reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part I - Miscellaneous Provisions › Section 12VAC30-20-110 - Nursing facility resident drug utilization review

Current through Register Vol. 40, No. 24, July 15, 2024
1. Definitions. The following words and
				  terms, when used in this regulation, shall have the following meanings unless
				  the context clearly indicates otherwise:
"DMAS" means the Department of Medical Assistance Services
					 consistent with the Code of Virginia, Chapter 10, Title 32.1, §§
					 32.1-323 et seq.
"Drug utilization review" means a formal continuing program
					 for assessing medical and/or drug use data against explicit standards and, as
					 necessary, introducing remedial strategies.
"Drug Utilization Review Committee (DUR Committee)" means a
					 committee composed of knowledgeable health care professionals who make
					 recommendations for developing and modifying drug therapy review standards or
					 criteria, participate in retrospective reviews, recommend remedial strategies,
					 and evaluate the success of the interventions.
"Exceptional drug utilization pattern" means
1) a pattern of drug utilization within a
				  nursing facility that differs substantially from predetermined standards
				  established pursuant to § 3(B);
2) individual resident's drug use patterns
				  that differ from the established standards; or
3) individual resident's drug use patterns
				  that exhibit a high risk for drug therapy induced illness.
"Retrospective drug review" means the drug utilization
					 review process that is conducted using historic or archived medical and/or drug
					 use data.
"Targeted facility" means a nursing facility where
					 residents' patterns of drug utilization demonstrate an exceptional drug
					 utilization pattern as defined herein.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part I - Miscellaneous Provisions › Section 12VAC30-20-120 - Cooperative arrangements with the state vocational rehabilitation agency and with Title V programs and grantees

Current through Register Vol. 40, No. 24, July 15, 2024
As the Single State Agency, the Department of Medical
					 Assistance Services promulgated agreements with the following State
					 agencies/activities concerning services rendered to Medical Assistance program
					 eligible recipients.
1. Agreement with
				  the Department of Social Services concerning responsibilities of that
				  Department for (a) determination of eligibility, (b) provision of social
				  services, (c) activity associated with fair hearings, (d) fraud, (e) quality
				  control, (f) non-discrimination, (g) staffing, (h) staff development and
				  recruiting, (i) maintenance of records, (j) review of local operations and (k)
				  exchange of information (6-29-89, as amended).
2. Agreement with the Department of
				  Vocational Rehabilitation concerning responsibilities of that Department for
				  providing rehabilitation services necessary to render disabled individuals to
				  attain a state of health which will permit them to engage in gainful employment
				  and for providing liaison personnel to assist the State Agency in screening
				  referrals for rehabilitation services (4-30-93, as amended).
3. Agreements with Department of Health
				  programs for Maternal, Child Health, Family Planning and Crippled Children and
				  for grantee project activities operated under these programs concerning
				  provision of medical and social services to eligible recipients and
				  reimbursements to be made for rendering covered services (3-12-93, as
				  amended).
4. Agreements with
				  Special Projects operating in this State under Federal grant funding procedures
				  and which provide medical or dental services covered by the Medical Assistance
				  Program concerning types and limits of services and reimbursement for services
				  rendered.
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 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part II - Liens/Estate Recoveries › Section 12VAC30-20-130 - Lien recoveries

Current through Register Vol. 40, No. 24, July 15, 2024
The Commonwealth does not recover, through the imposition
					 of liens, funds expended for recipients.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part III - Recipient Cost Sharing › Section 12VAC30-20-170 - Basis of payment for reserving beds during a recipient's absence from an inpatient facility

Current through Register Vol. 40, No. 24, July 15, 2024
1. Payment
				  is made for reserving beds in long-term care facilities for recipients during
				  their temporary absence for the following purpose: For leaves of absence up to
				  18 days per year for any reason other than inpatient hospital
				  admissions.
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 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part III - Recipient Cost Sharing › Section 12VAC30-20-180 - Definition of a claim by service

