reglab/statecodes huggingface dataset:
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-325.04. Eligibility for medical assistance; individuals confined in state correctional facilities

A. The Department shall coordinate with the Department of Corrections to identify persons in the custody of state correctional facilities who are currently enrolled in the Commonwealth's program of medical assistance or who may be eligible for services under the state plan for medical assistance upon release and shall, prior to the release of such persons, (i) review the eligibility of currently enrolled persons to ensure continued access to medical assistance upon release or (ii) enroll persons not previously enrolled who meet eligibility criteria in the Commonwealth's program of medical assistance services; however, no services under the state plan for medical assistance shall be furnished to any person while he is confined in a state correctional facility unless federal financial participation is available to pay for the cost of the services provided.
B. An individual who is enrolled in the Commonwealth's program of medical assistance services at the time of release from the custody of a state correctional facility shall be eligible for services upon release and shall continue to be eligible for services under the state plan for medical assistance until such time as the person is determined to no longer be eligible for medical assistance.
2022, c. 300.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-325.1:1. Definitions; recovery of overpayment for medical assistance services

A. For the purposes of this section, the following definitions shall apply:
"Agreement" means any contract executed for the delivery of services to recipients of medical assistance pursuant to subdivision D 2 of § 32.1-325.
"Successor in interest" means any person as defined in § 1-230 having stockholders, directors, officers, or partners in common with a health care provider for which an agreement has been terminated.
"Termination" means (i) the cessation of operations by a provider, (ii) the sale or transfer of the provider, (iii) the reorganization or restructuring of the health care provider, or (iv) the termination of an agreement by either party.
B. The Director of Medical Assistance Services shall collect by any means available to him at law any amount owed to the Commonwealth because of overpayment for medical assistance services. Upon making an initial determination that an overpayment has been made to the provider pursuant to § 32.1-325.1, the Director shall notify the provider of the amount of the overpayment. Such initial determination shall be made within the earlier of (i) four years, or (ii) 15 months after filing of the final cost report by the provider subsequent to sale of the facility or termination of the provider. The provider shall make arrangements satisfactory to the Director to repay the amount due. If the provider fails or refuses to make arrangements satisfactory to the Director for such repayment or fails or refuses to repay the Commonwealth for the amount due for overpayment in a timely manner, the Director may devise a schedule for reducing the Medicaid reimbursement due to any successor in interest.
C. In any case in which the Director is unable to recover the amount due for overpayment pursuant to subsection B, he shall not enter into another agreement with the responsible provider or any person who is the transferee, assignee, or successor in interest to such provider unless (i) he receives satisfactory assurances of repayment of all amounts due or (ii) the agreement with the provider is necessary in order to ensure that Medicaid recipients have access to the covered services rendered by the provider.
Further, to the extent consistent with federal and state law, the Director shall not enter into any agreement with a provider having any stockholder possessing a material financial interest, partner, director, officer, or owner in common with a provider which has terminated a previous agreement for participation in the medical assistance services program without making satisfactory arrangements to repay all outstanding Medicaid overpayment.
D. The provisions of this section shall not apply to successors in interest with respect to transfer of a medical care facility pursuant to contracts entered into before February 1, 1990.
1990, c. 389; 1994, c. 669; 1999, c. 1024; 2005, c. 839.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-325.2. Department is payor of last resort

A. Insurers, including group health plans as defined in § 607(1) of the Employee Retirement Income Security Act of 1974, self-insured plans, health services plans, service benefit plans, health maintenance organizations, managed care organizations, pharmacy benefits managers, or other parties that are, by statute, contract, or agreement legally responsible for payment of a claim for a health care item or service, are prohibited from including any clause in health care contracts which would exclude enrolling an individual or in making any payment for benefits to the individual or on the individual's behalf for health care when the individual is eligible for medical assistance.
B. The Department of Medical Assistance Services shall be the payor of last resort to any insurer, including a group health plan as defined in § 607(1) of the Employee Retirement Income Security Act of 1974, a self-insured plan, a health services plan, a service benefit plan, a health maintenance organization, a managed care organization, a pharmacy benefits manager, or other party that is, by statute, contract, or agreement legally responsible for payment of a claim for a health care item or service for persons eligible for medical assistance in the Commonwealth. The above entities, as a condition of doing business in the Commonwealth, shall comply with the requirements set forth in 42 U.S.C. 1396a (a) (25) (I) (i)-(iv).
C. To the extent the Department of Medical Assistance Services has made payment for medical services where a third party has a legal obligation to make payment for such services, the Commonwealth shall automatically acquire all rights to such payment from the third party.
D. To the extent the Department of Medical Assistance Services is permitted by law to obtain recoveries from third parties, actions at law for such recoveries shall be decided under the same laws, rules and standards including applicable bases of liability and defenses as would apply if the individual receiving the services had brought the action directly; provided that nothing herein shall affect the sovereign immunity of the Commonwealth.
E. The term "insurer" as used herein shall be deemed to include without limitation "insurance carriers."
1986, c. 550; 1994, c. 213; 1996, c. 851; 2007, c. 535.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-325.3. Disclosure or use of information for purpose not connected with medical assistance program; Department not subject to certain disclosure

