Section 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.

Historical Notes

Derived from Volume 18, Issue 17, eff. June 6, 2002; amended, Virginia Register Volume 22, Issue 25, eff. November 6, 2006.

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.