Current through Register Vol. 40, No. 24, July 15, 2024
A. Claims.
SERVICE
CLAIM
A) Inpatient Hospital
A Bill for Service
B) Outpatient Hospital
A Bill for Service
C) Rural Health Clinic
A Line Item for Service
D) Laboratory and X-Ray
A Line Item of Service
E) Skilled Nursing
A Bill for Service
F) EPSDT
A Bill for Service
G) Family Planning
A Bill for Service or Line Item depending on
								provider type
H) Physician
A Line Item of Service
I) Other Medical
A Bill for Service or Line Item depending on
								provider type
J) Home Health
A Bill for Service
K) Clinic
A Line for Service Item
L) Dental
A Line Item of Service
M) Pharmacy
A Line Item of Service
N) Intermediate Care
A Bill for Service
O) Transportation
A Line Item of Service
P) Physical Therapy
A Bill for Service or Line Item depending on
								provider type
Q) Nurse Midwife
A Line Item of Service
R) Eyeglasses
A Line Item of Service
B.
				  All providers that enroll with Medicaid on or after October 1, 2011, shall
				  submit electronically all claims for covered services they render in the
				  fee-for-service program under the State Plans for Title XIX and XXI of the
				  Social Security Act, and any waivers thereof, and enroll to receive electronic
				  funds transfer (EFT) for payment of those services. All other providers shall
				  comply with this electronic submission requirement by July 1, 2012.
1. Any provider who cannot comply with this
				  electronic claims submission or EFT requirement may request an exception from
				  DMAS for good cause shown.
2. Good
				  cause may include, but is not limited to, (i) the unavailability of the
				  infrastructure necessary to support electronic claims submission in the
				  provider's geographic region; (ii) the absence of a mechanism for electronic
				  submission for the particular claim type, such as in the case of a temporary
				  detention order; (iii) the provider's inability to transact business through a
				  banking institution capable of EFT; or (iv) financial hardship.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part V - Sanctions, Advance Directives › Section 12VAC30-20-215 - Sanctions for psychiatric hospitals

Current through Register Vol. 40, No. 24, July 15, 2024
(a) The state assures that the requirements
				  of § 1902(y)(1), § 1902(y)(2)(A), and § 1902(y)(3) of the Act
				  are met concerning sanctions for psychiatric hospitals that do not meet the
				  requirements of participation when the hospital's deficiencies immediately
				  jeopardize the health and safety of its patients or do not immediately
				  jeopardize the health and safety of its patients.
(b) The state terminates the hospital's
				  participation under the State plan when the state determines that the hospital
				  does not meet the requirements for a psychiatric hospital and further finds
				  that the hospital's deficiencies immediately jeopardize the health and safety
				  of its patients.
(c) When the state
				  determines that the hospital does not meet the requirements for a psychiatric
				  hospital and further finds that the hospital's deficiencies do not immediately
				  jeopardize the health and safety of its patients, the state may:
1. Terminate the hospital's participation
				  under the State plan; or
2. Provide
				  that no payment will be made under the State plan with respect to any
				  individual admitted to such hospital after the effective date of the finding;
				  or
3. Terminate the hospital's
				  participation under the State plan and provide that no payment will be made
				  under the State plan with respect to any individual admitted to such hospital
				  after the effective date of the finding.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part V - Sanctions, Advance Directives › Section 12VAC30-20-220 - Income and eligibility verification system procedures; requests to other state agencies

Current through Register Vol. 40, No. 24, July 15, 2024
The Department of Medical Assistance Services will meet
					 all of the applicable requirements of 42 CFR 431 Subparts A and F and 42 CFR
					 435 with respect to the Income and Eligibility Verification System.
In addition to the federal regulatory requirements, the
					 additional information match against Virginia Department of Motor Vehicles will
					 be made for new applicants and ongoing recipients of medical
					 assistance.
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 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part V - Sanctions, Advance Directives › Section 12VAC30-20-230 - Method for issuance of medicaid eligibility cards to homeless individuals

Current through Register Vol. 40, No. 24, July 15, 2024
Permanent addresses are not required. Recipients are
					 allowed to choose the method of receiving their Medicaid cards:
a) Mailing to General Delivery at a post
				  office of their choice;
b) Picking
				  up their card at the local department of social services;
c) An alternate mailing address with
				  assurance of receipt of mail.
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 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part V - Sanctions, Advance Directives › Section 12VAC30-20-240 - Requirements for advance directives under state plans for medical assistance

