TITLE 9. ENVIRONMENT

STATE WATER CONTROL BOARD

Fast-Track Regulation

Title of Regulation: 9VAC25-875. Virginia Erosion and Stormwater Management Regulation (amending 9VAC25-875-1330, 9VAC25-875-1400).

Statutory Authority: §§ 62.1-44.15:28 and 62.1-44.15:52 of the Code of Virginia.

Public Hearing Information: No public hearing is currently scheduled.

Public Comment Deadline: October 7, 2026.

Effective Date: October 22, 2026.

Agency Contact: April Rhodes, Department of Environmental Quality, 1111 East Main Street, Suite 1400, P.O. Box 1105, Richmond, VA 23218, telephone (571) 866-6091, or email april.rhodes@deq.virginia.gov.

Basis: Section 62.1-44.15:28 of the Code of Virginia authorizes the State Water Control Board to adopt regulations that establish requirements for the effective control of soil erosion, sediment deposition, and stormwater, including nonagricultural runoff, that must be met in any Virginia Erosion and Stormwater Management Program (VESMP) to prevent the unreasonable degradation of properties, stream channels, waters, and other natural resources. Section 62.1-44.15:31 of the Code of Virginia authorizes the establishment of a statewide fee schedule, including administrative charges for state agencies, for stormwater management for land-disturbing activities, and for municipal separate storm sewer systems.

Purpose: This action protects water quality in the Commonwealth by ensuring that the Department of Environmental Quality and localities that administer a VESMP have adequate resources for plan review, permitting, and program administration. Robust plan review, permitting, and inspection and compliance programs reduce erosion and stormwater runoff from land-disturbing activity and the impacts of stormwater and stormwater runoff, protecting water quality throughout the Commonwealth, which is essential to the health, safety, and welfare of Virginia's citizens.

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 does not significantly change the burden on the regulated community. The amendments are narrow in scope and do not increase permit fees but specify when the full fee amount is due during the permitting process. This action benefits the regulated community, localities, the department, and other stakeholders by providing regulatory clarity and consistency and by making the permitting process more efficient.

Substance: The amendments (i) clarify that applications will not be processed until the required fees are paid at the time of application submittal, unless the department approves an alternate payment schedule; (ii) clarify what an application submission may include for land-disturbing activities that require approval of an erosion control and stormwater management (ESM) plan or stormwater management plan; (iii) create organizational consistency with 9VAC25-20-60, which establishes fee schedules and due dates for other agency water permit programs, and clarify fee due dates for applications, modifications, transfers, and maintenance fees; and (iv) remove the requirement that no more than 50% of the total fee must be paid by an applicant at the time that a plan is submitted for review.

Issues: The primary advantage of this action for the public is an enhanced statewide erosion and stormwater management program that will be properly funded. This change will result in improved efficiency in the permitting process. In addition, the public will benefit from greater clarity of the fee collection procedures. The primary disadvantage will be adjusting from the current method of fee collection for Construction General Permits and VPDES individual permits for construction activities. However, the change does not increase permit fees but specifies when the fee is due during the permitting process, so the disadvantage is expected to be minimal. The advantage to the agency is that the amendments will allow the department and VESMP authorities to collect the full fee amount for a Construction General Permit at the beginning of the application process (i.e., when a plan is submitted, if required). There are no disadvantages to the agency or the Commonwealth.

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 State Water Control Board (board) proposes to require that the full fee amount for the General Virginia Pollutant Discharge Elimination System Permit for Discharges of Stormwater from Construction Activities (Construction General Permit) be due at the time that an application is submitted. The Board also proposes to amend other text for clarification.

Background. Under the current regulation, fee collection for the Construction General Permit is divided into two payments: no more than 50% of the total fee amount is due at the time that a plan is submitted for review (application), and the remaining fee balance is due prior to issuance of coverage under the permit. The board proposes to require that the full fee be paid upon application.

Estimated Benefits and Costs. According to the Department of Environmental Quality (DEQ), the current two-payment system at times results in the need for additional processing time and staff resources, especially when payments are late or incomplete. Additionally, when the second payment is not made or is incomplete, costs incurred by DEQ for plan processing and review may not be recuperated. The proposal benefits DEQ and the Commonwealth by having a statewide stormwater management program that is fully funded and efficiently and consistently administered. The fee amounts per applicant do not change. While some permittees may be indifferent or may even prefer paying fees just once, others may object to paying the full fee sooner. Three different trade organizations that each represent different groups of permittees were contacted concerning the proposal. Two of the organizations had no objection, while one believed that at least some of their members would prefer the status quo.

Businesses and Other Entities Affected. Applicants for the Construction General Permit would be particularly affected. According to DEQ, there are approximately 1,250 permit applications per year. Any entity that is disturbing one acre or more of land is required to obtain permit coverage. This could include building contractors, local governments, private or public entities, and the Virginia Department of Transportation.² The Code of Virginia requires DPB to assess whether an adverse impact may result from the proposed regulation.³ 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.⁴ Some permittees would likely consider themselves worse off by having to pay the full fee upfront. Thus, an adverse impact is indicated.

Small Businesses⁵ Affected.⁶ Types and Estimated Number of Small Businesses Affected: Data are not available to determine how many of the approximately 1,250 annual permit applicants are small businesses. Costs and Other Effects: The cost would be associated with having to pay the full fee sooner. Alternative Method that Minimizes Adverse Impact: There are no clear alternative methods that both reduce adverse impact and meet the intended policy goals.

Localities⁷ Affected.⁸ The proposal neither disproportionately affects particular localities nor substantively affects costs for local governments.

Projected Impact on Employment. The proposed amendments are unlikely to substantively affect total employment.

Effects on the Use and Value of Private Property. The proposal neither substantively affects the use and value of private property nor substantively affects 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 Source: DEQ.

³ 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.

⁴ 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.

⁵ 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."

⁶ 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.

⁷ "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.

⁸ Section 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

Agency Response to Economic Impact Analysis: The State Water Control Board has reviewed the economic impact analysis prepared by the Department of Planning and Budget and has no comment.

Summary:

The amendments (i) require the full fee payment at the time of application for coverage under the General Virginia Pollutant Discharge Elimination System (VPDES) Permit for Discharges of Stormwater from Construction Activities (Construction General Permit) or for a VPDES individual permit for construction activities; (ii) clarify fee due dates for maintenance, applications for individual and general municipal separate storm sewer system (MS4) permits, and requests for transfers or modifications of MS4 permits, Construction General Permits, and VPDES individual permits for construction activities; and (iii) create consistency between the Virginia Erosion and Stormwater Management Regulation and Fees for Permits and Certificates.

9VAC25-875-1330. Due dates for permits.

A. Requests An application or request for a permit, permit modification, or general permit coverage shall not be processed until the fees required pursuant to this part are paid in accordance with 9VAC25-875-1340, unless the department approves an alternate payment schedule.

B. VPDES Permits for discharges of stormwater from construction activities.

1. The fees for new coverage under a General VPDES Permit for Discharges of Stormwater from Construction Activities or an individual permit, as specified in 9VAC25-875-1400, are due at the time an application is submitted. An application may include the submission of an ESM plan or stormwater management plan for review in accordance with 9VAC25-875-530, or a variance or exception request.

2. Individual permit or general permit coverage maintenance fees, as specified in 9VAC25-875-1420, shall be paid annually to the department or the VESMP authority, as applicable, by April 1 of each year after the initial year of issuance, including owners whose individual permit or general permit coverage has been administratively continued. No permit will be reissued or automatically administratively continued without payment of the required fee. Individual permit or general permit coverage maintenance fees shall be applied until a notice of permit termination is effective.

3. Fees for modification or transfer of individual permits or of registration statements for coverage under a General VPDES Permit for Discharges of Stormwater from Construction Activities, as specified in 9VAC25-875-1410, are due at the time an application or request is submitted for a modification or transfer that occurs (and becomes effective) before the stated permit expiration date. There is no application fee for a modification or transfer that is made at the department's initiative.

C. VPDES Permits for MS4s.

1. The fees for issuance of a new MS4 individual permit or coverage under an MS4 General Permit, as specified in 9VAC25-875-1380, are due at the time an application is submitted.

2. Permit maintenance fees for MS4 individual permits or MS4 general permit coverages, as specified in 9VAC25-875-1420, are due by October 1 of each year. Effective April 1, 2014, any Any operator whose MS4 individual permit or MS4 general permit coverage, including operators whose permits MS4 individual permit or MS4 general permit coverages have coverage has been administratively continued, is effective as of April 1 of any given year shall pay the permit maintenance fee or fees to the department or the VESMP authority by October 1 of that same year.

Permit maintenance fees for discharges of stormwater from construction activities pursuant to 9VAC25-875-1420 are due by April 1 of each year. After approval of a VESMP authority, including the department when acting in that capacity, any owner whose permit or general permit coverage authorizing discharges of stormwater from construction activities, including owners whose permits or general permit coverages have been administratively continued, is effective as of the effective date of the VESMP authority shall pay the permit maintenance fee or fees to the department or the VESMP authority by April 1 of that same year.

3. When a modification of an MS4 individual permit is requested by the permittee, except as specifically exempt under 9VAC25-875-1320, the required fee as specified in 9VAC25-875-1390 is due at the time an application or request for modification is submitted.

9VAC25-875-1400. Fees for individual permit or coverage under the General Permit for Discharges of Stormwater from Construction Activities.

A. The following total fees to be paid by an applicant apply to any operator seeking coverage under a General VPDES Permit for Discharges of Stormwater from Construction Activities or a state agency or federal entity that does not file standards and specifications or an individual permit issued by the department. On and after approval by the department or a VESMP authority for coverage under the General VPDES Permit for Discharges of Stormwater from Construction Activities, no more than 50% of the total fee to be paid by an applicant set out in this part shall be due at the time that a stormwater management plan or an initial stormwater management plan is submitted for review in accordance with 9VAC25-875-530. The remaining total fee balance to be paid by an applicant shall be due prior to the issuance of coverage under the General VPDES Permit for Discharges of Stormwater from Construction Activities.

When a site is purchased for development within a previously permitted common plan of development or sale, the applicant shall be subject to fees ("total fee to be paid by applicant" column) in accordance with the disturbed acreage of the applicant's site according to the following table.

The following fees apply to coverage under the General VPDES Permit for Discharges of Stormwater from Construction Activities issued by the department for a state agency or federal entity that has standards and specifications approved by the department.

B. The amount of the permit fee due for a General VPDES Permit for Discharges of Stormwater from Construction Activities for a specified year as required by subsection A of this section shall be calculated according to the formulas in 9VAC25-875-1375 B.

TITLE 12. HEALTH

STATE BOARD OF HEALTH

Forms

Title of Regulation: 12VAC5-475. Regulations Implementing the Virginia Donor Registry.

Agency Contact: Raymond Rhodes, Anatomical Program Director, Virginia Department of Health, 8850 Times Dispatch Boulevard, Suite 200, Mechanicsville, VA 23116, telephone (804) 371-2143, fax (804) 225-3896, or email raymond.rhodes@vdh.virginia.gov.

FORMS (12VAC5-475)

Registry Removal Form, DonateLifeVirginia.org (eff. 12/13)

Registry Removal Form, DonateLifeVirginia.org (eff. 8/2026)

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Emergency Regulation

Titles of Regulations: 12VAC30-10. State Plan under Title XIX of the Social Security Act Medical Assistance Program; General Provisions (amending 12VAC30-10-140, 12VAC30-10-150).

12VAC30-30. Groups Covered and Agencies Responsible for Eligibility Determination (amending 12VAC30-30-10, 12VAC30-30-30).

12VAC30-40. Eligibility Conditions and Requirements (amending 12VAC30-40-100).

12VAC30-50. Amount, Duration, and Scope of Medical and Remedial Care Services (amending 12VAC30-50-10, 12VAC30-50-50, 12VAC30-50-190, 12VAC30-50-290).

12VAC30-141. Family Access to Medical Insurance Security Plan (amending 12VAC30-141-670, 12VAC30-141-750).

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Effective Dates: August 13, 2026, through February 18, 2028.

Agency Contact: Meredith Lee, Policy, Regulations, and Manuals Supervisor, Division of Policy and Research, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-0552, fax (804) 786-1680, TDD (800) 343-0634, or email meredith.lee@dmas.virginia.gov.

Preamble:

Section 2.2-4011 B 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.

The amendments provide continuous coverage through 12 months postpartum for Medicaid and Family Access to Medical Insurance Security (FAMIS) pregnant and postpartum members and eligible individuals. A pregnant individual who is deemed eligible will maintain coverage for the duration of 12 months from the date the pregnancy ends, regardless of what point in the prenatal or postpartum period individual enrolls in coverage. The coverage will be maintained regardless of a change in circumstances affecting income or household size.

12VAC30-10-140. Amount, duration, and scope of services: Categorically needy.

Medicaid is provided in accordance with the requirements of 42 CFR 440, Subpart B and § 1902(a), 1902(e), 1905(a), 1905(p), 1915, 1920, and 1925 of the Act.

Services for the categorically needy are described below and in 12VAC30-50-10 et seq. These services include:

1. Each item or service listed in § 1905(a)(1) through (5) and (21) of the Act, is provided as defined in 42 CFR Part 440, Subpart A, or, for EPSDT services, § 1905(r) and 42 CFR Part 411, Subpart B.

2. Nurse-midwife services listed in § 1905(a)(17) of the Act, are provided to the extent that nurse-midwives are authorized to practice under state law or regulation and without regard to whether the services are furnished in the area of management of the care of mothers and babies throughout the maternity cycle. Nurse-midwives are permitted to enter into independent provider agreements with the Medicaid agency without regard to whether the nurse-midwife is under the supervision of, or associated with, a physician or other health care provider.

3. Pregnancy-related, including family planning service, and postpartum services for a 60-day 12-month postpartum period (beginning on the last day of the pregnancy ends) and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends, are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

4. Services for medical conditions that may complicate the pregnancy (other than pregnancy-related or postpartum services) are provided to pregnant women.

5. Services related to pregnancy (including prenatal, delivery, postpartum, and family planning services) and to other conditions that may complicate pregnancy are the same services provided to poverty level pregnant women eligible under the provision of § 1902(a)(10)(A)(i)(IV) and 1902(a)(10)(A)(ii)(IX) of the Act.

6. Home health services are provided to individuals entitled to nursing facility services as indicated in 12VAC30-10-220 of this plan.

7. Inpatient services that are being furnished to infants and children described in § 1902(l)(1)(B) through (D), or § 1905(n)(2) of the Act, on the date the infant or child attains the maximum age for coverage under the approved State plan will continue until the end of the stay for which the inpatient services are furnished.

8. Respiratory care services are not provided to ventilator dependent individuals as indicated in 12VAC30-10-300 of this plan.

9. Services are provided to families eligible under § 1925 of the Act as indicated in 12VAC30-10-350 of this plan.

10. Home and community care for functionally disabled elderly individuals is not covered.

11. Program of All-Inclusive Care for the Elderly (PACE) services as described and limited in Supplement 6 to Attachment 3.1-A (12VAC30-50-320, 12VAC30-50-321, 12VAC30-50-325, and 12VAC30-50-328).

12VAC30-50-10 et seq. identifies the medical and remedial services provided to the categorically needy, specifies all limitations on the amount, duration, and scope of those service, and lists the additional coverage (that is in excess of established service limits) for pregnancy-related services and services for conditions that may complicate the pregnancy.

12VAC30-10-150. Amount, duration, and scope of services: Medically needy.

A. This State Plan covers the medically needy. The services described in this section and in Part II (12VAC30-50-40 et seq.) of 12VAC30-50 are provided. Services for the medically needy include:

1. If services in an institution for mental diseases (42 CFR 440.140 and 440.160) or an intermediate care facility for individuals with intellectual disabilities (or both) are provided to any medically needy group, then each medically needy group is provided either the services listed in § 1905(a)(1) through (5) and (17) of the Act, or seven of the services listed in § 1902(a)(1) through (20). The services are provided as defined in 42 CFR 440, Subpart A and in §§ 1902, 1905, and 1915 of the Act.

Subdivision 1 of this subsection is applicable with respect to nurse-midwife services under § 1902(a)(17).

2. Prenatal care and delivery services for pregnant women.

3. Pregnancy-related, including family planning services, and postpartum services for a 60-day 12-month postpartum period (beginning on the last day of the pregnancy ends) and including any remaining days in of the calendar month in which the sixtieth day falls 12-month period ends, are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

4. Services for any other medical condition that may complicate the pregnancy (other than pregnancy-related and postpartum services) are provided to pregnant women.

5. Ambulatory services as defined in 12VAC30-50-40 for recipients younger than 18 years of age and recipients entitled to institutional services.

6. Home health services to recipients entitled to nursing facility services as indicated in 12VAC30-10-220.

7. Services for the medically needy do not include services in an institution for mental diseases for individuals older than 65 years of age.

8. Services for the medically needy do not include services in an intermediate care facility for individuals with intellectual disabilities.

9. Services for the medically needy do not include inpatient psychiatric services for individuals younger than 21 years of age, other than those covered under early and periodic screening, diagnosis, and treatment (at 12VAC30-50-130).

10. Services for the medically needy do not include respiratory care services provided to ventilator dependent individuals. See 12VAC30-10-300.

11. Home and community care for functionally disabled elderly individuals is not covered.

12. Program of All-Inclusive Care for the Elderly (PACE) services as described and limited in Supplement 6 to Attachment 3.1-A (12VAC30-50-320, 12VAC30-50-321, 12VAC30-50-325, and 12VAC30-50-328) are covered.

B. Part II (12VAC30-50-40 et seq.) of 12VAC30-50 identifies services provided to each covered group of the medically needy. (Note: Other programs to be offered to medically needy beneficiaries would specify all limitations on the amount, duration, and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. In addition, other programs to be offered to medically needy beneficiaries would also list the additional coverage that is in excess of established service limits for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population, this also is not applicable for this program.)

12VAC30-30-10. Mandatory coverage: categorically needy and other required special groups.

The Title IV-A agency or the Department of Medical Assistance Services Central Processing Unit determines eligibility for Title XIX services. The following groups shall be eligible for medical assistance as specified:

1. Parents and other caretaker relatives of dependent children with household income at or below a standard established by the Commonwealth in 12VAC30-40-100 consistent with 42 CFR 435.110 and §§ 1902(a)(10)(A)(i)(l) and 1931(b) of the Social Security Act. Individuals qualifying under this eligibility group shall meet the following criteria:

a. Parents, other caretaker relatives (defined at 42 CFR 435.4) including pregnant women, or dependent children (defined at 42 CFR 435.4) younger than 18 years of age. This group includes individuals who are parents or other caretaker relatives of children who are 18 years of age provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training and are expected to complete such school or training before their 19th birthday.

b. Spouses of parents and other caretaker relatives shall include other relatives of the child based on blood (including those of half-blood), adoption, or marriage. Other relatives of a specified degree of the dependent child shall include any blood relative (including those of half-blood) and including (i) first cousins; (ii) nephews or nieces; (iii) persons of preceding generations as denoted by prefixes of grand, great, or great-great; (iv) stepbrother; (v) stepsister; (vi) a relative by adoption following entry of the interlocutory or final order, whichever is first; (vii) the same relatives by adoption as listed in this subdivision 1 b; and (viii) spouses of any persons named in this subdivision 1 b even after the marriage is terminated by death or divorce.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

2. Women who are pregnant or postpartum with household income at or below a standard established by the Commonwealth in 12VAC30-40-100, consistent with 42 CFR 435.116 and §§ 1902(a)(10)(A)(i)(III) and (IV), 1902(a)(10)(A)(ii)(I) and (IX), and 1931(b) of the Act. Individuals qualifying under this eligibility group shall be pregnant or postpartum as defined in 42 CFR 435.4.

a. A woman who, while pregnant, was eligible for, applied for, and received Medicaid under the approved state plan on the day her pregnancy ends. The woman continues to be eligible, as though she were pregnant, for all pregnancy-related and postpartum medical assistance under the plan for a 60-day 12-month postpartum period, beginning on the last day of her the pregnancy, and for including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

b. A pregnant woman who would otherwise lose eligibility because of an increase in income of the family in which she is a member during the pregnancy or the 12-month postpartum period that extends through the end of the month in which the 60-day period, beginning on the last day of pregnancy, and including any remaining days of the calendar month in which the 12-month period ends.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

3. Infants and children younger than 19 years of age with household income at or below standards based on this age group, consistent with 42 CFR 435.118 and §§ 1902(a)(10)(A)(i)(III), (IV) and (VIII); 1902(a)(10)(A)(ii)(IV) and (IX); and 1931(b) of the Act. Children qualifying under this eligibility group shall meet the following criteria:

a. They are younger than 19 years of age; and

b. They have a household income at or below the standard established by the Commonwealth.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

4. The adult group as described at 42 CFR 435.119.

5. Former foster care children younger than 26 years of age who are not otherwise mandatorily eligible in another Medicaid classification, who were on Medicaid and in foster care when they turned 18 years of age, or who aged out of foster care. Individuals qualifying under this eligibility group shall meet the following criteria:

a. They shall be younger than 26 years of age;

b. They shall not be otherwise eligible for and enrolled for mandatory coverage under the state plan; and

c. They were in foster care under the responsibility of the Commonwealth or a federally recognized tribe and were enrolled in Virginia Medicaid under the state plan when they turned 18 years of age or at the time of aging out of the foster care program.

6. Families terminated from coverage under § 1931 of the Act solely because of earnings or hours of employment shall be entitled to up to 12 months of extended benefits in accordance with § 1925 of the Act.

7. A child born to a woman who is eligible for and receiving Medicaid on the date of the child's birth. The child is deemed to have applied and been found eligible for Medicaid on the date of birth and remains eligible for one year from birth, as long as he remains a resident of the Commonwealth. A redetermination of eligibility must be completed on behalf of the deemed child at age one year and annually thereafter so long as he remains eligible.

8. Aged, blind, and disabled individuals receiving cash assistance.

a. Individuals who meet more restrictive requirements for Medicaid than the SSI requirements. (This includes persons who qualify for benefits under § 1619(a) of the Act or who meet the eligibility requirements for SSI status under § 1619(b)(1) of the Act and who met the Commonwealth's more restrictive requirements for Medicaid in the month before the month they qualified for SSI under § 1619(a) or met the requirements under § 1619(b)(1) of the Act. Medicaid eligibility for these individuals continues as long as they continue to meet the § 1619(a) eligibility standard or the requirements of § 1619(b) of the Act.)

b. These persons include the aged, the blind, and the disabled.

c. Protected SSI children (pursuant to § 1902(a)(10)(A)(i)(II) of the Act) (P.L. 105-33 § 4913). Children who meet the pre-welfare reform definition of childhood disability who lost their SSI coverage solely as a result of the change in the definition of childhood disability, and who also meet the more restrictive requirements for Medicaid than the SSI requirements.

d. The more restrictive categorical eligibility criteria are described in 12VAC30-30-40.

Financial criteria are described in 12VAC30-40-10.

9. Qualified severely impaired blind and disabled individuals younger than 65 years of age who:

a. For the month preceding the first month of eligibility under the requirements of § 1905(q)(2) of the Act, received SSI, a state supplementary payment (SSP) under § 1616 of the Act or under § 212 of P.L. 93-66 or benefits under § 1619(a) of the Act and were eligible for Medicaid; or

b. For the month of June 1987, were considered to be receiving SSI under § 1619(b) of the Act and were eligible for Medicaid. These individuals must:

(1) Continue to meet the criteria for blindness or have the disabling physical or mental impairment under which the individual was found to be disabled;

(2) Except for earnings, continue to meet all nondisability-related requirements for eligibility for SSI benefits;

(3) Have unearned income in amounts that would not cause them to be ineligible for a payment under § 1611(b) of the Act;

(4) Be seriously inhibited by the lack of Medicaid coverage in their ability to continue to work or obtain employment; and

(5) Have earnings that are not sufficient to provide for themselves a reasonable equivalent of the Medicaid, SSI (including any federally administered SSP), or public funded attendant care services that would be available if they did have such earnings.

The state applies more restrictive eligibility requirements for Medicaid than under SSI and under 42 CFR 435.121. Individuals who qualify for benefits under § 1619(a) of the Act or individuals described in this section who meet the eligibility requirements for SSI benefits under § 1619(b)(1) of the Act and who met the state's more restrictive requirements in the month before the month they qualified for SSI under § 1619(a) or met the requirements of § 1619(b)(1) of the Act are covered. Eligibility for these individuals continues as long as they continue to qualify for benefits under § 1619(a) of the Act or meet the SSI requirements under § 1619(b)(1) of the Act.

10. Except in states that apply more restrictive requirements for Medicaid than under SSI, blind or disabled individuals who:

a. Are at least 18 years of age; and

b. Lose SSI eligibility because they become entitled to Old Age, Survivor, and Disability Insurance (OASDI) child's benefits under § 202(d) of the Act or an increase in these benefits based on their disability. Medicaid eligibility for these individuals continues for as long as they would be eligible for SSI, absence their OASDI eligibility.

The Commonwealth does not apply more restrictive income eligibility requirements than those under SSI.

11. Except in states that apply more restrictive eligibility requirements for Medicaid than under SSI, individuals who are ineligible for SSI or optional state supplements (if the agency provides Medicaid under § 435.230 of the Act), because of requirements that do not apply under Title XIX of the Act.

12. Individuals receiving mandatory state supplements.

13. Individuals who in December 1973 were eligible for Medicaid as an essential spouse and who have continued, as a spouse, to live with and be essential to the well-being of a recipient of cash assistance. The recipient with whom the essential spouse is living continues to meet the December 1973 eligibility requirements of the Commonwealth's approved plan for Old Age Assistance, Aid to the Blind, Aid to the Permanently and Totally Disabled, or Aid to the Aged, Blind, and Disabled and the spouse continues to meet the December 1973 requirements for his needs to be included in computing the cash payment. In December 1973, Medicaid coverage of the essential spouse was limited to the aged, the blind, and the disabled.

14. Institutionalized individuals who were eligible for Medicaid in December 1973 as inpatients of Title XIX medical institutions or residents of Title XIX intermediate care facilities, if, for each consecutive month after December 1973, they:

a. Continue to meet the December 1973 Medicaid State Plan eligibility requirements;

b. Remain institutionalized; and

c. Continue to need institutional care.

15. Blind and disabled individuals who:

a. Meet all current requirements for Medicaid eligibility except the blindness or disability criteria;

b. Were eligible for Medicaid in December 1973 as blind or disabled; and

c. For each consecutive month after December 1973 continue to meet December 1973 eligibility criteria.

16. Individuals who would be SSI or SSP eligible except for the increase in OASDI benefits under P.L. 92-336 (July 1, 1972), who were entitled to OASDI in August 1972, and who were receiving cash assistance in August 1972. This includes persons who would have been eligible for cash assistance but had not applied in August 1972 (this group was included in this state's August 1972 plan), and persons who would have been eligible for cash assistance in August 1972 if not in a medical institution or intermediate care facility (this group was included in this state's August 1972 plan).

17. Individuals who:

a. Are receiving OASDI and were receiving SSI or SSP but became ineligible for SSI or SSP after April 1977; and

b. Would still be eligible for SSI or SSP if cost-of-living increases in OASDI paid under § 215(i) of the Act received after the last month for which the individual was eligible for and received SSI or SSP and OASDI, concurrently, were deducted from income.

The state applies more restrictive eligibility requirements than those under SSI and the amount of increase that caused SSI or SSP ineligibility and subsequent increases are deducted when determining the amount of countable income for categorically needy eligibility.

18. Disabled widows and widowers who would be eligible for SSI or SSP except for the increase in their OASDI benefits as a result of the elimination of the reduction factor required by § 134 of P.L. 98-21 and who are deemed, for purposes of Title XIX, to be SSI beneficiaries or SSP beneficiaries for individuals who would be eligible for SSP only, under § 1634(b) of the Act.

The state does not apply more restrictive income eligibility standards than those under SSI.

19. Disabled widows, disabled widowers, and disabled unmarried divorced spouses who had been married to the insured individual for a period of at least 10 years before the divorce became effective, who have attained the age of 50, who are receiving Title II payments, and who because of the receipt of Title II income lost eligibility for SSI or SSP which they received in the month prior to the month in which they began to receive Title II payments, who would be eligible for SSI or SSP if the amount of the Title II benefit were not counted as income, and who are not entitled to Medicare Part A.

The state applies more restrictive eligibility requirements for its blind or disabled than those of the SSI program.

20. Qualified Medicare beneficiaries:

a. Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under § 1818 of the Act);

b. Whose income does not exceed 100% of the federal level; and

c. Whose resources do not exceed twice the maximum standard under SSI or, effective January 1, 2010, the resource limit set for the Medicare Part D Low Income Subsidy Program.

Medical assistance for this group is limited to Medicare cost sharing as defined in item 3.2 of this plan.

21. Qualified disabled and working individuals:

a. Who are entitled to hospital insurance benefits under Medicare Part A under § 1818A of the Act;

b. Whose income does not exceed 200% of the federal poverty level;

c. Whose resources do not exceed twice the maximum standard under SSI; and

d. Who are not otherwise eligible for medical assistance under Title XIX of the Act.

Medical assistance for this group is limited to Medicare Part A premiums under §§ 1818 and 1818A of the Act.

22. Specified low-income Medicare beneficiaries:

a. Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under § 1818A of the Act);

b. Whose income for calendar years 1993 and 1994 exceeds the income level in subdivision 25 b of this section, but is less than 110% of the federal poverty level, and whose income for calendar years beginning 1995 is less than 120% of the federal poverty level; and

c. Whose resources do not exceed twice the maximum standard under SSI or, effective January 1, 2010, the resource limit set for the Medicare Part D Low Income Subsidy Program.

Medical assistance for this group is limited to Medicare Part B premiums under § 1839 of the Act.

23. a. Each person to whom SSI benefits by reason of disability are not payable for any month solely by reason of § 1611(e)(3)(A)(i) or (v) shall be treated, for purposes of Title XIX, as receiving SSI benefits for the month.

b. The state applies more restrictive eligibility standards than those under SSI. Individuals whose eligibility for SSI benefits are based solely on disability who are not payable for any months solely by reason of § 1611(e)(3)(A)(i) or (v) and who continue to meet the more restrictive requirements for Medicaid eligibility under the state plan, are eligible for Medicaid as categorically needy.

12VAC30-30-30. Optional coverage of the medically needy.

The Title IV A Agency determines eligibility for Title XIX services.

This plan includes the medically needy:

1. Pregnant women who, except for income and/or resources, would be eligible as categorically needy under Title XIX of the Act.

2. Women who, while pregnant, were eligible for and have applied for Medicaid and receive Medicaid as medically needy under the approved State plan on the date the pregnancy ends. These women continue to be eligible, as though they were pregnant, for all pregnancy-related and postpartum services under the plan for a 60-day 12-month postpartum period after beginning on the last day of the pregnancy ends, and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

3. Individuals under age 18 who, but for income and/or resources, would be eligible under § 1902(a)(10)(A)(i) of the Act.

4. Newborn children born on or after October 1, 1984, to a woman who is eligible as medically needy and is receiving Medicaid on the date of the child's birth. The child is deemed to have applied and been found eligible for Medicaid on the date of birth and remains eligible for one year so long as the woman remains eligible and the child is a member of the woman's household.

5. Reasonable classification of financially eligible individuals under the ages of 21, 20, 19, or 18 as specified below:

(1) Individuals for whom public agencies are assuming full or partial financial responsibility and who are:

(a) In foster homes (and are under the age of 21).

(b) In private institutions (and are under the age of 21).

(c) In addition to the group under (1)(a) and (b), individuals placed in foster homes or private institutions by private, nonprofit agencies (and are under the age of 21).

(2) Individuals in adoptions subsidized in full or part by the public agency (who are under the age of 21).

(3) Individuals in NFs (who are under the age of 21). NF services are provided under this plan.

(4) In addition to the group under (3), individuals in ICFs/MR (who are under the age of 21).

6. Aged Individuals.

7. Blind Individuals.

8. Disabled Individuals.

9. Blind and disabled individuals who:

a. Meet all current requirements for Medicaid eligibility except the blindness or disability criteria;

b. Were eligible as medically needy in December 1973 as blind or disabled; and

c. For each consecutive month after December 1973 continue to meet the December 1973 eligibility criteria.

10. Individuals required to enroll in cost-effective employer-based group health plans remain eligible for a minimum enrollment period of one month.

12VAC30-40-100. Methods of determining income.

A. Families and Children Medically Needy individuals.

1. In determining countable income for Families and Children Medically Needy individuals, the methods under the state's July 16, 1996, approved Aid to Families with Dependent Children plan and any more liberal methods described in 12VAC30-40-280 are used.

2. In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to children living with parents until the children become 21 years of age.

3. Agency continues to treat women eligible under the provisions of § 1902(a)(10) of the Act as eligible, without regard to any changes in income of the family of which she is a member, for the 60-day 12-month postpartum period after her beginning on the last day of the pregnancy ends and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

B. Individuals subject to the use of modified adjusted gross income (MAGI) methodology. In determining income eligibility for individuals subject to the use of MAGI-based methodologies, the following shall apply:

1. The Commonwealth shall apply MAGI-based methodologies as described in this subsection, and consistent with 42 CFR 435.603 and § 1902(e)(14) of the Act. Individuals subject to the use of MAGI-based income methodologies include:

a. Parents/caretaker relatives under §§ 1902(a)(10)(A)(i)(l) and 1931 of the Act.

b. Pregnant women under §§ 1902(a)(10)(A)(i)(I), (III), (IV), (ii)(l), ((IV), (IX) and 1931 of the Act.

c. Children under the age of 19 years under §§ 1902(a)(10)(A)(i)(l), (lll), (IV), (VI), (VII), (ii)((IV), (IX) and 1931 of the Act.

d. Reasonable classifications of children younger than the age of 21 years under §§ 1902(a)(10)(A)(ii)(l) and (IV) of the Act.

e. Individuals younger than the age of 21 years who are under a state adoption assistance agreement under § 1902(a)(10)(A)(ii)(VIII) of the Act.

2. In the case of determining the ongoing eligibility for individuals determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies shall not be applied until March 31, 2014, or the next regularly scheduled renewal of eligibility, whichever is later, if the applications of such methods should result in determination of ineligibility prior to such date.

C. In determining family size for the eligibility determination of a pregnant woman, the pregnant woman shall be counted as herself plus each of the children she is expected to deliver. In determining family size during the eligibility determination of the other individuals in a household that includes a pregnant woman, the pregnant woman shall be counted as just herself.

D. Financial eligibility shall be determined consistent with the following provisions:

1. Financial eligibility shall be based on current monthly income and family size when determining eligibility for new applicants.

2. Financial eligibility shall be based on current monthly household income and family size when determining eligibility for currently enrolled individuals.

3. Household income shall be the sum of the MAGI-based income of every individual included in the individual's household except as provided at 42 CFR 435.603(d)(2) through 42 CFR 435.603(d)(4).

4. An amount equivalent to five percentage points of the federal poverty level for the applicable family size shall be deducted, in determining eligibility for Medicaid, from the household income in accordance with 42 CFR 435.603(d).

5. The age used for children with respect to 42 CFR 435.603(f)(3)(iv) shall be 19 years of age.

E. Aged individuals. In determining countable income for aged individuals, including aged individuals with incomes up to the federal poverty level described in § 1902(m)(1) of the Act, the following methods are used.

1. The methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

2. For optional state supplement recipients in § 1902(f) states and SSI criteria states without § 1616 or § 1634 agreements, SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

3. In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses.

F. Blind individuals. In determining countable income for blind individuals, only the methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

For optional state supplement recipients in § 1902(f) states and SSI criteria states without § 1616 or § 1634 agreements, the SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses and the income of parents as available to children living with parents until the children become 21 years of age.

G. Disabled individuals. In determining countable income of disabled individuals, including disabled individuals with incomes up to the federal poverty level described in § 1902(m) of the Act, the methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

For optional state supplement recipients in § 1902(f) of the Act states and SSI criteria states without § 1616 or § 1634 agreements, the SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses and the income of parents as available to children living with parents until the children become 21 years of age.

H. Qualified Medicare beneficiaries. In determining countable income for qualified Medicare beneficiaries covered under § 1902(a)(10)(E)(i) of the Act, the methods of the SSI program, more liberal methods described in 12VAC30-40-280, or both are used.

If an individual receives a Title II benefit, any amounts attributable to the most recent increase in the monthly insurance benefit as a result of a Title II COLA is not counted as income during a "transition period" beginning with January, when the Title II benefit for December is received, and ending with the last day of the month following the month of publication of the revised annual federal poverty level.

For individuals with Title II income, the revised poverty levels are not effective until the first day of the month following the end of the transition period.

For individuals not receiving Title II income, the revised poverty levels are effective no later than the date of publication.

I. Qualified disabled and working individuals. In determining countable income for qualified disabled and working individuals covered under § 1902(a)(10)(E)(ii) of the Act, the methods of the SSI program are used.

12VAC30-50-10. Services provided to the categorically needy with limitations.

The following services are provided with limitations as described in Part III (12VAC30-50-100 et seq.) of this chapter:

1. Inpatient hospital services other than those provided in an institution for mental diseases.

2. Outpatient hospital services.

3. Other laboratory and x-ray services; nonemergency outpatient Magnetic Resonance Imaging (MRI), including Magnetic Resonance Angiography (MRA), Computerized Axial Tomography (CAT) scans, including Computed Tomography Angiography (CTA), and Positron Emission Tomography (PET) scans performed for the purpose of diagnosing a disease process or physical injury require prior authorization.

4. Rural health clinic services and other ambulatory services furnished by a rural health clinic.

5. Federally Qualified Health Center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with § 4231 of the State Medicaid Manual (HCFA Pub. 45-4).

6. Early and periodic screening and diagnosis of individuals under 21 years of age, and treatment of conditions found.

7. Family planning services and supplies for individuals of child-bearing age.

8. Physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere.

9. Medical and surgical services furnished by a dentist (in accordance with § 1905(a)(5)(B) of the Act).

10. Medical care or any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by state law: podiatrists, optometrists and other practitioners.

11. Home health services: intermittent or part-time nursing service provided by a home health agency or by a registered nurse when no home health agency exists in the area; home health aide services provided by a home health agency; and medical supplies, equipment, and appliances suitable for use in the home; physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility.

12. Clinic services.

13. Dental services.

14. Physical therapy and related services, including occupational therapy and services for individuals with speech, hearing, and language disorders (provided by or under supervision of a speech pathologist or audiologist).

15. Prescribed drugs, prosthetic devices, and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

16. Other rehabilitative services, screening services, preventive services.

17. Nurse-midwife services.

18. Case management services as defined in, and to the group specified in, 12VAC30-50-95 et seq. (in accordance with § 1905(a)(19) or § 1915(g) of the Act).

19. Extended services to pregnant women: pregnancy-related and postpartum services for a 60-day 12-month postpartum period after beginning on the last day of the pregnancy ends and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends (see 12VAC30-50-510). (Note: Additional coverage beyond limitations.)

20. Pediatric or family nurse practitioners' service.

21. Any other medical care and any other type of remedial care recognized by state law, specified by the Secretary: transportation.

12VAC30-50-50. Services provided to the medically needy with limitations.

Services as described in Part III (12VAC30-50-100 et seq.) of this chapter are provided to the medically needy with limitations.

1. Inpatient hospital services other than those provided in an institution for mental diseases.

2. Outpatient hospital services.

3. Other laboratory and x-ray services; nonemergency outpatient Magnetic Resonance Imaging (MRI), Computer Axial Tomography (CAT) scans, and Positron Emission Tomography (PET) scans require prior authorization.

