LIS

Virginia Law

Administrative Code

Creating a Report: Check the sections you'd like to appear in the report, then use the "Create Report" button at the bottom of the page to generate your report. Once the report is generated you'll then have the option to download it as a pdf, print or email the report.

Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 120. Waivered Services
12/22/2024

12VAC30-120-400. Quality control and utilization review.

A. DMAS shall rigorously monitor the quality of care provided by the MCOs. DMAS and the MCOs shall comply with (i) the contract; (ii) 42 CFR 438 Subpart E, entitled Quality Measurement and Improvement: External Quality Review; and (iii) the MCO standards identified in 42 CFR 438 Subpart D, entitled MCO, PIHP, and PAHP Standards. DMAS shall monitor the MCOs to determine their compliance with the contract, 42 CFR Subpart A, and all other relevant sections of 42 CFR Part 438 (Managed Care) as follows:

1. If the MCO fails substantially to provide the medically necessary items and services required under law or under the contract to be provided to an enrolled recipient and the failure has adversely affected or has substantial likelihood of adversely affecting the individual.

2. If the MCO engages in any practice that discriminates against individuals on the basis of their health status or requirements for health care services, including expulsion or refusal to reenroll an individual, or any practice that could reasonably be expected to have the effect of denying or discouraging enrollment (except as permitted by § 1903(m) of the Social Security Act (42 USC § 1396(m)) by eligible individuals whose medical conditions or histories indicate a need for substantial future medical services.

3. If the MCO misrepresents or falsifies information that it furnishes, under § 1903(m) of the Social Security Act (42 USC § 1396b(m)) to CMS, DMAS, an individual, or any other entity.

4. If the MCO fails to comply with the requirements of 42 CFR 417.479(d) through 42 CFR 417.479(g) relating to physician incentive plans or fails to submit to DMAS its physician incentive plans as required or requested in 42 CFR 434.70.

5. If the MCO imposes on members premiums or charges that are in excess of the premiums or charges permitted under the Medicaid program.

B. DMAS shall ensure that data on performance and patient results are collected.

C. DMAS shall ensure that quality outcomes information is provided to MCOs. DMAS shall ensure that changes that are determined to be needed as a result of quality control or utilization review are made.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396.

Historical Notes

Derived from Virginia Register Volume 13, Issue 5, eff. January 1, 1997; amended, Virginia Register Volume 14, Issue 5, eff. January 1, 1998; Volume 19, Issue 3, eff. December 1, 2002; Volume 19, Issue 23, eff. August 27, 2003; Volume 21, Issue 11, eff. March 10, 2005; Volume 32, Issue 22, eff. July 27, 2016; Volume 35, Issue 14, eff. April 18, 2019.

Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.

As a service to the public, the Virginia Administrative Code is provided online by the Virginia General Assembly. We are unable to answer legal questions or respond to requests for legal advice, including application of law to specific fact. To understand and protect your legal rights, you should consult an attorney.