Current through Register Vol. 40, No. 24, July 15, 2024
The following is a written description of the law of the
					 State (whether statutory or as recognized by the courts of the State)
					 concerning advance directives. If applicable States should include definitions
					 of living will, durable power of attorney for health care, durable power of
					 attorney, witness requirements, special State limitations on living will
					 declarations, proxy designation, process information and State forms, and
					 identify whether State law allows for a health care provider or agent of the
					 provider to object to the implementation of advance directives on the basis of
					 conscience.
1.0. All specified
				  providers, receiving funds under this Plan, shall maintain written policies,
				  procedures, and materials concerning advance directives to ensure compliance
				  with the law. All providers must:
A. give
				  written information to all adults (as defined by the Code of Virginia §
				  54.1-2981 et seq., receiving medical care concerning their rights under state
				  law to:
1. Make decisions concerning their
				  medical care,
2. Accept or refuse
				  medical or surgical treatment, and
3. Formulate advance directives, e.g., living
				  wills or durable powers of attorney for health care.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VI - Nursing Facility Enforcement › Section 12VAC30-20-251 - Termination of provider agreement

Current through Register Vol. 40, No. 24, July 15, 2024
A. Mandatory termination. As set forth by
				  42 CFR
				  488.408(1995), the
				  Commonwealth shall (i) impose temporary management on the nursing facility;
				  (ii) terminate the nursing facility's provider agreement; or (iii) impose both
				  of these remedies when there are one or more deficiencies that constitute
				  immediate jeopardy to resident health or safety. In addition, the Commonwealth
				  shall terminate the nursing facility's provider agreement when the nursing
				  facility fails to relinquish control to the temporary manager, or in situations
				  when a facility's deficiencies do not pose immediate jeopardy, if the nursing
				  facility does not meet the eligibility criteria for continuation of payment set
				  forth in 42 CFR
				  488.412(a) (1995).
B. The Commonwealth shall have the authority
				  to terminate a nursing facility's provider agreement if such nursing facility:
1. Is not in substantial compliance with the
				  requirements of participation, regardless of whether or not immediate jeopardy
				  is present; or
2. Fails to submit
				  an acceptable plan of correction within the timeframe specified by the
				  Commonwealth. For purposes of this section, substantial compliance shall be
				  defined as meaning a level of compliance with the requirements of participation
				  such that any identified deficiencies pose no greater risk to resident health
				  or safety than the potential for causing minimal harm.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VI - Nursing Facility Enforcement › Section 12VAC30-20-253 - Denial of payment for new admissions

Current through Register Vol. 40, No. 24, July 15, 2024
A. Denial of payment for new admissions. The
				  Commonwealth shall (i) deny payment for new admissions; (ii) impose civil money
				  penalties of $50 to $3,000 per day; or (iii) impose both of these remedies when
				  there are widespread deficiencies that constitute no actual harm with a
				  potential for more than minimal harm but not immediate jeopardy, or one or more
				  deficiencies that constitute actual harm that is not immediate jeopardy. As set
				  forth by 42 CFR
				  488.417(1995), the
				  Commonwealth shall deny payment for new admissions when a nursing facility is
				  not in substantial compliance three months after the last day of the survey
				  identifying the noncompliance, or the survey agency has cited a nursing
				  facility with substandard quality of care on the last three consecutive
				  standard surveys. As set forth by
				  42 CFR
				  488.417, the Commonwealth shall have the
				  authority to deny payment for all new admissions when a facility is not in
				  substantial compliance. For the purposes of this section, a new admission shall
				  be defined as a resident who is admitted to the facility on or after the
				  effective date of a denial of payment remedy and, if previously admitted, has
				  been discharged before that effective date. Residents admitted before the
				  effective date of the denial of payment, and taking temporary leave, are not
				  considered new admissions, nor subject to the denial of payment. Also for the
				  purposes of this section, substantial compliance shall mean a level of
				  compliance with the requirements of participation such that any identified
				  deficiencies pose no greater risk to resident health or safety than the
				  potential for causing minimal harm.
B. Denial of payment for substandard quality
				  of care on last three surveys. As set forth by
				  42 CFR
				  488.414 and
				  42 CFR
				  488.417(1995), if a facility
				  is found to have provided substandard quality of care on the last three
				  consecutive standard surveys, regardless of other remedies provided, the
				  Commonwealth shall deny payment for all new admissions and shall impose state
				  monitoring until such facility demonstrates to the satisfaction of the
				  Commonwealth that it is in substantial compliance with all requirements and
				  will remain in substantial compliance with all requirements.
C. The Commonwealth shall have the authority
				  to deny payment for new admissions for any deficiency except when the facility
				  is in substantial compliance.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VI - Nursing Facility Enforcement › Section 12VAC30-20-254 - Civil money penalty

