Administrative Code

Virginia Administrative Code
1/24/2022

Chapter 10. State Plan under Title XIX of the Social Security Act Medical Assistance Program; General Provisions

Part I
Single State Agency Organization

12VAC30-10-10. Designation and authority.

A. The Department of Medical Assistance Services is the single state agency designated to administer or supervise the administration of the Medicaid program under Title XIX of the Social Security Act. (All references in this plan to "the Medicaid agency" mean the agency named in this subsection.)

12VAC30-20-10 is a certification signed by the State Attorney General identifying the single state agency and citing the legal authority under which it administers or supervises administration of the program.

B. The entire plan under Title XIX is administered or supervised by the state agency named in subsection A of this section.

C. No waivers of the single state agency requirements have ever been granted.

D. Determinations of eligibility for Medicaid under this plan are made by the agency or agencies specified in 12VAC30-30-10. There is a written agreement between the agency named in subsection A of this section and other agencies making such determinations for specific groups covered under this plan. The agreement defines the relationships and respective responsibilities of the agencies.

E. All other provisions of this plan are administered by the Medicaid agency except for those functions for which final authority has been granted to a Professional Standards Review Organization under Title XI of the Act.

F. All other requirements of 42 CFR 431.10 are met.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Subsection (a) derived from VR460-01-2, eff. March 1, 1985; subsection (b) derived from VR460-01-3, eff. October 1, 1976; subsection (c) derived from VR460-01-4, eff. October 1, 1976; subsection (d) derived from VR460-01-5, eff. October 1, 1976; subsections (e) and (f) derived from VR460-01-6, eff. October 1, 1976.

12VAC30-10-20. Organization for administration.

A. 12VAC30-20-20 contains a description of the organization and functions of the Medicaid agency and an organization chart of the agency.

B. Within the state agency, the Department of Medical Assistance Services has been designated as the medical assistance unit. 12VAC30-20-30 contains a description of the organization and functions of the medical assistance unit and an organization chart of the unit.

C. 12VAC30-20-40 contains a description of the kinds and numbers of professional medical personnel and supporting staff used in the administration of the plan and their responsibilities.

D. Eligibility determinations are made by state or local staff of an agency other than the agency named in 12VAC30-10-10 A.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-7, eff. March 1, 1985; amended, Virginia Register Volume 17, Issue 19, eff. August eff. August 1, 2001; Errata, 17:24 VA.R. August 13, 2001.

12VAC30-10-30. Statewide operation.

The plan is in operation on a Statewide basis in accordance with all requirements of 42 CFR 431.50.

The plan is State administered.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-8, eff. October 18, 1974.

12VAC30-10-40. State Medical Care Advisory Committee.

A. There is an advisory committee to the Medicaid agency director on health and medical care services established in accordance with and meeting all the requirements of 42 CFR 431.12.

B. Tribal consultation. Section 1902(a)(73) of the Social Security Act requires a state in which one or more Indian health programs or Urban Indian organizations furnish health care services to establish a process for the state Medicaid agency to seek advice on a regular, ongoing basis from designees of Indian health programs, whether operated by the Indian Health Service, a Tribe, or Tribal organizations under the Indian Self-Determination and Education Assistance Act (P.L. 93-638) or Urban Indian Organizations under the Indian Health Care Improvement Act (25 USC § 1601 et seq.), concerning Medicaid matters having a direct impact on Indian health programs.

C. The Department of Medical Assistance Services (DMAS) seeks advice on an ongoing basis from federally recognized tribes, Indian health programs, and Urban Indian organizations on matters related to Medicaid and Children's Health Insurance Program programs. DMAS has identified a program designee as an advisory contact, through which the dissemination of information will occur. Designees from each Tribe, Indian health program, and Urban Indian organization receive written communication from DMAS about State Plan amendments, waiver proposals, waiver extensions, waiver amendments, and waiver renewals before any of these documents are submitted to the Centers for Medicare and Medicaid Services. Tribes, Indian health programs, and Urban Indian organizations may request additional information and may request meetings to discuss the proposed changes. DMAS invites these groups to request additional information or offer comments on proposed changes within 30 days of the notification of State Plan amendments, waiver proposals, waiver extensions, waiver amendments, or waiver renewals. For emergency-related submissions, such as a natural disaster or a legislative mandate, DMAS seeks information requests, comments, or proposed changes within 15 days of notification. The coordination of this consultation process was established through an email communication with designees from each Tribe and Indian health program on January 29, 2021. To maintain a cooperative channel of communication and informative dialogue between DMAS and the Tribal organizations, the agency sought out and will continue to seek advice on a regular, ongoing basis via email, teleconference, or meetings.

Statutory Authority

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

Historical Notes

Derived from VR460-01-9, eff. October 18, 1974; amended, Virginia Register Volume 38, Issue 4, eff. November 11, 2021.

12VAC30-10-50. Pediatric immunization program.

A. The state has implemented a program for the distribution of pediatric vaccines to program-registered providers for the immunization of federally vaccine-eligible children in accordance with § 1928 as indicated below.

1. The state program will provide each vaccine-eligible child with medically appropriate vaccines according to the schedule developed by the Advisory Committee on Immunization Practices and without charge for the vaccines.

2. The state will outreach and encourage a variety of providers to participate in the program and to administer vaccines in multiple settings, e.g., private health care providers, providers that receive funds under Title V of the Indian Health Care Improvement Act, health programs or facilities operated by Indian tribes, and maintain a list of program-registered providers.

3. With respect to any population of vaccine-eligible children a substantial portion of whose parents have limited ability to speak the English language, the state will identify program-registered providers who are able to communicate with this vaccine-eligible population in the language and cultural context which is most appropriate.

4. The state will instruct program-registered providers to determine eligibility in accordance with § 1928(b) and (h) of the Social Security Act.

5. The state will assure that no program-registered provider will charge more for the administration of the vaccine than the regional maximum established by the Secretary. The state will inform program-registered providers of the maximum fee for the administration of vaccines.

6. The state will assure that no vaccine-eligible child is denied vaccines because of an inability to pay an administration fee.

7. Except as authorized under § 1915(b) of the Social Security Act or as permitted by the Secretary to prevent fraud or abuse, the state will not impose any additional qualifications or conditions, in addition to those indicated above, in order for a provider to qualify as a program-registered provider.

B. The state has not modified or repealed any immunization law in effect as of May 1, 1993, to reduce the amount of health insurance coverage of pediatric vaccines.

C. The state Medicaid agency has coordinated with the state public health agency in the completion of this preprint page.

D. The state agency with overall responsibility for the implementation and enforcement of the provisions of § 1928 is the State Public Health Agency.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-9.1, eff. October 1, 1994.

Part II
Coverage and Eligibility

12VAC30-10-60. Application; determination of eligibility and furnishing Medicaid.

A. The Medicaid agency meets all requirements of 42 CFR Part 435, Subpart J for processing applications, determining eligibility and furnishing Medicaid.

B. 1. Except as provided in subdivisions 2 and 3 of this subsection, individuals are entitled to Medicaid services under the plan during the three months preceding the month of application, if they were, or on application would have been, eligible. The effective date of prospective and retroactive eligibility is specified in 12VAC30-40-10.

2. For individuals who are eligible for Medicaid cost sharing expenses as qualified Medicare beneficiaries under § 1902(a)(10)(E)(i) of the Act, coverage is available for services furnished after the end of the month in which the individual is first determined to be a qualified Medicare beneficiary. 12VAC30-40-10 specifies the requirements for determination of eligibility for this group.

3. Pregnant women are not entitled to ambulatory prenatal care under the plan during a presumptive eligibility in accordance with § 1920 of the Act. 12VAC30-40-10 specifies the requirements for determination of eligibility of this group.

C. The Medicaid agency elects to enter into a risk contract with an HMO that is qualified under Title XIII of the Public Health Service Act or is provisionally qualified as an HMO pursuant to § 1903(m)(3) of the Social Security Act (42 USC § 1396(m)).

The Medicaid agency elects to enter into a risk contract with an HMO that is not federally qualified, but meets the requirements of 42 CFR 434.20(c) and is defined in 12VAC30-20-60.

D. The Medicaid agency has procedures to take applications, assist applicants, and perform initial processing of applications from those low income pregnant women, infants, and children under age 19, described in § 1902(a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), and (a)(10)(A)(ii)(IX) at locations other than those used by the Title IV-A program including FQHCs and disproportionate share hospitals. Such application forms do not include the ADFC form except as permitted by HCFA instructions.

E. Supplemental Nutrition Assistance Program (SNAP) income will be used to support Medicaid eligibility determinations for individuals currently enrolled in SNAP. The Medicaid agency will not alter SNAP procedures while using the reported income to determine Medicaid eligibility using Medicaid rules. The Medicaid agency will obtain all information necessary for a Medicaid eligibility determination that is not in the case record for SNAP from the Medicaid eligibility application.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1315 and 42 USC § 1396 et seq.

Historical Notes

Subsection A derived from VR460-01-10, eff. June 16, 1993; subsections B and C derived from VR460-01-11, eff. July 1, 1995; subsection D derived from VR460-01-11.1, eff. June 16, 1993; amended, Virginia Register Volume 11, Issue 18, eff. July 1, 1995; Volume 13, Issue 5, eff. January 1, 1997; Volume 37, Issue 24, eff. September 2, 2021.

12VAC30-10-70. Coverage and conditions of eligibility.

Medicaid is available to the groups specified in 12VAC30-30-10 et seq., that is, the mandatory categorically needy, other required special groups, specified optional groups, and the medically needy.*

The conditions of eligibility that must be met are specified in 12VAC30-40-10.

All applicable requirements of 42 CFR 435 and § 1902(a)(10)(A)(i)(IV), (V), and (VI), 1902(a)(10)(A)(ii)(XI), 1902(a)(10)(E), 1902(l) and (m), 1905(p), (q) and (s), 1920, and 1925 of the Act are met.

*Medicaid is available to the groups as identified in 12VAC30-30-10, except for the following: eligibility will be denied any individual for a period of twelve (12) months following the date of their conviction for fraud against the Program.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-12, eff. June 16, 1993.

12VAC30-10-80. Residence.

Medicaid is furnished to eligible individuals who are residents of the State under 42 CFR 435.403, regardless of whether or not the individuals maintain the residence permanently or maintain it at a fixed address.

See 12VAC30-20-230.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-13, eff. July 1, 1987.

12VAC30-10-90. Blindness.

All of the requirements of 42 CFR 435.530 and 42 CFR 435.531 are met. The more restrictive definition of blindness in terms of ophthalmic measurement used in this plan is specified in 12VAC30-30-10.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-14, eff. July 1, 1987.

12VAC30-10-100. Disability.

All of the requirements of 42 CFR 435.540 and 435.541 are met. The State uses the same definition of disability used under the SSI program unless a more restrictive definition of disability is specified in 12VAC30-30-10 item 13 of this plan.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-15, eff. June 16, 1993.

12VAC30-10-110. Financial eligibility.

The Financial eligibility conditions for Medicaid-only eligibility groups and for persons deemed to be cash assistance recipients are described in 12VAC30-40-10 et seq.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-16 and VR460-01-17, eff. June 16, 1993.

12VAC30-10-120. Medicaid furnished out of state.

Medicaid is furnished under the conditions specified in 42 CFR 431.52 to an eligible individual who is a resident of the State while the individual is in another State, to the same extent that Medicaid is furnished to residents in the State.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-18, eff. January 1, 1987.

12VAC30-10-130. Requirements for advance directives.

An advance directive shall be defined as a written instruction, such as a living will or durable power of attorney for health care, recognized under state law and relating to the provision of medical care when the individual is incapacitated. Each specified provider receiving funds under this Plan must maintain written policies, procedures, and materials concerning advance directives to ensure compliance with the law. The specified providers shall be: hospitals, nursing facilities, providers of home health care or personal care services, hospices, health maintenance organizations and health insuring organizations.

Refer to 12VAC30-20-70 for further requirements.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-18.1, eff. December 18, 1991.

Part III
Services; General Provisions

12VAC30-10-140. Amount, duration, and scope of services: Categorically needy.

