reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VI - Quality Assurance and Utilization Control › Section 12VAC30-141-570 - Utilization control

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each
				  MCHIP shall implement a utilization review system as determined by contract
				  with DMAS, or administered by DMAS.
B. For the fee-for-service program, DMAS
				  shall use the utilization controls already established and operational in the
				  State Plan for Medical Assistance.
C. DMAS may collect and review comprehensive
				  data to monitor utilization after receipt of services.
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 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VI - Quality Assurance and Utilization Control › Section 12VAC30-141-580 to 12VAC30-141-590 - 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 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VI - Quality Assurance and Utilization Control › Section 12VAC30-141-600 - Recipient audit unit

Current through Register Vol. 40, No. 24, July 15, 2024
A. Pursuant
				  to Chapter 9 (§ 32.1-310 et seq.) of Title 32.1 of the Code of Virginia,
				  the recipient audit unit shall investigate allegations of acts of fraud or
				  abuse, committed by persons enrolled in the FAMIS program or the parent, adult
				  caretaker relative, guardian, legal custodian or authorized representative on
				  behalf of a person or persons enrolled in the FAMIS program, which result in
				  misspent funds.
B. Any FAMIS
				  enrollee, parent, adult caretaker relative, guardian, legal custodian or
				  authorized representative of a FAMIS enrollee who, on the behalf of others,
				  attempts to obtain benefits to which the enrollee is not entitled by means of a
				  willful false statement or by willful misrepresentation, or by willful
				  concealment of any material facts, shall be liable for repayment of any excess
				  benefits received and the appropriate interest charges.
C. Upon the determination that fraud or abuse
				  has been committed, criminal or civil action may be initiated.
D. When determining the amount of misspent
				  funds to be recovered, capitation fees shall be included for FAMIS enrollees
				  who received benefits through managed care.
E. Access to FAMIS enrollees' records by
				  authorized DMAS representatives shall be permitted upon request.
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 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VI - Quality Assurance and Utilization Control › Section 12VAC30-141-610 to 12VAC30-141-640 - 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 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VI - Quality Assurance and Utilization Control › Section 12VAC30-141-650 - Provider review

Current through Register Vol. 40, No. 24, July 15, 2024
A. The provider
				  review unit shall be responsible for reviewing enrolled FAMIS providers to
				  identify potential inappropriate utilization of services and potential billing
				  errors.
B. Providers agree to keep
				  such records as DMAS determines necessary. The providers shall furnish DMAS,
				  upon request, information regarding payments claimed for providing services
				  under the State Plan for Title XXI.
C. Access to records and facilities by
				  authorized DMAS representatives shall be permitted upon request.
D. Providers shall be required to refund
				  payments made by DMAS if they are found to have billed DMAS contrary to policy,
				  failed to maintain records or adequate documentation to support their claims,
				  or billed for medically unnecessary services.
E. A review of adverse actions concerning
				  provider reimbursement shall be heard in accordance with the Administrative
				  Process Act (§ 2.2-4000 et seq. of the Code of Virginia) and the Virginia
				  Administrative Code,
				  12VAC30-10-1000 and
				  12VAC30-20-500 through
				  12VAC30-20-560.
F. MCHIPs shall be responsible for keeping
				  provider profile and utilization mechanisms to monitor provider activities.
				  MCHIPs shall be reviewed by DMAS.
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 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VI - Quality Assurance and Utilization Control › Section 12VAC30-141-660 - Assignment to managed care

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Except for children enrolled in the Virginia Birth-Related Neurological Injury
				  Compensation Program established pursuant to Chapter 50 (§
										38.2-5000 et seq.) of
				  Title 38.2 of the Code of Virginia, all eligible enrollees shall be assigned in
				  managed care through the department or CPU. FAMIS individuals, during the
				  preassignment period to an MCHIP, shall receive Title XXI benefits via
				  fee-for-service utilizing a FAMIS card issued by DMAS. After assignment to an
				  MCHIP, benefits and the delivery of benefits shall be administered specific to
				  the managed care program in which the individual is enrolled. DMAS shall
				  contract with MCHIPs to deliver health care services for infants born to
				  mothers enrolled in FAMIS for the month of birth plus two additional months
				  regardless of the status of the newborn's application for FAMIS. If federal
				  funds are not available for those months of coverage, DMAS shall use state
				  funding only.
1. MCHIPs shall be offered to
				  enrollees in all areas.
2. All
				  enrollees shall be assigned to the contracted MCHIPs.
3. Applicants for FAMIS may choose an MCHIP
				  at the time of application. If a choice is not made at application, enrollees
				  shall be assigned through a random system algorithm; provided however, all
				  children within the same family shall be assigned to the same MCHIP.
4. All children enrolled in the Virginia
				  Birth-Related Neurological Injury Compensation Program shall be assigned to the
				  fee-for-service component.
5.
				  Enrolled individuals will receive a letter indicating that they may select one
				  of the contracted MCHIPs that serve such area. Enrollees who do not select an
				  MCHIP as described above, shall be assigned to an MCHIP as described in
				  subdivision 3 of this subsection.
6. Individuals assigned to an MCHIP who lose
				  and then regain eligibility for FAMIS within 60 days will be reassigned to
				  their previous MCHIP.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-680 - Administration and general background

