reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VIII - Applications for Medicaid › Section 12VAC30-110-1370 - Applicant's signature

Current through Register Vol. 40, No. 24, July 15, 2024
The applicant must sign a state-approved official
					 application form, even if another person fills out the form, unless the
					 application is filed and signed by the applicant's parent, caretaker relative,
					 legal guardian or conservator, attorney-in-fact or authorized representative.
					 If the applicant cannot sign his name, but can make a mark, the mark must be
					 correctly designated and witnessed by one person.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia; 42 CFR
						435.906 and
						435.907.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VIII - Applications for Medicaid › Section 12VAC30-110-1400 - Authorized representative for a deceased applicant

Current through Register Vol. 40, No. 24, July 15, 2024
An application may be made on behalf of a deceased person
					 by his guardian or conservator, attorney-in-fact, executor or administrator of
					 his estate, his surviving spouse, or his surviving family member, in this order
					 of preference: adult child, parent, adult sibling, adult niece or nephew, or
					 aunt or uncle. Such application must be filed within the three-month period
					 subsequent to the month in which the death occurred if the deceased applicant
					 received a Medicaid-covered service on or before the date of death and the date
					 of service occurred within a month covered by the Medicaid
					 application.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia; 42 CFR
						435.906 and
						435.907.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VIII - Applications for Medicaid › Section 12VAC30-110-1410 - Persons prohibited from signing an application

Current through Register Vol. 40, No. 24, July 15, 2024
An employee of, or an entity hired by, a medical service
					 provider who could obtain Medicaid payments shall not sign a Medicaid
					 application for a deceased individual or on behalf of an individual who cannot
					 designate an authorized representative.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia; 42 CFR
						435.906 and
						435.907.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VIII - Applications for Medicaid › Section 12VAC30-110-1500 - Working individuals with disabilities; basic coverage group (Ticket to Work and Work Incentive Improvement Act (TWWIIA))

Current through Register Vol. 40, No. 24, July 15, 2024
A. Definitions.
"Eligible person" means someone who is (i) disabled: an
					 applicant is deemed to be disabled for the purposes of program eligibility if
					 he is enrolled in the Supplemental Security Income (SSI) or Social Security
					 Disability Insurance (SSDI) programs. If the applicant has not had a disability
					 determination through the Social Security Administration, he must have such a
					 determination through the Disability Determination Services program; (ii)
					 employed or can show proof of imminent prospective employment; (iii) between
					 the ages of 16 years and 64 years; (iv) not subject to spending down of excess
					 resources; (v) not an inpatient in an institution of mental disease (IMD), nor
					 an inmate in a public institution that is not medical facility pursuant to the
					 Act § 1902(a)(10)(A)(ii)(XV).
B. Scope/purpose. The purpose of this program
				  shall be to afford persons who are disabled with the opportunity to be employed
				  and retain more of their earned income without risking the loss of their
				  Medicaid coverage of critical health care benefits.
C. In conformance with
				  12VAC30-30-20,
				  12VAC30-40-280,
				  12VAC30-40-290, and
				  12VAC30-40-105, eligible persons
				  must meet the definition in subsection A of this section to be approved for
				  this program.
D. In conformance
				  with 12VAC30-40-105, working
				  individuals with disabilities must meet these requirements for continuing
				  eligibility pursuant to the Act § 1902(a)(10)(A)(ii)(XV):
1. Continue to meet the disability, age, and
				  employment criteria described in this section. Individuals who, as enrollees,
				  are unable to maintain employment due to illness or unavoidable job loss may
				  remain in the program as unemployed for up to six months;
2. Have enrollee-countable earned income of
				  no more than 200% FPL;
a. The standard SSI
				  methodology shall be used to determine "countable" income;
b. The enrollee shall be treated as a
				  "household of one" and spousal income shall be disregarded for ongoing enrollee
				  eligibility; and
3. Have
				  resources or assets up to the annual SSI "threshold amount" (Social Security
				  Act, § 1619(b)) as established for Virginia by the Social Security
				  Administration (SSA), if such resources or assets are accumulated solely from
				  enrollee earnings after the individual is enrolled with Medicaid Buy-In under
				  § 1902(a)(10)(A)(ii)(XV).
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VIII - Applications for Medicaid › Section 12VAC30-110-1600 - (Reserved)

