reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-150 - Amount, duration, and scope of services: Medically needy

Current through Register Vol. 40, No. 24, July 15, 2024
A. This State Plan
				  covers the medically needy. The services described in this section and in Part
				  II (12VAC30-50-40 et seq.) of
				  12VAC30-50 are provided. Services for medically needy include:
1. If services in an institution for mental
				  diseases ( 42 CFR
				  440.140 and
				  440.160 ) or an intermediate care
				  facility for the mentally retarded (or both) are provided to any medically
				  needy group, then each medically needy group is provided either the services
				  listed in § 1905(a)(1) through (5) and (17) of the Act, or seven of the
				  services listed in § 1902(a)(1) through (20). The services are provided as
				  defined in 42 CFR 440, Subpart A and in §§ 1902, 1905, and 1915 of
				  the Act.
Subdivision 1 of this subsection is applicable with
					 respect to nurse-midwife services under § 1902(a)(17).
2. Prenatal care and delivery services for
				  pregnant women.
3.
				  Pregnancy-related, including family planning services, and postpartum services
				  for a 60-day period (beginning on the day the pregnancy ends) and any remaining
				  days in the month in which the sixtieth day falls are provided to women who,
				  while pregnant, were eligible for, applied for, and received medical assistance
				  on the day the pregnancy ends.
4.
				  Services for any other medical condition that may complicate the pregnancy
				  (other than pregnancy-related and postpartum services) are provided to pregnant
				  women.
5. Ambulatory services as
				  defined in
				  12VAC30-50-40 for recipients under
				  age 18 and recipients entitled to institutional services.
6. Home health services to recipients
				  entitled to nursing facility services as indicated in
				  12VAC30-10-220.
7. Services for the medically needy do not
				  include services in an institution for mental diseases for individuals over age
				  65.
8. Services for the medically
				  needy do not include services in an intermediate care facility for the mentally
				  retarded.
9. Services for the
				  medically needy do not include inpatient psychiatric services for individuals
				  under age 21, other than those covered under early and periodic screening,
				  diagnosis, and treatment (at
				  12VAC30-50-130 ).
10. Services for the medically needy do not
				  include respiratory care services provided to ventilator dependent individuals.
				  See 12VAC30-10-300.
11. Home and community care for functionally
				  disabled elderly individuals is not covered.
12. Program of All-Inclusive Care for the
				  Elderly (PACE) services as described and limited in Supplement 6 to Attachment
				  3.1-A (12VAC30-50-320,
				  12VAC30-50-321,
				  12VAC30-50-325, and
				  12VAC30-50-328 ) are
				  covered.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-160 - Amount, duration, and scope of services: Other required special groups

Current through Register Vol. 40, No. 24, July 15, 2024
A. Qualified
				  Medicare beneficiaries. Medicare cost sharing for qualified Medicare
				  beneficiaries described in § 1905(p) of the Act is provided only as
				  indicated in
				  12VAC30-10-310.
B. Qualified disabled and working
				  individuals. Medicare Part A premiums for qualified disabled and working
				  individuals described in § 1902(a)(10)(E)(ii) of the Act are provided as
				  indicated in
				  12VAC30-10-310.
C. Specified low-income Medicare
				  beneficiaries. Medicare Part B premiums for specified low-income Medicare
				  beneficiaries described in § 1902(a)(10)(E)(iii) of the Act are provided
				  as indicated in
				  12VAC30-10-310.
D. Qualifying Individuals-1. Medicare Part B
				  premiums for qualifying individuals described in § 1902(a)(10)(E)(iv)(I)
				  and subject to § 1933 of the Act are provided as indicated in
				  12VAC30-10-310.
E. Qualifying Individuals-2. The portion of
				  the amount of increase to the Medicare Part B premium attributable to the home
				  health provisions for qualifying individuals described in §
				  1902(a)(10)(E)(iv)(II) and subject to § 1933 of the Act are provided as
				  indicated in
				  12VAC30-10-310.
F. Families receiving extended Medicaid
				  benefits. Extended Medicaid benefits for families described in § 1925 of
				  the Act are provided as indicated in
				  12VAC30-10-300.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-170 - Amount, duration, and scope of services: Limited coverage for certain aliens

