reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part II - State/Local Hospitalization Program › Section 12VAC30-100-100 - Amount, duration, and scope of services covered

Current through Register Vol. 40, No. 24, July 15, 2024
The amount, duration, and scope of services covered by the
					 SLH program shall be equal to the amount, duration, and scope of the same
					 services covered by the MAP established by the State Plan. SLH services shall
					 be limited to inpatient and outpatient hospital services; and to services
					 rendered in free-standing ambulatory surgical centers and local public health
					 departments.
Statutory Authority
§§ 32.1-344 and 32.1-346 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part II - State/Local Hospitalization Program › Section 12VAC30-100-110 - Changes in amount, duration, and scope of services covered

Current through Register Vol. 40, No. 24, July 15, 2024
Changes in the amount, duration, and scope of services
					 covered by the MAP shall, unless modified by the BMAS, automatically change the
					 amount, duration, and scope of services covered by the SLH
					 program.
Statutory Authority
§§ 32.1-344 and 32.1-346 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part II - State/Local Hospitalization Program › Section 12VAC30-100-120 - Inpatient hospital reimbursement rate

Current through Register Vol. 40, No. 24, July 15, 2024
The inpatient hospital reimbursement rate shall be
					 consistent with the Medicaid inpatient rate methodology. However, no
					 disproportionate share or medical education adjustment for SLH inpatient
					 hospital reimbursement shall be provided. For the two-year DRG phase-in period
					 beginning July 1, 1996, the daily inpatient hospital reimbursement rate shall
					 be the same as that per diem rate established and in effect on July 1 of each
					 year by DMAS for the specific hospital established by § 32.1-346B 2 of the
					 Code of Virginia. Inpatient hospital reimbursement rates for SLH services shall
					 not be subject to readjustment through the year-end cost reporting
					 process.
The department shall delay implementation of the Diagnosis
					 Related Groups reimbursement methodology for inpatient hospital services
					 provided under this program until July 1, 1999. Until that time, the daily
					 inpatient hospital reimbursement rate shall be the same as the per diem rate
					 established by the department and in effect on June 30, 1998.
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item 338 C
						of Chapter 464 of the 1998 Acts of Assembly.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part II - State/Local Hospitalization Program › Section 12VAC30-100-130 - Local health department and outpatient hospital clinics reimbursement

Current through Register Vol. 40, No. 24, July 15, 2024
Reimbursement to local health departments and outpatient
					 hospital clinics shall be an all inclusive fee per visit and at the rate
					 established by § 32.1-346B 1 of the Code of Virginia. Outpatient hospital
					 clinics reimbursement rates shall not be subject to readjustment through the
					 year-end cost reporting process.
Statutory Authority
§§ 32.1-344 and 32.1-346 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part II - State/Local Hospitalization Program › Section 12VAC30-100-140 - Emergency services reimbursement

Current through Register Vol. 40, No. 24, July 15, 2024
Reimbursement for hospital emergency room services shall
					 be an all inclusive fee per visit and shall be reimbursed at the rate
					 established by § 32.1-346B 4 of the Code of Virginia. Emergency room
					 services reimbursement rates shall not be subject to readjustment through the
					 year-end cost reporting process.
Statutory Authority
§§ 32.1-344 and 32.1-346 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part II - State/Local Hospitalization Program › Section 12VAC30-100-150 - Eligibility criteria

Current through Register Vol. 40, No. 24, July 15, 2024
An individual is eligible to receive SLH program services
					 if he:
1. Has filed an application
				  with the locality where he resides within 30 days of discharge, in the case of
				  inpatient services, or within 30 days of the date of service, in the case of
				  outpatient services;
2. Is a bona
				  fide resident of the locality to which he has applied;
3. Has a net countable income, using the
				  current budget methodology of the Virginia Aid to Families with Dependent
				  Children Program, equal to or less than 100% of the federal nonfarm poverty
				  income guidelines as published for the then current year in the United States
				  Code of Federal Regulations (CFR), except that localities which in fiscal year
				  1989 used a higher income level may continue to use the 1989 income level in
				  subsequent years; and
4. Has net
				  countable resources, using the current budget methodology of the Virginia Aid
				  to Families with Dependent Children Program, equal to or less than the then
				  current resource standards of the federal Supplemental Security Income Program
				  (SSI).
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part II - State/Local Hospitalization Program › Section 12VAC30-100-155 - Application not required