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority
§ 32.1-351 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VIII - Applications for Medicaid › Section 12VAC30-110-1610 - Deemed newborn eligibility under FAMIS

Current through Register Vol. 40, No. 24, July 15, 2024
A child born to a woman who is eligible for and receiving
					 Title XXI coverage through the Family Access to Medical Insurance Security Plan
					 (FAMIS) or related waivers, such as FAMIS MOMS, as of the date of the child's
					 birth and who is screened to be income eligible for coverage under Medicaid is
					 deemed Medicaid/FAMIS eligible for one year from his date of
					 birth.
Statutory Authority
§ 32.1-351 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VIII - Applications for Medicaid › Section 12VAC30-110-1620 - Coverage of former foster care youth

Current through Register Vol. 40, No. 24, July 15, 2024
A. The Title IV-A agency or the Department of
				  Medical Assistance Services Central Processing Unit determines eligibility for
				  Title XIX services.
B. Former
				  foster care children younger than the age of 26 years who are not otherwise
				  mandatorily eligible in another Medicaid classification and who were on
				  Medicaid and in foster care when they turned age 18 years or aged out of foster
				  care are eligible for medical assistance as specified. Individuals qualifying
				  under this eligibility group shall meet the following criteria:
1. They shall be younger than the age of 26
				  years;
2. They shall not be
				  otherwise eligible for or enrolled in mandatory coverage under the state plan;
				  and
3. They were in foster care in
				  a state other than Virginia and were enrolled in Medicaid under the state plan
				  of that state when they turned age 18 years or at the time of aging out of the
				  foster care program.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part II - Home and Community-Based Services for Technology Assisted Individuals › Section 12VAC30-120-70

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part II - Home and Community-Based Services for Technology Assisted Individuals › Section 12VAC30-120-80

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part II - Home and Community-Based Services for Technology Assisted Individuals › Section 12VAC30-120-90

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part II - Home and Community-Based Services for Technology Assisted Individuals › Section 12VAC30-120-100

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part II - Home and Community-Based Services for Technology Assisted Individuals › Section 12VAC30-120-110

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part II - Home and Community-Based Services for Technology Assisted Individuals › Section 12VAC30-120-115

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part II - Home and Community-Based Services for Technology Assisted Individuals › Section 12VAC30-120-120

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part IV - Mental Retardation Waiver (Repealed) › Section 12VAC30-120-237

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part V - Medallion › Section 12VAC30-120-260

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part V - Medallion › Section 12VAC30-120-270

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part V - Medallion › Section 12VAC30-120-280

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part V - Medallion › Section 12VAC30-120-290

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part V - Medallion › Section 12VAC30-120-300

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part V - Medallion › Section 12VAC30-120-310

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part V - Medallion › Section 12VAC30-120-320

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part V - Medallion › Section 12VAC30-120-330

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part V - Medallion › Section 12VAC30-120-340

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part V - Medallion › Section 12VAC30-120-350

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: § 32.1-325 of the Code of
						Virginia; 42 USC § 1396 et seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VI - Medallion Mandatory Managed Care › Section 12VAC30-120-370 - Medallion mandatory managed care members

Current through Register Vol. 40, No. 24, July 15, 2024
A. DMAS shall determine enrollment in
				  Medallion mandatory managed care.
1. Medicaid
				  eligible persons not meeting the exclusion criteria set out in subsection B of
				  this section shall participate in the Medallion mandatory managed care program.
				  Enrollment in Medallion mandatory managed care shall not be a guarantee of
				  continuing eligibility for services and benefits under the Virginia Medical
				  Assistance Services Program.
2.
				  DMAS reserves the right to exclude from participation in the Medallion
				  mandatory managed care program any member who has been consistently
				  noncompliant with the policies and procedures of managed care or who is
				  threatening to providers, MCOs, or DMAS. There must be sufficient documentation
				  from various providers, the MCO, and DMAS of these noncompliance issues and any
				  attempts at resolution. Members excluded from Medallion mandatory managed care
				  through this provision may appeal the decision to DMAS.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VI - Medallion Mandatory Managed Care › Section 12VAC30-120-380 - Medallion MCO responsibilities