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Immediate jeopardy. In situations of immediate jeopardy, the Commonwealth shall
				  have the authority to impose (in accordance with
				  42 CFR
				  488.430 through
				  42 CFR
				  488.444 ) a civil money penalty in the range
				  of $3,050 to $10,000 in addition to the remedies of imposing temporary
				  management or terminating the nursing facility's provider agreement. In
				  imposing civil money penalties, the Commonwealth shall comply with all
				  provisions of 42 CFR
				  488.430 through
				  488.444(1995).
B. No immediate jeopardy. In accordance with
				  42 CFR
				  488.430 through
				  42 CFR
				  488.444, the Commonwealth shall (i) deny
				  payment for new admissions; (ii) impose civil money penalties of $50 to $3,000
				  per day; or (iii) impose both of these remedies when there are widespread
				  deficiencies that constitute no actual harm with a potential for more than
				  minimal harm but not immediate jeopardy, or one or more deficiencies that
				  constitute actual harm that is not immediate jeopardy.
C. Notice. Either HCFA or the Commonwealth,
				  as appropriate, shall send a prior written notice of the penalty to the
				  facility as set forth by 42
				  CFR 488.434(1995).
D. The Commonwealth shall have the authority
				  to impose civil money penalties of $50 to $3,000 per day to any deficiency
				  except when the nursing facility is in substantial compliance. If the
				  Commonwealth imposes a civil money penalty for a deficiency that constitutes
				  immediate jeopardy, the penalty must be in the range of $3,050 to $10,000 per
				  day. For the purposes of this section, substantial compliance shall mean a
				  level of compliance with the requirements of participation such that any
				  identified deficiencies pose no greater risk to resident health or safety than
				  the potential for causing minimal harm.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VI - Nursing Facility Enforcement › Section 12VAC30-20-255 - State monitoring

Current through Register Vol. 40, No. 24, July 15, 2024
A. In
				  accordance with 42 CFR
				  488.422(1995), the
				  Commonwealth shall directly monitor the delivery of services for nursing
				  facilities to have isolated deficiencies that constitute no actual harm with a
				  potential for more than minimal harm but not immediate jeopardy, or found to
				  have a pattern of deficiencies that constitute no actual harm with a potential
				  for more than minimal harm but not immediate jeopardy. As set forth by
				  42 CFR
				  488.408(c)(3) (1995), the
				  Commonwealth shall have the authority to impose state monitoring at any time to
				  any deficiency except when the facility is in substantial compliance. As set
				  forth by 42 CFR
				  488.414(1995), if a facility
				  is found to have provided substandard quality of care on the last three
				  consecutive standard surveys, regardless of other remedies provided, the
				  Commonwealth shall deny payment for all new admissions and shall impose state
				  monitoring as specified in 42 CFR 488.422 until such facility
				  demonstrates to the satisfaction of the Commonwealth that it is in substantial
				  compliance with all requirements and will remain in substantial compliance with
				  all requirements. For purposes of this section, a new admission shall be
				  defined as a resident who is admitted to the facility on or after the effective
				  date of a denial of payment remedy and, if previously admitted, has been
				  discharged before that effective date. Residents admitted before the effective
				  date of the denial of payment, and taking temporary leave, are not considered
				  new admissions, nor subject to the denial of payment. For the purposes of this
				  section, substantial compliance shall mean a level of compliance with the
				  requirements of participation such that any identified deficiencies pose no
				  greater risk to resident health or safety than the potential for causing
				  minimal harm.
B. For state
				  monitoring, no prior notice shall be required of the Commonwealth to the
				  nursing facility.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VI - Nursing Facility Enforcement › Section 12VAC30-20-256 - Transfer of residents; transfer of residents with closure of facility

Current through Register Vol. 40, No. 24, July 15, 2024
A. The Commonwealth
				  shall arrange for the safe and orderly transfer of Medicare and Medicaid
				  nursing facility residents when the provider agreement with the nursing
				  facility is terminated.
B. In an
				  emergency, the Commonwealth shall have the authority to transfer Medicare and
				  Medicaid residents to another facility, or close the facility and transfer the
				  Medicare and Medicaid residents to another facility.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VI - Nursing Facility Enforcement › Section 12VAC30-20-257 - Required plan of correction