Current through Register Vol. 40, No. 24, July 15, 2024
The locality where the applicant resides is not required
					 to accept an application to receive SLH program services from an individual
					 after SLH locality funds have been exhausted for the fiscal
					 year.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part II - State/Local Hospitalization Program › Section 12VAC30-100-160 - Length of effective period of application

Current through Register Vol. 40, No. 24, July 15, 2024
An eligibility decision favorable to the applicant shall
					 remain in effect for a period of 180 days. If the recipient requires further
					 medical treatment during the eligibility period, no new application shall be
					 required. If the eligibility period has expired a new application shall be
					 required.
Statutory Authority
§§ 32.1-344 and 32.1-346 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part II - State/Local Hospitalization Program › Section 12VAC30-100-170 - Persons eligible for Title XIX services

Current through Register Vol. 40, No. 24, July 15, 2024
Persons who have been determined eligible for services as
					 defined by and contained in the Social Security Act Title XIX shall not be
					 eligible for SLH program benefits established by § 32.1-346B 3 of the Code
					 of Virginia. This exclusion does not apply to Medicaid-eligible individuals who
					 are enrolled in the Family Planning Waiver described in
					 12VAC30-135-10 through
					 12VAC30-135-40, or those
					 determined eligible as a Qualified Medicare Beneficiary (QMB). Individuals
					 determined eligible for Medicare coverage as a QMB may be determined eligible
					 for SLH program benefits for the months prior to their enrollment for services
					 as a QMB.
Statutory Authority
§§ 32.1-324, 32.1-325, 32.1-344, 32.1-346 and
						32.1-347 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part II - State/Local Hospitalization Program › Section 12VAC30-100-180 - Appeal

Current through Register Vol. 40, No. 24, July 15, 2024
An applicant for SLH may appeal an appealable adverse
					 determination regarding eligibility for services or liability for excess
					 payments as defined in § 32.1-349 of the Code of Virginia. SLH appeals
					 will follow the procedures established by Medicaid for client appeals.
					 Exhaustion of appropriated funds in a given locality for payment of SLH
					 services is not an appealable issue. Funds allocated for one fiscal year shall
					 not be used to pay for provider claims in another fiscal
					 year.
Statutory Authority
§§ 32.1-344 and 32.1-346 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part II - State/Local Hospitalization Program › Section 12VAC30-100-190 - State funds remaining at the end of the fiscal year

Current through Register Vol. 40, No. 24, July 15, 2024
State funds remaining at the end of the fiscal year shall
					 be used as an offset to the calculated local share for the following year. The
					 funds shall be allocated among localities in accordance with a procedure
					 established by DMAS to ensure that state funds remaining at the end of the
					 fiscal year are used first to offset increases in calculated local shares, then
					 to offset calculated local share for all localities. Remaining state funds
					 shall be applied toward offsetting calculated local share only and shall not be
					 added to a locality's base allocation. State funds remaining at the end of the
					 state fiscal year shall not be used for other purposes including payment for
					 claims rendered in a prior SLH payment year.
Statutory Authority
§§ 32.1-344 and 32.1-346 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part II - State/Local Hospitalization Program › Section 12VAC30-100-200 - Determination of liability for excess payments

Current through Register Vol. 40, No. 24, July 15, 2024
The department shall be employed to recover excess SLH
					 payments. Such disputes shall be heard in accordance with the Administrative
					 Process Act. Potential fraud cases shall be referred to the appropriate
					 law-enforcement agency.
Statutory Authority
§§ 32.1-344 and 32.1-346 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part III - HIV Premium Assistance Program › Section 12VAC30-100-260 - Eligibility requirements