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  The MCO shall provide, at a minimum, all medically necessary covered services
				  provided under the State Plan for Medical Assistance and further defined by
				  written federal and state regulations, the Medallion contract, policies, and
				  instructions, except as otherwise modified or excluded in this part.
1. Nonemergency services provided by hospital
				  emergency departments shall be covered by MCOs in accordance with rates
				  negotiated between the MCOs and the hospital emergency departments.
2. Services that shall be provided outside
				  the MCO network shall include those services identified and defined by the
				  contract between DMAS and the MCO. Services reimbursed by DMAS include dental
				  and orthodontic services for children younger than 21 years of age, dental
				  services for others as described in
				  12VAC30-50-190,
				  and school health services.
3. The
				  MCOs shall pay for emergency services and family planning services and supplies
				  whether such services are provided inside or outside the MCO
				  network.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VI - Medallion Mandatory Managed Care › Section 12VAC30-120-390 - Payment rate for MCOs

Current through Register Vol. 40, No. 24, July 15, 2024
The payment rate to MCOs that participate in the Medallion
					 mandatory managed care program shall be set by negotiated contracts and in
					 accordance with
					 42 CFR 438.4
					 through 42 CFR 438.8 and other pertinent federal regulations.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VI - Medallion Mandatory Managed Care › Section 12VAC30-120-395 - Preauthorized, emergency, and post-stabilization services and payment rate for care provided by out-of-network providers

Current through Register Vol. 40, No. 24, July 15, 2024
The MCOs shall pay for preauthorized, emergency, and
					 post-stabilization services to members in compliance with the contract and
					 42 CFR
					 438.114. Preauthorized, emergency, and
					 post-stabilization services provided to a managed care member by a provider or
					 facility not participating in the MCO's network will be reimbursed according to
					 the current Medicaid fee schedule. This reimbursement shall be considered
					 payment in full to the provider or facility of emergency
					 services.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VI - Medallion Mandatory Managed Care › Section 12VAC30-120-400 - Quality control and utilization review

Current through Register Vol. 40, No. 24, July 15, 2024
A. DMAS shall rigorously monitor the quality
				  of care provided by the MCOs. DMAS and the MCOs shall comply with (i) the
				  contract; (ii) 42 CFR 438 Subpart E, entitled Quality Measurement and
				  Improvement: External Quality Review; and (iii) the MCO standards identified in
				  42 CFR 438 Subpart D, entitled MCO, PIHP, and PAHP Standards. DMAS shall
				  monitor the MCOs to determine their compliance with the contract, 42 CFR
				  Subpart A, and all other relevant sections of 42 CFR Part 438 (Managed Care) as
				  follows:
1. If the MCO fails substantially to
				  provide the medically necessary items and services required under law or under
				  the contract to be provided to an enrolled recipient and the failure has
				  adversely affected or has substantial likelihood of adversely affecting the
				  individual.
2. If the MCO engages
				  in any practice that discriminates against individuals on the basis of their
				  health status or requirements for health care services, including expulsion or
				  refusal to reenroll an individual, or any practice that could reasonably be
				  expected to have the effect of denying or discouraging enrollment (except as
				  permitted by § 1903(m) of the Social Security Act (
				  42 USC §
												1396b(m) ) by eligible
				  individuals whose medical conditions or histories indicate a need for
				  substantial future medical services.
3. If the MCO misrepresents or falsifies
				  information that it furnishes, under § 1903(m) of the Social Security Act
				  (
				  42 USC §
												1396b(m) ) to CMS, DMAS, an
				  individual, or any other entity.
4.
				  If the MCO fails to comply with the requirements of
				  42 CFR
				  417.479(d) through 42 CFR
				  417.479(g) relating to physician incentive plans or fails to submit to DMAS its
				  physician incentive plans as required or requested in
				  42 CFR
				  434.70.
5. If the MCO imposes on members premiums or
				  charges that are in excess of the premiums or charges permitted under the
				  Medicaid program.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VI - Medallion Mandatory Managed Care › Section 12VAC30-120-410 - Sanctions