A. The Board of Medical Assistance Services shall promulgate regulations consistent with federal law to provide safeguards against the use or disclosure of information, including information provided to a managed care organization pursuant to § 32.1-330.5, concerning applicants for and recipients of medical assistance services for any purpose that is not directly connected with the administration of the state plan for medical assistance services.
B. Information in the possession or control of the Department or a managed care organization pursuant to § 32.1-330.5 concerning applicants for and recipients of medical assistance services shall not be subject to disclosure through discovery in litigation to which the Department is not a necessary party, unless the appropriate circuit court, for good cause shown, shall order such disclosure.
1989, c. 67; 1992, c. 107; 2018, c. 382.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-325.4. Penalty for violation

Any person who willfully violates or refuses, fails, or neglects to comply with any regulation or order of the Board or the Director promulgated pursuant to § 32.1-325.3 shall be guilty of a Class 1 misdemeanor.
1989, c. 67.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-326. Director may make payments to or for eligible persons in state-owned medical facilities

The Director of Medical Assistance Services is authorized, subject to the state plan provided for in § 32.1-325 and any other regulations of the Board, to make payments to or on behalf of eligible persons in state-owned mental hospitals, nursing or geriatric units or other state-owned medical facilities.
1984, c. 781.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-326.1. Department to operate program of estate recovery

In accordance with applicable federal law and regulations, including those under Title XIX of the Social Security Act, the Department shall operate a program of estate recovery for all persons who receive payments or on whose behalf payments are made for Medicaid-financed nursing facility care by the Department. The amount recovered from the estate of a deceased recipient shall not exceed the amount of total Medicaid payments made on behalf of such recipient.
1993, cc. 193, 700.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-326.2. Pilot school/community health centers

The Department of Medical Assistance Services, in cooperation with the Department of Education, shall, consistent with the biennium budget cycle, examine and may revise the funding and components of the pilot school/community health centers. Any revisions shall be designed to maximize access to health care for poor children, and to improve the funding by making use of every possible, cost-effective means, Medicaid reimbursement or program. Any revisions shall be focused on prevention of large costs for acute or medical care and may include, but not be limited to:
1. Funding sources and means of distribution for the state match which will clearly demonstrate that local governments are not funding the state match for these centers.
2. The benefits and drawbacks of allowing school divisions to provide services to disabled students as Medicaid providers.
3. The appropriate credentials of the providers of care in the school health centers, e.g., licensure by the Board of Education and compliance with federal requirements or licensure by a regulatory board within the Department of Health Professions.
4. Utilization of the individualized education plan, when signed by a physician, as the plan of care authorizing services.
5. Delivery of medically necessary services, such as rehabilitation services, psychiatric and psychological evaluations and therapy, transportation, and nursing.
6. Payment for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services, with proper medical oversight, in consultation with the students' primary care physicians.
7. The role of the Medallion and Options programs in regard to the school health centers and flexibility for school divisions regarding any required referrals.
Any funds necessary to support revisions to the school/community health center projects shall be included in the budget estimates for the departments, as appropriate.
1996, c. 864.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-327. Claim against indigent's estate for payments made

In accordance with applicable federal law and regulations, including those under Title XIX of the Social Security amendments of 1965, the Department may make claim against the estate of an indigent or medically indigent person for the amount of any medical assistance payments made on his behalf by the Department. The Department may waive its claim if it determines that enforcement of the claim would result in substantial hardship to the heirs or dependents of the individual against whose estate the claim exists.
1984, c. 781.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-330.1. Department to implement premium assistance program for HIV-positive individuals