Medicaid is provided in accordance with the requirements of 42 CFR 440, Subpart B and § 1902(a), 1902(e), 1905(a), 1905(p), 1915, 1920, and 1925 of the Act.

Services for the categorically needy are described below and in 12VAC30-50-10 et seq. These services include:

1. Each item or service listed in § 1905(a)(1) through (5) and (21) of the Act, is provided as defined in 42 CFR Part 440, Subpart A, or, for EPSDT services, § 1905(r) and 42 CFR Part 411, Subpart B.

2. Nurse-midwife services listed in § 1905(a)(17) of the Act, are provided to the extent that nurse-midwives are authorized to practice under state law or regulation and without regard to whether the services are furnished in the area of management of the care of mothers and babies throughout the maternity cycle. Nurse-midwives are permitted to enter into independent provider agreements with the Medicaid agency without regard to whether the nurse-midwife is under the supervision of, or associated with, a physician or other health care provider.

3. Pregnancy-related, including family planning service, and postpartum services for a 60-day period (beginning on the day pregnancy ends) and any remaining days in the month in which the 60th day falls are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

4. Services for medical conditions that may complicate the pregnancy (other than pregnancy-related or postpartum services) are provided to pregnant women.

5. Services related to pregnancy (including prenatal, delivery, postpartum, and family planning services) and to other conditions that may complicate pregnancy are the same services provided to poverty level pregnant women eligible under the provision of § 1902(a)(10)(A)(i)(IV) and 1902(a)(10)(A)(ii)(IX) of the Act.

6. Home health services are provided to individuals entitled to nursing facility services as indicated in 12VAC30-10-220 of this plan.

7. Inpatient services that are being furnished to infants and children described in § 1902(l)(1)(B) through (D), or § 1905(n)(2) of the Act, on the date the infant or child attains the maximum age for coverage under the approved State plan will continue until the end of the stay for which the inpatient services are furnished.

8. Respiratory care services are not provided to ventilator dependent individuals as indicated in 12VAC30-10-300 of this plan.

9. Services are provided to families eligible under § 1925 of the Act as indicated in 12VAC30-10-350 of this plan.

10. Home and community care for functionally disabled elderly individuals is not covered.

11. Program of All-Inclusive Care for the Elderly (PACE) services as described and limited in Supplement 6 to Attachment 3.1-A (12VAC30-50-320, 12VAC30-50-321, 12VAC30-50-325, and 12VAC30-50-328).

12VAC30-50-10 et seq. identifies the medical and remedial services provided to the categorically needy, specifies all limitations on the amount, duration, and scope of those service, and lists the additional coverage (that is in excess of established service limits) for pregnancy-related services and services for conditions that may complicate the pregnancy.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-19, VR460-01-19.1, VR460-01-19.2, eff. June 16, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995; Volume 12, Issue 3, eff. November 29, 1995; Volume 16, Issue 18, eff. July 1, 2000; Volume 23, Issue 16, eff. July 1, 2007.

12VAC30-10-150. Amount, duration, and scope of services: Medically needy.

A. This State Plan covers the medically needy. The services described in this section and in Part II (12VAC30-50-40 et seq.) of 12VAC30-50 are provided. Services for medically needy include:

1. If services in an institution for mental diseases (42 CFR 440.140 and 440.160) or an intermediate care facility for the mentally retarded (or both) are provided to any medically needy group, then each medically needy group is provided either the services listed in § 1905(a)(1) through (5) and (17) of the Act, or seven of the services listed in § 1902(a)(1) through (20). The services are provided as defined in 42 CFR 440, Subpart A and in §§ 1902, 1905, and 1915 of the Act.

Subdivision 1 of this subsection is applicable with respect to nurse-midwife services under § 1902(a)(17).

2. Prenatal care and delivery services for pregnant women.

3. Pregnancy-related, including family planning services, and postpartum services for a 60-day period (beginning on the day the pregnancy ends) and any remaining days in the month in which the sixtieth day falls are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

4. Services for any other medical condition that may complicate the pregnancy (other than pregnancy-related and postpartum services) are provided to pregnant women.

5. Ambulatory services as defined in 12VAC30-50-40 for recipients under age 18 and recipients entitled to institutional services.

6. Home health services to recipients entitled to nursing facility services as indicated in 12VAC30-10-220.

7. Services for the medically needy do not include services in an institution for mental diseases for individuals over age 65.

8. Services for the medically needy do not include services in an intermediate care facility for the mentally retarded.

9. Services for the medically needy do not include inpatient psychiatric services for individuals under age 21, other than those covered under early and periodic screening, diagnosis, and treatment (at 12VAC30-50-130).

10. Services for the medically needy do not include respiratory care services provided to ventilator dependent individuals. See 12VAC30-10-300.

11. Home and community care for functionally disabled elderly individuals is not covered.

12. Program of All-Inclusive Care for the Elderly (PACE) services as described and limited in Supplement 6 to Attachment 3.1-A (12VAC30-50-320, 12VAC30-50-321, 12VAC30-50-325, and 12VAC30-50-328) are covered.

B. Part II (12VAC30-50-40 et seq.) of 12VAC30-50 identifies services provided to each covered group of the medically needy. (Note: Other programs to be offered to medically needy beneficiaries would specify all limitations on the amount, duration and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. In addition, other programs to be offered to medically needy beneficiaries would also list the additional coverage that is in excess of established service limits for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population, this also is not applicable for this program.)

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-20, VR460-01-20.1, VR460-01-20.2, eff. June 16, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995; Volume 17, Issue 5, eff. January 1, 2001; Volume 25, Issue 14, eff. April 15, 2009.

12VAC30-10-160. Amount, duration, and scope of services: Other required special groups.

A. Qualified Medicare beneficiaries. Medicare cost sharing for qualified Medicare beneficiaries described in § 1905(p) of the Act is provided only as indicated in 12VAC30-10-310.

B. Qualified disabled and working individuals. Medicare Part A premiums for qualified disabled and working individuals described in § 1902(a)(10)(E)(ii) of the Act are provided as indicated in 12VAC30-10-310.

C. Specified low-income Medicare beneficiaries. Medicare Part B premiums for specified low-income Medicare beneficiaries described in § 1902(a)(10)(E)(iii) of the Act are provided as indicated in 12VAC30-10-310.

D. Qualifying Individuals-1. Medicare Part B premiums for qualifying individuals described in § 1902(a)(10)(E)(iv)(I) and subject to § 1933 of the Act are provided as indicated in 12VAC30-10-310.

E. Qualifying Individuals-2. The portion of the amount of increase to the Medicare Part B premium attributable to the home health provisions for qualifying individuals described in § 1902(a)(10)(E)(iv)(II) and subject to § 1933 of the Act are provided as indicated in 12VAC30-10-310.

F. Families receiving extended Medicaid benefits. Extended Medicaid benefits for families described in § 1925 of the Act are provided as indicated in 12VAC30-10-300.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-21, eff. January 1, 1993; amended, Virginia Register Volume 17, Issue 13, eff. April 11, 2001.

12VAC30-10-170. Amount, duration, and scope of services: Limited coverage for certain aliens.

A. Aliens granted lawful temporary resident status under § 245A of the Immigration and Nationality Act who meet the financial and categorical eligibility requirements under the approved State Medicaid plan are provided the services covered under the plan if they--

1. Are aged, blind, or disabled individuals as defined in § 1614(a)(1) of the Act;

2. Are children under 18 years of age; or

3. Are Cuban or Haitian entrants as defined in § 501(e)(1) and (2)(A) of P.L. 96-422 in effect on April 1, 1983.

B. Except for emergency services and pregnancy-related services, as described in 42 CFR 447.53(b), aliens granted lawful temporary resident status under § 245A of the Immigration and Nationality Act who are not identified in subdivisions A 1 through A 3 of this section, and who meet the financial and categorical eligibility requirements under the approved State plan are provided services under the plan no earlier than five years from the date the alien is granted temporary resident status.

C. Aliens who are not lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law who meet the eligibility conditions under the State's approved Medicaid plan, except for the requirement for receipt of AFDC, SSI or a State supplementary payment are provided, Medicaid only for care and services necessary for the treatment of an emergency medical condition (including emergency labor and delivery) as defined in § 1903(v)(3) of the Act.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-21.1, VR460-01-21.2, eff. June 16, 1993.

12VAC30-10-180. Amount, duration, and scope of services: Homeless individuals.

Clinic services furnished to eligible individuals who do not reside in a permanent dwelling or do not have a fixed home or mailing address are provided without restrictions regarding the site at which the services are furnished.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-21.2, eff. June 16, 1993.

12VAC30-10-190. Amount, duration, and scope of services: Presumptively eligible pregnant women.

Ambulatory prenatal care for pregnant women is not provided during a presumptive eligibility period.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-21.2, eff. June 16, 1993.

12VAC30-10-200. Amount, duration, and scope of services: EPSDT services.

The Medicaid agency meets the requirements of § 1902(a)(43), 1905(a)(4)(B), and 1905(r) of the Act with respect to early and periodic screening, diagnostic, and treatment (EPSDT) services.

The Medicaid agency does not have in effect agreements with continuing care providers.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-21.2, eff. June 16, 1993.

12VAC30-10-210. Amount, duration, and scope of services: Comparability of services.

Except for those items or services for which § 1902(a), 1902(a)(10), 1903(v), 1915 and 1925 of the Act, 42 CFR 440.250, and § 245A of the Immigration and Naturalization Act, permit exceptions:

A. Services made available to the categorically needy are equal in amount, duration, and scope for each categorically needy person.

B. The amount, duration, and scope of services made available to the categorically needy are equal to or greater than those made available to the medically needy.

C. Services made available to the medically needy are equal in amount, duration, and scope for each person in a medically needy coverage group.

D. Additional coverage for pregnancy-related services and services for conditions that may complicate the pregnancy are equal for categorically and medically needy.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-22, eff. June 16, 1993.

12VAC30-10-220. Amount, duration, and scope of services: home health services.

Home health services are provided in accordance with the requirements of 42 CFR 441.15.

A. Home health services are provided to all categorically needy individuals 21 years of age or over.

B. Home health services are provided to all categorically needy individuals under 21 years of age.

C. Home health services are provided to all the medically needy whether the individuals are under or over 21 years of age.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-23, eff. October 1, 1979.

12VAC30-10-230. Amount, duration, and scope of services: Assurance of transportation.

Provision is made for assuring necessary transportation of recipients to and from providers. Methods used to assure such transportation are described in 12VAC30-50-530.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-24, eff. April 20, 1994.

12VAC30-10-240. Amount, duration, and scope of services: payment for nursing facility services.

The state includes in nursing facility services at least the items and services specified in 42 CFR 483.10(f)(11).

Statutory Authority

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

Historical Notes

Derived from VR460-01-24, eff. April 20, 1994; amended, Virginia Register Volume 34, Issue 1, eff. October 19, 2017.

12VAC30-10-250. Amount, duration, and scope of services: Methods and standards to assure quality of services.

The standards established and the methods used to assure high quality care are described in 12VAC30-60-10 et seq.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-25, eff. October 1, 1976.

12VAC30-10-260. Amount, duration, and scope of services: Family planning services.

The requirements of 42 CFR 441.20 are met regarding freedom from coercion or pressure of mind and conscience, and freedom of choice of method to be used for family planning.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-26, eff. October 1, 1976.

12VAC30-10-270. Amount, duration, and scope of services: Optometric services.

Optometric services are provided. Services of the type an optometrist is legally authorized to perform are specifically included in the term "physicians' services" under this plan and are reimbursed whether furnished by a physician or an optometrist.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-27, eff. January 1, 1987.

12VAC30-10-280. Amount, duration, and scope of services: Organ transplant procedures.

Organ Transplant procedures are provided. Similarly situated individuals are treated alike and any restrictions on the facilities that may, or practitioners who may, provide those procedures is consistent with the accessibility of high quality care to individuals eligible for the procedures under this plan. Standards for the coverage of organ transplant procedures are described at 12VAC30-50-540.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-27, eff. January 1, 1987.

12VAC30-10-290. Amount, duration, and scope of services: Participation by Indian Health Service facilities.

