Title of Regulation: 12VAC30-20. Administration of Medical Assistance Services (adding 12VAC30-20-570).

Statutory Authority: § 2.2-4023.1 of the Code of Virginia.

Effective Dates: December 6, 2016, through June 5, 2018.

Agency Contact: Emily McClellan, Regulatory Supervisor, Policy Division, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-4300, FAX (804) 786-1680, or email emily.mcclellan@dmas.virginia.gov.

Preamble:

Section 2.2-4011 of the Code of Virginia states that agencies may adopt emergency regulations in situations in which Virginia statutory law or the appropriation act or federal law or federal regulation requires that a regulation be effective in 280 days or less from its enactment, and the regulation is not exempt under the provisions of § 2.2-4006 A 4 of the Code of Virginia. Chapter 694 of the 2016 Acts of Assembly, which enacted § 2.2-4023.1 of the Code of Virginia, establishes a reconsideration process by which appellants may petition the agency director to reconsider the final agency decision made pursuant to the § 2.2-4020 of the Code of Virginia. Chapter 694 specifically authorizes the agency to promulgate emergency regulations to specify the scope of the reconsideration review. This emergency regulation adding 12VAC30-20-570 is needed to accomplish the goal of establishing and defining the scope of review for reconsiderations conducted in accordance with § 2.2-4023.1 of the Code of Virginia. The reconsideration shall not authorize the reopening of the formal administrative hearing or acceptance of evidence or testimony not part of the record of the case in accordance with 1st Stop Health Services v. DMAS, 63 Va. App. 266, 756 S.E.2d 183 (2014).

This regulatory action is essential to protect the health, safety, and welfare of citizens by ensuring the integrity of the Department of Medical Assistance Services appeals process by ensuring that it is in accordance with the Code of Virginia so that individuals and providers may challenge health care determinations made by the state Medicaid agency.

Prior to the enactment of § 2.2-4023.1 of the Code of Virginia, there was no process by which an appellant could petition the agency director to reconsider a final agency case decision made pursuant to § 2.2-4020 of the Code of Virginia. 

12VAC30-20-570. Reconsideration of final agency decision.

A. Reconsiderations of a DMAS final appeal decision issued on a formal appeal conducted pursuant to § 2.2-4020 of the Code of Virginia shall be conducted in accordance with § 2.2-4023.1 of the Code of Virginia.

B. The DMAS director's review shall be made upon the case record of the formal appeal. Testimony or documentary submissions that were not part of the formal appeal case record prior to issuance of the final agency decision shall not be considered.