Current through Register Vol. 40, No. 24, July 15, 2024
A. The state shall use funds provided under
				  Title XXI for obtaining coverage that meets the requirements of Title XXI of
				  the Social Security Act and any waiver of federal regulations approved by the
				  Centers for Medicare and Medicaid Services.
B. The DMAS director will have the authority
				  to contract with entities for the purposes of establishing a centralized
				  processing site, determining eligibility, enrolling eligible pregnant women
				  into health plans, performing outreach, data collection, reporting, and other
				  services necessary for the administration of the FAMIS MOMS program.
C. Health care services under FAMIS MOMS
				  shall be provided through MCHIPs and fee-for-service or through any other
				  health care delivery system deemed appropriate by the Department of Medical
				  Assistance Services.
Statutory Authority: §
												32.1-351
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-690 - Outreach and public participation

Current through Register Vol. 40, No. 24, July 15, 2024
A. DMAS will work cooperatively with other
				  state agencies and contractors to ensure that state and federal law and any
				  applicable state and federal regulations are met.
B. DMAS shall develop a comprehensive
				  marketing and outreach effort. The marketing and outreach efforts will be aimed
				  at promoting FAMIS MOMS and Medicaid for pregnant women and increasing
				  enrollment and may include contracting with a public relations firm, nonprofit
				  agencies, and foundations, and coordination with other state agencies,
				  coordination with the business community, and coordination with health care
				  associations and providers.
Statutory Authority: §
												32.1-351
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-710 - Notice of adverse action or adverse benefit determination

Current through Register Vol. 40, No. 24, July 15, 2024
A. The LDSS, CPU,
				  DMAS, or DMAS contractor shall send written notification to enrollees at least
				  10 calendar days prior to suspension or termination of enrollment.
B. DMAS or the MCO shall send written
				  notification to enrollees at least 10 calendar days prior to reduction,
				  suspension, or termination of a previously authorized health service.
C. The local department of social services,
				  CPU, DMAS, or MCO shall send written notification to applicants and enrollees
				  of all other adverse actions within 10 calendar days of the adverse
				  action.
D. Notice shall include:
1. The determination the LDSS, CPU, DMAS, or
				  MCO has made or intends to make;
2.
				  The reasons for the determination, including the right of the enrollee to be
				  provided upon request and free of charge reasonable access to and copies of all
				  documents, records, and other information relevant to the
				  determination;
3. An explanation of
				  applicable rights to request an appeal of that determination. For adverse
				  benefit determinations by an MCO, this shall include information on the MCO's
				  internal appeals process and, after the internal appeals process is exhausted,
				  a state fair hearing pursuant to 42 CFR 402(b) and 42 CFR 402(c);
4. The procedures for exercising these appeal
				  rights;
5. The circumstances under
				  which an appeal process can be expedited and how to request it; and
6. The circumstances under which enrollment
				  or services may continue pending appeal, how to request benefits be continued,
				  and the circumstances, consistent with state policy, under which the enrollee
				  may be required to pay the costs of these services.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-720 - Request for appeal