Indian Health Service facilities are accepted as providers, in accordance with 42 CFR 431.110(b), on the same basis as other qualified providers.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-28, eff. July 1, 1987.

12VAC30-10-300. Amount, duration, and scope of services: Respiratory care services for ventilator-dependent individuals.

Respiratory care services, as defined in § 1902(e)(9)(C) of the Act, are not included in the plan.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-28, eff. July 1, 1987.

12VAC30-10-310. Coordination of Medicaid with Medicare and other insurance: Premiums.

A. Medicare Part A and Part B.

1. Qualified Medicare Beneficiary (QMB).

The Medicaid agency pays Medicare Part A premiums (if applicable) and Part B premiums for individuals in the QMB group defined in subsection 25 of 12VAC30-30-10 through the group premium payment arrangement, unless the agency has a buy-in agreement for such payment, as indicated in Part B.

The Medicaid agency does not pay premiums, for which the beneficiary would be liable, for enrollment in an HMO participating in Medicare.

2. Qualified Disabled and Working Individual (QDWI). The Medicaid agency pays Medicare Part A premiums under a group premium payment arrangement for individuals in the QDWI group defined in subsection 26 of 12VAC30-30-10 of this plan.

3. Specified Low-Income Medicare Beneficiary (SLMB). The Medicaid agency pays Medicare Part B premiums under the State buy-in process for individuals in the SLMB group defined in subsection 27 of 12VAC30-30-10 of this plan.

4. Other Medicaid Recipients.

The Medicaid agency pays Medicare Part B premiums to make Medicare Part B coverage available to all individuals who are a) receiving benefits under Titles I, IV-A, X, XIV, or XVI (AABD or SSI); b) receiving State supplements under Title XVI; or c) within a group listed at 42 CFR 431.625(d)(2).

The Medicaid agency does not pay Medicare Part B premiums for individuals receiving Title II or Railroad Retirement benefits.

The Medicaid agency does not pay Medicare Part B premiums for medically needy individuals (Federal Financial Participation is not available for this group).

B. Other Health Insurance. The Medicaid agency pays insurance premiums (through the Health Insurance Premium Payment Program (H.I.P.P.)) for medical or any other type of remedial care to maintain a third party resource for Medicaid covered services provided to eligible individuals (except those over 65 years of age and disabled individuals, entitled to Medicare Part A but not enrolled in Medicare Part B).

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-29, VR460-01-29.1, VR460-01-29.2, eff. January 1, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995.

12VAC30-10-320. Coordination of Medicaid with Medicare and other insurance: Deductibles/coinsurance.

A. Medicare Part A and B. 12VAC30-80-170 describes the methods and standards for establishing payment rates for services covered under Medicare, and/or the methodology for payment of Medicare deductible and coinsurance amounts, to the extent available for each of the following groups.

1. Qualified Medicare Beneficiaries (QMBS). The Medicaid agency pays Medicare Part A and Part B deductibles and coinsurance amounts for QMBs (subject to any nominal Medicaid copayment) for all services available under Medicare.

2. Other Medicaid Recipients. The Medicaid agency pays Medicaid services also covered under Medicare and furnished to recipients entitled to Medicare (subject to any nominal Medicaid copayment). For services furnished to individuals who are described in 12VAC30-10-310 A 4, payment is only for the amount, duration, and scope of services otherwise available under this plan.

3. Dual Eligible--QMB plus. The Medicaid agency pays Medicare Part A and Part B deductible and coinsurance amounts for all services available under Medicare and pays for all Medicaid services furnished to individuals eligible both as QMBs and categorically or medically needy (subject to any nominal Medicaid copayment).

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-29.3, eff. January 1, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995.

12VAC30-10-325. Premiums, deductibles, coinsurance and other cost sharing obligations.

A. Pursuant to § 1906 of the Act, the Medicaid agency pays all premiums, deductibles, coinsurance, and other cost sharing obligations for items and services covered under the State plan (subject to any nominal Medicaid copayment) for eligible individuals in employer-based cost-effective group health plans.

B. When coverage for eligible family members is not possible unless ineligible family members enroll, the Medicaid agency pays premiums for enrollment of other family members when cost-effective. In addition, the eligible individual is entitled to services covered by the State plan which are not included in the group health plan. Guidelines for determining cost effectiveness are described in 12VAC30-10-610 H.

C. Pursuant to § 1906A of the Act, the Medicaid agency pays all premiums, deductibles, coinsurance, and other cost sharing obligations for items and services covered under the State Plan, as specified in the qualified employer-sponsored coverage, without regard to limitations specified in § 1916 or § 1916A of the Act, for eligible individuals under age 19 who have access to and elect to enroll in such coverage. The eligible individual is entitled to services covered by the State Plan that are not included in the employer-sponsored coverage. For qualified employer-sponsored coverage, the employer must contribute at least 40% of the premium cost.

When coverage for eligible family members under age 19 is not possible unless an ineligible family member enrolls, the Medicaid agency pays premiums for enrollment of the ineligible family member and, at the option of the parent or legal guardian, other family members that are eligible for coverage under the employer-sponsored plan. The agency also pays deductibles, coinsurance, and other cost-sharing obligations for items and services covered under the State Plan for the ineligible family member. 12VAC30-20-205 provides a detailed description of this program.

D. The Medicaid agency pays premiums for individuals described in subsection 19 of 12VAC30-30-10.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-29.4, eff. April 1, 1993; amended, Virginia Register Volume 29, Issue 2, eff. November 8, 2012.

12VAC30-10-330. Medicaid for individuals age 65 or over in institutions for mental diseases.

Medicaid is provided for individuals 65 years of age or older who are patients in institutions for mental diseases.

The requirements of 42 CFR 441, Subpart C, and 42 CFR 431.620(c) and (d) are met.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-30, eff. October 1, 1976.

12VAC30-10-340. Special requirements applicable to sterilization procedures.

All requirements of 42 CFR 441, Subpart F are met.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-31, eff. March 31, 1979.

12VAC30-10-350. Families receiving extended Medicaid benefits.

A. Services provided to families during the first 6-month period of extended Medicaid benefits under § 1925 of the Act are equal in amount, duration, and scope to services provided to categorically needy AFDC recipients as described in 12VAC30-50-10 (or may be greater if provided though a caretaker relative employer's health insurance plan).

B. Services provided to families during the second 6-month period of extended Medicaid benefits under § 1925 of the Act are equal in amount, duration and scope to services provided to categorically needy AFDC recipients as described in 12VAC30-50-10 et seq. (or may be greater if provided through a caretaker relative employer's health insurance plan).

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-31.1, eff. June 16, 1993.

12VAC30-10-360. [Reserved]. (Reserved)

Part IV
General Program Administration

12VAC30-10-400. Methods of administration.

The Medicaid agency employs methods of administration found by the Secretary of Health and Human Services to be necessary for the proper and efficient operation of the plan.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-32, eff. July 1, 1987.

12VAC30-10-410. Hearings for applicants and recipients.

The Medicaid agency has a system of hearings that meets all the requirements of 42 CFR 431, Subpart E.

No termination of coverage under § 1925 shall be effective earlier than 10 days after the date of mailing of the notice required by § 1925(b)(3)(B).

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-33, eff. November 5, 1990.

12VAC30-10-420. Safeguarding information on applicants and recipients.

Under State statute which imposes legal sanctions, safeguards are provided that restrict the use or disclosure of information concerning applicants and recipients to purposes directly connected with the administration of the plan.

All other requirements of 42 CFR 431, Subpart F are met.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-34, eff. February 26, 1992.

12VAC30-10-430. Medicaid quality control.

A. A system of quality control is implemented in accordance with 42 CFR 431, Subpart P.

B. The state does not operate a claims processing assessment system that meets the requirements of 42 CFR 431.808, 42 CFR 431.818, 42 CFR 431.830, 42 CFR 431.832, 42 CFR 431.834, and 42 CFR 431.836. The state has an approved Medicaid Management Information System (MMIS).

Statutory Authority

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

Historical Notes

Derived from VR460-01-35, eff. July 1, 1987; amended, Virginia Register Volume 34, Issue 1, eff. October 19, 2017.

12VAC30-10-435. Medicaid prohibition on payments to institutions or entities located outside of the United States.

The state shall not provide any payments for items or services provided under the state plan or under a waiver to any financial institution or entity located outside of the United States.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 27, Issue 20, eff. July 6, 2011.

12VAC30-10-440. Medicaid Agency Fraud Detection and Investigation Program.

The Medicaid agency has established and will maintain methods, criteria, and procedures that meet all requirements of 42 CFR 455.13 through 455.21 and 455.23 for prevention and control of program fraud and abuse.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-36, eff. January 1, 1989.

12VAC30-10-441. Medicaid agency fraud detection and investigation program.

The Medicaid agency has established a mechanism to receive reports from beneficiaries and others and compile data concerning alleged instances of waste, fraud, and abuse relating to the operation of this chapter.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 15, Issue 26, eff. October 13, 1999.

12VAC30-10-445. Recovery audit contractors.

A. The state has established a program under which it will contract with one or more recovery audit contractors (RACs) for the purpose of identifying underpayments and overpayments of Medicaid claims under the State Plan and under any waiver of the State Plan.

B. The state/Medicaid agency has contracts of the type listed in § 1902(a)(42)(B)(ii)(I) of the Act. All contracts meet the requirements of the statute. RACs are consistent with the statute.

C. The state will make payments to the RACs only from amounts recovered.

D. The state will make payments to the RACs on a contingent basis for collecting overpayments.

E. The state attests that the contingency fee rate paid to the Medicaid RAC will not exceed the highest rate paid to Medicare RACs as published in the Federal Register.

F. The payment methodology used to determine state payments to Medicaid RACs for the identification of underpayments will be based upon the percentage of the contingency fee.

G. The state has an adequate appeal process in place for entities to appeal any adverse determination made by the Medicaid RACs.

H. The state assures that the amounts expended by the state to carry out the program will be amounts expended as necessary for the proper and efficient administration of the State Plan or a waiver of the plan.

I. The state assures that the recovered amounts will be subject to a state's quarterly expenditure estimates and funding of the state's share.

J. Efforts of the Medicaid RACs will be coordinated with other contractors or entities performing audits of entities receiving payments under the State Plan or waiver in the state, and/or state and federal law-enforcement entities and the CMS Medicaid Integrity Program.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 29, Issue 2, eff. October 25, 2012.

12VAC30-10-450. Reports.

The Medicaid agency will submit all reports in the form and with the content required by the Secretary, and will comply with any provisions that the Secretary finds necessary to verify and assure the correctness of the reports. All requirements of 42 CFR 431.16 are met.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-37, eff. October 1, 1977.

12VAC30-10-460. Maintenance of records.

The Medicaid agency maintains or supervises the maintenance of records necessary for the proper and efficient operation of the plan, including records regarding applications, determination of eligibility, the provision of medical assistance, and administrative costs, and statistical, fiscal and other records necessary for reporting and accountability, and retains these records in accordance with Federal requirements. All requirements of 42 CFR 431.17 are met.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-38, eff. October 1, 1977.

12VAC30-10-470. Availability of agency program manuals.

Program manuals and other policy issuances that affect the public, including the Medicaid agency's rules and regulations governing eligibility, need, and amount of assistance, recipient rights and responsibilities, and services offered by the agency are maintained in the State office and in each local and district office for examination, upon request, by individuals for review, study, or reproduction. All requirements of 42 CFR 431.18 are met.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-39, eff. March 29, 1974.

12VAC30-10-480. Reporting provider payments to Internal Revenue Service.

These are procedures implemented in accordance with 42 CFR 433.37 for identification of providers of services by social security number or by employer identification number and for reporting the information required by the Internal Revenue Code (26 USC 6041) with respect to payment for services under the plan.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-40, eff. March 29, 1974.

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.

12VAC30-10-500. Relations with standard-setting and survey agencies.

A. The State agency utilized by the Secretary to determine qualification of institutions and suppliers of services to participate in Medicare is responsible for establishing and maintaining health standards for private or public institutions (exclusive of Christian Science sanatoria) that provide services to Medicaid recipients. This agency is the Department of Health.