4. Rural health clinic services and other ambulatory services furnished by a rural health clinic.

5. Federally qualified health center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with § 4231 of the State Medicaid Manual (HCFA, Pub. 45-4).

6. Family planning services and supplies for individuals of childbearing age.

7. Physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere.

8. Medical and surgical services furnished by a dentist (in accordance with § 1905(a)(5)(B) of the Act).

9. Medical care and any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by state law, including:

a. Podiatrists' services;

b. Optometrists' services; and

c. Other practitioners' services.

10. Home health services' medical supplies, equipment, and appliances suitable for use in the home; intermittent or part-time nursing service provided by a home health agency or by a registered nurse when no home health agency exists in the area; home health aide services provided by a home health agency; physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility.

11. Clinic services.

12. Dental services.

13. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders provided by or under supervision of a speech pathologist or audiologist.

14. Prescribed drugs, prosthetic devices, and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

15. Rehabilitative services.

16. Nurse-midwife services.

17. Case management services as defined in, and to the group specified in, 12VAC30-50-410 (in accordance with § 1905(a)(19) or § 1915(g) of the Act).

18. Extended services for pregnant women, including pregnancy-related and post-partum postpartum services for 60 days after the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends.

19. Certified pediatric or family nurse practitioners' services.

20. Any other medical care and any other type of remedial care recognized under state law, specified by the secretary, specifically transportation.

12VAC30-50-190. Dental services.

A. Dental services shall be covered for individuals younger than 21 years of age in fulfillment of the treatment requirements under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program and defined as routine diagnostic, preventive, or restorative procedures necessary for oral health provided by or under the direct supervision of a dentist in accordance with Chapter 27 (§ 54.1-2700 et seq.) of Title 54.1 of the Code of Virginia.

1. The Department of Medical Assistance Services (DMAS) will provide any medically necessary dental service to individuals younger than 21 years of age.

2. Certain dental services, as described in the DMAS Office Reference Manual (Smiles for Children, March 13, 2014), prepared by DMAS's dental benefits administrator, require preauthorization or prepayment review by DMAS or its designee.

3. Dental services for individuals younger than the age of 21 years that do not require preauthorization or prepayment review are initial, periodic, and emergency examinations; required radiography necessary to develop a treatment plan; patient education; dental prophylaxis; fluoride treatments; routine amalgam and composite restorations; stainless steel crowns, prefabricated steel post and temporary (polycarbonate) crowns, and stainless steel bands; crown recementation; pulpotomies; emergency endodontics for temporary relief of pain; pulp capping; sedative fillings; therapeutic apical closure; topical palliative treatment for dental pain; removal of foreign body; simple extractions; root recovery; incision and drainage of abscess; surgical exposure of the tooth to aid eruption; sequestrectomy for osteomyelitis; and oral antral fistula closure.

B. Dental services determined by the dental provider to be medically appropriate for an adult woman during the term of her pregnancy and through the end of the month following the 60th day postpartum shall be provided to a Medicaid-enrolled pregnant woman individual during pregnancy and for the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends. The dental services that shall be covered are (i) diagnostic x-rays and exams; (ii) preventive cleanings; (iii) restorative fillings; (iv) endodontics (root canals); (v) periodontics (gum-related treatments); (vi) prosthodontics, both removable and fixed (crowns, bridges, partial plates, and dentures); (vii) oral surgery (tooth extractions and other oral surgeries); and (viii) adjunctive general services (all covered services that do not fall into specific professional categories). These services require prepayment review by DMAS or its designee.

C. For the dental services covered for Medicaid-enrolled adult pregnant women, DMAS may place appropriate limits on a service based on medical necessity, for utilization control, or both. Examples of service limitations are examinations, prophylaxis, fluoride treatment (once/six months); space maintenance appliances; bitewing x-ray - two films (once/12 months); routine amalgam and composite restorations (once/three years); dentures (once/five years); extractions, tooth guidance appliances, permanent crowns and bridges, endodontics, patient education and sealants (once).

D. Limited oral surgery procedures, as defined and covered under Title XVIII (Medicare), are covered for all recipients, and require preauthorization or prepayment review by DMAS or its designee as described in the agency's Office Reference Manual located on the DMAS website at http://www.dmas.virginia.gov/#/dentalresources.

E. Residents of nursing facilities shall be permitted to deduct the costs of limited specific dental procedures from their payments toward the costs of their nursing facility care. Nursing facility residents shall be limited to deducting the following dental procedures: (i) routine exams and x-rays and dental cleaning twice yearly; (ii) full mouth x-rays once every three years; and (iii) extractions and fillings shall be permitted only if medically necessary as determined by DMAS.

12VAC30-50-290. Extended services to pregnant women.

A. Pregnancy-related and postpartum services for 60 days after the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends. The same limitations on all covered services apply to this group as to all other recipient groups.

B. Services for any other medical conditions that may complicate pregnancy. The same limitations on all covered services apply to this group as to all other recipient groups.

12VAC30-141-670. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Adverse action," consistent with 42 CFR 457.1130, means the denial of eligibility; failure to make a timely determination of eligibility; suspension or termination of enrollment, including disenrollment for failure to pay cost sharing; or delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of services; and failure to approve, furnish, or provide payment for health services in a timely manner; provided, however, that determination of eligibility to participate in and termination of participation in the FAMIS Select program shall not constitute an adverse action.

"Adverse benefit determination," consistent with 42 CFR 438.400, means the denial or limited authorization of a requested service; the failure to take action or timely take action on a request for service; the reduction, suspension, or termination of a previously authorized service; denial in whole or in part of a payment for a service; failure to provide services within the timeframes required by the state; for a resident of a rural exception area with only one MCO, the denial of a enrollee's request to exercise the enrollee's right under 42 CFR 438.52(b)(2)(ii) to obtain services outside of the network; the denial of a enrollee's request to dispute a financial liability as provided in 42 CFR 438.400(b)(7); or the failure of an MCO to act within the timeframes provided in 42 CFR 438.408(b).

"Agency" means the same as defined in 12VAC30-141-10.

"Agent" means an individual designated in writing to act on behalf of a FAMIS MOMS Plan applicant or enrollee during the administrative review process.

"Appeal" means an enrollee's request for review of an adverse benefit determination by an MCO or an adverse action by the LDSS, CPU, or DMAS.

"Applicant" means a pregnant woman who has filed an application (or who has an application filed on her behalf) for health insurance and is awaiting a determination of eligibility. A pregnant woman is an applicant until her eligibility has been determined.

"Application for health insurance" means the single streamlined application for determining eligibility in public health insurance programs operated by the Commonwealth.

"Authorized representative" means a person who is authorized to conduct the personal or financial affairs for an individual who is 18 years of age or older.

"Central processing unit" or "CPU" means Cover Virginia, which is the same as defined in 12VAC30-141-10.

"Child" means an individual younger than 19 years of age.

"Conservator" means a person appointed by a court of competent jurisdiction to manage the estate and financial affairs of an incapacitated individual.

"Continuation of coverage" means ensuring an enrollee's benefits are continued until completion of the review process, with the condition that should the enrollee not prevail in the review process, the enrollee shall be liable for the repayment of all benefits received during the review process.

"Director" means the individual, or his designee, specified in § 32.1-324 of the Code of Virginia with all of the attendant duties and responsibilities to administer the State Plan for Medical Assistance and the State Plan for Title XXI.

"DMAS" or "department" means the Department of Medical Assistance Services.

"Enrollee" means a pregnant woman who has been determined eligible to participate in FAMIS MOMS and is enrolled in the FAMIS MOMS program.

"FAMIS" means the Family Access to Medical Insurance Security Plan.

"FAMIS MOMS" means the Title XXI program available to eligible pregnant women.

"Federal poverty level" or "FPL" means that income standard as published annually by the U.S. Department of Health and Human Services in the Federal Register.

"Fee-for-service" means the traditional Medicaid health care delivery and payment system in which physicians and other providers receive a payment for each unit of service they provide.

"Guardian" means a person appointed by a court of competent jurisdiction to be responsible for the affairs of an incapacitated individual, including responsibility for making decisions regarding the person's support, care, health, safety, habilitation, education, and therapeutic treatment, and, if not inconsistent with an order of commitment, residence.

"Incapacitated " means a person who, pursuant to an order of a court of competent jurisdiction, has been found to be incapable of receiving and evaluating information effectively or responding to people, events, or environments to such an extent that the individual lacks the capacity to (i) meet the essential requirements of her health, care, safety, or therapeutic needs without the assistance or protection of a guardian, or (ii) manage property or financial affairs or provide for her support or for the support of her legal dependents without the assistance or protection of a conservator.

"LDSS" or "local department" means the local department of social services.

"Managed care organization" or "MCO" means an organization that offers managed care health insurance plans (MCHIPs) as defined in § 32.1-137.1 of the Code of Virginia.

"Pregnant woman" means a woman of any age who is medically determined to be pregnant. The pregnant woman definition is met from the first day of the earliest month that the medical practitioner certifies as being a month in which the woman was pregnant, through the last day of the month in which the 60th day occurs, following and continues for the duration of the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which her pregnancy ended the 12-month period ends, regardless of the reason the pregnancy ended.

"Provider" means the individual, facility, or other entity registered, licensed, or certified, as appropriate, and enrolled by an MCHIP or in fee-for-service to render services to FAMIS MOMS enrollees eligible for services.

"State fair hearing" means, consistent with 42 CFR 438.400, the process set forth in 42 CFR 431 Subpart E.

"Title XXI" means the federal State Children's Health Insurance Program as established by Subtitle J of the Balanced Budget Act of 1997.

12VAC30-141-750. Duration of eligibility.

A. The effective date of FAMIS MOMS eligibility shall be the first day of the month in which an application was received by LDSS, DMAS, or the CPU if the applicant met all eligibility requirements in that month.

B. Eligibility for FAMIS MOMS will continue through the last day of the month in which the 60th day occurs, following the last day the woman was pregnant for the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends, regardless of the reason the pregnancy ended. Eligibility will continue until the end of the coverage period, regardless of changes in circumstances such as income or family size.

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Notice of Intended Regulatory Action

Notice is hereby given in accordance with § 2.2-4007.01 of the Code of Virginia that the Department of Medical Assistance Services intends to consider amending 12VAC30-10, State Plan Under Title XIX of the Social Security Act Medical Assistance Program; General Provisions; 12VAC30-30, Groups Covered and Agencies Responsible for Eligibility Determination; 12VAC30-40, Eligibility Conditions and Requirements; 12VAC30-50, Amount, Duration, and Scope of Medical and Remedial Care and Services; and 12VAC30-141, Family Access to Medical Insurance Security (FAMIS) Plan. The purpose of the proposed action is to provide continuous coverage through 12 months postpartum for Medicaid and Family Access to Medical Insurance Security (FAMIS) pregnant and postpartum members and eligible individuals. A pregnant individual who is deemed eligible will maintain coverage for the duration of 12 months from the date the pregnancy ends, regardless of what point in the prenatal or postpartum period the individual enrolls in coverage. The coverage will be maintained regardless of a change in circumstances affecting income or household size.

The agency does not intend to hold a public hearing on the proposed action after publication in the Virginia Register.

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Public Comment Deadline: October 7, 2026.

Agency Contact: Meredith Lee, Policy, Regulations, and Manuals Supervisor, Division of Policy and Research, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-0552, fax (804) 786-1680, TDD (800) 343-0634, or email meredith.lee@dmas.virginia.gov.

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Notice of Intended Regulatory Action

Notice is hereby given in accordance with § 2.2-4007.01 of the Code of Virginia that the Department of Medical Assistance Services intends to consider amending 12VAC30-10, State Plan Under Title XIX of the Social Security Act Medical Assistance Program; General Provisions; 12VAC30-30, Groups Covered and Agencies Responsible for Eligibility Determination; 12VAC30-40, Eligibility Conditions and Requirements; 12VAC30-50, Amount, Duration, and Scope of Medical and Remedial Care and Services; and 12VAC30-141, Family Access to Medical Insurance Security (FAMIS) Plan. The purpose of the proposed action is to provide continuous coverage through 12 months postpartum for Medicaid and Family Access to Medical Insurance Security (FAMIS) pregnant and postpartum members and eligible individuals. A pregnant individual who is deemed eligible will maintain coverage for the duration of 12 months from the date the pregnancy ends, regardless of what point in the prenatal or postpartum period the individual enrolls in coverage. The coverage will be maintained regardless of a change in circumstances affecting income or household size.

The agency does not intend to hold a public hearing on the proposed action after publication in the Virginia Register.

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Public Comment Deadline: October 7, 2026.

Agency Contact: Meredith Lee, Policy, Regulations, and Manuals Supervisor, Division of Policy and Research, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-0552, fax (804) 786-1680, TDD (800) 343-0634, or email meredith.lee@dmas.virginia.gov.

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Emergency Regulation

Titles of Regulations: 12VAC30-10. State Plan under Title XIX of the Social Security Act Medical Assistance Program; General Provisions (amending 12VAC30-10-140, 12VAC30-10-150).

12VAC30-30. Groups Covered and Agencies Responsible for Eligibility Determination (amending 12VAC30-30-10, 12VAC30-30-30).

12VAC30-40. Eligibility Conditions and Requirements (amending 12VAC30-40-100).

12VAC30-50. Amount, Duration, and Scope of Medical and Remedial Care Services (amending 12VAC30-50-10, 12VAC30-50-50, 12VAC30-50-190, 12VAC30-50-290).

12VAC30-141. Family Access to Medical Insurance Security Plan (amending 12VAC30-141-670, 12VAC30-141-750).

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Effective Dates: August 13, 2026, through February 18, 2028.

Agency Contact: Meredith Lee, Policy, Regulations, and Manuals Supervisor, Division of Policy and Research, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-0552, fax (804) 786-1680, TDD (800) 343-0634, or email meredith.lee@dmas.virginia.gov.

Preamble:

Section 2.2-4011 B 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.

The amendments provide continuous coverage through 12 months postpartum for Medicaid and Family Access to Medical Insurance Security (FAMIS) pregnant and postpartum members and eligible individuals. A pregnant individual who is deemed eligible will maintain coverage for the duration of 12 months from the date the pregnancy ends, regardless of what point in the prenatal or postpartum period individual enrolls in coverage. The coverage will be maintained regardless of a change in circumstances affecting income or household size.

12VAC30-10-140. Amount, duration, and scope of services: Categorically needy.

Medicaid is provided in accordance with the requirements of 42 CFR 440, Subpart B and § 1902(a), 1902(e), 1905(a), 1905(p), 1915, 1920, and 1925 of the Act.

Services for the categorically needy are described below and in 12VAC30-50-10 et seq. These services include:

1. Each item or service listed in § 1905(a)(1) through (5) and (21) of the Act, is provided as defined in 42 CFR Part 440, Subpart A, or, for EPSDT services, § 1905(r) and 42 CFR Part 411, Subpart B.

2. Nurse-midwife services listed in § 1905(a)(17) of the Act, are provided to the extent that nurse-midwives are authorized to practice under state law or regulation and without regard to whether the services are furnished in the area of management of the care of mothers and babies throughout the maternity cycle. Nurse-midwives are permitted to enter into independent provider agreements with the Medicaid agency without regard to whether the nurse-midwife is under the supervision of, or associated with, a physician or other health care provider.

3. Pregnancy-related, including family planning service, and postpartum services for a 60-day 12-month postpartum period (beginning on the last day of the pregnancy ends) and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends, are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

4. Services for medical conditions that may complicate the pregnancy (other than pregnancy-related or postpartum services) are provided to pregnant women.

5. Services related to pregnancy (including prenatal, delivery, postpartum, and family planning services) and to other conditions that may complicate pregnancy are the same services provided to poverty level pregnant women eligible under the provision of § 1902(a)(10)(A)(i)(IV) and 1902(a)(10)(A)(ii)(IX) of the Act.

6. Home health services are provided to individuals entitled to nursing facility services as indicated in 12VAC30-10-220 of this plan.

7. Inpatient services that are being furnished to infants and children described in § 1902(l)(1)(B) through (D), or § 1905(n)(2) of the Act, on the date the infant or child attains the maximum age for coverage under the approved State plan will continue until the end of the stay for which the inpatient services are furnished.

8. Respiratory care services are not provided to ventilator dependent individuals as indicated in 12VAC30-10-300 of this plan.

9. Services are provided to families eligible under § 1925 of the Act as indicated in 12VAC30-10-350 of this plan.

10. Home and community care for functionally disabled elderly individuals is not covered.

11. Program of All-Inclusive Care for the Elderly (PACE) services as described and limited in Supplement 6 to Attachment 3.1-A (12VAC30-50-320, 12VAC30-50-321, 12VAC30-50-325, and 12VAC30-50-328).

12VAC30-50-10 et seq. identifies the medical and remedial services provided to the categorically needy, specifies all limitations on the amount, duration, and scope of those service, and lists the additional coverage (that is in excess of established service limits) for pregnancy-related services and services for conditions that may complicate the pregnancy.

12VAC30-10-150. Amount, duration, and scope of services: Medically needy.

A. This State Plan covers the medically needy. The services described in this section and in Part II (12VAC30-50-40 et seq.) of 12VAC30-50 are provided. Services for the medically needy include:

1. If services in an institution for mental diseases (42 CFR 440.140 and 440.160) or an intermediate care facility for individuals with intellectual disabilities (or both) are provided to any medically needy group, then each medically needy group is provided either the services listed in § 1905(a)(1) through (5) and (17) of the Act, or seven of the services listed in § 1902(a)(1) through (20). The services are provided as defined in 42 CFR 440, Subpart A and in §§ 1902, 1905, and 1915 of the Act.

Subdivision 1 of this subsection is applicable with respect to nurse-midwife services under § 1902(a)(17).

2. Prenatal care and delivery services for pregnant women.

3. Pregnancy-related, including family planning services, and postpartum services for a 60-day 12-month postpartum period (beginning on the last day of the pregnancy ends) and including any remaining days in of the calendar month in which the sixtieth day falls 12-month period ends, are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

4. Services for any other medical condition that may complicate the pregnancy (other than pregnancy-related and postpartum services) are provided to pregnant women.

5. Ambulatory services as defined in 12VAC30-50-40 for recipients younger than 18 years of age and recipients entitled to institutional services.

6. Home health services to recipients entitled to nursing facility services as indicated in 12VAC30-10-220.

7. Services for the medically needy do not include services in an institution for mental diseases for individuals older than 65 years of age.

8. Services for the medically needy do not include services in an intermediate care facility for individuals with intellectual disabilities.

9. Services for the medically needy do not include inpatient psychiatric services for individuals younger than 21 years of age, other than those covered under early and periodic screening, diagnosis, and treatment (at 12VAC30-50-130).

10. Services for the medically needy do not include respiratory care services provided to ventilator dependent individuals. See 12VAC30-10-300.

11. Home and community care for functionally disabled elderly individuals is not covered.

12. Program of All-Inclusive Care for the Elderly (PACE) services as described and limited in Supplement 6 to Attachment 3.1-A (12VAC30-50-320, 12VAC30-50-321, 12VAC30-50-325, and 12VAC30-50-328) are covered.

B. Part II (12VAC30-50-40 et seq.) of 12VAC30-50 identifies services provided to each covered group of the medically needy. (Note: Other programs to be offered to medically needy beneficiaries would specify all limitations on the amount, duration, and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. In addition, other programs to be offered to medically needy beneficiaries would also list the additional coverage that is in excess of established service limits for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population, this also is not applicable for this program.)

12VAC30-30-10. Mandatory coverage: categorically needy and other required special groups.

The Title IV-A agency or the Department of Medical Assistance Services Central Processing Unit determines eligibility for Title XIX services. The following groups shall be eligible for medical assistance as specified:

1. Parents and other caretaker relatives of dependent children with household income at or below a standard established by the Commonwealth in 12VAC30-40-100 consistent with 42 CFR 435.110 and §§ 1902(a)(10)(A)(i)(l) and 1931(b) of the Social Security Act. Individuals qualifying under this eligibility group shall meet the following criteria:

a. Parents, other caretaker relatives (defined at 42 CFR 435.4) including pregnant women, or dependent children (defined at 42 CFR 435.4) younger than 18 years of age. This group includes individuals who are parents or other caretaker relatives of children who are 18 years of age provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training and are expected to complete such school or training before their 19th birthday.

b. Spouses of parents and other caretaker relatives shall include other relatives of the child based on blood (including those of half-blood), adoption, or marriage. Other relatives of a specified degree of the dependent child shall include any blood relative (including those of half-blood) and including (i) first cousins; (ii) nephews or nieces; (iii) persons of preceding generations as denoted by prefixes of grand, great, or great-great; (iv) stepbrother; (v) stepsister; (vi) a relative by adoption following entry of the interlocutory or final order, whichever is first; (vii) the same relatives by adoption as listed in this subdivision 1 b; and (viii) spouses of any persons named in this subdivision 1 b even after the marriage is terminated by death or divorce.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

2. Women who are pregnant or postpartum with household income at or below a standard established by the Commonwealth in 12VAC30-40-100, consistent with 42 CFR 435.116 and §§ 1902(a)(10)(A)(i)(III) and (IV), 1902(a)(10)(A)(ii)(I) and (IX), and 1931(b) of the Act. Individuals qualifying under this eligibility group shall be pregnant or postpartum as defined in 42 CFR 435.4.

a. A woman who, while pregnant, was eligible for, applied for, and received Medicaid under the approved state plan on the day her pregnancy ends. The woman continues to be eligible, as though she were pregnant, for all pregnancy-related and postpartum medical assistance under the plan for a 60-day 12-month postpartum period, beginning on the last day of her the pregnancy, and for including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

b. A pregnant woman who would otherwise lose eligibility because of an increase in income of the family in which she is a member during the pregnancy or the 12-month postpartum period that extends through the end of the month in which the 60-day period, beginning on the last day of pregnancy, and including any remaining days of the calendar month in which the 12-month period ends.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

3. Infants and children younger than 19 years of age with household income at or below standards based on this age group, consistent with 42 CFR 435.118 and §§ 1902(a)(10)(A)(i)(III), (IV) and (VIII); 1902(a)(10)(A)(ii)(IV) and (IX); and 1931(b) of the Act. Children qualifying under this eligibility group shall meet the following criteria:

a. They are younger than 19 years of age; and

b. They have a household income at or below the standard established by the Commonwealth.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

4. The adult group as described at 42 CFR 435.119.

5. Former foster care children younger than 26 years of age who are not otherwise mandatorily eligible in another Medicaid classification, who were on Medicaid and in foster care when they turned 18 years of age, or who aged out of foster care. Individuals qualifying under this eligibility group shall meet the following criteria:

a. They shall be younger than 26 years of age;

b. They shall not be otherwise eligible for and enrolled for mandatory coverage under the state plan; and

c. They were in foster care under the responsibility of the Commonwealth or a federally recognized tribe and were enrolled in Virginia Medicaid under the state plan when they turned 18 years of age or at the time of aging out of the foster care program.

6. Families terminated from coverage under § 1931 of the Act solely because of earnings or hours of employment shall be entitled to up to 12 months of extended benefits in accordance with § 1925 of the Act.

7. A child born to a woman who is eligible for and receiving Medicaid on the date of the child's birth. The child is deemed to have applied and been found eligible for Medicaid on the date of birth and remains eligible for one year from birth, as long as he remains a resident of the Commonwealth. A redetermination of eligibility must be completed on behalf of the deemed child at age one year and annually thereafter so long as he remains eligible.

8. Aged, blind, and disabled individuals receiving cash assistance.

a. Individuals who meet more restrictive requirements for Medicaid than the SSI requirements. (This includes persons who qualify for benefits under § 1619(a) of the Act or who meet the eligibility requirements for SSI status under § 1619(b)(1) of the Act and who met the Commonwealth's more restrictive requirements for Medicaid in the month before the month they qualified for SSI under § 1619(a) or met the requirements under § 1619(b)(1) of the Act. Medicaid eligibility for these individuals continues as long as they continue to meet the § 1619(a) eligibility standard or the requirements of § 1619(b) of the Act.)

b. These persons include the aged, the blind, and the disabled.

c. Protected SSI children (pursuant to § 1902(a)(10)(A)(i)(II) of the Act) (P.L. 105-33 § 4913). Children who meet the pre-welfare reform definition of childhood disability who lost their SSI coverage solely as a result of the change in the definition of childhood disability, and who also meet the more restrictive requirements for Medicaid than the SSI requirements.

d. The more restrictive categorical eligibility criteria are described in 12VAC30-30-40.

Financial criteria are described in 12VAC30-40-10.

9. Qualified severely impaired blind and disabled individuals younger than 65 years of age who:

a. For the month preceding the first month of eligibility under the requirements of § 1905(q)(2) of the Act, received SSI, a state supplementary payment (SSP) under § 1616 of the Act or under § 212 of P.L. 93-66 or benefits under § 1619(a) of the Act and were eligible for Medicaid; or

b. For the month of June 1987, were considered to be receiving SSI under § 1619(b) of the Act and were eligible for Medicaid. These individuals must:

(1) Continue to meet the criteria for blindness or have the disabling physical or mental impairment under which the individual was found to be disabled;

(2) Except for earnings, continue to meet all nondisability-related requirements for eligibility for SSI benefits;

(3) Have unearned income in amounts that would not cause them to be ineligible for a payment under § 1611(b) of the Act;

(4) Be seriously inhibited by the lack of Medicaid coverage in their ability to continue to work or obtain employment; and

(5) Have earnings that are not sufficient to provide for themselves a reasonable equivalent of the Medicaid, SSI (including any federally administered SSP), or public funded attendant care services that would be available if they did have such earnings.

The state applies more restrictive eligibility requirements for Medicaid than under SSI and under 42 CFR 435.121. Individuals who qualify for benefits under § 1619(a) of the Act or individuals described in this section who meet the eligibility requirements for SSI benefits under § 1619(b)(1) of the Act and who met the state's more restrictive requirements in the month before the month they qualified for SSI under § 1619(a) or met the requirements of § 1619(b)(1) of the Act are covered. Eligibility for these individuals continues as long as they continue to qualify for benefits under § 1619(a) of the Act or meet the SSI requirements under § 1619(b)(1) of the Act.

10. Except in states that apply more restrictive requirements for Medicaid than under SSI, blind or disabled individuals who:

a. Are at least 18 years of age; and

b. Lose SSI eligibility because they become entitled to Old Age, Survivor, and Disability Insurance (OASDI) child's benefits under § 202(d) of the Act or an increase in these benefits based on their disability. Medicaid eligibility for these individuals continues for as long as they would be eligible for SSI, absence their OASDI eligibility.

The Commonwealth does not apply more restrictive income eligibility requirements than those under SSI.

11. Except in states that apply more restrictive eligibility requirements for Medicaid than under SSI, individuals who are ineligible for SSI or optional state supplements (if the agency provides Medicaid under § 435.230 of the Act), because of requirements that do not apply under Title XIX of the Act.

12. Individuals receiving mandatory state supplements.

13. Individuals who in December 1973 were eligible for Medicaid as an essential spouse and who have continued, as a spouse, to live with and be essential to the well-being of a recipient of cash assistance. The recipient with whom the essential spouse is living continues to meet the December 1973 eligibility requirements of the Commonwealth's approved plan for Old Age Assistance, Aid to the Blind, Aid to the Permanently and Totally Disabled, or Aid to the Aged, Blind, and Disabled and the spouse continues to meet the December 1973 requirements for his needs to be included in computing the cash payment. In December 1973, Medicaid coverage of the essential spouse was limited to the aged, the blind, and the disabled.

14. Institutionalized individuals who were eligible for Medicaid in December 1973 as inpatients of Title XIX medical institutions or residents of Title XIX intermediate care facilities, if, for each consecutive month after December 1973, they:

a. Continue to meet the December 1973 Medicaid State Plan eligibility requirements;

b. Remain institutionalized; and

c. Continue to need institutional care.

15. Blind and disabled individuals who:

a. Meet all current requirements for Medicaid eligibility except the blindness or disability criteria;

b. Were eligible for Medicaid in December 1973 as blind or disabled; and

c. For each consecutive month after December 1973 continue to meet December 1973 eligibility criteria.

16. Individuals who would be SSI or SSP eligible except for the increase in OASDI benefits under P.L. 92-336 (July 1, 1972), who were entitled to OASDI in August 1972, and who were receiving cash assistance in August 1972. This includes persons who would have been eligible for cash assistance but had not applied in August 1972 (this group was included in this state's August 1972 plan), and persons who would have been eligible for cash assistance in August 1972 if not in a medical institution or intermediate care facility (this group was included in this state's August 1972 plan).

17. Individuals who:

a. Are receiving OASDI and were receiving SSI or SSP but became ineligible for SSI or SSP after April 1977; and

b. Would still be eligible for SSI or SSP if cost-of-living increases in OASDI paid under § 215(i) of the Act received after the last month for which the individual was eligible for and received SSI or SSP and OASDI, concurrently, were deducted from income.

The state applies more restrictive eligibility requirements than those under SSI and the amount of increase that caused SSI or SSP ineligibility and subsequent increases are deducted when determining the amount of countable income for categorically needy eligibility.

18. Disabled widows and widowers who would be eligible for SSI or SSP except for the increase in their OASDI benefits as a result of the elimination of the reduction factor required by § 134 of P.L. 98-21 and who are deemed, for purposes of Title XIX, to be SSI beneficiaries or SSP beneficiaries for individuals who would be eligible for SSP only, under § 1634(b) of the Act.

The state does not apply more restrictive income eligibility standards than those under SSI.

19. Disabled widows, disabled widowers, and disabled unmarried divorced spouses who had been married to the insured individual for a period of at least 10 years before the divorce became effective, who have attained the age of 50, who are receiving Title II payments, and who because of the receipt of Title II income lost eligibility for SSI or SSP which they received in the month prior to the month in which they began to receive Title II payments, who would be eligible for SSI or SSP if the amount of the Title II benefit were not counted as income, and who are not entitled to Medicare Part A.

The state applies more restrictive eligibility requirements for its blind or disabled than those of the SSI program.

20. Qualified Medicare beneficiaries:

a. Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under § 1818 of the Act);

b. Whose income does not exceed 100% of the federal level; and

c. Whose resources do not exceed twice the maximum standard under SSI or, effective January 1, 2010, the resource limit set for the Medicare Part D Low Income Subsidy Program.

Medical assistance for this group is limited to Medicare cost sharing as defined in item 3.2 of this plan.

21. Qualified disabled and working individuals:

a. Who are entitled to hospital insurance benefits under Medicare Part A under § 1818A of the Act;

b. Whose income does not exceed 200% of the federal poverty level;

c. Whose resources do not exceed twice the maximum standard under SSI; and

d. Who are not otherwise eligible for medical assistance under Title XIX of the Act.

Medical assistance for this group is limited to Medicare Part A premiums under §§ 1818 and 1818A of the Act.

22. Specified low-income Medicare beneficiaries:

a. Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under § 1818A of the Act);

b. Whose income for calendar years 1993 and 1994 exceeds the income level in subdivision 25 b of this section, but is less than 110% of the federal poverty level, and whose income for calendar years beginning 1995 is less than 120% of the federal poverty level; and

c. Whose resources do not exceed twice the maximum standard under SSI or, effective January 1, 2010, the resource limit set for the Medicare Part D Low Income Subsidy Program.

Medical assistance for this group is limited to Medicare Part B premiums under § 1839 of the Act.

23. a. Each person to whom SSI benefits by reason of disability are not payable for any month solely by reason of § 1611(e)(3)(A)(i) or (v) shall be treated, for purposes of Title XIX, as receiving SSI benefits for the month.

b. The state applies more restrictive eligibility standards than those under SSI. Individuals whose eligibility for SSI benefits are based solely on disability who are not payable for any months solely by reason of § 1611(e)(3)(A)(i) or (v) and who continue to meet the more restrictive requirements for Medicaid eligibility under the state plan, are eligible for Medicaid as categorically needy.

12VAC30-30-30. Optional coverage of the medically needy.

The Title IV A Agency determines eligibility for Title XIX services.

This plan includes the medically needy:

1. Pregnant women who, except for income and/or resources, would be eligible as categorically needy under Title XIX of the Act.

2. Women who, while pregnant, were eligible for and have applied for Medicaid and receive Medicaid as medically needy under the approved State plan on the date the pregnancy ends. These women continue to be eligible, as though they were pregnant, for all pregnancy-related and postpartum services under the plan for a 60-day 12-month postpartum period after beginning on the last day of the pregnancy ends, and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

3. Individuals under age 18 who, but for income and/or resources, would be eligible under § 1902(a)(10)(A)(i) of the Act.

4. Newborn children born on or after October 1, 1984, to a woman who is eligible as medically needy and is receiving Medicaid on the date of the child's birth. The child is deemed to have applied and been found eligible for Medicaid on the date of birth and remains eligible for one year so long as the woman remains eligible and the child is a member of the woman's household.

5. Reasonable classification of financially eligible individuals under the ages of 21, 20, 19, or 18 as specified below:

(1) Individuals for whom public agencies are assuming full or partial financial responsibility and who are:

(a) In foster homes (and are under the age of 21).

(b) In private institutions (and are under the age of 21).

(c) In addition to the group under (1)(a) and (b), individuals placed in foster homes or private institutions by private, nonprofit agencies (and are under the age of 21).

(2) Individuals in adoptions subsidized in full or part by the public agency (who are under the age of 21).

(3) Individuals in NFs (who are under the age of 21). NF services are provided under this plan.

(4) In addition to the group under (3), individuals in ICFs/MR (who are under the age of 21).

6. Aged Individuals.

7. Blind Individuals.

8. Disabled Individuals.

9. Blind and disabled individuals who:

a. Meet all current requirements for Medicaid eligibility except the blindness or disability criteria;

b. Were eligible as medically needy in December 1973 as blind or disabled; and

c. For each consecutive month after December 1973 continue to meet the December 1973 eligibility criteria.

10. Individuals required to enroll in cost-effective employer-based group health plans remain eligible for a minimum enrollment period of one month.

12VAC30-40-100. Methods of determining income.

A. Families and Children Medically Needy individuals.

1. In determining countable income for Families and Children Medically Needy individuals, the methods under the state's July 16, 1996, approved Aid to Families with Dependent Children plan and any more liberal methods described in 12VAC30-40-280 are used.

2. In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to children living with parents until the children become 21 years of age.

3. Agency continues to treat women eligible under the provisions of § 1902(a)(10) of the Act as eligible, without regard to any changes in income of the family of which she is a member, for the 60-day 12-month postpartum period after her beginning on the last day of the pregnancy ends and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

B. Individuals subject to the use of modified adjusted gross income (MAGI) methodology. In determining income eligibility for individuals subject to the use of MAGI-based methodologies, the following shall apply:

1. The Commonwealth shall apply MAGI-based methodologies as described in this subsection, and consistent with 42 CFR 435.603 and § 1902(e)(14) of the Act. Individuals subject to the use of MAGI-based income methodologies include:

a. Parents/caretaker relatives under §§ 1902(a)(10)(A)(i)(l) and 1931 of the Act.

b. Pregnant women under §§ 1902(a)(10)(A)(i)(I), (III), (IV), (ii)(l), ((IV), (IX) and 1931 of the Act.

c. Children under the age of 19 years under §§ 1902(a)(10)(A)(i)(l), (lll), (IV), (VI), (VII), (ii)((IV), (IX) and 1931 of the Act.

d. Reasonable classifications of children younger than the age of 21 years under §§ 1902(a)(10)(A)(ii)(l) and (IV) of the Act.

e. Individuals younger than the age of 21 years who are under a state adoption assistance agreement under § 1902(a)(10)(A)(ii)(VIII) of the Act.

2. In the case of determining the ongoing eligibility for individuals determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies shall not be applied until March 31, 2014, or the next regularly scheduled renewal of eligibility, whichever is later, if the applications of such methods should result in determination of ineligibility prior to such date.

C. In determining family size for the eligibility determination of a pregnant woman, the pregnant woman shall be counted as herself plus each of the children she is expected to deliver. In determining family size during the eligibility determination of the other individuals in a household that includes a pregnant woman, the pregnant woman shall be counted as just herself.

D. Financial eligibility shall be determined consistent with the following provisions:

1. Financial eligibility shall be based on current monthly income and family size when determining eligibility for new applicants.

2. Financial eligibility shall be based on current monthly household income and family size when determining eligibility for currently enrolled individuals.

3. Household income shall be the sum of the MAGI-based income of every individual included in the individual's household except as provided at 42 CFR 435.603(d)(2) through 42 CFR 435.603(d)(4).

4. An amount equivalent to five percentage points of the federal poverty level for the applicable family size shall be deducted, in determining eligibility for Medicaid, from the household income in accordance with 42 CFR 435.603(d).

5. The age used for children with respect to 42 CFR 435.603(f)(3)(iv) shall be 19 years of age.

E. Aged individuals. In determining countable income for aged individuals, including aged individuals with incomes up to the federal poverty level described in § 1902(m)(1) of the Act, the following methods are used.

1. The methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

2. For optional state supplement recipients in § 1902(f) states and SSI criteria states without § 1616 or § 1634 agreements, SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

3. In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses.

F. Blind individuals. In determining countable income for blind individuals, only the methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

For optional state supplement recipients in § 1902(f) states and SSI criteria states without § 1616 or § 1634 agreements, the SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses and the income of parents as available to children living with parents until the children become 21 years of age.

G. Disabled individuals. In determining countable income of disabled individuals, including disabled individuals with incomes up to the federal poverty level described in § 1902(m) of the Act, the methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

For optional state supplement recipients in § 1902(f) of the Act states and SSI criteria states without § 1616 or § 1634 agreements, the SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses and the income of parents as available to children living with parents until the children become 21 years of age.

H. Qualified Medicare beneficiaries. In determining countable income for qualified Medicare beneficiaries covered under § 1902(a)(10)(E)(i) of the Act, the methods of the SSI program, more liberal methods described in 12VAC30-40-280, or both are used.

If an individual receives a Title II benefit, any amounts attributable to the most recent increase in the monthly insurance benefit as a result of a Title II COLA is not counted as income during a "transition period" beginning with January, when the Title II benefit for December is received, and ending with the last day of the month following the month of publication of the revised annual federal poverty level.

For individuals with Title II income, the revised poverty levels are not effective until the first day of the month following the end of the transition period.

For individuals not receiving Title II income, the revised poverty levels are effective no later than the date of publication.

I. Qualified disabled and working individuals. In determining countable income for qualified disabled and working individuals covered under § 1902(a)(10)(E)(ii) of the Act, the methods of the SSI program are used.

12VAC30-50-10. Services provided to the categorically needy with limitations.

The following services are provided with limitations as described in Part III (12VAC30-50-100 et seq.) of this chapter:

1. Inpatient hospital services other than those provided in an institution for mental diseases.

2. Outpatient hospital services.

3. Other laboratory and x-ray services; nonemergency outpatient Magnetic Resonance Imaging (MRI), including Magnetic Resonance Angiography (MRA), Computerized Axial Tomography (CAT) scans, including Computed Tomography Angiography (CTA), and Positron Emission Tomography (PET) scans performed for the purpose of diagnosing a disease process or physical injury require prior authorization.

4. Rural health clinic services and other ambulatory services furnished by a rural health clinic.

5. Federally Qualified Health Center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with § 4231 of the State Medicaid Manual (HCFA Pub. 45-4).

6. Early and periodic screening and diagnosis of individuals under 21 years of age, and treatment of conditions found.

7. Family planning services and supplies for individuals of child-bearing age.

8. Physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere.

9. Medical and surgical services furnished by a dentist (in accordance with § 1905(a)(5)(B) of the Act).

10. Medical care or any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by state law: podiatrists, optometrists and other practitioners.

