TITLE 12. HEALTH
Title of Regulation: 12VAC30-120. Waivered Services (amending 12VAC30-120-370, 12VAC30-120-380).
Statutory Authority: §§32.1-324 and 32.1-325 of the Code of Virginia.
Public Hearing Information: No public hearings are scheduled.
Public Comments: Public comments may be submitted until November 14, 2008.
Agency Contact: Adrienne Fegans, Program Operations Administrator, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 786-4112, FAX (804) 786-1680, or email adrienne.fegans@dmas.virginia.gov.
Basis: Section 32.1-325 of the Code of Virginia grants to the Board of Medical Assistance Services the authority to administer and amend the Plan for Medical Assistance. Section 32.1-324 of the Code of Virginia authorizes the Director of DMAS to administer and amend the Plan for Medical Assistance according to the board's requirements. The Medicaid authority as established by §1902 (a) of the Social Security Act (42 USC §1396a) provides governing authority for payments for services.
The legislation (Chapter 3, 2006 Acts of Assembly, Special Session I) directed DMAS, in consultation with the appropriate stakeholders, to develop a long-range blueprint for the development and implementation of an integrated acute and long-term care system. In addition to this plan, the department was directed to move forward with two different models for the integration of acute and long-term care services: a community model (Chapter 847 Item 302, AAA) and the regional model (Item 302, BBB). Item 302 M.1 and M.2 of the 2006 Acts of Assembly provided DMAS with the authority to seek federal approval of these changes to its MEDALLION and Medallion II waivers.
Purpose: In order to best protect the health, safety, and welfare of the persons who qualify for home and community-based care services, DMAS is proposing that they retain their enrollment in their managed care organizations once approved for waiver services rather than being required to seek needed acute care services from the fee-for-service program. This change will sustain already established physician-patient relationships for these often fragile Medicaid recipients.
The goals of this action are to (i) better support these affected often fragile Medicaid recipients in their receipt of acute care services, once they qualify for waiver services and (ii) begin the process of integrating acute and long-term care services as mandated to the department.
Substance: Managed care systems (MCOs) were introduced in the Commonwealth in 1996. Currently, 114 localities are served by MCOs, with their approved provider networks that provide services to 400,783 Medicaid recipients. DMAS expends $1.17 billion on capitation rates for the seven MCOs that operate in the Commonwealth. The recipients who live in localities of the Commonwealth that are not served by MCOs obtain their acute medical care from individual fee-for-service providers. Presently, when a recipient who has been in managed care qualifies for waiver services, this individual is disenrolled from his MCO thereby requiring that he obtain his acute care services from individual fee-for-service providers. This has disrupted long-standing physician-patient relationships and forced vulnerable Medicaid recipients to negotiate a complex, unmanaged health care system on their own.
Governor Timothy Kaine, with support from the 2006 General Assembly, set in motion a major reform of the Virginia Medicaid funded long-term care services program to focus on care coordination and integration of acute and long-term care services for our most vulnerable citizens—low-income seniors and individuals with disabilities. The legislation (Chapter 3, 2006 Acts of Assembly, Special Session I) directed DMAS, in consultation with the appropriate stakeholders, to develop a long-range blueprint for the development and implementation of an integrated acute and long-term care system. In addition to this plan, the department was directed to move forward with two different models for the integration of acute and long-term care services: a community model and a regional model.
The proposed change will permit managed care enrolled persons to remain in their MCOs while receiving their waiver services. Excluded from this proposed program change are those persons who qualify for the Technology Assisted Waiver, nursing facility residents and persons classified as dual eligibles (Medicare-Medicaid eligibles).
The home and community-based waiver population is currently excluded from participation in the managed care program. This policy derives from years of federal policy that precluded recipients from participating in more than one waiver program at a time. In light of the ever-increasing nationwide aging population, more federal policy options are available to the states than ever before.
This regulatory change will expand managed care operations over previously "unmanaged" populations and also integrate acute and long-term care by increasing care coordination for the elderly and certain persons with disabilities. This program change will prevent enrollees, when they are approved for CBC waiver services, from having to change their current managed care organization for their acute medical care, therefore eliminating any disruptions in care (loss of established provider relationships). Key provisions allow for MCO enrollees who are newly enrolled into the HIV-AIDS, IFDDS, MR, EDCD, Day Support, and Alzheimer’s Waiver programs to continue enrollment in one of the contracted MCOs for their acute care medical needs.