Current through Register Vol. 40, No. 24, July 15, 2024
A. Aliens
				  granted lawful temporary resident status under § 245A of the Immigration
				  and Nationality Act who meet the financial and categorical eligibility
				  requirements under the approved State Medicaid plan are provided the services
				  covered under the plan if they--
1. Are aged,
				  blind, or disabled individuals as defined in § 1614(a)(1) of the
				  Act;
2. Are children under 18 years
				  of age; or
3. Are Cuban or Haitian
				  entrants as defined in § 501(e)(1) and (2)(A) of P.L. 96-422 in effect on
				  April 1, 1983.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-180 - Amount, duration, and scope of services: Homeless individuals

Current through Register Vol. 40, No. 24, July 15, 2024
Clinic services furnished to eligible individuals who do
					 not reside in a permanent dwelling or do not have a fixed home or mailing
					 address are provided without restrictions regarding the site at which the
					 services are furnished.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-190 - Amount, duration, and scope of services: Presumptively eligible pregnant women

Current through Register Vol. 40, No. 24, July 15, 2024
Ambulatory prenatal care for pregnant women is not
					 provided during a presumptive eligibility period.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-200 - Amount, duration, and scope of services: EPSDT services

Current through Register Vol. 40, No. 24, July 15, 2024
The Medicaid agency meets the requirements of §
					 1902(a)(43), 1905(a)(4)(B), and 1905(r) of the Act with respect to early and
					 periodic screening, diagnostic, and treatment (EPSDT) services.
The Medicaid agency does not have in effect agreements
					 with continuing care providers.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-210 - Amount, duration, and scope of services: Comparability of services

Current through Register Vol. 40, No. 24, July 15, 2024
Except for those items or services for which §
					 1902(a), 1902(a)(10), 1903(v), 1915 and 1925 of the Act,
					 42 CFR
					 440.250, and § 245A of the Immigration
					 and Naturalization Act, permit exceptions:
A. Services made available to the
				  categorically needy are equal in amount, duration, and scope for each
				  categorically needy person.
B. The
				  amount, duration, and scope of services made available to the categorically
				  needy are equal to or greater than those made available to the medically
				  needy.
C. Services made available
				  to the medically needy are equal in amount, duration, and scope for each person
				  in a medically needy coverage group.
D. Additional coverage for pregnancy-related
				  services and services for conditions that may complicate the pregnancy are
				  equal for categorically and medically needy.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-220 - Amount, duration, and scope of services: home health services

Current through Register Vol. 40, No. 24, July 15, 2024
Home health services are provided in accordance with the
					 requirements of 42 CFR
					 441.15.
A. Home health services are provided to all
				  categorically needy individuals 21 years of age or over.
B. Home health services are provided to all
				  categorically needy individuals under 21 years of age.
C. Home health services are provided to all
				  the medically needy whether the individuals are under or over 21 years of
				  age.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-230 - Amount, duration, and scope of services: Assurance of transportation

Current through Register Vol. 40, No. 24, July 15, 2024
Provision is made for assuring necessary transportation of
					 recipients to and from providers. Methods used to assure such transportation
					 are described in
					 12VAC30-50-530.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-240 - Amount, duration, and scope of services: Payment for nursing facility services

Current through Register Vol. 40, No. 24, July 15, 2024
The state includes in nursing facility services at least
					 the items and services specified in
					 42 CFR
					 483.10(f)(11).
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 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-250 - Amount, duration, and scope of services: Methods and standards to assure quality of services

Current through Register Vol. 40, No. 24, July 15, 2024
The standards established and the methods used to assure
					 high quality care are described in
					 12VAC30-60-10 et
					 seq.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-260 - Amount, duration, and scope of services: Family planning services

Current through Register Vol. 40, No. 24, July 15, 2024
The requirements of
					 42 CFR
					 441.20 are met regarding freedom from
					 coercion or pressure of mind and conscience, and freedom of choice of method to
					 be used for family planning.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-270 - Amount, duration, and scope of services: Optometric services

Current through Register Vol. 40, No. 24, July 15, 2024
Optometric services are provided. Services of the type an
					 optometrist is legally authorized to perform are specifically included in the
					 term "physicians' services" under this plan and are reimbursed whether
					 furnished by a physician or an optometrist.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-280 - Amount, duration, and scope of services: Organ transplant procedures