Current through Register Vol. 40, No. 24, July 15, 2024
A. Requests
				  for internal appeal of MCO adverse benefit determinations shall be submitted
				  orally or in writing to the MCO. Unless the enrollee requests an expedited
				  appeal, an oral appeal request must be followed by a written appeal request.
				  The enrollee must exhaust the MCO's internal appeals process before appealing
				  to DMAS.
B. If the MCO fails to
				  adhere to the notice or timing requirements set forth in this part, the
				  enrollee is deemed to have exhausted the MCO's internal appeals process and may
				  initiate a state fair hearing.
C.
				  Requests for appeal of adverse actions made by the LDSS, CPU, or DMAS, or of
				  internal appeal decisions by the MCO shall be submitted to DMAS.
D. Any communication expressing a desire to
				  have an adverse benefit determination by an MCO reviewed shall be treated as a
				  request for an internal appeal. Any communication expressing a desire to have
				  an adverse action by the LDSS, CPU, or DMAS reviewed shall be treated as a
				  request for a state fair hearing. Any communication expressing a desire to have
				  an MCO internal appeal decision reviewed shall be treated as a request for a
				  state fair hearing.
E. To be
				  timely, requests for an internal appeal of an MCO's adverse benefit
				  determination shall be received by the MCO no later than 60 calendar days from
				  the date of the MCO's notice of adverse benefit determination.
F. To be timely, requests for an appeal of an
				  adverse benefit determination upheld in whole or in part by the MCO's internal
				  appeal decision shall be received by DMAS within 120 calendar days from the
				  date of the internal appeal decision.
G. To be timely, requests for appeal of a
				  local department of social services, DMAS, or CPU adverse action shall be filed
				  with DMAS no later than 30 calendar days from the date of the notice of adverse
				  action. Requests for appeal of an agency determination shall be considered
				  filed with DMAS on the date the request is postmarked if mailed, or on the date
				  the request is received if delivered other than by mail, by DMAS.
Statutory Authority: §
												32.1-351
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-740 - General conditions of eligibility

Current through Register Vol. 40, No. 24, July 15, 2024
A. This section shall be used to determine
				  eligibility of pregnant women for FAMIS MOMS.
B. FAMIS MOMS shall be in effect
				  statewide.
C. Eligible pregnant
				  women must:
1. Be determined ineligible for
				  Medicaid due to excess income by LDSS, by DMAS, or by the CPU;
2. Be a pregnant woman at the time of
				  application;
3. Be a resident of
				  the Commonwealth as described in
				  12VAC30-141-100
				  E;
4. Be either a United States
				  citizen, United States national, lawfully residing, or a qualified noncitizen
				  as described in
				  12VAC30-141-100
				  E;
5. Be uninsured, that is, not
				  have creditable health insurance coverage; and
6. Not be an inpatient in an institution for
				  mental diseases, or an inmate in a public institution that is not a medical
				  facility.
"Lawfully residing" means the individual is lawfully
					 present in the United States and meets state residency requirements.
					 "Creditable health insurance coverage" means coverage that meets the definition
					 at
					 42 CFR
					 457.10.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-750 - Duration of eligibility

Current through Register Vol. 40, No. 24, July 15, 2024
A. The
				  effective date of FAMIS MOMS eligibility shall be the first day of the month in
				  which an application was received by LDSS, DMAS, or the CPU if the applicant
				  met all eligibility requirements in that month.
B. Eligibility for FAMIS MOMS will continue
				  through the last day of the month in which the 60th day occurs, following the
				  last day the woman was pregnant, regardless of the reason the pregnancy ended.
				  Eligibility will continue until the end of the coverage period, regardless of
				  changes in circumstances such as income or family size.
Statutory Authority: §
												32.1-351
						of the Code of Virginia;
						42 USC §
													1396 et
						seq.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-760 - Pregnant women ineligible for FAMIS MOMS

Current through Register Vol. 40, No. 24, July 15, 2024
A. If a pregnant woman is:
1. Eligible for Medicaid, she shall be
				  ineligible for coverage under FAMIS MOMS;
2. An inmate of a public institution as
				  provided in
				  42 CFR
				  435.1009(a)(1), she shall be
				  ineligible for FAMIS MOMS at the initial determination of eligibility;
				  or
3. An inpatient in an
				  institution for mental disease as defined in
				  42 CFR
				  435.1010, she shall be ineligible for FAMIS
				  MOMS at the initial determination of eligibility.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-770 - Nondiscriminatory provisions

Current through Register Vol. 40, No. 24, July 15, 2024
FAMIS MOMS shall be conducted in compliance with all civil
					 rights requirements. FAMIS MOMS shall not:
1. Discriminate during the eligibility
				  determination process on the basis of diagnosis;
2. Cover pregnant women of higher income
				  without first covering pregnant women with a lower family income; and
3. Deny eligibility based on a pregnant woman
				  having a preexisting medical condition.
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 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-780 - No entitlement