Current through Register Vol. 40, No. 24, July 15, 2024
An applicant will be determined to be eligible for the HIV
					 Premium Assistance Program if the individual:
1. Is a Virginia resident at the time of
				  application and is:
a. A citizen of the United
				  States;
b. An alien lawfully
				  admitted for permanent residence or otherwise permanently residing in the
				  United States under color of law, including an alien who is lawfully present in
				  the United States pursuant to 8 USC §
												1101 et seq.;
				  or
c. An alien lawfully admitted
				  under authority of the Indochina Migration and Refugee Assistance Act of 1975,
				  22 USC §
												2601 et seq.;
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part III - HIV Premium Assistance Program › Section 12VAC30-100-270 - Determination of countable income and liquid assets

Current through Register Vol. 40, No. 24, July 15, 2024
When determining eligibility for the HIV Premium Assistance
					 Program, the countable income and assets of each applicant shall be determined
					 as follows:
1. Income shall include
				  total projected applicant and spouse income for the year beginning with the
				  month of application to the program, including but not limited to:
a. Wages;
b. Commissions and fees;
c. Salaries and tips;
d. Profit from self-employment;
e. Dividends or interest income;
f. Disability benefits;
g. Unemployment;
h. Pension or retirement.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part III - HIV Premium Assistance Program › Section 12VAC30-100-280 - Program application and enrollment

Current through Register Vol. 40, No. 24, July 15, 2024
A. Any person requesting participation in the
				  program shall be given the opportunity to file an application and, if
				  determined eligible by the program, shall be enrolled in accordance with the
				  provisions of this part within established funding constraints.
B. An applicant or applicant's representative
				  shall complete an application on the form designated by the program. The
				  program may request additional documentation for eligibility determination
				  purposes as it deems necessary.
C.
				  An unmarried child younger than 18 years old shall have a representative
				  complete and sign the application.
D. Applications shall conform with the
				  requirements of this part and those set forth by the program. Applicants shall
				  be determined ineligible without prejudice when they fail to provide
				  information sufficient for the determination of eligibility.
E. An applicant or applicant's representative
				  shall sign a statement authorizing the program to verify from any source,
				  including banks and public or private agencies providing monetary benefits,
				  qualifying information submitted to the program as part of the application
				  process. Refusal to sign an authorization shall be considered failure to
				  provide sufficient information, and applicants shall be determined ineligible
				  in accordance with the provisions of this policy.
F. Eligibility determination shall be made
				  promptly, not later than 30 days from the date of receipt of the completed
				  application by the program.
G. An
				  applicant or applicant's representative may voluntarily withdraw the
				  application at any time without prejudice.
H. An individual previously determined
				  ineligible for program benefits may submit a new application at any
				  time.
I. Program enrollment shall
				  be effective on the day eligibility is approved. Premium payments for health
				  insurance coverage beginning on the first day of the month following
				  eligibility shall start as long as there is available funding.
Statutory Authority
§§ 32.1-325 and 32.1-330.1 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part III - HIV Premium Assistance Program › Section 12VAC30-100-290 - Changes in eligibility

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  program will promptly redetermine eligibility when it receives information
				  concerning an enrollee's circumstances that may affect eligibility.
B. The enrollee or representative shall
				  notify the program within 10 working days of any changes in circumstances which
				  would affect continuing eligibility, including but not limited to:
1. Sale, transfer or change of the value of
				  assets;
2. Change in
				  income;
3. Change in name or
				  address;
4. Change in COBRA
				  eligibility.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part III - HIV Premium Assistance Program › Section 12VAC30-100-300 - Enrollee openings