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  In accordance with 42 CFR
				  488.408(f) (1995), a nursing
				  facility found to have a deficiency with regard to a program requirement shall
				  submit a plan of correction for approval by the Commonwealth without regard to
				  the remedies which are imposed or the seriousness of the identified
				  deficiencies. A nursing facility shall not be required to submit a plan of
				  correction when it has been found to have deficiencies that are isolated that
				  the Commonwealth determines have only a potential for minimal harm but no
				  actual harm has occurred.
B. For
				  the purposes of this section, a plan of correction shall mean a plan developed
				  by the nursing facility or the appointed temporary manager and approved by HCFA
				  or the state survey agency that describes the actions the nursing facility will
				  take to correct deficiencies and specifies the date by which those deficiencies
				  will be corrected.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VI - Nursing Facility Enforcement › Section 12VAC30-20-258 - Appeals

Current through Register Vol. 40, No. 24, July 15, 2024
A. Nursing facility
				  appeal rights. As set forth by
				  42 CFR
				  488.408(g) (1995), a nursing
				  facility for which deficiencies have been identified may appeal a certification
				  of noncompliance leading to an enforcement remedy.
B. Appeal limits. As set forth by
				  42 CFR
				  488.408(g) (1995), nursing
				  facilities may not appeal the Commonwealth's choice of the remedy to be
				  applied, including the factors considered by the Commonwealth or HCFA in
				  selecting the remedy specified in
				  42 CFR
				  488.404.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VI - Nursing Facility Enforcement › Section 12VAC30-20-259 - Repeated substandard quality of care

Current through Register Vol. 40, No. 24, July 15, 2024
Any remedies or sanctions which may be imposed by the
					 Commonwealth pursuant to 42
					 CFR 488.414(a) shall be
					 imposed in accordance with the requirements set forth by
					 42 CFR
					 488.414(b) through
					 488.414(e) and
					 488.454(b).
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VII - Specialized Services; Categorical Determinations › Section 12VAC30-20-260 - Definition of specialized services

Current through Register Vol. 40, No. 24, July 15, 2024
The Department of Medical Assistance Services (DMAS) shall
					 define specialized services for the purposes of preadmission screening and
					 annual resident review as follows. The Department of Mental Health, Mental
					 Retardation and Substance Abuse Services shall ensure the provision of services
					 when they are provided by a non-Medicaid-enrolled provider or when the services
					 are not covered by Medicaid.
a.
				  Partial hospitalization
b.
				  Transportation to Medicaid-covered services or specialized services necessary
				  to treat conditions of mental illness or mental retardation
c. Day health and rehabilitation
d. Psychosocial rehabilitation
e. Crisis intervention
f. Customized durable medical equipment, for
				  residents without a patient pay, that would allow the resident to participate
				  in specialized services
g. Behavior
				  management interventions requiring ongoing consultation and monitoring by a
				  licensed psychiatrist or psychologist
h. One-to-one supervision necessary for
				  behavior management
i. Vision and
				  hearing needs related to mental illness or mental retardation for persons over
				  age 21
j. Dental needs resulting
				  from mental illness or mental retardation sequela for persons over age
				  21
k. Habilitation
l. Supported employment for persons with
				  mental illness or mental retardation
m. Case management services
n. Individual psychotherapy
o. Day treatment
p. Individual and group counseling
q. Inpatient psychiatric care
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 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VII - Specialized Services; Categorical Determinations › Section 12VAC30-20-270 - Categorical determinations

Current through Register Vol. 40, No. 24, July 15, 2024
1. A
				  Level II evaluation shall be required for any applicant to a Medicaid-certified
				  nursing facility who is determined, as a result of the Level I identification
				  screening, to have a condition of mental illness or mental retardation as
				  defined in 42 CFR
				  483.102.
2. If, however, the individual also meets one
				  of the following categorical determinations, a Level II evaluation is not
				  required to be completed for that individual. These determinations may only be
				  applied following the Level I review and only if existing data on the
				  individual appear to be current and accurate and are sufficient to allow the
				  evaluator readily to determine that the individual fits into the established
				  category.
3. The categorical
				  determinations are:
a. a terminal illness in
				  which a physician has documented that life expectancy is less than six months;
				  and
b. a severe physical illness
				  such as coma, functioning at brain stem level, or other conditions which result
				  in a level of impairment so severe that the individual could not be expected to
				  benefit from active treatment. When this category is used, documentation must
				  be available which fully describes the severity of the condition.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VIII - Nursing Facilities Survey/Certification › Section 12VAC30-20-272 - Survey and certification education program