The Board of Medical Assistance Services shall from funds eligible for this purpose from Title II of the Ryan White Comprehensive AIDS Resources Emergency CARE Act (42 U.S.C. § 300ff-21 et seq.) or other funds appropriated or made available for this purpose, implement, and may promulgate any necessary regulations for implementation of, a premium assistance program for HIV-positive individuals which shall have, at minimum, the following characteristics:
1. Payment of health insurance premiums for individuals who are not eligible for Medicaid and who can document (i) HIV infection and inability to continue working for medical reasons and (ii) eligibility to continue their employer's group policy pursuant to the Consolidated Omnibus Budget Reconciliation Act of 1985;
2. Financial eligibility criteria allowing a maximum income of no more than 250 percent of the federal poverty guidelines and countable liquid assets of no more than $10,000 in value;
3. Funds eligible under Title II of the Ryan White CARE Act shall not be used toward copayments and deductible payments; and
4. Coverage of family members, if the HIV-infected person's policy is the sole source of health insurance.
1994, c. 200; 1996, c. 195; 2000, c. 870.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-330.2. Medicaid managed care programs; program information documents; plain language required

A. As used in this section, "program information" means all forms of communication that (i) are provided to any person who is an applicant for or a recipient of medical assistance services provided by the Commonwealth pursuant to Titles XIX and XXI of the Social Security Act and (ii) describe eligibility requirements, available medical assistance services, and the rights and responsibilities of recipients of medical assistance services provided by the Commonwealth pursuant to Titles XIX and XXI of the Social Security Act.
B. The Board of Medical Assistance Services shall require that all program information be (i) communicated in nontechnical, readily understandable, plain language and (ii) made available in a manner that is timely and accessible to (a) individuals with limited English proficiency through the provision of language access services, including oral interpretation and written translations, and (b) individuals with disabilities through the provision of auxiliary aids services, when doing so is a reasonable step to providing meaningful access to health care coverage. A person that makes program information available may consider resources, including staffing, available to such person and the cost of responding to requests for language access or auxiliary aids services in determining the reasonableness of making program information available pursuant to this subsection.
C. Language access services and auxiliary aids services provided to ensure program information is accessible to individuals with limited English proficiency and individuals with disabilities shall be provided without charge to such individuals. Information regarding how to receive language access services and auxiliary aids services shall be included with program information documents on a website maintained by the Department and on the website of every state or local government agency or state agency contractor that provides program information.
D. Every person that provides program information shall use an objective readability measure approved by the Department to test the readability of its program information documents. The requirements of this subsection shall not apply to language that is mandated by federal or state laws, regulations, or agencies.
E. All program information documents within the scope of this section, and all amendments thereto, shall be made available for review upon the request of the Department. Any program information document that is exempt from the requirements of subsection B shall be accompanied by a documentation of the federal or state law, regulation, or agency mandate that authorizes the exemption.
1996, c. 318; 2022, c. 775.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-330.4. Uniform assessment instrument for PACE plans

Every individual who requests a screening for the purpose of enrollment in a PACE plan, as defined in § 32.1-330.3, shall be eligible for such screening, regardless of whether the individual is eligible under the state plan for medical assistance.
2014, c. 413.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-330.5. Reports related to eligibility renewal

The Department of Medical Assistance Services shall provide a quarterly report to each managed care organization that is contracted with the Department to provide services through the Medicaid managed care program that specifies the medical assistance application renewal date for each recipient of medical assistance services who has been attributed to the managed care organization.
2018, c. 382.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-331.01. Health Care Coverage Assessment Fund

A. As used in this section:
"Covered hospital" means any in-state private acute care hospital other than a hospital classified as a public hospital, freestanding psychiatric and rehabilitation hospital, children's hospital, long stay hospital, long-term care hospital, or critical access hospital.
"Newly eligible adult" means an individual described in 42 U.S.C. § 1396a(a)(10)(A)(i)(VIII).
"State Plan" means the state plan for medical assistance under Title XIX (42 U.S.C. § 1396 et seq.) of the Social Security Act.
B. There is hereby created in the state treasury a special nonreverting fund to be known as the Health Care Coverage Assessment Fund, referred to in this section as "the Fund." The Fund shall be established on the books of the Comptroller. All revenues collected or received as a result of imposition of a health care coverage assessment on covered hospitals and any other such moneys, public or private, received for the administration of the health care coverage assessment shall be paid into the state treasury and credited to the Fund. Interest earned on moneys in the Fund shall remain in the Fund and be credited to it. Any moneys remaining in the Fund, including interest thereon, at the end of each fiscal year shall not revert to the general fund but shall remain in the Fund. Moneys deposited to the Fund shall be used solely for the nonfederal share of the cost of medical assistance for newly eligible adults, the administrative costs of collecting the assessment and implementing and operating the coverage for newly eligible adults. Such moneys shall be appropriated as provided in the general appropriation act. Expenditures and disbursements from the Fund shall be made by the State Treasurer on warrants issued by the Comptroller upon written request signed by the Director of the Department of Medical Assistance Services.
2018, Sp. Sess. I, c. 2.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-331.02. Health Care Provider Payment Rate Assessment Fund

