Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 10. State Plan under Title XIX of the Social Security Act Medical Assistance Program; General Provisions

12VAC30-10-490. Free choice of providers.

A. Except as provided in subsection B of this section, the Medicaid agency assures that an individual eligible under the plan may obtain Medicaid services from any institution, agency, pharmacy, person or organization that is qualified to perform the services, including an organization that provides these services or arranges for their availability on a prepayment basis.

B. Subsection A of this section does not apply to services furnished to an individual:

1. Under an exception allowed under 42 CFR 431.54, subject to the limitations in subsection C of this section;

2. Under a waiver approved under 42 CFR 431.55, subject to the limitations in subsection C of this section;

3. By an individual or entity excluded from participation in accordance with § 1902(p) of the Act; or

4. By individuals or entities who have been convicted of a felony under federal or state law and for which the state determines that the offense is inconsistent with the best interests of the individual eligible to obtain Medicaid services.

C. Enrollment of an individual eligible for medical assistance in a primary care case management system described in § 1915(b)(1), a health maintenance organization, or a similar entity shall not restrict the choice of the qualified person from whom the individual may receive emergency services or services under § 1905(a)(4)(C).

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-41, eff. June 16, 1993; amended, Virginia Register Volume 15, Issue 26, eff. October 13, 1999.

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