Current through Register Vol. 40, No. 24, July 15, 2024
The state has in effect the following survey and
					 certification periodic education program for the staff and residents (and their
					 representatives) of nursing facilities in order to present current regulations,
					 procedures, and policies.
The state survey agency periodically conducts provider
					 training programs and orientation of OBRA regulations and the survey process
					 through programs or mailings. The state survey agency participates in the
					 Medicaid agency's training of facilities regarding the Resident Assessment
					 Instrument.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VIII - Nursing Facilities Survey/Certification › Section 12VAC30-20-274 - Process for the investigation of allegations of resident neglect and abuse and misappropriation of resident property

Current through Register Vol. 40, No. 24, July 15, 2024
The state has in effect the following process for the
					 receipt and timely review and investigation of allegations of neglect and abuse
					 and misappropriation of resident property by a nurse aide or a resident in a
					 nursing facility or by another individual used by the facility in providing
					 services to such a resident.
When the above described incidences involve a nurse aide,
					 they are reported to the Board of Health Professions, Board of Nursing. In
					 addition, such allegations are frequently received by the facility
					 administration which reports the allegations to the state survey agency. The
					 state survey agency conducts the follow-up investigations.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VIII - Nursing Facilities Survey/Certification › Section 12VAC30-20-275 - Procedures for scheduling and conduct of standards surveys

Current through Register Vol. 40, No. 24, July 15, 2024
The state has in effect the following procedures for the
					 scheduling and conduct of standard surveys to assure that it has taken all
					 reasonable steps to avoid giving notice.
Onsite survey schedules are only accessible to staff of
					 the Department of Health, Division of Licensure and Certification, which
					 conducts the surveys. After the onsite review is initiated by the Division
					 inspection staff, the Virginia Department of Health notifies the state agency
					 for the aging ombudsman, the state fire marshal, and other agencies as
					 needed.
Statutory Authority
§ 32.1.325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VIII - Nursing Facilities Survey/Certification › Section 12VAC30-20-277 - Programs to measure and reduce inconsistency

Current through Register Vol. 40, No. 24, July 15, 2024
The state has in effect the following programs to measure
					 and reduce inconsistency in the application of survey results among
					 surveyors.
The state survey agency conducts routine training
					 programs, routine informational memorandums and procedural clarifications,
					 routine team meetings, and ongoing supervisory review and monitoring of staff
					 training needs.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part VIII - Nursing Facilities Survey/Certification › Section 12VAC30-20-278 - Process for investigations of complaints and monitoring

Current through Register Vol. 40, No. 24, July 15, 2024
A. The state has in
				  effect the following process for investigating complaints of violations of
				  requirements by nursing facilities and monitors onsite on a regular, as needed
				  basis, a nursing facility's compliance with the requirements of § 1919(b),
				  (c), and (d) for the following reasons:
(i)
				  The facility has been found not to be in compliance with such requirements and
				  is in the process of correcting deficiencies to achieve such
				  compliance;
(ii) The facility was
				  previously found not to be in compliance with such requirements and has
				  corrected deficiencies to achieve such compliance, and verification of
				  continued compliance is indicated; or
(iii) The state has reason to question the
				  compliance of the facility with such requirements.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part IX - Administration, Civil Rights › Section 12VAC30-20-280 - Methods of administration; civil rights

