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.
A. The Medicaid agency has a system of hearings that meets all the requirements of 42 CFR 431, Subpart E.
The Medicaid agency is responsible for all Medicaid fair hearings.
B. The entities that conduct fair hearings with respect to eligibility based on applicable modified adjusted gross income (MAGI) are the Department of Medical Assistance Services (DMAS) and the Health and Human Services appeals entity within the Exchange.
C. The Commonwealth assures the following with respect to delegations of authority to conduct fair hearings regarding eligibility based on MAGI:
1. There is a written agreement between DMAS and the Exchange appeals entity that has been delegated authority to conduct Medicaid fair hearings in compliance with 42 CFR 431.10(d).
2. When authority is delegated to the Exchange appeals entity, individuals who have requested a fair hearing are given the option to have their hearing conducted instead by DMAS.
3. DMAS does not delegate authority to conduct fair hearings to entities other than government agencies that maintain personnel standards on a merit basis.
4. The delegated entity is capable of performing the delegated function.
D. All fair hearings not related to an eligibility determination based on MAGI are conducted at DMAS.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Historical Notes
Derived from VR460-01-33, eff. November 5, 1990; amended, Virginia Register Volume 38, Issue 12, eff. March 17, 2022.
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.
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.