Issues: There are no disadvantages to the public for these proposed regulations. The advantages to the public and the Commonwealth are that reductions in Medicaid expenditures may be realized for the coordination of services previously provided in an unmanaged care environment. Medicaid recipients will still have ready access to medical and long-term care providers and services.
The degree of chronic illness and disability among seniors and individuals with disabilities is a key policy and budget issue for the Commonwealth as well as nationwide with the graying of the general population. Seniors and individuals with disabilities make up 30% of the Medicaid population in the state, but 70% of the costs of a budget that now exceeds $5 billion annually. The Commonwealth’s challenge is curbing Medicaid growth in the long run without compromising access to services for vulnerable populations. While Virginia has been successful in implementing managed care for low-income children and families, it has not yet applied the same successful principles to programs specifically designed for the long-term care populations. Currently in Virginia, most Medicaid seniors and individuals with disabilities receive acute and long-term care services through a patchwork of fragmented health and social programs that are not necessarily responsive to individual consumer needs. Acute care for these often fragile individuals is provided in a fee-for-service environment with little chronic care management. Long-term care is provided in a nursing facility or by a variety of home and community-based care providers with little overall care coordination or case management. In addition, many Medicaid seniors and individuals with disabilities qualify for both Medicare and Medicaid, which further complicates the access, quality, and funding of an integrated system.
This regulatory change responds to the need to expand managed care operations over "unmanaged" populations and also integrate acute and long-term care by improving the current system and increasing care coordination for the elderly and disabled population.
The Department of Planning and Budget's Economic Impact Analysis:
Summary of the Proposed Amendments to Regulation. The proposed changes allow Medicaid recipients to retain their enrollment in managed care organizations and access needed acute care services through their managed care organization when they qualify for certain waivers. The proposed changes have been mandated by the 2006 Acts of Assembly and have been in effect since September 2007 under emergency regulations.
Result of Analysis. The benefits likely exceed the costs for all proposed changes.
Estimated Economic Impact. The main goal of the proposed regulations is to prevent disruption of a recipient’s relationship with his/her managed care organization when they become eligible for certain waivers1. The proposed changes have been mandated by the 2006 Acts of Assembly2 and have been in effect since September 2007 under emergency regulations.
Prior to the emergency regulations, when a managed care recipient enrolled in certain community-based care waivers, they were required to disenroll from their managed care organization and were provided acute care services through the fee-for-service delivery model. With the proposed changes, when a managed care recipient enrolls in the certain community-based care waivers, their acute care services will be provided through the managed care service delivery model rather than the fee-for-service delivery model, and they will not be required to drop their enrollment in the managed care organization.
The main fiscal effect of the proposed changes would be the cost difference of providing acute care services to approximately 500 individuals under fee-for-service delivery model versus delivering the same services under managed care model. Department of Medical Services (DMAS) estimates that fee-for-service payments would be about the same as managed care payments to provide acute care services rendering the proposed changes budget neutral.
A significant benefit of the proposed changes is preventing the interruption of the relationship between the managed care provider and the recipient. Prior to the emergency regulations, the recipient were required to disenroll from his/her managed care organization and receive services under unmanaged fee-for-service delivery model. Since managed care organizations have access to an individuals’ health history and have case management resources already in place, uninterrupted relationship is expected to produce better health outcomes and prevent otherwise likely health care costs.
Businesses and Entities Affected. The proposed regulations are expected to primarily affect approximately 500 recipients and seven managed care organizations.
Localities Particularly Affected. The proposed changes are statewide. However, the effects of the proposed changes are likely to occur in areas where managed care is available. According to DMAS, 114 localities are currently served by managed care organizations.
Projected Impact on Employment. The proposed changes are not expected to create any significant effect on employment.
Effects on the Use and Value of Private Property. The proposed changes are not expected to create any significant effect on the use and value of private property.
Small Businesses: Costs and Other Effects. The proposed changes are not expected to impose any significant costs or other affects on small businesses.
Small Businesses: Alternative Method that Minimizes Adverse Impact. No effect on small businesses is anticipated.
