Medical Assistance Program pursuant to Chapter 10 of this title asfollows:
1. The reimbursement rate per visit for outpatient hospital services shall bethe same as that established by the Department of Medical Assistance Servicesfor an intermediate office visit for an established patient;
2. The inpatient hospital reimbursement rate shall be consistent with theMedicaid inpatient rate methodology. However, no disproportionate share ormedical education adjustment for SLH inpatient hospital reimbursement shallbe provided;
3. Inpatient hospital stays for adults shall be limited to twenty-one days ofcovered hospitalization within sixty days for the same or similar diagnosis.The sixty day period shall begin with the initial hospital admission. Onlytwenty-one total medically necessary days shall be covered whether incurredfor one or more hospital stays, in the same or multiple hospitals, during thesixty day period. Inpatient hospital admissions on Friday and Saturday shallnot be covered except in cases of medical emergencies. Reimbursement ofinpatient hospital days on behalf of individuals up to the age of twenty-oneshall be for medically necessary stays in excess of twenty-one days asprovided in the State Plan for Medical Assistance Services;
4. The hospital emergency room reimbursement rate per visit shall be the sameas that rate established by the Department of Medical Assistance Services foran intermediate level, established patient emergency department visit; and
5. The outpatient surgical rate for hospitals and ambulatory surgical centersshall be the same as the rates established by the Department of MedicalAssistance Services for the facility component for ambulatory surgicalcenters.
C. Procedures identified by the Department of Medical Assistance Services asoutpatient surgical procedures shall be performed in an outpatient settingunless the inpatient care was medically necessary and outpatient surgerycould not be safely performed, the surgical procedure was performed withother surgical procedures requiring inpatient admission or adequateoutpatient facilities were not available.
D. Acceptance of payment for services by a provider under this Program shallconstitute payment in full.
§ 32.1-346. Director to establish standards; reimbursement of services.
A. The Director shall prescribe regulations setting forth the amount,duration and scope of medical services covered by the Program which shall beuniform in all localities. Such services shall consist only of inpatient andoutpatient hospital services, services rendered in free-standing ambulatorysurgical centers and local public health clinics by providers who have signedagreements to participate in the State/Local Hospitalization Program and areenrolled providers in the Medical Assistance Program. Services covered underthe Program shall not exceed in amount, duration or scope those available torecipients of Medical Assistance Services as provided in the State Plan forMedical Assistance pursuant to Chapter 10 (§ 32.1-323 et seq.) of this title.Subject to the above, the Board may modify such coverage so long asuniformity of coverage is maintained throughout the Commonwealth.
B. Reimbursement for services under this Program shall be equal to that ofthe Medical Assistance Program pursuant to Chapter 10 of this title asfollows:
1. The reimbursement rate per visit for outpatient hospital services shall bethe same as that established by the Department of Medical Assistance Servicesfor an intermediate office visit for an established patient;
2. The inpatient hospital reimbursement rate shall be consistent with theMedicaid inpatient rate methodology. However, no disproportionate share ormedical education adjustment for SLH inpatient hospital reimbursement shallbe provided;
3. Inpatient hospital stays for adults shall be limited to twenty-one days ofcovered hospitalization within sixty days for the same or similar diagnosis.The sixty day period shall begin with the initial hospital admission. Onlytwenty-one total medically necessary days shall be covered whether incurredfor one or more hospital stays, in the same or multiple hospitals, during thesixty day period. Inpatient hospital admissions on Friday and Saturday shallnot be covered except in cases of medical emergencies. Reimbursement ofinpatient hospital days on behalf of individuals up to the age of twenty-oneshall be for medically necessary stays in excess of twenty-one days asprovided in the State Plan for Medical Assistance Services;
4. The hospital emergency room reimbursement rate per visit shall be the sameas that rate established by the Department of Medical Assistance Services foran intermediate level, established patient emergency department visit; and
5. The outpatient surgical rate for hospitals and ambulatory surgical centersshall be the same as the rates established by the Department of MedicalAssistance Services for the facility component for ambulatory surgicalcenters.
C. Procedures identified by the Department of Medical Assistance Services asoutpatient surgical procedures shall be performed in an outpatient settingunless the inpatient care was medically necessary and outpatient surgerycould not be safely performed, the surgical procedure was performed withother surgical procedures requiring inpatient admission or adequateoutpatient facilities were not available.
D. Acceptance of payment for services by a provider under this Program shallconstitute payment in full.