A. As used in this section:
"Covered hospital" means any in-state private acute care hospital other than a hospital classified as a public hospital, freestanding psychiatric and rehabilitation hospital, children's hospital, long stay hospital, long-term care hospital, or critical access hospital.
"Managed care organization hospital payment gap" means the difference between the amount included in rates for inpatient and outpatient services provided by covered hospitals, based on historical paid claims, and the amount that would be included when hospital services are priced according to the existing State Plan methodology but using 100 percent of the adjustment factors, including the capital reimbursement percentage, and full inflation subject to approval by the Centers for Medicare and Medicaid Services pursuant to 42 C.F.R. § 438.6(c).
"State Plan" means the state plan for medical assistance under Title XIX (42 U.S.C. § 1396 et seq.) of the Social Security Act.
"Upper payment limit" means the amount equal to the maximum amount of payment for inpatient services for recipients of medical assistance services established in accordance with 42 C.F.R § 447.272 and outpatient services for recipients of medical assistance services pursuant to 42 CFR § 447.321.
B. There is hereby created in the state treasury a special nonreverting fund to be known as the Health Care Payment Rate Assessment Fund, referred to in this section as "the Fund." The Fund shall be established on the books of the Comptroller. All revenues collected or received as a result of imposition of a health care payment rate assessment on covered hospitals and any other such moneys, public or private, received for the administration of the health care payment assessment shall be paid into the state treasury and credited to the Fund. Interest earned on moneys in the Fund shall remain in the Fund and be credited to it. Any moneys remaining in the Fund, including interest thereon, at the end of each fiscal year shall not revert to the general fund but shall remain in the Fund. Moneys deposited to the Fund shall be used solely for the nonfederal share of the cost of payment rate actions associated with the payment rate assessment as provided in the general appropriation act and the administrative costs of collecting the assessment and of implementing and operating the associated payment rate actions. Such moneys shall be appropriated as provided in the general appropriation act. Expenditures and disbursements from the Fund shall be made by the State Treasurer on warrants issued by the Comptroller upon written request signed by the Director of the Department of Medical Assistance Services.
2018, Sp. Sess. I, c. 2.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-331.03. Process for payment directly to nursing facility or ICF/MR

The Department of Medical Assistance Services shall, to the extent permitted by federal law, implement a process for payment of the nursing facility or ICF/MR share of payments directly to the nursing facility or ICF/MR rather than to the hospice care provider for hospice services furnished to an individual who is a resident of a nursing facility or ICF/MR and who would be eligible under the Commonwealth's program of medical assistance for nursing facility services or services in an ICF/MR had he not elected hospice care. Payments made directly to a nursing facility or ICF/MR shall be the full amount that would be paid to the nursing facility or ICF/MR if the individual was not receiving hospice services, and shall not reflect any discount to such rates.
2019, c. 209.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-331.04. Personal care aides; orientation program

A. The Department of Medical Assistance Services shall establish an orientation program for all personal care aides who provide self-directed services through the Medicaid program. The program shall have the following requirements:
1. Attendance shall be limited to personal care aides, consumers who utilize the services of personal care aides, home care workers' employers of record, and worker advocacy organizations that represent personal care aides;
2. Orientations shall be held in-person or online at least quarterly, and personal care aides shall be invited and encouraged to attend at least one such orientation per calendar year; and
3. The orientation curriculum shall include content addressing operational procedures and recordkeeping, including pay and benefits; available assistance and resources; roles and responsibilities in self-direction; diversity and equity training; transparency and fraud; and worker rights and responsibilities.
B. The Department of Medical Assistance Services may, in its discretion, contract with another state agency to provide the orientation described in this section.
2021, Sp. Sess. I, c. 236.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-331.05. Coordinated specialty care; work group