Real Estate Development Costs. No effect on real estate development costs is anticipated.
Legal Mandate. The Department of Planning and Budget (DPB) has analyzed the economic impact of this proposed regulation in accordance with § 2.2-4007.04 of the Administrative Process Act and Executive Order Number 36 (06). Section 2.2-4007.04 requires that such economic impact analyses include, but need not be limited to, the projected number of businesses or other entities to whom the regulation would apply, the identity of any localities and types of businesses or other entities particularly affected, the projected number of persons and employment positions to be affected, the projected costs to affected businesses or entities to implement or comply with the regulation, and the impact on the use and value of private property. Further, if the proposed regulation has adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include (i) an identification and estimate of the number of small businesses subject to the regulation; (ii) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the regulation, including the type of professional skills necessary for preparing required reports and other documents; (iii) a statement of the probable effect of the regulation on affected small businesses; and (iv) a description of any less intrusive or less costly alternative methods of achieving the purpose of the regulation. The analysis presented above represents DPB’s best estimate of these economic impacts.
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2 Chapter 847, Item 302, AAA, BBB, M.1, M.2.
Agency's Response to the Department of Planning and Budget's Economic Impact Analysis: The Department of Medical Assistance Services concurs with the economic impact analysis prepared by the Virginia Department of Planning and Budget regarding the regulations concerning Acute Long Term Care (12VAC 30-120-370; 12VAC 30-120-380).
Summary:
This proposed change, generally referred to as Phase I of the Integration of Acute and Long-Term Care, will permit persons who become newly enrolled home-based and commnity-based care (CBC) waiver recipients (HIV-AIDS, Individual and Family Developmental Disabilities Support (IFDDS), Mental Retardation (MR), Elderly or Disabled with Consumer Direction (EDCD), Day Support, and Alzheimer’s Waiver programs) to retain their enrollment in their managed care organization for purposes of obtaining needed acute medical care. Excluded from this change will be persons newly admitted to the Technology Assisted waiver, to nursing facilities, and those persons who become dual eligibles (eligible for both Medicare and Medicaid). Prior to the agency’s current emergency regulation, these persons have been disenrolled from their managed care organization (once they qualify for certain CBC waivers) and have been required to seek needed acute care services in the unmanaged fee-for-service environment. The persons who will be affected by this change will have their home-based and community-based waiver services, including necessary transportation to waiver services, reimbursed by the Department of Medical Assistance Services (DMAS) through a fee-for-service mechanism. The managed care organizations will be financially responsible for these affected persons’ acute medical care.
12VAC30-120-370. Medallion II enrollees.
A. DMAS shall determine enrollment in Medallion II. Enrollment in Medallion II is not a guarantee of continuing eligibility for services and benefits under the Virginia Medical Assistance Services Program. DMAS reserves the right to exclude from participation in the Medallion II managed care program any recipient who has been consistently noncompliant with the policies and procedures of managed care or who is threatening to providers, MCOs, or DMAS. There must be sufficient documentation from various providers, the MCO, and DMAS of these noncompliance issues and any attempts at resolution. Recipients excluded from Medallion II through this provision may appeal the decision to DMAS.
B. The following individuals shall be excluded (as defined in 12VAC30-120-360) from participating in Medallion II. Individuals not meeting the exclusion criteria must participate in the Medallion II program.
