Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 120 - WAIVERED SERVICES › Part VII - Assisted Living Services for Individuals Receiving Auxiliary Grants Residing in Adult Care Residences › Section 12VAC30-120-600 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this part shall
					 have the following meanings unless the context clearly indicates
					 otherwise:
"Adverse action" means the denial, suspension, or reduction
					 in services or the denial or retraction, in whole or in part, of payment for a
					 service that has already been rendered.
"Adverse benefit determination" means, consistent with 42
					 CFR 438.400, any of the following: (i) the denial or limited authorization of a
					 requested service, including determinations based on the type or level of
					 service, requirements for medical necessity, appropriateness, setting, or
					 effectiveness of a covered benefit; (ii) the reduction, suspension, or
					 termination of a previously authorized service; (iii) the denial, in whole or
					 in part, of payment for a service; (iv) the failure to provide services in a
					 timely manner, as defined by the state; (v) the failure of an MCO, PIHP, or
					 PAHP to act within the timeframes provided in 42 CFR 438.408(b)(1) and 42 CFR
					 438.408(b)(2) regarding the standard resolution of grievances and appeals; (vi)
					 for a resident of a rural area with only one MCO, the denial of an enrollee's
					 request to exercise the enrollee's right under 42 CFR 438.52(b)(2)(ii) to
					 obtain services outside the network; or (vii) the denial of an enrollee's
					 request to dispute a financial liability, including cost sharing, copayments,
					 premiums, deductibles, coinsurance, and other enrollee financial liabilities.
"Appellant" means an applicant for or recipient of Medicaid
					 benefits who seeks to challenge an adverse benefit determination taken by the
					 participating plan, subcontractor, service provider, or DMAS regarding
					 eligibility for services and payment determinations.
"Authorized representative" means the same as set forth in
					 12VAC30-110-1380
					 and
					 12VAC30-110-1390.
"Centers for Medicare and Medicaid Services" or "CMS" means
					 the federal agency of the U.S. Department of Health and Human Services that is
					 responsible for the administration of Titles XVIII, XIX, and XXI of the Social
					 Security Act.
"Commonwealth Coordinated Care Plus program" or "CCC Plus"
					 means the department's mandatory integrated care initiative for certain
					 qualifying individuals, including dual eligible individuals and individuals
					 receiving long-term services and supports (LTSS). The CCC Plus program includes
					 individuals who receive services through nursing facility (NF) care or from the
					 four home and community-based services (HCBS) § 1915(c) waivers.
"Continuity of care period" means a set period of time
					 during which the MCO shall ensure a seamless transition from Medicaid FFS, or
					 from another MCO, for all members upon enrollment into a plan.
"Contractor" means a managed care health plan selected by
					 DMAS and contracted to participate in the CCC Plus program.
"Covered services" means the set of required services
					 offered by the participating plan.
"Department of Medical Assistance Services," "department,"
					 or "DMAS" means the Virginia Department of Medical Assistance Services, the
					 single state agency for the Medicaid program in Virginia that is responsible
					 for implementation and oversight of CCC Plus.
"Disenrollment" means the process of changing enrollment
					 from one participating plan to another participating plan or the process of
					 being excluded from CCC Plus by the department as described in
					 12VAC30-120-610.
"Division" or "Appeals Division" means the Appeals Division
					 of the Department of Medical Assistance Services.
"Dual eligible" means a Medicare member who receives
					 Medicare Parts A, B, and D benefits and also receives full Medicaid
					 benefits.
"Effective date" means the date on which a participating
					 plan's coverage begins for a member.
"Enrollment" means assignment of an individual to a health
					 plan by the department in accordance with the terms of the contract with the
					 participating plan. This does not include attaining eligibility for the
					 Medicaid program.
"Enrollment broker" means an independent contractor that
					 enrolls individuals in the contractor's plan and is responsible for the
					 operation and documentation of a toll-free individual service helpline. The
					 responsibilities of the enrollment broker include individual education and MCO
					 enrollment and assistance with and tracking of individuals' complaints and
					 their resolutions and may include individual marketing and outreach.
"Enrollment period" means the time that a member is
					 actually enrolled in a participating plan.
"External appeal" means an appeal, subsequent to the
					 participating plan internal appeal or reconsideration decision, to the state
					 fair hearing process (for a member appeal) or informal appeals process (for a
					 provider appeal).
"Fee-for-service" or "FFS" means the traditional health
					 care payment system in which physicians and other providers receive a payment
					 for each service they provide.
"Final decision" means a written determination by a
					 department hearing officer from an appeal of an internal appeal decision that
					 is binding on the department, unless modified during or after the judicial
					 process.
"Handbook" means a document prepared by the MCO and
					 provided to the member that is consistent with the requirements of 42 CFR
					 438.10 and the CCC Plus contract and includes information about all the
					 services covered by that plan.
"Hearing officer" means an impartial decision maker who
					 conducts evidentiary state fair hearings for member appeals on behalf of the
					 department.
