TITLE 12. HEALTH
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES
Final Regulation
REGISTRAR'S NOTICE: The Department of Medical Assistance Services is claiming an exemption from the Administrative Process Act in accordance with § 2.2-4006 A 4 a of the Code of Virginia, which excludes regulations that are necessary to conform to changes in Virginia statutory law where no agency discretion is involved. The Department of Medical Assistance Services will receive, consider, and respond to petitions from any interested person at any time with respect to reconsideration or revision.
Title of Regulation: 12VAC30-60. Standards Established and Methods Used to Assure High Quality Care (repealing 12VAC30-60-500).
Statutory Authority: §§ 32.1-324 and 32.1-325 of the Code of Virginia.
Effective Date: November 26, 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:
The 2010 Budget Reduction Plan directed DMAS to terminate its contract with the agency's disease management program contractor in November of 2009, effectively eliminating the program. In response to this mandate, DMAS is terminating the program contract on October 31, 2009, and repealing the disease management services section of the regulation.
12VAC30-60-500. Disease management services. (Repealed.)
A. The Commonwealth elects to provide secretary-approved
coverage as appropriate for the population served under § 1937 of the
Social Security Act (the Act). Virginia's disease management program is
designed to help patients better understand and manage their condition or
conditions through prevention, education, lifestyle changes, and adherence to
their physician-prescribed plans of care (POC). The purpose of the program is
not to offer medical advice, but rather to support providers in reinforcing
patients' POCs.
B. Populations.
1. The Commonwealth shall provide the alternative benefit
package to individuals who voluntarily enroll in the program (opt-in).
Individuals shall be informed of the available benefit options prior to having
the option to voluntarily enroll.
a. Opt-in alternative coverage will be offered to the
following populations of Medicaid recipients:
(1) All individuals in fee-for-service who have asthma or
diabetes.
(2) All individuals in fee-for-service age 18 and over who
have congestive heart failure (CHF), coronary artery disease (CAD), or chronic
obstructive pulmonary disease (COPD).
b. Individuals who choose to participate in the opt-in
program shall maintain their eligibility for the regular Medicaid benefits at
all times.
2. Persons excluded from this program shall be those:
a. Who have third-party insurance;
b. Who are enrolled in Medicaid managed care organizations;
c. Who reside in institutional settings;
d. Who are enrolled in both Medicare and Medicaid (dual
eligibles); or
e. Who are children enrolled in Virginia's Title XXI
program, Family Access to Medical Insurance Security (FAMIS). Children enrolled
in FAMIS receive disease management services through the FAMIS program pursuant
to 12VAC30-141-200.
3. The Commonwealth shall inform each individual that such
enrollment is voluntary, that such individual may opt out of such alternative
benefit package at any time, and retain eligibility for the standard Medicaid
program under the State Plan.
4. Individuals are to be encouraged to participate in the
program through mailings and telephonic outreach by DMAS or the designated
disease management program administrator.
C. Benchmark benefits. In addition to all regular Medicaid
program benefits, the alternative benefit package includes at least the
following disease management services:
1. Condition-specific education on an ongoing basis;
2. Access to a 24-hour nurse call line;
3. Regularly scheduled telephonic condition management,
support and referrals (for individuals identified by DMAS or the designated
disease management program administrator as having more acute or intensive
health care needs); and
4. Patient health activity monitoring and providing
information feedback to primary care physicians to help facilitate changes to
patients' plans of care pursuant to the provision of disease management
services (for individuals identified by DMAS or the designated disease
management program administrator as having more acute or intensive health care
needs).
D. Geographical classification. Services under this
alternative benefit package shall be available statewide.
E. Service delivery system. Alternative benefits shall be
offered through a prepaid ambulatory health plan, under contract with the
Commonwealth. All other Medicaid State Plan services shall be provided on a
fee-for-service basis.
F. Additional assurances.
1. The Commonwealth assures that individuals shall have
access, through benchmark coverage, benchmark-equivalent coverage, or
otherwise, to rural health clinic services and federally qualified health
center services as defined in § 1905(a)(2)(B) and (C) of the Act.
2. The Commonwealth assures that payment for rural health
clinic and federally qualified health clinic services shall be made in
accordance with the requirements of § 1902(bb) of the Act.
G. Cost effectiveness of plans. Benchmark or
benchmark-equivalent coverage and any additional benefits are provided in
accordance with economy and efficiency principles.
H. Compliance with the law. The Commonwealth shall
continue to comply with all other provisions of the Social Security Act in the
administration of the Commonwealth's disease management program under this
chapter.
VA.R. Doc. No. R10-2142; Filed October 5, 2009, 3:57 p.m.