1. Individuals who are inpatients in state mental hospitals;
2. Individuals who are approved by DMAS as inpatients in long-stay hospitals, nursing facilities, or intermediate care facilities for the mentally retarded;
3. Individuals who are placed on spend-down;
4. Individuals who are participating in the family planning waiver, and or in federal waiver programs for home-based and community-based Medicaid coverage prior to managed care enrollment;
5. Individuals who are participating in foster care or subsidized adoption programs;
6. Individuals under age 21 who are enrolled in DMAS authorized residential treatment or treatment foster care programs;
7. Newly eligible individuals who are in the third trimester of pregnancy and who request exclusion within a department-specified timeframe of the effective date of their MCO enrollment. Exclusion may be granted only if the member's obstetrical provider (physician or hospital) does not participate with the enrollee's assigned MCO. Exclusion requests made during the third trimester may be made by the recipient, MCO, or provider. DMAS shall determine if the request meets the criteria for exclusion. Following the end of the pregnancy, these individuals shall be required to enroll to the extent they remain eligible for Medicaid;
8. Individuals, other than students, who permanently live outside their area of residence for greater than 60 consecutive days except those individuals placed there for medically necessary services funded by the MCO;
9. Individuals who receive hospice services in accordance with DMAS criteria;
10. Individuals with other comprehensive group or individual health insurance coverage, including Medicare, insurance provided to military dependents, and any other insurance purchased through the Health Insurance Premium Payment Program (HIPP);
11. Individuals requesting exclusion who are inpatients in hospitals, other than those listed in subdivisions 1 and 2 of this subsection, at the scheduled time of enrollment or who are scheduled for inpatient hospital stay or surgery within 30 calendar days of the enrollment effective date. The exclusion shall remain effective until the first day of the month following discharge;
12. Individuals who request exclusion during preassignment to an MCO or within a time set by DMAS from the effective date of their MCO enrollment, who have been diagnosed with a terminal condition and who have a life expectancy of six months or less. The client's physician must certify the life expectancy;
13. Certain individuals between birth and age three certified by the Department of Mental Health, Mental Retardation and Substance Abuse Services as eligible for services pursuant to Part C of the Individuals with Disabilities Education Act (20 USC §1471 et seq.) who are granted an exception by DMAS to the mandatory Medallion II enrollment;
14. Individuals who have an eligibility period that is less than three months;
15. Individuals who are enrolled in the Commonwealth's Title XXI SCHIP program;
16. Individuals who have an eligibility period that is only retroactive; and
17. Children enrolled in the Virginia Birth-Related Neurological Injury Compensation Program established pursuant to Chapter 50 (§38.2-5000 et seq.) of Title 38.2 of the Code of Virginia.
C. Individuals enrolled with a MCO that subsequently meet one or more of the aforementioned criteria during MCO enrollment shall be excluded from MCO participation as determined by DMAS, with the exception of those who subsequently become recipients in the federal long-term care waiver programs, as otherwise defined elsewhere in this chapter, for home-based and community-based Medicaid coverage (AIDS, IFDDS, MR, EDCD, Day Support, or Alzheimers, or as may be amended from time to time). These individuals shall receive acute and primary medical services via the MCO and shall receive waiver services and related transportation to waiver services via the fee-for-service program.
Individuals excluded from mandatory managed care enrollment shall receive Medicaid services under the current fee-for-service system. When enrollees no longer meet the criteria for exclusion, they shall be required to enroll in the appropriate managed care program.
D. Medallion II managed care plans shall be offered to recipients, and recipients shall be enrolled in those plans, exclusively through an independent enrollment broker under contract to DMAS.
D. E. Clients shall be enrolled as follows:
1. All eligible persons, except those meeting one of the exclusions of subsection B of this section, shall be enrolled in Medallion II.
2. Clients shall receive a Medicaid card from DMAS, and shall be provided authorized medical care in accordance with DMAS' procedures after Medicaid eligibility has been determined to exist.
3. Once individuals are enrolled in Medicaid, they will receive a letter indicating that they may select one of the contracted MCOs. These letters shall indicate a preassigned MCO, determined as provided in subsection E F of this section, in which the client will be enrolled if he does not make a selection within a period specified by DMAS of not less than 30 days.
4. Any newborn whose mother is enrolled with an MCO at the time of birth shall be considered an enrollee of that same MCO for the newborn enrollment period. This requirement does not preclude the enrollee, once he is assigned a Medicaid identification number, from disenrolling from one MCO to another in accordance with subdivision F G 1 of this section.
The newborn's continued enrollment with the MCO is not contingent upon the mother's enrollment. Additionally, if the MCO's contract is terminated in whole or in part, the MCO shall continue newborn coverage if the child is born while the contract is active, until the newborn receives a Medicaid number or for the newborn enrollment period, whichever timeframe is earlier. Infants who do not receive a Medicaid identification number prior to the end of the newborn enrollment period will be disenrolled. Newborns who remain eligible for participation in Medallion II will be reenrolled in an MCO through the preassignment process upon receiving a Medicaid identification number.
5. Individuals who lose then regain eligibility for Medallion II within 60 days will be reenrolled into their previous MCO without going through preassignment and selection.
