Medallion Mandatory Managed Care
The following words and terms when used in this part shall
have the following meanings unless the context clearly indicates otherwise
All other words and terms used in this part shall comply with the definitions
in the contract and those identified 42 CFR 438.2: "Action" means the denial or limited
authorization of a requested service, including the type or level of service;
the reduction, suspension, or termination of a previously authorized service;
the denial, in whole or in part, of payment for a service; the failure to
provide services in a timely manner, as defined by the state; or the failure of
an MCO to act within the timeframes provided in 42 CFR 438.408(b).
"Adverse benefit determination" means, consistent with 42 CFR 438.400, (i) the denial or limited authorization of a requested service; (ii) the failure to take action or timely take action on a request for service; (iii) the reduction, suspension, or termination of a previously authorized service; (iv) the denial in whole or in part of a payment for a covered service; (v) the failure to provide services within the timeframes required by the state, or for a resident of a rural exception area with only one MCO, the denial of a member's request to exercise his right under 42 CFR 438.52(b)(2)(ii) to obtain services outside of the network; (vi) the denial of a member's request to dispute a financial liability; or (vii) the failure of an MCO to act within the timeframes provided in 42 CFR 438.408(b).
"Appeal" means a request for review of an action,
as "action" is defined in this section.
"Appeal" when applicable to a member means a request to DMAS to review an MCO's internal appeal decision to uphold the contractor's adverse benefit determination. For members, an appeal may only be requested after exhaustion of the MCO's one step internal appeal process. Member appeals to DMAS will be conducted in accordance with regulations at 42 CFR 431 Subpart E and 12VAC30-110-10 through 12VAC30-110-370.
"Appeal" when applicable to an appeal by a provider means a request to DMAS to review an MCO's reconsideration decision. For providers, an appeal may only be requested after exhaustion of the MCO's reconsideration process. Provider appeals to DMAS will be conducted in accordance with the requirements set forth in § 2.2-4000 et seq. of the Code of Virginia and 12VAC30-20-500 et seq.
"Area of residence" means the member's address in
the Medicaid eligibility file.
"Covered services" means Medicaid services as defined in the State Plan for Medical Assistance.
"Day" means calendar day unless otherwise stated.
"Disenrollment" means the process of changing
enrollment from one
Managed Care Organization managed care organization
(MCO) plan to another MCO, if applicable.
"DMAS" means the Department of Medical Assistance Services.
"Early Intervention" means EPSDT Early
Intervention services provided pursuant to Part C of the Individuals with
Disabilities Education Act (IDEA) of 2004 as set forth in 12VAC30-50-131.
"Eligible person" means any person eligible for Virginia Medicaid in accordance with the State Plan for Medical Assistance under Title XIX of the Social Security Act.
"Emergency medical condition" means a medical
condition manifesting itself by acute symptoms of sufficient severity
(including severe pain) that a prudent layperson, who possesses an average
knowledge of health and medicine, could reasonably expect the absence of
immediate medical attention to result in the following: 1. Placing the health of the individual (or, with respect to
a pregnant woman, the health of the woman or her unborn child) in serious
jeopardy, 2. Serious impairment to bodily functions, or 3. Serious dysfunction of any bodily organ or part.
"Emergency services" means
covered inpatient and
outpatient services that are furnished by a provider that is qualified to
furnish these services and that are needed to evaluate or stabilize an
emergency medical condition. those health care services that are
rendered by participating or nonparticipating providers after the sudden onset
of a medical condition manifesting itself by acute symptoms of sufficient
severity, including severe pain, that a prudent layperson who possesses an
average knowledge of health and medicine could reasonably expect the absence of
immediate medical attention to result in (i) placing the client's health in
serious jeopardy; (ii) with respect to a pregnant woman, placing the health of
the woman or her unborn child in serious jeopardy; (iii) serious impairment to
bodily functions; or (iv) serious dysfunction of any bodily organ or part. "Enrollment broker" means an independent
contractor that enrolls individuals in the contractor's plan and is responsible
for the operation and documentation of a toll-free individual service helpline.
The responsibilities of the enrollment broker include, but shall not be limited
to, individual education and MCO enrollment, assistance with and tracking of
individuals' complaints resolutions, and may include individual marketing and
"Exclude" means the removal of a member from the Medallion mandatory managed care program on a temporary or permanent basis.
"External quality review organization" or "EQRO" means an organization that meets the competence and independence requirements set forth in 42 CFR 438.354 and performs external quality reviews, other external quality review related activities as set forth in 42 CFR 438.358, or both.
"Grievance" means, in accordance with 42 CFR 438.400,
an expression of dissatisfaction about any matter other than an
is defined in this section "adverse benefit determination."
