Part IV. Cost Sharing
12VAC30-141-160. Copayments for families not participating in FAMIS Select.
A. Copayments shall apply to all enrollees in an MCHIP.
B. These cost-sharing provisions shall be implemented with the following restrictions:
1. Total cost sharing for each 12-month eligibility period shall be limited to (i) for families with incomes equal to or less than 150% of federal poverty level (FPL), the lesser of (a) $180 and (b) 2.5% of the family's income for the year (or 12-month eligibility period); and (ii) for families with incomes greater than 150% of FPL, the lesser of $350 and 5.0% of the family's income for the year (or 12-month eligibility period).
2. DMAS or its designee shall ensure that the annual aggregate cost sharing for all FAMIS enrollees in a family does not exceed the aforementioned caps.
3. Families will be required to submit documentation to DMAS or its designee showing that their maximum copayment amounts are met for the year.
4. Once the cap is met, DMAS or its designee will issue a new eligibility card excluding such families from paying additional copays for the 12-month enrollment period.
C. Exceptions to the above cost-sharing provisions:
1. Copayments shall not be required for well child, well baby, and pregnancy-related services. This shall include:
a. All healthy newborn inpatient physician visits, including routine screening (inpatient or outpatient);
b. Routine physical examinations, laboratory tests, immunizations, and related office visits;
c. Routine preventive and diagnostic dental services (i.e., oral examinations, prophylaxis and topical fluoride applications, sealants, and x-rays);
d. Services to pregnant females related to the pregnancy; and
e. Other preventive services as defined by the department.
2. Enrollees are not held liable for any additional costs, beyond the standard copayment amount, for emergency services furnished outside of the individual's managed care network. Only one copayment charge will be imposed for a single office visit.
3. No cost sharing will be charged to American Indians and Alaska Natives.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC 1396 seq.
Historical Notes
Derived from Virginia Register Volume 19, Issue 21, eff. August 1, 2003; amended, Virginia Register Volume 22, Issue 26, eff. October 4, 2006; Volume 26, Issue 12, eff. July 1, 2010; Errata, 26:13 2238 VA.R. March 1, 2010; amended, Virginia Register Volume 35, Issue 20, eff. June 26, 2019.
12VAC30-141-170. (Repealed.)
Historical Notes
Derived from Virginia Register Volume 19, Issue 21, eff. August 1, 2003; repealed, Virginia Register Volume 22, Issue 26, eff. October 4, 2006.
12VAC30-141-175. FAMIS Select.
A. Enrollees in FAMIS may, but shall not be required to, enroll in a private or employer-sponsored health plan if DMAS or its designee determines that such enrollment is cost effective, as defined in this section.
B. Eligibility determination. FAMIS children may elect to receive coverage under a health plan purchased privately or through an employer and DMAS may elect to provide coverage by paying all or a portion of the premium if all of the following conditions are met:
1. The children are determined to be eligible for FAMIS;
2. The cost of coverage for the child under FAMIS Select is equal to or less than the Commonwealth's cost of obtaining coverage under FAMIS only for the eligible targeted low-income children involved. The cost-effectiveness determination methodology is described in subsection E of this section;
3. The policyholder agrees to assign rights to benefits under the private or employer-sponsored health plan to DMAS to assist the Commonwealth in pursuing these third-party payments for childhood immunizations. When a child is provided coverage under a private or employer-sponsored health plan, that plan becomes the payer for all other services covered under that plan; and
4. The policyholder is not under a court order to provide medical support for the applicant child.
C. DMAS will continually verify the child's or coverage under the private or employer-sponsored health plan and will redetermine the eligibility of the child for the FAMIS Select component when it receives information concerning an applicant's or enrollee's circumstances that may affect eligibility.
D. Application requirements.
1. DMAS shall furnish the following information in written form and orally, as appropriate, to the families of FAMIS children who have indicated an interest in FAMIS Select:
a. The eligibility requirements for FAMIS Select;
b. A description of how the program operates, the amount of premium assistance available, and how children can move from FAMIS Select into FAMIS if requested;
c. A summary of the covered benefits and cost-sharing requirements available through FAMIS;
d. A guide to help families make an informed choice by comparing the FAMIS plan to their private or employer-sponsored health plan. Such guide shall include a notice to the effect that children covered by FAMIS Select will not receive FAMIS-covered services, but only those health services covered by their private or employer-sponsored health plan, and that the FAMIS Select enrollee shall be responsible for any and all costs associated with their chosen health plan;
e. Information on coverage for childhood immunizations through FAMIS; and
f. The rights and responsibilities of applicants and enrollees.
2. DMAS will provide interested families with applications for FAMIS Select.
3. An electronic or written application for the FAMIS Select component shall be required from interested families.
4. DMAS shall determine eligibility for the FAMIS Select component promptly, within 45 calendar days from the date of receiving an application that contains all information and verifications necessary to determine eligibility, except in unusual circumstances beyond the agency's control. Actual enrollment into the FAMIS Select component may not occur for extended periods of time, depending on the ability of the family to enroll in the employer's plan.
5. Incomplete FAMIS Select applications shall be held for a period of 30 calendar days to enable applicants to provide outstanding information needed for a FAMIS Select eligibility determination. Any applicant who, within 30 calendar days of the receipt of the initial application, fails to provide information or verifications necessary to determine FAMIS Select eligibility shall have his application denied.
