Title of Regulation: 12VAC30-141. Family Access to Medical Insurance Security Plan (amending 12VAC30-141-660).

Statutory Authority: §§ 32.1-324, 32.1-325 and 32.1-351 of the Code of Virginia.

Effective Dates: December 22, 2008, through December 21, 2009.

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) 786-1680, or email molly.carpenter@dmas.virginia.gov.

Preamble:

Item 305(E) of Chapter 879 of the 2008 Acts of Assembly states, “The Department of Medical Assistance Services shall have the authority to provide eligibility in the Family Access to Medical Insurance Security (FAMIS) Plan to infants born to mothers enrolled in FAMIS, for the month of birth plus two additional months, even if eligibility is not yet established for the newborn. If federal funds are not available for those months of eligibility, the department shall use state funding. The department shall promulgate emergency regulations to implement this amendment within 280 days or less from the enactment of this act.” This action fulfills Item 305(E) of Chapter 879.

This regulatory action is needed to help ensure that infants born to Family Access to Medical Insurance Security (FAMIS) recipients receive health care coverage immediately following birth. This is a critical period for early treatment of medical conditions and for establishing a medical home for preventive health care and management of special health care needs. The regulations will enable DMAS to provide uninterrupted comprehensive coverage for newborns of FAMIS enrollees through the mother’s health care plan.

Federal Medicaid rules (Title XIX of the Social Security Act) permit Medicaid coverage for infants born to Medicaid enrollees for up to one year without an application. However, there is currently no such rule for FAMIS (Title XXI of the Social Security Act). There is no automatic eligibility for the newborn of a Title XXI mother under federal rules, not even for the newborn’s hospital charges (the mother’s charges are covered). An application must be submitted to determine eligibility. Most children born to FAMIS recipients eventually have eligibility established for Medicaid or FAMIS retroactive to the date of birth, but some do not.

Approximately 85% of FAMIS enrollees receive services through a managed health care plan. The contract under which MCOs provide services to FAMIS enrollees requires the plans to provide coverage for the month of birth plus two additional months for infants born to FAMIS enrolled mothers. The majority of these newborns are subsequently enrolled in Medicaid or FAMIS. However, a small number do not become enrolled in either program. If eligibility is never established the children are disenrolled from the FAMIS managed care plan after the second full month following the birth month.

The new policy authorizes the use of state general funds to cover MCO services to FAMIS newborns for the birth month plus two additional months if federal funds are not available. Most newborns of FAMIS enrollees are subsequently enrolled in either Medicaid or FAMIS and receive retroactive coverage for the first three months. For these newborns, any general funds used to provide coverage upon birth will continue to be replaced by Medicaid or FAMIS funds with a federal match.

12VAC30-141-660. Assignment to managed care.

A. Except for children enrolled in the Virginia Birth-Related Neurological Injury Compensation Program established pursuant to Chapter 50 (§ 38.2-5000 et seq.) of Title 38.2 of the Code of Virginia, all eligible enrollees shall be assigned in managed care through the department or the central processing unit (CPU) under contract to DMAS. FAMIS recipients, during the pre-assignment period to a PCP or MCHIP, shall receive Title XXI benefits via fee-for-service utilizing a FAMIS card issued by DMAS. After assignment to a PCP or MCHIP, benefits and the delivery of benefits shall be administered specific to the type of managed care program in which the recipient is enrolled. DMAS shall contract with MCHIPs to deliver health care services for infants born to mothers enrolled in FAMIS, for the month of birth plus two additional months, regardless of the status of the newborn’s application for FAMIS. If federal funds are not available for those months of coverage, DMAS shall use state funding only.

1. MCHIPs shall be offered to enrollees in certain areas.

2. In areas with one contracted MCHIP, all enrollees shall be assigned to that contracted MCHIP.

3. In areas with multiple contracted MCHIPs or in PCCM areas without contracted MCHIPs, enrollees shall be assigned through a random system algorithm; provided however, all children within the same family shall be assigned to the same MCHIP or primary care provider (PCP), as is applicable.

4. In areas without contracted MCHIPs, enrollees shall be assigned to the primary care case management program (PCCM) or into the fee-for-service component. All children enrolled in the Virginia Birth-Related Neurological Injury Compensation Program shall be assigned to the fee-for-service component.

5. Enrolled individuals residing in PCCM areas without contracted MCHIPs or in areas with multiple MCHIPs, will receive a letter indicating that they may select one of the contracted MCHIPs or primary care provider (PCP) in the PCCM program, in each case, which serve such area. Enrollees who do not select an MCHIP/PCP as described above, shall be assigned to an MCHIP/PCP as described in subdivision 3 of this section.

6. Individuals assigned to an MCHIP or a PCCM who lose and then regain eligibility for FAMIS within 60 days will be re-assigned to their previous MCHIP or PCP.

B. Following their initial assignment to a MCHIP/PCP, those enrollees shall be restricted to that MCHIP/PCP until their next annual eligibility redetermination, unless appropriately disenrolled by the department.

1. During the first 90 calendar days of managed care assignment, an enrollee may request re-assignment for any reason from that MCHIP/PCP to another MCHIP/PCP serving that geographic area. Such re-assignment shall be effective no later than the first day of the second month after the month in which the enrollee requests re-assignment.

2. Re-assignment is available only in areas with the PCCM program or where multiple MCHIPs exist. If multiple MCHIPs exist, enrollees may only request re-assignment to another MCHIP serving that geographic area. In PCCM areas, an enrollee may only request re-assignment to another PCP serving that geographic area.

3. After the first 90 calendar days of the assignment period, the enrollee may only be re-assigned from one MCHIP/PCP to another MCHIP/PCP upon determination by DMAS that good cause exists pursuant to subsection C of this section.

C. Disenrollment for good cause may be requested at any time.

1. After the first 90 days of assignment in managed care, enrollees may request disenrollment from DMAS based on good cause. The request must be made in writing to DMAS and cite the reasons why the enrollee wishes to be re-assigned. The department shall establish procedures for good cause re-assignment through written policy directives.

2. DMAS shall determine whether good cause exists for re-assignment.