Possible subjects for grievances include the quality of care or services
provided; aspects of interpersonal relationships, such as rudeness of a
provider or employee; or failure to respect the member's rights.
"Health care professional" means a provider as defined in 42 CFR 438.2.
or "individuals" means
a person or persons who are is eligible for Medicaid ,
who are is not yet undergoing enrollment for mandatory managed
care , and who are is not enrolled in a mandatory managed
"Internal appeal" means a request to the MCO by a member or by a member's authorized representative or provider acting on behalf of the member and with the member's written consent for review of a contractor's adverse benefit determination, as defined in 42 CFR 438.400. The internal appeal is the only level of appeal with the MCO and must be exhausted by a member or deemed exhausted according to 42 CFR 438.408(c)(3) before the member may initiate a state fair hearing with DMAS.
"Managed care organization" or "MCO" means
entity that meets the participation and solvency criteria defined in 42
CFR Part 438 and has an executed contractual agreement with DMAS to provide
services covered under the mandatory managed care program. Covered services for
mandatory managed care program individuals shall be as accessible (in terms of
timeliness, amount, duration, and scope) as compared to other Medicaid
individuals served within the geographic area. organization that offers
managed care health insurance plans (MCHIP), as defined by § 38.2-5800 of the
Code of Virginia. Any health maintenance organization as defined in § 38.2-4300
of the Code of Virginia or health carrier that offers preferred provider
contracts or policies as defined in § 38.2-3407 of the Code of Virginia or
preferred provider subscription contracts as defined in § 38.2-4209 of the Code
of Virginia shall be deemed to be offering one or more MCHIPs. For the purposes
of this definition, the prohibition of balance billing by a provider shall not
be deemed a benefit payment differential incentive for covered persons to use
providers who are directly or indirectly managed by, owned by, under contract
with, or employed by the health carrier. A single managed care health insurance
plan may encompass multiple products and multiple types of benefit payment
differentials; however, a single managed care health insurance plan shall
encompass only one provider network or set of provider networks.
Additionally, and in accordance with 42 CFR 438.2, "managed care organization" or "MCO" means an entity that has qualified to provide the services covered in the Medallion program to qualifying Medallion members as accessible in terms of timeliness, amount, duration, and scope as those services are to other Medicaid members within the area served, and that meets the solvency standards of 42 CFR 438.116.
"Mandatory managed care program" shall mean the same as set forth in 42 CFR 438.54(b) and (d).
or "members" means people
who have current Medicaid eligibility who are also enrolled in mandatory
managed care a person eligible for Medicaid or Family Access to Medical
Insurance Security who has been assigned to a Medicaid MCO.
"Network provider" means doctors, hospitals,
or other health care providers who participate or contract with an MCO
, as a result , agree to accept a mutually agreed
upon sum or fee schedule as payment in full for covered services that are
rendered to eligible participants.
"Newborn enrollment period" means the period from the child's date of birth plus the next two calendar months.
"PCP of record" means a primary care physician of record with whom the recipient has an established history, and such history is documented in the individual's records.
"Retractions" means the departure of an enrolled
managed care organization from any one or more localities as provided for in
"Reconsideration" means a provider's request to the MCO for review of an adverse benefit determination. The MCO's reconsideration decision is a prerequisite to a provider's filing of an appeal, as provided for in 12VAC30-20-500 through 12VAC30-20-560, to DMAS Appeals Division.
"Rural exception" means a rural area designated in the § 1915(b) managed care waiver, pursuant to § 1932(a)(3)(B) of the Social Security Act and 42 CFR 438.52(b) and recognized by the Centers for Medicare and Medicaid Services, wherein qualifying mandatory managed care members are mandated to enroll in the one available contracted MCO.
"Spend-down" means the process of reducing
countable income by deducting incurred medical expenses for medically needy
individuals, as determined in the State Plan for Medical Assistance.
Mandatory Medallion mandatory
managed care members.
A. DMAS shall determine enrollment in Medallion mandatory managed care.
1. Medicaid eligible persons not meeting the exclusion criteria set out in subsection B of this section shall participate in the Medallion mandatory managed care program. Enrollment in Medallion mandatory managed care shall not be a guarantee of continuing eligibility for services and benefits under the Virginia Medical Assistance Services Program.
1. 2. DMAS reserves the right to exclude from
participation in the Medallion mandatory managed care program any member
who has been consistently noncompliant with the policies and procedures of
managed care or who is threatening to providers, MCOs, or DMAS. There must be
sufficient documentation from various providers, the MCO, and DMAS of these
noncompliance issues and any attempts at resolution. Members excluded from Medallion
mandatory managed care through this provision may appeal the decision to DMAS. 2. Qualifying individuals enrolled in the Elderly or
Disabled with Consumer Direction (EDCD) Waiver pursuant to Part IX
(12VAC30-120-900 et seq.) of this chapter who do not meet any exclusions in
subsection B of this section shall be required to enroll in managed care and
shall receive all acute care services through the mandatory managed care
delivery system. For these individuals, services provided under 12VAC30-120-380
A 2 shall continue to be provided through the DMAS fee-for-service system.