Current through Register Vol. 40, No. 24, July 15, 2024
In accordance with § 2102(b)(4) of the Social
					 Security Act and § 32.1-353 of the Code of Virginia, FAMIS MOMS shall not
					 create any entitlement for, right to, or interest in payment of medical
					 services on the part of any pregnant woman or any right or entitlement to
					 participation.
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 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-790 - Application requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Availability of program information. DMAS or its designee shall furnish the
				  following information in written form and orally as appropriate to all
				  applicants and to other individuals who request it:
1. The eligibility requirements;
2. Summary of covered benefits;
3. Copayment amounts required; and
4. The rights and responsibilities of
				  applicants and enrollees.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-800 - Copayments

Current through Register Vol. 40, No. 24, July 15, 2024
A. Pregnant women
				  enrolled in FAMIS MOMS will be subject to copayments for medical services in
				  the same manner and amount as pregnant women covered by the Medicaid program as
				  defined in
				  12VAC30-10-570
				  B and C.
B. These cost-sharing
				  provisions shall be implemented with the following restrictions:
1. Total cost sharing for a pregnant woman
				  shall be limited to (i) for families with incomes equal to or less than 150% of
				  federal poverty level (FPL), the lesser of (a) $180 and (b) 2.5% of the
				  family's income for the year; and (ii) for families with incomes greater than
				  150% of FPL, the lesser of $350 and 5.0% of the family's income for the year
				  for the duration of the pregnant woman's enrollment in FAMIS MOMS.
2. If a family includes a pregnant woman
				  enrolled in FAMIS MOMS and a child enrolled in FAMIS, DMAS or its designee
				  shall ensure that the annual aggregate cost sharing for all Title XXI enrollees
				  in a family does not exceed the cost sharing caps as defined in
				  12VAC30-141-160
				  B.
3. Families will be required to
				  submit documentation to DMAS or its designee showing that their maximum
				  copayment amounts are met for the year.
4. Once the cap is met, DMAS or its designee
				  will issue a new eligibility card or written documentation excluding such
				  families from paying additional copays.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-810 - Liability for excess benefits

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Any person who, without the intent to violate this section, obtains benefits or
				  payments under FAMIS MOMS to which she is not entitled shall be liable for any
				  excess benefits or payments received. If the enrollee knew or reasonably should
				  have known that she was not entitled to the excess benefits, she may also be
				  liable for interest on the amount of the excess benefits or payments at the
				  judgment rate as defined in § 6.1-330.54 of the Code of Virginia from the
				  date upon which excess benefits or payments to the date on which repayment is
				  made to the Commonwealth. No person shall be liable for payment of interest,
				  however, when excess benefits or payments were obtained as a result of errors
				  made solely by DMAS or its designee.
B. Any payment erroneously made on behalf of
				  a FAMIS MOMS enrollee or former enrollee may be recovered by DMAS from the
				  enrollee or the enrollee's income, assets, or estate unless state or federal
				  law or regulation otherwise exempts such property.
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 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-820 - Benefit packages

Current through Register Vol. 40, No. 24, July 15, 2024
Pregnant women covered through FAMIS MOMS may receive the
					 same medical and dental services and are subject to the same limitations on
					 services as pregnant women (see
					 12VAC30-50-190 ) covered by the
					 Medicaid program as defined in
					 12VAC30-10-140 and
					 12VAC30-50-10.
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 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-840 - Quality assurance

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each
				  provider entity shall meet requirements for the following either as
				  administered by DMAS or as determined by contract with DMAS: access to
				  well-child health services, immunizations, provider network adequacy, a system
				  to provide enrollees urgent care and emergency services, systems for
				  complaints, grievances and reviews, a data management system and quality
				  improvement programs and activities.
B. Each MCHIP shall meet requirements
				  determined by the contract for the internal and external quality monitoring and
				  reporting of access to services, timeliness of services, and appropriateness of
				  services, as determined by DMAS.
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 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-850 - Utilization control

Current through Register Vol. 40, No. 24, July 15, 2024
A. Each
				  MCHIP shall implement a utilization review system as determined by contract
				  with DMAS, or administered by DMAS.
B. For the fee-for-service program, DMAS
				  shall use the utilization controls already established and operational in the
				  State Plan for Medical Assistance.
C. DMAS may collect and review comprehensive
				  data to monitor utilization after receipt of services.
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 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-860 - Recipient audit unit

