State Funding of Certain Abortions

The Virginia Department of Health is authorized to use state funding to fund certain abortions as described by state law:

  • 32.1-92.1. Funding of certain abortions where pregnancy results from rape or incest.
  • 32.1-92.2. Funding of certain abortions where fetus is believed to have incapacitating physical deformity or mental deficiency; physician’s certificate.

In summary, VDH may use state funding for patients with Medicaid when they have 1) experienced rape or incest and have followed reporting requirements outlined by law, or 2) have a fetus with a documented incapacitating abnormality.

The Hyde Amendment, first implemented in 1977, is a federal legislative provision which forbids the use of federal funds for abortions except in cases of life endangerment, rape or incest. This Amendment applies only to funds allocated by the annual federal appropriations bill for the U.S. Department of Health and Human Services and primarily affects Medicaid.  In Virginia, the Department of Medical Assistance Services administers the Medicaid program, which only covers abortions in cases where the pregnancy threatens the life or health of the mother.

Application Instructions

Application

Application Fax Cover Sheet

FAQs

Definitions

For further information, contact sfa@vdh.virginia.gov.

 

FAQs for Providers

What are the patient eligibility requirements?

The patient must be a Virginia resident, meet the financial eligibility criteria of the Virginia Department of Medical Assistance Services Plan (Medicaid), and meet one of the two criteria outlined in the Code of Virginia:

  • 32.1-92.1. Funding of certain abortions where pregnancy results from rape or incest.
  • 32.1-92.2. Funding of certain abortions where fetus is believed to have incapacitating physical deformity or mental deficiency; physician’s certificate.

What documentation is required to meet the Intent of the Law/have an application approved? 

  • An application form (SFA-12) completed by a Certifying Physician and submitted to the Virginia Department of Health at least 48 hours before the procedure.
  • Rape or incest cases must be reported to law enforcement or to a Virginia Department of Health local health district office in the locality where the patient resides.
  • Cases of gross and totally incapacitating physical deformity or mental deficiency of the fetus must be certified as such by a physician who has performed medically appropriate tests to support the assessment. VDH requires copies of cited evidence including but not limited to ultrasound, amniocentesis, or blood work.
  • In order to demonstrate proof of financial eligibility, the application must include a copy of the patient’s Medicaid card, a copy of the patient’s Medicaid HMO card, the patient’s Medicaid card number, OR documented verification from a certified Medicaid eligibility specialist that the patient’s income meets the Virginia Medicaid financial eligibility screening criteria.

*VDH reserves the right for additional information in order to determine eligibility for funding.

My application was denied approval, and I think it was a mistake. What are my options?  

An appeal may be submitted in writing to VDH within five business days.  The appeal must be in writing and should be faxed to (804) 864-7771 and clearly state the grounds upon which the applicant believes the request meets the criteria of Code of Virginia § 32.1-92.1 or § 32.1-92.2. The final decision will be made by VDH’s Chief Deputy of Public Health or his/her designee and communicated in writing and by phone to the applicant within two business days of appeal receipt.

How does my facility get reimbursed?

Reimbursements are made in accordance with the Virginia Public Procurement Act, including prompt payment provisions. Approval for funding must be received prior to the procedure in order for VDH to reimburse the facility—no retrospective requests will be considered.

 

To receive payment, the facility and physician performing the abortion must submit a CMS 1500 Health Insurance Claim Form to:

Reproductive Health Unit

Virginia Department of Health

109 Governor St.

9th Floor

Richmond, VA 23219

  1. Billing codes must reflect the approved procedures performed.
  2. Payment shall be limited to the Medicaid allowable rate for the procedure.
  3. Payment shall constitute full and final payment for such services.
  4. The Department reserves the right to refuse payment if the following occur:
  5. The invoice is over one year from the date of the procedure, or
  6. The procedure occurred in a non-licensed facility, or
  7. The procedure was performed by a non-licensed provider, or
  8. The procedure was not pre-approved.

 

What if my payment is denied?  Payment may be denied if it is determined that there was a violation of applicable state and federal laws and regulations.

What if the case isn’t rape, incest, or fetal anomaly (e.g. the mother’s life is endangered)?  For cases involving endangerment of the mother’s life, contact DMAS (Medicaid) for assistance. The Commonwealth of Virginia does not appropriate funds for abortion services unless they meet the requirements outlined by state law. See the Patient Eligibility Requirements listed above.

What if a patient meets the eligibility requirements for State Funding for Certain Abortions, but the procedure has already happened? Applications must be submitted at least 48 hours before the procedure in order to allow time for the application to be processed. Applications cannot be backdated to cover procedures that have already occurred.

Definitions

  • Certifying Physician : Physician, who holds a current license to practice medicine in the state of Virginia, that has conducted a physical examination and appropriate tests of the applicant and based on this examination is able to certify the gestational age of the fetus and the presence of a gross and totally incapacitating physical deformity or mental deficiency.
  • Incest: Incest as defined in the Code of Virginia 18.2-366 means a person who commits adultery or fornication with any person whom he or she is forbidden by law to marry.
  • Mandated reporters: Persons who, in their professional or official capacity, have reason to suspect that a child is an abused or neglected child, shall report the matter immediately to the local department of the county or city wherein the child resides or wherein the abuse or neglect is believed to have occurred or to the Department’s toll-free child abuse and neglect hotline (Code of Virginia 63.2-1509).
  • Patient Applicant: Patient requesting payment for abortion services under Code of Virginia 32.1-92.1; Code of Virginia § 32.1-92.2.
  • Providers of Abortion Services: A general hospital or other provider appropriately licensed in the state of Virginia that is providing abortion services for the Patient Applicant.
  • Rape: If any person has sexual intercourse with a complaining witness, whether or not his or her spouse, or causes a complaining witness, whether or not his or her spouse, to engage in sexual intercourse with any other person and such act is accomplished (i) against the complaining witness’s will, by force, threat or intimidation of or against the complaining witness or another person; or (ii) through the use of the complaining witness’s mental incapacity or physical helplessness; or (iii) with a child under age 13 as the victim, he or she shall be guilty of rape. (Code of Virginia 18.2-61).