Current through Register Vol. 40, No. 24, July 15, 2024
Organ Transplant procedures are provided. Similarly
					 situated individuals are treated alike and any restrictions on the facilities
					 that may, or practitioners who may, provide those procedures is consistent with
					 the accessibility of high quality care to individuals eligible for the
					 procedures under this plan. Standards for the coverage of organ transplant
					 procedures are described at
					 12VAC30-50-540.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-290 - Amount, duration, and scope of services: Participation by Indian Health Service facilities

Current through Register Vol. 40, No. 24, July 15, 2024
Indian Health Service facilities are accepted as
					 providers, in accordance with
					 42 CFR
					 431.110(b), on the same
					 basis as other qualified providers.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-300 - Amount, duration, and scope of services: Respiratory care services for ventilator-dependent individuals

Current through Register Vol. 40, No. 24, July 15, 2024
Respiratory care services, as defined in §
					 1902(e)(9)(C) of the Act, are not included in the plan.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-310 - Coordination of Medicaid with Medicare and other insurance: Premiums

Current through Register Vol. 40, No. 24, July 15, 2024
A. Medicare Part A
				  and Part B.
1. Qualified Medicare Beneficiary
				  (QMB).
The Medicaid agency pays Medicare Part A premiums (if
					 applicable) and Part B premiums for individuals in the QMB group defined in
					 subsection 25 of
					 12VAC30-30-10 through the group
					 premium payment arrangement, unless the agency has a buy-in agreement for such
					 payment, as indicated in Part B.
The Medicaid agency does not pay premiums, for which the
					 beneficiary would be liable, for enrollment in an HMO participating in
					 Medicare.
2. Qualified
				  Disabled and Working Individual (QDWI). The Medicaid agency pays Medicare Part
				  A premiums under a group premium payment arrangement for individuals in the
				  QDWI group defined in subsection 26 of
				  12VAC30-30-10 of this
				  plan.
3. Specified Low-Income
				  Medicare Beneficiary (SLMB). The Medicaid agency pays Medicare Part B premiums
				  under the State buy-in process for individuals in the SLMB group defined in
				  subsection 27 of
				  12VAC30-30-10 of this
				  plan.
4. Other Medicaid Recipients.
The Medicaid agency pays Medicare Part B premiums to make
					 Medicare Part B coverage available to all individuals who are a) receiving
					 benefits under Titles I, IV-A, X, XIV, or XVI (AABD or SSI); b) receiving State
					 supplements under Title XVI; or c) within a group listed at
					 42 CFR
					 431.625(d)(2).
The Medicaid agency does not pay Medicare Part B premiums
					 for individuals receiving Title II or Railroad Retirement benefits.
The Medicaid agency does not pay Medicare Part B premiums
					 for medically needy individuals (Federal Financial Participation is not
					 available for this group).
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-320 - Coordination of Medicaid with Medicare and other insurance: Deductibles/coinsurance

Current through Register Vol. 40, No. 24, July 15, 2024
A. Medicare Part A and
B.
										12VAC30-80-170 describes the
				  methods and standards for establishing payment rates for services covered under
				  Medicare, and/or the methodology for payment of Medicare deductible and
				  coinsurance amounts, to the extent available for each of the following groups.
1. Qualified Medicare Beneficiaries (QMBS).
				  The Medicaid agency pays Medicare Part A and Part B deductibles and coinsurance
				  amounts for QMBs (subject to any nominal Medicaid copayment) for all services
				  available under Medicare.
2. Other
				  Medicaid Recipients. The Medicaid agency pays Medicaid services also covered
				  under Medicare and furnished to recipients entitled to Medicare (subject to any
				  nominal Medicaid copayment). For services furnished to individuals who are
				  described in
				  12VAC30-10-310 A 4, payment is
				  only for the amount, duration, and scope of services otherwise available under
				  this plan.
3. Dual Eligible--QMB
				  plus. The Medicaid agency pays Medicare Part A and Part B deductible and
				  coinsurance amounts for all services available under Medicare and pays for all
				  Medicaid services furnished to individuals eligible both as QMBs and
				  categorically or medically needy (subject to any nominal Medicaid
				  copayment).
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-325 - Premiums, deductibles, coinsurance and other cost sharing obligations

