Title of Regulation: 12VAC30-60. Standards Established and Methods Used to Assure High Quality Care (adding 12VAC30-60-500).

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

Effective Date: July 9, 2009.

Agency Contact: Suzanne Gore, Policy & Research Division, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 786-1609, FAX (804) 786-1680, or email suzanne.gore@dmas.virginia.gov.

Summary:

The amendments establish a voluntary alternative benefit package (known as the Healthy Returns^SM program) that combines traditional Medicaid services with comprehensive disease management (DM) services. Previous emergency regulations provided that (i) both adults and children in fee-for-service who are determined to have asthma and diabetes could participate in this program and (ii) individuals 21 years and older having coronary artery disease (CAD), congestive heart failure (CHF), and chronic obstructive pulmonary disease (COPD) were eligible for the Healthy Returns^SM program. The substantive change to the regulation drops the age limit of 21 years for CHF, CAD, and COPD to age 18 years and older.

Changes are made to the proposed regulation clarifying that designated disease management program administrators may also perform disease management services.

Summary of Public Comments and Agency's Response: No public comments were received by the promulgating agency.

12VAC30-60-500. Disease management services.

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.