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  number of enrollees in the program shall be limited to the number that can be
				  covered by the program's available funding as reflected in available openings.
				  DMAS shall project the expenditures for the current and expected enrollees and
				  funding levels for the program to determine the number of available enrollee
				  openings.
B. Initial available
				  openings in the program shall be filled based on the applicant's date of
				  completed application. In the event that more than one application is received
				  on any one day, applicants shall be considered based on the order of the day
				  and month of the applicant's birth, with January being month one.
C. Should the number of applications exceed
				  available funding at any time, a waiting list shall be maintained by the
				  program of applicants who are determined to be eligible for the program but for
				  whom openings are not available when the eligibility determinations are made.
1. Available openings shall be filled from
				  the waiting list on a first come, first served basis, using the same criteria
				  defined in
				  12VAC30-100-300.
2. If an opening becomes available, the
				  applicant shall be notified in writing by the program. The applicant must
				  provide any necessary information to the program to verify that he is still
				  eligible within 10 days of receiving such notification. The 10-day period may
				  be extended by the program for just cause. If determined to be still eligible,
				  the applicant shall be enrolled.
3.
				  At the end of three months from the date of application, and every three months
				  thereafter, if an opening has not yet become available, each applicant may be
				  contacted by DMAS to verify the applicant's interest in remaining on the
				  waiting list. At these contacts, applicants may be requested to inform the
				  program of changes in the contents of their applications. At such time as
				  funding becomes available for waiting list applicants, DMAS shall reexamine the
				  applications for program qualifications.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part III - HIV Premium Assistance Program › Section 12VAC30-100-310 - Authorization for benefits

Current through Register Vol. 40, No. 24, July 15, 2024
Authorization for benefits under this program shall be
					 granted until program termination, unless the recipient's status changes so
					 that he no longer meets the eligibility criteria.
Statutory Authority
§§ 32.1-325 and 32.1-330.1 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part III - HIV Premium Assistance Program › Section 12VAC30-100-320 - Notification

Current through Register Vol. 40, No. 24, July 15, 2024
The program shall inform an applicant, enrollee, or the
					 individual's representative of the individual's legal rights and obligations
					 and give written notice of the following:
1. The final determination on an application,
				  which shall include the reason or reasons if an applicant is found
				  ineligible;
2. The imminent
				  expiration of program authority and funding;
3. A notice of action to deny, cancel, or
				  suspend program benefits which shall:
a.
				  Include a statement of the proposed action, the reason for the action, and the
				  statutory or regulatory authority for the action;
b. Include notification of the right to
				  appeal the action;
c. Be mailed at
				  least 15 calendar days before the effective date of the action.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part III - HIV Premium Assistance Program › Section 12VAC30-100-330 - Appeals

Current through Register Vol. 40, No. 24, July 15, 2024
A. An applicant,
				  enrollee, or representative who is dissatisfied with a decision, action, or
				  inaction of the program may request and shall be granted an opportunity to
				  appeal, as provided for under the department's Client Appeals Regulations
				  (12VAC30-110-10 through
				  12VAC30-110-380 ).
B. The applicant or enrollee shall request in
				  writing reconsideration from the HIV Premium Assistance Program within 15 days
				  of the denial notice. DMAS will respond within five days to this request for
				  reconsideration. If the applicant or enrollee still disagrees with DMAS'
				  decision, he shall have the right to file an appeal in accordance with the
				  department's Client Appeals Regulations.
C. An enrollee shall be notified in writing
				  by the program that the program shall be responsible for the payment of health
				  insurance premiums until the appeal process is concluded. If the appeal results
				  in the enrollee being found ineligible for the program, the program shall seek
				  recovery in accordance with the department's recovery policies.
D. If an applicant is found eligible for the
				  program as a result of an appeal, the program shall reimburse the applicant
				  directly for premiums which were paid, beginning with a premium payment for the
				  month following the decision that was the subject of appeal. The applicant
				  shall provide proof of payment of premiums.
E. Cases on appeal which are in current
				  payment status shall be considered filled enrollee openings until the appeal
				  process has been completed.
Statutory Authority
§§ 32.1-325 and 32.1-330.1 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part III - HIV Premium Assistance Program › Section 12VAC30-100-340 - Health insurance premium payments