E. F. Clients who do not select an MCO as described in subdivision D E 3 of this section shall be assigned to an MCO as follows:
1. Clients are assigned through a system algorithm based upon the client's history with a contracted MCO.
2. Clients not assigned pursuant to subdivision 1 of this subsection shall be assigned to the MCO of another family member, if applicable.
3. All other clients shall be assigned to an MCO on a basis of approximately equal number by MCO in each locality.
4. In areas where there is only one contracted MCO, recipients have a choice of enrolling with the contracted MCO or the PCCM program. All eligible recipients in areas where one contracted MCO exists, however, are automatically assigned to the contracted MCO. Individuals are allowed 90 days after the effective date of new or initial enrollment to change from either the contracted MCO to the PCCM program or vice versa.
5. DMAS shall have the discretion to utilize an alternate strategy for enrollment or transition of enrollment from the method described in this section for expansions to new client populations, new geographical areas, expansion through procurement, or any or all of these.
F. G. Following their initial enrollment into an MCO or PCCM program, recipients shall be restricted to the MCO or PCCM program until the next open enrollment period, unless appropriately disenrolled or excluded by the department (as defined in 12VAC30-120-360).
1. During the first 90 calendar days of enrollment in a new or initial MCO, a client may disenroll from that MCO to enroll into another MCO or into PCCM, if applicable, for any reason. Such disenrollment shall be effective no later than the first day of the second month after the month in which the client requests disenrollment.
2. During the remainder of the enrollment period, the client may only disenroll from one MCO into another MCO or PCCM, if applicable, upon determination by DMAS that good cause exists as determined under subsection H I of this section.
G. H. The department shall conduct an annual open enrollment for all Medallion II participants. The open enrollment period shall be the 60 calendar days before the end of the enrollment period. Prior to the open enrollment period, DMAS will inform the recipient of the opportunity to remain with the current MCO or change to another MCO, without cause, for the following year. In areas with only one contracted MCO, recipients will be given the opportunity to select either the MCO or the PCCM program. Enrollment selections will be effective on the first day of the next month following the open enrollment period. Recipients who do not make a choice during the open enrollment period will remain with their current MCO selection.
H. I. Disenrollment for cause may be requested at any time.
1. After the first 90 days of enrollment in an MCO, clients must request disenrollment from DMAS based on cause. The request may be made orally or in writing to DMAS and must cite the reasons why the client wishes to disenroll. Cause for disenrollment shall include the following:
a. A recipient's desire to seek services from a federally qualified health center which is not under contract with the recipient's current MCO, and the recipient (i) requests a change to another MCO that subcontracts with the desired federally qualified health center or (ii) requests a change to the PCCM, if the federally qualified health center is contracting directly with DMAS as a PCCM;
b. Performance or nonperformance of service to the recipient by an MCO or one or more of its providers which is deemed by the department's external quality review organizations to be below the generally accepted community practice of health care. This may include poor quality care;
c. Lack of access to a PCP or necessary specialty services covered under the State Plan or lack of access to providers experienced in dealing with the enrollee's health care needs;
d. A client has a combination of complex medical factors that, in the sole discretion of DMAS, would be better served under another contracted MCO or PCCM program, if applicable, or provider;
e. The enrollee moves out of the MCO's service area;
f. The MCO does not, because of moral or religious objections, cover the service the enrollee seeks;
g. The enrollee needs related services to be performed at the same time; not all related services are available within the network, and the enrollee's primary care provider or another provider determines that receiving the services separately would subject the enrollee to unnecessary risk; or
h. Other reasons as determined by DMAS through written policy directives.
2. DMAS shall determine whether cause exists for disenrollment. Written responses shall be provided within a timeframe set by department policy; however, the effective date of an approved disenrollment shall be no later than the first day of the second month following the month in which the enrollee files the request, in compliance with 42 CFR 438.56.
3. Cause for disenrollment shall be deemed to exist and the disenrollment shall be granted if DMAS fails to take final action on a valid request prior to the first day of the second month after the request.
4. The DMAS determination concerning cause for disenrollment may be appealed by the client in accordance with the department's client appeals process at 12VAC30-110-10 through 12VAC30-110-380.