B. The State authority(ies) responsible for establishing and maintaining standards, other than those relating to health, for public or private institutions that provide services to Medicaid recipients is (are): Department of Health, Department of Mental Health and Mental Retardation, State Corporation Commission, Office of State Fire Marshall.

C. 12VAC30-20-100 describes the standards specified in paragraphs A and B above, that are kept on file and made available to the Health Care Financing Administration on request.

D. The Department of Health (agency) which is the State agency responsible for licensing health institutions, determines if institutions and agencies meet the requirements for participation in the Medicaid program. The requirements in 42 CFR 431.610(e), (f) and (g) are met.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Subsections A, B, and C derived from VR460-01-42, eff. March 29, 1974; subsection D derived from VR460-01-43, eff. March 29, 1974.

12VAC30-10-510. Consultation to medical facilities.

A. Consultative services are provided by health and other appropriate State agencies to hospitals, nursing facilities, home health agencies, clinics and laboratories in accordance with 42 CFR 431.105(b).

B. Similar services are provided to other types of facilities providing medical care to individuals receiving services under the programs specified in 42 CFR 431.105(b):

HURA and RHI Projects

Neighborhood Health Projects

Multiple Handicap Projects

Children and Youth Projects

Maternal and Infant Care Projects

Dental Health Projects

Cerebral Palsy Centers

Family Planning Clinics

Child Development Clinics

Crippled Children Programs

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-44, eff. October 1, 1977.

12VAC30-10-520. Required provider agreement.

With respect to agreements between the Medicaid agency and each provider furnishing services under the plan:

A. For all providers, the requirements of 42 CFR 431.107 and Subparts A and B of 42 CFR Part 442 (if applicable) are met.

B. For providers of NF services, the requirements of Subpart B of 42 CFR Part 483 and § 1919 of the Act are also met in addition to the requirements in subsections C, D, and E of this subsection.

C. For providers of ICF/IID services, the requirements of participation in Subpart I of 42 CFR Part 483 are also met.

D. Ambulatory prenatal care is not provided to pregnant women during a presumptive eligibility period.

E. For each provider receiving funds under the plan, all the requirements for advance directives of § 1902(w) are met:

1. Hospitals, nursing facilities, providers of home health care or personal care services, hospice programs, health maintenance organizations and health insuring organizations are required to do the following:

a. Maintain written policies and procedures with respect to all adult individuals receiving medical care by or through the provider or organization about their rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives;

b. Provide written information to all adult individuals on their policies concerning implementation of such rights;

c. Document in the individual's medical records whether or not the individual has executed an advance directive;

d. Not to discriminate against an individual based on whether or not the individual has executed an advance directive including the provision of care;

e. Ensure compliance with requirements of state law (whether statutory or recognized by the courts) concerning advance directives; and

f. Provide (individually or with others) for education for staff and the community on issues concerning advance directives.

2. Providers will furnish the written information described in subdivision 1 a of this subsection to all adult individuals at the time specified in this subdivision:

a. Hospitals at the time an individual is admitted as an inpatient;

b. Nursing facilities when the individual is admitted as a resident;

c. Providers of home health or personal care services before the individual comes under the care of the provider;

d. Hospice program at the time of initial receipt of hospice care by the individual from the program; and

e. Health maintenance organizations at the time of enrollment of the individual with the organization.

3. 12VAC30-20-240 describes law of the state (whether statutory or as recognized by the courts of the state) concerning advance directives.

As a condition of participation in the Virginia Medical Assistance Program all nursing facilities must agree that when an individual is discharged to a hospital, the nursing facility from which the individual is discharged shall ensure that the individual shall be given an opportunity to be readmitted to the facility at the time of the next available vacancy.

The only acceptable reasons for failure to readmit a specific individual who has been discharged to a hospital shall be the individual is certified for a level of care not provided by the facility, the individual is judged by a physician to be a danger to himself or others, or the individual, who at the time of readmission has an outstanding payment to the nursing facility for which he is responsible in accordance with Medicaid regulations.

F. The Department of Medical Assistance Services (DMAS) shall conduct provider screening according to the requirements of Subpart E of 42 CFR Part 455. DMAS shall terminate or deny enrollment to any provider in accordance with the requirements of 42 CFR 455.416.

Statutory Authority

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

Historical Notes

Paragraphs A through D derived from VR460-01-45, eff. June 16, 1993; paragraph E 1 a through E 1 e, derived from VR460-01-45.1, eff. June 16, 1993; paragraph E 1 f, E 2, and E 3 derived from VR460-01-45.2, eff. June 16, 1993; amended, Virginia Register Volume 33, Issue 2, eff. October 19, 2016; Volume 34, Issue 1, eff. October 19, 2017.

12VAC30-10-530. Utilization and quality control.

A. A Statewide program of surveillance and utilization control has been implemented that safeguards against unnecessary or inappropriate use of Medicaid services available under this plan and against excess payments, and that assesses the quality of services. The requirements of 42 CFR Part 456 are met directly.

Quality review requirements described in § 1902(a)(30)(C) of the Act relating to services furnished by HMO's under contract are undertaken through contract with the PRO designated under 42 CFR Part 462.

B. The Medicaid agency meets the requirements of 42 CFR Part 456, Subpart C, for control of the utilization of inpatient hospital services. No waivers have been granted.

C. The Medicaid agency meets the requirements of 42 CFR Part 456, Subpart D, for control of utilization of inpatient services in mental hospitals.

No waivers have been granted.

D. The Medicaid agency meets the requirements of 42 CFR Part 456, Subpart E, for the control of utilization of skilled nursing facility services.

No waivers have been granted.

E. The Medicaid agency meets the requirements of 42 CFR Part 456, Subpart F, for control of the utilization of intermediate care facility services as provided through:

1. Direct review by personnel of the medical assistance unit of the state agency.

2. Personnel under contract to the medical assistance unit of the state agency.

The program will allow a maximum of 10 administrative days for placement and transfer from NF to community in order to make an orderly transfer or placement possible without potential harm or trauma to the patient in accordance with 42 CFR 456.4.

One of the semiannual utilization reviews required by 42 CFR 456.434(b)(1) for ICF/MR recipients will be conducted by the Virginia Department of Health as part of the inspection of care visit. The second utilization review will be conducted by personnel of the Medical Assistance unit of the state agency.

F. The Medicaid agency meets the requirements of § 1902(a)(30) of the Act for control of the assurance of quality furnished by each health maintenance organization under contract with the Medicaid agency. Independent, external quality reviews are performed annually by a Utilization and Quality Control Peer Review Organization designated under 42 CFR Part 462 that has a contract with the agency to perform those reviews.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Subsection A derived from VR460-01-46, eff. June 16, 1993; subsection B; am from VR460-01-47, eff. August 16, 1985; subsection C derived from VR460-01-48, eff. September 30, 1985; subsection D derived from VR460-01-49, eff. August 16, 1985; subsection E derived from VR460-01-50, eff. February 15, 1990; subsection F derived from VR460-01-50.1, eff. June 16, 1993; amended, Virginia Register Volume 13, Issue 5, eff. January 1, 1997.

12VAC30-10-540. Inspection of care in intermediate care facilities for persons with intellectual and developmental disabilities, facilities providing inpatient....

All applicable requirements of 42 CFR 456, Subpart I are met with respect to periodic inspections of care and services.

Inspection of care in intermediate care facilities for persons with intellectual and developmental disabilities is completed through contractual arrangements with the Virginia Department of Health.

Statutory Authority

§ 32.1-325 of the Code of Virginia, 42 USC § 1396 et seq.

Historical Notes

Derived from VR460-01-51, eff. June 16, 1993; amended, Virginia Register Volume 35, Issue 24, eff. August 22, 2019.

12VAC30-10-550. Relations with state health and vocational rehabilitation agencies and Title V grantees.

The Medicaid agency has cooperative arrangements with State health and vocational rehabilitation agencies and with Title V grantees, that meet the requirements of 42 CFR 431.615.

12VAC30-20-120 describes the cooperative arrangements with the health and vocational rehabilitation agencies.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-52, eff. March 29, 1974.

12VAC30-10-560. Liens and recoveries.

Liens are not imposed against an individual's property.

A. Adjustments or recoveries for Medicaid claims correctly paid are as follows: See 12VAC30-20-141.

1. For permanently institutionalized individuals, adjustments or recoveries are made from the individual's estate.

2. For any individual who received medical assistance at age 55 or older, recovery of payments are made for nursing facility services, home- and community-based services, and related hospital and prescription drug services.

Payments are recovered for all services covered under the plan which are provided to individuals at age 55.

3. If an individual covered under a qualified long-term care partnership insurance policy pursuant to § 32.1-325 of the Code of Virginia received benefits for which assets or resources were disregarded as provided for in 12VAC30-40-290 G, the Commonwealth does not seek adjustment or recovery from the individual's estate for the amount of assets or resources disregarded.

B. No money payments under another program are reduced as a means of recovering Medicaid claims incorrectly paid.

C. Liens. See 12VAC30-20-130.

1. Specifies the process for determining that an institutionalized individual cannot reasonably be expected to be discharged from the medical institution and return home; the description of the process meets the requirements of 42 CFR 433.36(d).

The Commonwealth does not impose liens; therefore, this subsection is not applicable.

2. Specifies the criteria by which a son or daughter can establish that he or she has been providing care under 42 CFR 433.36(f).

The Commonwealth does not impose liens; therefore, this subsection is not applicable.

3. Definitions: individual's home; equity interest in home; residing in home for at least 1 or 2 years, on a continuing basis; discharge from the medical institution and return home; and lawfully residing.

The Commonwealth does not impose liens; therefore, this subsection is not applicable.

D. Estate recoveries.

12VAC30-20-141 (Attachment 4.17-C) specifies the policy for estate recoveries.

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-53, VR460-01-53.1, eff. March 20, 1983; amended, Virginia Register Volume 11, Issue 26, eff. October 18, 1995; Volume 23, Issue 14, eff. September 1, 2007; Volume 25, Issue 21, eff. July 23, 2009.

12VAC30-10-570. Recipient cost sharing and similar charges.

A. Unless a waiver under 42 CFR 431.55(g) applies, deductibles, coinsurance rates, and copayments do not exceed the maximum allowable charges under 42 CFR 447.54.

B. With respect to individuals covered as categorically needy or as qualified Medicare beneficiaries (as defined in § 1905(p)(1) of the Act) under the plan:

1. No enrollment fee, premium, or similar charge is imposed under the plan.

2. No deductible, coinsurance, copayment, or similar charge is imposed under the plan for the following:

a. Services to individuals under age 21. Reasonable categories of individuals who are age 18 or older, but under age 21, to whom charges apply are listed below, if applicable.

b. Services to pregnant women related to the pregnancy or any other medical condition that may complicate the pregnancy.

c. Charges apply for services to pregnant women unrelated to the pregnancy.

d. Services furnished to any individual who is an inpatient in a hospital, long-term care facility, or other medical institution, if the individual is required, as a condition of receiving medical services in the institution, to spend for medical care costs all but a minimal amount of his or her income required for personal needs.

e. Emergency services if the services meet the requirements in 42 CFR 447.53(b)(4).

f. Family planning services and supplies furnished to individuals of childbearing age.

g. Services furnished by a health maintenance organization in which the individual is enrolled.

h. Services furnished to an individual receiving hospice care, as defined in § 1905(o) of the Act.

3. Unless a waiver under 42 CFR 431.55(g) applies, nominal deductible, coinsurance, copayment, or similar charges are imposed for services that are not excluded from such charges under item B 2 above:

a. For any service, no more than one type of charge is imposed.

b. Charges apply to services furnished to persons 21 or older.

c. For the categorically needy and qualified Medicare beneficiaries, 12VAC30-20-150 specifies the:

(1) Service(s) for which a charge is applied;

(2) Nature of the charge imposed on each service;

(3) Amount(s) of and basis for determining the charge(s);

(4) Method used to collect the charge(s);

(5) Basis for determining whether an individual is unable to pay the charge and the means by which such an individual is identified to providers; and

(6) Procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b).

No cumulative maximum applies to deductible, coinsurance, or copayment charges imposed on a specified time period.

