TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Fast-Track Regulation

Title of Regulation: 12VAC30-20. Administration of Medical Assistance Services (amending 12VAC30-20-110, 12VAC30-20-272 through 12VAC30-20-278).

Statutory Authority: §§ 32.1-324 and 32.1-325 of the Code of Virginia.

Public Hearing Information: No public hearing is currently scheduled.

Public Comment Deadline: December 2, 2026.

Effective Date: December 17, 2026.

Agency Contact: Syreeta Stewart, Regulatory Coordinator, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 298-3863, fax (804) 786-1680, TDD (800) 343-0634, or email syreeta.stewart@dmas.virginia.gov.

Basis: Section 32.1-325 of the Code of Virginia authorizes the Board of Medical Assistance Services to administer and amend the State Plan for Medical Assistance and to promulgate regulations. Section 32.1-324 of the Code of Virginia grants the Director of the Department of Medical Assistance Services (DMAS) the authority of the board when it is not in session.

Purpose: This action protects the health, safety, and welfare of Medicaid recipients by ensuring that DMAS regulations and DMAS practices are aligned while maintaining quality of care for nursing facility patients.

Rationale for Using Fast-Track Rulemaking Process: This action is expected to be noncontroversial and therefore appropriate for the fast-track rulemaking process because it removes outdated language that was repealed by the Centers for Medicare and Medicaid in 1994.

Substance: The amendments (i) remove obsolete language related to the nursing facility drug utilization review (DUR) program and (ii) update provisions to reflect that the Division of Licensure and Certification is now referred to as the Office of Licensure and Certification (OLC).

Issues: The primary advantages of this action to both the public and the agency are the removal of outdated language and alignment of regulations with the state plan. There are no disadvantages to the public, the agency, the Commonwealth, or the regulated community.

Department of Planning and Budget Economic Impact Analysis:

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 Code of Virginia and Executive Order 19. The analysis presented represents DPB's best estimate of the potential economic impacts as of the date of this analysis.¹

Summary of the Proposed Amendments to Regulation. The Board of Medical Assistance Services (board) seeks to repeal obsolete text in 12VAC30-20-110 (Nursing facility resident drug utilization review) and replace it with a compliance statement from the State Plan. Other proposed changes would update references to the state survey agency with the Virginia Department of Health Office of Licensure and Certification (OLC) and reflect that the OLC no longer contracts with the State Fire Marshal's Office.

Background. This regulatory action follows a 2025 review of certain sections of the State Plan, which resulted in a State Plan amendment that is identical to the proposed changes.² According to the Department of Medical Assistance Services (DMAS), in addition to aligning the regulation with the State Plan, this action would also update stakeholders that Virginia remains in compliance with current federal nursing facility regulations. DMAS reports that the requirement in 12VAC30-20-110 was repealed by the Centers for Medicare and Medicaid in 1994. Instead DMAS has a Drug Utilization Review (DUR) Board that monitors nursing facility drug regiment review procedures in accordance with 42 CFR 456.703(b).³ Thus, the board seeks to repeal all the text currently in 12VAC30-20-10 and replace it with a statement citing 42 CFR 456.703(b). In addition, a reference to the state survey agency in 12VAC30-20-272 replaces with Virginia Department of Health, Office of Licensure and Certification (OLC). Subsequent references to state survey agency in that section as well as 12VAC30-20-274, 12VAC30-20-275, 12VAC30-20-277, and 12VAC30-20-278 are replaced with OLC. Lastly, 12VAC30-20-275 amend this list to reflect that the OLC no longer contracts with the State Fire Marshal's Office.

Estimated Benefits and Costs. The proposed amendments reflect the State Plan and current practice and would not create any new requirements. As mentioned previously, DMAS reports that the action would update stakeholders that although language about nursing facility-specific DUR would be removed from VAC, Virginia remains in compliance with current federal nursing facility regulations. The update may better inform some stakeholders and thus may be beneficial.

