Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart I - General › Article 1 - Definitions › Section 12VAC30-110-10 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms, when used in these
						  regulations, shall have the following meanings unless the context clearly
						  indicates otherwise:
"Action" means a denial of, termination of, suspension
						  of, or reduction in covered benefits or services; a denial of or termination,
						  suspension, or reduction in Medicaid eligibility; or an increase in beneficiary
						  liability, including a determination that a beneficiary must incur a greater
						  amount of medical expenses in order to establish income eligibility in
						  accordance with 42 CFR
						  435.121(e)(4) or
						  42 CFR
						  435.831 or is subject to an increase in
						  premiums or cost-sharing charges under Subpart A of 42 CFR Part 447. It also
						  means
(i) determinations by a skilled
						nursing facility or nursing facility to transfer, discharge, or fail to readmit
						a resident and
(ii) an adverse
						determination made by a state with regard to the preadmission screening and
						resident review requirements of § 1919(e)(7) of the Social Security Act.
						It also means the failure to take an application for benefits or to act with
						reasonable promptness on an application for benefits, on a reported change in
						circumstances, or on a request for a particular medical service.
"Adverse determination" means a determination made in
						  accordance with § 1919(b)(3)(F) or 1919(e)(7)(B) of the Social Security
						  Act that the individual does not require the level of services provided by a
						  nursing facility or that the individual does or does not require specialized
						  services.
"Agency" means:
1. An agency or contractor that, on the
						department's behalf, makes determinations regarding benefits or applications
						for benefits provided by the department; or
2. The department itself.
"Appellant" means
(i) an applicant for or recipient of medical
						assistance benefits from the department who seeks to challenge an action
						regarding the applicant's benefits or the applicant's eligibility for benefits
						and
(ii) a nursing facility
						resident who seeks to challenge a transfer, discharge, or failure to readmit.
						Appellant also means an individual who seeks to challenge an adverse
						determination regarding services provided by a nursing facility.
"Burden of proof" means the duty placed upon a party to
						  prove or disprove a disputed fact.
"Date of action" means the intended date on which a
						  termination, suspension, reduction, transfer, or discharge becomes effective.
						  It also means the date of the determination made by a state with regard to the
						  preadmission screening and annual resident review requirements of §
						  1919(e)(7) of the Social Security Act.
"Day" means calendar day unless otherwise specified or
						  required by law.
"De novo" means that, where a hearing is required, the
						  department's hearing officer will consider all relevant evidence submitted
						  during the appeal in order to make a determination on the issues on appeal,
						  even if the evidence was not previously received by the agency.
"Department" means the Department of Medical Assistance
						  Services.
"Division" means the department's Appeals
						  Division.
"Fail to readmit" means when a nursing facility refuses
						  to readmit a resident who meets the criteria for a bed hold under 42 CFR
						  438.15.
"Final decision" means a written determination by a
						  hearing officer that is binding on the department, unless modified on appeal or
						  review.
"Hearing" means the de novo evidentiary hearing
						  described in this chapter, conducted by a hearing officer employed by the
						  department.
"Preponderance of the evidence" means that the party
						  with the burden of proof has demonstrated to the hearing officer that their
						  position on the issue in the appeal is more likely valid than not.
"Representative" means an attorney or agent who has
						  been authorized to represent an appellant pursuant to these regulations.
"Send" means to deliver by mail or in electronic format
						  consistent with 42 CFR
						  431.201 and
						  42 CFR
						  435.918.
"State fair hearing" means the entire appeal process
						  for applicants and beneficiaries as set forth in 42 CFR Subpart
						  E.
Statutory Authority: §
														32.1-325 of the Code of
							 Virginia; 42 USC §
															1396 et
							 seq.