C. Individuals are covered as medically needy under the plan.

1. No enrollment fee, premium, or similar charge is imposed.

2. No deductible, coinsurance, copayment, or similar charge is imposed under the plan for:

a. Services to individuals under 21; reasonable categories of individuals who are age 18, but under age 21, to whom charges apply are listed below, if applicable.

b. Services to pregnant women related to the pregnancy or any other medical condition that may complicate the pregnancy.

c. Charges apply for services to pregnant women unrelated to the pregnancy.

d. Services furnished to any individual who is an inpatient in a hospital, long-term care facility, or other medical institution, if the individual is required, as a condition of receiving services in the institution, to spend for medical care costs all but a minimal amount of his income required for personal needs.

e. Emergency services if the services meet the requirements in 42 CFR 447.53(b)(4).

f. Family planning services and supplies furnished to individuals of childbearing age.

g. Services furnished to an individual receiving hospice care, as defined in § 1905(o) of the Act.

h. Services provided by a health maintenance organization (HMO) to enrolled individuals.

Unless a waiver under 42 CFR 431.55(g) applies, nominal deductible, coinsurance, copayment, or similar charges are imposed on services that are not excluded from such charges under item B 2 above.

(1) For any service, no more than one type of charge is imposed.

(2) Charges apply to services furnished to persons 21 or older.

Reasonable categories of individuals who are 18 years of age, but under 21, to whom charges apply are listed below, if applicable.

(3) For the medically needy, and other optional groups, 12VAC30-20-160 specifies the:

(a) Service(s) for which charge(s) is applied;

(b) Nature of the charge imposed on each service;

(c) Amount(s) of and basis for determining the charge(s);

(d) Method used to collect the charge(s);

(e) Basis for determining whether an individual is unable to pay the charge(s) and the means by which such an individual is identified to providers;

(f) Procedures for implementing and enforcing the exclusions from cost sharing contained in 42 CFR 447.53(b); and

(g) No cumulative maximum applies to deductible, coinsurance, or copayment charges imposed on a family during a specified time period.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Subsections A and B 1 through B 2 b derived from VR460-01-54, eff. June 6, 1993; subsections B 2 c through h derived from VR460-01-55, eff. June 16, 1993; subsections B 3 a and b, derived from VR460-01-56, eff. June 16, 1993; subsection B 3 c derived from VR460-01-56.1, eff. June 16, 1993; subsection C 1 and 2 a derived from VR460-01-56.3, eff. June 16, 1993; subsections C 2 b through h derived from VR460-01-56.4, eff. June 16, 1993; subsections C 3 a and b derived from VR460-01-56.5, eff. June 16, 1993; subsection C 3 c derived from VR460-01-56.6, eff. June 16, 1993.

12VAC30-10-580. Payment for services.

A. Medicaid agency meets the requirements of 42 CFR 447, Subpart C, and § 1902(a)(13) and 1923 of the Act with respect to payment for inpatient hospital services.

Chapter 70, 12VAC30-70-10 et seq., describes the methods and standards used to determine rates for payment for inpatient hospital services.

Inappropriate level of care days are not covered.

B. In addition to the services specified in paragraphs A, D, K, L and M, the Medicaid agency meets the following requirements:

1. Section 1902(a)(13)(E) of the Act regarding payment for services furnished by federally qualified health centers (FQHCs) under § 1905(a)(2)(C) of the Act. The agency meets the requirements of § 6303 of the State Medicaid Manual (HFCA-Pub. 45-6) regarding payment for FQHC services. Chapter 80, 12VAC30-80-10 et seq., describes the method of payment and how the agency determines the reasonable costs of the services (for example, cost reports, cost or budget reviews, or sample surveys).

2. Sections 1902(a)(13)(E) and 1926 of the Act, and 42 CFR 447, Subpart D, with respect to payment for all other types of ambulatory services provided by rural health clinics under the plan.

Chapter 80, 12VAC30-80-10 et seq., describes the methods and standards used for the payment of each of these services except for inpatient hospital, nursing facility services and services in intermediate care facilities for the mentally retarded that are described in other attachments.

12VAC30-80-170 describes the general methods and standards used for establishing payment for Medicare Part A and B deductible/coinsurance.

C. Payment is made to reserve a bed during a recipient's temporary absence from an inpatient facility, as described in 12VAC30-20-170.

D. 1. The Medicaid agency meets the requirements of 42 CFR 447, Subpart C, with respect to payments for skilled nursing and intermediate care facility services.

12VAC30-90-10 describes the methods and standards used to determine rates for payment for skilled nursing and intermediate care facility services.

2. The Medicaid agency does not provide payment for skilled nursing facility services to a swing-bed hospital.

3. The Medicaid agency does not provide payment for intermediate care facility services to a swing-bed hospital.

4. Subdivision 1 of this subsection is applicable with respect to intermediate care facility services; such services are provided under this plan.

E. The Medicaid agency meets all requirements of 42 CFR 447.45 for timely payment of claims.

12VAC30-20-180 specifies, for each type of service, the definition of a claim for purposes of meeting these requirements.

F. The Medicaid agency limits participation to providers who meet the requirements of 42 CFR 447.15.

No provider participating under this plan may deny services to any individual eligible under the plan on account of the individual's inability to pay a cost sharing amount imposed by the plan in accordance with 42 CFR 431.55(g) and 447.53. This service guarantee does not apply to an individual who is able to pay, nor does an individual's inability to pay eliminate his or her liability for the cost sharing change.

G. The Medicaid agency assures appropriate audit of records when payment is based on costs of services or on a fee plus cost of materials.

H. The Medicaid agency meets the requirements of 42 CFR 447.203 for documentation and availability of payment rates.

I. The Medicaid agency's payments are sufficient to enlist enough providers so that services under the plan are available to recipients at least to the extent that those services are available to the general population.

J. The Medicaid agency meets the requirements of 42 CFR 447.205 for public notice of any changes in statewide method or standards for setting payment rates.

K. The Medicaid agency meets the requirements of § 1903(v) of the Act with respect to payment for medical assistance furnished to qualified aliens who entered the United States on or after August 22, 1996, who are not eligible for Medicaid for five years after their entry and nonqualified aliens, including illegal aliens and legal nonimmigrants who are otherwise eligible. Payment is made only for care and services that are necessary for the treatment of an emergency condition, as defined in § 1903(v) of the Act.

L. The Medicaid agency meets the requirements of § 1903(i)(14) of the Act with respect to payment for physician services furnished to children under 21 and pregnant women. Payment for the physician services furnished by a physician to a child or pregnant woman is made only to physicians who meet one of the requirements listed under this section of the Act.

M. Medicaid reimbursement for administration of vaccines under the Pediatric Immunization Program.

A provider may impose a charge for the administration of a qualified pediatric vaccine as stated in § 1928(c)(2)(C)(ii) of the Act. Within this overall provision, Medicaid reimbursement to providers will be administered as follows:

1. The state sets a payment rate below the level of the regional maximum established by the Department of Health and Human Services Secretary.

The state pays $11 per vaccine administration.

2. Medicaid beneficiary access to immunizations is assured through the following methodology:

The Commonwealth will demonstrate access to such services by the Commonwealth's fee per vaccine administration being higher than that of a major insurance company.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Subsection A derived from VR460-01-57, eff. June 16, 1993; subsection B derived from VR460-01-58, eff. June 16, 1993; subsection C derived from VR460-01-59, eff. September 16, 1977; subsection D derived from VR460-01-60, eff. December 1, 1987; subsection E derived from VR460-01-61, eff. August 23, 1979; subsection F derived from VR460-01-62, eff. July 1, 1987; subsection G derived from VR460-01-63, eff. September 30, 1979; subsection H derived from VR460-01-64, eff. September 30, 1979; subsection I derived from VR460-01-65, eff. September 30, 1979; subsections J and K derived from VR460-01-66, eff. June 16, 1993; amended, Virginia Register Volume 11, Issue 26, eff. November 1, 1995; Volume 12, Issue 2, eff. November 15, 1995; Volume 13, Issue 18, eff. July 1, 1997.

12VAC30-10-590. Direct payments to certain recipients for physicians' or dentists' services.

No direct payments are made to recipients.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-67, eff. September 16, 1977.

12VAC30-10-600. Prohibition against reassignment of provider claims.

Payment for Medicaid services furnished by any provider under this plan is made only in accordance with the requirements of 42 CFR 447.10.

In the case of services furnished (during periods that do not exceed 14 continuous days in the case of an informal reciprocal arrangement or 90 continuous days (or such longer period as the Secretary may provide) in the case of an arrangement involving per diem, or other fee-for-time compensation) by or incident to the services of one physician to the patient of another physician who submits the claim for such services, payment shall be made to the physician submitting the claim (as if the services were furnished by, or incident to, the physician's services), but only if the claim identifies (in a manner specified by the Secretary) the physician who furnished the services.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-68, eff. November 5, 1990.

12VAC30-10-610. Third party liability.

A. The Medicaid agency meets all requirements of:

1. 42 CFR 433.138 and 433.139

2. 42 CFR 433.145 through 433.148

3. 42 CFR 433.151 through 433.154

4. Sections 1902(a)(25)(H) and (I) of the Act.

B. 12VAC30-20-190, governing the identification of liable resources with respect to third party liability:

1. Specifies the frequency with which the data exchanges required in § 433.138(d)(1), (d)(3) and (d)(4) and the diagnosis and trauma code edits required in § 433.138(e) are conducted;

2. Describes the methods the agency uses for meeting the follow-up requirements contained in §§ 433.138(g)(1)(i) and (g)(2)(i);

3. Describes the methods the agency uses for following up on information obtained through the State motor vehicle accident report file data exchange required under § 433.138(d)(4)(ii) and specifies the time frames for incorporation into the eligibility case file and into its third party data base and third party recovery unit of all information obtained through the follow-up that identifies legally liable third party resources; and

4. Describes the methods the agency uses for following up on paid claims identified under § 433.13(a) (methods include a procedure for periodically identifying those trauma codes that yield the highest third party collections and giving priority to following up on those codes) and specifies the time frames for incorporation into the eligibility case file and into its third party data base and third party recovery unit of all information obtained through the follow-up that identifies legally liable third party resources.

C. Providers are not required to bill liable third parties when services covered under the plan are furnished to an individual on whose behalf child support enforcement is being carried out by the State Title IV-D agency

D. 12VAC30-20-200, governing the payment of claims with respect to third party liability, specifies:

1. The method used in determining a provider's compliance with the third party billing requirements at § 433.139(b) (3) (ii) (C).

2. The threshold amount or other guideline used in determining whether to seek recovery or reimbursement from a liable third party, or the process by which the agency determines that seeking recovery of reimbursement would not be cost effective.

3. The dollar amount or time period the State uses to accumulate billings from a particular liable third party in making the decision to seek recovery of reimbursement.

E. The Medicaid agency ensures that the provider furnishing a service for which a third party is liable follows the restrictions specified in 42 CFR 447.20.

F. The Medicaid agency has written cooperative agreements for the enforcement of rights to and collection of third party benefits assigned to the State as a condition of eligibility for remedial assistance with the State Title IV-D agency. The requirements of 42 CFR 433.152(b) are met.

G. The Medicaid agency assures that the State has in effect the laws relating to medical child support under § 1908 of the Act.

H. The Medicaid agency specifies the guidelines used in determining the cost effectiveness of an employer-based group health plan; the State provides methods for determining cost effectiveness in 12VAC30-20-210.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Subsections A and B derived from VR460-01-69, eff. July 1, 1994; subsections C, D, and E derived from VR460-01-69.1, eff. July 1, 1994; subsections F, G and H derived from VR460-01-70, eff. July 1, 1994.

12VAC30-10-620. Use of contracts.

The Medicaid agency has contracts of the type(s) listed in 42 CFR 434. All contracts meet the requirements of 42 CFR 434.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-71, eff. April 15, 1984.

12VAC30-10-630. (Repealed.)

Historical Notes

Derived from VR460-01-72, eff. October 15, 1979; repealed, Virginia Register Volume 12, Issue 2, eff. November 15, 1995.

12VAC30-10-631. Standards for payment for nursing facility and intermediate care facility for the mentally retarded services.