11. Home health services: intermittent or part-time nursing service provided by a home health agency or by a registered nurse when no home health agency exists in the area; home health aide services provided by a home health agency; and medical supplies, equipment, and appliances suitable for use in the home; physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility.

12. Clinic services.

13. Dental services.

14. Physical therapy and related services, including occupational therapy and services for individuals with speech, hearing, and language disorders (provided by or under supervision of a speech pathologist or audiologist).

15. Prescribed drugs, prosthetic devices, and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

16. Other rehabilitative services, screening services, preventive services.

17. Nurse-midwife services.

18. Case management services as defined in, and to the group specified in, 12VAC30-50-95 et seq. (in accordance with § 1905(a)(19) or § 1915(g) of the Act).

19. Extended services to pregnant women: pregnancy-related and postpartum services for a 60-day 12-month postpartum period after beginning on the last day of the pregnancy ends and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends (see 12VAC30-50-510). (Note: Additional coverage beyond limitations.)

20. Pediatric or family nurse practitioners' service.

21. Any other medical care and any other type of remedial care recognized by state law, specified by the Secretary: transportation.

12VAC30-50-50. Services provided to the medically needy with limitations.

Services as described in Part III (12VAC30-50-100 et seq.) of this chapter are provided to the medically needy with limitations.

1. Inpatient hospital services other than those provided in an institution for mental diseases.

2. Outpatient hospital services.

3. Other laboratory and x-ray services; nonemergency outpatient Magnetic Resonance Imaging (MRI), Computer Axial Tomography (CAT) scans, and Positron Emission Tomography (PET) scans require prior authorization.

4. Rural health clinic services and other ambulatory services furnished by a rural health clinic.

5. Federally qualified health center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with § 4231 of the State Medicaid Manual (HCFA, Pub. 45-4).

6. Family planning services and supplies for individuals of childbearing age.

7. Physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere.

8. Medical and surgical services furnished by a dentist (in accordance with § 1905(a)(5)(B) of the Act).

9. Medical care and any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by state law, including:

a. Podiatrists' services;

b. Optometrists' services; and

c. Other practitioners' services.

10. Home health services' medical supplies, equipment, and appliances suitable for use in the home; intermittent or part-time nursing service provided by a home health agency or by a registered nurse when no home health agency exists in the area; home health aide services provided by a home health agency; physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility.

11. Clinic services.

12. Dental services.

13. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders provided by or under supervision of a speech pathologist or audiologist.

14. Prescribed drugs, prosthetic devices, and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

15. Rehabilitative services.

16. Nurse-midwife services.

17. Case management services as defined in, and to the group specified in, 12VAC30-50-410 (in accordance with § 1905(a)(19) or § 1915(g) of the Act).

18. Extended services for pregnant women, including pregnancy-related and post-partum postpartum services for 60 days after the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends.

19. Certified pediatric or family nurse practitioners' services.

20. Any other medical care and any other type of remedial care recognized under state law, specified by the secretary, specifically transportation.

12VAC30-50-190. Dental services.

A. Dental services shall be covered for individuals younger than 21 years of age in fulfillment of the treatment requirements under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program and defined as routine diagnostic, preventive, or restorative procedures necessary for oral health provided by or under the direct supervision of a dentist in accordance with Chapter 27 (§ 54.1-2700 et seq.) of Title 54.1 of the Code of Virginia.

1. The Department of Medical Assistance Services (DMAS) will provide any medically necessary dental service to individuals younger than 21 years of age.

2. Certain dental services, as described in the DMAS Office Reference Manual (Smiles for Children, March 13, 2014), prepared by DMAS's dental benefits administrator, require preauthorization or prepayment review by DMAS or its designee.

3. Dental services for individuals younger than the age of 21 years that do not require preauthorization or prepayment review are initial, periodic, and emergency examinations; required radiography necessary to develop a treatment plan; patient education; dental prophylaxis; fluoride treatments; routine amalgam and composite restorations; stainless steel crowns, prefabricated steel post and temporary (polycarbonate) crowns, and stainless steel bands; crown recementation; pulpotomies; emergency endodontics for temporary relief of pain; pulp capping; sedative fillings; therapeutic apical closure; topical palliative treatment for dental pain; removal of foreign body; simple extractions; root recovery; incision and drainage of abscess; surgical exposure of the tooth to aid eruption; sequestrectomy for osteomyelitis; and oral antral fistula closure.

B. Dental services determined by the dental provider to be medically appropriate for an adult woman during the term of her pregnancy and through the end of the month following the 60th day postpartum shall be provided to a Medicaid-enrolled pregnant woman individual during pregnancy and for the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends. The dental services that shall be covered are (i) diagnostic x-rays and exams; (ii) preventive cleanings; (iii) restorative fillings; (iv) endodontics (root canals); (v) periodontics (gum-related treatments); (vi) prosthodontics, both removable and fixed (crowns, bridges, partial plates, and dentures); (vii) oral surgery (tooth extractions and other oral surgeries); and (viii) adjunctive general services (all covered services that do not fall into specific professional categories). These services require prepayment review by DMAS or its designee.

C. For the dental services covered for Medicaid-enrolled adult pregnant women, DMAS may place appropriate limits on a service based on medical necessity, for utilization control, or both. Examples of service limitations are examinations, prophylaxis, fluoride treatment (once/six months); space maintenance appliances; bitewing x-ray - two films (once/12 months); routine amalgam and composite restorations (once/three years); dentures (once/five years); extractions, tooth guidance appliances, permanent crowns and bridges, endodontics, patient education and sealants (once).

D. Limited oral surgery procedures, as defined and covered under Title XVIII (Medicare), are covered for all recipients, and require preauthorization or prepayment review by DMAS or its designee as described in the agency's Office Reference Manual located on the DMAS website at http://www.dmas.virginia.gov/#/dentalresources.

E. Residents of nursing facilities shall be permitted to deduct the costs of limited specific dental procedures from their payments toward the costs of their nursing facility care. Nursing facility residents shall be limited to deducting the following dental procedures: (i) routine exams and x-rays and dental cleaning twice yearly; (ii) full mouth x-rays once every three years; and (iii) extractions and fillings shall be permitted only if medically necessary as determined by DMAS.

12VAC30-50-290. Extended services to pregnant women.

A. Pregnancy-related and postpartum services for 60 days after the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends. The same limitations on all covered services apply to this group as to all other recipient groups.

B. Services for any other medical conditions that may complicate pregnancy. The same limitations on all covered services apply to this group as to all other recipient groups.

12VAC30-141-670. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Adverse action," consistent with 42 CFR 457.1130, means the denial of eligibility; failure to make a timely determination of eligibility; suspension or termination of enrollment, including disenrollment for failure to pay cost sharing; or delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of services; and failure to approve, furnish, or provide payment for health services in a timely manner; provided, however, that determination of eligibility to participate in and termination of participation in the FAMIS Select program shall not constitute an adverse action.

"Adverse benefit determination," consistent with 42 CFR 438.400, means the denial or limited authorization of a requested service; the failure to take action or timely take action on a request for service; the reduction, suspension, or termination of a previously authorized service; denial in whole or in part of a payment for a service; failure to provide services within the timeframes required by the state; for a resident of a rural exception area with only one MCO, the denial of a enrollee's request to exercise the enrollee's right under 42 CFR 438.52(b)(2)(ii) to obtain services outside of the network; the denial of a enrollee's request to dispute a financial liability as provided in 42 CFR 438.400(b)(7); or the failure of an MCO to act within the timeframes provided in 42 CFR 438.408(b).

"Agency" means the same as defined in 12VAC30-141-10.

"Agent" means an individual designated in writing to act on behalf of a FAMIS MOMS Plan applicant or enrollee during the administrative review process.

"Appeal" means an enrollee's request for review of an adverse benefit determination by an MCO or an adverse action by the LDSS, CPU, or DMAS.

"Applicant" means a pregnant woman who has filed an application (or who has an application filed on her behalf) for health insurance and is awaiting a determination of eligibility. A pregnant woman is an applicant until her eligibility has been determined.

"Application for health insurance" means the single streamlined application for determining eligibility in public health insurance programs operated by the Commonwealth.

"Authorized representative" means a person who is authorized to conduct the personal or financial affairs for an individual who is 18 years of age or older.

"Central processing unit" or "CPU" means Cover Virginia, which is the same as defined in 12VAC30-141-10.

"Child" means an individual younger than 19 years of age.

"Conservator" means a person appointed by a court of competent jurisdiction to manage the estate and financial affairs of an incapacitated individual.

"Continuation of coverage" means ensuring an enrollee's benefits are continued until completion of the review process, with the condition that should the enrollee not prevail in the review process, the enrollee shall be liable for the repayment of all benefits received during the review process.

"Director" means the individual, or his designee, specified in § 32.1-324 of the Code of Virginia with all of the attendant duties and responsibilities to administer the State Plan for Medical Assistance and the State Plan for Title XXI.

"DMAS" or "department" means the Department of Medical Assistance Services.

"Enrollee" means a pregnant woman who has been determined eligible to participate in FAMIS MOMS and is enrolled in the FAMIS MOMS program.

"FAMIS" means the Family Access to Medical Insurance Security Plan.

"FAMIS MOMS" means the Title XXI program available to eligible pregnant women.

"Federal poverty level" or "FPL" means that income standard as published annually by the U.S. Department of Health and Human Services in the Federal Register.

"Fee-for-service" means the traditional Medicaid health care delivery and payment system in which physicians and other providers receive a payment for each unit of service they provide.

"Guardian" means a person appointed by a court of competent jurisdiction to be responsible for the affairs of an incapacitated individual, including responsibility for making decisions regarding the person's support, care, health, safety, habilitation, education, and therapeutic treatment, and, if not inconsistent with an order of commitment, residence.

"Incapacitated " means a person who, pursuant to an order of a court of competent jurisdiction, has been found to be incapable of receiving and evaluating information effectively or responding to people, events, or environments to such an extent that the individual lacks the capacity to (i) meet the essential requirements of her health, care, safety, or therapeutic needs without the assistance or protection of a guardian, or (ii) manage property or financial affairs or provide for her support or for the support of her legal dependents without the assistance or protection of a conservator.

"LDSS" or "local department" means the local department of social services.

"Managed care organization" or "MCO" means an organization that offers managed care health insurance plans (MCHIPs) as defined in § 32.1-137.1 of the Code of Virginia.

"Pregnant woman" means a woman of any age who is medically determined to be pregnant. The pregnant woman definition is met from the first day of the earliest month that the medical practitioner certifies as being a month in which the woman was pregnant, through the last day of the month in which the 60th day occurs, following and continues for the duration of the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which her pregnancy ended the 12-month period ends, regardless of the reason the pregnancy ended.

"Provider" means the individual, facility, or other entity registered, licensed, or certified, as appropriate, and enrolled by an MCHIP or in fee-for-service to render services to FAMIS MOMS enrollees eligible for services.

"State fair hearing" means, consistent with 42 CFR 438.400, the process set forth in 42 CFR 431 Subpart E.

"Title XXI" means the federal State Children's Health Insurance Program as established by Subtitle J of the Balanced Budget Act of 1997.

12VAC30-141-750. Duration of eligibility.

A. The effective date of FAMIS MOMS eligibility shall be the first day of the month in which an application was received by LDSS, DMAS, or the CPU if the applicant met all eligibility requirements in that month.

B. Eligibility for FAMIS MOMS will continue through the last day of the month in which the 60th day occurs, following the last day the woman was pregnant for the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends, regardless of the reason the pregnancy ended. Eligibility will continue until the end of the coverage period, regardless of changes in circumstances such as income or family size.

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Emergency Regulation

Titles of Regulations: 12VAC30-10. State Plan under Title XIX of the Social Security Act Medical Assistance Program; General Provisions (amending 12VAC30-10-140, 12VAC30-10-150).

12VAC30-30. Groups Covered and Agencies Responsible for Eligibility Determination (amending 12VAC30-30-10, 12VAC30-30-30).

12VAC30-40. Eligibility Conditions and Requirements (amending 12VAC30-40-100).

12VAC30-50. Amount, Duration, and Scope of Medical and Remedial Care Services (amending 12VAC30-50-10, 12VAC30-50-50, 12VAC30-50-190, 12VAC30-50-290).

12VAC30-141. Family Access to Medical Insurance Security Plan (amending 12VAC30-141-670, 12VAC30-141-750).

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Effective Dates: August 13, 2026, through February 18, 2028.

Agency Contact: Meredith Lee, Policy, Regulations, and Manuals Supervisor, Division of Policy and Research, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-0552, fax (804) 786-1680, TDD (800) 343-0634, or email meredith.lee@dmas.virginia.gov.

Preamble:

Section 2.2-4011 B 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.

The amendments provide continuous coverage through 12 months postpartum for Medicaid and Family Access to Medical Insurance Security (FAMIS) pregnant and postpartum members and eligible individuals. A pregnant individual who is deemed eligible will maintain coverage for the duration of 12 months from the date the pregnancy ends, regardless of what point in the prenatal or postpartum period individual enrolls in coverage. The coverage will be maintained regardless of a change in circumstances affecting income or household size.

12VAC30-10-140. Amount, duration, and scope of services: Categorically needy.

Medicaid is provided in accordance with the requirements of 42 CFR 440, Subpart B and § 1902(a), 1902(e), 1905(a), 1905(p), 1915, 1920, and 1925 of the Act.

Services for the categorically needy are described below and in 12VAC30-50-10 et seq. These services include:

1. Each item or service listed in § 1905(a)(1) through (5) and (21) of the Act, is provided as defined in 42 CFR Part 440, Subpart A, or, for EPSDT services, § 1905(r) and 42 CFR Part 411, Subpart B.

2. Nurse-midwife services listed in § 1905(a)(17) of the Act, are provided to the extent that nurse-midwives are authorized to practice under state law or regulation and without regard to whether the services are furnished in the area of management of the care of mothers and babies throughout the maternity cycle. Nurse-midwives are permitted to enter into independent provider agreements with the Medicaid agency without regard to whether the nurse-midwife is under the supervision of, or associated with, a physician or other health care provider.

3. Pregnancy-related, including family planning service, and postpartum services for a 60-day 12-month postpartum period (beginning on the last day of the pregnancy ends) and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends, are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

4. Services for medical conditions that may complicate the pregnancy (other than pregnancy-related or postpartum services) are provided to pregnant women.

5. Services related to pregnancy (including prenatal, delivery, postpartum, and family planning services) and to other conditions that may complicate pregnancy are the same services provided to poverty level pregnant women eligible under the provision of § 1902(a)(10)(A)(i)(IV) and 1902(a)(10)(A)(ii)(IX) of the Act.

6. Home health services are provided to individuals entitled to nursing facility services as indicated in 12VAC30-10-220 of this plan.

7. Inpatient services that are being furnished to infants and children described in § 1902(l)(1)(B) through (D), or § 1905(n)(2) of the Act, on the date the infant or child attains the maximum age for coverage under the approved State plan will continue until the end of the stay for which the inpatient services are furnished.

8. Respiratory care services are not provided to ventilator dependent individuals as indicated in 12VAC30-10-300 of this plan.

9. Services are provided to families eligible under § 1925 of the Act as indicated in 12VAC30-10-350 of this plan.

10. Home and community care for functionally disabled elderly individuals is not covered.

11. Program of All-Inclusive Care for the Elderly (PACE) services as described and limited in Supplement 6 to Attachment 3.1-A (12VAC30-50-320, 12VAC30-50-321, 12VAC30-50-325, and 12VAC30-50-328).

12VAC30-50-10 et seq. identifies the medical and remedial services provided to the categorically needy, specifies all limitations on the amount, duration, and scope of those service, and lists the additional coverage (that is in excess of established service limits) for pregnancy-related services and services for conditions that may complicate the pregnancy.

12VAC30-10-150. Amount, duration, and scope of services: Medically needy.

A. This State Plan covers the medically needy. The services described in this section and in Part II (12VAC30-50-40 et seq.) of 12VAC30-50 are provided. Services for the medically needy include:

1. If services in an institution for mental diseases (42 CFR 440.140 and 440.160) or an intermediate care facility for individuals with intellectual disabilities (or both) are provided to any medically needy group, then each medically needy group is provided either the services listed in § 1905(a)(1) through (5) and (17) of the Act, or seven of the services listed in § 1902(a)(1) through (20). The services are provided as defined in 42 CFR 440, Subpart A and in §§ 1902, 1905, and 1915 of the Act.

Subdivision 1 of this subsection is applicable with respect to nurse-midwife services under § 1902(a)(17).

2. Prenatal care and delivery services for pregnant women.

3. Pregnancy-related, including family planning services, and postpartum services for a 60-day 12-month postpartum period (beginning on the last day of the pregnancy ends) and including any remaining days in of the calendar month in which the sixtieth day falls 12-month period ends, are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

4. Services for any other medical condition that may complicate the pregnancy (other than pregnancy-related and postpartum services) are provided to pregnant women.

5. Ambulatory services as defined in 12VAC30-50-40 for recipients younger than 18 years of age and recipients entitled to institutional services.

6. Home health services to recipients entitled to nursing facility services as indicated in 12VAC30-10-220.

7. Services for the medically needy do not include services in an institution for mental diseases for individuals older than 65 years of age.

8. Services for the medically needy do not include services in an intermediate care facility for individuals with intellectual disabilities.

9. Services for the medically needy do not include inpatient psychiatric services for individuals younger than 21 years of age, other than those covered under early and periodic screening, diagnosis, and treatment (at 12VAC30-50-130).

10. Services for the medically needy do not include respiratory care services provided to ventilator dependent individuals. See 12VAC30-10-300.

11. Home and community care for functionally disabled elderly individuals is not covered.

12. Program of All-Inclusive Care for the Elderly (PACE) services as described and limited in Supplement 6 to Attachment 3.1-A (12VAC30-50-320, 12VAC30-50-321, 12VAC30-50-325, and 12VAC30-50-328) are covered.

B. Part II (12VAC30-50-40 et seq.) of 12VAC30-50 identifies services provided to each covered group of the medically needy. (Note: Other programs to be offered to medically needy beneficiaries would specify all limitations on the amount, duration, and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. In addition, other programs to be offered to medically needy beneficiaries would also list the additional coverage that is in excess of established service limits for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population, this also is not applicable for this program.)

12VAC30-30-10. Mandatory coverage: categorically needy and other required special groups.

The Title IV-A agency or the Department of Medical Assistance Services Central Processing Unit determines eligibility for Title XIX services. The following groups shall be eligible for medical assistance as specified:

1. Parents and other caretaker relatives of dependent children with household income at or below a standard established by the Commonwealth in 12VAC30-40-100 consistent with 42 CFR 435.110 and §§ 1902(a)(10)(A)(i)(l) and 1931(b) of the Social Security Act. Individuals qualifying under this eligibility group shall meet the following criteria:

a. Parents, other caretaker relatives (defined at 42 CFR 435.4) including pregnant women, or dependent children (defined at 42 CFR 435.4) younger than 18 years of age. This group includes individuals who are parents or other caretaker relatives of children who are 18 years of age provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training and are expected to complete such school or training before their 19th birthday.

b. Spouses of parents and other caretaker relatives shall include other relatives of the child based on blood (including those of half-blood), adoption, or marriage. Other relatives of a specified degree of the dependent child shall include any blood relative (including those of half-blood) and including (i) first cousins; (ii) nephews or nieces; (iii) persons of preceding generations as denoted by prefixes of grand, great, or great-great; (iv) stepbrother; (v) stepsister; (vi) a relative by adoption following entry of the interlocutory or final order, whichever is first; (vii) the same relatives by adoption as listed in this subdivision 1 b; and (viii) spouses of any persons named in this subdivision 1 b even after the marriage is terminated by death or divorce.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

2. Women who are pregnant or postpartum with household income at or below a standard established by the Commonwealth in 12VAC30-40-100, consistent with 42 CFR 435.116 and §§ 1902(a)(10)(A)(i)(III) and (IV), 1902(a)(10)(A)(ii)(I) and (IX), and 1931(b) of the Act. Individuals qualifying under this eligibility group shall be pregnant or postpartum as defined in 42 CFR 435.4.

a. A woman who, while pregnant, was eligible for, applied for, and received Medicaid under the approved state plan on the day her pregnancy ends. The woman continues to be eligible, as though she were pregnant, for all pregnancy-related and postpartum medical assistance under the plan for a 60-day 12-month postpartum period, beginning on the last day of her the pregnancy, and for including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

b. A pregnant woman who would otherwise lose eligibility because of an increase in income of the family in which she is a member during the pregnancy or the 12-month postpartum period that extends through the end of the month in which the 60-day period, beginning on the last day of pregnancy, and including any remaining days of the calendar month in which the 12-month period ends.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

3. Infants and children younger than 19 years of age with household income at or below standards based on this age group, consistent with 42 CFR 435.118 and §§ 1902(a)(10)(A)(i)(III), (IV) and (VIII); 1902(a)(10)(A)(ii)(IV) and (IX); and 1931(b) of the Act. Children qualifying under this eligibility group shall meet the following criteria:

a. They are younger than 19 years of age; and

b. They have a household income at or below the standard established by the Commonwealth.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

4. The adult group as described at 42 CFR 435.119.

5. Former foster care children younger than 26 years of age who are not otherwise mandatorily eligible in another Medicaid classification, who were on Medicaid and in foster care when they turned 18 years of age, or who aged out of foster care. Individuals qualifying under this eligibility group shall meet the following criteria:

a. They shall be younger than 26 years of age;

b. They shall not be otherwise eligible for and enrolled for mandatory coverage under the state plan; and

c. They were in foster care under the responsibility of the Commonwealth or a federally recognized tribe and were enrolled in Virginia Medicaid under the state plan when they turned 18 years of age or at the time of aging out of the foster care program.

6. Families terminated from coverage under § 1931 of the Act solely because of earnings or hours of employment shall be entitled to up to 12 months of extended benefits in accordance with § 1925 of the Act.

7. A child born to a woman who is eligible for and receiving Medicaid on the date of the child's birth. The child is deemed to have applied and been found eligible for Medicaid on the date of birth and remains eligible for one year from birth, as long as he remains a resident of the Commonwealth. A redetermination of eligibility must be completed on behalf of the deemed child at age one year and annually thereafter so long as he remains eligible.

8. Aged, blind, and disabled individuals receiving cash assistance.

a. Individuals who meet more restrictive requirements for Medicaid than the SSI requirements. (This includes persons who qualify for benefits under § 1619(a) of the Act or who meet the eligibility requirements for SSI status under § 1619(b)(1) of the Act and who met the Commonwealth's more restrictive requirements for Medicaid in the month before the month they qualified for SSI under § 1619(a) or met the requirements under § 1619(b)(1) of the Act. Medicaid eligibility for these individuals continues as long as they continue to meet the § 1619(a) eligibility standard or the requirements of § 1619(b) of the Act.)

b. These persons include the aged, the blind, and the disabled.

c. Protected SSI children (pursuant to § 1902(a)(10)(A)(i)(II) of the Act) (P.L. 105-33 § 4913). Children who meet the pre-welfare reform definition of childhood disability who lost their SSI coverage solely as a result of the change in the definition of childhood disability, and who also meet the more restrictive requirements for Medicaid than the SSI requirements.

d. The more restrictive categorical eligibility criteria are described in 12VAC30-30-40.

Financial criteria are described in 12VAC30-40-10.

9. Qualified severely impaired blind and disabled individuals younger than 65 years of age who:

a. For the month preceding the first month of eligibility under the requirements of § 1905(q)(2) of the Act, received SSI, a state supplementary payment (SSP) under § 1616 of the Act or under § 212 of P.L. 93-66 or benefits under § 1619(a) of the Act and were eligible for Medicaid; or

b. For the month of June 1987, were considered to be receiving SSI under § 1619(b) of the Act and were eligible for Medicaid. These individuals must:

(1) Continue to meet the criteria for blindness or have the disabling physical or mental impairment under which the individual was found to be disabled;

(2) Except for earnings, continue to meet all nondisability-related requirements for eligibility for SSI benefits;

(3) Have unearned income in amounts that would not cause them to be ineligible for a payment under § 1611(b) of the Act;

(4) Be seriously inhibited by the lack of Medicaid coverage in their ability to continue to work or obtain employment; and

(5) Have earnings that are not sufficient to provide for themselves a reasonable equivalent of the Medicaid, SSI (including any federally administered SSP), or public funded attendant care services that would be available if they did have such earnings.

The state applies more restrictive eligibility requirements for Medicaid than under SSI and under 42 CFR 435.121. Individuals who qualify for benefits under § 1619(a) of the Act or individuals described in this section who meet the eligibility requirements for SSI benefits under § 1619(b)(1) of the Act and who met the state's more restrictive requirements in the month before the month they qualified for SSI under § 1619(a) or met the requirements of § 1619(b)(1) of the Act are covered. Eligibility for these individuals continues as long as they continue to qualify for benefits under § 1619(a) of the Act or meet the SSI requirements under § 1619(b)(1) of the Act.

10. Except in states that apply more restrictive requirements for Medicaid than under SSI, blind or disabled individuals who:

a. Are at least 18 years of age; and

b. Lose SSI eligibility because they become entitled to Old Age, Survivor, and Disability Insurance (OASDI) child's benefits under § 202(d) of the Act or an increase in these benefits based on their disability. Medicaid eligibility for these individuals continues for as long as they would be eligible for SSI, absence their OASDI eligibility.

The Commonwealth does not apply more restrictive income eligibility requirements than those under SSI.

11. Except in states that apply more restrictive eligibility requirements for Medicaid than under SSI, individuals who are ineligible for SSI or optional state supplements (if the agency provides Medicaid under § 435.230 of the Act), because of requirements that do not apply under Title XIX of the Act.

12. Individuals receiving mandatory state supplements.

13. Individuals who in December 1973 were eligible for Medicaid as an essential spouse and who have continued, as a spouse, to live with and be essential to the well-being of a recipient of cash assistance. The recipient with whom the essential spouse is living continues to meet the December 1973 eligibility requirements of the Commonwealth's approved plan for Old Age Assistance, Aid to the Blind, Aid to the Permanently and Totally Disabled, or Aid to the Aged, Blind, and Disabled and the spouse continues to meet the December 1973 requirements for his needs to be included in computing the cash payment. In December 1973, Medicaid coverage of the essential spouse was limited to the aged, the blind, and the disabled.

14. Institutionalized individuals who were eligible for Medicaid in December 1973 as inpatients of Title XIX medical institutions or residents of Title XIX intermediate care facilities, if, for each consecutive month after December 1973, they:

a. Continue to meet the December 1973 Medicaid State Plan eligibility requirements;

b. Remain institutionalized; and

c. Continue to need institutional care.

15. Blind and disabled individuals who:

a. Meet all current requirements for Medicaid eligibility except the blindness or disability criteria;

b. Were eligible for Medicaid in December 1973 as blind or disabled; and

c. For each consecutive month after December 1973 continue to meet December 1973 eligibility criteria.

16. Individuals who would be SSI or SSP eligible except for the increase in OASDI benefits under P.L. 92-336 (July 1, 1972), who were entitled to OASDI in August 1972, and who were receiving cash assistance in August 1972. This includes persons who would have been eligible for cash assistance but had not applied in August 1972 (this group was included in this state's August 1972 plan), and persons who would have been eligible for cash assistance in August 1972 if not in a medical institution or intermediate care facility (this group was included in this state's August 1972 plan).

17. Individuals who:

a. Are receiving OASDI and were receiving SSI or SSP but became ineligible for SSI or SSP after April 1977; and

b. Would still be eligible for SSI or SSP if cost-of-living increases in OASDI paid under § 215(i) of the Act received after the last month for which the individual was eligible for and received SSI or SSP and OASDI, concurrently, were deducted from income.

The state applies more restrictive eligibility requirements than those under SSI and the amount of increase that caused SSI or SSP ineligibility and subsequent increases are deducted when determining the amount of countable income for categorically needy eligibility.

18. Disabled widows and widowers who would be eligible for SSI or SSP except for the increase in their OASDI benefits as a result of the elimination of the reduction factor required by § 134 of P.L. 98-21 and who are deemed, for purposes of Title XIX, to be SSI beneficiaries or SSP beneficiaries for individuals who would be eligible for SSP only, under § 1634(b) of the Act.

The state does not apply more restrictive income eligibility standards than those under SSI.

19. Disabled widows, disabled widowers, and disabled unmarried divorced spouses who had been married to the insured individual for a period of at least 10 years before the divorce became effective, who have attained the age of 50, who are receiving Title II payments, and who because of the receipt of Title II income lost eligibility for SSI or SSP which they received in the month prior to the month in which they began to receive Title II payments, who would be eligible for SSI or SSP if the amount of the Title II benefit were not counted as income, and who are not entitled to Medicare Part A.

The state applies more restrictive eligibility requirements for its blind or disabled than those of the SSI program.

20. Qualified Medicare beneficiaries:

a. Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under § 1818 of the Act);

b. Whose income does not exceed 100% of the federal level; and

c. Whose resources do not exceed twice the maximum standard under SSI or, effective January 1, 2010, the resource limit set for the Medicare Part D Low Income Subsidy Program.

Medical assistance for this group is limited to Medicare cost sharing as defined in item 3.2 of this plan.

21. Qualified disabled and working individuals:

a. Who are entitled to hospital insurance benefits under Medicare Part A under § 1818A of the Act;

b. Whose income does not exceed 200% of the federal poverty level;

c. Whose resources do not exceed twice the maximum standard under SSI; and

d. Who are not otherwise eligible for medical assistance under Title XIX of the Act.

Medical assistance for this group is limited to Medicare Part A premiums under §§ 1818 and 1818A of the Act.

22. Specified low-income Medicare beneficiaries:

a. Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under § 1818A of the Act);

b. Whose income for calendar years 1993 and 1994 exceeds the income level in subdivision 25 b of this section, but is less than 110% of the federal poverty level, and whose income for calendar years beginning 1995 is less than 120% of the federal poverty level; and

c. Whose resources do not exceed twice the maximum standard under SSI or, effective January 1, 2010, the resource limit set for the Medicare Part D Low Income Subsidy Program.

Medical assistance for this group is limited to Medicare Part B premiums under § 1839 of the Act.

23. a. Each person to whom SSI benefits by reason of disability are not payable for any month solely by reason of § 1611(e)(3)(A)(i) or (v) shall be treated, for purposes of Title XIX, as receiving SSI benefits for the month.

b. The state applies more restrictive eligibility standards than those under SSI. Individuals whose eligibility for SSI benefits are based solely on disability who are not payable for any months solely by reason of § 1611(e)(3)(A)(i) or (v) and who continue to meet the more restrictive requirements for Medicaid eligibility under the state plan, are eligible for Medicaid as categorically needy.

12VAC30-30-30. Optional coverage of the medically needy.

The Title IV A Agency determines eligibility for Title XIX services.

This plan includes the medically needy:

1. Pregnant women who, except for income and/or resources, would be eligible as categorically needy under Title XIX of the Act.

2. Women who, while pregnant, were eligible for and have applied for Medicaid and receive Medicaid as medically needy under the approved State plan on the date the pregnancy ends. These women continue to be eligible, as though they were pregnant, for all pregnancy-related and postpartum services under the plan for a 60-day 12-month postpartum period after beginning on the last day of the pregnancy ends, and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

3. Individuals under age 18 who, but for income and/or resources, would be eligible under § 1902(a)(10)(A)(i) of the Act.

4. Newborn children born on or after October 1, 1984, to a woman who is eligible as medically needy and is receiving Medicaid on the date of the child's birth. The child is deemed to have applied and been found eligible for Medicaid on the date of birth and remains eligible for one year so long as the woman remains eligible and the child is a member of the woman's household.

5. Reasonable classification of financially eligible individuals under the ages of 21, 20, 19, or 18 as specified below:

(1) Individuals for whom public agencies are assuming full or partial financial responsibility and who are:

(a) In foster homes (and are under the age of 21).

(b) In private institutions (and are under the age of 21).

(c) In addition to the group under (1)(a) and (b), individuals placed in foster homes or private institutions by private, nonprofit agencies (and are under the age of 21).

(2) Individuals in adoptions subsidized in full or part by the public agency (who are under the age of 21).

(3) Individuals in NFs (who are under the age of 21). NF services are provided under this plan.

(4) In addition to the group under (3), individuals in ICFs/MR (who are under the age of 21).

6. Aged Individuals.

7. Blind Individuals.

8. Disabled Individuals.

9. Blind and disabled individuals who:

a. Meet all current requirements for Medicaid eligibility except the blindness or disability criteria;

b. Were eligible as medically needy in December 1973 as blind or disabled; and

c. For each consecutive month after December 1973 continue to meet the December 1973 eligibility criteria.

10. Individuals required to enroll in cost-effective employer-based group health plans remain eligible for a minimum enrollment period of one month.

12VAC30-40-100. Methods of determining income.

A. Families and Children Medically Needy individuals.

1. In determining countable income for Families and Children Medically Needy individuals, the methods under the state's July 16, 1996, approved Aid to Families with Dependent Children plan and any more liberal methods described in 12VAC30-40-280 are used.

2. In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to children living with parents until the children become 21 years of age.

3. Agency continues to treat women eligible under the provisions of § 1902(a)(10) of the Act as eligible, without regard to any changes in income of the family of which she is a member, for the 60-day 12-month postpartum period after her beginning on the last day of the pregnancy ends and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

B. Individuals subject to the use of modified adjusted gross income (MAGI) methodology. In determining income eligibility for individuals subject to the use of MAGI-based methodologies, the following shall apply:

1. The Commonwealth shall apply MAGI-based methodologies as described in this subsection, and consistent with 42 CFR 435.603 and § 1902(e)(14) of the Act. Individuals subject to the use of MAGI-based income methodologies include:

a. Parents/caretaker relatives under §§ 1902(a)(10)(A)(i)(l) and 1931 of the Act.

b. Pregnant women under §§ 1902(a)(10)(A)(i)(I), (III), (IV), (ii)(l), ((IV), (IX) and 1931 of the Act.

c. Children under the age of 19 years under §§ 1902(a)(10)(A)(i)(l), (lll), (IV), (VI), (VII), (ii)((IV), (IX) and 1931 of the Act.

d. Reasonable classifications of children younger than the age of 21 years under §§ 1902(a)(10)(A)(ii)(l) and (IV) of the Act.

e. Individuals younger than the age of 21 years who are under a state adoption assistance agreement under § 1902(a)(10)(A)(ii)(VIII) of the Act.

2. In the case of determining the ongoing eligibility for individuals determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies shall not be applied until March 31, 2014, or the next regularly scheduled renewal of eligibility, whichever is later, if the applications of such methods should result in determination of ineligibility prior to such date.

C. In determining family size for the eligibility determination of a pregnant woman, the pregnant woman shall be counted as herself plus each of the children she is expected to deliver. In determining family size during the eligibility determination of the other individuals in a household that includes a pregnant woman, the pregnant woman shall be counted as just herself.

D. Financial eligibility shall be determined consistent with the following provisions:

1. Financial eligibility shall be based on current monthly income and family size when determining eligibility for new applicants.

2. Financial eligibility shall be based on current monthly household income and family size when determining eligibility for currently enrolled individuals.

3. Household income shall be the sum of the MAGI-based income of every individual included in the individual's household except as provided at 42 CFR 435.603(d)(2) through 42 CFR 435.603(d)(4).

4. An amount equivalent to five percentage points of the federal poverty level for the applicable family size shall be deducted, in determining eligibility for Medicaid, from the household income in accordance with 42 CFR 435.603(d).

5. The age used for children with respect to 42 CFR 435.603(f)(3)(iv) shall be 19 years of age.

E. Aged individuals. In determining countable income for aged individuals, including aged individuals with incomes up to the federal poverty level described in § 1902(m)(1) of the Act, the following methods are used.

1. The methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

2. For optional state supplement recipients in § 1902(f) states and SSI criteria states without § 1616 or § 1634 agreements, SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

3. In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses.

F. Blind individuals. In determining countable income for blind individuals, only the methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

For optional state supplement recipients in § 1902(f) states and SSI criteria states without § 1616 or § 1634 agreements, the SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses and the income of parents as available to children living with parents until the children become 21 years of age.

G. Disabled individuals. In determining countable income of disabled individuals, including disabled individuals with incomes up to the federal poverty level described in § 1902(m) of the Act, the methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

For optional state supplement recipients in § 1902(f) of the Act states and SSI criteria states without § 1616 or § 1634 agreements, the SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses and the income of parents as available to children living with parents until the children become 21 years of age.

H. Qualified Medicare beneficiaries. In determining countable income for qualified Medicare beneficiaries covered under § 1902(a)(10)(E)(i) of the Act, the methods of the SSI program, more liberal methods described in 12VAC30-40-280, or both are used.

If an individual receives a Title II benefit, any amounts attributable to the most recent increase in the monthly insurance benefit as a result of a Title II COLA is not counted as income during a "transition period" beginning with January, when the Title II benefit for December is received, and ending with the last day of the month following the month of publication of the revised annual federal poverty level.

For individuals with Title II income, the revised poverty levels are not effective until the first day of the month following the end of the transition period.

For individuals not receiving Title II income, the revised poverty levels are effective no later than the date of publication.

I. Qualified disabled and working individuals. In determining countable income for qualified disabled and working individuals covered under § 1902(a)(10)(E)(ii) of the Act, the methods of the SSI program are used.

12VAC30-50-10. Services provided to the categorically needy with limitations.

The following services are provided with limitations as described in Part III (12VAC30-50-100 et seq.) of this chapter:

1. Inpatient hospital services other than those provided in an institution for mental diseases.

2. Outpatient hospital services.

3. Other laboratory and x-ray services; nonemergency outpatient Magnetic Resonance Imaging (MRI), including Magnetic Resonance Angiography (MRA), Computerized Axial Tomography (CAT) scans, including Computed Tomography Angiography (CTA), and Positron Emission Tomography (PET) scans performed for the purpose of diagnosing a disease process or physical injury require prior authorization.

4. Rural health clinic services and other ambulatory services furnished by a rural health clinic.

5. Federally Qualified Health Center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with § 4231 of the State Medicaid Manual (HCFA Pub. 45-4).

6. Early and periodic screening and diagnosis of individuals under 21 years of age, and treatment of conditions found.

7. Family planning services and supplies for individuals of child-bearing age.

8. Physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere.

9. Medical and surgical services furnished by a dentist (in accordance with § 1905(a)(5)(B) of the Act).

10. Medical care or any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by state law: podiatrists, optometrists and other practitioners.

11. Home health services: intermittent or part-time nursing service provided by a home health agency or by a registered nurse when no home health agency exists in the area; home health aide services provided by a home health agency; and medical supplies, equipment, and appliances suitable for use in the home; physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility.

12. Clinic services.

13. Dental services.

14. Physical therapy and related services, including occupational therapy and services for individuals with speech, hearing, and language disorders (provided by or under supervision of a speech pathologist or audiologist).

15. Prescribed drugs, prosthetic devices, and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

16. Other rehabilitative services, screening services, preventive services.

17. Nurse-midwife services.

18. Case management services as defined in, and to the group specified in, 12VAC30-50-95 et seq. (in accordance with § 1905(a)(19) or § 1915(g) of the Act).

19. Extended services to pregnant women: pregnancy-related and postpartum services for a 60-day 12-month postpartum period after beginning on the last day of the pregnancy ends and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends (see 12VAC30-50-510). (Note: Additional coverage beyond limitations.)

20. Pediatric or family nurse practitioners' service.

21. Any other medical care and any other type of remedial care recognized by state law, specified by the Secretary: transportation.

12VAC30-50-50. Services provided to the medically needy with limitations.