Current through Register Vol. 40, No. 24, July 15, 2024
A. Pursuant to
				  § 1906 of the Act, the Medicaid agency pays all premiums, deductibles,
				  coinsurance, and other cost sharing obligations for items and services covered
				  under the State plan (subject to any nominal Medicaid copayment) for eligible
				  individuals in employer-based cost-effective group health plans.
B. When coverage for eligible family members
				  is not possible unless ineligible family members enroll, the Medicaid agency
				  pays premiums for enrollment of other family members when cost-effective. In
				  addition, the eligible individual is entitled to services covered by the State
				  plan which are not included in the group health plan. Guidelines for
				  determining cost effectiveness are described in
				  12VAC30-10-610 H.
C. Pursuant to § 1906A of the Act, the
				  Medicaid agency pays all premiums, deductibles, coinsurance, and other cost
				  sharing obligations for items and services covered under the State Plan, as
				  specified in the qualified employer-sponsored coverage, without regard to
				  limitations specified in § 1916 or § 1916A of the Act, for eligible
				  individuals under age 19 who have access to and elect to enroll in such
				  coverage. The eligible individual is entitled to services covered by the State
				  Plan that are not included in the employer-sponsored coverage. For qualified
				  employer-sponsored coverage, the employer must contribute at least 40% of the
				  premium cost.
When coverage for eligible family members under age 19 is
					 not possible unless an ineligible family member enrolls, the Medicaid agency
					 pays premiums for enrollment of the ineligible family member and, at the option
					 of the parent or legal guardian, other family members that are eligible for
					 coverage under the employer-sponsored plan. The agency also pays deductibles,
					 coinsurance, and other cost-sharing obligations for items and services covered
					 under the State Plan for the ineligible family member.
					 12VAC30-20-205 provides a detailed
					 description of this program.
D. The Medicaid agency pays premiums for
				  individuals described in subsection 19 of
				  12VAC30-30-10.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-330 - Medicaid for individuals age 65 or over in institutions for mental diseases

Current through Register Vol. 40, No. 24, July 15, 2024
Medicaid is provided for individuals 65 years of age or
					 older who are patients in institutions for mental diseases.
The requirements of 42 CFR 441, Subpart C, and
					 42 CFR
					 431.620(c) and (d) are
					 met.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-340 - Special requirements applicable to sterilization procedures

Current through Register Vol. 40, No. 24, July 15, 2024
All requirements of 42 CFR 441, Subpart F are
					 met.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-350 - Families receiving extended Medicaid benefits

Current through Register Vol. 40, No. 24, July 15, 2024
A. Services provided to families during the
				  first 6-month period of extended Medicaid benefits under § 1925 of the Act
				  are equal in amount, duration, and scope to services provided to categorically
				  needy AFDC recipients as described in
				  12VAC30-50-10 (or may be greater
				  if provided though a caretaker relative employer's health insurance
				  plan).
B. Services provided to
				  families during the second 6-month period of extended Medicaid benefits under
				  § 1925 of the Act are equal in amount, duration and scope to services
				  provided to categorically needy AFDC recipients as described in
				  12VAC30-50-10 et seq. (or may be
				  greater if provided through a caretaker relative employer's health insurance
				  plan).
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part III - Services; General Provisions › Section 12VAC30-10-360 to 12VAC30-10-390 - Reserved

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-400 - Methods of administration

Current through Register Vol. 40, No. 24, July 15, 2024
The Medicaid agency employs methods of administration found
					 by the Secretary of Health and Human Services to be necessary for the proper
					 and efficient operation of the plan.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-410 - Hearings for applicants and recipients