With respect to nursing facilities and intermediate care facilities for the mentally retarded, all applicable requirements of 42 CFR Part 442, Subparts B and C are met.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 18, Issue 7, eff. January 16, 2002.

12VAC30-10-640. Program for licensing administrators of nursing homes.

The state has a program that, except with respect to religious nonmedical health care institutions, meets the requirements of 42 CFR Part 431, Subpart N, for the licensing of nursing home administrators.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-73, eff. March 29, 1974; amended, Virginia Register Volume 18, Issue 7, eff. January 16, 2002.

12VAC30-10-650. Drug Utilization Review Program.

A. 1. The Medicaid agency meets the requirements of § 1927(g) of the Social Security Act for a drug use review (DUR) program for outpatient drug claims.

2. The DUR program assures that prescriptions for outpatient drugs are:

a. Appropriate.

b. Medically necessary.

c. Are not likely to result in adverse medical results.

B. The DUR program is designed to educate physicians and pharmacists to identify and to reduce the frequency of patterns of fraud, abuse, gross overuse, or inappropriate or medically unnecessary care among physicians, pharmacists, and patients or associated with specific drugs as well as:

1. Potential and actual adverse drug reactions;

2. Therapeutic appropriateness;

3. Overutilization and underutilization;

4. Appropriate use of generic products;

5. Therapeutic duplication;

6. Drug disease contraindications;

7. Drug-drug interactions;

8. Incorrect drug dosage or duration of drug treatment;

9. Drug allergy interactions;

10. Clinical abuse or misuse; and

11. Provisions of § 1004 of the SUPPORT Act.

C. SUPPORT Act provisions.

1. Claim review limitations:

a. Prospective safety edits, including early, duplicate fill, and quantity limits for clinical appropriateness for opioids.

b. Maximum daily morphine milligram equivalents safety edits. A maximum dosing limit on opioids limits the daily morphine milliequivalents as recommended by clinical guidelines.

c. Concurrent utilization alerts. Prospective drug-to-drug interaction alerts will require a response from the pharmacy if an opioid and benzodiazepine or opioid and antipsychotics are being dispensed within an overlapping period with retrospective reviews performed on an ongoing periodic basis.

d. Comprehensive retrospective DUR is performed on opioid prescriptions on an ongoing periodic basis.

2. Programs to monitor antipsychotic medications to children. Antipsychotic agents are reviewed for age appropriateness, duplicate therapy, and adverse effects in children based on the U.S. Food and Drug Administration product approval and clinical guidelines.

3. Fraud and abuse identification. The Client Medical Management (CMM) program for fee-for-service (FFS) beneficiaries that may require restriction to physician, pharmacy, or both limiting the beneficiary's access to services identified as not medically necessary, excessive, or both. The beneficiary's designated physician is responsible for supervising, coordinating, and providing initial and primary medical care; initiating written referrals for specialist care; and maintaining the continuity of patient care.

D. The DUR program shall assess data use against predetermined standards whose source materials for their development are consistent with peer-reviewed medical literature that has been critically reviewed by unbiased independent experts and the following compendia:

1. American Hospital Formulary Service Drug Information (2003, as amended);

2. United States Pharmacopeia-Drug Information (2003, as amended);

3. MICROMEDEX (as updated monthly);

4. Drug Facts and Comparisons (as updated monthly); and

5. Drug Information Handbook (2003, as amended in 2004).

E. DUR is not required for drugs dispensed to residents of nursing facilities that are in compliance with drug regimen review procedures set forth in 42 CFR 483.60. The state has nevertheless chosen to include nursing home drugs in retrospective DUR.

F. 1. The DUR program includes prospective review of drug therapy at the point of sale or point of distribution before each prescription is filled or delivered to the Medicaid recipient.

2. Prospective DUR includes screening each prescription filled or delivered to an individual receiving benefits for potential drug therapy problems due to:

a. Therapeutic duplication;

b. Drug disease contraindications;

c. Drug-drug interactions;

d. Drug-interactions with nonprescription or over-the-counter drugs;

e. Incorrect dosage or duration of drug treatment;

f. Drug allergy interactions; and

g. Clinical abuse or misuse.

3. Prospective DUR includes counseling for Medicaid recipients based on standards established by State law and maintenance of patient profiles.

4. Prospective DUR may also include electronic messages as well as rejection of claims at point-of-sale pending appropriate designated interventions by the dispensing pharmacist or prescribing physician.

5. Designated interventions may include provider override, obtaining prior authorization via communication to a call center staffed with appropriate clinicians, or written communication to prescribers.

G. 1. The DUR program includes retrospective DUR through its mechanized drug claims processing and information retrieval system or otherwise that undertakes ongoing periodic examination of claims data and other records to identify:

a. Patterns of fraud and abuse;

b. Gross overuse; and

c. Inappropriate or medically unnecessary care among physicians, pharmacists, Medicaid recipients, or associated with specific drugs or groups of drugs.

2. The DUR program assesses data on drug use against explicit predetermined standards, including monitoring for:

a. Therapeutic appropriateness;

b. Overutilization and underutilization;

c. Appropriate use of generic products;

d. Therapeutic duplication;

e. Drug disease contraindications;

f. Drug-to-drug interactions;

g. Incorrect dosage or duration of drug treatment; and

h. Clinical abuse or misuse.

3. The DUR program through its state DUR Board, using data provided by the board, provides for active and ongoing educational outreach programs to educate practitioners and pharmacists on common drug therapy problems to improve prescribing and dispensing practices.

4. In situations of conflict with these criteria, DMAS, pursuant to the DUR Board's criteria and requirements, shall reject or deny presented claims and require the dispensing pharmacist to intervene as specified through electronic messages in the point-of-sale system before the claim will be approved for payment.

5. Designated interventions may include provider override, obtaining prior authorization via communication to a call center staffed with appropriate clinicians, or written communication to prescribers.

H. 1. The DUR program has established a state DUR Board directly.

2. The DUR Board membership includes health professionals (one-third licensed actively practicing pharmacists and one-third but no more than 51% licensed and actively practicing physicians) with knowledge and experience in one or more of the following:

a. Clinically appropriate prescribing of covered outpatient drugs.

b. Clinically appropriate dispensing and monitoring of covered outpatient drugs.

c. Drug use review, evaluation, and intervention.

d. Medical quality assurance.

3. The activities of the DUR Board include:

a. Prospective DUR;

b. Retrospective DUR;

c. Application of Standards as defined in § 1927(g)(2)(C); and

d. Ongoing interventions for physicians and pharmacists targeted toward therapy problems or individuals identified in the course of retrospective DUR.

4. The interventions include in appropriate instances:

a. Information dissemination.

b. Written, oral, and electronic reminders.

c. Face-to-Face and telephonic discussions.

d. Intensified monitoring or review of prescribers or dispensers.

e. Rejected or denied claims, as appropriate, to prevent the violation of the DUR Board's predetermined criteria.

Provider override, obtaining prior authorization via communication to a call center staffed with appropriate clinicians, or written communication to prescribers.

I. The state assures that it will prepare and submit an annual report to the secretary, which incorporates a report from the state DUR Board, and that the state will adhere to the plans, steps, procedures as described in the report.

The Medicaid agency ensures that predetermined criteria and standards have been recommended by the DUR Board and approved by either Board of Medical Assistance Services (BMAS) or the director, acting on behalf of the BMAS, pursuant to § 32.1-324 of the Code of Virginia and that they are based upon documentary evidence of the DUR Board. The activities of the DUR Board and the Medicaid fraud control programs are and shall be maintained as separate. The DUR Board shall refer suspected cases of fraud or abuse to the appropriate fraud and abuse control unit with the Medicaid agency.

J. 1. The state establishes, as its principal means of processing claims for covered outpatient drugs under this title, a point-of-sale electronic claims management system to perform on-line:

a. Real time eligibility verification.

b. Claims data capture.

c. Adjudication of claims. Such adjudication may include the rejection or denial of claims found to be in conflict with DUR criteria. Should such rejection or denial occur during the adjudication process, the dispensing pharmacist shall have the opportunity to resolve the conflict and resubmit the claim for readjudication.

d. Assistance to pharmacists, etc., applying for and receiving payment.

2. Prospective DUR is performed using an electronic point of sale drug claims processing system.

K. Hospitals which dispense covered outpatient drugs are exempted pursuant to federal law from the drug utilization review requirements of this section when facilities use drug formulary systems and bill the Medicaid program no more than the hospital's purchasing cost for such covered outpatient drugs.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1315 and 42 USC § 1396 et seq.

Historical Notes

Subsections A, B, and C derived from VR460-01-74, eff. June 16, 1993; subsections D, E, and F 1 derived from VR460-01-74.1, eff. June 16, 1993; subsections F 2 through G 3 derived from VR460-01-74.2, eff. June 16, 1993; subsections G 4 and H, I, and J derived from VR460-01-74.3, eff. June 16, 1993; amended, Virginia Register Volume 21, Issue 6, eff. January 3, 2005; Volume 37, Issue 24, eff. September 2, 2021.

12VAC30-10-660. Disclosure of survey information and provider or contractor evaluation.

The Medicaid agency has established procedures for disclosing pertinent findings obtained from surveys and provider and contractor evaluations that meet all the requirements in 42 CFR 431.115.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-75, eff. October 15, 1979.

12VAC30-10-670. Appeals process.

A. The Medicaid agency has established appeals procedures for NFs as specified in 42 CFR 431.153 and 431.154.

B. The state provides an appeals system that meets the requirements of Subpart E of 42 CFR Part 431, 42 CFR 483.15, Subpart E of 42 CFR Part 483, and 12VAC30-110-10 through 12VAC30-110-370 for residents who wish to appeal a notice of intent to transfer or discharge from a NF and for individuals adversely affected by the preadmission screening or annual resident review requirements of Subpart C of 42 CFR Part 483.

Statutory Authority

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

Historical Notes

Derived from VR460-01-76, eff. June 1, 1993; amended, Virginia Register Volume 34, Issue 1, eff. October 19, 2017.

12VAC30-10-680. Conflict of interest provisions.

The Medicaid agency meets the requirements of § 1902(a)(4)(C) of the Act concerning the prohibition against acts, with respect to any activity under the plan, that are prohibited by § 207 or § 208 of Title 18, United States Code.

The Medicaid agency meets the requirements of § 1902(a)(4)(D) of the act concerning the safeguards against conflicts of interest that are at least as stringent as the safeguards that apply under § 27 of the Office of Federal Procurement Policy Act (41 USC § 423).

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-77, eff. June 30, 1979; amended, Virginia Register Volume 15, Issue 26, eff. October 13, 1999.

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.

12VAC30-10-700. Disclosure of information by providers and fiscal agents.

The Medicaid agency has established procedures for the disclosure of information by providers and fiscal agents as specified in 42 CFR 455.104 through 455.106 and sections 1128(b)(9) and 1902(a)(38) of the Act.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-79, eff. January 1, 1988.

12VAC30-10-710. Income and eligibility verification system.

A. The Medicaid agency has established a system for income and eligibility verification in accordance with the requirements of 42 CFR 435.940 through 435.960.

B. 12VAC30-20-220 describes, in accordance with 42 CFR 435.958(a)(6), the information that will be requested in order to verify eligibility or the correct payment amount and the agencies and the state or states from which that information will be requested.

C. The Commonwealth has an eligibility determination system that provides for data matching through the Public Assistance Reporting Information System (PARIS), or any successor system, including matching with medical assistance programs operated by other states. The information that is requested will be exchanged with states and other entities legally entitled to verify Title XIX applicants and individuals eligible for covered Title XIX services consistent with applicable PARIS agreements.

Statutory Authority

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

Historical Notes

Derived from VR460-01-79, eff. January 1, 1988; amended, Virginia Register Volume 29, Issue 14, eff. April 10, 2013.

12VAC30-10-720. Medicaid eligibility cards for homeless individuals.

A. The Medicaid agency has a method for making cards evidencing eligibility for medical assistance available to an individual eligible under the State's approved plan who does not reside in a permanent dwelling or does not have a fixed home or mailing address.

