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: 12VAC30-10. State Plan Under Title XIX of the Social Security Act
Medical Assistance Program; General Provisions (amending 12VAC30-10-690).
Statutory Authority: § 32.1-325 of the Code of
Virginia; Title XIX of the Social Security Act (42 USC § 1396 et seq.).
Effective Date: October 1, 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 incorporates
into the Virginia Administrative Code (VAC), for the purpose of maintaining the
necessary consistency between the VAC and the State Plan for Medical Assistance
Services, language issued by the Centers for Medicare and Medicaid Services to
be included in the State Plan. The language establishes DMAS' compliance with §
1932(d)(1) of the Social Security Act and 42 CFR 438.610 prohibiting managed
care organizations from having affiliations with individuals who have been
suspended or otherwise excluded from federal health care programs.
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 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 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 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 state licensing
authorities in accordance with § 1921 of the Act.
VA.R. Doc. No. R09-2073;
Filed August 12, 2009, 11:46 a.m.