Current through Register Vol. 40, No. 24, July 15, 2024
A. Premium payments shall be made to the
				  employer, the insurer, or the enrollee, according to procedures established by
				  the program.
B. Applicants and
				  enrollees shall provide information as may be necessary for the payment of
				  health insurance premiums by the program, including but not limited to the name
				  and address of the employer or health insurance company, the last day of
				  employment, the type of policy, the amount of the premium, and the date by
				  which the premium must be paid.
C.
				  Payments under this program are limited to the cost of the health insurance
				  premium currently in effect and shall not include copayments, deductibles, or
				  any other costs incurred by the enrollees. Payments under this program shall
				  include coverage of family members if the enrollee's policy is the sole source
				  of health insurance.
Statutory Authority: §§
												32.1-325 and
						32.1-330.1 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part III - HIV Premium Assistance Program › Section 12VAC30-100-350 - Recovery

Current through Register Vol. 40, No. 24, July 15, 2024
In all cases in which program benefits have been
					 incorrectly paid or paid during an appeal in which the program action was
					 upheld, the program shall seek recovery from the payee, according to the
					 department's recovery policies.
Statutory Authority
§§ 32.1-325 and 32.1-330.1 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part III - HIV Premium Assistance Program › Section 12VAC30-100-360 - Fraud

Current through Register Vol. 40, No. 24, July 15, 2024
Cases of suspected misrepresentation or fraud shall be
					 investigated according to the department's fraud prevention and control
					 policies and any other applicable statutory provision.
Statutory Authority
§§ 32.1-325 and 32.1-330.1 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part III - HIV Premium Assistance Program › Section 12VAC30-100-370 - Confidentiality

Current through Register Vol. 40, No. 24, July 15, 2024
All information maintained by the program containing
					 personal data including name, address, employer, insurance company, HIV status,
					 application to or enrollment in the program, and any other information which
					 could identify or reasonably be used to identify any applicant or enrollee in
					 the program shall be maintained in confidence according to all applicable DMAS
					 policies and procedures and any other applicable laws or regulations. Such
					 information shall not be disclosed to any individual or organization without
					 the written and dated consent of the applicant, enrollee, or
					 representative.
Statutory Authority
§§ 32.1-325 and 32.1-330.1 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part IV - Health Insurance for the Working Uninsured › Form - FORMS (12VAC30-100)

Current through Register Vol. 40, No. 24, July 15, 2024
HIV Premium Assistance Program - Application
					 (3/97).
HIV Premium Payment Program - Physician's Verification
					 Form (3/97).
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.
"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.
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 2 - Appeal System › Section 12VAC30-110-20 - Appeals Division

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
						division maintains an appeals system for appellants to challenge
(i) actions, as defined in
						42 CFR
						431.201, regarding services and benefits
						provided by the department, and
(ii) adverse determinations regarding
						services provided by a nursing facility in accordance with § 1919(b)(3)(F)
						or 1919(e)(7)(B). Appellants shall be entitled to a hearing before a hearing
						officer. See Subpart II (12VAC30-110-130 et seq.) of this
						chapter.
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 2 - Appeal System › Section 12VAC30-110-30 - Time limitation for appeals

Current through Register Vol. 40, No. 24, July 15, 2024
Hearing officer appeals shall be scheduled and
						  conducted to comply with the 90-day time limitation imposed by federal
						  regulations, unless waived in writing by the appellant or the appellant's
						  representative.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 2 - Appeal System › Section 12VAC30-110-35 - Expedited appeals