Current through Register Vol. 40, No. 24, July 15, 2024
A. The Medicaid agency has a system of
				  hearings that meets all the requirements of 42 CFR 431, Subpart E.
The Medicaid agency is responsible for all Medicaid fair
					 hearings.
B. The entities
				  that conduct fair hearings with respect to eligibility based on applicable
				  modified adjusted gross income (MAGI) are the Department of Medical Assistance
				  Services (DMAS) and the Health and Human Services appeals entity within the
				  Exchange.
C. The Commonwealth
				  assures the following with respect to delegations of authority to conduct fair
				  hearings regarding eligibility based on MAGI:
1. There is a written agreement between DMAS
				  and the Exchange appeals entity that has been delegated authority to conduct
				  Medicaid fair hearings in compliance with
				  42 CFR
				  431.10(d).
2. When authority is delegated to the
				  Exchange appeals entity, individuals who have requested a fair hearing are
				  given the option to have their hearing conducted instead by DMAS.
3. DMAS does not delegate authority to
				  conduct fair hearings to entities other than government agencies that maintain
				  personnel standards on a merit basis.
4. The delegated entity is capable of
				  performing the delegated function.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-420 - Safeguarding information on applicants and recipients

Current through Register Vol. 40, No. 24, July 15, 2024
Under State statute which imposes legal sanctions,
					 safeguards are provided that restrict the use or disclosure of information
					 concerning applicants and recipients to purposes directly connected with the
					 administration of the plan.
All other requirements of 42 CFR 431, Subpart F are
					 met.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-430 - Medicaid quality control

Current through Register Vol. 40, No. 24, July 15, 2024
A. A
				  system of quality control is implemented in accordance with 42 CFR 431, Subpart
				  P.
B. The state does not operate a
				  claims processing assessment system that meets the requirements of
				  42 CFR
				  431.808, 42 CFR 431.818,
				  42 CFR
				  431.830, 42 CFR 431.832,
				  42 CFR
				  431.834, and 42 CFR 431.836. The state has an
				  approved Medicaid Management Information System (MMIS).
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 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-435 - Medicaid prohibition on payments to institutions or entities located outside of the United States

Current through Register Vol. 40, No. 24, July 15, 2024
The state shall not provide any payments for items or
					 services provided under the state plan or under a waiver to any financial
					 institution or entity located outside of the United States.
Statutory Authority
§ 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-440 - Medicaid Agency Fraud Detection and Investigation Program

Current through Register Vol. 40, No. 24, July 15, 2024
The Medicaid agency has established and will maintain
					 methods, criteria, and procedures that meet all requirements of
					 42 CFR
					 455.13 through
					 455.21 and
					 455.23 for prevention and control
					 of program fraud and abuse.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-441 - Medicaid agency fraud detection and investigation program

Current through Register Vol. 40, No. 24, July 15, 2024
The Medicaid agency has established a mechanism to receive
					 reports from beneficiaries and others and compile data concerning alleged
					 instances of waste, fraud, and abuse relating to the operation of this
					 chapter.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-445 - Recovery audit contractors

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  The state has established a program under which it will contract with one or
				  more recovery audit contractors (RACs) for the purpose of identifying
				  underpayments and overpayments of Medicaid claims under the State Plan and
				  under any waiver of the State Plan.
B. The state/Medicaid agency has contracts of
				  the type listed in § 1902(a)(42)(B)(ii)(I) of the Act. All contracts meet
				  the requirements of the statute. RACs are consistent with the
				  statute.
C. The state will make
				  payments to the RACs only from amounts recovered.
D. The state will make payments to the RACs
				  on a contingent basis for collecting overpayments.
E. The state attests that the contingency fee
				  rate paid to the Medicaid RAC will not exceed the highest rate paid to Medicare
				  RACs as published in the Federal Register.
F. The payment methodology used to determine
				  state payments to Medicaid RACs for the identification of underpayments will be
				  based upon the percentage of the contingency fee.
G. The state has an adequate appeal process
				  in place for entities to appeal any adverse determination made by the Medicaid
				  RACs.
H. The state assures that the
				  amounts expended by the state to carry out the program will be amounts expended
				  as necessary for the proper and efficient administration of the State Plan or a
				  waiver of the plan.
I. The state
				  assures that the recovered amounts will be subject to a state's quarterly
				  expenditure estimates and funding of the state's share.
J. Efforts of the Medicaid RACs will be
				  coordinated with other contractors or entities performing audits of entities
				  receiving payments under the State Plan or waiver in the state, and/or state
				  and federal law-enforcement entities and the CMS Medicaid Integrity
				  Program.
Statutory Authority
§ 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-450 - Reports