Businesses and Other Entities Affected. The proposed changes would not create any new requirements for any entity as they reflect current practice. Stakeholders, including nursing facilities, their residents, and entities that represent the interests of either party, would benefit from having updated regulations. The Code of Virginia requires DPB to assess whether an adverse impact may result from the proposed regulation.⁴ An adverse impact is indicated if there is any increase in net cost or reduction in net benefit for any entity, even if the benefits exceed the costs for all entities combined.⁵ As proposed changes would align the regulation with the State Plan and reflect current practice, an adverse impact is not indicated.

Small Businesses⁶ Affected.⁷ The proposed amendments would not adversely affect small businesses.

Localities⁸ Affected.⁹ The proposed amendments would not affect any locality in particular. Local governments would not be affected.

Projected Impact on Employment. The proposed amendments do not affect total employment.

Effects on the Use and Value of Private Property. The proposed amendments would not affect the use and value of private property. The proposed amendments do not affect real estate development costs.

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¹ Section 2.2-4007.04 of the Code of Virginia requires that such economic impact analyses determine the public benefits and costs of the proposed amendments. Further the analysis should include but not be limited to: (1) the projected number of businesses or other entities to whom the proposed regulatory action would apply, (2) the identity of any localities and types of businesses or other entities particularly affected, (3) the projected number of persons and employment positions to be affected, (4) the projected costs to affected businesses or entities to implement or comply with the regulation, and (5) the impact on the use and value of private property.

² See https://www.dmas.virginia.gov/media/getlvdgc/approved_va-25-0020.pdf.

³ See https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-456/subpart-K/section-456.703.

⁴ Pursuant to § 2.2-4007.04 D: In the event this economic impact analysis reveals that the proposed regulation would have an adverse economic impact on businesses or would impose a significant adverse economic impact on a locality, business, or entity particularly affected, the Department of Planning and Budget shall advise the Joint Commission on Administrative Rules, the House Committee on Appropriations, and the Senate Committee on Finance. Statute does not define "adverse impact," state whether only Virginia entities should be considered, nor indicate whether an adverse impact results from regulatory requirements mandated by legislation.

⁵ Statute does not define "adverse impact," state whether only Virginia entities should be considered, nor indicate whether an adverse impact results from regulatory requirements mandated by legislation. As a result, DPB has adopted a definition of adverse impact that assesses changes in net costs and benefits for each affected Virginia entity that directly results from discretionary changes to the regulation.

⁶ Pursuant to § 2.2-4007.04, small business is defined as "a business entity, including its affiliates, that (i) is independently owned and operated and (ii) employs fewer than 500 full-time employees or has gross annual sales of less than $6 million."

⁷ If the proposed regulatory action may have an adverse effect on small businesses, § 2.2-4007.04 requires that such economic impact analyses include: (1) an identification and estimate of the number of small businesses subject to the proposed regulation, (2) the projected reporting, recordkeeping, and other administrative costs required for small businesses to comply with the proposed regulation, including the type of professional skills necessary for preparing required reports and other documents, (3) a statement of the probable effect of the proposed regulation on affected small businesses, and (4) a description of any less intrusive or less costly alternative methods of achieving the purpose of the proposed regulation. Additionally, pursuant to § 2.2-4007.1 of the Code of Virginia, if there is a finding that a proposed regulation may have an adverse impact on small business, the Joint Commission on Administrative Rules shall be notified.

⁸ "Locality" can refer to either local governments or the locations in the Commonwealth where the activities relevant to the regulatory change are most likely to occur.

⁹ Section 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

Agency Response to Economic Impact Analysis: The Department of Medical Assistance Services has reviewed the economic impact analysis prepared by the Department of Planning and Budget and raises no issues with this analysis.

Summary:

The amendments (i) remove obsolete language related to nursing facility drug utilization review, which was repealed by the Centers for Medicare and Medicaid (CMS) in 1994; (ii) update text to reflect the Division of Licensure and Certification's name change to the Office of Licensure and Certification (OLC); and (iii) clarify that the OLC no longer contracts with the State Fire Marshal's Office.