Current through Register Vol. 40, No. 24, July 15, 2024
A. An
						appellant may request and the agency shall provide an expedited appeals process
						for claims for which the agency determines that the 90-day timeframe for
						conducting an appeal could jeopardize the individual's life, health, or ability
						to attain, maintain, or regain maximum function.
B. If an expedited appeal request is granted,
						the following timeframes for conducting the appeal apply from receipt of the
						appeal request:
1. Seventy-two hours for:
a. A claim related to services or benefits
						described in
						42 CFR
						431.220(a)(1);
b. A MCO, PIHP, or PAHP enrollee who is
						entitled to a hearing under Subpart F of 42 CFR Part 438;
c. An enrollee in a nonemergency medical
						transportation prepaid ambulatory health plan who has an action; and
d. An enrollee who is entitled to a hearing
						under Subpart B of 42 CFR Part 438.
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 2 - Appeal System › Section 12VAC30-110-40 - Judicial review

Current through Register Vol. 40, No. 24, July 15, 2024
An appellant who believes a final decision as defined
						  herein is incorrect may seek judicial review pursuant to The Administrative
						  Process Act (§ 2.2-4000 et seq. of the Code of Virginia) and Part 2A,
						  Rules of the Virginia Supreme Court.
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 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart I - General › Article 3 - Representation › Section 12VAC30-110-50 - Right to representation

Current through Register Vol. 40, No. 24, July 15, 2024
An appellant shall have the full right to
						  representation by an attorney or agent at all stages of
						  appeal.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 3 - Representation › Section 12VAC30-110-60 - Designation of representative

Current through Register Vol. 40, No. 24, July 15, 2024
A.
						Agents. An agent must be designated in a written statement which is signed by
						the appellant. If the appellant is physically or mentally unable to sign a
						written statement, the division may allow a family member or other person
						acting on appellant's behalf to represent the appellant.
B. Attorneys. If the agent is an attorney or
						a paralegal working under the supervision of an attorney, a signed statement by
						such attorney or paralegal that he is authorized to represent the appellant
						prepared on the attorney's letterhead, shall be accepted as a designation of
						representation.
C. Substitution. A
						member of the same law firm as a designated representative shall have the same
						rights as the designated representative.
D. Revocation. An appellant may revoke
						representation by another person at any time. The revocation is effective when
						the department receives written notice from the appellant.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 4 - Notice and Appeal Rights › Section 12VAC30-110-70 - Notification of adverse agency action

Current through Register Vol. 40, No. 24, July 15, 2024
The agency that takes action or makes an adverse
						  determination shall inform the applicant or recipient in a written
						  notice:
1. What action or adverse
						determination the agency intends to take;
2. The reasons for the intended action or
						adverse determination;
3. The
						specific regulations that support or the change in law that requires the action
						or adverse determination;
4. The
						right to request an evidentiary hearing, and the methods and time limits for
						doing so;
5. The circumstances
						under which benefits are continued if a hearing is requested (see
						12VAC30-110-100 ); and
6. The right to representation.
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 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart I - General › Article 4 - Notice and Appeal Rights › Section 12VAC30-110-80 - Advance notice

Current through Register Vol. 40, No. 24, July 15, 2024
When the agency plans to terminate, suspend, or reduce
						  an individual's eligibility or covered services, the agency must send the
						  notice described in
						  12VAC30-110-70 at least 10 days
						  before the date of action, except as otherwise permitted by federal
						  law.
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 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart I - General › Article 4 - Notice and Appeal Rights › Section 12VAC30-110-90 - Right to appeal