B. 12VAC30-20-230 specifies the method for issuance of Medicaid eligibility cards to homeless individuals.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-79.1, eff. January 1, 1988.

12VAC30-10-730. Systematic alien verification for entitlements.

The State Medicaid agency has established procedures for the verification of alien status through the Immigration & Naturalization Service (INS) designated system, Systematic Alien Verification for Entitlements (SAVE), effective October 1, 1988.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-79.2, eff. January 1, 1989.

12VAC30-10-740. (Repealed.)

Historical Notes

Subsections A through E derived from VR460-01-79.3, eff. October 1, 1990; subsections F, G, and H derived from VR460-01-79.4, eff. October 1, 1990; subsections I and J derived from VR460-01-79.5, eff. October 1, 1990; repealed, Virginia Register Volume 12, Issue 2, eff. November 15, 1995.

12VAC30-10-750. (Repealed.)

Historical Notes

Derived from VR460-01-79.6, eff. July 4, 1990; repealed, Virginia Register Volume 12, Issue 25, eff. October 2, 1996.

12VAC30-10-751. Enforcement of compliance for nursing facilities.

A. The Commonwealth shall comply with the Medicaid Program requirements of Subpart E of 42 CFR Part 488.

B. Notification of enforcement remedies. When taking an enforcement action against a nonstate operated nursing facility, the state provides notification in accordance with 42 CFR 488.402(f).

1. The notice (except for civil money penalties and state monitoring) specifies:

a. The nature of noncompliance;

b. Which remedy is imposed;

c. The effective date of the remedy; and

d. The right to appeal the determination leading to the remedy.

2. The notice for civil money penalties is in writing and contains the information specified in 42 CFR 488.434 and 42 CFR 488.440.

3. Except for civil money penalties and state monitoring, notice is given at least two calendar days before the effective date of the enforcement remedy for immediate jeopardy situations and at least 15 calendar days before the effective date of the enforcement remedy when immediate jeopardy does not exist. The two-day and 15-day notice periods begin when the facility receives the notice, but, in no event will the effective date of the enforcement action be later than 20 calendar days after the notice is sent. (42 CFR 488.402(f)(3),(4), and (5))

4. Notification of termination is given to the facility and to the public at least two calendar days before the remedy's effective date if the noncompliance constitutes immediate jeopardy and at least 15 calendar days before the remedy's effective date if the noncompliance does not constitute immediate jeopardy. The state must terminate the provider agreement of a nursing facility in accordance with procedures in 42 CFR Parts 431 and 442. (42 CFR 488.456(c) and (d))

C. Factors to be considered in selecting remedies. In determining the seriousness of deficiencies, the state considers the factors specified in 42 CFR 488.404(b)(1) and (2).

D. Application of remedies.

1. If there is immediate jeopardy to resident health or safety, the state terminates the nursing facility's provider agreement within 23 calendar days from the date of the last survey or immediately imposes temporary management to remove the threat within 23 days. (42 CFR 488.410)

2. The state imposes the denial of payment (or its approved alternative) with respect to any newly admitted individual to a nursing facility that has not come into substantial compliance within three months after the last day of the survey. (42 CFR 488.417(b)(1) and § 1919(h)(2)(C) of the Act)

3. The state imposes the denial of payment for new admissions remedy as specified in 42 CFR 488.417 (or its approved alternative) and a state monitor as specified at 42 CFR 488.422, when a facility has been found to have provided substandard quality of care on the last three consecutive standard surveys. (42 CFR 488.414 and § 1919(h)(2)(D) of the Act)

4. The state follows the criteria specified at 42 CFR 488.408(c)(2), (d)(2), and (e)(2) when it imposes remedies in place of or in addition to termination. (42 CFR 488.408(b) and § 1919(h)(2)(A) of the Act)

5. When immediate jeopardy does not exist, the state terminates a nursing facility's provider agreement no later than six months from the finding of noncompliance if the conditions of 42 CFR 488.412(a) are not met.

E. Available remedies. The state has established the remedies defined in 42 CFR 488.406(b). 12VAC30-20-251 through 12VAC30-20-259 describe the criteria for applying the remedies, plan of correction, nursing facility appeals, and repeated substandard quality of care.

F. In the event that the Commonwealth and CMS disagree on findings of noncompliance or application of remedies in a nonstate operated nursing facility or a dually participating facility when there is no immediate jeopardy, such disagreement shall be resolved in accordance with the provisions of 42 CFR 488.452.

G. The Commonwealth shall have the authority to apply one or more remedies for each deficiency constituting noncompliance or for all deficiencies constituting noncompliance.

H. As set forth by 42 CFR 488.454, remedies shall terminate on the date that CMS or the Commonwealth can verify as the date that substantial compliance was achieved and the facility has demonstrated that it could maintain substantial compliance once the facility supplies documentation acceptable to CMS or the Commonwealth that it was in substantial compliance and was capable of remaining in compliance.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 12, Issue 25, eff. October 2, 1996; amended, Virginia Register Volume 34, Issue 1, eff. October 19, 2017.

12VAC30-10-760. Pharmacy services rebate agreement terms.

The Commonwealth conforms to § 1927(b) (2) with regard to the reporting of information on the total number of dosage units of each covered outpatient drug dispensed under the plan during the quarter, and in such a manner as specified by the Secretary of HHS and also shall promptly transmit a copy of such report to the Secretary. The Commonwealth also conforms to § 1927(b) (3) (D) with regard to assuring the confidentiality of the disclosure of the identity of a manufacturer or wholesaler and prices charged for drugs by such manufacturer or wholesaler.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-79.7, eff. April 1, 1993.

12VAC30-10-770. Required coordination between the Medicaid and WIC Programs.

The Medicaid agency provides for the coordination between the Medicaid program and the Special Supplemental Food Program for Women, Infants, and Children (WIC) and provides timely notice and referral to WIC in accordance with § 1902(a)(53) of the Act.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-79.8, eff. June 16, 1993.

12VAC30-10-780. Nurse aide training and competency evaluation for nursing facilities.

A. The State assures that the requirements of 42 CFR 483.150(a), which relate to individuals deemed to meet the nurse aide training and competency evaluation requirements, are met.

B. The State does not elect to waive the competency evaluation requirements for individuals who meet the requirements of 42 CFR 483.150(b)(1).

C. The State does not elect to deem individuals who meet the requirements of 42 CFR 483.150(b)(2) to have met the nurse aide training and competency evaluation requirements.

D. The State specifies any nurse aide training and competency evaluation programs it approves as meeting the requirements of 42 CFR 483.152 and competency evaluation programs it approves as meeting the requirements of 42 CFR 483.154.

E. The State offers a nurse aide training and competency evaluation program that meets the requirements of 42 CFR 483.152.

F. The State offers a nurse aide competency evaluation program that meets the requirements of 42 CFR 483.154.

G. If the State does not choose to offer a nurse aide training and competency evaluation program or nurse aide competency evaluation program, the State reviews all nurse aide training and competency evaluation programs and competency evaluation programs upon request.

H. The State survey agency determines, during the course of all surveys, whether the requirements of 483.75(e) are met.

I. Before approving a nurse aide training and competency evaluation program, the State determines whether the requirements of 42 CFR 483.152 are met.

J. Before approving a nurse aide competency evaluation program, the State determines whether the requirements of 42 CFR 483.154 are met.

K. For program reviews other than the initial review, the State visits the entity providing the program.

L. The State does not approve a nurse aide training and competency evaluation program or competency evaluation program offered by or in certain facilities as described in 42 CFR 483.151(b)(2) and (3).

M. The State, within 90 days of receiving a request for approval of a nurse aide training and competency evaluation program or competency evaluation program, either advises the requestor whether or not the program has been approved or requests additional information from the requestor.

N. The State does not grant approval of a nurse aide training and competency evaluation program for a period longer than 2 years.

O. The State reviews programs when notified of substantive changes (e.g., extensive curriculum modification).

P. The State withdraws approval from nurse aide training and competency evaluation programs and competency evaluation programs when the program is described in 42 CFR 483.151(b)(2) or (3).

Q. The State withdraws approval of nurse aide training and competency evaluation programs that cease to meet the requirements of 42 CFR 483.152 and competency evaluation programs that cease to meet the requirements of 42 CFR 483.154.

R. The State withdraws approval of nurse aide training and competency evaluation programs and competency evaluation programs that do not permit unannounced visits by the State.

S. When the State withdraws approval from a nurse aide training and competency evaluation program or competency evaluation program, the State notifies the program in writing, indicating the reasons for withdrawal of approval.

T. The State permits students who have started a training and competency evaluation program from which approval is withdrawn to finish the program.

U. The State provides for the reimbursement of costs incurred in completing a nurse aide training and competency evaluation program or competency evaluation program for nurse aides who become employed by or who obtain an offer of employment from a facility within 12 months of completing such program.

V. The State provides advance notice that a record of successful completion of competency evaluation will be included in the State's nurse aide registry.

W. Competency evaluation programs are administered by the State or by a State-approved entity which is neither a skilled nursing facility participating in Medicare nor a nursing facility participating in Medicaid.

X. The State does not elect to permit proctoring of the competency evaluation in accordance with 42 CFR 483.154(d).

Y. The State has a standard for successful completion of competency evaluation programs.

Z. The State includes a record of successful completion of a competency evaluation within 30 days of the date an individual is found competent.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Subsections A through F derived from VR460-01-79.14, eff. June 16, 1993; subsections G through L derived from VR460-01-79.15, eff. June 16, 1993; subsections M through R derived from VR460-01-79.16, eff. June 16, 1993; subsections S through Y derived from VR460-01-79.17, eff. June 16, 1993; subsection Z derived from VR460-01-79.18, eff. June 16, 1993.

12VAC30-10-790. Preadmission screening and annual resident review in nursing facilities.

A. The Medicaid agency has in effect a written agreement with the State mental health and mental retardation authorities that meet the requirements of 42 CFR 431.621(c).

B. The State operates a preadmission screening and annual resident review program that meets the requirements of 42 CFR 483.100-138.

C. The State does not claim as "medical assistance under the State Plan" the cost of services to individuals who should receive preadmission screening or annual resident review until such individuals are screened or reviewed.

D. With the exception of NF services furnished to certain NF residents defined in 42 CFR 483.118(c)(1), the State does not claim as "medical assistance under the State plan" the cost of NF services to individuals who are found not to require NF services.

E. 12VAC30-20-260 specifies the State's definition of specialized services.

F. Except for residents identified in 42 CFR 483.118(c)(1), the State mental health authority makes categorical determinations that individuals with certain mental conditions or levels of severity of mental illness would normally require specialized services of such an intensity that a specialized services program could not be delivered by the State in most, if not all, NFs and that a more appropriate placement should be utilized.

G. The State describes an categorical determinations it applies in 12VAC30-20-270.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Subsections A through E derived from VR460-01-79.19, eff. June 1, 1993; subsections F and G derived from VR460-01-79.20, eff. June 1, 1993.

12VAC30-10-800. Survey and certification process.

A. The state assures that the requirements of § 1919(a)(1)(A) through (C) and § 1919(g)(2)(A) through (E)(iii) of the Act which relate to the survey and certification of non-state owned facilities based on the requirements of § 1919(b), (c) and (d) of the Act, are met.

B. The state conducts periodic education programs for staff and residents (and their representatives). 12VAC30-20-272 describes the survey and certification educational program.

C. The state provides for a process for the receipt and timely review and investigation of allegations of neglect and abuse and misappropriation of resident property by a nurse aide of a resident in a nursing facility or by another individual used by the facility. 12VAC30-20-274 describes the state's process.

D. The state agency responsible for surveys and certification of nursing facilities conducts the process for the receipt and timely review and investigation of allegations of neglect and abuse and misappropriation of resident property.

E. The state assures that a nurse aide, found to have neglected or abused a resident or misappropriated resident property in a facility, is notified of the finding. The name and finding is placed on the nurse aide registry.

F. The state notifies the appropriate licensure authority of any licensed individual found to have neglected or abused a resident or misappropriated resident property in a facility.

G. The state has procedures, as provided for at § 1919(g)(2)(A)(i), for the scheduling and conduct of standard surveys to assure that the state has taken all reasonable steps to avoid giving notice through the scheduling procedures and the conduct of the surveys themselves. 12VAC30-20-275 describes the state's procedures.