Services as described in Part III (12VAC30-50-100 et seq.) of this chapter are provided to the medically needy with limitations.

1. Inpatient hospital services other than those provided in an institution for mental diseases.

2. Outpatient hospital services.

3. Other laboratory and x-ray services; nonemergency outpatient Magnetic Resonance Imaging (MRI), Computer Axial Tomography (CAT) scans, and Positron Emission Tomography (PET) scans require prior authorization.

4. Rural health clinic services and other ambulatory services furnished by a rural health clinic.

5. Federally qualified health center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with § 4231 of the State Medicaid Manual (HCFA, Pub. 45-4).

6. Family planning services and supplies for individuals of childbearing age.

7. Physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere.

8. Medical and surgical services furnished by a dentist (in accordance with § 1905(a)(5)(B) of the Act).

9. Medical care and any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by state law, including:

a. Podiatrists' services;

b. Optometrists' services; and

c. Other practitioners' services.

10. Home health services' medical supplies, equipment, and appliances suitable for use in the home; intermittent or part-time nursing service provided by a home health agency or by a registered nurse when no home health agency exists in the area; home health aide services provided by a home health agency; physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility.

11. Clinic services.

12. Dental services.

13. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders provided by or under supervision of a speech pathologist or audiologist.

14. Prescribed drugs, prosthetic devices, and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

15. Rehabilitative services.

16. Nurse-midwife services.

17. Case management services as defined in, and to the group specified in, 12VAC30-50-410 (in accordance with § 1905(a)(19) or § 1915(g) of the Act).

18. Extended services for pregnant women, including pregnancy-related and post-partum postpartum services for 60 days after the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends.

19. Certified pediatric or family nurse practitioners' services.

20. Any other medical care and any other type of remedial care recognized under state law, specified by the secretary, specifically transportation.

12VAC30-50-190. Dental services.

A. Dental services shall be covered for individuals younger than 21 years of age in fulfillment of the treatment requirements under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program and defined as routine diagnostic, preventive, or restorative procedures necessary for oral health provided by or under the direct supervision of a dentist in accordance with Chapter 27 (§ 54.1-2700 et seq.) of Title 54.1 of the Code of Virginia.

1. The Department of Medical Assistance Services (DMAS) will provide any medically necessary dental service to individuals younger than 21 years of age.

2. Certain dental services, as described in the DMAS Office Reference Manual (Smiles for Children, March 13, 2014), prepared by DMAS's dental benefits administrator, require preauthorization or prepayment review by DMAS or its designee.

3. Dental services for individuals younger than the age of 21 years that do not require preauthorization or prepayment review are initial, periodic, and emergency examinations; required radiography necessary to develop a treatment plan; patient education; dental prophylaxis; fluoride treatments; routine amalgam and composite restorations; stainless steel crowns, prefabricated steel post and temporary (polycarbonate) crowns, and stainless steel bands; crown recementation; pulpotomies; emergency endodontics for temporary relief of pain; pulp capping; sedative fillings; therapeutic apical closure; topical palliative treatment for dental pain; removal of foreign body; simple extractions; root recovery; incision and drainage of abscess; surgical exposure of the tooth to aid eruption; sequestrectomy for osteomyelitis; and oral antral fistula closure.

B. Dental services determined by the dental provider to be medically appropriate for an adult woman during the term of her pregnancy and through the end of the month following the 60th day postpartum shall be provided to a Medicaid-enrolled pregnant woman individual during pregnancy and for the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends. The dental services that shall be covered are (i) diagnostic x-rays and exams; (ii) preventive cleanings; (iii) restorative fillings; (iv) endodontics (root canals); (v) periodontics (gum-related treatments); (vi) prosthodontics, both removable and fixed (crowns, bridges, partial plates, and dentures); (vii) oral surgery (tooth extractions and other oral surgeries); and (viii) adjunctive general services (all covered services that do not fall into specific professional categories). These services require prepayment review by DMAS or its designee.

C. For the dental services covered for Medicaid-enrolled adult pregnant women, DMAS may place appropriate limits on a service based on medical necessity, for utilization control, or both. Examples of service limitations are examinations, prophylaxis, fluoride treatment (once/six months); space maintenance appliances; bitewing x-ray - two films (once/12 months); routine amalgam and composite restorations (once/three years); dentures (once/five years); extractions, tooth guidance appliances, permanent crowns and bridges, endodontics, patient education and sealants (once).

D. Limited oral surgery procedures, as defined and covered under Title XVIII (Medicare), are covered for all recipients, and require preauthorization or prepayment review by DMAS or its designee as described in the agency's Office Reference Manual located on the DMAS website at http://www.dmas.virginia.gov/#/dentalresources.

E. Residents of nursing facilities shall be permitted to deduct the costs of limited specific dental procedures from their payments toward the costs of their nursing facility care. Nursing facility residents shall be limited to deducting the following dental procedures: (i) routine exams and x-rays and dental cleaning twice yearly; (ii) full mouth x-rays once every three years; and (iii) extractions and fillings shall be permitted only if medically necessary as determined by DMAS.

12VAC30-50-290. Extended services to pregnant women.

A. Pregnancy-related and postpartum services for 60 days after the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends. The same limitations on all covered services apply to this group as to all other recipient groups.

B. Services for any other medical conditions that may complicate pregnancy. The same limitations on all covered services apply to this group as to all other recipient groups.

12VAC30-141-670. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Adverse action," consistent with 42 CFR 457.1130, means the denial of eligibility; failure to make a timely determination of eligibility; suspension or termination of enrollment, including disenrollment for failure to pay cost sharing; or delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of services; and failure to approve, furnish, or provide payment for health services in a timely manner; provided, however, that determination of eligibility to participate in and termination of participation in the FAMIS Select program shall not constitute an adverse action.

"Adverse benefit determination," consistent with 42 CFR 438.400, means the denial or limited authorization of a requested service; the failure to take action or timely take action on a request for service; the reduction, suspension, or termination of a previously authorized service; denial in whole or in part of a payment for a service; failure to provide services within the timeframes required by the state; for a resident of a rural exception area with only one MCO, the denial of a enrollee's request to exercise the enrollee's right under 42 CFR 438.52(b)(2)(ii) to obtain services outside of the network; the denial of a enrollee's request to dispute a financial liability as provided in 42 CFR 438.400(b)(7); or the failure of an MCO to act within the timeframes provided in 42 CFR 438.408(b).

"Agency" means the same as defined in 12VAC30-141-10.

"Agent" means an individual designated in writing to act on behalf of a FAMIS MOMS Plan applicant or enrollee during the administrative review process.

"Appeal" means an enrollee's request for review of an adverse benefit determination by an MCO or an adverse action by the LDSS, CPU, or DMAS.

"Applicant" means a pregnant woman who has filed an application (or who has an application filed on her behalf) for health insurance and is awaiting a determination of eligibility. A pregnant woman is an applicant until her eligibility has been determined.

"Application for health insurance" means the single streamlined application for determining eligibility in public health insurance programs operated by the Commonwealth.

"Authorized representative" means a person who is authorized to conduct the personal or financial affairs for an individual who is 18 years of age or older.

"Central processing unit" or "CPU" means Cover Virginia, which is the same as defined in 12VAC30-141-10.

"Child" means an individual younger than 19 years of age.

"Conservator" means a person appointed by a court of competent jurisdiction to manage the estate and financial affairs of an incapacitated individual.

"Continuation of coverage" means ensuring an enrollee's benefits are continued until completion of the review process, with the condition that should the enrollee not prevail in the review process, the enrollee shall be liable for the repayment of all benefits received during the review process.

"Director" means the individual, or his designee, specified in § 32.1-324 of the Code of Virginia with all of the attendant duties and responsibilities to administer the State Plan for Medical Assistance and the State Plan for Title XXI.

"DMAS" or "department" means the Department of Medical Assistance Services.

"Enrollee" means a pregnant woman who has been determined eligible to participate in FAMIS MOMS and is enrolled in the FAMIS MOMS program.

"FAMIS" means the Family Access to Medical Insurance Security Plan.

"FAMIS MOMS" means the Title XXI program available to eligible pregnant women.

"Federal poverty level" or "FPL" means that income standard as published annually by the U.S. Department of Health and Human Services in the Federal Register.

"Fee-for-service" means the traditional Medicaid health care delivery and payment system in which physicians and other providers receive a payment for each unit of service they provide.

"Guardian" means a person appointed by a court of competent jurisdiction to be responsible for the affairs of an incapacitated individual, including responsibility for making decisions regarding the person's support, care, health, safety, habilitation, education, and therapeutic treatment, and, if not inconsistent with an order of commitment, residence.

"Incapacitated " means a person who, pursuant to an order of a court of competent jurisdiction, has been found to be incapable of receiving and evaluating information effectively or responding to people, events, or environments to such an extent that the individual lacks the capacity to (i) meet the essential requirements of her health, care, safety, or therapeutic needs without the assistance or protection of a guardian, or (ii) manage property or financial affairs or provide for her support or for the support of her legal dependents without the assistance or protection of a conservator.

"LDSS" or "local department" means the local department of social services.

"Managed care organization" or "MCO" means an organization that offers managed care health insurance plans (MCHIPs) as defined in § 32.1-137.1 of the Code of Virginia.

"Pregnant woman" means a woman of any age who is medically determined to be pregnant. The pregnant woman definition is met from the first day of the earliest month that the medical practitioner certifies as being a month in which the woman was pregnant, through the last day of the month in which the 60th day occurs, following and continues for the duration of the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which her pregnancy ended the 12-month period ends, regardless of the reason the pregnancy ended.

"Provider" means the individual, facility, or other entity registered, licensed, or certified, as appropriate, and enrolled by an MCHIP or in fee-for-service to render services to FAMIS MOMS enrollees eligible for services.

"State fair hearing" means, consistent with 42 CFR 438.400, the process set forth in 42 CFR 431 Subpart E.

"Title XXI" means the federal State Children's Health Insurance Program as established by Subtitle J of the Balanced Budget Act of 1997.

12VAC30-141-750. Duration of eligibility.

A. The effective date of FAMIS MOMS eligibility shall be the first day of the month in which an application was received by LDSS, DMAS, or the CPU if the applicant met all eligibility requirements in that month.

B. Eligibility for FAMIS MOMS will continue through the last day of the month in which the 60th day occurs, following the last day the woman was pregnant for the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends, regardless of the reason the pregnancy ended. Eligibility will continue until the end of the coverage period, regardless of changes in circumstances such as income or family size.

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Notice of Intended Regulatory Action

Notice is hereby given in accordance with § 2.2-4007.01 of the Code of Virginia that the Department of Medical Assistance Services intends to consider amending 12VAC30-10, State Plan Under Title XIX of the Social Security Act Medical Assistance Program; General Provisions; 12VAC30-30, Groups Covered and Agencies Responsible for Eligibility Determination; 12VAC30-40, Eligibility Conditions and Requirements; 12VAC30-50, Amount, Duration, and Scope of Medical and Remedial Care and Services; and 12VAC30-141, Family Access to Medical Insurance Security (FAMIS) Plan. The purpose of the proposed action is to provide continuous coverage through 12 months postpartum for Medicaid and Family Access to Medical Insurance Security (FAMIS) pregnant and postpartum members and eligible individuals. A pregnant individual who is deemed eligible will maintain coverage for the duration of 12 months from the date the pregnancy ends, regardless of what point in the prenatal or postpartum period the individual enrolls in coverage. The coverage will be maintained regardless of a change in circumstances affecting income or household size.

The agency does not intend to hold a public hearing on the proposed action after publication in the Virginia Register.

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Public Comment Deadline: October 7, 2026.

Agency Contact: Meredith Lee, Policy, Regulations, and Manuals Supervisor, Division of Policy and Research, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-0552, fax (804) 786-1680, TDD (800) 343-0634, or email meredith.lee@dmas.virginia.gov.

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Emergency Regulation

Titles of Regulations: 12VAC30-10. State Plan under Title XIX of the Social Security Act Medical Assistance Program; General Provisions (amending 12VAC30-10-140, 12VAC30-10-150).

12VAC30-30. Groups Covered and Agencies Responsible for Eligibility Determination (amending 12VAC30-30-10, 12VAC30-30-30).

12VAC30-40. Eligibility Conditions and Requirements (amending 12VAC30-40-100).

12VAC30-50. Amount, Duration, and Scope of Medical and Remedial Care Services (amending 12VAC30-50-10, 12VAC30-50-50, 12VAC30-50-190, 12VAC30-50-290).

12VAC30-141. Family Access to Medical Insurance Security Plan (amending 12VAC30-141-670, 12VAC30-141-750).

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Effective Dates: August 13, 2026, through February 18, 2028.

Agency Contact: Meredith Lee, Policy, Regulations, and Manuals Supervisor, Division of Policy and Research, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-0552, fax (804) 786-1680, TDD (800) 343-0634, or email meredith.lee@dmas.virginia.gov.

Preamble:

Section 2.2-4011 B 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.

The amendments provide continuous coverage through 12 months postpartum for Medicaid and Family Access to Medical Insurance Security (FAMIS) pregnant and postpartum members and eligible individuals. A pregnant individual who is deemed eligible will maintain coverage for the duration of 12 months from the date the pregnancy ends, regardless of what point in the prenatal or postpartum period individual enrolls in coverage. The coverage will be maintained regardless of a change in circumstances affecting income or household size.

12VAC30-10-140. Amount, duration, and scope of services: Categorically needy.

Medicaid is provided in accordance with the requirements of 42 CFR 440, Subpart B and § 1902(a), 1902(e), 1905(a), 1905(p), 1915, 1920, and 1925 of the Act.

Services for the categorically needy are described below and in 12VAC30-50-10 et seq. These services include:

1. Each item or service listed in § 1905(a)(1) through (5) and (21) of the Act, is provided as defined in 42 CFR Part 440, Subpart A, or, for EPSDT services, § 1905(r) and 42 CFR Part 411, Subpart B.

2. Nurse-midwife services listed in § 1905(a)(17) of the Act, are provided to the extent that nurse-midwives are authorized to practice under state law or regulation and without regard to whether the services are furnished in the area of management of the care of mothers and babies throughout the maternity cycle. Nurse-midwives are permitted to enter into independent provider agreements with the Medicaid agency without regard to whether the nurse-midwife is under the supervision of, or associated with, a physician or other health care provider.

3. Pregnancy-related, including family planning service, and postpartum services for a 60-day 12-month postpartum period (beginning on the last day of the pregnancy ends) and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends, are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

4. Services for medical conditions that may complicate the pregnancy (other than pregnancy-related or postpartum services) are provided to pregnant women.

5. Services related to pregnancy (including prenatal, delivery, postpartum, and family planning services) and to other conditions that may complicate pregnancy are the same services provided to poverty level pregnant women eligible under the provision of § 1902(a)(10)(A)(i)(IV) and 1902(a)(10)(A)(ii)(IX) of the Act.

6. Home health services are provided to individuals entitled to nursing facility services as indicated in 12VAC30-10-220 of this plan.

7. Inpatient services that are being furnished to infants and children described in § 1902(l)(1)(B) through (D), or § 1905(n)(2) of the Act, on the date the infant or child attains the maximum age for coverage under the approved State plan will continue until the end of the stay for which the inpatient services are furnished.

8. Respiratory care services are not provided to ventilator dependent individuals as indicated in 12VAC30-10-300 of this plan.

9. Services are provided to families eligible under § 1925 of the Act as indicated in 12VAC30-10-350 of this plan.

10. Home and community care for functionally disabled elderly individuals is not covered.

11. Program of All-Inclusive Care for the Elderly (PACE) services as described and limited in Supplement 6 to Attachment 3.1-A (12VAC30-50-320, 12VAC30-50-321, 12VAC30-50-325, and 12VAC30-50-328).

12VAC30-50-10 et seq. identifies the medical and remedial services provided to the categorically needy, specifies all limitations on the amount, duration, and scope of those service, and lists the additional coverage (that is in excess of established service limits) for pregnancy-related services and services for conditions that may complicate the pregnancy.

12VAC30-10-150. Amount, duration, and scope of services: Medically needy.

A. This State Plan covers the medically needy. The services described in this section and in Part II (12VAC30-50-40 et seq.) of 12VAC30-50 are provided. Services for the medically needy include:

1. If services in an institution for mental diseases (42 CFR 440.140 and 440.160) or an intermediate care facility for individuals with intellectual disabilities (or both) are provided to any medically needy group, then each medically needy group is provided either the services listed in § 1905(a)(1) through (5) and (17) of the Act, or seven of the services listed in § 1902(a)(1) through (20). The services are provided as defined in 42 CFR 440, Subpart A and in §§ 1902, 1905, and 1915 of the Act.

Subdivision 1 of this subsection is applicable with respect to nurse-midwife services under § 1902(a)(17).

2. Prenatal care and delivery services for pregnant women.

3. Pregnancy-related, including family planning services, and postpartum services for a 60-day 12-month postpartum period (beginning on the last day of the pregnancy ends) and including any remaining days in of the calendar month in which the sixtieth day falls 12-month period ends, are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

4. Services for any other medical condition that may complicate the pregnancy (other than pregnancy-related and postpartum services) are provided to pregnant women.

5. Ambulatory services as defined in 12VAC30-50-40 for recipients younger than 18 years of age and recipients entitled to institutional services.

6. Home health services to recipients entitled to nursing facility services as indicated in 12VAC30-10-220.

7. Services for the medically needy do not include services in an institution for mental diseases for individuals older than 65 years of age.

8. Services for the medically needy do not include services in an intermediate care facility for individuals with intellectual disabilities.

9. Services for the medically needy do not include inpatient psychiatric services for individuals younger than 21 years of age, other than those covered under early and periodic screening, diagnosis, and treatment (at 12VAC30-50-130).

10. Services for the medically needy do not include respiratory care services provided to ventilator dependent individuals. See 12VAC30-10-300.

11. Home and community care for functionally disabled elderly individuals is not covered.

12. Program of All-Inclusive Care for the Elderly (PACE) services as described and limited in Supplement 6 to Attachment 3.1-A (12VAC30-50-320, 12VAC30-50-321, 12VAC30-50-325, and 12VAC30-50-328) are covered.

B. Part II (12VAC30-50-40 et seq.) of 12VAC30-50 identifies services provided to each covered group of the medically needy. (Note: Other programs to be offered to medically needy beneficiaries would specify all limitations on the amount, duration, and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. In addition, other programs to be offered to medically needy beneficiaries would also list the additional coverage that is in excess of established service limits for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population, this also is not applicable for this program.)

12VAC30-30-10. Mandatory coverage: categorically needy and other required special groups.

The Title IV-A agency or the Department of Medical Assistance Services Central Processing Unit determines eligibility for Title XIX services. The following groups shall be eligible for medical assistance as specified:

1. Parents and other caretaker relatives of dependent children with household income at or below a standard established by the Commonwealth in 12VAC30-40-100 consistent with 42 CFR 435.110 and §§ 1902(a)(10)(A)(i)(l) and 1931(b) of the Social Security Act. Individuals qualifying under this eligibility group shall meet the following criteria:

a. Parents, other caretaker relatives (defined at 42 CFR 435.4) including pregnant women, or dependent children (defined at 42 CFR 435.4) younger than 18 years of age. This group includes individuals who are parents or other caretaker relatives of children who are 18 years of age provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training and are expected to complete such school or training before their 19th birthday.

b. Spouses of parents and other caretaker relatives shall include other relatives of the child based on blood (including those of half-blood), adoption, or marriage. Other relatives of a specified degree of the dependent child shall include any blood relative (including those of half-blood) and including (i) first cousins; (ii) nephews or nieces; (iii) persons of preceding generations as denoted by prefixes of grand, great, or great-great; (iv) stepbrother; (v) stepsister; (vi) a relative by adoption following entry of the interlocutory or final order, whichever is first; (vii) the same relatives by adoption as listed in this subdivision 1 b; and (viii) spouses of any persons named in this subdivision 1 b even after the marriage is terminated by death or divorce.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

2. Women who are pregnant or postpartum with household income at or below a standard established by the Commonwealth in 12VAC30-40-100, consistent with 42 CFR 435.116 and §§ 1902(a)(10)(A)(i)(III) and (IV), 1902(a)(10)(A)(ii)(I) and (IX), and 1931(b) of the Act. Individuals qualifying under this eligibility group shall be pregnant or postpartum as defined in 42 CFR 435.4.

a. A woman who, while pregnant, was eligible for, applied for, and received Medicaid under the approved state plan on the day her pregnancy ends. The woman continues to be eligible, as though she were pregnant, for all pregnancy-related and postpartum medical assistance under the plan for a 60-day 12-month postpartum period, beginning on the last day of her the pregnancy, and for including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

b. A pregnant woman who would otherwise lose eligibility because of an increase in income of the family in which she is a member during the pregnancy or the 12-month postpartum period that extends through the end of the month in which the 60-day period, beginning on the last day of pregnancy, and including any remaining days of the calendar month in which the 12-month period ends.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

3. Infants and children younger than 19 years of age with household income at or below standards based on this age group, consistent with 42 CFR 435.118 and §§ 1902(a)(10)(A)(i)(III), (IV) and (VIII); 1902(a)(10)(A)(ii)(IV) and (IX); and 1931(b) of the Act. Children qualifying under this eligibility group shall meet the following criteria:

a. They are younger than 19 years of age; and

b. They have a household income at or below the standard established by the Commonwealth.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

4. The adult group as described at 42 CFR 435.119.

5. Former foster care children younger than 26 years of age who are not otherwise mandatorily eligible in another Medicaid classification, who were on Medicaid and in foster care when they turned 18 years of age, or who aged out of foster care. Individuals qualifying under this eligibility group shall meet the following criteria:

a. They shall be younger than 26 years of age;

b. They shall not be otherwise eligible for and enrolled for mandatory coverage under the state plan; and

c. They were in foster care under the responsibility of the Commonwealth or a federally recognized tribe and were enrolled in Virginia Medicaid under the state plan when they turned 18 years of age or at the time of aging out of the foster care program.

6. Families terminated from coverage under § 1931 of the Act solely because of earnings or hours of employment shall be entitled to up to 12 months of extended benefits in accordance with § 1925 of the Act.

7. A child born to a woman who is eligible for and receiving Medicaid on the date of the child's birth. The child is deemed to have applied and been found eligible for Medicaid on the date of birth and remains eligible for one year from birth, as long as he remains a resident of the Commonwealth. A redetermination of eligibility must be completed on behalf of the deemed child at age one year and annually thereafter so long as he remains eligible.

8. Aged, blind, and disabled individuals receiving cash assistance.

a. Individuals who meet more restrictive requirements for Medicaid than the SSI requirements. (This includes persons who qualify for benefits under § 1619(a) of the Act or who meet the eligibility requirements for SSI status under § 1619(b)(1) of the Act and who met the Commonwealth's more restrictive requirements for Medicaid in the month before the month they qualified for SSI under § 1619(a) or met the requirements under § 1619(b)(1) of the Act. Medicaid eligibility for these individuals continues as long as they continue to meet the § 1619(a) eligibility standard or the requirements of § 1619(b) of the Act.)

b. These persons include the aged, the blind, and the disabled.

c. Protected SSI children (pursuant to § 1902(a)(10)(A)(i)(II) of the Act) (P.L. 105-33 § 4913). Children who meet the pre-welfare reform definition of childhood disability who lost their SSI coverage solely as a result of the change in the definition of childhood disability, and who also meet the more restrictive requirements for Medicaid than the SSI requirements.

d. The more restrictive categorical eligibility criteria are described in 12VAC30-30-40.

Financial criteria are described in 12VAC30-40-10.

9. Qualified severely impaired blind and disabled individuals younger than 65 years of age who:

a. For the month preceding the first month of eligibility under the requirements of § 1905(q)(2) of the Act, received SSI, a state supplementary payment (SSP) under § 1616 of the Act or under § 212 of P.L. 93-66 or benefits under § 1619(a) of the Act and were eligible for Medicaid; or

b. For the month of June 1987, were considered to be receiving SSI under § 1619(b) of the Act and were eligible for Medicaid. These individuals must:

(1) Continue to meet the criteria for blindness or have the disabling physical or mental impairment under which the individual was found to be disabled;

(2) Except for earnings, continue to meet all nondisability-related requirements for eligibility for SSI benefits;

(3) Have unearned income in amounts that would not cause them to be ineligible for a payment under § 1611(b) of the Act;

(4) Be seriously inhibited by the lack of Medicaid coverage in their ability to continue to work or obtain employment; and

(5) Have earnings that are not sufficient to provide for themselves a reasonable equivalent of the Medicaid, SSI (including any federally administered SSP), or public funded attendant care services that would be available if they did have such earnings.

The state applies more restrictive eligibility requirements for Medicaid than under SSI and under 42 CFR 435.121. Individuals who qualify for benefits under § 1619(a) of the Act or individuals described in this section who meet the eligibility requirements for SSI benefits under § 1619(b)(1) of the Act and who met the state's more restrictive requirements in the month before the month they qualified for SSI under § 1619(a) or met the requirements of § 1619(b)(1) of the Act are covered. Eligibility for these individuals continues as long as they continue to qualify for benefits under § 1619(a) of the Act or meet the SSI requirements under § 1619(b)(1) of the Act.

10. Except in states that apply more restrictive requirements for Medicaid than under SSI, blind or disabled individuals who:

a. Are at least 18 years of age; and

b. Lose SSI eligibility because they become entitled to Old Age, Survivor, and Disability Insurance (OASDI) child's benefits under § 202(d) of the Act or an increase in these benefits based on their disability. Medicaid eligibility for these individuals continues for as long as they would be eligible for SSI, absence their OASDI eligibility.

The Commonwealth does not apply more restrictive income eligibility requirements than those under SSI.

11. Except in states that apply more restrictive eligibility requirements for Medicaid than under SSI, individuals who are ineligible for SSI or optional state supplements (if the agency provides Medicaid under § 435.230 of the Act), because of requirements that do not apply under Title XIX of the Act.

12. Individuals receiving mandatory state supplements.

13. Individuals who in December 1973 were eligible for Medicaid as an essential spouse and who have continued, as a spouse, to live with and be essential to the well-being of a recipient of cash assistance. The recipient with whom the essential spouse is living continues to meet the December 1973 eligibility requirements of the Commonwealth's approved plan for Old Age Assistance, Aid to the Blind, Aid to the Permanently and Totally Disabled, or Aid to the Aged, Blind, and Disabled and the spouse continues to meet the December 1973 requirements for his needs to be included in computing the cash payment. In December 1973, Medicaid coverage of the essential spouse was limited to the aged, the blind, and the disabled.

14. Institutionalized individuals who were eligible for Medicaid in December 1973 as inpatients of Title XIX medical institutions or residents of Title XIX intermediate care facilities, if, for each consecutive month after December 1973, they:

a. Continue to meet the December 1973 Medicaid State Plan eligibility requirements;

b. Remain institutionalized; and

c. Continue to need institutional care.

15. Blind and disabled individuals who:

a. Meet all current requirements for Medicaid eligibility except the blindness or disability criteria;

b. Were eligible for Medicaid in December 1973 as blind or disabled; and

c. For each consecutive month after December 1973 continue to meet December 1973 eligibility criteria.

16. Individuals who would be SSI or SSP eligible except for the increase in OASDI benefits under P.L. 92-336 (July 1, 1972), who were entitled to OASDI in August 1972, and who were receiving cash assistance in August 1972. This includes persons who would have been eligible for cash assistance but had not applied in August 1972 (this group was included in this state's August 1972 plan), and persons who would have been eligible for cash assistance in August 1972 if not in a medical institution or intermediate care facility (this group was included in this state's August 1972 plan).

17. Individuals who:

a. Are receiving OASDI and were receiving SSI or SSP but became ineligible for SSI or SSP after April 1977; and

b. Would still be eligible for SSI or SSP if cost-of-living increases in OASDI paid under § 215(i) of the Act received after the last month for which the individual was eligible for and received SSI or SSP and OASDI, concurrently, were deducted from income.

The state applies more restrictive eligibility requirements than those under SSI and the amount of increase that caused SSI or SSP ineligibility and subsequent increases are deducted when determining the amount of countable income for categorically needy eligibility.

18. Disabled widows and widowers who would be eligible for SSI or SSP except for the increase in their OASDI benefits as a result of the elimination of the reduction factor required by § 134 of P.L. 98-21 and who are deemed, for purposes of Title XIX, to be SSI beneficiaries or SSP beneficiaries for individuals who would be eligible for SSP only, under § 1634(b) of the Act.

The state does not apply more restrictive income eligibility standards than those under SSI.

19. Disabled widows, disabled widowers, and disabled unmarried divorced spouses who had been married to the insured individual for a period of at least 10 years before the divorce became effective, who have attained the age of 50, who are receiving Title II payments, and who because of the receipt of Title II income lost eligibility for SSI or SSP which they received in the month prior to the month in which they began to receive Title II payments, who would be eligible for SSI or SSP if the amount of the Title II benefit were not counted as income, and who are not entitled to Medicare Part A.

The state applies more restrictive eligibility requirements for its blind or disabled than those of the SSI program.

20. Qualified Medicare beneficiaries:

a. Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under § 1818 of the Act);

b. Whose income does not exceed 100% of the federal level; and

c. Whose resources do not exceed twice the maximum standard under SSI or, effective January 1, 2010, the resource limit set for the Medicare Part D Low Income Subsidy Program.

Medical assistance for this group is limited to Medicare cost sharing as defined in item 3.2 of this plan.

21. Qualified disabled and working individuals:

a. Who are entitled to hospital insurance benefits under Medicare Part A under § 1818A of the Act;

b. Whose income does not exceed 200% of the federal poverty level;

c. Whose resources do not exceed twice the maximum standard under SSI; and

d. Who are not otherwise eligible for medical assistance under Title XIX of the Act.

Medical assistance for this group is limited to Medicare Part A premiums under §§ 1818 and 1818A of the Act.

22. Specified low-income Medicare beneficiaries:

a. Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under § 1818A of the Act);

b. Whose income for calendar years 1993 and 1994 exceeds the income level in subdivision 25 b of this section, but is less than 110% of the federal poverty level, and whose income for calendar years beginning 1995 is less than 120% of the federal poverty level; and

c. Whose resources do not exceed twice the maximum standard under SSI or, effective January 1, 2010, the resource limit set for the Medicare Part D Low Income Subsidy Program.

Medical assistance for this group is limited to Medicare Part B premiums under § 1839 of the Act.

23. a. Each person to whom SSI benefits by reason of disability are not payable for any month solely by reason of § 1611(e)(3)(A)(i) or (v) shall be treated, for purposes of Title XIX, as receiving SSI benefits for the month.

b. The state applies more restrictive eligibility standards than those under SSI. Individuals whose eligibility for SSI benefits are based solely on disability who are not payable for any months solely by reason of § 1611(e)(3)(A)(i) or (v) and who continue to meet the more restrictive requirements for Medicaid eligibility under the state plan, are eligible for Medicaid as categorically needy.

12VAC30-30-30. Optional coverage of the medically needy.

The Title IV A Agency determines eligibility for Title XIX services.

This plan includes the medically needy:

1. Pregnant women who, except for income and/or resources, would be eligible as categorically needy under Title XIX of the Act.

2. Women who, while pregnant, were eligible for and have applied for Medicaid and receive Medicaid as medically needy under the approved State plan on the date the pregnancy ends. These women continue to be eligible, as though they were pregnant, for all pregnancy-related and postpartum services under the plan for a 60-day 12-month postpartum period after beginning on the last day of the pregnancy ends, and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

3. Individuals under age 18 who, but for income and/or resources, would be eligible under § 1902(a)(10)(A)(i) of the Act.

4. Newborn children born on or after October 1, 1984, to a woman who is eligible as medically needy and is receiving Medicaid on the date of the child's birth. The child is deemed to have applied and been found eligible for Medicaid on the date of birth and remains eligible for one year so long as the woman remains eligible and the child is a member of the woman's household.

5. Reasonable classification of financially eligible individuals under the ages of 21, 20, 19, or 18 as specified below:

(1) Individuals for whom public agencies are assuming full or partial financial responsibility and who are:

(a) In foster homes (and are under the age of 21).

(b) In private institutions (and are under the age of 21).

(c) In addition to the group under (1)(a) and (b), individuals placed in foster homes or private institutions by private, nonprofit agencies (and are under the age of 21).

(2) Individuals in adoptions subsidized in full or part by the public agency (who are under the age of 21).

(3) Individuals in NFs (who are under the age of 21). NF services are provided under this plan.

(4) In addition to the group under (3), individuals in ICFs/MR (who are under the age of 21).

6. Aged Individuals.

7. Blind Individuals.

8. Disabled Individuals.

9. Blind and disabled individuals who:

a. Meet all current requirements for Medicaid eligibility except the blindness or disability criteria;

b. Were eligible as medically needy in December 1973 as blind or disabled; and

c. For each consecutive month after December 1973 continue to meet the December 1973 eligibility criteria.

10. Individuals required to enroll in cost-effective employer-based group health plans remain eligible for a minimum enrollment period of one month.

12VAC30-40-100. Methods of determining income.

A. Families and Children Medically Needy individuals.

1. In determining countable income for Families and Children Medically Needy individuals, the methods under the state's July 16, 1996, approved Aid to Families with Dependent Children plan and any more liberal methods described in 12VAC30-40-280 are used.

2. In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to children living with parents until the children become 21 years of age.

3. Agency continues to treat women eligible under the provisions of § 1902(a)(10) of the Act as eligible, without regard to any changes in income of the family of which she is a member, for the 60-day 12-month postpartum period after her beginning on the last day of the pregnancy ends and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

B. Individuals subject to the use of modified adjusted gross income (MAGI) methodology. In determining income eligibility for individuals subject to the use of MAGI-based methodologies, the following shall apply:

1. The Commonwealth shall apply MAGI-based methodologies as described in this subsection, and consistent with 42 CFR 435.603 and § 1902(e)(14) of the Act. Individuals subject to the use of MAGI-based income methodologies include:

a. Parents/caretaker relatives under §§ 1902(a)(10)(A)(i)(l) and 1931 of the Act.

b. Pregnant women under §§ 1902(a)(10)(A)(i)(I), (III), (IV), (ii)(l), ((IV), (IX) and 1931 of the Act.

c. Children under the age of 19 years under §§ 1902(a)(10)(A)(i)(l), (lll), (IV), (VI), (VII), (ii)((IV), (IX) and 1931 of the Act.

d. Reasonable classifications of children younger than the age of 21 years under §§ 1902(a)(10)(A)(ii)(l) and (IV) of the Act.

e. Individuals younger than the age of 21 years who are under a state adoption assistance agreement under § 1902(a)(10)(A)(ii)(VIII) of the Act.

2. In the case of determining the ongoing eligibility for individuals determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies shall not be applied until March 31, 2014, or the next regularly scheduled renewal of eligibility, whichever is later, if the applications of such methods should result in determination of ineligibility prior to such date.

C. In determining family size for the eligibility determination of a pregnant woman, the pregnant woman shall be counted as herself plus each of the children she is expected to deliver. In determining family size during the eligibility determination of the other individuals in a household that includes a pregnant woman, the pregnant woman shall be counted as just herself.

D. Financial eligibility shall be determined consistent with the following provisions:

1. Financial eligibility shall be based on current monthly income and family size when determining eligibility for new applicants.

2. Financial eligibility shall be based on current monthly household income and family size when determining eligibility for currently enrolled individuals.

3. Household income shall be the sum of the MAGI-based income of every individual included in the individual's household except as provided at 42 CFR 435.603(d)(2) through 42 CFR 435.603(d)(4).

4. An amount equivalent to five percentage points of the federal poverty level for the applicable family size shall be deducted, in determining eligibility for Medicaid, from the household income in accordance with 42 CFR 435.603(d).

5. The age used for children with respect to 42 CFR 435.603(f)(3)(iv) shall be 19 years of age.

E. Aged individuals. In determining countable income for aged individuals, including aged individuals with incomes up to the federal poverty level described in § 1902(m)(1) of the Act, the following methods are used.

1. The methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

2. For optional state supplement recipients in § 1902(f) states and SSI criteria states without § 1616 or § 1634 agreements, SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

3. In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses.

F. Blind individuals. In determining countable income for blind individuals, only the methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

For optional state supplement recipients in § 1902(f) states and SSI criteria states without § 1616 or § 1634 agreements, the SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses and the income of parents as available to children living with parents until the children become 21 years of age.

G. Disabled individuals. In determining countable income of disabled individuals, including disabled individuals with incomes up to the federal poverty level described in § 1902(m) of the Act, the methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

For optional state supplement recipients in § 1902(f) of the Act states and SSI criteria states without § 1616 or § 1634 agreements, the SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses and the income of parents as available to children living with parents until the children become 21 years of age.

H. Qualified Medicare beneficiaries. In determining countable income for qualified Medicare beneficiaries covered under § 1902(a)(10)(E)(i) of the Act, the methods of the SSI program, more liberal methods described in 12VAC30-40-280, or both are used.

If an individual receives a Title II benefit, any amounts attributable to the most recent increase in the monthly insurance benefit as a result of a Title II COLA is not counted as income during a "transition period" beginning with January, when the Title II benefit for December is received, and ending with the last day of the month following the month of publication of the revised annual federal poverty level.

For individuals with Title II income, the revised poverty levels are not effective until the first day of the month following the end of the transition period.

For individuals not receiving Title II income, the revised poverty levels are effective no later than the date of publication.

I. Qualified disabled and working individuals. In determining countable income for qualified disabled and working individuals covered under § 1902(a)(10)(E)(ii) of the Act, the methods of the SSI program are used.

12VAC30-50-10. Services provided to the categorically needy with limitations.

The following services are provided with limitations as described in Part III (12VAC30-50-100 et seq.) of this chapter:

1. Inpatient hospital services other than those provided in an institution for mental diseases.

2. Outpatient hospital services.

3. Other laboratory and x-ray services; nonemergency outpatient Magnetic Resonance Imaging (MRI), including Magnetic Resonance Angiography (MRA), Computerized Axial Tomography (CAT) scans, including Computed Tomography Angiography (CTA), and Positron Emission Tomography (PET) scans performed for the purpose of diagnosing a disease process or physical injury require prior authorization.

4. Rural health clinic services and other ambulatory services furnished by a rural health clinic.

5. Federally Qualified Health Center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with § 4231 of the State Medicaid Manual (HCFA Pub. 45-4).

6. Early and periodic screening and diagnosis of individuals under 21 years of age, and treatment of conditions found.

7. Family planning services and supplies for individuals of child-bearing age.

8. Physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere.

9. Medical and surgical services furnished by a dentist (in accordance with § 1905(a)(5)(B) of the Act).

10. Medical care or any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by state law: podiatrists, optometrists and other practitioners.

11. Home health services: intermittent or part-time nursing service provided by a home health agency or by a registered nurse when no home health agency exists in the area; home health aide services provided by a home health agency; and medical supplies, equipment, and appliances suitable for use in the home; physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility.

12. Clinic services.

13. Dental services.

14. Physical therapy and related services, including occupational therapy and services for individuals with speech, hearing, and language disorders (provided by or under supervision of a speech pathologist or audiologist).

15. Prescribed drugs, prosthetic devices, and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

16. Other rehabilitative services, screening services, preventive services.

17. Nurse-midwife services.

18. Case management services as defined in, and to the group specified in, 12VAC30-50-95 et seq. (in accordance with § 1905(a)(19) or § 1915(g) of the Act).

19. Extended services to pregnant women: pregnancy-related and postpartum services for a 60-day 12-month postpartum period after beginning on the last day of the pregnancy ends and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends (see 12VAC30-50-510). (Note: Additional coverage beyond limitations.)