Current through Register Vol. 40, No. 24, July 15, 2024
A. If DMAS
				  determines that an MCO is not in compliance with applicable state or federal
				  laws or regulations (including the requirements of or pursuant to §
				  1932(e)(1) of the Social Security Act (the Act),
				  12VAC30-120-380,
				  or 42 CFR 438 Subpart I) or the MCO contract, DMAS may impose sanctions on the
				  MCO pursuant to § 1932(e) of the Act and this section. The sanctions may
				  include:
1. Limiting enrollments in the MCO
				  by freezing voluntary member enrollments;
2. Freezing DMAS assignment of members to the
				  MCO;
3. Limiting MCO enrollment to
				  specific areas;
4. Denying,
				  withholding, or retracting payments to the MCO;
5. Terminating the MCO's contract as provided
				  in § 1932(e)(4) of the Act;
6.
				  Civil monetary penalties as specified in
				  42 CFR
				  438.704; and
7. Appointment of temporary management for an
				  MCO as provided in
				  42 CFR
				  438.706.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-490 to 12VAC30-120-550

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-610 - CCC Plus mandatory managed care members; enrollment process

Current through Register Vol. 40, No. 24, July 15, 2024
A. The following
				  individuals shall be enrolled in CCC Plus per the CCC Plus § 1915(b)
				  waiver:
1. Dual eligible individuals with
				  Medicare A or B coverage and full Medicaid coverage.
2. Non-dual eligible individuals who receive
				  long-term services and supports through an institution, the CCC Plus waiver,
				  Building Independence waiver, Community Living waiver, and Family and
				  Individual Supports waiver.
Those enrolled in the Building Independence, Community
					 Living, and Family and Individual Supports waivers will continue to receive
					 their LTSS including LTSS related transportation services through Medicaid
					 fee-for-service.
3. All
				  individuals classified as aged, blind, or disabled (ABD) without Medicare and
				  not receiving LTSS.
4. Individuals
				  who qualify for and enroll under Medicaid expansion who have been identified as
				  medically complex.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-615 - CCC Plus providers; Medicaid enrollment process

Current through Register Vol. 40, No. 24, July 15, 2024
A. All individuals and entities who provide
				  services of any type to CCC Plus members, including health care providers;
				  pharmacies; ordering, referring, and prescribing providers; and providers who
				  do not participate in Medicaid fee-for-service shall abide by all CCC Plus
				  contract requirements regarding Provider Enrollment, pursuant to the 21st
				  Century Cures Act (
				  P.L.
				  114-255 ).
B. Each provider shall be screened and
				  enrolled with DMAS through the DMAS provider enrollment system by December 1,
				  2019. The MCO shall ensure that all providers are registered in the DMAS
				  provider enrollment system prior to contracting with the provider.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-620 - MCO responsibilities; sanctions