Current through Register Vol. 40, No. 24, July 15, 2024
The Medicaid agency will submit all reports in the form
					 and with the content required by the Secretary, and will comply with any
					 provisions that the Secretary finds necessary to verify and assure the
					 correctness of the reports. All requirements of
					 42 CFR
					 431.16 are met.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-460 - Maintenance of records

Current through Register Vol. 40, No. 24, July 15, 2024
The Medicaid agency maintains or supervises the
					 maintenance of records necessary for the proper and efficient operation of the
					 plan, including records regarding applications, determination of eligibility,
					 the provision of medical assistance, and administrative costs, and statistical,
					 fiscal and other records necessary for reporting and accountability, and
					 retains these records in accordance with Federal requirements. All requirements
					 of 42 CFR
					 431.17 are met.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-470 - Availability of agency program manuals

Current through Register Vol. 40, No. 24, July 15, 2024
Program manuals and other policy issuances that affect the
					 public, including the Medicaid agency's rules and regulations governing
					 eligibility, need, and amount of assistance, recipient rights and
					 responsibilities, and services offered by the agency are maintained in the
					 State office and in each local and district office for examination, upon
					 request, by individuals for review, study, or reproduction. All requirements of
					 42 CFR
					 431.18 are met.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-480 - Reporting provider payments to Internal Revenue Service

Current through Register Vol. 40, No. 24, July 15, 2024
These are procedures implemented in accordance with
					 42 CFR
					 433.37 for identification of providers of
					 services by social security number or by employer identification number and for
					 reporting the information required by the Internal Revenue Code (
					 26 USC
					 6041 ) with respect to payment for services
					 under the plan.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-490 - Free choice of providers

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Except as provided in subsection B of this section, the Medicaid agency assures
				  that an individual eligible under the plan may obtain Medicaid services from
				  any institution, agency, pharmacy, person or organization that is qualified to
				  perform the services, including an organization that provides these services or
				  arranges for their availability on a prepayment basis.
B. Subsection A of this section does not
				  apply to services furnished to an individual:
1. Under an exception allowed under
				  42 CFR
				  431.54, subject to the limitations in
				  subsection C of this section;
2.
				  Under a waiver approved under
				  42 CFR
				  431.55, subject to the limitations in
				  subsection C of this section;
3. By
				  an individual or entity excluded from participation in accordance with §
				  1902(p) of the Act; or
4. By
				  individuals or entities who have been convicted of a felony under federal or
				  state law and for which the state determines that the offense is inconsistent
				  with the best interests of the individual eligible to obtain Medicaid
				  services.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-500 - Relations with standard-setting and survey agencies

Current through Register Vol. 40, No. 24, July 15, 2024
A. The State agency utilized by the Secretary
				  to determine qualification of institutions and suppliers of services to
				  participate in Medicare is responsible for establishing and maintaining health
				  standards for private or public institutions (exclusive of Christian Science
				  sanatoria) that provide services to Medicaid recipients. This agency is the
				  Department of Health.
B. The State
				  authority(ies) responsible for establishing and maintaining standards, other
				  than those relating to health, for public or private institutions that provide
				  services to Medicaid recipients is (are): Department of Health, Department of
				  Mental Health and Mental Retardation, State Corporation Commission, Office of
				  State Fire Marshall.
C.
										12VAC30-20-100 describes the
				  standards specified in paragraphs A and B above, that are kept on file and made
				  available to the Health Care Financing Administration on request.
D. The Department of Health (agency) which is
				  the State agency responsible for licensing health institutions, determines if
				  institutions and agencies meet the requirements for participation in the
				  Medicaid program. The requirements in
				  42 CFR
				  431.610(e), (f) and (g) are
				  met.
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-510 - Consultation to medical facilities