20. Pediatric or family nurse practitioners' service.

21. Any other medical care and any other type of remedial care recognized by state law, specified by the Secretary: transportation.

12VAC30-50-50. Services provided to the medically needy with limitations.

Services as described in Part III (12VAC30-50-100 et seq.) of this chapter are provided to the medically needy with limitations.

1. Inpatient hospital services other than those provided in an institution for mental diseases.

2. Outpatient hospital services.

3. Other laboratory and x-ray services; nonemergency outpatient Magnetic Resonance Imaging (MRI), Computer Axial Tomography (CAT) scans, and Positron Emission Tomography (PET) scans require prior authorization.

4. Rural health clinic services and other ambulatory services furnished by a rural health clinic.

5. Federally qualified health center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with § 4231 of the State Medicaid Manual (HCFA, Pub. 45-4).

6. Family planning services and supplies for individuals of childbearing age.

7. Physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere.

8. Medical and surgical services furnished by a dentist (in accordance with § 1905(a)(5)(B) of the Act).

9. Medical care and any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by state law, including:

a. Podiatrists' services;

b. Optometrists' services; and

c. Other practitioners' services.

10. Home health services' medical supplies, equipment, and appliances suitable for use in the home; intermittent or part-time nursing service provided by a home health agency or by a registered nurse when no home health agency exists in the area; home health aide services provided by a home health agency; physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility.

11. Clinic services.

12. Dental services.

13. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders provided by or under supervision of a speech pathologist or audiologist.

14. Prescribed drugs, prosthetic devices, and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

15. Rehabilitative services.

16. Nurse-midwife services.

17. Case management services as defined in, and to the group specified in, 12VAC30-50-410 (in accordance with § 1905(a)(19) or § 1915(g) of the Act).

18. Extended services for pregnant women, including pregnancy-related and post-partum postpartum services for 60 days after the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends.

19. Certified pediatric or family nurse practitioners' services.

20. Any other medical care and any other type of remedial care recognized under state law, specified by the secretary, specifically transportation.

12VAC30-50-190. Dental services.

A. Dental services shall be covered for individuals younger than 21 years of age in fulfillment of the treatment requirements under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program and defined as routine diagnostic, preventive, or restorative procedures necessary for oral health provided by or under the direct supervision of a dentist in accordance with Chapter 27 (§ 54.1-2700 et seq.) of Title 54.1 of the Code of Virginia.

1. The Department of Medical Assistance Services (DMAS) will provide any medically necessary dental service to individuals younger than 21 years of age.

2. Certain dental services, as described in the DMAS Office Reference Manual (Smiles for Children, March 13, 2014), prepared by DMAS's dental benefits administrator, require preauthorization or prepayment review by DMAS or its designee.

3. Dental services for individuals younger than the age of 21 years that do not require preauthorization or prepayment review are initial, periodic, and emergency examinations; required radiography necessary to develop a treatment plan; patient education; dental prophylaxis; fluoride treatments; routine amalgam and composite restorations; stainless steel crowns, prefabricated steel post and temporary (polycarbonate) crowns, and stainless steel bands; crown recementation; pulpotomies; emergency endodontics for temporary relief of pain; pulp capping; sedative fillings; therapeutic apical closure; topical palliative treatment for dental pain; removal of foreign body; simple extractions; root recovery; incision and drainage of abscess; surgical exposure of the tooth to aid eruption; sequestrectomy for osteomyelitis; and oral antral fistula closure.

B. Dental services determined by the dental provider to be medically appropriate for an adult woman during the term of her pregnancy and through the end of the month following the 60th day postpartum shall be provided to a Medicaid-enrolled pregnant woman individual during pregnancy and for the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends. The dental services that shall be covered are (i) diagnostic x-rays and exams; (ii) preventive cleanings; (iii) restorative fillings; (iv) endodontics (root canals); (v) periodontics (gum-related treatments); (vi) prosthodontics, both removable and fixed (crowns, bridges, partial plates, and dentures); (vii) oral surgery (tooth extractions and other oral surgeries); and (viii) adjunctive general services (all covered services that do not fall into specific professional categories). These services require prepayment review by DMAS or its designee.

C. For the dental services covered for Medicaid-enrolled adult pregnant women, DMAS may place appropriate limits on a service based on medical necessity, for utilization control, or both. Examples of service limitations are examinations, prophylaxis, fluoride treatment (once/six months); space maintenance appliances; bitewing x-ray - two films (once/12 months); routine amalgam and composite restorations (once/three years); dentures (once/five years); extractions, tooth guidance appliances, permanent crowns and bridges, endodontics, patient education and sealants (once).

D. Limited oral surgery procedures, as defined and covered under Title XVIII (Medicare), are covered for all recipients, and require preauthorization or prepayment review by DMAS or its designee as described in the agency's Office Reference Manual located on the DMAS website at http://www.dmas.virginia.gov/#/dentalresources.

E. Residents of nursing facilities shall be permitted to deduct the costs of limited specific dental procedures from their payments toward the costs of their nursing facility care. Nursing facility residents shall be limited to deducting the following dental procedures: (i) routine exams and x-rays and dental cleaning twice yearly; (ii) full mouth x-rays once every three years; and (iii) extractions and fillings shall be permitted only if medically necessary as determined by DMAS.

12VAC30-50-290. Extended services to pregnant women.

A. Pregnancy-related and postpartum services for 60 days after the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends. The same limitations on all covered services apply to this group as to all other recipient groups.

B. Services for any other medical conditions that may complicate pregnancy. The same limitations on all covered services apply to this group as to all other recipient groups.

12VAC30-141-670. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Adverse action," consistent with 42 CFR 457.1130, means the denial of eligibility; failure to make a timely determination of eligibility; suspension or termination of enrollment, including disenrollment for failure to pay cost sharing; or delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of services; and failure to approve, furnish, or provide payment for health services in a timely manner; provided, however, that determination of eligibility to participate in and termination of participation in the FAMIS Select program shall not constitute an adverse action.

"Adverse benefit determination," consistent with 42 CFR 438.400, means the denial or limited authorization of a requested service; the failure to take action or timely take action on a request for service; the reduction, suspension, or termination of a previously authorized service; denial in whole or in part of a payment for a service; failure to provide services within the timeframes required by the state; for a resident of a rural exception area with only one MCO, the denial of a enrollee's request to exercise the enrollee's right under 42 CFR 438.52(b)(2)(ii) to obtain services outside of the network; the denial of a enrollee's request to dispute a financial liability as provided in 42 CFR 438.400(b)(7); or the failure of an MCO to act within the timeframes provided in 42 CFR 438.408(b).

"Agency" means the same as defined in 12VAC30-141-10.

"Agent" means an individual designated in writing to act on behalf of a FAMIS MOMS Plan applicant or enrollee during the administrative review process.

"Appeal" means an enrollee's request for review of an adverse benefit determination by an MCO or an adverse action by the LDSS, CPU, or DMAS.

"Applicant" means a pregnant woman who has filed an application (or who has an application filed on her behalf) for health insurance and is awaiting a determination of eligibility. A pregnant woman is an applicant until her eligibility has been determined.

"Application for health insurance" means the single streamlined application for determining eligibility in public health insurance programs operated by the Commonwealth.

"Authorized representative" means a person who is authorized to conduct the personal or financial affairs for an individual who is 18 years of age or older.

"Central processing unit" or "CPU" means Cover Virginia, which is the same as defined in 12VAC30-141-10.

"Child" means an individual younger than 19 years of age.

"Conservator" means a person appointed by a court of competent jurisdiction to manage the estate and financial affairs of an incapacitated individual.

"Continuation of coverage" means ensuring an enrollee's benefits are continued until completion of the review process, with the condition that should the enrollee not prevail in the review process, the enrollee shall be liable for the repayment of all benefits received during the review process.

"Director" means the individual, or his designee, specified in § 32.1-324 of the Code of Virginia with all of the attendant duties and responsibilities to administer the State Plan for Medical Assistance and the State Plan for Title XXI.

"DMAS" or "department" means the Department of Medical Assistance Services.

"Enrollee" means a pregnant woman who has been determined eligible to participate in FAMIS MOMS and is enrolled in the FAMIS MOMS program.

"FAMIS" means the Family Access to Medical Insurance Security Plan.

"FAMIS MOMS" means the Title XXI program available to eligible pregnant women.

"Federal poverty level" or "FPL" means that income standard as published annually by the U.S. Department of Health and Human Services in the Federal Register.

"Fee-for-service" means the traditional Medicaid health care delivery and payment system in which physicians and other providers receive a payment for each unit of service they provide.

"Guardian" means a person appointed by a court of competent jurisdiction to be responsible for the affairs of an incapacitated individual, including responsibility for making decisions regarding the person's support, care, health, safety, habilitation, education, and therapeutic treatment, and, if not inconsistent with an order of commitment, residence.

"Incapacitated " means a person who, pursuant to an order of a court of competent jurisdiction, has been found to be incapable of receiving and evaluating information effectively or responding to people, events, or environments to such an extent that the individual lacks the capacity to (i) meet the essential requirements of her health, care, safety, or therapeutic needs without the assistance or protection of a guardian, or (ii) manage property or financial affairs or provide for her support or for the support of her legal dependents without the assistance or protection of a conservator.

"LDSS" or "local department" means the local department of social services.

"Managed care organization" or "MCO" means an organization that offers managed care health insurance plans (MCHIPs) as defined in § 32.1-137.1 of the Code of Virginia.

"Pregnant woman" means a woman of any age who is medically determined to be pregnant. The pregnant woman definition is met from the first day of the earliest month that the medical practitioner certifies as being a month in which the woman was pregnant, through the last day of the month in which the 60th day occurs, following and continues for the duration of the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which her pregnancy ended the 12-month period ends, regardless of the reason the pregnancy ended.

"Provider" means the individual, facility, or other entity registered, licensed, or certified, as appropriate, and enrolled by an MCHIP or in fee-for-service to render services to FAMIS MOMS enrollees eligible for services.

"State fair hearing" means, consistent with 42 CFR 438.400, the process set forth in 42 CFR 431 Subpart E.

"Title XXI" means the federal State Children's Health Insurance Program as established by Subtitle J of the Balanced Budget Act of 1997.

12VAC30-141-750. Duration of eligibility.

A. The effective date of FAMIS MOMS eligibility shall be the first day of the month in which an application was received by LDSS, DMAS, or the CPU if the applicant met all eligibility requirements in that month.

B. Eligibility for FAMIS MOMS will continue through the last day of the month in which the 60th day occurs, following the last day the woman was pregnant for the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends, regardless of the reason the pregnancy ended. Eligibility will continue until the end of the coverage period, regardless of changes in circumstances such as income or family size.

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Notice of Intended Regulatory Action

Notice is hereby given in accordance with § 2.2-4007.01 of the Code of Virginia that the Department of Medical Assistance Services intends to consider amending 12VAC30-10, State Plan Under Title XIX of the Social Security Act Medical Assistance Program; General Provisions; 12VAC30-30, Groups Covered and Agencies Responsible for Eligibility Determination; 12VAC30-40, Eligibility Conditions and Requirements; 12VAC30-50, Amount, Duration, and Scope of Medical and Remedial Care and Services; and 12VAC30-141, Family Access to Medical Insurance Security (FAMIS) Plan. The purpose of the proposed action is to provide continuous coverage through 12 months postpartum for Medicaid and Family Access to Medical Insurance Security (FAMIS) pregnant and postpartum members and eligible individuals. A pregnant individual who is deemed eligible will maintain coverage for the duration of 12 months from the date the pregnancy ends, regardless of what point in the prenatal or postpartum period the individual enrolls in coverage. The coverage will be maintained regardless of a change in circumstances affecting income or household size.

The agency does not intend to hold a public hearing on the proposed action after publication in the Virginia Register.

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Public Comment Deadline: October 7, 2026.

Agency Contact: Meredith Lee, Policy, Regulations, and Manuals Supervisor, Division of Policy and Research, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-0552, fax (804) 786-1680, TDD (800) 343-0634, or email meredith.lee@dmas.virginia.gov.

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Fast-Track Regulation

Title of Regulation: 12VAC30-130. Amount, Duration and Scope of Selected Services (amending 12VAC30-130-5020).

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Public Hearing Information: No public hearing is currently scheduled.

Public Comment Deadline: October 7, 2026.

Effective Date: October 22, 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 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 the authority of the board when it is not in session.

Purpose: This action is essential to the health, safety, and welfare of Medicaid recipients because the amendments ensure that the regulation permits appropriate practitioner types to provide behavioral health services. The goal of the regulatory change is to ensure that the regulation accurately reflects the types of providers approved to provide services under the Addiction and Recovery Treatment Services (ARTS) Program available to Medicaid members.

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 aligns with current behavioral health practices.

Substance: The amendments expand the definition of credentialed addiction treatment professionals for services in the ARTS program to include licensed behavior analysts (LBAs), which reflects the inclusion of LBAs as providers for services in the ARTS program.

Issues: The primary advantage of this action is that it expands access to the ARTS program by adding LBAs to the list of approved providers for Medicaid recipients, which could lead to better health outcomes. 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. On behalf of the Board of Medical Assistance Services (board), the Director of the Department of Medical Assistance Services (DMAS) proposes to amend the definition of "credentialed addiction treatment professional" to include Licensed Behavioral Analysts (LBAs) pursuant to Chapter 288 of the 2024 General Assembly.²

Background. According to DMAS, LBAs are currently included in the definition of a "licensed mental health professional." However, the Medicaid provider community asked the General Assembly to also include LBAs in the definition of a "credentialed addiction treatment professional," because substance use disorder (SUD) treatment is a subspecialty of behavioral analysis and LBAs may provide SUD services within the scope of their license. In response, the General Assembly enacted Chapter 288, and DMAS now proposes to amend its regulations to add LBAs to the list of professionals who can provide addiction treatment as directed by legislation.

Estimated Benefits and Costs. In addition to complying with the legislative mandate, DMAS states that adding LBAs to the definition of a "Credentialed Addiction Treatment Professional" represents an effort to address the shortage of available addiction treatment professionals in Virginia. DMAS believes that increasing the number of professionals who can provide addiction treatment would not increase utilization or unit costs because the proposed change does not affect the eligibility of Medicaid enrollees for such services. However, the proposal is expected to make it easier for enrollees to find an addiction treatment professional to meet their addiction treatment needs. In essence, DMAS assesses that the demand for addiction treatment prior to 2024 legislation had been fully met albeit with some difficulty. Therefore, increasing the supply of addiction treatment professionals would not increase expenditures, but would instead improve recipient access to these services.

Businesses and Other Entities Affected. The proposal is expected to increase the number of professionals who can provide addiction treatment. However, there are no available data on the magnitude of such an increase in the treatment providers, nor are there any data on the number of Medicaid recipients who may benefit from this change. No affected entity appears to be disproportionately affected. The Code of Virginia requires DPB to assess whether an adverse impact may result from the proposed regulation.³ 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.⁴ The proposal may reduce the revenues of incumbent treatment professionals due to an increased number of professional who can serve the same recipients, but the proposal stems from a legislative mandate. Thus, no adverse impact is indicated on account of the proposed change to the regulation.

Small Businesses⁵ Affected.⁶ No adverse effect on small businesses is expected on account of the regulatory proposal as the change is mandated by legislation.

Localities⁷ Affected.⁸ The proposed change does not introduce costs for localities, nor does it disproportionately affect any particular locality.

Projected Impact on Employment. The proposed regulatory change by itself would not affect total employment as the legislation is the driving force for the proposed change.

Effects on the Use and Value of Private Property. No impact on the use and value of private property nor on real estate development costs is expected on account of the proposed regulatory change.

_____________________________

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 https://legacylis.virginia.gov/cgi-bin/legp604.exe?241+ful+CHAP0288.

³ 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.

⁴ 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.

⁵ 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."

⁶ 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.

⁷ "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.

⁸ 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:

Pursuant to Chapter 288 of the 2024 Acts of Assembly, the amendments add licensed behavioral analysts (LBAs) to the definition of credentialed addiction treatment professional.

12VAC30-130-5020. Definitions.

The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise:

"Abstinence" means the intentional and consistent restraint from the pathological pursuit of reward or relief, or both, that involves the use of substances.

"Addiction" means a primary, chronic disease of brain reward, motivation, memory, and related circuitry. Addiction is defined as the inability to consistently abstain, impairment in behavioral control, persistence of cravings, diminished recognition of significant problems with one's behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

"Addiction-credentialed physician" means a physician who holds a board certification in addiction medicine from the American Board of Addiction Medicine, a subspecialty board certification in addition to certification in psychiatry from the American Board of Psychiatry and Neurology, or subspecialty board certification in addiction medicine from the American Osteopathic Association. DMAS also recognizes physicians treating addiction who have specialty training or experience in addiction medicine or addiction psychiatry. If treating adolescents, "addiction-credentialed physician" means an addiction-credentialed physician who also has experience and specialty training with adolescent medicine.

"Adherence" means the individual receiving treatment has demonstrated ability to cooperate with, follow, and take personal responsibility for the implementation of treatment plans.

"Adolescent" means an individual from 12 years of age to 20 years of age.

"Allied health professional" means counselor aides or group living workers who meet the DBHDS licensing requirements for unlicensed staff in residential settings.

"ARTS" means addiction and recovery treatment services.

"ARTS care coordinator" means an employee of DMAS, its contractor, or an MCO who is a licensed practitioner of the healing arts, including a physician or medical director, licensed clinical psychologist, licensed clinical social worker, licensed professional counselor, licensed substance abuse treatment practitioner, licensed marriage and family therapist, nurse practitioner, or registered nurse with two years of clinical experience in the treatment of substance use disorders. The ARTS care coordinator performs independent assessments of requests for all ARTS intensive outpatient programs (ASAM Level 2.1); partial hospitalization programs (ASAM Level 2.5); residential treatment services (ASAM Levels 3.1, 3.3, 3.5, and 3.7); and inpatient services (ASAM Levels 3.7 and 4.0).

"ASAM" means the American Society of Addiction Medicine.

"ASAM criteria" means the six different life areas used by the ASAM Patient Placement Criteria to develop a holistic biopsychosocial assessment of an individual that is used for service planning, level of care, and length of stay treatment decisions.

"BHA" means behavioral health authority.

"Biomedical" means biological or physical aspects of a member's condition that require assessment and services that are delivered by appropriately credentialed medical staff, who are available to assess and treat co-occurring biomedical disorders that may be the result of, or independent of, a substance use disorder.

"Care coordination" means collaboration and sharing of information among health care providers who are involved with an individual's health care to assist in improving the care of the individual. This includes e-consultations from primary care providers to specialists.

"Certified substance abuse counselor" or "CSAC" means the same as that term is defined in § 54.1-3507.1 of the Code of Virginia.

"Certified substance abuse counseling assistant" or "CSAC-A" means the same as that term is defined in § 54.1-3507.2 of the Code of Virginia.

"Certified substance abuse counselor-supervisee" means an individual who has completed the educational requirements described in clause (i) of § 54.1-3507.1 C of the Code of Virginia, but who has not completed the practice hours described in clause (ii) of § 54.1-3507.1 C of the Code of Virginia.

"Child" means an individual from birth to 12 years of age.

"Clinical experience" means, for the purpose of these ARTS requirements, practical experience in providing direct services to individuals with diagnoses of substance use disorder. Clinical experience shall include includes supervised internships, supervised practicums, or supervised field experience. Clinical experience shall does not include unsupervised internships, unsupervised practicums, and unsupervised field experience.

"Counseling" means the same as that term is defined in § 54.1-3500 of the Code of Virginia.

"Credentialed addiction treatment professional" or "CATP" means an individual licensed or registered with the appropriate board in the following roles: (i) an addiction-credentialed physician or physician with experience or training in addiction medicine; (ii) physician extenders with experience or training in addiction medicine; (iii) a licensed psychiatrist; (iv) a licensed clinical psychologist; (v) a licensed clinical social worker; (vi) a licensed professional counselor; (vii) a certified psychiatric clinical nurse specialist; (viii) a licensed psychiatric nurse practitioner; (ix) a licensed marriage and family therapist; (x) a licensed substance abuse treatment practitioner; (xi) a licensed behavior analyst; (xii) a resident who is under the supervision of a licensed professional counselor (18VAC115-20-10), licensed marriage and family therapist (18VAC115-50-10), or licensed substance abuse treatment practitioner (18VAC115-60-10) and is registered with the Virginia Board of Counseling; (xii) (xiii) a resident in psychology who is under supervision of a licensed clinical psychologist and is registered with the Virginia Board of Psychology (18VAC125-20-10); or (xiii) (xiv) a supervisee in social work who is under the supervision of a licensed clinical social worker and is registered with the Virginia Board of Social Work (18VAC140-20-10).

"CSB" means community services board.

"DBHDS" means the Department of Behavioral Health and Developmental Services consistent with Chapter 3 (§ 37.2-300 et seq.) of Title 37.2 of the Code of Virginia.

"DEA" means Drug Enforcement Administration.

"DMAS" means the Department of Medical Assistance Services and its contractors consistent with Chapter 10 (§ 32.1-323 et seq.) of Title 32.1 of the Code of Virginia.

"DSM-5" means the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, copyright 2013, American Psychiatric Association.

"Evidence-based" means an empirically supported clinical practice or intervention with a proven ability to produce positive outcomes.

"Face-to-face" means encounters that occur in person or through telemedicine.

"FQHC" means federally qualified health center.

"Individual" means the patient, client, beneficiary, or member who receives services set out in 12VAC30-130-5000 et seq. These terms are used interchangeably.

"Individual service plan" or "ISP" means an initial and comprehensive treatment plan that is regularly updated and specific to an individual's unique treatment needs as identified in the assessment. An ISP contains an individual's treatment or training needs, the individual's goals and measurable objectives to meet the identified needs, services to be provided with the recommended frequency to accomplish the measurable goals and objectives, and an individualized discharge plan that describes transition to other appropriate services. An individual is included in the development of the ISP, and the ISP is signed by the individual. If the individual is a minor, the ISP is also signed by the individual's parent or legal guardian. An ISP includes documentation if the individual is a minor child or an adult who lacks legal capacity and is unable or unwilling to sign the ISP.

"Induction phase" means the medically monitored initiation of buprenorphine, buprenorphine and naloxone, naltrexone, or methadone treatment performed in a qualified practitioner's office or licensed OTP. The goal of the induction phase is to find the individual's ideal dose of buprenorphine, buprenorphine and naloxone, naltrexone, or methadone. The ideal dose minimizes both side effects and drug craving.

"Licensed practical nurse" means a professional who is licensed by the Commonwealth as a practical nurse or holds a multistate licensure privilege to practice practical nursing according to 18VAC90-19-80.

"Managed care organization" or "MCO" means an organization that offers managed care health insurance plans (MCHIP), as defined by § 38.2-5800 of the Code of Virginia, which means an arrangement for the delivery of health care in which a health carrier undertakes to provide, arrange for, pay for, or reimburse any of the costs of health care services for a covered person on a prepaid or insured basis that (i) contains one or more incentive arrangements, including any credentialing requirements intended to influence the cost or level of health care services between the health carrier and one or more providers with respect to the delivery of health care services and (ii) requires or creates benefit payment differential incentives for covered persons to use providers that are directly or indirectly managed, owned, under contract with, or employed by the health carrier.

"Medication assisted treatment" or "MAT" means the same as that term is defined in 42 CFR 8.2.

"Multidimensional assessment" or "assessment" means the individualized, person-centered biopsychosocial assessment performed face-to-face, in which the provider obtains comprehensive information from the individual, and family members and significant others as needed, including history of the present illness; family history; developmental history; alcohol, tobacco, and other drug use or addictive behavior history; personal or social history; legal history; psychiatric history; medical history; spiritual history as appropriate; review of systems; mental status exam; physical examination; formulation and diagnoses; survey of assets, vulnerabilities, and supports; and treatment recommendations. The ASAM multidimensional assessment is a theoretical framework for this individualized, person-centered assessment that includes the following dimensions: (i) acute intoxication or likelihood of withdrawal, or both; (ii) medical conditions and complications, both historical and current; (iii) emotional, behavioral, or cognitive status and any identified issues; (iv) an individual's readiness to change; (v) risks for relapse or continued use; and (vi) home environment. The level of care determination, ISP, and recovery strategies development may be based upon this multidimensional assessment.

"Opioid" means any psychoactive chemical that resembles morphine in pharmacological effects, including opiates and synthetic or semisynthetic agents that exert their effects by binding to highly selective receptors in the brain where morphine and endogenous opioids affect their actions.

"Opioid treatment program" or "OTP" means the same as that term is defined in 42 CFR 8.2.

"Opioid treatment services" or "OTS" means preferred office-based opioid treatment (OBOT) and OTPs that encompass a variety of pharmacological and nonpharmacological treatment modalities, including substance use disorder counseling and psychotherapy.

"Overdose" means the inadvertent or deliberate consumption of a dose of a chemical substance much larger than either habitually used by the individual or ordinarily used for treatment of an illness that is likely to result in a serious toxic reaction or death.

"Physician extenders" means licensed nurse practitioners as defined in § 54.1-3000 of the Code of Virginia and licensed physician assistants as defined in § 54.1-2900 of the Code of Virginia.

"Preferred office-based opioid treatment" or "preferred OBOT" means addiction treatment services for individuals with a primary opioid use disorder provided by physicians and physician extenders who have a current DEA registration authorizing the prescribing of scheduled drugs, including Schedule III drugs, working in collaboration with CATPs providing psychotherapy and substance use disorder counseling in public and private practice settings.

"Program of assertive community treatment" or "PACT" means the same as that term is defined in 12VAC35-105-20.

"Psychoeducation" means (i) a specific form of education aimed at helping individuals who have a substance use disorder or mental illness and their family members or caregivers to access clear and concise information about substance use disorders or mental illness and (ii) a way of accessing and learning strategies to deal with substance use disorders or mental illness and its effects in order to design effective treatment plans and strategies.

"Psychotherapy" or "therapy" means the use of psychological methods in a professional relationship to assist a person to acquire great human effectiveness or to modify feelings, conditions, attitudes, and behaviors that are emotionally, intellectually, or socially ineffectual or maladaptive.

"Recovery" means a process of sustained effort that addresses the biological, psychological, social, and spiritual disturbances inherent in addiction and consistently pursues abstinence, behavior control, dealing with cravings, recognizing problems in one's behaviors and interpersonal relationships, and more effective coping with emotional responses leading to reversal of negative, self-defeating internal processes and behaviors and allowing healing of relationships with self and others. The concepts of humility, acceptance, and surrender are useful in this process.

"Registered nurse" or "RN" means the same as "professional nurse" is defined in § 54.1-3000 of the Code of Virginia.

"Relapse" means a process in which an individual who has established abstinence or sobriety experiences recurrence of signs and symptoms of active addiction, often including resumption of the pathological pursuit of reward or relief through the use of substances and other behaviors often leading to disengagement from recovery activities. Relapse can be triggered by exposure to (i) rewarding substances and behaviors, (ii) environmental cues to use, and (iii) emotional stressors that trigger heightened activity in brain stress circuits. The event of using or acting out is the latter part of the process, which can be prevented by early intervention.

"RHC" means rural health clinic.

"SBIRT" means screening, brief intervention, and referral to treatment. SBIRT services are an evidence-based and community-based practice designed to identify, reduce, and prevent problematic substance use disorders.

"Service authorization" means the process to approve specific services for an enrolled Medicaid, FAMIS Plus, or FAMIS individual by DMAS or its contractor, or an MCO prior to service delivery and reimbursement in order to validate that the service requested is medically necessary and meets DMAS and DMAS contractor criteria for reimbursement. Service authorization does not guarantee payment for the service.

"Substance use care coordinator" means staff in an OTP or preferred OBOT setting who have:

1. At least a bachelor's degree in one of the following fields: social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, or human services counseling, and at least either (i) one year of substance use disorder related direct experience or training or a combination of experience or training in providing services to individuals with a diagnosis of substance use disorder or (ii) a minimum of one year of clinical experience or training in working with individuals with co-occurring diagnoses of substance use disorder and mental illness;

2. Licensure by the Commonwealth as a registered nurse with at least either (i) one year of direct experience or training or a combination of experience and training in providing services to individuals with a diagnosis of substance use disorder or (ii) a minimum of one year of clinical experience or training or a combination of experience and training in working with individuals with co-occurring diagnoses of substance use disorder and mental illness; or

3. Certification as a CSAC or a CSAC-A.

"Substance use case management" means the same as set out in 12VAC30-50-491.

"Substance use disorder" or "SUD" means a substance-related addictive disorder, as defined in the DSM-5 with the exception of tobacco-related disorders and non-substance-related disorders, marked by a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues to use, is seeking treatment for the use of, or is in active recovery from the use of alcohol or other drugs despite significant related problems.

"Substance use disorder counseling" means the same as "substance abuse counseling" is defined in 18VAC115-30-10.

"Telemedicine" means the real-time, two-way transfer of medical data and information using an interactive audio-video connection for the purposes of medical diagnosis and treatment. The member is located at the originating site, while the provider renders services from a remote location via the audio-video connection. Equipment utilized for telemedicine shall be of sufficient audio quality and visual clarity as to be functionally equivalent to a face-to-face encounter for professional medical services.

"Tolerance" or "tolerate" means a state of adaptation in which exposure to a drug induces changes that result in diminution of one or more of the drug's effects over time.

"Withdrawal management" means services to assist an individual's withdrawal from the use of substances.

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Notice of Intended Regulatory Action

Notice is hereby given in accordance with § 2.2-4007.01 of the Code of Virginia that the Department of Medical Assistance Services intends to consider amending 12VAC30-10, State Plan Under Title XIX of the Social Security Act Medical Assistance Program; General Provisions; 12VAC30-30, Groups Covered and Agencies Responsible for Eligibility Determination; 12VAC30-40, Eligibility Conditions and Requirements; 12VAC30-50, Amount, Duration, and Scope of Medical and Remedial Care and Services; and 12VAC30-141, Family Access to Medical Insurance Security (FAMIS) Plan. The purpose of the proposed action is to provide continuous coverage through 12 months postpartum for Medicaid and Family Access to Medical Insurance Security (FAMIS) pregnant and postpartum members and eligible individuals. A pregnant individual who is deemed eligible will maintain coverage for the duration of 12 months from the date the pregnancy ends, regardless of what point in the prenatal or postpartum period the individual enrolls in coverage. The coverage will be maintained regardless of a change in circumstances affecting income or household size.

The agency does not intend to hold a public hearing on the proposed action after publication in the Virginia Register.

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Public Comment Deadline: October 7, 2026.

Agency Contact: Meredith Lee, Policy, Regulations, and Manuals Supervisor, Division of Policy and Research, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-0552, fax (804) 786-1680, TDD (800) 343-0634, or email meredith.lee@dmas.virginia.gov.

TITLE 12. HEALTH

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

Emergency Regulation

Titles of Regulations: 12VAC30-10. State Plan under Title XIX of the Social Security Act Medical Assistance Program; General Provisions (amending 12VAC30-10-140, 12VAC30-10-150).

12VAC30-30. Groups Covered and Agencies Responsible for Eligibility Determination (amending 12VAC30-30-10, 12VAC30-30-30).

12VAC30-40. Eligibility Conditions and Requirements (amending 12VAC30-40-100).

12VAC30-50. Amount, Duration, and Scope of Medical and Remedial Care Services (amending 12VAC30-50-10, 12VAC30-50-50, 12VAC30-50-190, 12VAC30-50-290).

12VAC30-141. Family Access to Medical Insurance Security Plan (amending 12VAC30-141-670, 12VAC30-141-750).

Statutory Authority: § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Effective Dates: August 13, 2026, through February 18, 2028.

Agency Contact: Meredith Lee, Policy, Regulations, and Manuals Supervisor, Division of Policy and Research, Department of Medical Assistance Services, 600 East Broad Street, Suite 1300, Richmond, VA 23219, telephone (804) 371-0552, fax (804) 786-1680, TDD (800) 343-0634, or email meredith.lee@dmas.virginia.gov.

Preamble:

Section 2.2-4011 B 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.

The amendments provide continuous coverage through 12 months postpartum for Medicaid and Family Access to Medical Insurance Security (FAMIS) pregnant and postpartum members and eligible individuals. A pregnant individual who is deemed eligible will maintain coverage for the duration of 12 months from the date the pregnancy ends, regardless of what point in the prenatal or postpartum period individual enrolls in coverage. The coverage will be maintained regardless of a change in circumstances affecting income or household size.

12VAC30-10-140. Amount, duration, and scope of services: Categorically needy.

Medicaid is provided in accordance with the requirements of 42 CFR 440, Subpart B and § 1902(a), 1902(e), 1905(a), 1905(p), 1915, 1920, and 1925 of the Act.

Services for the categorically needy are described below and in 12VAC30-50-10 et seq. These services include:

1. Each item or service listed in § 1905(a)(1) through (5) and (21) of the Act, is provided as defined in 42 CFR Part 440, Subpart A, or, for EPSDT services, § 1905(r) and 42 CFR Part 411, Subpart B.

2. Nurse-midwife services listed in § 1905(a)(17) of the Act, are provided to the extent that nurse-midwives are authorized to practice under state law or regulation and without regard to whether the services are furnished in the area of management of the care of mothers and babies throughout the maternity cycle. Nurse-midwives are permitted to enter into independent provider agreements with the Medicaid agency without regard to whether the nurse-midwife is under the supervision of, or associated with, a physician or other health care provider.

3. Pregnancy-related, including family planning service, and postpartum services for a 60-day 12-month postpartum period (beginning on the last day of the pregnancy ends) and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends, are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

4. Services for medical conditions that may complicate the pregnancy (other than pregnancy-related or postpartum services) are provided to pregnant women.

5. Services related to pregnancy (including prenatal, delivery, postpartum, and family planning services) and to other conditions that may complicate pregnancy are the same services provided to poverty level pregnant women eligible under the provision of § 1902(a)(10)(A)(i)(IV) and 1902(a)(10)(A)(ii)(IX) of the Act.

6. Home health services are provided to individuals entitled to nursing facility services as indicated in 12VAC30-10-220 of this plan.

7. Inpatient services that are being furnished to infants and children described in § 1902(l)(1)(B) through (D), or § 1905(n)(2) of the Act, on the date the infant or child attains the maximum age for coverage under the approved State plan will continue until the end of the stay for which the inpatient services are furnished.

8. Respiratory care services are not provided to ventilator dependent individuals as indicated in 12VAC30-10-300 of this plan.

9. Services are provided to families eligible under § 1925 of the Act as indicated in 12VAC30-10-350 of this plan.

10. Home and community care for functionally disabled elderly individuals is not covered.

11. Program of All-Inclusive Care for the Elderly (PACE) services as described and limited in Supplement 6 to Attachment 3.1-A (12VAC30-50-320, 12VAC30-50-321, 12VAC30-50-325, and 12VAC30-50-328).

12VAC30-50-10 et seq. identifies the medical and remedial services provided to the categorically needy, specifies all limitations on the amount, duration, and scope of those service, and lists the additional coverage (that is in excess of established service limits) for pregnancy-related services and services for conditions that may complicate the pregnancy.

12VAC30-10-150. Amount, duration, and scope of services: Medically needy.

A. This State Plan covers the medically needy. The services described in this section and in Part II (12VAC30-50-40 et seq.) of 12VAC30-50 are provided. Services for the medically needy include:

1. If services in an institution for mental diseases (42 CFR 440.140 and 440.160) or an intermediate care facility for individuals with intellectual disabilities (or both) are provided to any medically needy group, then each medically needy group is provided either the services listed in § 1905(a)(1) through (5) and (17) of the Act, or seven of the services listed in § 1902(a)(1) through (20). The services are provided as defined in 42 CFR 440, Subpart A and in §§ 1902, 1905, and 1915 of the Act.

Subdivision 1 of this subsection is applicable with respect to nurse-midwife services under § 1902(a)(17).

2. Prenatal care and delivery services for pregnant women.

3. Pregnancy-related, including family planning services, and postpartum services for a 60-day 12-month postpartum period (beginning on the last day of the pregnancy ends) and including any remaining days in of the calendar month in which the sixtieth day falls 12-month period ends, are provided to women who, while pregnant, were eligible for, applied for, and received medical assistance on the day the pregnancy ends.

4. Services for any other medical condition that may complicate the pregnancy (other than pregnancy-related and postpartum services) are provided to pregnant women.

5. Ambulatory services as defined in 12VAC30-50-40 for recipients younger than 18 years of age and recipients entitled to institutional services.

6. Home health services to recipients entitled to nursing facility services as indicated in 12VAC30-10-220.

7. Services for the medically needy do not include services in an institution for mental diseases for individuals older than 65 years of age.

8. Services for the medically needy do not include services in an intermediate care facility for individuals with intellectual disabilities.

9. Services for the medically needy do not include inpatient psychiatric services for individuals younger than 21 years of age, other than those covered under early and periodic screening, diagnosis, and treatment (at 12VAC30-50-130).

10. Services for the medically needy do not include respiratory care services provided to ventilator dependent individuals. See 12VAC30-10-300.

11. Home and community care for functionally disabled elderly individuals is not covered.

12. Program of All-Inclusive Care for the Elderly (PACE) services as described and limited in Supplement 6 to Attachment 3.1-A (12VAC30-50-320, 12VAC30-50-321, 12VAC30-50-325, and 12VAC30-50-328) are covered.

B. Part II (12VAC30-50-40 et seq.) of 12VAC30-50 identifies services provided to each covered group of the medically needy. (Note: Other programs to be offered to medically needy beneficiaries would specify all limitations on the amount, duration, and scope of those services. As PACE provides services to the frail elderly population without such limitation, this is not applicable for this program. In addition, other programs to be offered to medically needy beneficiaries would also list the additional coverage that is in excess of established service limits for pregnancy-related services for conditions that may complicate the pregnancy. As PACE is for the frail elderly population, this also is not applicable for this program.)

12VAC30-30-10. Mandatory coverage: categorically needy and other required special groups.

