Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part I - General Provisions › Section 12VAC30-141-10 - 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 a local department of social services, the
					 central processing unit, or other entity designated by DMAS to make eligibility
					 determinations for FAMIS.
"Agent" means an individual designated in writing to act on
					 behalf of a FAMIS 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 child who has filed an application (or
					 who has an application filed on his behalf) for child health insurance and is
					 awaiting a determination of eligibility. A child is an applicant until his
					 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, 18 years of age
					 or older, who is authorized to conduct the personal or financial affairs for an
					 individual.
"Central processing unit" or "CPU" means Cover Virginia,
					 which is the centralized entity supported by DMAS to accept and act on
					 applications for health insurance.
"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
					 FAMIS.
"DMAS" or "department" means the Department of Medical
					 Assistance Services.
"Ex parte review" means the review of administratively
					 available information pertinent to the application or renewal process,
					 conducted by eligibility staff, in order to expediently process the applicant's
					 renewal without seeking that information from the applicant.
"Family," when used in the context of the FAMIS Select
					 component, means a unit or group that has access to a private or employer's
					 group health plan. Thus, it includes the policyholder or employee and any
					 dependents who can be covered under the plan.
"FAMIS" means the Family Access to Medical Insurance
					 Security Plan.
"FAMIS Select" means an optional program available to
					 children determined eligible for FAMIS, whereby DMAS provides premium
					 assistance to the family to cover the child through a private or
					 employer-sponsored health plan instead of directly through the FAMIS
					 program.
"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.
"Fixed premium assistance amount" means a predetermined
					 amount of premium assistance that DMAS will pay per child to a family who
					 chooses to enroll its FAMIS eligible child in a private or employer-sponsored
					 health plan. The fixed premium assistance amount will be determined annually by
					 DMAS to ensure that the FAMIS Select program is cost-effective as compared to
					 the cost of covering a child directly through the FAMIS program.
"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.
"Household" means the household composition and follows the
					 federal tax rules through the use of modified adjusted gross income (MAGI)
					 methodology. An individual's household is based upon the tax filing
					 relationships of applicant, persons living with the individual, and those
					 claimed as dependents and as outlined in 42 USC § 435.603(3)(f)(1) through
					 (f)(4)
"Household income" means the sum of MAGI-based income as
					 outlined in 42 USC § 435.603(3)(d) through (3)(e) to include every
					 individual in the household.
"Internal appeal" means a request to the MCO by an
					 enrollee, an enrollee's authorized representative, or a provider, acting on
					 behalf of the enrollee and with the enrollee's written consent, for review of
					 an MCO's adverse benefit determination. The internal appeal is the only level
					 of appeal with the MCO and must be exhausted by an enrollee or deemed exhausted
					 according to
					 42 CFR
					 438.408(c)(3) before the
					 enrollee may initiate a state fair hearing.
"Lawfully residing" means the individual is lawfully
					 present in the United States.
"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 "MCHIP" is defined
					 in §
										32.1-137.1 of the
					 Code of Virginia.
"Premium assistance" means the portion of the family's cost
					 of participating in a private or employer's health plan that DMAS will pay to
					 cover the FAMIS-eligible children under the private or employer-sponsored plan
					 if DMAS determines it is cost effective to do so.
"Private or employer-sponsored health plan" means a health
					 insurance policy that is either purchased by an individual directly or through
					 an employer. This component of FAMIS refers to the ability of DMAS to provide
					 coverage to FAMIS-eligible children by providing premium assistance to families
					 who enroll the FAMIS-eligible children in a private or employer-sponsored
					 health plan.
"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 enrollees eligible for
					 services.
"Reasonable opportunity period" means a 90-calendar-day
					 period given to applicants to supply verification of citizenship and
					 identity.
"State fair hearing" means, consistent with
					 42 CFR
					 438.400, the process set forth in 42 CFR 431
					 Subpart E.
"Targeted low-income child" means an uninsured child
					 younger than age 19 years whose household income is within the FAMIS
					 eligibility standards established by the Commonwealth.
"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.