A. The Department shall establish a work group in coordination with the Department of Behavioral Health and Developmental Services to evaluate and make recommendations to improve approaches to early psychosis and mood disorder detection approaches, make program funding recommendations, and recommend a core set of standardized clinical and outcome measures. Early psychosis intervention includes services to youth and young adults who are determined to either be at a clinical high risk for psychosis or are experiencing a first episode of psychosis.
B. The work group shall include (i) a representative from the Bureau of Insurance; (ii) a representative from the Department of Health Professions; (iii) a representative from the Department of Behavioral Health and Developmental Services; (iv) a psychiatrist with working knowledge of first-episode psychosis and coordinated specialty care; (v) a mental health clinician with working knowledge of first-episode psychosis and coordinated specialty care; (vi) a support services specialist with experience in supported education and employment; (vii) a representative of a state, regional, or local mental health advocacy group as recommended by such group; (viii) an individual who has experienced psychosis or a family member of an individual who has experienced psychosis; and (ix) up to three representatives of health insurance issuers or managed care organizations operating in the Commonwealth as recommended by such issuers or organizations.
C. The work group shall develop a five-year strategic plan to accomplish the following objectives:
1. Enhance services to existing coordinated specialty care programs;
2. Expand early psychosis intervention in underserved areas of the Commonwealth;
3. Develop a strategy to identify and apply for funds from individual foundations and federal and state sources and disburse those funds; and
4. Develop a strategy to advance the goals and utilization of coordinated specialty care for Medicaid beneficiaries and individuals who are privately insured.
The strategic plan shall identify current coordinated specialty care programs in the Commonwealth and include information on how they are funded, how many individuals use the current programs, and the insurance status of the programs. As used in this section, "coordinated specialty care" means a team-based service provided to a person for treatment of first-episode psychosis that is composed of case management, family support and education, pharmacotherapy and medication management, individual and group psychotherapy, supported education and employment, coordination with primary care, and outreach and recruitment activities.
D. The work group shall meet to produce an initial five-year plan report to the General Assembly no later than November 1, 2022, and then provide annual updates to the five-year strategic plan beginning November 1, 2023.
2022, c. 621.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-331.12. Definitions

As used in this article:
"Board" means the Board of Medical Assistance Services.
"Committee" means the Medicaid Prior Authorization Advisory Committee established pursuant to this article.
"Department" means the Department of Medical Assistance Services.
"Director" means the Director of Medical Assistance Services.
"Drug" shall have the same meaning, unless the context otherwise dictates or the Board otherwise provides by regulation, as provided in the Drug Control Act (§ 54.1-3400 et seq.).
1993, c. 537.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-331.13. Medicaid Prior Authorization Advisory Committee; membership

The Board shall amend the state plan and promulgate regulations to establish the Medicaid Prior Authorization Advisory Committee, composed of 11 members to be appointed by the Board. Five members shall be physicians, at least three of whom shall care for a significant number of Medicaid patients; four shall be pharmacists, two of whom shall be community pharmacists; one member shall be an individual receiving mental health services; and one member shall be a Medicaid recipient. A quorum for action of the Committee shall consist of six members. The members shall serve at the pleasure of the Board, and vacancies shall be filled in the same manner as the original appointment. The Board shall consider nominations made by The Medical Society of Virginia, the Old Dominion Medical Society, the Psychiatric Society of Virginia, the Virginia Pharmaceutical Association, the National Alliance on Mental Illness of Virginia and the Virginia Mental Health Consumers Association when making appointments to the Committee.
The Committee shall elect its own officers, establish its own procedural rules, and meet as needed or as called by the Board, the Director, or any two members of the Committee. The Department shall provide appropriate staffing to the Committee.
1993, c. 537; 1996, c. 515; 2012, cc. 476, 507.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-331.14. Duties of the Committee

A. The Committee shall make recommendations to the Board regarding drugs or categories of drugs to be subject to prior authorization and prior authorization requirements for prescription drug coverage under the state plan, as well as any subsequent amendments to or revisions of such prior authorization requirements from time to time. The Board may accept or reject such recommendations in whole or in part, and may amend or add to such recommendations, except that the Board may not add to the recommendation of drugs and categories of drugs to be subject to prior authorization.
B. In formulating its recommendations to the Board, the Committee shall not be deemed to be formulating regulations for the purposes of the Administrative Process Act (§ 2.2-4000 et seq.). The Committee shall, however, conduct public hearings prior to making such recommendations to the Board. The Committee shall give thirty days' written notice by mail of the time and place of its hearings and meetings to any manufacturer whose product is being reviewed by the Committee and to those manufacturers who request the Committee in writing that they be informed of such hearings and meetings. Such persons shall be afforded a reasonable opportunity to be heard and present information. In addition, the Committee shall give thirty days' notice of such public hearings to the public by publishing its intention to conduct hearings and meetings in the Calendar of Events of the Virginia Register of Regulations and a newspaper of general circulation located in Richmond.
C. In acting on the recommendations of the Committee, the Board shall be required to conduct further proceedings under the Administrative Process Act.
1993, c. 537.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-331.15. Prior authorization of prescription drug products; coverage under state plan