The Title IV-A agency or the Department of Medical Assistance Services Central Processing Unit determines eligibility for Title XIX services. The following groups shall be eligible for medical assistance as specified:

1. Parents and other caretaker relatives of dependent children with household income at or below a standard established by the Commonwealth in 12VAC30-40-100 consistent with 42 CFR 435.110 and §§ 1902(a)(10)(A)(i)(l) and 1931(b) of the Social Security Act. Individuals qualifying under this eligibility group shall meet the following criteria:

a. Parents, other caretaker relatives (defined at 42 CFR 435.4) including pregnant women, or dependent children (defined at 42 CFR 435.4) younger than 18 years of age. This group includes individuals who are parents or other caretaker relatives of children who are 18 years of age provided the children are full-time students in a secondary school or the equivalent level of vocational or technical training and are expected to complete such school or training before their 19th birthday.

b. Spouses of parents and other caretaker relatives shall include other relatives of the child based on blood (including those of half-blood), adoption, or marriage. Other relatives of a specified degree of the dependent child shall include any blood relative (including those of half-blood) and including (i) first cousins; (ii) nephews or nieces; (iii) persons of preceding generations as denoted by prefixes of grand, great, or great-great; (iv) stepbrother; (v) stepsister; (vi) a relative by adoption following entry of the interlocutory or final order, whichever is first; (vii) the same relatives by adoption as listed in this subdivision 1 b; and (viii) spouses of any persons named in this subdivision 1 b even after the marriage is terminated by death or divorce.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

2. Women who are pregnant or postpartum with household income at or below a standard established by the Commonwealth in 12VAC30-40-100, consistent with 42 CFR 435.116 and §§ 1902(a)(10)(A)(i)(III) and (IV), 1902(a)(10)(A)(ii)(I) and (IX), and 1931(b) of the Act. Individuals qualifying under this eligibility group shall be pregnant or postpartum as defined in 42 CFR 435.4.

a. A woman who, while pregnant, was eligible for, applied for, and received Medicaid under the approved state plan on the day her pregnancy ends. The woman continues to be eligible, as though she were pregnant, for all pregnancy-related and postpartum medical assistance under the plan for a 60-day 12-month postpartum period, beginning on the last day of her the pregnancy, and for including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

b. A pregnant woman who would otherwise lose eligibility because of an increase in income of the family in which she is a member during the pregnancy or the 12-month postpartum period that extends through the end of the month in which the 60-day period, beginning on the last day of pregnancy, and including any remaining days of the calendar month in which the 12-month period ends.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

3. Infants and children younger than 19 years of age with household income at or below standards based on this age group, consistent with 42 CFR 435.118 and §§ 1902(a)(10)(A)(i)(III), (IV) and (VIII); 1902(a)(10)(A)(ii)(IV) and (IX); and 1931(b) of the Act. Children qualifying under this eligibility group shall meet the following criteria:

a. They are younger than 19 years of age; and

b. They have a household income at or below the standard established by the Commonwealth.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

4. The adult group as described at 42 CFR 435.119.

5. Former foster care children younger than 26 years of age who are not otherwise mandatorily eligible in another Medicaid classification, who were on Medicaid and in foster care when they turned 18 years of age, or who aged out of foster care. Individuals qualifying under this eligibility group shall meet the following criteria:

a. They shall be younger than 26 years of age;

b. They shall not be otherwise eligible for and enrolled for mandatory coverage under the state plan; and

c. They were in foster care under the responsibility of the Commonwealth or a federally recognized tribe and were enrolled in Virginia Medicaid under the state plan when they turned 18 years of age or at the time of aging out of the foster care program.

6. Families terminated from coverage under § 1931 of the Act solely because of earnings or hours of employment shall be entitled to up to 12 months of extended benefits in accordance with § 1925 of the Act.

7. A child born to a woman who is eligible for and receiving Medicaid on the date of the child's birth. The child is deemed to have applied and been found eligible for Medicaid on the date of birth and remains eligible for one year from birth, as long as he remains a resident of the Commonwealth. A redetermination of eligibility must be completed on behalf of the deemed child at age one year and annually thereafter so long as he remains eligible.

8. Aged, blind, and disabled individuals receiving cash assistance.

a. Individuals who meet more restrictive requirements for Medicaid than the SSI requirements. (This includes persons who qualify for benefits under § 1619(a) of the Act or who meet the eligibility requirements for SSI status under § 1619(b)(1) of the Act and who met the Commonwealth's more restrictive requirements for Medicaid in the month before the month they qualified for SSI under § 1619(a) or met the requirements under § 1619(b)(1) of the Act. Medicaid eligibility for these individuals continues as long as they continue to meet the § 1619(a) eligibility standard or the requirements of § 1619(b) of the Act.)

b. These persons include the aged, the blind, and the disabled.

c. Protected SSI children (pursuant to § 1902(a)(10)(A)(i)(II) of the Act) (P.L. 105-33 § 4913). Children who meet the pre-welfare reform definition of childhood disability who lost their SSI coverage solely as a result of the change in the definition of childhood disability, and who also meet the more restrictive requirements for Medicaid than the SSI requirements.

d. The more restrictive categorical eligibility criteria are described in 12VAC30-30-40.

Financial criteria are described in 12VAC30-40-10.

9. Qualified severely impaired blind and disabled individuals younger than 65 years of age who:

a. For the month preceding the first month of eligibility under the requirements of § 1905(q)(2) of the Act, received SSI, a state supplementary payment (SSP) under § 1616 of the Act or under § 212 of P.L. 93-66 or benefits under § 1619(a) of the Act and were eligible for Medicaid; or

b. For the month of June 1987, were considered to be receiving SSI under § 1619(b) of the Act and were eligible for Medicaid. These individuals must:

(1) Continue to meet the criteria for blindness or have the disabling physical or mental impairment under which the individual was found to be disabled;

(2) Except for earnings, continue to meet all nondisability-related requirements for eligibility for SSI benefits;

(3) Have unearned income in amounts that would not cause them to be ineligible for a payment under § 1611(b) of the Act;

(4) Be seriously inhibited by the lack of Medicaid coverage in their ability to continue to work or obtain employment; and

(5) Have earnings that are not sufficient to provide for themselves a reasonable equivalent of the Medicaid, SSI (including any federally administered SSP), or public funded attendant care services that would be available if they did have such earnings.

The state applies more restrictive eligibility requirements for Medicaid than under SSI and under 42 CFR 435.121. Individuals who qualify for benefits under § 1619(a) of the Act or individuals described in this section who meet the eligibility requirements for SSI benefits under § 1619(b)(1) of the Act and who met the state's more restrictive requirements in the month before the month they qualified for SSI under § 1619(a) or met the requirements of § 1619(b)(1) of the Act are covered. Eligibility for these individuals continues as long as they continue to qualify for benefits under § 1619(a) of the Act or meet the SSI requirements under § 1619(b)(1) of the Act.

10. Except in states that apply more restrictive requirements for Medicaid than under SSI, blind or disabled individuals who:

a. Are at least 18 years of age; and

b. Lose SSI eligibility because they become entitled to Old Age, Survivor, and Disability Insurance (OASDI) child's benefits under § 202(d) of the Act or an increase in these benefits based on their disability. Medicaid eligibility for these individuals continues for as long as they would be eligible for SSI, absence their OASDI eligibility.

The Commonwealth does not apply more restrictive income eligibility requirements than those under SSI.

11. Except in states that apply more restrictive eligibility requirements for Medicaid than under SSI, individuals who are ineligible for SSI or optional state supplements (if the agency provides Medicaid under § 435.230 of the Act), because of requirements that do not apply under Title XIX of the Act.

12. Individuals receiving mandatory state supplements.

13. Individuals who in December 1973 were eligible for Medicaid as an essential spouse and who have continued, as a spouse, to live with and be essential to the well-being of a recipient of cash assistance. The recipient with whom the essential spouse is living continues to meet the December 1973 eligibility requirements of the Commonwealth's approved plan for Old Age Assistance, Aid to the Blind, Aid to the Permanently and Totally Disabled, or Aid to the Aged, Blind, and Disabled and the spouse continues to meet the December 1973 requirements for his needs to be included in computing the cash payment. In December 1973, Medicaid coverage of the essential spouse was limited to the aged, the blind, and the disabled.

14. Institutionalized individuals who were eligible for Medicaid in December 1973 as inpatients of Title XIX medical institutions or residents of Title XIX intermediate care facilities, if, for each consecutive month after December 1973, they:

a. Continue to meet the December 1973 Medicaid State Plan eligibility requirements;

b. Remain institutionalized; and

c. Continue to need institutional care.

15. Blind and disabled individuals who:

a. Meet all current requirements for Medicaid eligibility except the blindness or disability criteria;

b. Were eligible for Medicaid in December 1973 as blind or disabled; and

c. For each consecutive month after December 1973 continue to meet December 1973 eligibility criteria.

16. Individuals who would be SSI or SSP eligible except for the increase in OASDI benefits under P.L. 92-336 (July 1, 1972), who were entitled to OASDI in August 1972, and who were receiving cash assistance in August 1972. This includes persons who would have been eligible for cash assistance but had not applied in August 1972 (this group was included in this state's August 1972 plan), and persons who would have been eligible for cash assistance in August 1972 if not in a medical institution or intermediate care facility (this group was included in this state's August 1972 plan).

17. Individuals who:

a. Are receiving OASDI and were receiving SSI or SSP but became ineligible for SSI or SSP after April 1977; and

b. Would still be eligible for SSI or SSP if cost-of-living increases in OASDI paid under § 215(i) of the Act received after the last month for which the individual was eligible for and received SSI or SSP and OASDI, concurrently, were deducted from income.

The state applies more restrictive eligibility requirements than those under SSI and the amount of increase that caused SSI or SSP ineligibility and subsequent increases are deducted when determining the amount of countable income for categorically needy eligibility.

18. Disabled widows and widowers who would be eligible for SSI or SSP except for the increase in their OASDI benefits as a result of the elimination of the reduction factor required by § 134 of P.L. 98-21 and who are deemed, for purposes of Title XIX, to be SSI beneficiaries or SSP beneficiaries for individuals who would be eligible for SSP only, under § 1634(b) of the Act.

The state does not apply more restrictive income eligibility standards than those under SSI.

19. Disabled widows, disabled widowers, and disabled unmarried divorced spouses who had been married to the insured individual for a period of at least 10 years before the divorce became effective, who have attained the age of 50, who are receiving Title II payments, and who because of the receipt of Title II income lost eligibility for SSI or SSP which they received in the month prior to the month in which they began to receive Title II payments, who would be eligible for SSI or SSP if the amount of the Title II benefit were not counted as income, and who are not entitled to Medicare Part A.

The state applies more restrictive eligibility requirements for its blind or disabled than those of the SSI program.

20. Qualified Medicare beneficiaries:

a. Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under § 1818 of the Act);

b. Whose income does not exceed 100% of the federal level; and

c. Whose resources do not exceed twice the maximum standard under SSI or, effective January 1, 2010, the resource limit set for the Medicare Part D Low Income Subsidy Program.

Medical assistance for this group is limited to Medicare cost sharing as defined in item 3.2 of this plan.

21. Qualified disabled and working individuals:

a. Who are entitled to hospital insurance benefits under Medicare Part A under § 1818A of the Act;

b. Whose income does not exceed 200% of the federal poverty level;

c. Whose resources do not exceed twice the maximum standard under SSI; and

d. Who are not otherwise eligible for medical assistance under Title XIX of the Act.

Medical assistance for this group is limited to Medicare Part A premiums under §§ 1818 and 1818A of the Act.

22. Specified low-income Medicare beneficiaries:

a. Who are entitled to hospital insurance benefits under Medicare Part A (but not pursuant to an enrollment under § 1818A of the Act);

b. Whose income for calendar years 1993 and 1994 exceeds the income level in subdivision 25 b of this section, but is less than 110% of the federal poverty level, and whose income for calendar years beginning 1995 is less than 120% of the federal poverty level; and

c. Whose resources do not exceed twice the maximum standard under SSI or, effective January 1, 2010, the resource limit set for the Medicare Part D Low Income Subsidy Program.

Medical assistance for this group is limited to Medicare Part B premiums under § 1839 of the Act.

23. a. Each person to whom SSI benefits by reason of disability are not payable for any month solely by reason of § 1611(e)(3)(A)(i) or (v) shall be treated, for purposes of Title XIX, as receiving SSI benefits for the month.

b. The state applies more restrictive eligibility standards than those under SSI. Individuals whose eligibility for SSI benefits are based solely on disability who are not payable for any months solely by reason of § 1611(e)(3)(A)(i) or (v) and who continue to meet the more restrictive requirements for Medicaid eligibility under the state plan, are eligible for Medicaid as categorically needy.

12VAC30-30-30. Optional coverage of the medically needy.

The Title IV A Agency determines eligibility for Title XIX services.

This plan includes the medically needy:

1. Pregnant women who, except for income and/or resources, would be eligible as categorically needy under Title XIX of the Act.

2. Women who, while pregnant, were eligible for and have applied for Medicaid and receive Medicaid as medically needy under the approved State plan on the date the pregnancy ends. These women continue to be eligible, as though they were pregnant, for all pregnancy-related and postpartum services under the plan for a 60-day 12-month postpartum period after beginning on the last day of the pregnancy ends, and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

3. Individuals under age 18 who, but for income and/or resources, would be eligible under § 1902(a)(10)(A)(i) of the Act.

4. Newborn children born on or after October 1, 1984, to a woman who is eligible as medically needy and is receiving Medicaid on the date of the child's birth. The child is deemed to have applied and been found eligible for Medicaid on the date of birth and remains eligible for one year so long as the woman remains eligible and the child is a member of the woman's household.

5. Reasonable classification of financially eligible individuals under the ages of 21, 20, 19, or 18 as specified below:

(1) Individuals for whom public agencies are assuming full or partial financial responsibility and who are:

(a) In foster homes (and are under the age of 21).

(b) In private institutions (and are under the age of 21).

(c) In addition to the group under (1)(a) and (b), individuals placed in foster homes or private institutions by private, nonprofit agencies (and are under the age of 21).

(2) Individuals in adoptions subsidized in full or part by the public agency (who are under the age of 21).

(3) Individuals in NFs (who are under the age of 21). NF services are provided under this plan.

(4) In addition to the group under (3), individuals in ICFs/MR (who are under the age of 21).

6. Aged Individuals.

7. Blind Individuals.

8. Disabled Individuals.

9. Blind and disabled individuals who:

a. Meet all current requirements for Medicaid eligibility except the blindness or disability criteria;

b. Were eligible as medically needy in December 1973 as blind or disabled; and

c. For each consecutive month after December 1973 continue to meet the December 1973 eligibility criteria.

10. Individuals required to enroll in cost-effective employer-based group health plans remain eligible for a minimum enrollment period of one month.

12VAC30-40-100. Methods of determining income.

A. Families and Children Medically Needy individuals.

1. In determining countable income for Families and Children Medically Needy individuals, the methods under the state's July 16, 1996, approved Aid to Families with Dependent Children plan and any more liberal methods described in 12VAC30-40-280 are used.

2. In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to children living with parents until the children become 21 years of age.

3. Agency continues to treat women eligible under the provisions of § 1902(a)(10) of the Act as eligible, without regard to any changes in income of the family of which she is a member, for the 60-day 12-month postpartum period after her beginning on the last day of the pregnancy ends and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends.

B. Individuals subject to the use of modified adjusted gross income (MAGI) methodology. In determining income eligibility for individuals subject to the use of MAGI-based methodologies, the following shall apply:

1. The Commonwealth shall apply MAGI-based methodologies as described in this subsection, and consistent with 42 CFR 435.603 and § 1902(e)(14) of the Act. Individuals subject to the use of MAGI-based income methodologies include:

a. Parents/caretaker relatives under §§ 1902(a)(10)(A)(i)(l) and 1931 of the Act.

b. Pregnant women under §§ 1902(a)(10)(A)(i)(I), (III), (IV), (ii)(l), ((IV), (IX) and 1931 of the Act.

c. Children under the age of 19 years under §§ 1902(a)(10)(A)(i)(l), (lll), (IV), (VI), (VII), (ii)((IV), (IX) and 1931 of the Act.

d. Reasonable classifications of children younger than the age of 21 years under §§ 1902(a)(10)(A)(ii)(l) and (IV) of the Act.

e. Individuals younger than the age of 21 years who are under a state adoption assistance agreement under § 1902(a)(10)(A)(ii)(VIII) of the Act.

2. In the case of determining the ongoing eligibility for individuals determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies shall not be applied until March 31, 2014, or the next regularly scheduled renewal of eligibility, whichever is later, if the applications of such methods should result in determination of ineligibility prior to such date.

C. In determining family size for the eligibility determination of a pregnant woman, the pregnant woman shall be counted as herself plus each of the children she is expected to deliver. In determining family size during the eligibility determination of the other individuals in a household that includes a pregnant woman, the pregnant woman shall be counted as just herself.

D. Financial eligibility shall be determined consistent with the following provisions:

1. Financial eligibility shall be based on current monthly income and family size when determining eligibility for new applicants.

2. Financial eligibility shall be based on current monthly household income and family size when determining eligibility for currently enrolled individuals.

3. Household income shall be the sum of the MAGI-based income of every individual included in the individual's household except as provided at 42 CFR 435.603(d)(2) through 42 CFR 435.603(d)(4).

4. An amount equivalent to five percentage points of the federal poverty level for the applicable family size shall be deducted, in determining eligibility for Medicaid, from the household income in accordance with 42 CFR 435.603(d).

5. The age used for children with respect to 42 CFR 435.603(f)(3)(iv) shall be 19 years of age.

E. Aged individuals. In determining countable income for aged individuals, including aged individuals with incomes up to the federal poverty level described in § 1902(m)(1) of the Act, the following methods are used.

1. The methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

2. For optional state supplement recipients in § 1902(f) states and SSI criteria states without § 1616 or § 1634 agreements, SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

3. In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses.

F. Blind individuals. In determining countable income for blind individuals, only the methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

For optional state supplement recipients in § 1902(f) states and SSI criteria states without § 1616 or § 1634 agreements, the SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses and the income of parents as available to children living with parents until the children become 21 years of age.

G. Disabled individuals. In determining countable income of disabled individuals, including disabled individuals with incomes up to the federal poverty level described in § 1902(m) of the Act, the methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

For optional state supplement recipients in § 1902(f) of the Act states and SSI criteria states without § 1616 or § 1634 agreements, the SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses and the income of parents as available to children living with parents until the children become 21 years of age.

H. Qualified Medicare beneficiaries. In determining countable income for qualified Medicare beneficiaries covered under § 1902(a)(10)(E)(i) of the Act, the methods of the SSI program, more liberal methods described in 12VAC30-40-280, or both are used.

If an individual receives a Title II benefit, any amounts attributable to the most recent increase in the monthly insurance benefit as a result of a Title II COLA is not counted as income during a "transition period" beginning with January, when the Title II benefit for December is received, and ending with the last day of the month following the month of publication of the revised annual federal poverty level.

For individuals with Title II income, the revised poverty levels are not effective until the first day of the month following the end of the transition period.

For individuals not receiving Title II income, the revised poverty levels are effective no later than the date of publication.

I. Qualified disabled and working individuals. In determining countable income for qualified disabled and working individuals covered under § 1902(a)(10)(E)(ii) of the Act, the methods of the SSI program are used.

12VAC30-50-10. Services provided to the categorically needy with limitations.

The following services are provided with limitations as described in Part III (12VAC30-50-100 et seq.) of this chapter:

1. Inpatient hospital services other than those provided in an institution for mental diseases.

2. Outpatient hospital services.

3. Other laboratory and x-ray services; nonemergency outpatient Magnetic Resonance Imaging (MRI), including Magnetic Resonance Angiography (MRA), Computerized Axial Tomography (CAT) scans, including Computed Tomography Angiography (CTA), and Positron Emission Tomography (PET) scans performed for the purpose of diagnosing a disease process or physical injury require prior authorization.

4. Rural health clinic services and other ambulatory services furnished by a rural health clinic.

5. Federally Qualified Health Center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with § 4231 of the State Medicaid Manual (HCFA Pub. 45-4).

6. Early and periodic screening and diagnosis of individuals under 21 years of age, and treatment of conditions found.

7. Family planning services and supplies for individuals of child-bearing age.

8. Physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere.

9. Medical and surgical services furnished by a dentist (in accordance with § 1905(a)(5)(B) of the Act).

10. Medical care or any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by state law: podiatrists, optometrists and other practitioners.

11. Home health services: intermittent or part-time nursing service provided by a home health agency or by a registered nurse when no home health agency exists in the area; home health aide services provided by a home health agency; and medical supplies, equipment, and appliances suitable for use in the home; physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility.

12. Clinic services.

13. Dental services.

14. Physical therapy and related services, including occupational therapy and services for individuals with speech, hearing, and language disorders (provided by or under supervision of a speech pathologist or audiologist).

15. Prescribed drugs, prosthetic devices, and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

16. Other rehabilitative services, screening services, preventive services.

17. Nurse-midwife services.

18. Case management services as defined in, and to the group specified in, 12VAC30-50-95 et seq. (in accordance with § 1905(a)(19) or § 1915(g) of the Act).

19. Extended services to pregnant women: pregnancy-related and postpartum services for a 60-day 12-month postpartum period after beginning on the last day of the pregnancy ends and including any remaining days in of the calendar month in which the 60th day falls 12-month period ends (see 12VAC30-50-510). (Note: Additional coverage beyond limitations.)

20. Pediatric or family nurse practitioners' service.

21. Any other medical care and any other type of remedial care recognized by state law, specified by the Secretary: transportation.

12VAC30-50-50. Services provided to the medically needy with limitations.

Services as described in Part III (12VAC30-50-100 et seq.) of this chapter are provided to the medically needy with limitations.

1. Inpatient hospital services other than those provided in an institution for mental diseases.

2. Outpatient hospital services.

3. Other laboratory and x-ray services; nonemergency outpatient Magnetic Resonance Imaging (MRI), Computer Axial Tomography (CAT) scans, and Positron Emission Tomography (PET) scans require prior authorization.

4. Rural health clinic services and other ambulatory services furnished by a rural health clinic.

5. Federally qualified health center (FQHC) services and other ambulatory services that are covered under the plan and furnished by an FQHC in accordance with § 4231 of the State Medicaid Manual (HCFA, Pub. 45-4).

6. Family planning services and supplies for individuals of childbearing age.

7. Physicians' services whether furnished in the office, the patient's home, a hospital, a skilled nursing facility, or elsewhere.

8. Medical and surgical services furnished by a dentist (in accordance with § 1905(a)(5)(B) of the Act).

9. Medical care and any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by state law, including:

a. Podiatrists' services;

b. Optometrists' services; and

c. Other practitioners' services.

10. Home health services' medical supplies, equipment, and appliances suitable for use in the home; intermittent or part-time nursing service provided by a home health agency or by a registered nurse when no home health agency exists in the area; home health aide services provided by a home health agency; physical therapy, occupational therapy, or speech pathology and audiology services provided by a home health agency or medical rehabilitation facility.

11. Clinic services.

12. Dental services.

13. Physical therapy, occupational therapy, and services for individuals with speech, hearing, and language disorders provided by or under supervision of a speech pathologist or audiologist.

14. Prescribed drugs, prosthetic devices, and eyeglasses prescribed by a physician skilled in diseases of the eye or by an optometrist.

15. Rehabilitative services.

16. Nurse-midwife services.

17. Case management services as defined in, and to the group specified in, 12VAC30-50-410 (in accordance with § 1905(a)(19) or § 1915(g) of the Act).

18. Extended services for pregnant women, including pregnancy-related and post-partum postpartum services for 60 days after the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends.

19. Certified pediatric or family nurse practitioners' services.

20. Any other medical care and any other type of remedial care recognized under state law, specified by the secretary, specifically transportation.

12VAC30-50-190. Dental services.

A. Dental services shall be covered for individuals younger than 21 years of age in fulfillment of the treatment requirements under the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program and defined as routine diagnostic, preventive, or restorative procedures necessary for oral health provided by or under the direct supervision of a dentist in accordance with Chapter 27 (§ 54.1-2700 et seq.) of Title 54.1 of the Code of Virginia.

1. The Department of Medical Assistance Services (DMAS) will provide any medically necessary dental service to individuals younger than 21 years of age.

2. Certain dental services, as described in the DMAS Office Reference Manual (Smiles for Children, March 13, 2014), prepared by DMAS's dental benefits administrator, require preauthorization or prepayment review by DMAS or its designee.

3. Dental services for individuals younger than the age of 21 years that do not require preauthorization or prepayment review are initial, periodic, and emergency examinations; required radiography necessary to develop a treatment plan; patient education; dental prophylaxis; fluoride treatments; routine amalgam and composite restorations; stainless steel crowns, prefabricated steel post and temporary (polycarbonate) crowns, and stainless steel bands; crown recementation; pulpotomies; emergency endodontics for temporary relief of pain; pulp capping; sedative fillings; therapeutic apical closure; topical palliative treatment for dental pain; removal of foreign body; simple extractions; root recovery; incision and drainage of abscess; surgical exposure of the tooth to aid eruption; sequestrectomy for osteomyelitis; and oral antral fistula closure.

B. Dental services determined by the dental provider to be medically appropriate for an adult woman during the term of her pregnancy and through the end of the month following the 60th day postpartum shall be provided to a Medicaid-enrolled pregnant woman individual during pregnancy and for the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends. The dental services that shall be covered are (i) diagnostic x-rays and exams; (ii) preventive cleanings; (iii) restorative fillings; (iv) endodontics (root canals); (v) periodontics (gum-related treatments); (vi) prosthodontics, both removable and fixed (crowns, bridges, partial plates, and dentures); (vii) oral surgery (tooth extractions and other oral surgeries); and (viii) adjunctive general services (all covered services that do not fall into specific professional categories). These services require prepayment review by DMAS or its designee.

C. For the dental services covered for Medicaid-enrolled adult pregnant women, DMAS may place appropriate limits on a service based on medical necessity, for utilization control, or both. Examples of service limitations are examinations, prophylaxis, fluoride treatment (once/six months); space maintenance appliances; bitewing x-ray - two films (once/12 months); routine amalgam and composite restorations (once/three years); dentures (once/five years); extractions, tooth guidance appliances, permanent crowns and bridges, endodontics, patient education and sealants (once).

D. Limited oral surgery procedures, as defined and covered under Title XVIII (Medicare), are covered for all recipients, and require preauthorization or prepayment review by DMAS or its designee as described in the agency's Office Reference Manual located on the DMAS website at http://www.dmas.virginia.gov/#/dentalresources.

E. Residents of nursing facilities shall be permitted to deduct the costs of limited specific dental procedures from their payments toward the costs of their nursing facility care. Nursing facility residents shall be limited to deducting the following dental procedures: (i) routine exams and x-rays and dental cleaning twice yearly; (ii) full mouth x-rays once every three years; and (iii) extractions and fillings shall be permitted only if medically necessary as determined by DMAS.

12VAC30-50-290. Extended services to pregnant women.

A. Pregnancy-related and postpartum services for 60 days after the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends. The same limitations on all covered services apply to this group as to all other recipient groups.

B. Services for any other medical conditions that may complicate pregnancy. The same limitations on all covered services apply to this group as to all other recipient groups.

12VAC30-141-670. Definitions.

The following words and terms when used in this chapter shall have the following meanings unless the context clearly indicates otherwise:

"Adverse action," consistent with 42 CFR 457.1130, means the denial of eligibility; failure to make a timely determination of eligibility; suspension or termination of enrollment, including disenrollment for failure to pay cost sharing; or delay, denial, reduction, suspension, or termination of health services, in whole or in part, including a determination about the type or level of services; and failure to approve, furnish, or provide payment for health services in a timely manner; provided, however, that determination of eligibility to participate in and termination of participation in the FAMIS Select program shall not constitute an adverse action.

"Adverse benefit determination," consistent with 42 CFR 438.400, means the denial or limited authorization of a requested service; the failure to take action or timely take action on a request for service; the reduction, suspension, or termination of a previously authorized service; denial in whole or in part of a payment for a service; failure to provide services within the timeframes required by the state; for a resident of a rural exception area with only one MCO, the denial of a enrollee's request to exercise the enrollee's right under 42 CFR 438.52(b)(2)(ii) to obtain services outside of the network; the denial of a enrollee's request to dispute a financial liability as provided in 42 CFR 438.400(b)(7); or the failure of an MCO to act within the timeframes provided in 42 CFR 438.408(b).

"Agency" means the same as defined in 12VAC30-141-10.

"Agent" means an individual designated in writing to act on behalf of a FAMIS MOMS Plan applicant or enrollee during the administrative review process.

"Appeal" means an enrollee's request for review of an adverse benefit determination by an MCO or an adverse action by the LDSS, CPU, or DMAS.

"Applicant" means a pregnant woman who has filed an application (or who has an application filed on her behalf) for health insurance and is awaiting a determination of eligibility. A pregnant woman is an applicant until her eligibility has been determined.

"Application for health insurance" means the single streamlined application for determining eligibility in public health insurance programs operated by the Commonwealth.

"Authorized representative" means a person who is authorized to conduct the personal or financial affairs for an individual who is 18 years of age or older.

"Central processing unit" or "CPU" means Cover Virginia, which is the same as defined in 12VAC30-141-10.

"Child" means an individual younger than 19 years of age.

"Conservator" means a person appointed by a court of competent jurisdiction to manage the estate and financial affairs of an incapacitated individual.

"Continuation of coverage" means ensuring an enrollee's benefits are continued until completion of the review process, with the condition that should the enrollee not prevail in the review process, the enrollee shall be liable for the repayment of all benefits received during the review process.

"Director" means the individual, or his designee, specified in § 32.1-324 of the Code of Virginia with all of the attendant duties and responsibilities to administer the State Plan for Medical Assistance and the State Plan for Title XXI.

"DMAS" or "department" means the Department of Medical Assistance Services.

"Enrollee" means a pregnant woman who has been determined eligible to participate in FAMIS MOMS and is enrolled in the FAMIS MOMS program.

"FAMIS" means the Family Access to Medical Insurance Security Plan.

"FAMIS MOMS" means the Title XXI program available to eligible pregnant women.

"Federal poverty level" or "FPL" means that income standard as published annually by the U.S. Department of Health and Human Services in the Federal Register.

"Fee-for-service" means the traditional Medicaid health care delivery and payment system in which physicians and other providers receive a payment for each unit of service they provide.

"Guardian" means a person appointed by a court of competent jurisdiction to be responsible for the affairs of an incapacitated individual, including responsibility for making decisions regarding the person's support, care, health, safety, habilitation, education, and therapeutic treatment, and, if not inconsistent with an order of commitment, residence.

"Incapacitated " means a person who, pursuant to an order of a court of competent jurisdiction, has been found to be incapable of receiving and evaluating information effectively or responding to people, events, or environments to such an extent that the individual lacks the capacity to (i) meet the essential requirements of her health, care, safety, or therapeutic needs without the assistance or protection of a guardian, or (ii) manage property or financial affairs or provide for her support or for the support of her legal dependents without the assistance or protection of a conservator.

"LDSS" or "local department" means the local department of social services.

"Managed care organization" or "MCO" means an organization that offers managed care health insurance plans (MCHIPs) as defined in § 32.1-137.1 of the Code of Virginia.

"Pregnant woman" means a woman of any age who is medically determined to be pregnant. The pregnant woman definition is met from the first day of the earliest month that the medical practitioner certifies as being a month in which the woman was pregnant, through the last day of the month in which the 60th day occurs, following and continues for the duration of the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which her pregnancy ended the 12-month period ends, regardless of the reason the pregnancy ended.

"Provider" means the individual, facility, or other entity registered, licensed, or certified, as appropriate, and enrolled by an MCHIP or in fee-for-service to render services to FAMIS MOMS enrollees eligible for services.

"State fair hearing" means, consistent with 42 CFR 438.400, the process set forth in 42 CFR 431 Subpart E.

"Title XXI" means the federal State Children's Health Insurance Program as established by Subtitle J of the Balanced Budget Act of 1997.

12VAC30-141-750. Duration of eligibility.

A. The effective date of FAMIS MOMS eligibility shall be the first day of the month in which an application was received by LDSS, DMAS, or the CPU if the applicant met all eligibility requirements in that month.

B. Eligibility for FAMIS MOMS will continue through the last day of the month in which the 60th day occurs, following the last day the woman was pregnant for the 12-month postpartum period beginning on the last day of the pregnancy and including any remaining days of the calendar month in which the 12-month period ends, regardless of the reason the pregnancy ended. Eligibility will continue until the end of the coverage period, regardless of changes in circumstances such as income or family size.

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

VIRGINIA BOARD FOR ASBESTOS, LEAD, AND HOME INSPECTORS

Final Regulation

Titles of Regulations: 18VAC15-21. Asbestos Licensing Regulations (amending 18VAC15-21-380).

18VAC15-30. Lead-Based Paint Activities Regulations (amending 18VAC15-30-810).

18VAC15-40. Home Inspector Licensing Regulations (amending 18VAC15-40-150).

Statutory Authority: §§ 54.1-201 and 54.1-501 of the Code of Virginia.

Effective Date: November 1, 2026.

Agency Contact: Jeannette Galanis, Executive Director, Board for Contractors, 9960 Mayland Drive, Suite 400, Richmond, VA 23233, telephone (804) 367-2785, fax (866) 430-1033, or email alhi@dpor.virginia.gov.

Summary:

The amendments conform the regulation to Chapter 772 of the 2026 Acts of Assembly, which permits regulatory boards under the Department of Professional and Occupational Regulation to take disciplinary cases under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia. The amendments also adjust board authority to impose regulatory discipline, clarifying that the board may (i) reprimand, (ii) fine, (iii) suspend a credential of, (iv) place on probation, (v) refuse to renew a credential of, or (vi) revoke a credential of a regulant.

18VAC15-21-380. Grounds for disciplinary action.

A. The In accordance with § 54.1-516 of the Code of Virginia, the board has the power to reprimand, or fine, any regulant or (i) suspend, (ii) place on probation, (iii) fail to renew, or (iv) revoke the license or training program approval of any regulant in accordance with § 54.1-516 of the Code of Virginia or this chapter when the regulant has been found to have violated or cooperated with others in violating any provision of Chapter 1 (§ 54.1-100 et seq.), 2 (§ 54.1-200 et seq.), 3 (§ 54.1-300 et seq.), or 5 (§ 54.1-500 et seq.) of Title 54.1 of the Code of Virginia or this chapter. The board may also take a case against a regulant under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

B. Any regulant whose license or training program approval is revoked under this section will not be eligible to reapply for a period of 12 months from the effective date of the order of revocation.

C. Any unlawful act or violation of any provision of Chapter 5 of Title 54.1 of the Code of Virginia or of the regulations of the board by any asbestos supervisor or asbestos worker may be cause for disciplinary action against the asbestos contractor for whom the asbestos supervisor or worker works if it appears to the satisfaction of the board that the asbestos contractor knew or should have known of the unlawful act or violation.

18VAC15-30-810. Grounds for disciplinary action.

A. The In accordance with § 54.1-516 of the Code of Virginia, the board has the power to reprimand, or fine, or any licensee or training provider or (i) suspend, (ii) place on probation, (iii) fail to renew, or (iv) revoke the license or training program approval of any licensee or training provider in accordance with § 54.1-516 of the Code of Virginia or this chapter when the licensee or training provider has been found to have violated or cooperated with others in violating any provision of Chapter 1 (§ 54.1-100 et seq.), 2 (§ 54.1-200 et seq.), 3 (§ 54.1-300 et seq.), or 5 (§ 54.1-500 et seq.) of Title 54.1 of the Code of Virginia or this chapter. The board may also take a case against a licensee or training provider under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

B. Any individual or firm whose license or training program approval is revoked will not be eligible to reapply for a period of 12 months from the effective date of the order of revocation.

C. Any unlawful act or violation of any provision of Chapter 5 of Title 54.1 of the Code of Virginia or of the regulations of the board by any lead supervisor or lead worker may be cause for disciplinary action against the lead contractor for whom the individual works if it appears to the satisfaction of the board that the lead contractor knew or should have known of the unlawful act or violation.

18VAC15-40-150. Grounds for disciplinary action.

The In accordance with § 54.1-516 of the Code of Virginia, the board has the power to reprimand, or fine, revoke, any licensee or (i) suspend, (ii) place on probation, (iii) fail to renew, or (iv) revoke a license in accordance with § 54.1-516 of the Code of Virginia when the licensee has been found to have violated or cooperated with others in violating any provision of the regulations of the board or Chapter 1 (§ 54.1-100 et seq.), 2 (§ 54.1-200 et seq.), 3 (§ 54.1-300 et seq.), or 5 (§ 54.1-500 et seq.) of Title 54.1 of the Code of Virginia. The board may also take a case against a licensee under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

VIRGINIA BOARD FOR ASBESTOS, LEAD, AND HOME INSPECTORS

Final Regulation

Titles of Regulations: 18VAC15-21. Asbestos Licensing Regulations (amending 18VAC15-21-380).

18VAC15-30. Lead-Based Paint Activities Regulations (amending 18VAC15-30-810).

18VAC15-40. Home Inspector Licensing Regulations (amending 18VAC15-40-150).

Statutory Authority: §§ 54.1-201 and 54.1-501 of the Code of Virginia.

Effective Date: November 1, 2026.

Agency Contact: Jeannette Galanis, Executive Director, Board for Contractors, 9960 Mayland Drive, Suite 400, Richmond, VA 23233, telephone (804) 367-2785, fax (866) 430-1033, or email alhi@dpor.virginia.gov.

Summary:

The amendments conform the regulation to Chapter 772 of the 2026 Acts of Assembly, which permits regulatory boards under the Department of Professional and Occupational Regulation to take disciplinary cases under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia. The amendments also adjust board authority to impose regulatory discipline, clarifying that the board may (i) reprimand, (ii) fine, (iii) suspend a credential of, (iv) place on probation, (v) refuse to renew a credential of, or (vi) revoke a credential of a regulant.

18VAC15-21-380. Grounds for disciplinary action.

A. The In accordance with § 54.1-516 of the Code of Virginia, the board has the power to reprimand, or fine, any regulant or (i) suspend, (ii) place on probation, (iii) fail to renew, or (iv) revoke the license or training program approval of any regulant in accordance with § 54.1-516 of the Code of Virginia or this chapter when the regulant has been found to have violated or cooperated with others in violating any provision of Chapter 1 (§ 54.1-100 et seq.), 2 (§ 54.1-200 et seq.), 3 (§ 54.1-300 et seq.), or 5 (§ 54.1-500 et seq.) of Title 54.1 of the Code of Virginia or this chapter. The board may also take a case against a regulant under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

B. Any regulant whose license or training program approval is revoked under this section will not be eligible to reapply for a period of 12 months from the effective date of the order of revocation.

C. Any unlawful act or violation of any provision of Chapter 5 of Title 54.1 of the Code of Virginia or of the regulations of the board by any asbestos supervisor or asbestos worker may be cause for disciplinary action against the asbestos contractor for whom the asbestos supervisor or worker works if it appears to the satisfaction of the board that the asbestos contractor knew or should have known of the unlawful act or violation.

18VAC15-30-810. Grounds for disciplinary action.

A. The In accordance with § 54.1-516 of the Code of Virginia, the board has the power to reprimand, or fine, or any licensee or training provider or (i) suspend, (ii) place on probation, (iii) fail to renew, or (iv) revoke the license or training program approval of any licensee or training provider in accordance with § 54.1-516 of the Code of Virginia or this chapter when the licensee or training provider has been found to have violated or cooperated with others in violating any provision of Chapter 1 (§ 54.1-100 et seq.), 2 (§ 54.1-200 et seq.), 3 (§ 54.1-300 et seq.), or 5 (§ 54.1-500 et seq.) of Title 54.1 of the Code of Virginia or this chapter. The board may also take a case against a licensee or training provider under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

B. Any individual or firm whose license or training program approval is revoked will not be eligible to reapply for a period of 12 months from the effective date of the order of revocation.

C. Any unlawful act or violation of any provision of Chapter 5 of Title 54.1 of the Code of Virginia or of the regulations of the board by any lead supervisor or lead worker may be cause for disciplinary action against the lead contractor for whom the individual works if it appears to the satisfaction of the board that the lead contractor knew or should have known of the unlawful act or violation.

18VAC15-40-150. Grounds for disciplinary action.

The In accordance with § 54.1-516 of the Code of Virginia, the board has the power to reprimand, or fine, revoke, any licensee or (i) suspend, (ii) place on probation, (iii) fail to renew, or (iv) revoke a license in accordance with § 54.1-516 of the Code of Virginia when the licensee has been found to have violated or cooperated with others in violating any provision of the regulations of the board or Chapter 1 (§ 54.1-100 et seq.), 2 (§ 54.1-200 et seq.), 3 (§ 54.1-300 et seq.), or 5 (§ 54.1-500 et seq.) of Title 54.1 of the Code of Virginia. The board may also take a case against a licensee under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

VIRGINIA BOARD FOR ASBESTOS, LEAD, AND HOME INSPECTORS

Final Regulation

Titles of Regulations: 18VAC15-21. Asbestos Licensing Regulations (amending 18VAC15-21-380).

18VAC15-30. Lead-Based Paint Activities Regulations (amending 18VAC15-30-810).