Current through Register Vol. 40, No. 24, July 15, 2024
A statement of compliance (Form CB-FS 5022) and the State
					 Agency's method of implementing administration in the Medical Assistance
					 Program, which was submitted to the Department of Health, Education, and
					 Welfare on November 30, 1967, are certified to be applicable to this State
					 Plan.
The Methods of Administration for Title VI as initially
					 furnished by the State Agency in 1965 in conformity with the requirements of
					 Title VI of the Civil Rights Act of 1964, along with the agreements
					 subsequently negotiated with the Office of Civil Rights in 1969 provide the
					 working basis for the State Agency's administration of its compliance
					 responsibilities under Title VI. This Plan provides for on site reviews of all
					 vendor facilities, including facilities used under Title XIX, to be conducted
					 annually to assure compliance with Title VI. This all programs operated by the
					 Virginia Health Department (and by other State Agencies) are being and will be
					 conducted in such a manner that no person will be excluded from participation
					 in, be denied the benefits of, or be otherwise subjected to discrimination on
					 the ground of race, color, or national origin.
For all employees under the Medical Assistance Program,
					 assurance is made that equal opportunity practices will exist in conformance
					 with the requirements of Federal law, Title VII, Civil Rights Act of 1964. An
					 Equal Employment Opportunity Plan was directed by State Executive order number
					 twenty-nine to be applicable policy effective January 1, 1973, governing State
					 personnel administration. Copies of this Plan were submitted to the Department
					 of Health, Education, and Welfare, of the U.S. government. By directive of the
					 Commissioner of Health, affirmative action on this Plan was directed on all
					 levels of management of the Department of Health of Virginia and thereby on all
					 employees of the State's Medical Assistance Program.
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 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part XII - Provider Appeals › Section 12VAC30-20-500 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms when used in this part shall
					 have the following meanings:
"Administrative dismissal" means a dismissal that requires
					 only the issuance of a decision with appeal rights but does not require the
					 submission of a case summary or any further proceeding.
"Day" means a calendar day unless otherwise stated.
"DMAS" means the Virginia Department of Medical Assistance
					 Services or its agents or contractors.
"Hearing officer" means an individual selected by the
					 Executive Secretary of the Supreme Court of Virginia to conduct the formal
					 appeal in an impartial manner pursuant to §§
										2.2-4020 and
					 32.1-325.1 of the Code of
					 Virginia and this part.
"Informal appeals agent" means a DMAS employee who conducts
					 the informal appeal in an impartial manner pursuant to §§ .2-4019 and
					 32.1-325.1 of the Code of Virginia and this part.
"Last known address" means the provider's physical or
					 electronic correspondence address on record in the DMAS Medicaid Management
					 Information System as of the date DMAS transmits an item to the provider or the
					 address of the provider's counsel of record. Nothing herein shall prevent DMAS
					 and the provider from agreeing in writing during the course of an audit or an
					 appeal to use an alternative location for the transmittal of an item or items
					 related to the audit or the appeal.
"Provider" means an individual or entity that has a
					 contract with DMAS to provide covered services and that is not operated by the
					 Commonwealth of Virginia.
"Transmit" means to send by means of the United States
					 mail, courier or other hand delivery, facsimile, electronic mail, or electronic
					 submission.
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 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part XII - Provider Appeals › Section 12VAC30-20-540 - Informal appeals

Current through Register Vol. 40, No. 24, July 15, 2024
A. Notice
				  of informal appeal.
1. Providers appealing
				  the termination or denial of their Medicaid agreement pursuant to §
											32.1-325E
				  of the Code of Virginia shall file a written notice of informal appeal with the
				  DMAS Appeals Division within 15 days of the provider's receipt of the notice of
				  termination or denial.
2. Providers
				  appealing adjustments to a cost report shall file a written notice of informal
				  appeal with the DMAS Appeals Division within 90 days of the provider's receipt
				  of the notice of program reimbursement. The written notice of informal appeal
				  shall identify the issues, adjustments, or items that the provider is
				  appealing.
3. Providers appealing
				  all other DMAS decisions shall file a written notice of informal appeal with
				  the DMAS Appeals Division within 30 days of the provider's receipt of the
				  decision. The written notice of informal appeal shall identify each adjustment,
				  patient, service date, or other disputed matter that the provider is
				  appealing.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part XII - Provider Appeals › Section 12VAC30-20-560 - Formal appeals

