TITLE 12. HEALTH
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Final Regulation
REGISTRAR'S NOTICE: The following regulatory
action is exempt from the Administrative Process Act in accordance with § 2.2-4006
A 4 c of the Code of Virginia, which excludes regulations that are necessary to
meet the requirements of federal law or regulations, provided such regulations
do not differ materially from those required by federal law or regulation. The
Department of Medical Assistance Services will receive, consider, and respond
to petitions by any interested person at any time with respect to
reconsideration or revision.
Title of Regulation:
12VAC30-141. Family Access to Medical Insurance Security Plan (amending
12VAC30-141-660).
Statutory Authority: § 32.1-351 of the Code
of Virginia.
Effective Date: September 16, 2009.
Agency Contact: Brian McCormick, Regulatory
Supervisor, Department of Medical Assistance Services, 600 East Broad Street,
Suite 1300, Richmond, VA 23219, telephone (804) 371-8856, FAX (804) 786-1680,
or email brian.mccormick@dmas.Virginia.gov.
Summary:
This action implements a
mandate in § 403 of the Children’s Health Insurance Program
Reauthorization Act (CHIPRA) of 2009 (P. L. 111-3) that applies certain managed
care quality safeguards to the federal State Children's Health Insurance
Program. This action allows those children who are assigned to a managed care
health insurance plan (MCHIP) in an area where there is only one contracted
MCHIP to request reassignment to the traditional fee-for-service delivery and
payment system as an alternative.
12VAC30-141-660.
Assignment to managed care.
A. Except for
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, all eligible enrollees shall be
assigned in managed care through the department or the central processing unit
(CPU) under contract to DMAS. FAMIS recipients, during the preassignment period
to a PCP or MCHIP, shall receive Title XXI benefits via fee-for-service
utilizing a FAMIS card issued by DMAS. After assignment to a PCP or MCHIP,
benefits and the delivery of benefits shall be administered specific to the
type of managed care program in which the recipient is enrolled. DMAS shall
contract with MCHIPs to deliver health care services for infants born to
mothers enrolled in FAMIS for the month of birth plus two additional months
regardless of the status of the newborn's application for FAMIS. If federal
funds are not available for those months of coverage, DMAS shall use state
funding only.
1. MCHIPs shall be offered
to enrollees in certain areas.
2. In areas with one
contracted MCHIP, all enrollees shall be assigned to that contracted MCHIP.
3. In areas with multiple
contracted MCHIPs or in PCCM areas without contracted MCHIPs, enrollees shall
be assigned through a random system algorithm; provided however, all children
within the same family shall be assigned to the same MCHIP or primary care
provider (PCP), as is applicable.
4. In areas without
contracted MCHIPs, enrollees shall be assigned to the primary care case
management program (PCCM) or into the fee-for-service component. All children
enrolled in the Virginia Birth-Related Neurological Injury Compensation Program
shall be assigned to the fee-for-service component.
5. Enrolled individuals
residing in PCCM areas without contracted MCHIPs or in areas with multiple
MCHIPs, will receive a letter indicating that they may select one of the
contracted MCHIPs or primary care provider (PCP) in the PCCM program, in each
case, which serve such area. Enrollees who do not select an MCHIP/PCP as
described above, shall be assigned to an MCHIP/PCP as described in subdivision
3 of this section.
6. Individuals assigned to
an MCHIP or a PCCM who lose and then regain eligibility for FAMIS within 60
days will be re-assigned to their previous MCHIP or PCP.
B. Following
their initial assignment to a MCHIP/PCP, those enrollees shall be restricted to
that MCHIP/PCP until their next annual eligibility redetermination, unless
appropriately disenrolled by the department.
1. During the first 90
calendar days of managed care assignment, an enrollee may request reassignment
for any reason from that MCHIP/PCP to another MCHIP/PCP serving that
geographic area. Such reassignment shall be effective no later than the
first day of the second month after the month in which the enrollee requests
reassignment.
2. Reassignment is
available only in areas with the PCCM program or where multiple MCHIPs exist.
If multiple MCHIPs exist, enrollees may only request reassignment to another
MCHIP serving that geographic area. In PCCM areas, an enrollee may only request
reassignment to another PCP serving that geographic area. In areas with only
one MCHIP, enrollees may request reassignment to fee-for-service.
3. After the first 90
calendar days of the assignment period, the enrollee may only be reassigned
from one MCHIP/PCP to another MCHIP/PCP or to fee-for-service in areas with
only one MCHIP upon determination by DMAS that good cause exists pursuant
to subsection C of this section.
C. Disenrollment
for good cause may be requested at any time.
1. After the first 90 days
of assignment in managed care, enrollees may request disenrollment from DMAS
based on good cause. The request must be made in writing to DMAS and cite the
reasons why the enrollee wishes to be reassigned. The department shall
establish procedures for good cause reassignment through written policy
directives.
2. DMAS shall determine
whether good cause exists for reassignment.
VA.R. Doc. No. R09-2024;
Filed July 24, 2009, 10:37 a.m.