18VAC15-40. Home Inspector Licensing Regulations (amending 18VAC15-40-150).

Statutory Authority: §§ 54.1-201 and 54.1-501 of the Code of Virginia.

Effective Date: November 1, 2026.

Agency Contact: Jeannette Galanis, Executive Director, Board for Contractors, 9960 Mayland Drive, Suite 400, Richmond, VA 23233, telephone (804) 367-2785, fax (866) 430-1033, or email alhi@dpor.virginia.gov.

Summary:

The amendments conform the regulation to Chapter 772 of the 2026 Acts of Assembly, which permits regulatory boards under the Department of Professional and Occupational Regulation to take disciplinary cases under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia. The amendments also adjust board authority to impose regulatory discipline, clarifying that the board may (i) reprimand, (ii) fine, (iii) suspend a credential of, (iv) place on probation, (v) refuse to renew a credential of, or (vi) revoke a credential of a regulant.

18VAC15-21-380. Grounds for disciplinary action.

A. The In accordance with § 54.1-516 of the Code of Virginia, the board has the power to reprimand, or fine, any regulant or (i) suspend, (ii) place on probation, (iii) fail to renew, or (iv) revoke the license or training program approval of any regulant in accordance with § 54.1-516 of the Code of Virginia or this chapter when the regulant has been found to have violated or cooperated with others in violating any provision of Chapter 1 (§ 54.1-100 et seq.), 2 (§ 54.1-200 et seq.), 3 (§ 54.1-300 et seq.), or 5 (§ 54.1-500 et seq.) of Title 54.1 of the Code of Virginia or this chapter. The board may also take a case against a regulant under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

B. Any regulant whose license or training program approval is revoked under this section will not be eligible to reapply for a period of 12 months from the effective date of the order of revocation.

C. Any unlawful act or violation of any provision of Chapter 5 of Title 54.1 of the Code of Virginia or of the regulations of the board by any asbestos supervisor or asbestos worker may be cause for disciplinary action against the asbestos contractor for whom the asbestos supervisor or worker works if it appears to the satisfaction of the board that the asbestos contractor knew or should have known of the unlawful act or violation.

18VAC15-30-810. Grounds for disciplinary action.

A. The In accordance with § 54.1-516 of the Code of Virginia, the board has the power to reprimand, or fine, or any licensee or training provider or (i) suspend, (ii) place on probation, (iii) fail to renew, or (iv) revoke the license or training program approval of any licensee or training provider in accordance with § 54.1-516 of the Code of Virginia or this chapter when the licensee or training provider has been found to have violated or cooperated with others in violating any provision of Chapter 1 (§ 54.1-100 et seq.), 2 (§ 54.1-200 et seq.), 3 (§ 54.1-300 et seq.), or 5 (§ 54.1-500 et seq.) of Title 54.1 of the Code of Virginia or this chapter. The board may also take a case against a licensee or training provider under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

B. Any individual or firm whose license or training program approval is revoked will not be eligible to reapply for a period of 12 months from the effective date of the order of revocation.

C. Any unlawful act or violation of any provision of Chapter 5 of Title 54.1 of the Code of Virginia or of the regulations of the board by any lead supervisor or lead worker may be cause for disciplinary action against the lead contractor for whom the individual works if it appears to the satisfaction of the board that the lead contractor knew or should have known of the unlawful act or violation.

18VAC15-40-150. Grounds for disciplinary action.

The In accordance with § 54.1-516 of the Code of Virginia, the board has the power to reprimand, or fine, revoke, any licensee or (i) suspend, (ii) place on probation, (iii) fail to renew, or (iv) revoke a license in accordance with § 54.1-516 of the Code of Virginia when the licensee has been found to have violated or cooperated with others in violating any provision of the regulations of the board or Chapter 1 (§ 54.1-100 et seq.), 2 (§ 54.1-200 et seq.), 3 (§ 54.1-300 et seq.), or 5 (§ 54.1-500 et seq.) of Title 54.1 of the Code of Virginia. The board may also take a case against a licensee under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

AUCTIONEERS BOARD

Final Regulation

Title of Regulation: 18VAC25-21. Regulations of the Auctioneers Board (amending 18VAC25-21-180).

Statutory Authority: §§ 54.1-201 and 54.1-602 of the Code of Virginia.

Effective Date: November 1, 2026.

Agency Contact: Kathleen R. Nosbisch, Executive Director, Auctioneers Board, 9960 Mayland Drive, Suite 400, Richmond, VA 23233, telephone (804) 367-8514, fax (866) 465-6206, or email auctioneers@dpor.virginia.gov.

Summary:

The amendments conform the regulation to statutory changes made by Chapter 772 of the 2026 Acts of Assembly, which permits regulatory boards under the Department of Professional and Occupational Regulation to take disciplinary cases under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia. The amendments also adjust board authority to impose regulatory discipline, clarifying that the board may fine, suspend a license of, place on probation, refuse to renew a license of, or revoke a license of a regulant.

18VAC25-21-180. Discipline.

The A. In accordance with § 54.1-902 of the Code of Virginia, the board has the power to fine any individual or firm licensee or to (i) suspend, (ii) place on probation, (iii) fail to renew, or (iv) revoke any license issued under the provisions of Chapter 6 (§ 54.1-600 et seq.) of Title 54.1 of the Code of Virginia and the regulations of the board pursuant to the provisions of the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia) if the board finds that:

1. The license was obtained, renewed, or reinstated through fraud or misrepresentation;

2. The licensee has been convicted or found guilty, regardless of the manner of adjudication, in any jurisdiction of the United States, of a non-marijuana misdemeanor involving dishonest or fraudulent acts or any felony, there being no appeal pending therefrom or the time for appeal having elapsed. Review of prior criminal convictions will be subject to the requirements of § 54.1-204 of the Code of Virginia;

3. The licensee has been found by any regulatory board, agency, or jurisdiction where licensed to have had a license or registration suspended, revoked, or surrendered in connection with a disciplinary action, to have been the subject of discipline in another jurisdiction, or to have violated any applicable regulations or laws in the course of performing auctioneer duties;

4. The licensee has not demonstrated reasonable care, judgment, or application of the licensee's knowledge and ability in the performance of auctioneering duties;

5. The licensee violated or assisted another to violate any provisions of Chapter 1 (§ 54.1-100 et seq.), 2 (§ 54.1-200 et seq.), 3 (§ 54.1-300 et seq.), or 6 of Title 54.1 of the Code of Virginia, this chapter, or combined or conspired with or acted as agent, partner, or associate for another; or

6. The licensee fails to comply, or misrepresents any information pertaining to the licensee's compliance, with any of the continuing education requirements contained in this chapter.

B. The board may also take a case against a licensee under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD FOR BRANCH PILOTS

Final Regulation

Title of Regulation: 18VAC45-20. Board for Branch Pilots Regulations (amending 18VAC45-20-40).

Statutory Authority: § 54.1-902 of the Code of Virginia.

Effective Date: November 1, 2026.

Agency Contact: Kathleen R. Nosbisch, Executive Director, Auctioneers Board, 9960 Mayland Drive, Suite 400, Richmond, VA 23233, telephone (804) 367-8514, fax (866) 465-6206, or email branchpilots@dpor.virginia.gov.

Summary:

The amendments conform the regulation to Chapter 772 of the 2026 Acts of Assembly, which permits regulatory boards under the Department of Professional and Occupational Regulation to take disciplinary cases under advisement as provided for in 54.1-201 A 7 of the Code of Virginia. The amendments also adjust board authority to impose regulatory discipline, clearly specifying that the board may (i) impose a monetary penalty, (ii) suspend a license of, (iii) place on probation, (iv) refuse to renew a license of, or (v) revoke a license of a regulant.

18VAC45-20-40. Grounds for denial of licensure, denial of renewal, or discipline.

A. The board shall have the authority to deny initial licensure to, deny an extension of license to, or deny renewal of license to as well as to discipline, pursuant to § 54.1-902 of the Code of Virginia, existing licensees, whether limited or not, for the following reasons:

1. Having been convicted or found guilty, regardless of adjudication, in any jurisdiction of the United States of any felony or a misdemeanor involving fraudulent or dishonest acts or any alcohol-related or drug-related offense, there being no appeal pending therefrom or the time for appeal having elapsed.

Any plea of nolo contendere shall be considered a conviction for the purposes of this subdivision. The record of a conviction certified or authenticated in such form as to be admissible in evidence of the laws of the jurisdiction where convicted shall be admissible as prima facie evidence of such conviction.

2. Failing to inform the board in writing within seven calendar days of pleading guilty or nolo contendere or being convicted or found guilty of any felony or of a misdemeanor involving fraudulent or dishonest acts or any alcohol-related or drug-related offense.

3. Failing to report to the board in writing any reports of the National Transportation Safety Board involving the licensee or the results of any disciplinary action taken by the U.S. Coast Guard against the licensee within seven calendar days of that report or action.

4. Refusing or in any other way failing to carry out an order from the pilot officers for reasons other than the public health, safety, or welfare.

5. Negligence or misconduct in the performance of duties.

6. Violating or cooperating with others in violating any provision of Chapter 9 (§ 54.1-900 et seq.) of Title 54.1 of the Code of Virginia or any regulation of the board.

7. Failing to immediately file with the president or vice president of the board, with a copy to the board administrator, a complete written account of any violation of the statutes of Virginia or of the United States relating to pilotage or failing to report in writing to the president or vice president of the board, with a copy to the board administrator, an account of all collisions, groundings, or other maritime mishaps of any description that may occur during the discharge of the pilot's duties. This report shall be received no later than seven days after such an incident.

8. Failing to report to the board any physical or mental condition that may affect the licensee's ability to perform the duties of a pilot. Such reports shall be provided within seven calendar days of the onset of the condition.

9. Refusing to comply with the board's requirement for a chemical test. Such test is required:

a. Immediately and no later than 12 hours after involvement in a collision, grounding, or other incident resulting in personal injury, death, environmental hazard, or property damage in excess of $100,000;

b. In any instance in which the board has reasonable cause to believe there is evidence of impaired performance and a test is necessary to protect the public health, safety, or welfare; or

c. Under the provisions of 18VAC45-20-50.

Refusing to comply with this requirement of subdivisions subdivision 9 a or 9 b of this section may result in summary suspension of the pilot's license in accordance with § 54.1-902 of the Code of Virginia.

10. Failing to send proof of any test required by subdivision 9 of this section to the president or vice president of the board, with a copy to the board administrator, within 48 hours of the administration of the test.

11. Reasonable cause by the board to believe there is a threat to the public health, safety, or welfare based on evidence of impaired performance or substance abuse or a positive chemical test. Such a finding may result in summary suspension of the pilot's license in accordance with § 54.1-902 of the Code of Virginia.

12. Performing or attempting to perform any of the duties of the licensee's office or job while:

a. Under the influence of illegal drugs; or

b. Under the influence of alcohol, marijuana, or any medication (controlled substance or otherwise) to the extent that the licensee was unfit for the performance of the duties or the licensee's office or job.

13. Failing to comply with any of the provisions of 18VAC45-20-50.

B. In accordance with § 54.1-902 of the Code of Virginia, discipline by the board may include (i) imposition of a monetary penalty, (ii) suspension of a license, (iii) placing a licensee on probation, (iv) failing to renew a license, or (v) revocation of a license. The board may also take a case against a licensee under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD FOR CONTRACTORS

Final Regulation

Titles of Regulations: 18VAC50-22. Board for Contractors Regulations (amending 18VAC50-22-200).

18VAC50-30. Individual License and Certification Regulations (amending 18VAC50-30-185).

Statutory Authority:

18VAC50-22-200: §§ 54.1-201 and 54.1-1102 of the Code of Virginia.

18VAC50-30-185: §§ 54.1-201, 54.1-1102, and 54.1-1146 of the Code of Virginia.

Effective Date: November 1, 2026.

Agency Contact: Jeannette Galanis, Executive Director, Board for Contractors, 9960 Mayland Drive, Suite 400, Richmond, VA 23233, telephone (804) 367-2785, fax (866) 430-1033, or email contractor@dpor.virginia.gov.

Summary:

The amendments conform the regulation to statutory changes made by Chapter 772 of the 2026 Acts of Assembly, which permits regulatory boards under the Department of Professional and Occupational Regulation to take disciplinary cases under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia. The amendments also adjust board authority to impose regulatory discipline, clarifying that the board may impose remedial education, charge a monetary penalty, suspend a credential of, place on probation, refuse to renew a credential of, or revoke a credential of a regulant.

18VAC50-22-200. Remedial education, revocation or suspension; fines Grounds for disciplinary action.

The In accordance with § 54.1-1110 of the Code of Virginia, the board may impose remedial education and or a monetary penalty in accordance with § 54.1-202 A of the Code of Virginia against any licensee or (i) suspend, (ii) place on probation, (iii) fail to renew, or (iv) revoke or suspend any license when a licensee has been found to have violated or cooperated with others in violating any provision of the regulations of the board or Chapter 1 (§ 54.1-100 et seq.) or Chapter 11 (§ 54.1-1100 et seq.) of Title 54.1 of the Code of Virginia. The board may also take a case against a licensee under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

18VAC50-30-185. Grounds for disciplinary action.

The In accordance with § 54.1-1134 of the Code of Virginia, the board may impose remedial education, or a monetary penalty in accordance with § 54.1-202 A of the Code of Virginia against any licensee or certificate holder or (i) suspend, (ii) place on probation, (iii) fail to renew, or (iv) revoke, suspend, or refuse to renew any license or certification when the licensee or certificate holder has been found to have violated or cooperated with others in violating any provision of Chapter 1 (§ 54.1-100 et seq.) or Chapter 11 (§ 54.1-1100 et seq.) of Title 54.1 of the Code of Virginia or the regulations of the board. The board may also take a case against a licensee or certificate holder under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD FOR CONTRACTORS

Final Regulation

Titles of Regulations: 18VAC50-22. Board for Contractors Regulations (amending 18VAC50-22-200).

18VAC50-30. Individual License and Certification Regulations (amending 18VAC50-30-185).

Statutory Authority:

18VAC50-22-200: §§ 54.1-201 and 54.1-1102 of the Code of Virginia.

18VAC50-30-185: §§ 54.1-201, 54.1-1102, and 54.1-1146 of the Code of Virginia.

Effective Date: November 1, 2026.

Agency Contact: Jeannette Galanis, Executive Director, Board for Contractors, 9960 Mayland Drive, Suite 400, Richmond, VA 23233, telephone (804) 367-2785, fax (866) 430-1033, or email contractor@dpor.virginia.gov.

Summary:

The amendments conform the regulation to statutory changes made by Chapter 772 of the 2026 Acts of Assembly, which permits regulatory boards under the Department of Professional and Occupational Regulation to take disciplinary cases under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia. The amendments also adjust board authority to impose regulatory discipline, clarifying that the board may impose remedial education, charge a monetary penalty, suspend a credential of, place on probation, refuse to renew a credential of, or revoke a credential of a regulant.

18VAC50-22-200. Remedial education, revocation or suspension; fines Grounds for disciplinary action.

The In accordance with § 54.1-1110 of the Code of Virginia, the board may impose remedial education and or a monetary penalty in accordance with § 54.1-202 A of the Code of Virginia against any licensee or (i) suspend, (ii) place on probation, (iii) fail to renew, or (iv) revoke or suspend any license when a licensee has been found to have violated or cooperated with others in violating any provision of the regulations of the board or Chapter 1 (§ 54.1-100 et seq.) or Chapter 11 (§ 54.1-1100 et seq.) of Title 54.1 of the Code of Virginia. The board may also take a case against a licensee under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

18VAC50-30-185. Grounds for disciplinary action.

The In accordance with § 54.1-1134 of the Code of Virginia, the board may impose remedial education, or a monetary penalty in accordance with § 54.1-202 A of the Code of Virginia against any licensee or certificate holder or (i) suspend, (ii) place on probation, (iii) fail to renew, or (iv) revoke, suspend, or refuse to renew any license or certification when the licensee or certificate holder has been found to have violated or cooperated with others in violating any provision of Chapter 1 (§ 54.1-100 et seq.) or Chapter 11 (§ 54.1-1100 et seq.) of Title 54.1 of the Code of Virginia or the regulations of the board. The board may also take a case against a licensee or certificate holder under advisement as provided for in § 54.1-201 A 7 of the Code of Virginia.

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD OF MEDICINE

Fast-Track Regulation

Title of Regulation: 18VAC85-20. Regulations Governing the Practice of Medicine, Osteopathic Medicine, Podiatry, and Chiropractic (amending 18VAC85-20-330).

Statutory Authority: § 54.1-2400 of the Code of Virginia.

Public Hearing Information: No public hearing is currently scheduled.

Public Comment Deadline: October 7, 2026.

Effective Date: October 22, 2026.

Agency Contact: William L. Harp, MD, Executive Director, Board of Medicine, 9960 Mayland Drive, Suite 300, Richmond, VA 23233-1463, telephone (804) 367-4621, fax (804) 527-4429, or email william.harp@dhp.virginia.gov.

Basis: Section 54.1-2400 authorizes the Board of Medicine to promulgate regulations that are reasonable and necessary to effectively administer the regulatory system.

Purpose: This action is essential to protect the health, safety, and welfare of citizens because reasonable requirements help encourage practitioners to enter and stay in the field.

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 reduces continuing education requirements consistent with previous changes by the board.

Substance: This action amends the reference to continuing education for doctors from 60 hours each biennium to 30 and eliminates the reference to a random audit conducted by the board.

Issues: There are no primary advantages or disadvantages to the public. There are no primary advantages or disadvantages to the agency or the Commonwealth.

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 Medicine (board) seeks to make two changes that would make the regulation internally consistent with changes made in a 2025 regulatory action.

Background. The board conducted a periodic review of the Regulations Governing the Practice of Medicine, Osteopathic Medicine, Podiatry, and Chiropractic (18VAC85-20) in 2022² and subsequently made changes that became effective in 2025.³ The board seeks to make two corrections to reflect changes made in the 2025 action that applied to all providers under this regulation; the proposed changes would resolve inconsistencies within the regulation. The board seeks to amend 18VAC85-20-330 B 2, which currently states that any doctor who administers office-based anesthesia without the use of an anesthesiologist or certified registered nurse anesthetist shall obtain four hours of continuing education in topics related to anesthesia within the 60 hours required each biennium for licensure renewal, which are subject to random audit by the board. To make this section consistent with the 2025 changes, the board seeks to (i) replace 60 with 30 because the continuing education requirement for all doctors has been reduced to 30 hours in 18VAC85-20-235 A, and (ii) strike the clause regarding random audits because this requirement has been removed from 18VAC85-20-235 D.

Estimated Benefits and Costs. The proposed amendments would benefit readers of the regulation by correcting inconsistencies and avoiding any confusion regarding the continuing education requirements for doctors who administer office-based anesthesia without the use of an anesthesiologist or certified registered nurse anesthetist. The proposed amendments would not create any new costs.

Businesses and Other Entities Affected. The proposed amendments would affect readers of the regulation, which may include physicians, their employers, and providers of continuing education. 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 Because the proposed changes are corrections that would conform the language to the requirements currently in effect, an adverse impact is not indicated.

Small Businesses⁶ Affected.⁷ The proposed changes would not adversely impact small businesses.

Localities⁸ Affected.⁹ No locality would be disproportionately affected. Local governments would not be affected.

Projected Impact on Employment. The proposed amendments are not expected to have an impact on total employment.

Effects on the Use and Value of Private Property. The proposed amendments are not expected to affect the use or value of private property. Real estate development costs would not be affected.

_____________________________

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://townhall.virginia.gov/L/ViewPReview.cfm?PRid=2147.

³ See https://townhall.virginia.gov/L/ViewStage.cfm?stageid=9843.

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 Board of Medicine concurs with the economic impact analysis prepared by the Department of Planning and Budget.

Summary:

The amendments make the section consistent with a previous regulatory action by updating the reference to biennial continuing education to 30 hours and removing a reference to a random audit by the board.

18VAC85-20-330. Qualifications of providers.

A. Doctors who utilize office-based anesthesia shall ensure that all medical personnel assisting in providing patient care are appropriately trained, qualified, and supervised, are sufficient in numbers to provide adequate care, and maintain training in basic cardiopulmonary resuscitation.

B. All providers of office-based anesthesia shall hold the appropriate license and have the necessary training and skills to deliver the level of anesthesia being provided.

1. Deep sedation, general anesthesia, or a major conductive block shall be administered by an anesthesiologist or by a certified registered nurse anesthetist. If a major conductive block is performed for diagnostic or therapeutic purposes, it may be administered by a doctor qualified by training and scope of practice.

2. Moderate sedation/conscious sedation may be administered by the operating doctor with the assistance of and monitoring by a licensed nurse, a physician assistant, or a licensed intern or resident.

C. Additional training.

1. On or after December 18, 2003, the doctor who provides office-based anesthesia or who supervises the administration of anesthesia shall maintain current certification in advanced resuscitation techniques.

2. Any doctor who administers office-based anesthesia without the use of an anesthesiologist or certified registered nurse anesthetist shall obtain four hours of continuing education in topics related to anesthesia within the 60 30 hours required each biennium for licensure renewal, which are subject to random audit by the board.

D. Prior to administration, the anesthesia plan shall be discussed with the patient or responsible party by the health care practitioner administering the anesthesia or supervising the administration of anesthesia. Informed consent for the nature and objectives of the anesthesia planned shall be in writing and obtained from the patient or responsible party before the procedure is performed. Such consent shall include a discussion of discharge planning and what care or assistance the patient is expected to require after discharge. Informed consent shall only be obtained after a discussion of the risks, benefits, and alternatives, contain the name of the anesthesia provider, and be documented in the medical record.

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD OF LONG-TERM CARE ADMINISTRATORS

Fast-Track Regulation

Titles of Regulations: 18VAC95-20. Regulations Governing the Practice of Nursing Home Administrators (amending 18VAC95-20-340, 18VAC95-20-380).

18VAC95-30. Regulations Governing the Practice of Assisted Living Facility Administrators (amending 18VAC95-30-180).

Statutory Authority: § 54.1-2400 of the Code of Virginia.

Public Hearing Information: No public hearing is currently scheduled.

Public Comment Deadline: October 7, 2026.

Effective Date: October 22, 2026.

Agency Contact: Corie Tillman Wolf, Executive Director, Board of Long-Term Care Administrators, 9960 Mayland Drive, Suite 300, Henrico, VA 23233-1463, telephone (804) 367-4595, fax (804) 527-4413, or email corie.wolf@dhp.virginia.gov.

Basis: Section 54.1-2400 of the Code of Virginia authorizes the Board of Long-Term Care Administrators to promulgate regulations that are reasonable and necessary to effectively administer the regulatory system.

Purpose: This action is essential to protect the health, safety, and welfare of citizens because more administrators-in-training (AITs) will be able to be trained and enter the workforce, ensuring an adequate supply of long-term care administrators.

Rationale for Using Fast-Track Rulemaking Process: This action is expected to be noncontroversial and therefore appropriate for the fast-track rulemaking process because the reduction of requirements is designed to help more AITs be trained and enter the workforce.

Substance: The action (i) expands to three the number of trainees a preceptor may supervise and (ii) clarifies who may serve as a preceptor to include those who have been administrators under contract with a facility and regional administrators.

Issues: The primary advantage to the public is an increased supply of AITs becoming trained and getting licensed as nursing home administrators or assisted living facility administrators, ensuring an adequate workforce to meet the demands of the public. There are no disadvantages to the public. There are no advantages or disadvantages to the agency or the Commonwealth.

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 Long-Term Care Administrators (board) seeks to amend two regulations in order to reduce the necessary qualifications for preceptors in long-term care facilities and increase the number of trainees a preceptor may supervise, among other changes.

Background. The board is proposing amendments to the regulations governing nursing home administrators (18VAC95-20) and assisted living facility (ALF) administrators (18VAC95-30). In both regulations, the board proposes to (i) expand eligibility criteria for preceptors by allowing an ALF or nursing home administrator who is under contract or written agreement with the facility where training occurs to serve as a preceptor; currently, only administrators employed full-time at the facility are eligible; and (ii) increase the number of trainees a preceptor may supervise from two to three. In addition, the board seeks to align certain requirements in the regulation for nursing home administrators with current requirements for ALF administrators by (i) reducing the experience requirement for preceptors to two years in practice as an administrator of record out of the past four years, instead of two out of the past three years, and (ii) allowing regional administrators with onsite supervisory responsibilities for a training facility to serve as preceptors.

Estimated Benefits and Costs. The board reports that there are currently an insufficient number of licensed and qualified administrators for nursing homes and ALFs, and that a shortage of qualified preceptors represents a significant bottleneck for facilities to provide training to administrators-in-training (AITs).² The proposed changes are intended to reduce the burden on nursing homes and ALFs that provide training by reducing the requirements for preceptors and increasing the number of AITs that each preceptor can supervise. Staff at nursing homes and ALFs who seek to become AITs may benefit from the increased capacity for preceptors and the increased number of potential preceptors.

Businesses and Other Entities Affected. The proposed amendments would primarily benefit facilities that train administrators by allowing them to expand their training programs. 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 The proposed amendments would not create any new costs or reduce net benefits for nursing homes, ALFs, preceptors, or AITs. An increase in the supply of licensed administrators as a result of the proposed changes may eventually increase competition and dampen wage growth for administrators; however, this is a more indirect and long-term effect and may not result if the demand for administrators continues to outpace supply. Thus, an adverse impact is not indicated.

Small Businesses⁵ Affected.⁶ The proposed changes would benefit nursing homes and ALFs that provide training, all of which are likely small businesses, by allowing them to expand their AIT programs.

Localities⁷ Affected.⁸ No locality would be disproportionately affected. Local governments would not be affected.

Projected Impact on Employment. The proposed amendments would eventually increase the number of individuals employed as AITs and subsequently, as administrators of nursing homes and ALFs. The proposed amendments are not expected to affect total employment.

Effects on the Use and Value of Private Property. Private nursing homes and ALFs that provide training would be able to expand their training programs; as a result, the value of such private businesses could increase. Real estate development costs would not be affected.

_____________________________

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 A regulatory advisory panel on this issue discussed these proposed changes as well as other changes for the board to consider and/or for the board to continue stakeholder engagement to develop changes. More details can be found in meeting minutes and attachments here: https://townhall.virginia.gov/L/GetFile.cfm?File=meeting\28\41365\Minutes_DHP_41365_v2.pdf.

³ 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.

⁴ 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.

⁵ 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."

⁶ 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.

⁷ "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.

⁸ Section 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

Agency Response to Economic Impact Analysis: The Board of Long-Term Care Administrators concurs with the economic impact analysis prepared by the Department of Planning and Budget.

Summary:

The amendments (i) reduce requirements to serve as a preceptor in a long-term care facility and (ii) raise to three the number of trainees a preceptor may supervise.

18VAC95-20-340. Supervision of trainees.

A. Training shall be under the supervision of a preceptor who is registered or recognized by a licensing board.

B. A preceptor may supervise no more than two three AIT's at any one time.

C. A preceptor shall:

1. Provide direct instruction, planning, and evaluation in the training facility;

2. Shall be Be routinely present with the trainee for on-site supervision in the training facility as appropriate to the experience and training of the AIT and the needs of the residents in the facility; and

3. Shall continually Continually evaluate the development and experience of the AIT to determine specific areas in the Domains of Practice that need to be addressed.

18VAC95-20-380. Qualifications of preceptors.

A. To be registered by the board as a preceptor, a person shall:

1. Hold a current, unrestricted Virginia nursing home administrator license and be employed full time;

2. Have at least two years in practice as an administrator of record in a training facility for a minimum of two of the past three four years immediately prior to registration; 2. and either:

a. Be employed full time in or be under contract or written agreement with the facility where training occurs; or

b. Be a regional administrator with on-site supervisory responsibilities for a training facility;

3. Provide evidence that he the person has completed the online preceptor training course offered by NAB; and

3. 4. Meet the application requirements in 18VAC95-20-230.

B. To renew registration as a preceptor, a person shall:

1. Hold a current, unrestricted Virginia nursing home administrator license and be employed by or have an agreement with a training facility for a preceptorship; and

2. Meet the renewal requirements of 18VAC95-20-170.

18VAC95-30-180. Preceptors.

A. Training in an ALF AIT program shall be under the supervision of a preceptor who is registered or recognized by Virginia or a similar licensing board in another jurisdiction.

B. To be registered by the board as a preceptor, a person shall:

1. Hold a current, unrestricted Virginia assisted living facility administrator or nursing home administrator license;

2. Be employed full time Have at least two years in practice as an administrator in a training facility for a minimum of two of record in the past four years immediately prior to registration or be and either:

a. Be employed full time in or be under contract or written agreement with the facility where training occurs; or

b. Be a regional administrator with on-site supervisory responsibilities for a training facility;

3. Provide evidence that he the preceptor has completed the online preceptor training course offered by NAB; and

4. Submit an application and fee as prescribed in 18VAC95-30-40. The board may waive such application and fee for a person who is already approved as a preceptor for nursing home licensure.

C. A preceptor shall:

1. Provide direct instruction, planning, and evaluation;

2. Be routinely present for on-site supervision of the trainee in the training facility as appropriate to the experience and training of the ALF AIT and the needs of the residents in the facility; and

3. Continually evaluate the development and experience of the trainee to determine specific areas needed for concentration.

D. A preceptor may supervise no more than two three trainees at any one time.

E. A preceptor for a person who is serving as an acting administrator while in an ALF AIT program shall be present in the training facility for face-to-face instruction and review of the trainee's performance for a minimum of four hours per week.

F. To renew registration as a preceptor, a person shall:

1. Hold a current, unrestricted Virginia assisted living facility or nursing home license and be employed by or have a written agreement with a training facility for a preceptorship; and

2. Meet the renewal requirements of 18VAC95-30-60.

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD OF LONG-TERM CARE ADMINISTRATORS

Fast-Track Regulation

Titles of Regulations: 18VAC95-20. Regulations Governing the Practice of Nursing Home Administrators (amending 18VAC95-20-340, 18VAC95-20-380).

18VAC95-30. Regulations Governing the Practice of Assisted Living Facility Administrators (amending 18VAC95-30-180).

Statutory Authority: § 54.1-2400 of the Code of Virginia.

Public Hearing Information: No public hearing is currently scheduled.

Public Comment Deadline: October 7, 2026.

Effective Date: October 22, 2026.

Agency Contact: Corie Tillman Wolf, Executive Director, Board of Long-Term Care Administrators, 9960 Mayland Drive, Suite 300, Henrico, VA 23233-1463, telephone (804) 367-4595, fax (804) 527-4413, or email corie.wolf@dhp.virginia.gov.

Basis: Section 54.1-2400 of the Code of Virginia authorizes the Board of Long-Term Care Administrators to promulgate regulations that are reasonable and necessary to effectively administer the regulatory system.

Purpose: This action is essential to protect the health, safety, and welfare of citizens because more administrators-in-training (AITs) will be able to be trained and enter the workforce, ensuring an adequate supply of long-term care administrators.

Rationale for Using Fast-Track Rulemaking Process: This action is expected to be noncontroversial and therefore appropriate for the fast-track rulemaking process because the reduction of requirements is designed to help more AITs be trained and enter the workforce.

Substance: The action (i) expands to three the number of trainees a preceptor may supervise and (ii) clarifies who may serve as a preceptor to include those who have been administrators under contract with a facility and regional administrators.

Issues: The primary advantage to the public is an increased supply of AITs becoming trained and getting licensed as nursing home administrators or assisted living facility administrators, ensuring an adequate workforce to meet the demands of the public. There are no disadvantages to the public. There are no advantages or disadvantages to the agency or the Commonwealth.

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 Long-Term Care Administrators (board) seeks to amend two regulations in order to reduce the necessary qualifications for preceptors in long-term care facilities and increase the number of trainees a preceptor may supervise, among other changes.

Background. The board is proposing amendments to the regulations governing nursing home administrators (18VAC95-20) and assisted living facility (ALF) administrators (18VAC95-30). In both regulations, the board proposes to (i) expand eligibility criteria for preceptors by allowing an ALF or nursing home administrator who is under contract or written agreement with the facility where training occurs to serve as a preceptor; currently, only administrators employed full-time at the facility are eligible; and (ii) increase the number of trainees a preceptor may supervise from two to three. In addition, the board seeks to align certain requirements in the regulation for nursing home administrators with current requirements for ALF administrators by (i) reducing the experience requirement for preceptors to two years in practice as an administrator of record out of the past four years, instead of two out of the past three years, and (ii) allowing regional administrators with onsite supervisory responsibilities for a training facility to serve as preceptors.

Estimated Benefits and Costs. The board reports that there are currently an insufficient number of licensed and qualified administrators for nursing homes and ALFs, and that a shortage of qualified preceptors represents a significant bottleneck for facilities to provide training to administrators-in-training (AITs).² The proposed changes are intended to reduce the burden on nursing homes and ALFs that provide training by reducing the requirements for preceptors and increasing the number of AITs that each preceptor can supervise. Staff at nursing homes and ALFs who seek to become AITs may benefit from the increased capacity for preceptors and the increased number of potential preceptors.

Businesses and Other Entities Affected. The proposed amendments would primarily benefit facilities that train administrators by allowing them to expand their training programs. 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 The proposed amendments would not create any new costs or reduce net benefits for nursing homes, ALFs, preceptors, or AITs. An increase in the supply of licensed administrators as a result of the proposed changes may eventually increase competition and dampen wage growth for administrators; however, this is a more indirect and long-term effect and may not result if the demand for administrators continues to outpace supply. Thus, an adverse impact is not indicated.

Small Businesses⁵ Affected.⁶ The proposed changes would benefit nursing homes and ALFs that provide training, all of which are likely small businesses, by allowing them to expand their AIT programs.

Localities⁷ Affected.⁸ No locality would be disproportionately affected. Local governments would not be affected.

Projected Impact on Employment. The proposed amendments would eventually increase the number of individuals employed as AITs and subsequently, as administrators of nursing homes and ALFs. The proposed amendments are not expected to affect total employment.

Effects on the Use and Value of Private Property. Private nursing homes and ALFs that provide training would be able to expand their training programs; as a result, the value of such private businesses could increase. Real estate development costs would not be affected.

_____________________________

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 A regulatory advisory panel on this issue discussed these proposed changes as well as other changes for the board to consider and/or for the board to continue stakeholder engagement to develop changes. More details can be found in meeting minutes and attachments here: https://townhall.virginia.gov/L/GetFile.cfm?File=meeting\28\41365\Minutes_DHP_41365_v2.pdf.

³ 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.

⁴ 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.

⁵ 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."

⁶ 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.

⁷ "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.

⁸ Section 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

Agency Response to Economic Impact Analysis: The Board of Long-Term Care Administrators concurs with the economic impact analysis prepared by the Department of Planning and Budget.

Summary:

The amendments (i) reduce requirements to serve as a preceptor in a long-term care facility and (ii) raise to three the number of trainees a preceptor may supervise.

18VAC95-20-340. Supervision of trainees.

A. Training shall be under the supervision of a preceptor who is registered or recognized by a licensing board.

B. A preceptor may supervise no more than two three AIT's at any one time.

C. A preceptor shall:

1. Provide direct instruction, planning, and evaluation in the training facility;

2. Shall be Be routinely present with the trainee for on-site supervision in the training facility as appropriate to the experience and training of the AIT and the needs of the residents in the facility; and

3. Shall continually Continually evaluate the development and experience of the AIT to determine specific areas in the Domains of Practice that need to be addressed.

18VAC95-20-380. Qualifications of preceptors.

A. To be registered by the board as a preceptor, a person shall:

1. Hold a current, unrestricted Virginia nursing home administrator license and be employed full time;

2. Have at least two years in practice as an administrator of record in a training facility for a minimum of two of the past three four years immediately prior to registration; 2. and either:

a. Be employed full time in or be under contract or written agreement with the facility where training occurs; or

b. Be a regional administrator with on-site supervisory responsibilities for a training facility;

3. Provide evidence that he the person has completed the online preceptor training course offered by NAB; and

3. 4. Meet the application requirements in 18VAC95-20-230.

B. To renew registration as a preceptor, a person shall:

1. Hold a current, unrestricted Virginia nursing home administrator license and be employed by or have an agreement with a training facility for a preceptorship; and

2. Meet the renewal requirements of 18VAC95-20-170.

18VAC95-30-180. Preceptors.

A. Training in an ALF AIT program shall be under the supervision of a preceptor who is registered or recognized by Virginia or a similar licensing board in another jurisdiction.

B. To be registered by the board as a preceptor, a person shall:

1. Hold a current, unrestricted Virginia assisted living facility administrator or nursing home administrator license;

2. Be employed full time Have at least two years in practice as an administrator in a training facility for a minimum of two of record in the past four years immediately prior to registration or be and either:

a. Be employed full time in or be under contract or written agreement with the facility where training occurs; or

b. Be a regional administrator with on-site supervisory responsibilities for a training facility;

3. Provide evidence that he the preceptor has completed the online preceptor training course offered by NAB; and

4. Submit an application and fee as prescribed in 18VAC95-30-40. The board may waive such application and fee for a person who is already approved as a preceptor for nursing home licensure.

C. A preceptor shall:

1. Provide direct instruction, planning, and evaluation;

2. Be routinely present for on-site supervision of the trainee in the training facility as appropriate to the experience and training of the ALF AIT and the needs of the residents in the facility; and

3. Continually evaluate the development and experience of the trainee to determine specific areas needed for concentration.

D. A preceptor may supervise no more than two three trainees at any one time.

E. A preceptor for a person who is serving as an acting administrator while in an ALF AIT program shall be present in the training facility for face-to-face instruction and review of the trainee's performance for a minimum of four hours per week.

F. To renew registration as a preceptor, a person shall:

1. Hold a current, unrestricted Virginia assisted living facility or nursing home license and be employed by or have a written agreement with a training facility for a preceptorship; and

2. Meet the renewal requirements of 18VAC95-30-60.

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD OF PHARMACY

Fast-Track Regulation

Title of Regulation: 18VAC110-20. Regulations Governing the Practice of Pharmacy (amending 18VAC110-20-275).

Statutory Authority: § 54.1-2400 of the Code of Virginia.

Public Hearing Information: No public hearing is currently scheduled.

Public Comment Deadline: October 7, 2026.

Effective Date: October 22, 2026.

Agency Contact: Caroline Juran, RPh, Executive Director, Board of Pharmacy, 9960 Mayland Drive, Suite 300, Richmond, VA 23233-1463, telephone (804) 367-4456, fax (804) 527-4472, or email caroline.juran@dhp.virginia.gov.

Basis: Section 54.1-2400 of the Code of Virginia authorizes the Board of Pharmacy to promulgate regulations that are reasonable and necessary to effectively administer the regulatory system.

Purpose: This action is essential to protect the health, safety, and welfare of citizens because adherence to safety measures imposed by the board for the delivery of dispensed prescriptions helps protect the drug supply in the Commonwealth. The goal of this action is to clarify the regulation, and the problem the action is intended to solve is practitioner confusion about existing requirements.

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 does not change, but clarifies, existing requirements.

Substance: The amendments clarify the circumstances under which a pharmacy can deliver a dispensed prescription to a practitioner of the healing arts.

Issues: The primary advantage to the public is ensuring that practitioners understand alternative delivery site requirements, which ensures the safety of drug stock in the Commonwealth. There are no disadvantages to the public. There are no advantages or disadvantages to the agency or the Commonwealth.

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 Pharmacy (board) proposes to clarify the delivery requirements of dispensed prescriptions to a practitioner of the healing arts.