Current through Register Vol. 40, No. 24, July 15, 2024
A. A
				  provider appealing a DMAS informal appeal decision shall file a written notice
				  of formal appeal with the DMAS Appeals Division within 30 days of the
				  provider's receipt of the informal appeal decision. The notice of formal appeal
				  shall identify each adjustment, patient, service date, or other disputed matter
				  that the provider is appealing. Failure to file a written notice of formal
				  appeal in the detail specified within 30 days of receipt of the informal appeal
				  decision shall result in dismissal of the appeal. Pursuant to §
										2.2-4019A
				  of the Code of Virginia, DMAS shall ascertain the fact basis for decisions
				  through informal proceedings unless the parties consent in writing to waive
				  such a conference or proceeding to go directly to a formal hearing, and
				  therefore only issues that were addressed pursuant to §
										2.2-4019
				  of the Code of Virginia shall be addressed in the formal appeal, unless DMAS
				  and the provider consent to waive the informal fact-finding process under
				  §
										2.2-4019A
				  of the Code of Virginia.
B.
				  Documentary evidence, objections to documentary evidence, opening briefs, and
				  reply briefs.
1. Documentary evidence,
				  objections to documentary evidence, opening briefs, and reply briefs shall be
				  filed with the DMAS Appeals Division on the date specified in this subsection.
				  The hearing officer shall only consider those documents or pleadings that are
				  filed within the required timeline. Simultaneous with filing, the filing party
				  shall transmit a copy to the other party and to the hearing officer.
a. All documentary evidence upon which DMAS
				  or the provider relies shall be filed within 21 days of the filing of the
				  notice of formal appeal.
b. Any
				  objections to the admissibility of documentary evidence shall be filed within
				  seven days of the filing of the documentary evidence. The hearing officer shall
				  rule on any such objections within seven days of the filing of the
				  objections.
c. The opening brief
				  shall be filed by DMAS and the provider within 30 days of the completion of the
				  hearing.
d. Any reply brief from
				  DMAS or the provider shall be filed within 10 days of the filing of the opening
				  brief to which the reply brief responds.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part XII - Provider Appeals › Section 12VAC30-20-570 - Reconsideration of final agency decision

Current through Register Vol. 40, No. 24, July 15, 2024
A. Reconsiderations of a DMAS final appeal
				  decision issued on a formal appeal conducted pursuant to §
										2.2-4020
				  of the Code of Virginia shall be conducted in accordance with §
										2.2-4023.1 of the
				  Code of Virginia.
B. The DMAS
				  director's review shall be made upon the case record of the formal appeal.
				  Testimony or documentary submissions that were not part of the formal appeal
				  case record prior to issuance of the final agency decision shall not be
				  considered.
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 20 - ADMINISTRATION OF MEDICAL ASSISTANCE SERVICES › Part XII - Provider Appeals › Form - FORMS (12VAC30-20)

Current through Register Vol. 40, No. 24, July 15, 2024
Health
					 Insurance Premium Payment HIPP for Kids (HFK) Program - Cost Sharing of
					 Co-Pays, Deductibles and Co-insurance (undated)
Health
					 Insurance Premium Payment Programs Application/Renewal, DMAS 500, and Employer
					 Insurance Verification Form, DMAS-502 (rev. 2/2012)
Health
					 Insurance Premium Payment (HIPP) and HIPP for Kids Program - Consent for
					 Authorization for Release of Information - Family Member Eligibility Release
					 (undated)
Health
					 Insurance Premium Payment Program - Change Form (undated)
.
Health
					 Insurance Premium Payment Program (HIPP) for Kids - Change Form (eff.
					 9/2010)
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 30 - GROUPS COVERED AND AGENCIES RESPONSIBLE FOR ELIGIBILITY DETERMINATION › Section 12VAC30-30-5 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The follows words and terms when used in this chapter shall
				  have the following meanings unless the context clearly indicates
				  otherwise:
"Act" means the Social Security Act (
				  42 USC §§
										301 through
				  1397mm ).
"MAGI" means modified adjusted gross income and is an
				  eligibility methodology for how income is counted and how household composition
				  and family size are determined. MAGI is based on federal tax rules for
				  determining adjusted gross income.
"SSI" means supplemental security income.
"SSP" means state supplementary payment.
"Title IV-A" means Title IV, Part A of the Social Security
				  Act, 42 USC §§
										601 through
				  619.
"Title IV-A agency" means the agency described in
				  42 USC §
										602(a)(4).
"Title XIX" means Title XIX of the Social Security Act,
				  42 USC §§
										1396 through
				  1396w-5.
Statutory Authority: §
											32.1-325 of the Code of
					 Virginia; 42 USC §
												1396 et
					 seq.