Virginia Administrative Code › Title 1 - ADMINISTRATION › Agency 55 - DEPARTMENT OF HUMAN RESOURCE MANAGEMENT › Chapter 20 - COMMONWEALTH OF VIRGINIA HEALTH BENEFITS PROGRAM › Part II - Rights and Duties of the Department › Section 1VAC55-20-210 - Oversight

Current through Register Vol. 40, No. 24, July 15, 2024
The department has the responsibility and authority to
					 maintain the health benefits program and take any action it deems necessary to
					 maintain the financial and administrative integrity of the program.
A. The department shall review local
				  administration, including state agency administration of the health benefits
				  program to determine compliance with this chapter, law, and administrative
				  directives. Deficiencies shall be reported to the governing body or agency
				  administrator, who shall take prompt action to remedy the noted deficiencies.
				  To this end, the department shall provide guidance to responsible parties
				  regarding their duties and responsibilities in the administration of the
				  program. Failure to correct noted deficiencies may result in the unilateral
				  termination of participation (in the case of a local employer) in the health
				  benefits program, or a revocation of the agency's administrative responsibility
				  for the health benefits program (in the case of a state agency) and the
				  imposition of a special employer contribution on the state agency to pay for
				  the cost of direct administration of the program by the department. The cost of
				  direct administration shall be determined by the department.
B. The department may exclude from coverage
				  any person who is not eligible for coverage notwithstanding the participation
				  of the state agency or local employer in the health benefits program or the
				  payment of contributions or the previous payment of claims on behalf of such
				  person.
If a person is determined to be ineligible for coverage,
					 claims paid by the program during this period of ineligibility shall be
					 recouped by the program from providers of care and from the ineligible employee
					 to the extent practicable as determined by the department.
Employer contributions on behalf of ineligible persons
					 shall not be returned to the participating employer in as much as the employer
					 agrees by participating in the health benefits program that the amount of such
					 contributions constitute liquidated damages for enrolling ineligible employees
					 and/or their dependents. Employee contributions will not be refunded, and the
					 membership level and contributions rate will be maintained, at the level they
					 had been prior to the removal of the ineligible dependent, until such time as
					 the employee makes a membership change due to a consistent qualifying midyear
					 event, or during open enrollment.
C. The department may exclude from coverage
				  for a period of three years any employee (and dependent) who is found by the
				  department to have enrolled in the health benefits program through fraud,
				  deceit, or misrepresentation of a dependent who is not eligible for the
				  program. A signed enrollment form or equivalent enrollment action shall be
				  deemed prima facie evidence of misrepresentation.
D. The department may refuse, notwithstanding
				  any agreement or assignment from a participant or third party, to make a
				  payment on behalf of a participant for covered services to a provider of care
				  who has been determined by the department to be abusing or defrauding the
				  program. A pattern of billing for services not rendered, misrepresenting the
				  complexity or length of the procedures or services actually rendered, or
				  similar abuses shall compel the department to make such a determination. For
				  the purposes of this section, a "pattern" constitutes a number of instances
				  over a period of at least three months which are so similar as to suggest that
				  the abuse is present in 5.0% or more of the services or procedures
				  billed.
Statutory Authority
§§ 2.2-1204 and 2.2-2818 of the Code of Virginia.