Administrative Code

Virginia Administrative Code
10/22/2021

Part III. HIV Premium Assistance Program

12VAC30-100-250. Definitions.

"Appeal" means the process by which an applicant or enrollee in the HIV Premium Assistance Program can obtain a review of a decision, action, or failure to act on the part of the program.

"Applicant" means an individual who has applied for or is in the process of applying for HIV Premium Assistance Program benefits.

"Applicant's representative" means a person who, because of the applicant's or enrollee's mental or physical incapacity or standing as a child, is permitted to act, complete, sign, or withdraw an application for the benefits of the program; activate the appeal process; and otherwise supply any information requested by the program on behalf of the applicant or enrollee.

"Child" means an unmarried person younger than 18 years of age and who lives with a parent or legal guardian.

"Date of application" means the date that an application is officially received by the program.

"Department" or "DMAS" means the Virginia Department of Medical Assistance Services which has administrative authority and responsibility for the program.

"Enrollee" means an individual who has been determined to be eligible for and is receiving assistance from the program.

"Family" means:

1. The applicant or enrollee,

2. The applicant or enrollee's spouse,

3. The applicant's or enrollee's children who are under 21 years if the children live with the applicant,

4. When the applicant or enrollee is a child:

a. The applicant's parent or parents,

b. The minor applicant's unmarried siblings under 21 years, at the option of the applicant's or enrollee's parents.

"Group health insurance plan" means a plan which meets § 5000(b)(1) of the Internal Revenue Code of 1986, as amended, includes continuation coverage pursuant to Title XXII of the Public Health Services Act, § 4980B of the Internal Revenue Code of 1986, or Title VI of the Employee Retirement Income Security Act of 1974, and is consistent with the provisions of the Consolidated Omnibus Budget Reconciliation Act of 1985, Public Law 99-272 and any subsequent modifications to the Act. Section 5000(b)(1) of the Internal Revenue Code provides that a group health plan is any plan of, or contributed to by, an employer (including a self-insured plan) to provide health care (directly or otherwise) to the employer's employees, former employees, or the families of such employees or former employees.

"Health insurance premiums" or "premiums" means the health insurance premiums paid by or on behalf of an individual in order to obtain or maintain health insurance plan benefits.

"HIV positive" means a positive diagnosis of infection with the human immune deficiency virus (HIV) as determined by the enzyme-linked immunosorbent assay (ELISA) and confirmed by the Western Blot, or another generally accepted diagnostic test for HIV infection.

"HIV Premium Assistance Program" or "the program" means the Virginia program that provides payment of health insurance premiums under certain circumstances to individuals who are HIV positive, in accordance with the provision of the Consolidated Omnibus Budget Reconciliation Act of 1985, Public Law 99-272 and any subsequent modifications to the Act and as authorized by § 32.1-330.1 of the Code of Virginia.

"Medicaid" means the state-federal medical assistance program of comprehensive medical and other health-related care for indigent and medically indigent persons authorized by Title XIX of the Social Security Act and administered by the Virginia Department of Medical Assistance Services.

"Nongroup health insurance plan" means a health insurance plan that is offered to an individual or an individual family unit without being tied to an employer.

"Physician verification" means certification by a licensed physician of medical information regarding an applicant's or enrollee's HIV positive status and inability to work due to the disease or the substantial likelihood that within three months the individual will be too ill to continue working.

"Poverty level" means the official federal poverty income level, as revised annually.

Statutory Authority

§§ 32.1-325 and 32.1-330.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 15, eff. June 1, 1997.

12VAC30-100-260. Eligibility requirements.

An applicant will be determined to be eligible for the HIV Premium Assistance Program if the individual:

1. Is a Virginia resident at the time of application and is:

a. A citizen of the United States;

b. An alien lawfully admitted for permanent residence or otherwise permanently residing in the United States under color of law, including an alien who is lawfully present in the United States pursuant to 8 USC § 1101 et seq.; or

c. An alien lawfully admitted under authority of the Indochina Migration and Refugee Assistance Act of 1975, 22 USC § 2601 et seq.;

2. Is certified by a licensed physician to be HIV positive;

3. Is certified by a licensed physician to be unable to work or to have a substantial likelihood of being unable to work within three months of the date of the physician's certification due to the HIV infection;

4. Is eligible for continuation of group health insurance plan benefits through the employer and the provisions of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, or for continuation of benefits under any type of health insurance plan unless DMAS has reason to believe it is not cost effective;

5. Has applicant and spouse income no greater than 250% of the poverty level;

6. Has countable liquid assets no more than $10,000 in value; and

7. Is not eligible for Medicaid.

Statutory Authority

§§ 32.1-325 and 32.1-330.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 15, eff. June 1, 1997; amended, Virginia Register Volume 16, Issue 18, eff. July 1, 2000; Volume 32, Issue 1, eff. October 22, 2015.

