Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 5. Department of Health
Chapter 408. Certificate of Quality Assurance of Managed Care Health Insurance Plan Licensees
6/18/2024

12VAC5-408-160. Management and administration.

A. No person shall establish or operate a managed care health insurance plan in Virginia without first obtaining a license from the Bureau of Insurance and a certificate of quality assurance from the department.

B. The MCHIP licensee must comply with:

1. This chapter;

2. Other applicable federal, state or local laws and regulations; and

3. The MCHIP licensee's own policies and procedures.

C. The MCHIP licensee shall submit or make available reports and information as described in § 32.1-137.4 of the Code of Virginia necessary to establish compliance with these standards and applicable laws.

D. The MCHIP licensee shall permit representatives from the center to conduct examinations or reviews to:

1. Verify application information;

2. Determine compliance with these standards;

3. Review necessary records, including contracts for delegated services and capitated rate information; and

4. Investigate complaints and review appeals procedures.

E. The licensee shall notify the center and providers in writing within 30 days of implementing any material changes affecting the MCHIP licensee, including:

1. Mailing address;

2. Ownership;

3. Health care services provided, including any delegated services;

4. Medical director;

5. MCHIP or licensee name;

6. Significant provider network changes; and

7. Any material changes in the quality assurance program, complaint process, or utilization review process.

If more advanced notice of a specific change is required by law for notices to providers or covered persons, notice given to the department under this section shall be no less than notice given to covered persons under the law.

F. All applications, including those for renewal, shall require:

1. A description of the geographic area to be served with a map clearly delineating the boundaries of the service area or areas;

2. A description of the complaint system required under § 32.1-137.6 of the Code of Virginia and 12VAC5-408-130;

3. A description of the procedures and programs established by the licensee to assure both availability and accessibility of adequate personnel and facilities;

4. A list of the MCHIP licensee's managed care health insurance plans; and

5. A description of the MCHIP's quality assurance program.

G. In addition, applications shall include the following:

1. A detailed description of the MCHIP's prescription drug benefit program, if one is offered;

2. If the MCHIP requires or performs utilization management, the utilization review plan including a description of the criteria, clinical and therapeutic guidelines, and their derivation or source;

3. A description of the MCHIP licensee's credentialing process;

4. The current provider directory, so that the department can determine whether it complies with subsection G of § 38.2-3407.10 of the Code of Virginia;

5. A copy of the MCHIP's evidence of coverage or insurance plan coverage limitations and exclusions and other information provided to covered persons;

6. A description of all types of payment arrangements that the MCHIP licensee uses to compensate providers for health care services rendered to covered persons, including, but not limited to, withholds, bonus payments, capitation, processing fees, and fee-for-service discounts; and

7. For those MCHIP licensees that conduct clinical studies, a list of clinical studies with abstracts of study design, objectives and, if available, results as applicable to the type of MCHIP licensee.

H. A list demonstrating the health care services, as required by law, that the licensee provides, arranges, pays for, or reimburses shall be appropriately integrated throughout the MCHIP's service area. Services shall be based upon prevailing nationally recognized standards of medical practice.

I. The licensee shall have a written policy stating the MCHIP licensee treats covered persons in a manner that respects their rights as well as its expectations of provider and covered person responsibilities. The services shall be accessible to all covered persons, including those with diverse cultural and ethnic backgrounds, and those with physical and mental disabilities.

Statutory Authority

§ 32.1-137.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 16, Issue 7, eff. January 20, 2000; amended, Virginia Register Volume 18, Issue 8, eff. January 30, 2002.

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