B. The following individuals shall be excluded (as defined in
12VAC30-120-360 and the § 1915(b) managed care waiver) from
participating in Medallion mandatory managed care
as defined in the
§ 1915(b) managed care waiver. Individuals excluded from Medallion
mandatory managed care shall include the following:
1. Individuals who are inpatients in state mental hospitals;
2. Individuals who are approved by DMAS as inpatients in long-stay hospitals, nursing facilities, or intermediate care facilities for individuals with intellectual disabilities;
3. Individuals who are placed on spend-down, which is the process of reducing countable income by deducting incurred medical expenses for medically needy individuals, as determined in the State Plan for Medical Assistance;
4. Individuals who are participating in the family planning
, or in federal waiver programs for home-based and community-based
Medicaid coverage prior to managed care enrollment (except eligible EDCD
Individuals under age Prior to April 1, 2019,
individuals younger than 21 years of age who are approved for DMAS
residential facility Level C programs as defined in 12VAC30-130-860; 6. Newly eligible individuals who are in the third trimester
of pregnancy and who request exclusion within a department-specified timeframe
of the effective date of their MCO enrollment. Exclusion may be granted only if
the member's obstetrical provider (i.e., physician, hospital, or midwife) does
not participate with the member's assigned MCO. Exclusion requests made during
the third trimester may be made by the member, MCO, or provider. DMAS shall
determine if the request meets the criteria for exclusion. Following the end of
the pregnancy, these individuals shall be required to enroll to the extent they
remain eligible for Medicaid; 7. 6. Individuals, other than students, who
permanently live outside their area of residence, which is the member's
address in the Medicaid eligibility file, for greater than 60 consecutive
days except those individuals placed there for medically necessary services
funded by the MCO; 8. 7. Individuals who receive hospice services in
accordance with DMAS criteria; 9. 8. Individuals with other comprehensive
group or individual health insurance coverage, including Medicare, insurance
provided to military dependents, and any other insurance purchased through
the Health Insurance Premium Payment Program (HIPP); 10. 9. Individuals requesting exclusion who are
inpatients in hospitals, other than those listed in subdivisions 1 and 2 of
this subsection, at the scheduled time of MCO enrollment or who are scheduled
for inpatient hospital stay or surgery within 30 calendar days of the MCO
enrollment effective date. The exclusion shall remain effective until the first
day of the month following discharge. This exclusion reason shall not apply to
members admitted to the hospital while already enrolled in a
department-contracted MCO; 11. 10. Individuals who request exclusion during
assignment to an MCO or within a time set by DMAS from the effective date of
their MCO enrollment, who have been diagnosed with a terminal condition and who
have a life expectancy of six months or less. The individual's physician must
certify the life expectancy; 12. Certain individuals between birth and age three
certified by the Department of Behavioral Health and Developmental Services as
eligible for services pursuant to Part C of the Individuals with Disabilities
Education Act (20 USC § 1471 et seq.) who are granted an exception by DMAS to
the mandatory managed care enrollment; 13. 11. Individuals who have an eligibility
period that is less than three months; 14. Individuals who are enrolled in the Commonwealth's Title
XXI SCHIP program; 15. 12. Individuals who have an eligibility
period that is only retroactive; and 16. 13. Children enrolled in the Virginia
Birth-Related Neurological Injury Compensation Program established pursuant to
Chapter 50 (§ 38.2-5000 et seq.) of Title 38.2 of the Code of Virginia.
C. Members enrolled with
a an MCO who
subsequently meet one or more of the criteria of subsection B of this section
during MCO enrollment shall be excluded from MCO participation as determined by
DMAS , with the exception of those who subsequently become participants in
the federal long-term care waiver programs, as otherwise defined elsewhere in
this chapter, for home-based and community-based Medicaid coverage (IFDDS, ID,
EDCD, Day Support, or Alzheimer's, or as may be amended from time to time).
These members shall receive acute and primary medical services via the MCO
and shall receive waiver services and related transportation to waiver services
via the fee-for-service program. Individuals excluded from mandatory managed care enrollment
shall receive Medicaid services under the current fee-for-service system. When
individuals no longer meet the criteria for exclusion, they shall be required
to enroll in the appropriate managed care program.