Current through Register Vol. 40, No. 24, July 15, 2024
A. The MCO and any of its subcontractors
				  shall abide by all CCC Plus contract requirements, including:
1. The MCO shall provide medically necessary
				  covered services in accordance with the CCC Plus contract.
a. Each MCO and its subcontractors shall have
				  in place and follow written policies and procedures for processing requests for
				  initial and continuing authorizations of service. Each MCO and its
				  subcontractors shall ensure that any decision to deny a service authorization
				  request or to authorize a service in an amount, duration, or scope that is less
				  than requested be made by a health care professional who has appropriate
				  clinical expertise in treating the member's condition or disease. Each MCO and
				  its subcontractors shall have in effect mechanisms to ensure consistent
				  application of review criteria for authorization decisions and shall consult
				  with the requesting provider when appropriate.
b. In accordance with § 1932(f) of the
				  Social Security Act ( 42 USC § 1396a-2 ), the contractor shall pay all
				  in-network and out-of-network providers (including Native American health care
				  providers) on a timely basis, consistent with the claims payment procedure
				  described in 42 CFR 447.45 and 42 CFR 447.46 and § 1902(a)(37) of the
				  Social Security Act, upon receipt of all clean claims, for covered services
				  rendered to covered members who are enrolled with the contractor at the time
				  the service was delivered. The MCO may deny claims in whole or in part for not
				  meeting payment criteria established by the MCO.
c. Utilization review and audit. MCOs may
				  perform utilization reviews and audits on their network providers. As a result
				  of such a review or audit, an overpayment may be determined.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-625 - Continuity of care

Current through Register Vol. 40, No. 24, July 15, 2024
The MCO shall ensure continuity of care for each member
					 upon enrollment into the member's plan. During the time period set forth in
					 this section, the MCO shall maintain the member's current providers at the
					 Medicaid FFS rate and honor service authorizations (SAs) issued prior to
					 enrollment for the specified time period. The continuity of care period is as
					 follows:
1. Within the first 30
				  calendar days of a member's enrollment, the MCO shall allow a member to
				  maintain the member's current providers, including out-of-network providers.
				  The MCO shall extend this timeframe as necessary to ensure continuity of care
				  pending the provider contracting with the MCO or the member's safe and
				  effective transition to a contracted provider. DMAS has sole discretion to
				  extend the continuity of care period timeframe.
2. The MCO shall reimburse nursing facilities
				  and specialized care services (described in
				  12VAC30-60-40,
				  12VAC30-60-320,
				  and
				  12VAC30-60-340
				  ) no less than the Medicaid established per diem rate for Medicaid covered
				  days, using the DMAS methodologies, unless the MCO and the provider mutually
				  agree to an alternative payment methodology or value-based payment arrangement;
				  however, the rate paid shall not be less than the current Medicaid
				  fee-for-service rate.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-630 - Covered services

Current through Register Vol. 40, No. 24, July 15, 2024
A. The MCO
				  shall, at a minimum, provide all medically necessary Medicaid covered services
				  required under the state plan (12VAC30-50-10
				  through
				  12VAC30-50-310,
				  12VAC30-50-410
				  through
				  12VAC30-50-430,
				  and
				  12VAC30-50-470
				  through
				  12VAC30-50-580
				  ) and Elderly and Disabled with Consumer Direction waiver regulations
				  (12VAC30-120-924
				  and
				  12VAC30-120-927
				  ) and the Technology Assisted waiver regulations (12VAC30-120-1720
				  ) and, effective January 1, 2018, community mental health services
				  (12VAC30-50-130
				  and
				  12VAC30-50-226
				  ).
B. The following services are
				  not covered by the MCO and shall be provided through fee-for-service outside
				  the CCC Plus MCO contract:
1. Dental services
				  (12VAC30-50-190
				  );
2. School health services
				  (12VAC30-50-130
				  );
3. Preadmission screening
				  (12VAC30-60-303
				  );
4. Individual and Developmental
				  Disability Support waiver services (12VAC30-120-700 et
				  seq.);
5. Intellectual Disability
				  Waiver (12VAC30-120-1000 et
				  seq.); or
6. Day Support Waiver
				  (12VAC30-120-1500 et
				  seq.).
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-635 - Payment rates for MCOs

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  payment rate to MCOs shall be set by negotiated contracts and in accordance
				  with 42 CFR 438.6 Subpart A through 42 CFR 438.8 and other pertinent federal
				  regulations.
B. In accordance with
				  § 1932(b)(2)(D) of the Social Security Act and State Medicaid Director
				  Letter 06-010, the contractor shall pay noncontracted providers for emergency
				  services no more than the amount that would have been paid if the service had
				  been provided under the state's FFS Medicaid program. The contractor shall
				  reimburse out-of-network providers and providers of emergent or urgent care, as
				  defined by 42 CFR 424.101 and 42 CFR 405.400 respectively, at the Medicaid FFS
				  payment level for that service.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-640 - State fair hearing process

