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 12VAC30-141-700 - Appeal of adverse actions or adverse benefit determinations

Current through Register Vol. 40, No. 24, July 15, 2024
A. Upon request,
				  all FAMIS MOMS program applicants and enrollees shall have the right to a state
				  fair hearing of an adverse action made by the local department of social
				  services, CPU, or DMAS, or an internal appeal of an adverse benefit
				  determination made by the MCO.
B.
				  During the appeal of a suspension or termination of enrollment or a reduction,
				  suspension, or termination of services, the enrollee shall have the right to
				  continuation of coverage if the enrollee requests an internal appeal with the
				  MCO or an appeal to DMAS prior to the effective date of the suspension or
				  termination of enrollment or suspension, reduction, or termination of
				  services.
C. An appeal of an
				  adverse action made by the local department of social services, CPU, or DMAS
				  shall be heard and decided by an agent of DMAS who has not been directly
				  involved in the adverse action under appeal.
D. An internal appeal of an adverse benefit
				  determination made by the MCO must be conducted by a person or agent of the MCO
				  who has not been directly involved in the adverse benefit determination under
				  appeal.
E. Pursuant to
				  42 CFR
				  438.402(c)(1)(B), after
				  exhausting the MCO's internal appeals process, there shall be opportunity for
				  the enrollee to request an external medical review by an independent external
				  quality review organization. "External quality review organization" means the
				  independent contractor assigned by DMAS to handle quality reviews and to
				  conduct final review of MCHIP adverse actions for FAMIS MOMS. The review is
				  optional and shall not be required before proceeding to a state fair hearing.
				  The review shall not extend any of the timeframes for issuing a decision and
				  shall not disrupt any continuation of coverage granted to the
				  enrollee.
F. There will be no
				  opportunity for appeal of an adverse action to the extent that such adverse
				  action is based on a determination by the director that funding for FAMIS MOMS
				  has been terminated or exhausted. There will be no opportunity for appeal if
				  the sole basis for the decision is a provision in the State Plan or in a state
				  or federal law requiring an automatic change in eligibility or enrollment or a
				  change in coverage under the health benefits package that affects all
				  applicants or enrollees or a group of applicants or enrollees without regard to
				  their individual circumstances.
G.
				  The burden of proof shall be assigned to the party who is attempting to make a
				  change per
				  12VAC30-110-220 C.
H. At no time shall the failure of MCO, LDSS,
				  CPU, or DMAS to meet the timeframes set in this chapter or set in the MCO or
				  DMAS written appeal procedure constitute a basis for granting the applicant or
				  enrollee the relief sought.
Statutory Authority: §
												32.1-325 of the Code of
						Virginia; 42 USC §
													1396 et
						seq.