Current through Register Vol. 40, No. 24, July 15, 2024
An individual has the right to file an appeal
						  when:
1. His application for benefits
						administered by the department is denied. However, if an application for State
						and Local Hospitalization coverage is denied because of a lack of funds which
						is confirmed by the hearing officer, there is no right to appeal;
2. The agency takes action or proposes to
						take action that will adversely affect, reduce, or terminate his receipt of
						benefits;
3. His request for a
						particular medical service is denied, suspended, reduced, or terminated, in
						whole or in part;
4. The agency
						fails to take an application and/or fails to act with reasonable promptness on
						his application for benefits or request for a particular medical
						service;
5. The agency takes action
						or proposes to take action regarding the recovery of applicable medical
						assistance payments from a decedent's estate;
6. The agency takes action or proposes to
						take action regarding the recovery of expenditures for services received by
						ineligible individuals;
7. The
						agency takes action or proposes to take action regarding the recovery of
						expenditures paid on behalf of individuals whose coverage was continued during
						the appeals process; or
8. Federal
						regulations require that a fair hearing be granted.
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 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart I - General › Article 4 - Notice and Appeal Rights › Section 12VAC30-110-100 - Maintaining services

Current through Register Vol. 40, No. 24, July 15, 2024
A. If the
						agency sends the 10-day notice described in
						12VAC30-110-80 and the appellant
						files his Request for Appeal before the date of action, his services shall not
						be terminated or reduced until the hearing officer issues a final decision
						unless it is determined at the hearing that the sole issue is one of federal or
						state law or policy and the appellant is promptly informed in writing that
						services are to be terminated or reduced pending the final decision.
B. If the agency's action is sustained on
						appeal, the agency may institute any available recovery procedures against the
						appellant to recoup the cost of any services furnished to the appellant, to the
						extent they were furnished solely by reason of subsection A of this
						section.
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 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart I - General › Article 5 - Miscellaneous Provisions › Section 12VAC30-110-110 - Appeals Division records

Current through Register Vol. 40, No. 24, July 15, 2024
A.
						Removal of records. No person shall take from the division's custody any
						original record, paper, document, or exhibit that has been certified to the
						division except as the Director of the Appeals Division authorizes, or as may
						be necessary to furnish or transmit copies for other official
						purposes.
B. Confidentiality of
						records. Information in the appellant's record can be released only to a
						properly designated representative or other person or persons named in a
						release of information authorization signed by an appellant, his guardian, or
						power of attorney.
C. Fees. The
						fees to be charged and collected for any copies 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. Waiver of fees. When copies are requested
						from records in the division's custody, the required fee shall be waived if the
						copies are requested in connection with an individual's own review or
						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 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart I - General › Article 5 - Miscellaneous Provisions › Section 12VAC30-110-120 - Computation of time limits

Current through Register Vol. 40, No. 24, July 15, 2024
A.
						Acceptance of postmark date. Documents postmarked on or before a time limit's
						expiration shall be accepted as timely.
B. Computation of time limit. In computing
						any time period under these regulations, the day of the act or event from which
						the designated period of time begins to run shall be excluded and the last day
						included. If a time limit would expire on a Saturday, Sunday, or state or
						federal holiday, it shall be extended until the next regular business
						day.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart II - Hearing Officer Review › Article 1 - Commencement of Appeals › Section 12VAC30-110-130 - Request for appeal

Current through Register Vol. 40, No. 24, July 15, 2024
Subpart II
Hearing Officer Review
Any written communication from an appellant or his
						  representative which clearly expresses that he wants to present his case to a
						  reviewing authority shall constitute an appeal request. This communication
						  should explain the basis for the appeal.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart II - Hearing Officer Review › Article 1 - Commencement of Appeals › Section 12VAC30-110-140 - Place of filing a Request for Appeal

Current through Register Vol. 40, No. 24, July 15, 2024
A Request for Appeal shall be sent to the Appeals
						  Division.
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 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart II - Hearing Officer Review › Article 1 - Commencement of Appeals › Section 12VAC30-110-150 - Filing date

Current through Register Vol. 40, No. 24, July 15, 2024
The date of filing shall be the date the request is
						  postmarked, if mailed, or the date the request is received by the department,
						  if delivered other than by mail.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart II - Hearing Officer Review › Article 1 - Commencement of Appeals › Section 12VAC30-110-160 - Time limit for filing