Current through Register Vol. 40, No. 24, July 15, 2024
A. Notwithstanding the provisions of
				  12VAC30-110-10
				  through
				  12VAC30-110-370,
				  this section through 12VAC30-120-690 govern state fair hearings for individuals
				  enrolled in CCC Plus.
B. The
				  Appeals Division maintains an appeals and fair hearings system for members
				  (referred to as "appellants" once the appeal process has begun) to challenge
				  appeal decisions rendered by the MCO in response to member appeals of adverse
				  benefit determinations related to Medicaid services. Exhaustion of the MCO's
				  appeals process is a prerequisite to requesting a state fair hearing with the
				  department. Appellants who meet the criteria for a state fair hearing shall be
				  entitled to a state fair hearing before a department hearing officer.
C. The MCO shall conduct an internal appeal,
				  pursuant to 42 CFR Part 431 Subpart E and 42 CFR Part 438 Subpart F, and issue
				  a written decision that includes its findings and information regarding the
				  appellant's right to file an appeal with DMAS for a state fair hearing for
				  Medicaid appeals.
D. Members must
				  be notified in writing of the MCO's internal appeals process in accordance with
				  42 CFR 438.400 et seq.:
1. With the handbook;
				  and
2. Upon receipt of a notice of
				  adverse benefit determination from the MCO.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-660 - Pre state fair hearing decisions

Current through Register Vol. 40, No. 24, July 15, 2024
A. If the Appeals Division determines that
				  any of the conditions as described in this subsection exist, a state fair
				  hearing will not be held and the appeal process shall be terminated.
1. A request for appeal may be invalidated
				  if:
a. It was not filed within the time limit
				  imposed by 12VAC30-120-650; or
b.
				  The individual who filed the appeal ("filer") is not the appellant or parent of
				  a minor appellant, and the Appeals Division sends a letter to the filer
				  requesting proof of the filer's authority to appeal on behalf of the appellant;
				  and
(1) The filer did not reply within 10
				  calendar days to the request for authorization to represent the appellant;
				  or
(2) The filer replied within 10
				  calendar days of the request, and the Appeals Division determined that the
				  authorization submitted was insufficient to allow the filer to represent the
				  appellant under the provisions of 12VAC30-120-640.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-670 - State fair hearing process and final decision

Current through Register Vol. 40, No. 24, July 15, 2024
A. All state
				  fair hearings shall be conducted de novo per
				  12VAC30-110-220.
B. All state fair hearings must be scheduled
				  at a reasonable time, date, and place, and the appellant and the appellant's
				  authorized representative shall be notified in writing prior to the hearing.
1. The state fair hearing location will be
				  determined by the Appeals Division.
2. A state fair hearing may be rescheduled at
				  the appellant's request no more than twice unless compelling reasons exist,
				  which shall be determined by the department hearing officer.
3. Rescheduling the state fair hearing at the
				  appellant's request will result in automatic waiver of the 90-day deadline for
				  resolution of the appeal. The delay date for the decision will be calculated as
				  set forth in
				  12VAC30-120-650
				  H and I.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-670 - State fair hearing process and final decision

Current through Register Vol. 40, No. 24, July 15, 2024
A. All state fair hearings shall be conducted
				  de novo per
				  12VAC30-110-220. As such, no
				  deference will be given to the entity that made the adverse action being
				  appealed.
B. All state fair
				  hearings must be scheduled at a reasonable time, date, and place, and the
				  appellant and the appellant's authorized representative shall be notified in
				  writing prior to the hearing.
1. The state
				  fair hearing location will be determined by the Appeals Division.
2. A state fair hearing may be rescheduled at
				  the appellant's request no more than twice unless compelling reasons exist,
				  which shall be determined by the department hearing officer.
3. Rescheduling the state fair hearing at the
				  appellant's request will result in automatic waiver of the 90-day deadline for
				  resolution of the appeal. The delay date for the decision will be calculated as
				  set forth in
				  12VAC30-120-650 H and
				  I.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-680 - Appeals Division records