12VAC30-20-110. Nursing facility resident drug utilization review.

1. Definitions. The following words and terms, when used in this regulation, shall have the following meanings unless the context clearly indicates otherwise:

"DMAS" means the Department of Medical Assistance Services consistent with the Code of Virginia, Chapter 10, Title 32.1, §§ 32.1-323 et seq.

"Drug utilization review" means a formal continuing program for assessing medical and/or drug use data against explicit standards and, as necessary, introducing remedial strategies.

"Drug Utilization Review Committee (DUR Committee)" means a committee composed of knowledgeable health care professionals who make recommendations for developing and modifying drug therapy review standards or criteria, participate in retrospective reviews, recommend remedial strategies, and evaluate the success of the interventions.

"Exceptional drug utilization pattern" means 1) a pattern of drug utilization within a nursing facility that differs substantially from predetermined standards established pursuant to § 3(B); 2) individual resident's drug use patterns that differ from the established standards; or 3) individual resident's drug use patterns that exhibit a high risk for drug therapy induced illness.

"Retrospective drug review" means the drug utilization review process that is conducted using historic or archived medical and/or drug use data.

"Targeted facility" means a nursing facility where residents' patterns of drug utilization demonstrate an exceptional drug utilization pattern as defined herein.

2. Scope

A. Medicaid shall conduct a drug utilization review program for covered drugs prescribed for nursing facility residents. The program shall help to ensure that prescriptions are appropriate, medically necessary, and are not likely to cause adverse actions. The primary objectives are 1) improvement in the quality of care; 2) conserving program funds and individual expenditures; and 3) maintaining program integrity (i.e., controlling problems of fraud and benefit abuse).

B. Retrospective drug utilization review will be conducted on an ongoing basis in targeted nursing facilities demonstrating exceptional drug utilization patterns.

C. With the aim of improving prescribing practices, the program shall provide for ongoing educational outreach programs to educate practitioners on common drug therapy problems.

3. Utilization Review Process

A. The program shall provide, through its drug claims processing and information retrieval systems, for the ongoing periodic examination of claims data and other records for targeted facilities to identify patterns of inappropriate or medically unnecessary care for individuals receiving benefits under Title XIX of the Social Security Act.

B. The program shall, on an ongoing basis, assess data on drug use against predetermined standards (as described in this section) including, but not limited to, monitoring for therapeutic appropriateness, overutilization and underutilization, appropriate use of generic products, therapeutic duplication, drug-disease contraindications, drug/drug interactions, incorrect drug dosage or duration of treatment, clinical abuse/misuse, fraud, and, as necessary, introduce to physicians and pharmacists remedial strategies in order to improve the quality of care.

C. The Department of Medical Assistance Services may assess data on drug use against such standards as the American Hospital Formulary Service Drug Information (1995, as amended), United States Pharmacopeia-Drug Information (1995, as amended), American Medical Association Drug Evaluations (1993, as amended), and peer-reviewed medical literature.

4. Drug Use Review Committee

A. DMAS shall provide for the establishment of a drug use review committee (hereinafter referred to as the "DUR Committee"). The Director of DMAS shall determine the number of members and appoint the members of the DUR committee.

B. The membership of the DUR Committee shall include health care professionals who have recognized knowledge and expertise in one or more of the following areas:

1. The clinically appropriate prescribing of covered drugs;

2. The clinically appropriate dispensing and monitoring of covered drugs;

3. Drug use review, evaluation, and intervention; and

4. Medical quality assurance;

5. Clinical practice and drug therapy in the long term care setting.

C. The membership of the DUR Committee shall include physicians, pharmacists, and other health care professionals, including those with recognized expertise and knowledge in long term care.

D. Activities of the DUR Committee shall include, but not be limited to, the following:

1. Retrospective drug utilization review as defined in § 2 (B) of this regulation;

2. Application of standards as defined in § 3 (C) of this regulation; and

3. Ongoing interventions for physicians and pharmacists, targeted toward therapy problems of individuals identified in the course of retrospective drug use reviews.