Current through Register Vol. 40, No. 24, July 15, 2024
A. Pursuant
				  to Chapter 9 (§ 32.1-310 et seq.) of Title 32.1 of the Code of Virginia,
				  the recipient audit unit shall investigate allegations of acts of fraud or
				  abuse, committed by persons enrolled in the FAMIS MOMS program or the parent,
				  adult caretaker relative, guardian, legal custodian or authorized
				  representative on behalf of a person or persons enrolled in the FAMIS MOMS
				  program, which result in misspent funds.
B. Any FAMIS MOMS enrollee, parent, adult
				  caretaker relative, guardian, legal custodian or authorized representative of a
				  FAMIS MOMS enrollee who, on the behalf of others, attempts to obtain benefits
				  to which the enrollee is not entitled by means of a willful false statement or
				  by willful misrepresentation, or by willful concealment of any material facts,
				  shall be liable for repayment of any excess benefits received and the
				  appropriate interest charges.
C.
				  Upon the determination that fraud or abuse has been committed, criminal or
				  civil action may be initiated.
D.
				  When determining the amount of misspent funds to be recovered, capitation fees
				  shall be included for FAMIS MOMS enrollees who received benefits through
				  managed care.
E. Access to FAMIS
				  MOMS enrollees' records by authorized DMAS representatives shall be permitted
				  upon request.
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 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-870 - Provider review

Current through Register Vol. 40, No. 24, July 15, 2024
A. The provider
				  review unit shall be responsible for reviewing enrolled FAMIS MOMS providers to
				  identify potential inappropriate utilization of services and potential billing
				  errors.
B. Providers agree to keep
				  such records as DMAS determines necessary. The providers shall furnish DMAS,
				  upon request, information regarding payments claimed for providing services
				  under the State Plan for Title XXI.
C. Access to records and facilities by
				  authorized DMAS representatives shall be permitted upon request.
D. Providers shall be required to refund
				  payments made by DMAS if they are found to have billed DMAS contrary to policy,
				  failed to maintain records or adequate documentation to support their claims,
				  or billed for medically unnecessary services.
E. A review of adverse actions concerning
				  provider reimbursement shall be heard in accordance with the Administrative
				  Process Act (§ 2.2-4000 et seq. of the Code of Virginia) and the Virginia
				  Administrative Code,
				  12VAC30-10-1000 and
				  12VAC30-20-500 through
				  12VAC30-20-560.
F. MCHIPs shall be responsible for keeping
				  provider profile and utilization mechanisms to monitor provider activities.
				  MCHIPs shall be reviewed by DMAS.
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 141 - FAMILY ACCESS TO MEDICAL INSURANCE SECURITY PLAN › Part VII - Famis Moms › Section 12VAC30-141-880 - Assignment to managed care

Current through Register Vol. 40, No. 24, July 15, 2024
A. All
				  eligible enrollees shall be assigned in managed care through the department or
				  the central processing unit (CPU) under contract to DMAS. FAMIS MOMS
				  individuals, during the preassignment period to an MCHIP, shall receive
				  Medicaid-like benefits via fee-for-service utilizing a FAMIS MOMS card issued
				  by DMAS. After assignment to an MCHIP, benefits and the delivery of benefits
				  shall be administered specific to the managed care program in which the
				  individual is enrolled.
1. MCHIPs shall be
				  offered to enrollees in all areas.
2. All enrollees shall be assigned to that
				  contracted MCHIP.
3. Enrollees
				  shall be assigned through a random system algorithm.
4. Enrolled individuals will receive a letter
				  indicating that they may select one of the contracted MCHIPs that serve such
				  area. Enrollees who do not select an MCHIP as described above, shall be
				  assigned to an MCHIP as described in subdivision 3 of this
				  subsection.
5. Individuals assigned
				  to an MCHIP who lose and then regain eligibility for FAMIS MOMS within 60 days
				  will be reassigned to their previous MCHIP.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 150 - UNINSURED MEDICAL CATASTROPHE FUND › Section 12VAC30-150-10 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
As used in this chapter, the following terms shall have the
				  following meanings unless the context clearly indicates otherwise:
"Applicant" means the individual who applies for assistance
				  under these regulations and § 32.1-324.3 of the Code of Virginia. An
				  application may be filed for or on behalf of a minor or person under a legal
				  disability by a parent, legal guardian, an attorney in fact, or an attorney at
				  law.
"DMAS" means the Department of Medical Assistance
				  Services.
"Life-threatening illness or injury" means a medical
				  condition (i) requiring specialized medical treatment, hospitalization, or both
				  and (ii) that would more likely than not result directly in death within 12
				  months if left untreated.
"Recipient" means the individual for whom assistance is
				  committed under these regulations and § 32.1-324.3 of the Code of
				  Virginia.
"Resident" means an individual who is residing in the
				  Commonwealth of Virginia at the time of application for Uninsured Medical
				  Catastrophe Funds with the intent of remaining indefinitely in the Commonwealth
				  and who did not establish residency for the purpose of obtaining Uninsured
				  Medical Catastrophe Fund benefits. Aliens illegally living in the United States
				  and migrant workers shall not be considered residents of the Commonwealth for
				  purposes of the UMCF. A resident may temporarily reside outside of the
				  Commonwealth to receive treatment.
"Treatment plan" means the written plan of services
				  submitted by the contracting provider, certified by the patient's physician,
				  and approved by DMAS to treat the life-threatening illness or injury.
"UMCF" means the Uninsured Medical Catastrophe
				  Fund.
Statutory Authority
§§ 32.1-324.3 and 32.1-325 of the Code of
					 Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 150 - UNINSURED MEDICAL CATASTROPHE FUND › Section 12VAC30-150-20 - UMCF program established