12VAC30-100-270. Determination of countable income and liquid assets.

When determining eligibility for the HIV Premium Assistance Program, the countable income and assets of each applicant shall be determined as follows:

1. Income shall include total projected applicant and spouse income for the year beginning with the month of application to the program, including but not limited to:

a. Wages;

b. Commissions and fees;

c. Salaries and tips;

d. Profit from self-employment;

e. Dividends or interest income;

f. Disability benefits;

g. Unemployment;

h. Pension or retirement.

2. Countable liquid assets shall include assets available as of the date of the application which are convertible to cash. The following liquid assets shall be counted when determining eligibility:

a. Savings accounts;

b. Checking accounts;

c. Money market certificates;

d. Certificates of deposit;

e. Mutual funds;

f. Stocks and bonds; or

g. All other liquid assets as provided in § 6.2-1100 of the Code of Virginia.

Statutory Authority

§§ 32.1-325 and 32.1-330.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 15, eff. June 1, 1997; amended, Virginia Register Volume 32, Issue 1, eff. October 22, 2015.

12VAC30-100-280. Program application and enrollment.

A. Any person requesting participation in the program shall be given the opportunity to file an application and, if determined eligible by the program, shall be enrolled in accordance with the provisions of this part within established funding constraints.

B. An applicant or applicant's representative shall complete an application on the form designated by the program. The program may request additional documentation for eligibility determination purposes as it deems necessary.

C. An unmarried child younger than 18 years old shall have a representative complete and sign the application.

D. Applications shall conform with the requirements of this part and those set forth by the program. Applicants shall be determined ineligible without prejudice when they fail to provide information sufficient for the determination of eligibility.

E. An applicant or applicant's representative shall sign a statement authorizing the program to verify from any source, including banks and public or private agencies providing monetary benefits, qualifying information submitted to the program as part of the application process. Refusal to sign an authorization shall be considered failure to provide sufficient information, and applicants shall be determined ineligible in accordance with the provisions of this policy.

F. Eligibility determination shall be made promptly, not later than 30 days from the date of receipt of the completed application by the program.

G. An applicant or applicant's representative may voluntarily withdraw the application at any time without prejudice.

H. An individual previously determined ineligible for program benefits may submit a new application at any time.

I. Program enrollment shall be effective on the day eligibility is approved. Premium payments for health insurance coverage beginning on the first day of the month following eligibility shall start as long as there is available funding.

Statutory Authority

§§ 32.1-325 and 32.1-330.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 15, eff. June 1, 1997.

12VAC30-100-290. Changes in eligibility.

A. The program will promptly redetermine eligibility when it receives information concerning an enrollee's circumstances that may affect eligibility.

B. The enrollee or representative shall notify the program within 10 working days of any changes in circumstances which would affect continuing eligibility, including but not limited to:

1. Sale, transfer or change of the value of assets;

2. Change in income;

3. Change in name or address;

4. Change in COBRA eligibility.

C. If any changes in status result in an enrollee no longer qualifying for the program, the enrollee shall be considered ineligible for program benefits and enrollment shall be canceled. The cancellation shall be effective on the last day of the month in which notice has been given consistent with 12VAC30-100-320. The program shall notify the enrollee of its determination in writing, and inform the enrollee of any legal rights to appeal the decision pursuant to the notification requirements of this policy.

D. Failure to make such required notification may be considered to be fraudulent and may be addressed pursuant to the department's fraud prevention and control policies (12VAC30-100-360).

Statutory Authority

§§ 32.1-325 and 32.1-330.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 15, eff. June 1, 1997.

12VAC30-100-300. Enrollee openings.

A. The number of enrollees in the program shall be limited to the number that can be covered by the program's available funding as reflected in available openings. DMAS shall project the expenditures for the current and expected enrollees and funding levels for the program to determine the number of available enrollee openings.

B. Initial available openings in the program shall be filled based on the applicant's date of completed application. In the event that more than one application is received on any one day, applicants shall be considered based on the order of the day and month of the applicant's birth, with January being month one.

C. Should the number of applications exceed available funding at any time, a waiting list shall be maintained by the program of applicants who are determined to be eligible for the program but for whom openings are not available when the eligibility determinations are made.

1. Available openings shall be filled from the waiting list on a first come, first served basis, using the same criteria defined in 12VAC30-100-300.

2. If an opening becomes available, the applicant shall be notified in writing by the program. The applicant must provide any necessary information to the program to verify that he is still eligible within 10 days of receiving such notification. The 10-day period may be extended by the program for just cause. If determined to be still eligible, the applicant shall be enrolled.