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  No person shall take from the department's custody any original record, paper,
				  document, or exhibit that has been certified to the Appeals Division except as
				  the Appeals Division Director or the director's designee authorizes, or as may
				  be necessary to furnish or transmit copies for other official
				  purposes.
B. Information in the
				  appellant's record can be released only to the appellant, the appellant's
				  authorized representative, the MCO, other entities for official purposes, and
				  other persons named in a release of information authorization signed by an
				  appellant or the appellant's authorized representative.
C. The fees to be charged and collected for
				  any copy of Appeals Division records will be in accordance with Virginia's
				  Freedom of Information Act (§
										2.2-3700 et
				  seq. of the Code of Virginia) or other controlling law.
D. When copies are requested from records in
				  the Appeals Division's custody, the required fee shall be waived if the copies
				  are requested in connection with a member's own appeal.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-690 - Provider appeals

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  Appeals Division maintains an appeal process for network and Medicaid-enrolled
				  providers of Medicaid services that have rendered services to members and are
				  requesting to challenge an MCO's reconsideration decision regarding an adverse
				  action affecting service authorization or payment. The MCO's internal
				  reconsideration process is a prerequisite to filing for an external appeal to
				  the department's provider appeal process. The appeal process is available to
				  network and Medicaid-enrolled providers that (i) have rendered services and
				  have been denied payment in whole or part for Medicaid covered services; (ii)
				  have rendered services and have been denied authorization for the services; and
				  (iii) have received a notice of program reimbursement or overpayment demand
				  from the department or its contractors. Providers that have had their
				  enrollment in the MCO's network denied or terminated by the MCO do not have the
				  right to an external appeal with the Appeals Division.
B. Department provider appeals shall be
				  conducted in accordance with the department's provider appeal regulations
				  (12VAC30-20-500 et
				  seq.), §
										32.1-325
				  et seq. of the Code of Virginia, and the Virginia Administrative Process Act
				  (§
										2.2-4000 et
				  seq. of the Code of Virginia).
C.
				  The department's external appeal decision shall be binding upon the MCO and not
				  subject to further appeal by the MCO.
D. If the provider is successful in its
				  appeal of a reimbursement issue, then the MCO shall reimburse the provider for
				  the appealed issue.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 1 - General Requirements › Section 12VAC30-120-700

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 1 - General Requirements › Section 12VAC30-120-710

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 1 - General Requirements › Section 12VAC30-120-720

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 1 - General Requirements › Section 12VAC30-120-730

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 1 - General Requirements › Section 12VAC30-120-740

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 2 - Covered Services and Limitations and Related Provider Requirements › Section 12VAC30-120-750

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 2 - Covered Services and Limitations and Related Provider Requirements › Section 12VAC30-120-751

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 2 - Covered Services and Limitations and Related Provider Requirements › Section 12VAC30-120-752

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 2 - Covered Services and Limitations and Related Provider Requirements › Section 12VAC30-120-753

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 2 - Covered Services and Limitations and Related Provider Requirements › Section 12VAC30-120-754

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 2 - Covered Services and Limitations and Related Provider Requirements › Section 12VAC30-120-755

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 2 - Covered Services and Limitations and Related Provider Requirements › Section 12VAC30-120-756

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 2 - Covered Services and Limitations and Related Provider Requirements › Section 12VAC30-120-757

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 2 - Covered Services and Limitations and Related Provider Requirements › Section 12VAC30-120-758

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VIII - Individual and Family Developmental Disabilities Support Waiver › Article 2 - Covered Services and Limitations and Related Provider Requirements › Section 12VAC30-120-759

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority: §
													32.1-325
						  of the Code of Virginia;
						  42 USC §
														1396 et
						  seq.