A. The Committee shall review prescription drug products to recommend prior authorization under the state plan in accordance with this article and regulations promulgated by the Board. Such review may be initiated by the Director, the Committee itself, or by written request of the Board. The Committee shall complete its recommendations to the Board within no more than six months from receipt of any such request.
B. Coverage under the state plan for any drug requiring prior authorization shall not be approved unless the prescriber obtains prior approval of such use in accordance with regulations promulgated by the Board and procedures established by the Department.
In formulating its recommendations to the Board, the Committee shall consider the potential impact on patient care and the potential fiscal impact of prior authorization on pharmacy, prescriber, hospitalization and outpatient costs. Any proposed regulation making a drug or category of drugs subject to prior authorization shall be accompanied by a statement of the estimated impact of such action on pharmacy, prescriber, hospitalization and outpatient costs.
C. The Committee shall not review any drug for which it has recommended or the Board has required prior authorization within the previous 12 months, unless new or previously unavailable relevant and objective information is presented.
D. Confidential proprietary information identified as such by a manufacturer or supplier in writing in advance and furnished to the Committee or the Board pursuant to this article shall not be subject to the disclosure requirements of the Virginia Freedom of Information Act (§ 2.2-3700 et seq.). The Board shall establish by regulation the means by which such confidential proprietary information shall be protected.
1993, c. 537; 2004, c. 855.
2023 Code of Virginia › Title 32.1 - Health › Chapter 10 - Department of Medical Assistance Services › § 32.1-331.16. Immunity

The members of the Committee and of the Board, as well as the staff of the Department, shall be immune, individually and jointly, from civil liability for any act, decision, or omission done or made in performance of their duties pursuant to this article while serving as a member of such Board, Committee, or staff provided that such act, decision, or omission is not done or made in bad faith or with malicious intent.
1993, c. 537.
2023 Code of Virginia › Title 32.1 - Health › Chapter 12 - State/Local Hospitalization Program › § 32.1-343. Definitions

As used in this chapter unless the context requires a different meaning:
"Board" means the Board of Medical Assistance Services.
"Director" means the Director of the Department of Medical Assistance Services.
"Indigent person" means a person who is a bona fide resident of the county or city, whether gainfully employed or not and who, either by himself or by those upon whom he is dependent, is unable to pay for required hospitalization or treatment. Residence shall not be established for the purpose of obtaining the benefits of this chapter. Migrant workers and aliens living in the United States illegally shall not be considered bona fide residents of the county or city for purposes of the State/Local Hospitalization Program.
1989, cc. 657, 746.
2023 Code of Virginia › Title 32.1 - Health › Chapter 12 - State/Local Hospitalization Program › § 32.1-344. State/Local Hospitalization Program

There is hereby established within the Department of Medical Assistance Services the State/Local Hospitalization Program for indigent persons. With such funds as are appropriated for this purpose, the Director of the Department of Medical Assistance Services is authorized to administer this program and to expend state and local funds in accordance with the provisions of this chapter.
1989, cc. 657, 746.
2023 Code of Virginia › Title 32.1 - Health › Chapter 12 - State/Local Hospitalization Program › § 32.1-345. Counties and cities required to participate; allocation and payment of funds to and payments by counties and cities

A. The governing body of each city and county in the Commonwealth shall participate in the State/Local Hospitalization Program for indigent persons established in this chapter.
B. The Director shall allocate annually to the counties and cities of the Commonwealth such funds as may be appropriated by the General Assembly for this program. The allocation of state funds shall be based on the estimated total cost of required services in each county and city less the funds which shall be provided by the counties and cities.
C. Each county and city shall provide funds for a share of the estimated total costs as determined by the Director. The share for each county and city shall be calculated by dividing its per capita revenue capacity by the statewide total per capita revenue capacity, as determined by the Commission on Local Government, and by multiplying the resulting ratio by an aggregate local share of twenty-five percent. Each local share shall be adjusted according to local income, as determined by dividing the median adjusted gross income for all state income tax returns in each county and city by the median adjusted gross income for all income tax returns statewide. However, no county or city shall contribute more than twenty-five percent to the total cost for providing required hospitalization and treatment for indigent persons. The Director of Medical Assistance Services shall report each year by December 1 to the Senate Committees on Education and Health and on Finance and Appropriations and the House Committees on Health, Welfare and Institutions and Appropriations on the estimates of the costs of the program, based on trend analyses of the estimated costs of the actual local per capita demand.
D. Upon allocation of funds appropriated pursuant to subsection B of this section, each city and county shall remit within thirty days to the Department the amount determined to be the local share pursuant to subsection C of this section.
1989, cc. 657, 746; 1996, cc. 782, 792.
2023 Code of Virginia › Title 32.1 - Health › Chapter 12 - State/Local Hospitalization Program › § 32.1-349. Liability for excess payments