3. At the end of three months from the date of application, and every three months thereafter, if an opening has not yet become available, each applicant may be contacted by DMAS to verify the applicant's interest in remaining on the waiting list. At these contacts, applicants may be requested to inform the program of changes in the contents of their applications. At such time as funding becomes available for waiting list applicants, DMAS shall reexamine the applications for program qualifications.

Statutory Authority

§§ 32.1-325 and 32.1-330.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 15, eff. June 1, 1997.

12VAC30-100-310. Authorization for benefits.

Authorization for benefits under this program shall be granted until program termination, unless the recipient's status changes so that he no longer meets the eligibility criteria.

Statutory Authority

§§ 32.1-325 and 32.1-330.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 15, eff. June 1, 1997.

12VAC30-100-320. Notification.

The program shall inform an applicant, enrollee, or the individual's representative of the individual's legal rights and obligations and give written notice of the following:

1. The final determination on an application, which shall include the reason or reasons if an applicant is found ineligible;

2. The imminent expiration of program authority and funding;

3. A notice of action to deny, cancel, or suspend program benefits which shall:

a. Include a statement of the proposed action, the reason for the action, and the statutory or regulatory authority for the action;

b. Include notification of the right to appeal the action;

c. Be mailed at least 15 calendar days before the effective date of the action.

Statutory Authority

§§ 32.1-325 and 32.1-330.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 15, eff. June 1, 1997; amended, Virginia Register Volume 32, Issue 1, eff. October 22, 2015.

12VAC30-100-330. Appeals.

A. An applicant, enrollee, or representative who is dissatisfied with a decision, action, or inaction of the program may request and shall be granted an opportunity to appeal, as provided for under the department's Client Appeals Regulations (12VAC30-110-10 through 12VAC30-110-380).

B. The applicant or enrollee shall request in writing reconsideration from the HIV Premium Assistance Program within 15 days of the denial notice. DMAS will respond within five days to this request for reconsideration. If the applicant or enrollee still disagrees with DMAS' decision, he shall have the right to file an appeal in accordance with the department's Client Appeals Regulations.

C. An enrollee shall be notified in writing by the program that the program shall be responsible for the payment of health insurance premiums until the appeal process is concluded. If the appeal results in the enrollee being found ineligible for the program, the program shall seek recovery in accordance with the department's recovery policies.

D. If an applicant is found eligible for the program as a result of an appeal, the program shall reimburse the applicant directly for premiums which were paid, beginning with a premium payment for the month following the decision that was the subject of appeal. The applicant shall provide proof of payment of premiums.

E. Cases on appeal which are in current payment status shall be considered filled enrollee openings until the appeal process has been completed.

Statutory Authority

§§ 32.1-325 and 32.1-330.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 15, eff. June 1, 1997.

12VAC30-100-340. Health insurance premium payments.

A. Premium payments shall be made to the employer, the insurer, or the enrollee, according to procedures established by the program.

B. Applicants and enrollees shall provide information as may be necessary for the payment of health insurance premiums by the program, including but not limited to the name and address of the employer or health insurance company, the last day of employment, the type of policy, the amount of the premium, and the date by which the premium must be paid.

C. Payments under this program are limited to the cost of the health insurance premium currently in effect and shall not include copayments, deductibles, or any other costs incurred by the enrollees. Payments under this program shall include coverage of family members if the enrollee's policy is the sole source of health insurance.

Statutory Authority

§§ 32.1-325 and 32.1-330.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 15, eff. June 1, 1997; amended, Virginia Register Volume 32, Issue 1, eff. October 22, 2015.

12VAC30-100-350. Recovery.

In all cases in which program benefits have been incorrectly paid or paid during an appeal in which the program action was upheld, the program shall seek recovery from the payee, according to the department's recovery policies.

Statutory Authority

§§ 32.1-325 and 32.1-330.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 15, eff. June 1, 1997.

12VAC30-100-360. Fraud.

Cases of suspected misrepresentation or fraud shall be investigated according to the department's fraud prevention and control policies and any other applicable statutory provision.

Statutory Authority

§§ 32.1-325 and 32.1-330.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 15, eff. June 1, 1997.

12VAC30-100-370. Confidentiality.

All information maintained by the program containing personal data including name, address, employer, insurance company, HIV status, application to or enrollment in the program, and any other information which could identify or reasonably be used to identify any applicant or enrollee in the program shall be maintained in confidence according to all applicable DMAS policies and procedures and any other applicable laws or regulations. Such information shall not be disclosed to any individual or organization without the written and dated consent of the applicant, enrollee, or representative.

Statutory Authority

§§ 32.1-325 and 32.1-330.1 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 13, Issue 15, eff. June 1, 1997.

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