E. The DUR Committee shall re-evaluate interventions after an appropriate period of time to determine if the intervention improved the quality of drug therapy, to evaluate the success of the interventions and recommend modifications as necessary.

5. Medical Quality Assurance

A. Documentation of drug regimens in nursing facilities shall, at a minimum:

1. Be included in a plan of care that must be established and periodically reviewed by a physician;

2. Indicate all drugs administered to the resident in accordance with the plan with specific attention to frequency, quantity, and type and identify who administered the drug (include full name and title); and

3. Include the drug regimen review prescribed for nursing facilities in regulations implementing 42 CFR 483.6.

B. Documentation specified in paragraph A will serve as the basis for drug utilization reviews provided for in these regulations.

Virginia is in compliance with drug regimen review procedures prescribed in regulations at 42 CFR 456.70(b); therefore, prospective and retrospective drug utilization review of program drugs dispensed to residents of a nursing facility is not required.

12VAC30-20-272. Survey and certification education program.

The state has in effect the following survey and certification periodic education program for the staff and residents (and their representatives) of nursing facilities in order to present current regulations, procedures, and policies.

The state survey agency Virginia Department of Health, Office of Licensure and Certification (OLC) periodically conducts provider training programs and orientation of OBRA Omnibus Budget Reconciliation Act of 1989 regulations and the survey process through programs or mailings. The state survey agency OLC participates in the Medicaid agency's training of facilities regarding the Resident Assessment Instrument.

12VAC30-20-274. Process for the investigation of allegations of resident neglect and abuse and misappropriation of resident property.

The state has in effect the following process for the receipt and timely review and investigation of allegations of neglect and abuse and misappropriation of resident property by a nurse aide or a resident in a nursing facility or by another individual used authorized by the facility in providing to provide services to such a resident.

When the above described incidences involve an incident described in this section involves a nurse aide, they are the incident is reported to the Board of Health Professions, and the Board of Nursing. In addition, such allegations are frequently received by the facility administration, which reports the allegations to the state survey agency Virginia Department of Health, Office of Licensure and Certification (OLC). The state survey agency OLC conducts the follow-up investigations.

12VAC30-20-275. Procedures for scheduling and conduct of standards surveys.

The state has in effect the following procedures for the scheduling and conduct of standard surveys to assure ensure that it has taken all reasonable steps to avoid giving notice.

Onsite survey schedules are only accessible to staff of the Virginia Department of Health, Division Office of Licensure and Certification (OLC), which conducts the surveys. After the onsite review is initiated by the Division inspection staff OLC, the Virginia Department of Health notifies the state agency for the aging ombudsman, the state fire marshal, and other agencies as needed.

12VAC30-20-277. Programs to measure and reduce inconsistency.

The state has in effect the following programs to measure and reduce inconsistency in the application of survey results among surveyors.

The state survey agency Virginia Department of Health, Office of Licensure and Certification conducts routine training programs, routine informational memorandums and procedural clarifications, routine team meetings, and ongoing supervisory review and monitoring of staff training needs.

12VAC30-20-278. Process for investigations of complaints and monitoring.

A. The state has in effect the following process for investigating complaints of violations of requirements by nursing facilities and monitors onsite on a regular, as needed basis, a nursing facility's compliance with the requirements of § 1919(b), (c), and (d) of the Social Security Act (42 USC § 1396) for the following reasons:

(i) 1. The facility has been found not to be in compliance with such requirements and is in the process of correcting deficiencies to achieve such compliance;

(ii) 2. The facility was previously found not to be in compliance with such requirements and has corrected deficiencies to achieve such compliance, and verification of continued compliance is indicated; or

(iii) 3. The state has reason to question the compliance of the facility with such requirements.

B. All complaints are investigated by the Virginia Department of Health, Office of Health Facilities Regulation Licensure and Certification, per nature of the complaint.