Title of Regulation: 12VAC30-141. Family Access to Medical Insurance Security Plan (amending 12VAC30-141-160).

Statutory Authority: § 32.1-351 of the Code of Virginia.

Effective Date: March 17, 2010.

Agency Contact: Molly Carpenter, Division of Maternal and Child Health, Department of Medical Assistance Services, 600 East Broad Street, Richmond, VA 23219, telephone (804) 786-1493, FAX (804) 225-3961, or email molly.carpenter@dmas.virginia.gov.

Summary:

The amendment eliminates cost sharing for pregnancy-related services covered under the Family Access to Medical Security Insurance Plan (FAMIS). Current policy allows copayments to be charged for pregnancy-related services covered under FAMIS. Under the current contract, managed care organizations (MCOs) may apply a copayment to the first prenatal care visit only. There is no cost sharing for any pregnancy-related service covered under Medicaid. Under the revised policy, copayments are not allowed for services to pregnant females related to the pregnancy, which is consistent with cost sharing limitations for Medicaid found at 12VAC30-10-570 C 2 b.

These changes are being made to conform DMAS' FAMIS regulations to the new requirements found in the federal Child Health Insurance Plan Reauthorization Act of 2009 (CHIPRA), which prohibits the use of cost sharing for pregnancy-related services in a state's Child Health Insurance Plan for states that cover targeted low-income pregnant women. The current FAMIS regulations do not exclude cost sharing for pregnancy-related services. Because of the CHIPRA mandate, DMAS is putting pregnancy-related services on the cost sharing exclusion list for FAMIS in 12VAC30-141-160.

Section 111(a) of CHIPRA adds § 2112 to the Social Security Act, which includes a list of requirements for states that cover targeted low-income pregnant women. The list includes the requirement that the "State provides pregnancy-related assistance to a targeted low-income woman consistent with the cost-sharing protections under section 2103(e)." Section 2103(e)(3)(A)(ii) of the Social Security Act states, "[i]n the case of a targeted low-income child whose family income is at or below 150 percent of the poverty line, the State child health plan may not impose … (ii) a deductible, cost sharing, or similar charge that exceeds an amount that is nominal." Section 111(d)(2) of CHIPRA states, “[t]he term 'pregnancy-related assistance' has the meaning given the term 'child health assistance' in section 2110(a),” which states, "the term 'child health assistance' means payment for part or all of the cost of health benefits coverage for targeted low-income children that includes any of the following, … as specified under the State plan." The language "any of the following" includes essentially all Medicaid covered services, including prenatal care.

Part IV
Cost Sharing

12VAC30-141-160. Copayments for families not participating in FAMIS Select.

A. Copayments shall apply to all enrollees in an MCHIP.

B. These cost-sharing provisions shall be implemented with the following restrictions:

1. Total cost sharing for each 12-month eligibility period shall be limited to (i) for families with incomes equal to or less than 150% of FPL, the lesser of (a) $180 and (b) 2.5% of the family's income for the year (or 12-month eligibility period); and (ii) for families with incomes greater than 150% of FPL, the lesser of $350 and 5.0% of the family's income for the year (or 12-month eligibility period).

2. DMAS or its designee shall ensure that the annual aggregate cost sharing for all FAMIS enrollees in a family does not exceed the aforementioned caps.

3. Families will be required to submit documentation to DMAS or its designee showing that their maximum copayment amounts are met for the year.

4. Once the cap is met, DMAS or its designee will issue a new eligibility card excluding such families from paying additional copays.

C. Exceptions to the above cost-sharing provisions:

1. Copayments shall not be required for well-child and, well baby, and pregnancy-related services. This shall include:

a. All healthy newborn inpatient physician visits, including routine screening (inpatient or outpatient);

b. Routine physical examinations, laboratory tests, immunizations, and related office visits;

c. Routine preventive and diagnostic dental services (i.e., oral examinations, prophylaxis and topical fluoride applications, sealants, and x-rays); and

d. Services to pregnant females related to the pregnancy; and

e. Other preventive services as defined by the department.

2. Enrollees are not held liable for any additional costs, beyond the standard copayment amount, for emergency services furnished outside of the individual's managed care network. Only one copayment charge will be imposed for a single office visit.

3. No cost sharing will be charged to American Indians and Alaska Natives.