Current through Register Vol. 40, No. 24, July 15, 2024
The Uninsured Medical Catastrophe Fund program is hereby
				  established within the Department of Medical Assistance Services to provide
				  funds for uninsured persons who need treatment for a life-threatening illness
				  or injury. The DMAS director shall administer this program and expend funds in
				  accordance with the provisions of these regulations and § 32.1-324.3 of
				  the Code of Virginia.
Statutory Authority
§§ 32.1-324.3 and 32.1-325 of the Code of
					 Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 150 - UNINSURED MEDICAL CATASTROPHE FUND › Section 12VAC30-150-30 - Criteria for disbursements from the UMCF

Current through Register Vol. 40, No. 24, July 15, 2024
Disbursements from the UMCF will be made:
1. On behalf of a person who meets the
				eligibility criteria in
				12VAC30-150-40;
2. Based on an approved treatment plan
				consistent with
				12VAC30-150-50;
3. If funds are available consistent with
				12VAC30-150-60; and
4. If a provider is willing to accept the
				UMCF contract consistent with
				12VAC30-150-70.
Statutory Authority
§§ 32.1-324.3 and 32.1-325 of the Code of
					 Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 150 - UNINSURED MEDICAL CATASTROPHE FUND › Section 12VAC30-150-40 - Eligibility criteria

Current through Register Vol. 40, No. 24, July 15, 2024
An individual is eligible to receive Uninsured Medical
				  Catastrophe Funds for the period of time that he:
1. Is a citizen of the United States or a
				legally resident alien;
2. Is a
				resident of the Commonwealth (eligibility will end if the recipient is no
				longer a resident);
3. Has a gross
				income equal to or less than 300% of the current federal nonfarm poverty income
				guidelines;
4. Has a
				life-threatening illness or injury;
5. Is uninsured for the needed treatment on
				the date of application and is not eligible for coverage for the needed
				treatment through private insurance or federal, state, or local government
				medical assistance programs. If an individual becomes insured for the needed
				treatment after the date of application, the UMCF will only pay for services
				not otherwise covered by the existing insurance.
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 150 - UNINSURED MEDICAL CATASTROPHE FUND › Section 12VAC30-150-50 - Treatment plan

Current through Register Vol. 40, No. 24, July 15, 2024
A. Except as
				otherwise provided in this section, any medical services that are not
				experimental or investigational may be covered under a treatment
				plan.
B. Services provided for in
				the treatment plan must be for a course of treatment approved by DMAS to
				remediate, cure, or ameliorate the life-threatening illness or injury. The
				course of treatment proposed in the plan may not exceed 12 months.
C. The treatment plan should reflect the
				standard of practice for treating the life-threatening illness or injury given
				the applicant's health status at the time the treatment plan is approved.
				Treatment plans will not be approved for any illness or injury that is expected
				to be terminal even with the treatment.
D. DMAS may approve the treatment plan as
				submitted, modify the treatment plan, or deny the treatment plan. DMAS may
				review and revise treatment plan decisions based on additional information up
				until the time a contract is signed. A treatment plan may only be altered if,
				during the course of treatment approved, the medical condition of the person
				substantially changes and renders the original course of treatment no longer
				appropriate, as determined by the contracting health provider. If any
				alteration increases the established dollar amount, additional funds can be
				approved if available. Any alteration cannot exceed the one-year time frame
				from initial authorization.
E. The
				UMCF is not responsible for maintenance medications or additional treatments
				beyond the course of treatment approved by DMAS and contracted with a
				provider.
F. The UMCF will not
				commit funds or pay for services provided prior to the date the application is
				approved.
G. Covered services
				include specialized medical treatment, hospitalization, or both, to include the
				following to the extent they are part of the approved treatment plan:
1. Inpatient hospital services;
2. Outpatient hospital services and
				ambulatory surgical centers;
3.
				Ambulatory care;
4. Laboratory and
				x-ray services;
5. Physician's
				services and other ambulatory care;
6. Medical care furnished by licensed
				practitioners within the scope of their practice as defined by state
				law;
7. Prescribed drugs;
				and
8. Rehabilitative services to
				the extent necessary to recover from medical treatment.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 150 - UNINSURED MEDICAL CATASTROPHE FUND › Section 12VAC30-150-60 - Availability of funds; no entitlement

