Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-670 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this chapter
					 shall have the following meanings unless the context clearly indicates
					 otherwise:
"Adverse action," consistent with
					 42 CFR
					 457.1130, means the denial of eligibility;
					 failure to make a timely determination of eligibility; suspension or
					 termination of enrollment, including disenrollment for failure to pay cost
					 sharing; or delay, denial, reduction, suspension, or termination of health
					 services, in whole or in part, including a determination about the type or
					 level of services; and failure to approve, furnish, or provide payment for
					 health services in a timely manner; provided, however, that determination of
					 eligibility to participate in and termination of participation in the FAMIS
					 Select program shall not constitute an adverse action.
"Adverse benefit determination," consistent with
					 42 CFR
					 438.400, means the denial or limited
					 authorization of a requested service; the failure to take action or timely take
					 action on a request for service; the reduction, suspension, or termination of a
					 previously authorized service; denial in whole or in part of a payment for a
					 service; failure to provide services within the timeframes required by the
					 state; for a resident of a rural exception area with only one MCO, the denial
					 of a enrollee's request to exercise the enrollee's right under
					 42 CFR
					 438.52(b)(2)(ii) to obtain
					 services outside of the network; the denial of a enrollee's request to dispute
					 a financial liability as provided in
					 42 CFR
					 438.400(b)(7); or the
					 failure of an MCO to act within the timeframes provided in
					 42 CFR
					 438.408(b).
"Agency" means the same as defined in
					 12VAC30-141-10.
"Agent" means an individual designated in writing to act on
					 behalf of a FAMIS MOMS Plan applicant or enrollee during the administrative
					 review process.
"Appeal" means an enrollee's request for review of an
					 adverse benefit determination by an MCO or an adverse action by the LDSS, CPU,
					 or DMAS.
"Applicant" means a pregnant woman who has filed an
					 application (or who has an application filed on her behalf) for health
					 insurance and is awaiting a determination of eligibility. A pregnant woman is
					 an applicant until her eligibility has been determined.
"Application for health insurance" means the single
					 streamlined application for determining eligibility in public health insurance
					 programs operated by the Commonwealth.
"Authorized representative" means a person who is
					 authorized to conduct the personal or financial affairs for an individual who
					 is 18 years of age or older.
"Central processing unit" or "CPU" means Cover Virginia,
					 which is the same as defined in 12VAC30-141-10.
"Child" means an individual younger than 19 years of
					 age.
"Conservator" means a person appointed by a court of
					 competent jurisdiction to manage the estate and financial affairs of an
					 incapacitated individual.
"Continuation of coverage" means ensuring an enrollee's
					 benefits are continued until completion of the review process, with the
					 condition that should the enrollee not prevail in the review process, the
					 enrollee shall be liable for the repayment of all benefits received during the
					 review process.
"Director" means the individual, or his designee, specified
					 in §
										32.1-324
					 of the Code of Virginia with all of the attendant duties and responsibilities
					 to administer the State Plan for Medical Assistance and the State Plan for
					 Title XXI.
"DMAS" or "department" means the Department of Medical
					 Assistance Services.
"Enrollee" means a pregnant woman who has been determined
					 eligible to participate in FAMIS MOMS and is enrolled in the FAMIS MOMS
					 program.
"FAMIS" means the Family Access to Medical Insurance
					 Security Plan.
"FAMIS MOMS" means the Title XXI program available to
					 eligible pregnant women.
"Federal poverty level" or "FPL" means that income standard
					 as published annually by the U.S. Department of Health and Human Services in
					 the Federal Register.
"Fee-for-service" means the traditional Medicaid health
					 care delivery and payment system in which physicians and other providers
					 receive a payment for each unit of service they provide.
"Guardian" means a person appointed by a court of competent
					 jurisdiction to be responsible for the affairs of an incapacitated individual,
					 including responsibility for making decisions regarding the person's support,
					 care, health, safety, habilitation, education, and therapeutic treatment, and,
					 if not inconsistent with an order of commitment, residence.
"Incapacitated " means a person who, pursuant to an order
					 of a court of competent jurisdiction, has been found to be incapable of
					 receiving and evaluating information effectively or responding to people,
					 events, or environments to such an extent that the individual lacks the
					 capacity to (i) meet the essential requirements of her health, care, safety, or
					 therapeutic needs without the assistance or protection of a guardian, or (ii)
					 manage property or financial affairs or provide for her support or for the
					 support of her legal dependents without the assistance or protection of a
					 conservator.
"LDSS" or "local department" means the local department of
					 social services.
"Managed care organization" or "MCO" means an organization
					 that offers managed care health insurance plans (MCHIPs) as defined in §
										32.1-137.1 of the
					 Code of Virginia.
"Pregnant woman" means a woman of any age who is medically
					 determined to be pregnant. The pregnant woman definition is met from the first
					 day of the earliest month that the medical practitioner certifies as being a
					 month in which the woman was pregnant, through the last day of the month in
					 which the 60th day occurs, following the last day of the month in which her
					 pregnancy ended, regardless of the reason the pregnancy ended.
"Provider" means the individual, facility, or other entity
					 registered, licensed, or certified, as appropriate, and enrolled by an MCHIP or
					 in fee-for-service to render services to FAMIS MOMS enrollees eligible for
					 services.
"State fair hearing" means, consistent with
					 42 CFR
					 438.400, the process set forth in 42 CFR 431
					 Subpart E.
"Title XXI" means the federal State Children's Health
					 Insurance Program as established by Subtitle J of the Balanced Budget Act of
					 1997.
Statutory Authority: §
												32.1-351
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.