6. DMAS must send each applicant a written notice of the agency's decision on his application for FAMIS Select and, if approved, his obligations under the program. If eligibility is denied, notice will be given concerning the reasons for the denial.
E. Cost effectiveness. DMAS may elect to provide coverage to FAMIS children by paying all or a portion of the family's private or employer-sponsored health insurance premium if the cost of such premium assistance under FAMIS Select is equal to or less than the Commonwealth's cost of obtaining coverage under FAMIS only for the eligible, targeted, low-income child involved. Providing premium assistance for the FAMIS-eligible children may result in the coverage of an adult or other relative or dependent; however, this coverage shall be solely incidental to covering the FAMIS child.
1. To ensure that the FAMIS Select program remains cost effective, DMAS will establish a fixed premium assistance amount per child that will be paid to a family choosing to enroll their FAMIS-eligible child in FAMIS Select. The fixed premium assistance amount will be determined annually by:
a. Determining the cost of covering a child under FAMIS. The cost will be determined by using the capitated payment rate paid to MCHIPs, or an average cost amount developed by DMAS;
b. Determining the administrative costs associated with the FAMIS Select program; and
c. Establishing a fixed premium assistance amount that includes administrative costs and is less than or equal to the cost of covering the FAMIS child under FAMIS.
DMAS will ensure that the total of the fixed premium assistance amounts for all the FAMIS-eligible children per family do not exceed the total cost of the family's health insurance premium payment for the private or employer-sponsored health plan. If the total fixed premium assistance amounts do exceed the family's premium payment, then the family premium assistance will be reduced by an amount necessary to ensure the premium assistance payment is less than or equal to the family's premium payment.
F. Enrollment and disenrollment.
1. FAMIS children applying for FAMIS Select will receive coverage under FAMIS until their eligibility for coverage under the FAMIS Select component is established and until they are able to enroll in the private or employer-sponsored health plan.
2. The timing and procedures employed to transfer FAMIS children's coverage to the FAMIS Select component will be coordinated between DMAS and the agency managing the case to ensure continuation of coverage.
3. Participation by families in the FAMIS Select component shall be voluntary. Families may disenroll their child from the FAMIS Select component as long as the proper timing and procedures established by DMAS are followed to ensure continued health coverage.
G. Premium assistance. When a child is determined eligible for coverage under the FAMIS Select component, premium assistance payments shall become effective the month in which the FAMIS child is enrolled in the employer's plan. Payment of premium assistance shall end:
1. On the last day of the month in which FAMIS eligibility ends;
2. The last day of the month in which the child loses eligibility for coverage under the private or employer-sponsored health plan;
3. The last day of the month in which the family notifies DMAS that it wishes to disenroll its child from the FAMIS Select component; or
4. On the next business day following a request by the family to immediately transfer the child from FAMIS Select into the FAMIS program. The request must include notification that the child's private or employer-sponsored health plan has been terminated as of the date of transfer and an agreement by the family to return to DMAS the premium assistance payment prorated for that portion of the month in which the child was not enrolled in the private or employer-sponsored health plan.
H. Supplemental health benefits coverage will be provided to ensure that FAMIS children enrolled in the FAMIS Select component receive all childhood immunizations available under the FAMIS benefits. FAMIS children can obtain these supplemental benefits through Medicaid providers.
I. Cost sharing. FAMIS Select families will be responsible for all copayments, deductibles, coinsurance, fees, or other cost-sharing requirements of the private or employer-sponsored health plan in which they enroll their children. There is no Title XXI family cost-sharing cap applied to families with children enrolled in FAMIS Select.
There is no copayment required for the supplemental immunization benefits provided through FAMIS.
Statutory Authority
§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Historical Notes
Derived from Virginia Register Volume 22, Issue 26, eff. October 4, 2006; amended, Virginia Register Volume 35, Issue 20, eff. June 26, 2019.
12VAC30-141-180. Liability for excess benefits; liability for excess benefits or payments obtained without intent; recovery of FAMIS payments.
A. Any person who, without the intent to violate this section, obtains benefits or payments under FAMIS to which he is not entitled shall be liable for any excess benefits or payments received. If the enrollee knew or reasonably should have known that he was not entitled to the excess benefits, he may also be liable for interest on the amount of the excess benefits or payments at the judgment rate as defined in § 6.1-330.54 of the Code of Virginia from the date upon which excess benefits or payments to the date on which repayment is made to the Commonwealth. No person shall be liable for payment of interest, however, when excess benefits or payments were obtained as a result of errors made solely by DMAS or its designee.
B. Any payment erroneously made on behalf of a FAMIS enrollee or former enrollee may be recovered by DMAS from the enrollee or the enrollee's income, assets, or estate unless state or federal law or regulation otherwise exempts such property.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of Virginia.
Historical Notes
Derived from Virginia Register Volume 19, Issue 21, eff. August 1, 2003; amended, Virginia Register Volume 23, Issue 7, eff. January 10, 2007.
12VAC30-141-190. [Reserved].
Historical Notes
Derived from Virginia Register Volume 19, Issue 21, eff. August 1, 2003.