H. The state assures that each facility shall have a standard survey which includes (for a case-mix stratified sample of residents) a survey of the quality of care furnished, as measured by indicators of medical, nursing and rehabilitative care, dietary and nutritional services, activities and social participation, and sanitation, infection control, and the physical environment, written plans of care and audit of resident's assessments, and a review of the compliance with resident's rights not later than 15 months after the date of the previous standard survey.

I. The state assures that the statewide average interval between standard surveys of nursing facilities does not exceed 12 months.

J. The state may conduct a special standard or special abbreviated standard survey within two months of any change of ownership, administration, management, or director of nursing of the nursing facility to determine whether the change has resulted in any decline in the quality of care furnished by the facility.

K. The state conducts extended surveys immediately or, if not practicable, not later than two weeks following a completed standard survey in a nursing facility which is found to have provided substandard care or in any other facility at the secretary's or state's discretion.

L. The state conducts standard and extended surveys based upon a protocol, i.e., survey forms, methods, procedures and guidelines developed by HCFA, using individuals in the survey team who meet minimum qualifications established by the secretary.

M. The state provides for programs to measure and reduce inconsistency in the application of survey results among surveyors. 12VAC30-20-277 describes the state's programs.

N. The state issues a multidisciplinary team of professionals including a registered professional nurse.

O. The state assures that members of a survey team do not serve (or have not served within the previous two years) as a member of the staff or consultant to the nursing facility or has no personal or familial financial interest in the facility being surveyed.

P. The state assures that no individual shall serve as a member of any survey team unless the individual has successfully completed a training and test program in survey and certification techniques approved by the secretary.

Q. The state maintains procedures and adequate staff to investigate complaints of violations of requirements by nursing facilities and onsite monitoring. 12VAC30-20-278 describes the state's complaint procedures.

R. The state makes available to the public information respecting surveys and certification of nursing facilities including statements of deficiencies, plans of correction, copies of cost reports, statements of ownership and the information disclosed under § 1126 of the Act.

S. The state notifies the state long-term care ombudsman of the state's finding of noncompliance with any the requirements of subsection B, C, and D or of any adverse actions taken against a nursing facility.

T. If the state finds substandard quality of care in a facility, the state notifies the attending physician of each resident with respect to which such finding is made and the nursing facility administrator licensing board.

U. The state provides the state Medicaid fraud and abuse agency access to all information concerning survey and certification actions.

Statutory Authority

§ 32.1-325 of the Code of Virginia; §§ 1919(g)(1) through (2) and 1919(g)(4) through (5) of the Act, P.L. 100-203 (§ 4212(a)).

Historical Notes

Derived from VR460-01-79.21, eff. November 15, 1995.

12VAC30-10-810. Resident assessment for nursing facilities.

A. The state specifies the instrument to be used by nursing facilities for conducting a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity as required in § 1919(b)(3)(A) of the Act.

B. The state is using the resident assessment instrument designated by CMS (Appendix R "Resident Assessment Instrument for Long-Term Care Facilities" of the CMS State Operations Manual).

Statutory Authority

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

Historical Notes

Derived from VR460-01-79.24, eff. November 15, 1995; amended, Virginia Register Volume 34, Issue 1, eff. October 19, 2017.

12VAC30-10-815. Cooperation with Medicaid Integrity Program efforts.

The Medicaid agency assures it complies with such requirements determined by the Secretary to be necessary for carrying out the Medicaid Integrity Program established under § 1936 of the Act.

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 25, Issue 4, eff. November 26, 2008.

12VAC30-10-820. Employee education about false claims recoveries.

12VAC30-10-820. Employee education about false claims recoveries.

A. Definitions. The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise:

"Contractor" or "agent" includes any contractor, subcontractor, agent, or other person that or who, on behalf of the entity, furnishes, or otherwise authorizes the furnishing of, Medicaid health care items or services, performs billing or coding functions, or is involved in the monitoring of health care provided by the entity.

"Employee" means any officer or employee of the entity.

"Entity" means a governmental agency, organization, unit, corporation, partnership, or other business arrangement (including any Medicaid managed care organization, irrespective of the form of business structure or arrangement by which it exists), whether for-profit or not-for-profit, which receives or makes payments, under a state plan approved under title XIX or under any waiver of such plan, totaling at least $5,000,000 annually. A governmental component providing Medicaid health care items or services for which Medicaid payments are made would qualify as an "entity" (e.g., a state mental health facility or school district providing school-based health services). A government agency that merely administers the Medicaid program, in whole or part (e.g., managing the claims processing system or determining beneficiary eligibility), is not, for these purposes, considered to be an entity.

B. The Medicaid agency meets the requirements regarding establishment of policies and procedures for the education of employees of entities covered by § 1902(a)(68) of the Social Security Act (the Act) regarding false claims recoveries and methodologies for oversight of entities' compliance with these requirements.

C. Provider requirements.

1. If an entity furnishes items or services at more than a single location or under more than one contractual or other payment arrangement, the provisions of § 1902(a)(68) of the Act apply if the aggregate payments to that entity meet the $5,000,000 annual threshold. This applies whether the entity submits claims for payments using one or more provider identification or tax identification numbers.

2. An entity will have met the $5,000,000 annual threshold as of January 1, 2007, if it received or made payments in that amount in federal fiscal year 2006. Future determinations regarding an entity's responsibility stemming from the requirements of § 1902(a)(68) of the Act will be made by January 1 of each subsequent year based upon the amount of payments an entity either received or made under the state plan during the preceding federal fiscal year.

3. The entity must establish and disseminate written policies that must also be adopted by its contractors or agents. Written policies may be on paper or in electronic form, but must be readily available to all employees, contractors, or agents. The entity need not create an employee handbook if none already exists.

4. An entity shall establish written policies for all employees (including management), and of any contractor or agent of the entity, that include detailed information about the False Claims Act and the other provisions named in § 1902(a)(68)(A) of the Act, including the Virginia Fraud Against Taxpayers Act (§ 8.01-216.1 et seq. of the Code of Virginia). The entity shall include in those written policies detailed information about the entity's policies and procedures for detecting and preventing waste, fraud, and abuse. The entity shall also include in any employee handbook a specific discussion of the laws described in the written policies, the rights of employees to be protected as whistleblowers and a specific discussion of the entity's policies and procedures for detecting and preventing fraud, waste, and abuse.

D. 12VAC30-20-275 describes, in accordance with § 1902(a)(68) of the Act, the methodology of compliance oversight and the frequency with which the Commonwealth will reassess compliance on an ongoing basis.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 24, Issue 2, eff. October 31, 2007.

Part V
Personnel Administration

12VAC30-10-850. Standards of personnel administration.

A. The Medicaid agency has established and will maintain methods of personnel administration in conformity with standards prescribed by the U.S. Civil Service Commission in accordance with § 208 of the Intergovernmental Personnel Act of 1970 and the regulations on Administration of the Standards for a Merit System of Personnel Administration, 5 CFR 900, Subpart F. All requirements of 42 CFR 432.10 are met.

B. Affirmative Action Plan. The Medicaid agency has in effect an affirmative action plan for equal employment opportunity that includes specific action steps and timetables and meets all other requirements of 5 CFR 900, Subpart F.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-80, eff. October 1, 1977.

12VAC30-10-860. [Reserved]. (Reserved)

12VAC30-10-870. Training programs; subprofessional and volunteer programs.

The Medicaid agency meets the requirements of 42 CFR 432, Subpart B, with respect to a training program for agency personnel and the training and use of subprofessional staff and volunteers.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-82, eff. February 28, 1978.

12VAC30-10-880. [Reserved]. (Reserved)

Part VI
Financial Administration

12VAC30-10-900. Fiscal policies and administration.

The Medicaid agency and, where applicable, local agencies administering the plan, maintains an accounting system and supporting fiscal records adequate to assure that claims for Federal funds are in accord with applicable Federal requirements. The requirements of 42 CFR 433.32 are met.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-83, eff. September 30, 1976.

12VAC30-10-910. Cost allocation.

There is an approved cost allocation plan on file with the Department in accordance with the requirements contained in 45 CFR 95, Subpart E.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-84, eff. October 1, 1982.

12VAC30-10-920. State financial participation.

A. State funds are used in both assistance and administration.

There is local participation. State funds are used to pay not less than 40 percent of the non-Federal share of the total expenditures under the plan. There is a method of apportioning Federal and State funds among the political subdivisions of the State on an equalization or other basis which assures that lack of adequate funds from local sources will not result in lowering the amount, duration, scope, or quality of care and services or level of administration under the plan in any part of the State.

B. State and Federal funds are apportioned among the political subdivisions of the State on a basis consistent with equitable treatment of individuals in similar circumstances throughout the State.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-85, eff. February 15, 1990.

12VAC30-10-930. Hospital credit balance reporting.

Hospitals shall be required to report Medicaid credit balances on a quarterly basis no later than 30 days after the close of each quarter. For a credit balance arising on a Medicaid claim within three years of the date paid by the DMAS, the hospital shall either submit a check for the balance due or an adjustment claim with the Credit Balance Report. For credit balances arising on claims over three years old, the hospital shall submit a check for the balance due. Interest at the maximum rate allowed shall be assessed for those credit balances (overpayments) that are identified on the quarterly report but not reimbursed with the submission of the form. Interest will begin to accrue 30 days after the end of the quarter and will continue to accrue until the overpayment has been refunded or adjusted. A penalty shall be imposed for failure to submit the form timely as follows:

1. Hospitals that have not submitted their Medicaid credit balance data within the required 30 days after the end of a quarter shall be notified in writing. If the required report is not submitted within the next 30 days, there will be a 20% reduction in the DMAS payment.

2. If the required report is not submitted within the next 30 days (60 days after the due date), the DMAS payments shall be reduced to -0- until the report is received.

3. If the credit balance has not been refunded within 90 days of the end of a quarter, it shall be recovered, with interest, through the use of a negative balance transaction on the weekly remittance.

4. A periodic audit shall be conducted of hospitals' quarterly submission of Medicaid credit balance data. Hospitals shall maintain an audit trail back to the underlying accounts receivable records supporting each quarterly report.

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-01-85.1, eff. October 1, 1994; amended, Virginia Register Volume 25, Issue 14, eff. April 15, 2009.

12VAC30-10-940. [Reserved]. (Reserved)

Part VII
General Provisions

12VAC30-10-960. Plan amendments.

The plan will be amended whenever necessary to reflect new or revised Federal statutes or regulations or material change in State law, organization, policy or State agency operation.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-86, eff. June 16, 1993.

12VAC30-10-970. Nondiscrimination.

In accordance with Title VI of the Civil Rights Act of 1964 (42 USC 2000d et. seq.), § 504 of the Rehabilitation Act of 1973 (29 USC 70b), and the regulations at 45 CFR 80 and 84, the Medicaid agency assures that no individual shall be subjected to discrimination under this plan on the grounds of race, color, national origin, or handicap.

The Medicaid agency has methods of administration to assure that each program or activity for which it receives Federal financial assistance will be operated in accordance with Title VI regulations. These methods for Title VI are described in 12VAC30-20-280.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-87, eff. June 16, 1993.

12VAC30-10-980. (Repealed.)

Historical Notes

Derived from VR460-01-88, eff. June 16, 1993; repealed, Virginia Register Volume 12, Issue 2, eff. November 15, 1995.

12VAC30-10-990. State Governor's review.

The Office of the Governor does not wish to review amendments, long-range program planning projections, and other periodic reports thereon, excluding periodic statistical, budget and fiscal reports and has designated the Secretary of Health and Human Resources to review Plan amendment material per Executive Order 31 (94).

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 CFR 430.12(b).

Historical Notes

Derived from VR460-01-89, eff. June 16, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995.

12VAC30-10-1000. General provider appeals.

These provisions shall apply to all provider types for informal and formal administrative appeals.

12VAC30-20-500 (Attachment 7.5) describes the process, procedures, and time frames for all provider informal and formal administrative appeals.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 17, Issue 19, eff. July 4, 2001.

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