Current through Register Vol. 40, No. 24, July 15, 2024
Expenditures shall be limited to available funding. These
				  regulations do not create any legally enforceable right or entitlement to
				  payment for medical services on the part of any person or any right or
				  entitlement to participation.
Except as otherwise provided in this chapter, funds shall be
				  committed on behalf of eligible individuals on a first-come, first-served basis
				  based on the date DMAS or its agent receives the original signed
				  application.
Statutory Authority
§§ 32.1-324.3 and 32.1-325 of the Code of
					 Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 150 - UNINSURED MEDICAL CATASTROPHE FUND › Section 12VAC30-150-70 - Contracts with providers

Current through Register Vol. 40, No. 24, July 15, 2024
A. It
				shall be the responsibility of the applicant to find a qualified provider
				willing to contract with DMAS under the terms in this section.
B. Reimbursement for covered services shall
				be a global fee based on existing Medicaid or Medicare rates (whichever is
				higher) or Medicaid reimbursement methodology to cover all services in the
				approved treatment plan. The global fee will cover: procurement costs for
				transplants; any hospital costs from admission to discharge; total physician
				costs for all physicians providing services during the course of treatment; and
				any other medical or drug costs associated with the treatment plan approved by
				DMAS.
C. A provider may agree to
				less than the full global fee as long as the provider agrees to complete the
				treatment plan with no additional payment by the applicant or on behalf of the
				applicant subject to subsection D of this section.
D. A provider may accept private funds raised
				on behalf of the applicant. The sum of private funds plus UMCF commitment may
				not exceed the global fee determined in subsection B of this section. Private
				funding must be fully disclosed in the contract, and the contract cannot be
				contingent on funds to be raised in the future. Private funds are not
				considered part of the applicant's income for purposes of determining
				eligibility. Private funds are not a factor in determining access to the UMCF
				or its waiting list.
E. A contract
				shall commit Uninsured Medical Catastrophe Funds to a course of treatment for
				up to one year from the date the contract is signed.
F. Reimbursement agreed to in the contract
				pursuant to this section shall constitute payment in full.
G. An application shall be denied if no
				provider is willing to sign a contract pursuant to this section within 30 days
				after the date all of the following are in place: a favorable determination of
				eligibility, approval of the treatment plan, and the availability of
				funds.
H. Facilities providing
				transplant procedures must be recognized as being capable of providing high
				quality care in the performance of the transplant by meeting the selection
				criteria outlined in
				12VAC30-50-540,
				12VAC30-50-560, and
				12VAC30-50-570 under the Virginia
				Title XIX State Plan for Medical Assistance.
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 150 - UNINSURED MEDICAL CATASTROPHE FUND › Section 12VAC30-150-80 - Payments

Current through Register Vol. 40, No. 24, July 15, 2024
A. Payments shall
				be made only to providers that have contracted with DMAS in accordance with
				12VAC30-150-70. No payments shall
				be made directly to eligible individuals or applicants.
B. Payments are based on a global fee as
				provided for in
				12VAC30-150-70. Payments may be
				made to more than one provider if it is determined that one global payment
				cannot be made due to a provider's limitation to disburse funds to other
				medical providers. An individual provider's payments shall be based upon that
				provider's component of the global fee. DMAS may establish a schedule of
				payments in the contract consistent with phases of the treatment plan. Payments
				will be made to contracting providers upon the completion of the treatment or
				phases of the treatment as specified in the contract.
C. Any committed funds not paid out by the
				fund within one year from the date of the contract will revert back to the UMCF
				and will be made available for other applicants. If a recipient dies during the
				contract period, the UMCF is responsible for payment of that portion of the
				treatment plan that has been completed. The remainder of the committed funds
				revert back to the UMCF to be available for other applicants.
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 150 - UNINSURED MEDICAL CATASTROPHE FUND › Section 12VAC30-150-90 - Application procedures and waiting list