Current through Register Vol. 40, No. 24, July 15, 2024
A. Consultative services are provided by
				  health and other appropriate State agencies to hospitals, nursing facilities,
				  home health agencies, clinics and laboratories in accordance with
				  42 CFR
				  431.105(b).
B. Similar services are provided to other
				  types of facilities providing medical care to individuals receiving services
				  under the programs specified in
				  42 CFR
				  431.105(b):
HURA and RHI Projects
Neighborhood Health Projects
Multiple Handicap Projects
Children and Youth Projects
Maternal and Infant Care Projects
Dental Health Projects
Cerebral Palsy Centers
Family Planning Clinics
Child Development Clinics
Crippled Children Programs
Statutory Authority
Social Security Act Title XIX; 42 CFR 430 to end; all
						other applicable Statutory and regulatory sections.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-520 - Required provider agreement

Current through Register Vol. 40, No. 24, July 15, 2024
With respect to agreements between the Medicaid agency and
					 each provider furnishing services under the plan:
A. For all providers, the requirements of
				  42 CFR
				  431.107 and Subparts A and B of 42 CFR Part
				  442 (if applicable) are met.
B. For
				  providers of NF services, the requirements of Subpart B of 42 CFR Part 483 and
				  § 1919 of the Act are also met in addition to the requirements in
				  subsections C, D, and E of this subsection.
C. For providers of ICF/IID services, the
				  requirements of participation in Subpart I of 42 CFR Part 483 are also
				  met.
D. Ambulatory prenatal care is
				  not provided to pregnant women during a presumptive eligibility
				  period.
E. For each provider
				  receiving funds under the plan, all the requirements for advance directives of
				  § 1902(w) are met:
1. Hospitals, nursing
				  facilities, providers of home health care or personal care services, hospice
				  programs, health maintenance organizations and health insuring organizations
				  are required to do the following:
a. Maintain
				  written policies and procedures with respect to all adult individuals receiving
				  medical care by or through the provider or organization about their rights
				  under state law to make decisions concerning medical care, including the right
				  to accept or refuse medical or surgical treatment and the right to formulate
				  advance directives;
b. Provide
				  written information to all adult individuals on their policies concerning
				  implementation of such rights;
c.
				  Document in the individual's medical records whether or not the individual has
				  executed an advance directive;
d.
				  Not to discriminate against an individual based on whether or not the
				  individual has executed an advance directive including the provision of
				  care;
e. Ensure compliance with
				  requirements of state law (whether statutory or recognized by the courts)
				  concerning advance directives; and
f. Provide (individually or with others) for
				  education for staff and the community on issues concerning advance
				  directives.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 10 - STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT MEDICAL ASSISTANCE PROGRAM; GENERAL PROVISIONS › Part IV - General Program Administration › Section 12VAC30-10-530 - Utilization and quality control

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  A Statewide program of surveillance and utilization control has been
				  implemented that safeguards against unnecessary or inappropriate use of
				  Medicaid services available under this plan and against excess payments, and
				  that assesses the quality of services. The requirements of 42 CFR Part 456 are
				  met directly.
Quality review requirements described in §
					 1902(a)(30)(C) of the Act relating to services furnished by HMO's under
					 contract are undertaken through contract with the PRO designated under 42 CFR
					 Part 462.
B. The Medicaid
				  agency meets the requirements of 42 CFR Part 456, Subpart C, for control of the
				  utilization of inpatient hospital services. No waivers have been
				  granted.
C. The Medicaid agency
				  meets the requirements of 42 CFR Part 456, Subpart D, for control of
				  utilization of inpatient services in mental hospitals.
No waivers have been granted.
D. The Medicaid agency meets the requirements
				  of 42 CFR Part 456, Subpart E, for the control of utilization of skilled
				  nursing facility services.
No waivers have been granted.
E. The Medicaid agency meets the requirements
				  of 42 CFR Part 456, Subpart F, for control of the utilization of intermediate
				  care facility services as provided through:
1. Direct review by personnel of the medical
				  assistance unit of the state agency.
2. Personnel under contract to the medical
				  assistance unit of the state agency.
The program will allow a maximum of 10 administrative days
					 for placement and transfer from NF to community in order to make an orderly
					 transfer or placement possible without potential harm or trauma to the patient
					 in accordance with 42 CFR
					 456.4.
One of the semiannual utilization reviews required by
					 42 CFR
					 456.434(b)(1) for ICF/MR
					 recipients will be conducted by the Virginia Department of Health as part of
					 the inspection of care visit. The second utilization review will be conducted
					 by personnel of the Medical Assistance unit of the state agency.