Any person who obtains benefits under this program to which he is not entitled shall be liable for any excess benefits received. If the recipient knew or reasonably should have known that he was not entitled to the excess benefits, he may also be liable for interest on the amount of the excess benefits at the judgment rate as defined in § 6.2-302 from the date upon which he knew or reasonably should have known that he had received excess benefits to the date on which repayment is made to the Commonwealth. No person shall be liable for payment of interest, however, when excess benefits were obtained as a result of errors made solely by the Department of Medical Assistance Services or any local welfare or social services agency.
Any payment erroneously made on behalf of a recipient or former recipient of this program may be recovered by the Department of Medical Assistance Services from the recipient or the recipient's income, assets or estate unless such property is otherwise exempted by state or federal law or regulation.
Any person who, on behalf of himself or another, obtains or attempts to obtain the benefits of this program by means of (i) willful false statement, (ii) willful misrepresentation or concealment of a material fact, or (iii) any other fraudulent scheme or device shall be liable for repayment of any excess benefits received, plus interest on the amount of the excess benefits at the rate of 1.5 percent per month for the period from the date upon which payment was made for such benefits to the date on which repayment is made to the Commonwealth.
All civil penalties collected pursuant to this section shall be deposited with the Comptroller for the State/Local Hospitalization Program in the same manner as the state and local shares.
1989, cc. 657, 746.
2023 Code of Virginia › Title 32.1 - Health › Chapter 12 - State/Local Hospitalization Program › § 32.1-350. Fraudulently obtaining benefits; criminal penalty

A. Any person who engages in the following activities, on behalf of himself or another, shall be guilty of a Class 1 misdemeanor in addition to any other penalties provided by law:
1. Knowingly and willfully making or causing to be made any false statement or misrepresentation of a material fact in an application for eligibility under this program or in order to participate in or receive reimbursement from the program;
2. Knowingly and willfully concealing or failing to disclose any event affecting the initial or continued right of any individual to any benefits with an intent to secure fraudulently such benefits in a greater amount or quantity than is authorized or when no such benefit is authorized;
3. Knowingly and willfully failing to notify the local department of social services, through whom the benefits of this program were obtained, of changes in the circumstances of any recipient or applicant which could result in reduction or termination of the benefits;
4. Knowingly and willfully failing to provide any reports or data to the Department as required in this chapter.
B. Conviction of any provider or any employee or officer of such provider of any offense under this section shall also result in forfeiture of any payments due.
1989, cc. 657, 746; 2002, c. 747.
2023 Code of Virginia › Title 32.1 - Health › Chapter 13 - Family Access to Medical Insurance Security Plan › § 32.1-351.1. Assistance with employer-sponsored health insurance

A. For purposes of this chapter, "employer-sponsored health insurance" or "ESHI" means comprehensive health insurance offered by the employer when the employer contributes to the cost of dependent or family coverage as defined in the Virginia Plan for Title XXI of the Social Security Act, or as otherwise approved by the Centers for Medicare & Medicaid Services in the U.S. Department of Health and Human Services.
B. For purposes of this chapter, ESHI shall be deemed cost-effective when the payment by the Department of Medical Assistance Services for health insurance coverage of the enrollee or enrollees under the Family Access to Medical Insurance Security Plan shall be no greater than what would have otherwise been paid by the Department or its designee for the enrollee or enrollees.
C. If a family chooses to participate in ESHI and ESHI is deemed cost-effective, the Department of Medical Assistance Services shall contribute to the cost of ESHI for eligible dependent children for those program participants that have access to ESHI. Participants receiving ESHI under the Family Access to Medical Insurance Security Plan shall apply for the full premium contribution available from the employer. Those eligible for Family Access to Medical Insurance Security Plan with access to ESHI may enroll in their designated ESHI at the first available opportunity and shall be covered under the Family Access to Medical Insurance Security Plan until coverage under ESHI becomes available.
2000, cc. 824, 848; 2003, c. 513; 2009, c. 578.
2023 Code of Virginia › Title 32.1 - Health › Chapter 13 - Family Access to Medical Insurance Security Plan › § 32.1-351.2. Children's Health Insurance Program Advisory Committee; purpose; membership; etc.