5. The current MCO shall provide, within two working days of a request from DMAS, information necessary to determine cause.
6. Individuals enrolled with a MCO that subsequently meet one or more of the exclusions in subsection B of this section during MCO enrollment shall be disenrolled as appropriate by DMAS, with the exception of those who subsequently become recipients into the AIDS, IFDDS, MR, EDCD, Day Support, or Alzheimer's federal waiver programs for home-based and community-based Medicaid coverage. These individuals shall receive acute and primary medical services via the MCO and shall receive waiver services and related transportation to waiver services via the fee-for-service program.
Individuals excluded from mandatory managed care enrollment shall receive Medicaid services under the current fee-for-service system. When enrollees no longer meet the criteria for exclusion, they shall be required to enroll in the appropriate managed care program.
12VAC30-120-380. Medallion II MCO responsibilities.
A. The MCO shall provide, at a minimum, all medically necessary covered services provided under the State Plan for Medical Assistance and further defined by written DMAS regulations, policies and instructions, except as otherwise modified or excluded in this part.
1. Nonemergency services provided by hospital emergency departments shall be covered by MCOs in accordance with rates negotiated between the MCOs and the emergency departments.
2. Services that shall be provided outside the MCO network shall include those services identified and defined by the contract between DMAS and the MCO. Services reimbursed by DMAS include dental and orthodontic services for children up to age 21; for all others, dental services (as described in 12VAC30-50-190), school health services (as defined in 12VAC30-120-360) and, community mental health services (rehabilitative, targeted case management and substance abuse services), and long-term care services provided under the §1915(c) home-based and community-based waivers including related transportation to such authorized waiver services.
3. The MCOs shall pay for emergency services and family planning services and supplies whether they are provided inside or outside the MCO network.
B. EPSDT services shall be covered by the MCO. The MCO shall have the authority to determine the provider of service for EPSDT screenings.
C. The MCOs shall report data to DMAS under the contract requirements, which may include data reports, report cards for clients, and ad hoc quality studies performed by the MCO or third parties.
D. Documentation requirements.
1. The MCO shall maintain records as required by federal and state law and regulation and by DMAS policy. The MCO shall furnish such required information to DMAS, the Attorney General of Virginia or his authorized representatives, or the State Medicaid Fraud Control Unit on request and in the form requested.
2. Each MCO shall have written policies regarding enrollee rights and shall comply with any applicable federal and state laws that pertain to enrollee rights and shall ensure that its staff and affiliated providers take those rights into account when furnishing services to enrollees in accordance with 42 CFR 438.100.
E. The MCO shall ensure that the health care provided to its clients meets all applicable federal and state mandates, community standards for quality, and standards developed pursuant to the DMAS managed care quality program.
F. The MCOs shall promptly provide or arrange for the provision of all required services as specified in the contract between the state and the contractor. Medical evaluations shall be available within 48 hours for urgent care and within 30 calendar days for routine care. On-call clinicians shall be available 24 hours per day, seven days per week.
G. The MCOs must meet standards specified by DMAS for sufficiency of provider networks as specified in the contract between the state and the contractor.
H. Each MCO and its subcontractors shall have in place, and follow, written policies and procedures for processing requests for initial and continuing authorizations of service. Each MCO and its subcontractors shall ensure that any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested, be made by a health care professional who has appropriate clinical expertise in treating the enrollee's condition or disease. Each MCO and its subcontractors shall have in effect mechanisms to ensure consistent application of review criteria for authorization decisions and shall consult with the requesting provider when appropriate.
I. In accordance with 42 CFR 447.50 through 42 CFR 447.60, MCOs shall not impose any cost sharing obligations on enrollees except as set forth in 12VAC30-20-150 and 12VAC30-20-160.
J. An MCO may not prohibit, or otherwise restrict, a health care professional acting within the lawful scope of practice, from advising or advocating on behalf of an enrollee who is his patient in accordance with 42 CFR 438.102.
K. An MCO that would otherwise be required to reimburse for or provide coverage of a counseling or referral service is not required to do so if the MCO objects to the service on moral or religious grounds and furnishes information about the service it does not cover in accordance with 42 CFR 438.102.
VA.R. Doc. No. R07-729; Filed August 27, 2008, 11:38 a.m.