Current through Register Vol. 40, No. 24, July 15, 2024
A. An application for assistance under the
				Uninsured Medical Catastrophe Fund must be on a form prescribed by DMAS and
				signed by the applicant. Funds will be committed on behalf of eligible
				individuals on a first-come, first-served basis based on the date and time the
				original signed application is received by DMAS or its agent.
B. Applicants must:
(i) provide a statement signed by a physician
				licensed in the state in which he practices who has examined the individual
				certifying that the individual has a life-threatening illness or injury as
				defined in this regulation and
(ii)
				submit a treatment plan developed by a potential contracting provider and
				signed by a physician licensed in the state in which he practices.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 150 - UNINSURED MEDICAL CATASTROPHE FUND › Section 12VAC30-150-100 - Appeals

Current through Register Vol. 40, No. 24, July 15, 2024
A. Except as
				otherwise provided in this section, a UMCF applicant may appeal an adverse
				determination regarding eligibility and the treatment plan. UMCF will follow
				the procedures established under 12VAC30-110, Eligibility and Appeals, except
				that applicants have no right to appeal a denial of benefits because of a lack
				of funds.
B. An applicant who
				wishes to appeal an adverse determination must follow an expedited appeal
				process to maintain a position on the waiting list if sufficient funds are not
				available. The expedited appeal has no impact on appeal rights granted under
				12VAC30-110.
1. An expedited appeal must be
				made within 15 days of receiving an adverse determination.
2. The expedited appeal can be filed by
				facsimile, e-mail, or by regular mail or courier, but it must be in
				writing.
3. The agency's expedited
				appeal decision shall be rendered by a DMAS hearing officer.
4. The agency must make an expedited appeal
				decision within 15 days of receiving an appeal.
5. The agency shall advise the appellant
				within one day of its decision.
Virginia Administrative Code › Title 12 - HEALTH › Agency 35 - DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES › Chapter 12 - PUBLIC PARTICIPATION GUIDELINES › Part I - Purpose and Definitions › Section 12VAC35-12-10 - Purpose

Current through Register Vol. 40, No. 24, July 15, 2024
The purpose of this chapter is to promote public
					 involvement in the development, amendment or repeal of the regulations of the
					 State Board of Behavioral Health and Developmental Services and the Department
					 of Behavioral Health and Developmental Services. This chapter does not apply to
					 regulations, guidelines, or other documents exempted or excluded from the
					 provisions of the Administrative Process Act (§ 2.2-4000 et seq. of the
					 Code of Virginia).
Statutory Authority
§§ 2.2-4007.02 and 37.2-203 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 35 - DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES › Chapter 12 - PUBLIC PARTICIPATION GUIDELINES › Part II - Notification of Interested Persons › Section 12VAC35-12-30 - Notification list

Current through Register Vol. 40, No. 24, July 15, 2024
A. The agency shall
				  maintain a list of persons who have requested to be notified of regulatory
				  actions being pursued by the agency.
B. Any person may request to be placed on a
				  notification list by registering as a public user on the Town Hall or by making
				  a request to the agency. Any person who requests to be placed on a notification
				  list shall elect to be notified either by electronic means or through a postal
				  carrier.
C. The agency may maintain
				  additional lists for persons who have requested to be informed of specific
				  regulatory issues, proposals, or actions.
D. When electronic mail is returned as
				  undeliverable on multiple occasions at least 24 hours apart, that person may be
				  deleted from the list. A single undeliverable message is insufficient cause to
				  delete the person from the list.
E.
				  When mail delivered by a postal carrier is returned as undeliverable on
				  multiple occasions, that person may be deleted from the list.
F. The agency may periodically request those
				  persons on the notification list to indicate their desire to either continue to
				  be notified electronically, receive documents through a postal carrier, or be
				  deleted from the list.
Statutory Authority
§§ 2.2-4007.02 and 37.2-203 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 35 - DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES › Chapter 12 - PUBLIC PARTICIPATION GUIDELINES › Part II - Notification of Interested Persons › Section 12VAC35-12-40 - Information to be sent to persons on the notification list

Current through Register Vol. 40, No. 24, July 15, 2024
A. To persons
				  electing to receive electronic notification or notification through a postal
				  carrier as described in
				  12VAC35-12-30, the agency shall
				  send the following information:
1. A notice
				  of intended regulatory action (NOIRA).
2. A notice of the comment period on a
				  proposed, a reproposed, or a fast-track regulation and hyperlinks to, or
				  instructions on how to obtain, a copy of the regulation and any supporting
				  documents.
3. A notice soliciting
				  comment on a final regulation when the regulatory process has been extended
				  pursuant to § 2.2-4007.06 or 2.2-4013C of the Code of Virginia.