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

12VAC30-10-690. Exclusion of providers and suspension of practitioners and other individuals.

A. All of the requirements of 42 CFR 1002, Subpart B are met.

In addition to meeting all federal requirements, the agency, under the authority of state law, imposes broader sanctions.

B. The Medicaid agency meets the requirements of:

1. § 1902(p) of the Act by excluding from participation:

a. At the state's discretion, any individual or entity for any reason for which the Secretary could exclude the individual or entity from participation in a program under Title XVIII in accordance with § 1128, 1128A, or 1866(b)(2).

b. Any HMO (as defined in § 1903(m) of the Act) or an entity furnishing services under a waiver approved under § 1915(b)(1) of the Act, that:

(1) Could be excluded under § 1128(b)(8) relating to owners and managing employees who have been convicted of certain crimes or received other sanctions; or

(2) Has, directly or indirectly, a substantial contractual relationship (as defined by the Secretary) with an individual or entity that is described in § 1128(b)(8)(B) of the Act.

2. An MCO, PIHP, PAHP, or PCCM may not have prohibited affiliations with individuals (as defined in 42 CFR 438.610(b)) who are debarred, suspended, or otherwise excluded from participating in procurement activities under the Federal Acquisition Regulation or from participating in nonprocurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order No. 12549. If the Commonwealth finds that an MCO, PCCM, PIHP, or PAHP is not in compliance, the Commonwealth will comply with the requirements of 42 CFR 438.610(c).

3. § 1902(a)(39) of the Act by:

a. Excluding an individual or entity from participation for the period specified by the Secretary, when required by the Secretary to do so in accordance with § 1128 or 1128A of the Act; and

b. Providing that no payment will be made with respect to any item or service furnished by an individual or entity during this period.

C. The Medicaid agency meets the requirements of:

1. § 1902(a)(41) of the Act with respect to prompt notification to HCFA whenever a provider is terminated, suspended, sanctioned, or otherwise excluded from participating under this state plan; and

2. § 1902(a)(49) of the Act with respect to providing information and access to information regarding sanctions taken against health care practitioners and providers by state licensing authorities in accordance with § 1921 of the Act.

D. Provider terminations or exclusions shall be in accordance with § 32.1-325 D and E of the Code of Virginia.

Statutory Authority

§ 32.1-325 of the Code of Virginia; Title XIX of the Social Security Act (42 USC § 1396 et seq.).

Historical Notes

Subsection A derived from VR460-01-78, eff. June 30, 1979; subsection B 1 derived from VR460-01-78.1, eff. January 1, 1988; subsections B 2 [now 3] and C derived from VR460-01-78.2, eff. January 1, 1988; amended, Virginia Register Volume 25, Issue 26, eff. October 1, 2009; Volume 26, Issue 19, eff. July 1, 2010.

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