Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part II - Appeal of Adverse Actions › Section 12VAC30-141-40 - Appeal of adverse actions or adverse benefit determinations

Current through Register Vol. 40, No. 24, July 15, 2024
A. Upon written
				  request, all FAMIS 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 and to an internal appeal of an adverse benefit
				  determination made by an 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. 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 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 is 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 the local department of social services, MCO, CPU, or DMAS
				  to meet the timeframes set in this chapter or set in the MCO or DMAS written
				  appeal procedures constitute a basis for granting the applicant or enrollee the
				  relief sought.
I. Adverse actions
				  related to health benefits covered through the FAMIS Select program shall be
				  resolved between the insurance company or employer's plan and the FAMIS Select
				  enrollee and are not subject to further appeal by DMAS or its
				  contractors.
Statutory Authority: §
												32.1-325 of the Code of
						Virginia; 42 USC §
													1396 et
						seq.