The Department of Medical Assistance Services shall maintain a Children's Health Insurance Program Advisory Committee to assess the policies, operations, and outreach efforts for Family Access to Medical Insurance Security (FAMIS) and FAMIS Plus and to evaluate enrollment, utilization of services, and the health outcomes of children eligible for such programs. The Committee shall consist of no more than 20 members and shall include membership from appropriate entities, as follows: one representative of the Joint Commission on Health Care, the Department of Social Services, the Department of Health, the Department of Education, the Department of Behavioral Health and Developmental Services, the Virginia Health Care Foundation, various provider associations and children's advocacy groups; and other individuals with significant knowledge and interest in children's health insurance. The Committee may report on the current status of FAMIS and FAMIS Plus and make recommendations as deemed necessary to the Director of the Department of Medical Assistance Services and the Secretary of Health and Human Resources.
The Department of Medical Assistance Services shall enter into agreements with the Department of Education and the Department of Health to identify children who are eligible for free or reduced price school lunches or for services through the Women, Infants, and Children program (WIC) in order that the eligibility of such children for the Virginia Plan for Title XXI of the Social Security Act may be determined expeditiously.
2000, cc. 824, 848; 2002, c. 329; 2004, c. 301; 2009, cc. 813, 840.
2023 Code of Virginia › Title 32.1 - Health › Chapter 13 - Family Access to Medical Insurance Security Plan › § 32.1-352. Virginia Family Access to Medical Insurance Security Plan Trust Fund

A. There is hereby created in the state treasury a special nonreverting fund to be known as the Virginia Family Access to Medical Insurance Security Plan Trust Fund, hereinafter referred to as the "Fund." The Fund shall be established on the books of the Comptroller and shall be administered by the Director of the Department of Medical Assistance Services. The Fund shall consist of the premium differential, any and all employer contributions which may be solicited or received by the Department of Medical Assistance Services, grants, donations, gifts, and bequests, or any and all moneys designated for the Fund, from any source, public or private. As used in this section, "premium differential" means an amount equal to the difference between (i) 0.75 percent of the direct gross subscriber fee income derived from eligible contracts and (ii) the amount of license tax revenue generated pursuant to former subdivision A 4 of § 58.1-2501 with respect to eligible contracts. As used in this section, "eligible contract" means any subscription contract for any kind of plan classified and defined in § 38.2-4201 or 38.2-4501 issued other than to (i) an individual or (ii) a primary small group employer if income from the contract is subject to license tax at the rate of 2.25 percent pursuant to former subsection D of § 38.2-4229.1. The Department of Taxation shall annually, on or before June 30, calculate the premium differential for the immediately preceding taxable year and notify the Comptroller of the Commonwealth to transfer such amount to the Virginia Family Access to Medical Insurance Security Plan Trust Fund as established on the books of the Comptroller.
B. Any moneys remaining in the Fund, including interest thereon, at the end of each fiscal year shall not revert to the general fund but shall remain in the Fund. Moneys in the Fund shall be used solely to support the Virginia Family Access to Medical Insurance Security Plan in accordance with the requirements of Title XXI of the Social Security Act, as amended, the Commonwealth's plan for the State Children's Health Insurance Program (SCHIP), as established in Subtitle J of the federal Balanced Budget Act of 1997 (P. L. 105-33), and any conditions set forth in the appropriation act.
C. The Director of the Department of Medical Assistance Services shall report annually on December 1 to the Governor, the General Assembly, and the Joint Commission on Health Care on the status of the Fund, the number of children served by this program, the costs of such services, and any issues related to the Virginia Family Access to Medical Insurance Security Plan that may need to be addressed.
1997, c. 679; 1999, c. 1034; 2000, cc. 824, 848; 2011, c. 850; 2013, cc. 136, 210.
2023 Code of Virginia › Title 32.1 - Health › Chapter 13 - Family Access to Medical Insurance Security Plan › § 32.1-353. Rights and responsibilities

This chapter shall not be construed as creating any legally enforceable right or entitlement to benefits under the Family Access to Medical Insurance Security Plan under Title XXI of the Social Security Act, as amended, on the part of any person or any right or entitlement to participation. The Department of Medical Assistance Services shall enroll applicants into the Family Access to Medical Insurance Security Plan under Title XXI to the extent funds are made available or as directed by the appropriation act. The Family Access to Medical Insurance Security Plan and any benefits provided thereunder shall not be assistance or public assistance pursuant to Chapter 5 (§ 63.2-500 et seq.) of Title 63.2.
1997, c. 679; 2000, cc. 824, 848.