Background. The current regulatory text allows delivery of prescriptions dispensed by a pharmacy to a practitioner of the healing arts licensed to practice pharmacy or to sell controlled substances, among other alternatives. According to the Department of Health Professions (DHP), a practitioner of the healing arts may be licensed to practice pharmacy under § 54.1-3304 of the Code of Virginia or may be allowed to sell controlled substances at a location holding a permit for selling controlled substances pursuant to § 54.1-3304.1 of the Code of Virginia. Under the latter, the physician must hold a license to sell controlled substances and the location must have a facility permit for selling controlled substances. The location requirement for delivery of a dispensed prescription to a physician was confusing for a practitioner and their authorized representative. Thus, the board proposes to clarify the relevant phrase by adding text: to a practitioner of the healing arts licensed to practice pharmacy pursuant to § 54.1-3304 of the Code of Virginia or to sell controlled substances at a location holding a permit for selling controlled substances pursuant to § 54.1-3304.1 of the Code of Virginia.

Estimated Benefits and Costs. The proposal would clarify that the delivery of dispensed controlled substances to a practitioner of the healing arts requires (i) that the physician be licensed to sell controlled substances and (ii) that the location must hold a permit for selling controlled substances. Since the proposal clarifies an existing requirement, it is expected to reduce the potential for confusion among the readers of the regulatory text. No other economic impact is expected.

Businesses and Other Entities Affected. The proposed amendments would clarify an existing requirement for the readers of the regulation. The Code of Virginia requires DPB to assess whether an adverse impact may result from the proposed regulation.² 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.³ The proposal is editorial in nature clarifying an existing requirement. Thus, no adverse impact on any entity is indicated.

Small Businesses⁴ Affected.⁵ The proposed amendments do not adversely affect small businesses.

Localities⁶ Affected.⁷ The proposed amendments do not introduce costs for localities nor do they disproportionately affect them.

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

Effects on the Use and Value of Private Property. No effects on the use and value of private property or on real estate development costs are expected.

_____________________________

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 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.

³ 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.

⁴ 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."

⁵ 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.

⁶ "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.

⁷ Section 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

Agency Response to Economic Impact Analysis: The Board of Pharmacy concurs with the economic impact analysis prepared by the Department of Planning and Budget.

Summary:

The amendments clarify location requirements for the delivery of dispensed prescriptions.

18VAC110-20-275. Delivery of dispensed prescriptions.

A. Pursuant to § 54.1-3420.2 B of the Code of Virginia, in addition to direct hand delivery to a patient or patient's agent or delivery to a patient's residence, a pharmacy may deliver a dispensed prescription drug order for Schedule VI controlled substances to another pharmacy, to a practitioner of the healing arts licensed to practice pharmacy pursuant to § 54.1-3304 of the Code of Virginia or to sell controlled substances at a location holding a permit for selling controlled substances pursuant to § 54.1-3304.1 of the Code of Virginia, or to an authorized person or entity holding a controlled substances registration issued for this purpose in compliance with this section and any other applicable state or federal law. Prescription drug orders for Schedule II through Schedule V controlled substances may not be delivered to an alternate delivery location unless if such delivery is authorized by federal law and regulations of the board.

B. Delivery to another pharmacy.

1. One pharmacy may fill prescriptions and deliver the prescriptions to a second pharmacy for patient pickup or direct delivery to the patient provided the two pharmacies have the same owner or have a written contract or agreement specifying the services to be provided by each pharmacy, the responsibilities of each pharmacy, and the manner in which each pharmacy will comply with all applicable federal and state law.

2. Each pharmacy using such a drug delivery system shall maintain and comply with all procedures in a current policy and procedure manual that includes the following information:

a. A description of how each pharmacy will comply with all applicable federal and state law;

b. The procedure for maintaining required, retrievable dispensing records to include which pharmacy maintains the hard-copy prescription, which pharmacy maintains the active prescription record for refilling purposes, how each pharmacy will access prescription information necessary to carry out its assigned responsibilities, method of recordkeeping for identifying the pharmacist responsible for dispensing the prescription and counseling the patient, and how and where this information can be accessed upon request by the board;

c. The procedure for tracking the prescription during each stage of the filling, dispensing, and delivery process;

d. The procedure for identifying on the prescription label all pharmacies involved in filling and dispensing the prescription;

e. The policy and procedure for providing adequate security to protect the confidentiality and integrity of patient information;

f. The policy and procedure for ensuring accuracy and accountability in the delivery process;

g. The procedure and recordkeeping for returning to the initiating pharmacy any prescriptions that are not delivered to the patient; and

h. The procedure for informing the patient and obtaining consent for using such a dispensing and delivery process.

3. Drugs waiting to be picked up at or delivered from the second pharmacy shall be stored in accordance with subsection A of 18VAC110-20-200 and subsection A of 18VAC110-20-490, if applicable.

C. Delivery to a practitioner of the healing arts licensed by the board to practice pharmacy pursuant to § 54.1-3304 of the Code of Virginia or to sell controlled substances at a location holding a permit for selling controlled substances pursuant to § 54.1-3304.1 of the Code of Virginia or other authorized person or entity holding a controlled substances registration authorized for this purpose.

1. A prescription may be delivered by a pharmacy to the office of such a practitioner or other authorized person provided there is a written contract or agreement between the two parties describing the procedures for such a delivery system and the responsibilities of each party.

2. Each pharmacy using this delivery system shall maintain a policy and procedure manual that includes the following information:

a. Procedure for tracking and ensuring security, accountability, integrity, and accuracy of delivery for the dispensed prescription from the time it leaves the pharmacy until it is handed to the patient or agent of the patient;

b. Procedure for providing counseling;

c. Procedure and recordkeeping for return of any prescription medications not delivered to the patient;

d. The procedure for ensuring confidentiality of patient information; and

e. The procedure for informing the patient and obtaining consent for using such a delivery process.

3. Prescriptions waiting to be picked up by a patient at the alternate site shall be stored in a lockable room or lockable cabinet, cart, remote dispensing system as defined in § 54.1-3401 of the Code of Virginia and pursuant to subsection A of 18VAC110-20-490, or other device that cannot be easily moved and that shall be locked at all times when not in use. Access shall be restricted to the licensed practitioner of the healing arts or the responsible party listed on the application for the controlled substances registration, or either person's designee.

D. The contracts or agreements and the policy and procedure manuals required by this section for alternate delivery shall be maintained both at the originating pharmacy as well as the alternate delivery site.

E. A controlled substances registration as an alternate delivery site shall only be issued to an entity without a prescriber or pharmacist present at all times the site is open if there is a valid patient health or safety reason not to deliver dispensed prescriptions directly to the patient and if compliance with all requirements for security, policies, and procedures can be reasonably ensured.

F. The pharmacy and alternate delivery site shall be exempt from compliance with subsections B through E of this section if (i) the alternate delivery site is a pharmacy, a practitioner of healing arts licensed by the board to practice pharmacy or sell controlled substances, or other entity holding a controlled substances registration for the purpose of delivering controlled substances; (ii) the alternate delivery site does not routinely receive deliveries from the pharmacy; and (iii) compliance with subsections B through E of this section would create a delay in delivery that may result in potential patient harm. However, the pharmacy and alternate delivery site shall comply with following requirements:

1. To ensure appropriate coordination of patient care, the pharmacy shall notify the alternate delivery site of the anticipated arrival date of the shipment, the exact address to where the drug was shipped, the name of the patient for whom the drug was dispensed, and any special storage requirements.

2. The pharmacy shall provide counseling or ensure a process is in place for the patient to receive counseling.

3. Prescriptions delivered to the alternate delivery site shall be stored in a lockable room or lockable cabinet, cart, remote dispensing system as defined in § 54.1-3401 of the Code of Virginia and pursuant to subsection A of 18VAC110-20-490, or other device that cannot be easily moved and that shall be locked at all times when not in use. Access shall be restricted to the licensed prescriber, pharmacist, or either person's designee.

4. The pharmacy shall provide a procedure for the return of any prescription drugs not delivered or subsequently administered to the patient.

G. A pharmacy shall not deliver dispensed drugs to a patient's residence that are intended to be subsequently transported by the patient or patient's agent to a hospital, medical clinic, prescriber's office, or pharmacy for administration and that require special storage, reconstitution or compounding prior to administration. An exception to this requirement may be made for patients with inherited bleeding disorders who may require therapy to prevent or treat bleeding episodes.

TITLE 18. PROFESSIONAL AND OCCUPATIONAL LICENSING

BOARD OF PHARMACY

Fast-Track Regulation

Title of Regulation: 18VAC110-21. Regulations Governing the Licensure of Pharmacists and Registration of Pharmacy Technicians (amending 18VAC110-21-80).

Statutory Authority: § 54.1-2400 of the Code of Virginia.

Public Hearing Information: No public hearing is currently scheduled.

Public Comment Deadline: October 7, 2026.

Effective Date: October 22, 2026.

Agency Contact: Caroline Juran, RPh, Executive Director, Board of Pharmacy, 9960 Mayland Drive, Suite 300, Henrico, VA 23233, telephone (804) 367-4456, fax (804) 527-4472, or email caroline.juran@dhp.virginia.gov.

Basis: Section 54.1-2400 of the Code of Virginia authorizes the Board of Pharmacy to promulgate regulations that are reasonable and necessary to effectively administer the regulatory system.

Purpose: This action is essential to protect the health, safety, and welfare of citizens because it streamlines the licensure of pharmacists.

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 reduces burdens for applicants and streamlines the process for licensure as a pharmacist.

Substance: The amendments permit the board to use the National Association of Boards of Pharmacy (NAPB) exam eligibility services and allow students of pharmacy to take the NABP exam prior to graduation.

Issues: There are no advantages or disadvantages to the public, the agency, or the Commonwealth.

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 Pharmacy (board) proposes to allow students of pharmacy to take the National Association of Boards of Pharmacy (NABP) examinations prior to graduation and to allow the board to use NABP exam eligibility service.

Background. Pharmacy students in Virginia must take two examinations offered by the NABP in order to qualify for licensure: the North American Pharmacist Licensure Examination (NAPLEX) and Multistate Pharmacy Jurisprudence Examination (MPJE). As an alternative to the MPJE, the NABP has also begun to offer a Uniform MPJE (UMPJE) examination, and Virginia students will have the option of taking the UMPJE effective October 1, 2026. Afterwards, Virginia students will no longer have the option to take the MPJE, but the date of this transition does not appear to have been determined at this time.² Before taking the test, student eligibility to take the test must be confirmed. The NABP currently confirms student eligibility to test for residents of several states (Arizona, Colorado, District of Columbia, Kentucky, Louisiana, Maine, Nebraska, North Carolina, Oregon, Rhode Island, Utah, and Wisconsin). Residents of these jurisdictions must pay an additional $85 fee during the application process. The NABP also confirms eligibility to test for the UMPJE for all participating jurisdictions; there is no separate fee for this. The eligibility review is valid for one year and includes retakes during that period. After confirming eligibility to test, and ensuring all other application requirements are met, candidates may be approved to purchase the exam. After purchase, the student receives an Authorization to Test (ATT). In order to receive the ATT, NABP requires applicants for the NAPLEX or MPJE to submit an official transcript upon degree conferral.³ In 2024, an NABP task force was tasked with examining feasible options to expand access to the examination process, including allowing candidates to take the examinations prior to degree conferral.⁴ The task force conducted a pilot program in North Dakota and Wisconsin that allowed students to take the MPJE prior to graduation, and it appears that this option has been expanded to the jurisdictions where NABP confirms eligibility to test.⁵ Board regulation currently prohibits use of this option in Virginia. 18VAC110-21-80 A requires that prior to admission to any examination required for licensure, the applicant shall have met all other requirements to include education and practical experience requirements, but in no case shall the applicant be admitted if grounds exist to deny licensure under § 54.1-3316 of the Code of Virginia. This language in 18VAC110-21-80 A has two important effects. First, it effectively prohibits students from taking the NABP examinations prior to graduation from a pharmacy program. Second, it also implicitly requires the board to verify that each applicant has met the education and practical experience requirements and to ascertain that the applicant would not be denied licensure under § 54.1-3316 of the Code of Virginia. Thus, the current language in 18VAC110-21-80 A prevents the board from utilizing NABP eligibility verification service, because that service only considers compliance with education requirements. Thus, the board seeks to strike subsection A so that students may (i) take one or both examinations before graduation, as allowed by NABP, and (ii) use the NABP eligibility verification service. A shift to using NABP eligibility verification service is not expected to limit board ability to refuse to issue a license or take disciplinary action, because § 54.1-3316 of the Code of Virginia authorizes the board to refuse to admit an applicant to any examination; refuse to issue a license, permit, certificate, or registration to any applicant for a list of specific violations.

Estimated Benefits and Costs. The proposed amendments would benefit pharmacy students by allowing them to take one or both of the required licensing examinations prior to graduating from a pharmacy program, thereby reducing the time it takes to obtain a pharmacist license and start working. The median annual wage for pharmacists in Virginia was $137,470 in May 2024; for comparison, the median annual wage for pharmacy technicians was $42,490.⁶ Assuming pharmacy graduates (prelicensure) work as pharmacy interns performing similar work to pharmacy technicians for similar pay, they could reasonably expect a significant salary increase once they become licensed, even if their starting salary is below the median for pharmacists. Thus, reducing the time taken to obtain a license even by a few months could have a significant monetary benefit to pharmacy students seeking licensure. The proposed amendments would also implicitly require pharmacy students to pay a new $85 fee for NABP eligibility verification service; this fee would cover both the NAPLEX and MPJE for up to one year and includes any retakes within that one-year period. This fee would be additional to the examination application fees. However, the board reports that once Virginia adopts the UMPJE, which is expected to occur this fall, the application fees will cover all eligibility processing, for both the UMPJE and NAPLEX exams, and include any retakes within a one-year period. However, the exam application fee may be higher to reflect the inclusion of the eligibility verification service. Lastly, the proposed amendments would reduce administrative burden for the board by no longer having to verify applicant eligibility to take the NABP examinations.

Businesses and Other Entities Affected. As described previously, the proposed amendments would largely benefit pharmacy students seeking licensure as pharmacists; however, it would also create a new cost, at least temporarily. In 2025, 869 new pharmacist licenses were issued, of which approximately 250 were Virginia students.⁷ The Code of Virginia requires DPB to assess whether an adverse impact may result from the proposed regulation.⁸ 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.⁹ Because the proposed changes would require students to pay a new $85 fee to NABP for verifying examination eligibility, an adverse impact is indicated. However, it should be noted that this service will be included in the application fee for the UMPJE effective October 1, 2026, and that the MPJE will be retired eventually.

Small Businesses¹⁰ Affected.¹¹ The proposed changes would not adversely impact small businesses.

Localities¹² Affected.¹³ No locality would be disproportionately affected. Local governments would not be affected.

Projected Impact on Employment. Although the proposed changes would reduce the time taken for pharmacy students to receive their license, this impact is unlikely to attract more individuals to pursue an education and career as a pharmacist or affect employment rates for licensed pharmacists.

Effects on the Use and Value of Private Property. The proposed amendments are not expected to substantively affect the use or value of private property. Real estate development costs would not be affected.

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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://nabp.pharmacy/programs/examinations/mpje/uniform-mpje/participating-states/.

³ See https://nabp.pharmacy/programs/examinations/naplex/#steps-to-apply and https://nabp.pharmacy/programs/examinations/mpje/how-to-apply/.

⁴ See https://nabp.pharmacy/wp-content/uploads/2024/12/Report-of-the-Task-Force-to-Assess-Expanding-Access-to-NABP-Competence-Assessment-Examinations.pdf.

⁵ Because the pilot only included MPJE, the report states that eligibility review may include the NAPLEX if the student is applying up to six months in advance of the testing date.

6 Data source: U.S. Bureau of Labor Statistics Occupational Employment and Wage Statistics; May 2024 is the most recently available data. https://data.bls.gov/oes/#/home.

7 Source: https://www.dhp.virginia.gov/about/stats/2026Q3/05NewLicenseCountQ3FY2026.pdf.

⁸ 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.

⁹ 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.

¹⁰ 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."

¹¹ 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.

¹² "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.

¹³ Section 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

Agency Response to Economic Impact Analysis: The Board of Pharmacy concurs with the economic impact analysis prepared by the Department of Planning and Budget.

Summary:

The amendments (i) remove the prohibition on candidates for licensure as a pharmacist from sitting for the national examination prior to graduation and (ii) allow the Board of Pharmacy to use exam eligibility services provided by the National Association of Boards of Pharmacy (NABP).

18VAC110-21-80. Content of the examination and grades required; limitation on admittance to examination.

A. Prior to admission to any examination required for licensure, the applicant shall have met all other requirements to include education and practical experience requirements, but in no case shall the applicant be admitted if grounds exist to deny licensure under § 54.1-3316 of the Code of Virginia.

B. A. The applicant shall achieve a passing score as determined by the board on the licensure examination that is approved by the board and that shall consist of an integrated examination of pharmacy practice, pharmacology, pharmacy mathematics, and such other subjects as are necessary to assure ensure that the candidate possesses the necessary knowledge and skills to practice pharmacy.

C. B. When an applicant for licensure by examination fails to meet the passing requirements of the board-approved integrated pharmacy examination on three occasions, the applicant shall not be readmitted to the examination until he the applicant has completed an additional 1,000 hours of practical experience as a pharmacy intern as set forth in 18VAC110-21-60.

D. C. The applicant shall also achieve a passing score as determined by the board on an examination that tests the candidate's knowledge of federal and state laws related to pharmacy practice. If an applicant has not subsequently been issued a license by any jurisdiction in the United States within three years of achieving a passing score, the applicant shall retake the examination in order to be licensed in Virginia.

E. D. When an applicant fails to pass the law examination, the applicant shall not be allowed to retake it for a period of 30 days.

F. E. If an applicant requests a testing accommodation for either examination based on a physical or mental impairment that substantially limits one or more major life activities, subject to the Americans with Disabilities Act, the board may approve a reasonable accommodation that does not compromise the security or integrity of the examination.

1. Supporting documentation shall be provided by the applicant to include the following to be considered for review:

a. A letter of request from the candidate that specifies the testing accommodation requested;

b. A written report of an evaluation (educational, psychological, or physical) within the preceding two years from a qualified professional that states a diagnosis of the disability, describes the disability, recommends specific accommodations, and provides justification that the accommodation is appropriate and necessary for the diagnosed disability. If the comprehensive evaluation was done more than two years ago and the condition is one that is not subject to change, the original evaluation report may be submitted along with a current letter from the qualified professional stating that there has been no change in the condition since the time of the evaluation; and

c. A written statement from the appropriate person at the applicant's school of pharmacy that describes any testing accommodations made while the student was enrolled, if applicable.

2. The applicant will be notified in writing of the decision. If the request for accommodation is granted, the approval information will be forwarded to the examination contractor and the form of the accommodation will be coordinated with the contractor.

TITLE 22. SOCIAL SERVICES

DEPARTMENT FOR AGING AND REHABILITATIVE SERVICES

Fast-Track Regulation

Title of Regulation: 22VAC30-100. Adult Protective Services (repealing 22VAC30-100-15).

Statutory Authority: §§ 51.5-131 and 51.5-148 of the Code of Virginia.

Public Hearing Information: No public hearing is currently scheduled.

Public Comment Deadline: October 7, 2026.

Effective Date: October 22, 2026.

Agency Contact: Paige L. McCleary, Division Director, Adult Protective Services, Department for Aging and Rehabilitative Services, 8004 Franklin Farms Drive, Richmond, VA 23229, telephone (804) 662-7605, or email paige.mccleary@dars.virginia.gov.

Basis: Section 51.5-131 of the Code of Virginia authorizes the Commissioner of the Department of Aging and Rehabilitative Services to promulgate regulations necessary to carry out the provisions of the laws of the Commonwealth of Virginia. Section 51.5-148 of the Code of Virginia authorizes the department to plan and oversee adult protective services in the Commonwealth.

Purpose: Adult protective services (APS) programs prevent and protect vulnerable adults from abuse, neglect, and exploitation, and enhance the independence of older adults and individuals with disabilities. This action supports public health, safety, and welfare by ensuring consistency and accuracy in the statutory and regulatory authorities governing the implementation and oversight of Virginia's APS program.

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 does not change the list of mandated reporters required to report suspected adult abuse, neglect, or exploitation when acting in their professional capacities, which is still governed by § 63.2-1606 of the Code of Virginia, and it removes duplicative language, ensuring statute and the regulation remain clear and that there is reduced potential for confusion.

Substance: This action repeals 22VAC30-100-15, which is a comprehensive list of the professional staff that are required to report a suspicion that adult abuse, neglect, or exploitation has occurred when acting in their professional capacity. This action does not change the list of mandated reporters required to report suspected adult abuse, neglect, or exploitation when acting in their professional capacities, which is still governed by § 63.2-1606 of the Code of Virginia.

Issues: The primary advantage of this action for the public, the agency, and the Commonwealth is that it removes language that is redundant of the Code of Virginia. There are no disadvantages to the public, the agency, or the Commonwealth.

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 Commissioner of the Department for Aging and Rehabilitative Services (DARS) proposes to repeal 22VAC30-100-15.

Background. The term "mandated reporters" is defined in 22VAC30-100-10 as "persons identified in § 63.2-1606 of the Code of Virginia who are required to report to [adult protective services] APS when such persons have reason to suspect that an adult is abused, neglected, or exploited or is at risk of abuse, neglect, or exploitation." APS is defined as services provided by the local department of social services that are necessary to protect an adult as defined in § 63.2-1603 of the Code of Virginia from abuse, neglect, or exploitation. 22VAC30-100-15 is largely duplicative of the portion of § 63.2-1606 of the Code of Virginia that lists mandated reporters. The section starts with "Reports shall be made to the local department of social services or the State Department of Social Services Adult Protective Services Hotline forthwith by the following persons acting in their professional capacity upon their suspicion that adult abuse, neglect or exploitation has occurred:" and then lists eight categories of persons. However, there is one category in § 63.2-1606, "any person who engages in the practice of behavior analysis" that is not in 22VAC30-100-15. Chapter 766 of the 2022 Acts of Assembly added behavior analysists to § 63.2-1606, but 22VAC30-100-15 has not been amended to reflect the legislation. According to DARS, the repeal of this section would ensure the Virginia Administrative Code is kept current and does not contain provisions that are duplicative or potentially inconsistent with state law.

Estimated Benefits and Costs. 22VAC30-100-15 does not include a category of persons that has been added to the list of mandated reporters. When the Code of Virginia and the Virginia Administrative Code conflict, the Code of Virginia prevails. Thus, repealing 22VAC30-100-15 would not affect which persons are legally mandated reporters. On the other hand, readers of 22VAC30-100-15 and not the Code of Virginia currently would be misled concerning the identity of legally required mandated reporters. Thus, repealing 22VAC30-100-15 may be beneficial in that it would reduce the likelihood that some members of the public may be misled concerning the identity of legally required mandated reporters. Additionally, since the definition of mandated reporters in 22VAC30-100-10 references § 63.2-1606 of the Code of Virginia, readers of the regulation would know where to look to find the identity of legally mandated reporters.

Businesses and Other Entities Affected. Readers of the regulation could be affected as described above. In particular, persons who engage in the practice of behavior analysis may be affected in that it could be less likely that they would be misled into believing that they are not mandated reporters. The Code of Virginia requires DPB to assess whether an adverse impact may result from the proposed regulation.² 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.³ As the proposal neither increases costs nor reduces net revenue for any entity, no adverse impact is indicated.

Small Businesses⁴ Affected.⁵ The proposal does not adversely affect small businesses.

Localities⁶ Affected.⁷ The proposal neither disproportionally affects any particular localities nor affects costs for local governments.

Projected Impact on Employment. The proposal does not affect employment.

Effects on the Use and Value of Private Property. The proposal does not affect the use and value of private property or real estate development costs.

_____________________________

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 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.

³ 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.

⁴ 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."

⁵ 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.

⁶ "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.

⁷ Section 2.2-4007.04 defines "particularly affected" as bearing disproportionate material impact.

Agency Response to Economic Impact Analysis: The Department for Aging and Rehabilitative Services concurs with the economic impact analysis prepared by the Department of Planning and Budget.

Summary:

Following a periodic review, the action repeals 22VAC30-100-15, Mandated reporters, which is redundant to § 63.2-1606 of the Code of Virginia. This action does not change the statutory list of persons required to report suspected adult abuse, neglect, or exploitation when acting in their professional capacities.

22VAC30-100-15. Mandated reporters. (Repealed.)

Reports shall be made forthwith by the following persons acting in their professional capacity upon their suspicion that adult abuse, neglect or exploitation has occurred:

1. Any person licensed, certified, or registered by health regulatory boards listed in § 54.1-2503 of the Code of Virginia, with the exception of persons licensed by the Board of Veterinary Medicine;

2. Any mental health services provider as defined in § 54.1-2400.1 of the Code of Virginia;

3. Any emergency medical services personnel certified by the Board of Health pursuant to § 32.1-111.5 of the Code of Virginia, unless such personnel immediately reports the suspected abuse, neglect, or exploitation directly to the attending physician at the hospital to which the adult is transported, who shall make such report forthwith;

4. Any guardian or conservator of an adult;

5. Any person employed by or contracted with a public or private agency or facility and working with adults in an administrative, supportive or direct care capacity;

6. Any person providing full, intermittent or occasional care to an adult for compensation including, but not limited to, companion, chore, homemaker, and personal care workers;

7. Any law-enforcement officer; and

8. Medical facilities inspectors of the Department of Health. However, medical facilities inspectors are exempt from reporting suspected abuse immediately while conducting federal inspection surveys in accordance with Title XVIII (§ 1846) and Title XIX of the Social Security Act, as amended, of certified nursing facilities as defined in § 32.1-123 of the Code of Virginia. Findings of adult abuse, neglect or exploitation by a medical facilities inspector shall be made known to adult protective services after the exit conference at the facility so that the local department can provide follow up to facility residents who may be at risk of further abuse, neglect or exploitation.

TITLE 22. SOCIAL SERVICES

STATE BOARD OF SOCIAL SERVICES

Final Regulation

Title of Regulation: 22VAC40-191. Background Checks for Child Welfare Agencies (amending 22VAC40-191-20, 22VAC40-191-50).

Statutory Authority: §§ 63.2-217, 63.2-1732, 63.2-1733, and 63.2-1734 of the Code of Virginia.

Effective Date: October 7, 2026.

Agency Contact: Alisa Foley, Program Consultant, Department of Social Services, 801 East Main Street, Richmond, VA 23219, telephone (804) 726-7138, or email alisa.foley@dss.virginia.gov.

Summary:

The amendments align the regulation with Chapter 726 of the 2026 Acts of Assembly, which consolidates existing barrier crimes exceptions applicable for foster or adoptive homes, including adult household members, into one statute.

22VAC40-191-20. Describing background checks.

A. The background checks covered by this regulation are:

1. Sworn statement or affirmation;

2. Criminal history record check;

3. National criminal background check; and

4. Central registry search.

B. The provisions for background checks are in §§ 63.2-901.1, 63.2-1720, 63.2-1721, 63.2-1722, and 63.2-1723 of the Code of Virginia.

C. Provisions for enforcement of background check regulations and other licensing and approval standards are in § 63.2-901.1 and Chapter 17 (§ 63.2-1700 et seq.) of Title 63.2 of the Code of Virginia.

D. The sworn statement or affirmation is a written document in which a person must disclose any criminal conviction and any pending criminal charges within or outside Virginia.

1. Conviction includes any juvenile conviction or determination of delinquency if the offense involved would be a felony if committed by an adult within or outside Virginia.

2. The person must also disclose any instance of being the subject of a founded complaint of child abuse or neglect within or outside Virginia.

3. The person must use either the model form prepared by the department or use a self-created form that includes all of the information that appears on the model form.

The department provides the model sworn statement or affirmation form on its website. Requesters are permitted to submit copies of the form. The person who signs the sworn statement or affirmation affirms the truth of the statement.

E. The criminal history record check is the process of the Department of State Police to generate a criminal record report on a person. The report must be either the criminal record clearance or the criminal history record. The criminal record clearance shows whether the person is guilty of:

1. A barrier crime, as defined in § 19.2-392.02 of the Code of Virginia; or

2. Any other felony not included in the definition of barrier crime unless five years have elapsed since the conviction.

The criminal history record report shows all convictions.

F. The person must use the form and process of the Central Criminal Records Exchange (CCRE) of the Department of State Police for this check. The Department of State Police provides original criminal history record check forms to facilities upon receipt of request. The Department of State Police also provides website access to this form for facilities that are noncriminal justice inquiry interface users. The CCRE verifies criminal history record reports.

G. The national criminal background check is the process of obtaining criminal history record information from the Federal Bureau of Investigation through the Central Criminal Records Exchange.

1. The person must submit to fingerprinting and provide personal descriptive information.

2. The person must use the process of the department's Office of Background Investigations (OBI) to request and receive a national criminal background check.

H. The search of the central registry is a check to determine if the person has ever been the subject of a founded complaint of child abuse or neglect in Virginia.

I. The person must use the form and process of the OBI. The department provides the central registry request form on its website. Requesters are permitted to submit copies of this form. OBI verifies child protective services central registry check findings.

22VAC40-191-50. Explaining requirements for satisfactory background checks.

A. The department and registering and approving authorities must require documentation of satisfactory background checks for applicants, agents, employees, volunteers, and others living in foster and adoptive homes as specified in 22VAC40-191-40.

1. A satisfactory sworn statement or affirmation is:

a. A fully completed statement that states that the person does not have an offense; and

b. There is no other knowledge that the individual has a disqualifying background check.

Criminal convictions include prior adult convictions and juvenile convictions or adjudications of delinquency based on a crime that would be a felony if committed by an adult within or outside the Commonwealth. Convictions also include convictions in other states that are equivalent to those specified in this section.

2. A satisfactory central registry finding is one in which:

a. A copy of the department's child protective services check form is returned to the requesting agency or state or local Department of Social Services indicating that, as of the date on the reply, the individual whose name was searched is not identified in the central registry as an involved caregiver with a founded disposition of child abuse/neglect abuse or neglect; and

b. There is no other knowledge that the individual has a founded disposition in Virginia or elsewhere.

3. A satisfactory criminal history record check report is one in which:

a. An original hard copy or Internet inquiry reply from the Department of State Police is returned to the agency, individual, or authorized agent making the request with:

(1) No convictions indicated; or

(2) Convictions indicated, but no barrier crimes, offenses, or other felony convictions in the last five years;

b. A letter is received from the Office of Background Investigations with a finding of "eligible"; and

c. There is no other knowledge that the individual has an offense in Virginia or elsewhere.

The facility must have viewed an original criminal history record report maintained by a contract employee or contract agency that is dated less than six months before the independent contract employee or contract employee is hired by a contract agency begins providing services at the facility. (See also 22VAC40-191-90.)

4. A child-placing agency may approve as an adoptive or foster parent home where an applicant and any adult household member have each been convicted of not more than one misdemeanor of assault and battery, as defined in § 18.2-57 of the Code of Virginia, or any substantially similar offense under the laws of another jurisdiction not involving abuse, neglect or moral turpitude, or of a minor, provided 10 years have elapsed following the conviction.

5. A child-placing agency may approve as a an adoptive or foster parent home where an applicant or any adult household member has been convicted of statutory burglary for breaking and entering a dwelling home or other structure with intent to commit larceny who any offense set forth in clause (iii) of the definition of barrier crime in § 19.2-392.02 of the Code of Virginia and where the individual has had his their civil rights restored by the Governor or other appropriate authority, provided 25 20 years have elapsed following the conviction.

6. A child-placing agency must consider the results of background checks on a birth parent prior to placing the child of the birth parent with the birth parent, when the child is in a foster care placement (unless the birth parent has revoked an entrustment agreement pursuant to § 63.2-1223 or 63.2-1817 of the Code of Virginia or a local board or the birth parent revokes a placement agreement with legal custody remaining with the parent, parents, or guardians pursuant to § 63.2-900 of the Code of Virginia).

7. No petition for adoption shall be granted if an adoptive parent has been convicted of a sexually violent offense or an offense requiring registration pursuant to § 9.1-902 of the Code of Virginia.

8. A child-placing agency may approve as an adoptive or foster parent home where an applicant or any adult household member has been convicted of felony possession of drugs, who any offense set forth in clause (iv) of the definition of barrier crime in § 19.2-392.02 of the Code of Virginia where (i) the individual has had his their civil rights restored by the Governor or other appropriate authority, provided 10 years have elapsed following the conviction pursuant to § 63.2-1721 G of the Code of Virginia or (ii) eight years have elapsed following the conviction and the individual (a) has complied with all obligations imposed by the criminal court, (b) has completed a substance abuse treatment program, (c) has completed a drug test administered by a laboratory or medical professional within 90 days prior to being approved and the test returned with a negative result, and (d) complies with any other obligations as determined by the department.

9. A child-placing agency may approve as a kinship foster care parent an applicant convicted of the following offenses, provided that 10 years have elapsed from the date of the conviction and the local board or child-placing agency makes a specific finding that approving the kinship foster care placement would not adversely affect the safety and well-being of the child: (i) a felony conviction for possession of drugs as set out in Article 1 (§ 18.2-247 et seq.) of Chapter 7 of Title 18.2 of the Code of Virginia, but not including a felony conviction for possession of drugs with the intent to distribute; (ii) a misdemeanor conviction for arson as set out in Article 1 (§ 18.2-77 et seq.) of Chapter 5 of Title 18.2; or (iii) an equivalent offense in another state.

B. Background checks results are not open ended.

1. If a person leaves a facility and the criminal history record report or central registry check finding is less than 91 days old, the person must be permitted to take the report or reports with him. The facility must keep a copy of any report a person takes and write on it that it is a copy, and that the original of any criminal history record report was verified.

2. Unless there is a criminal conviction or a founded complaint of child abuse and neglect during that period, a background check remains valid at a facility if no more than 12 consecutive months have passed from when a person:

a. Began a leave of absence from that facility;

b. Was terminated from employment at that facility; or

c. Was transferred to a center owned and operated by the same employer or entity.

3. The facility, department, or approving authority may require a new background check relevant to this suspicion if there is reason to suspect that a person who has submitted acceptable background checks, as required by this regulation, has an offense in Virginia or elsewhere.

4. When the facility, department, or approving authority chooses to require a new background check:

a. The facility, department, or approving authority may allow the person to continue the same relationship with the child welfare agency until the licensing or approval authority receives the new Virginia background check information or equivalent documentation from another state; or

b. If there is reason to suspect that a person has an offense, the facility, department, or approving authority may require that the person not be alone with children, even if the documentation is not Virginia background check information or equivalent information from another state.

C. Waivers of some criminal convictions are possible. Refer to 22VAC40-191-90 through 22VAC40-191-130 for an explanation of the waiver.

TITLE 22. SOCIAL SERVICES

STATE BOARD OF SOCIAL SERVICES

Final Regulation

Title of Regulation: 22VAC40-211. Foster and Adoptive Home Approval Standards for Local Departments of Social Services (amending 22VAC40-211-90).

Statutory Authority: §§ 63.2-217 and 63.2-319 of the Code of Virginia.

Effective Date: October 7, 2026.

Agency Contact: Anya Horning, Program Consultant, Department of Social Services, 5600 Cox Road, Glen Allen, VA 23060, telephone (804) 389-1396, or email anya.horning9@dss.virginia.gov.

Summary:

Pursuant to Chapters 647 and 648 of the 2026 Acts of Assembly, the amendments (i) allow for a barrier crime waiver to be requested for prospective kinship foster parents and adult household members in the home and (ii) require that local departments of social services perform a safety assessment, home inspection, and a permanency assessment before submitting a request for a waiver to the department.

22VAC40-211-90. Allowing a waiver.

A. The local department may request and the provider may receive a permanent or temporary waiver from the department on a standard if the waiver does not jeopardize the safety and proper care of the child or violate federal or state laws or local ordinances.

B. To allow children to be placed with kinship foster parents, temporary waivers may be granted for preservice training, completion of a mutual family assessment, tuberculosis assessment, screening, or tests and physical examinations for a period not to exceed six months. Permanent waivers related to standards for the home of a provider as referenced in 22VAC40-211-70 may be granted to kinship foster parents.

C. If a provider is granted a waiver and is in compliance with all other requirements of this chapter, the provider is considered fully approved.

D. Any temporary waivers granted are for a period not to exceed six months. Before the end of the six-month period, the kinship foster parent must have completed all requirements that had previously been waived under subsection B of this section.

E. Any permanent waivers granted are considered on a case-by-case basis and must be reviewed on an annual basis by the department.

F. A local department may request a barrier crime waiver for prospective kinship foster parents and adult household members in accordance with § 63.2-901.2 of the Code of Virginia.

1. No child shall be placed in a home where a prospective kinship foster parent or an adult household member has a conviction for a barrier crime as defined in § 19.2-392.02 of the Code of Virginia and the individual does not meet the exceptions in § 63.2-901.1 E, F, G, H, or I of the Code of Virginia, unless the barrier crime waiver has been approved by the department.

2. The local department must complete the following before submitting an application to request a barrier crime waiver:

a. A safety assessment that includes the factors in § 63.2-901.2 C of the Code of Virginia;

b. An in-person inspection of the home; and

c. A permanency assessment on the department-issued template.

TITLE 22. SOCIAL SERVICES

STATE BOARD OF SOCIAL SERVICES

Final Regulation

Title of Regulation: 22VAC40-411. General Relief Program (adding 22VAC40-411-230).

Statutory Authority: § 63.2-217 of the Code of Virginia.

Effective Date: October 7, 2026.

Agency Contact: Mark Golden, TANF Program Manager, Department of Social Services, 5600 Cox Road, Glen Allen, VA 23060, telephone (804) 726-7385, or email mark.golden@dss.virginia.gov.

Background: This optional program for local departments of social services is a new component of the General Relief Program. The change gives local departments of social services a clear legal basis to provide financial assistance, subject to the availability of funding, when a qualifying individual dies without resources or family support to cover burial costs.

Summary:

Pursuant to Chapter 843 of the 2026 Acts of Assembly, the amendments allow local departments of social services to pay the reasonable funeral expenses of a decedent who was a recipient of social services or Supplemental Security Income (SSI).

22VAC40-411-230. Burial assistance.

Subject to the availability of funding, a local department may provide burial assistance to a decedent who was a recipient of public assistance or Supplemental Security Income at the time of death. The local department must indicate in the General Relief Plan the maximum amount of assistance available and any additional eligibility criteria required for the local department's locality.

TITLE 22. SOCIAL SERVICES

DEPARTMENT OF SOCIAL SERVICES

Action Withdrawn

Title of Regulation: 22VAC40-680. Virginia Energy Assistance Program - Low Income Home Energy Assistance Program (LIHEAP).

Statutory Authority: § 63.2-217 of the Code of Virginia.

The State Board of Social Services has WITHDRAWN the regulatory action for 22VAC40-680, Virginia Energy Assistance Program - Low Income Home Energy Assistance Program (LIHEAP), which was published as a Notice of Intended Regulatory Action in 39:14 VA.R. 1657 February 7, 2023. The purpose of the proposed action was to extend the eligibility period for the Energy Assistance Program (EAP), add details regarding the assistance provided, and update the information regarding administrative costs for local departments of social services. As a result of recent legislative changes exempting the action from the Administrative Process Act (§ 2.2-4000 et seq. of the Code of Virginia) three-step process, the board voted on August 18, 2026, to withdraw this action. An exempt action containing these regulatory amendments is currently in process.

Agency Contact: Denise Surber, Program Manager, Department of Social Services, 801 East Main Street, Richmond, VA 23219, telephone (804) 726-7386, fax (804) 726-7358, or email denise.t.surber@dss.virginia.gov.