"Internal appeal" means an oral or a written request to the
					 MCO by a member, a member's authorized representative, or a provider acting on
					 behalf of the member and with the member's written consent for review of a
					 contractor's adverse benefit determination. The internal appeal is the only
					 level of appeal with the MCO and must be exhausted by a member or deemed
					 exhausted according to 42 CFR 438.408(c)(3) before the member may initiate a
					 state fair hearing.
"Long-term services and supports" or "LTSS" means a variety
					 of services and supports that (i) help elderly members and members with
					 disabilities who need assistance to perform activities of daily living and
					 instrumental activities of daily living to improve the quality of their lives
					 and (ii) are provided over an extended period, predominantly in homes and
					 communities, but also in facility-based settings such as nursing
					 facilities.
"MCO" means a health plan selected to participate in
					 Virginia's CCC Plus program. "MCO" means the same as "participating
					 plan."
"Medicaid" means the program of medical assistance benefits
					 under Title XIX of the Social Security Act.
"Medically complex" means those who have a complex medical
					 or behavioral health condition and a functional impairment or an intellectual
					 or developmental disability.
"Medically necessary" or "medical necessity" means an item
					 or service provided for the diagnosis or treatment of an enrollee's condition
					 consistent with standards of medical practice and in accordance with Virginia
					 Medicaid policy (12VAC30-130-600 et
					 seq.) or EPSDT criteria, for those younger than 21 years of age, in accordance
					 with 42 CFR 441 Subpart B (§§ 50 through 62), 42 CFR 438.210, and 42
					 CFR 440.230.
"Medicare" means Title XVIII of the Social Security Act,
					 the federal health insurance program for people age 65 years or older, people
					 younger than 65 years of age who have certain disabilities, and people with end
					 stage renal disease or amyotrophic lateral sclerosis.
"Member" means an individual who has enrolled in a
					 participating plan to receive services under CCC plus.
"Member appeal" means a member's request for review of an
					 adverse benefit determination.
"Network provider" means a doctor, hospital, or other
					 health care provider that participates or contracts with a participating plan
					 and, as a result, agrees to accept a mutually-agreed upon payment amount or fee
					 schedule as payment in full for covered services that are rendered to eligible
					 members.
"Nursing facility" means any skilled nursing facility,
					 skilled care facility, intermediate care facility, nursing care facility, or
					 nursing facility, whether freestanding or a portion of a freestanding medical
					 care facility, that is certified for participation as a Medicare or Medicaid
					 provider, or both, pursuant to Title XVIII and Title XIX of the Social Security
					 Act, as amended, and §
										32.1-137
					 of the Code of Virginia.
"Open enrollment" means the timeframe in which members are
					 permitted to change from one MCO to another without cause.
"Participating plan" means the same as "MCO."
"Previously authorized" means, in relation to continuation
					 of benefits, as described in 42 CFR 438.420, a prior approved course of
					 treatment.
"Primary care provider" means a practitioner who provides
					 preventive and primary medical care and certifies service authorizations and
					 referrals for medically necessary specialty services. Primary care providers
					 may include pediatricians, family and general practitioners, internists,
					 obstetricians or gynecologists, geriatricians, specialists who perform primary
					 care functions (such as surgeons), and clinics, including local health
					 departments, federally qualified health centers, and rural health
					 clinics.
"Program of All-Inclusive Care for the Elderly" or "PACE"
					 means the program in which the PACE provider provides the entire spectrum of
					 health services (preventive, primary, and acute) and long-term services and
					 supports to its members without limit as to duration or cost of services
					 pursuant to
					 12VAC30-50-320
					 et seq.
"Provider appeal" means an appeal to the department filed
					 by a Medicaid-enrolled or network service provider that has already provided a
					 service to a member and has received an adverse reconsideration decision
					 regarding service authorization, payment, or audit result.
"Reconsideration" means a provider's request to the MCO for
					 review of an adverse action related to service authorization or payment. The
					 MCO's reconsideration decision is a prerequisite to a provider's filing of an
					 appeal to the Appeals Division.
"Remand" means the return of a case by the department's
					 hearing officer to the MCO for further review, evaluation, and action.
"Reverse" means to overturn the MCO's internal appeal
					 decision and to direct that the MCO fully approve the amount, duration, and
					 scope of requested services.
"Social Security Act" means the federal act, codified
					 through Chapter 7 of Title 42 of the United States Code, that established
					 social insurance programs including Medicare and Medicaid.
"State fair hearing" means the DMAS evidentiary hearing as
					 administered by the Appeals Division. A state fair hearing is conducted by a
					 department hearing officer to allow a member the opportunity to present the
					 member's concerns with or objections to the participating plan's internal
					 appeal decision.
"Subcontractor" means an entity that has contracted with
					 the contractor to perform part of the responsibilities within the CCC Plus
					 program. All subcontractors shall be approved by DMAS.
"Sustain" means to uphold the MCO's appeal decision.
"Withdraw" means a written request from the member or the
					 member's authorized representative for the department to terminate the member
					 appeal.
Statutory Authority: §
												32.1-325
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.