Current through Register Vol. 40, No. 24, July 15, 2024
A Request for Appeal shall be filed within 30 days of
						  the appellant's receipt of the notice of an action or adverse determination
						  described in
						  12VAC30-110-70. It is presumed
						  that appellants will receive the notice five days after the agency mails the
						  notice unless the appellant shows that he did not receive the notice within the
						  five-day period. A Request for Appeal on the grounds that an agency has not
						  acted with reasonable promptness may be filed at any time until the agency has
						  acted.
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 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart II - Hearing Officer Review › Article 1 - Commencement of Appeals › Section 12VAC30-110-170 - Extension of time for filing

Current through Register Vol. 40, No. 24, July 15, 2024
An extension of the 30-day period for filing a Request
						  for Appeal may be granted for good cause shown. Examples of good cause include,
						  but are not limited to, the following situations:
1. Appellant was seriously ill and was
						prevented from contacting the division;
2. Appellant did not receive notice of the
						agency's decision;
3. Appellant
						sent the Request for Appeal to another government agency in good faith within
						the time limit;
4. Unusual or
						unavoidable circumstances prevented a timely filing.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart II - Hearing Officer Review › Article 1 - Commencement of Appeals › Section 12VAC30-110-180 - Provision of information

Current through Register Vol. 40, No. 24, July 15, 2024
Upon receipt of a Request for Appeal, the division
						  shall notify the appellant and his representative of general appeals procedures
						  and shall provide further detailed information upon request.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart II - Hearing Officer Review › Article 1 - Commencement of Appeals › Section 12VAC30-110-185 - Appeal summary

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
						agency proposing the action about which the individual requested the state
						hearing shall complete an appeal summary, which shall include:
1. The appellant's name and case name, if
						different;
2. The appellant's case
						number, Medicaid identification number, or other identifying
						information;
3. The local office
						responsible for the appellant's case;
4. A summary of the facts surrounding and the
						grounds supporting the adverse action;
5. Citations to the statutes, regulations,
						and specific provisions of the department's Medicaid manual or other policy
						that support the agency's action; and
6. The adverse benefit determination or the
						decision notice and any other documents relating to the appeal upon which the
						agency relied in making its decision.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart II - Hearing Officer Review › Article 1 - Commencement of Appeals › Section 12VAC30-110-185 - Appeal summary

Current through Register Vol. 40, No. 24, July 15, 2024
A. The agency
						proposing the action about which the individual requested the state fair
						hearing shall complete an appeal summary, which shall include:
1. The appellant's name and case name, if
						different;
2. The appellant's case
						number, Medicaid identification number, or other identifying
						information;
3. The agency or
						contractor responsible for the appellant's case;
4. A summary of the facts surrounding and the
						grounds supporting the action, the failure to take an application for benefits
						or to act with reasonable promptness on an application for benefits, a reported
						change in circumstances, or a request for a particular medical service. The
						summary of facts must include:
a. A list of
						the documents reviewed or relied upon, including those reviewed as part of the
						appeal.
b. A narrative explanation
						describing the agency's or contractor's position on the action when considering
						all documentation submitted until the appeal summary is filed. When the action
						under appeal is for a reduction of termination of existing coverage, the
						narrative should include an explanation as to what has changed or how the
						previous approval was made in error.
5. Citations to the statutes, regulations,
						and specific provisions of the Virginia Medical Assistance Eligibility manual
						or other policy that support the agency's action; and
6. The adverse benefit determination or the
						decision notice and any other documents relating to the appeal upon which the
						agency relied in making its decision.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart II - Hearing Officer Review › Article 2 - Prehearing Review › Section 12VAC30-110-190 - Review

Current through Register Vol. 40, No. 24, July 15, 2024
A hearing officer shall initially review an assigned
						  case for compliance with prehearing requirements and may communicate with the
						  appellant or his representative and the agency to confirm the agency action and
						  schedule the hearing.
Statutory Authority
§ 32.1-325 of the Code of Virginia.