D. Individuals who are enrolled in localities that qualify for the rural exception may meet exclusion criteria if their PCP of record, as defined in 12VAC30-120-360, cannot or will not participate with the one MCO in the locality. Individual requests to be excluded from MCO participation in localities meeting the qualification for the rural exception must be made to DMAS for consideration on a case-by-case basis. Members enrolled in MCO rural exception areas shall not have open enrollment periods and shall not be afforded the 90-day window after initial enrollment during which they may make a health plan or program change.
Individuals excluded from Medallion mandatory managed care enrollment shall receive Medicaid services under the current fee-for-service system. When individuals no longer meet the criteria for exclusion, they shall be required to enroll in the appropriate managed care program.
Mandatory Medallion mandatory managed care
plans shall be offered to individuals, and individuals shall be enrolled in
those plans , exclusively through an. DMAS has sole responsibility for
determining enrollment in the contractor's plan. DMAS utilizes an
independent enrollment broker under contract to DMAS to assist members with
making plan choices after initial preassignment and during open enrollment.
An enrollment broker is an independent contractor that enrolls individuals in
the contractor's plan and is responsible for the operation and documentation of
a toll-free individual service helpline.
F. Members shall be enrolled as follows:
1. All eligible individuals, except those meeting one of the
of in subsection B of this section, shall be enrolled
in Medallion mandatory managed care.
2. Individuals shall receive a Medicaid card from DMAS and
shall be provided authorized medical care in accordance with
procedures after Medicaid eligibility has been determined to exist.
3. Once individuals are enrolled in Medicaid, they will receive
a letter indicating that they may select one of the contracted MCOs. These
letters shall indicate an assigned MCO, determined as provided in subsection
G of this section, in which the member will be enrolled if he does not
make a selection within a period specified by DMAS of not less than 30 days.
Members who are enrolled in one mandatory MCO program who immediately become
eligible for another mandatory MCO program are able to maintain consistent
enrollment with their the member's currently assigned MCO ,
if available. These members will receive a notification letter including
information regarding their ability to change health plans under the new
4. Any newborn whose mother is enrolled with an MCO at the time of birth shall be considered a member of that same MCO for the newborn enrollment period.
a. This requirement does not preclude the member, once
the member is assigned a Medicaid identification number, from disenrolling
from one MCO to enrolling with another in accordance with subdivision H 1 of
b. The newborn's continued enrollment with the MCO is not
contingent upon the mother's enrollment. Additionally, if the MCO's contract is
terminated in whole or in part, the MCO shall continue newborn coverage if the
child is born while the contract is active
, until the newborn receives a
Medicaid number or for the newborn enrollment period, whichever timeframe is
earlier. Newborns who remain eligible for participation in Medallion mandatory
managed care will be reenrolled in an MCO through the assignment process upon
receiving a Medicaid identification number.
c. Any newborn whose mother is enrolled in an MCO at the time of birth shall receive a Medicaid identification number prior to the end of the newborn enrollment period in order to maintain the newborn's enrollment in an MCO.
5. Individuals who lose then regain eligibility for Medallion mandatory managed care within 60 days will be reenrolled into their previous MCO without going through assignment and selection.
G. Individuals who do not select an MCO as described in subdivision F 3 of this section shall be assigned to an MCO as follows:
1. Individuals are assigned through a system algorithm based upon the member's history with a contracted MCO.
2. Individuals not assigned pursuant to subdivision 1 of this
subsection shall be assigned to the MCO of another family member
3. Individuals who live in rural exception areas as defined in 12VAC30-120-360 shall enroll with the one available MCO. These individuals shall receive an assignment notification for enrollment into the MCO. Individuals in rural exception areas who are assigned to the one MCO may request exclusion from MCO participation if their PCP of record, as defined in 12VAC30-120-360, cannot or will not participate with the one MCO in the locality. Individual requests to be excluded from MCO participation in rural exception localities must be made to DMAS for consideration on a case-by-case basis.
4. All other individuals shall be assigned to an MCO on a basis of approximately equal number by MCO in each locality.
5. All eligible members are automatically assigned to a
contracted MCO in their localities. Members are allowed 90 days after the
effective date of
new or initial enrollment to change to another MCO
that participates in the geographic area where the member lives. Members
residing in localities qualifying for a rural exception shall not be afforded
the 90-day window after initial enrollment during which they may make a health
plan or program change.
6. DMAS shall have the discretion to
an alternate strategy for enrollment or transition of enrollment from the
method described in this section for expansions, retractions, or changes to member
populations, geographical areas, procurements, or any or all of these; such
alternate strategy shall comply with federal waiver requirements. "Retractions"
means the departure of an enrolled managed care organization from any one or
more localities as provided in this section.
their the member's initial
enrollment into an MCO, members the member shall be restricted to
the MCO until the next open enrollment period, unless appropriately disenrolled
or excluded by the department (as, as defined in 12VAC30-120-360 ).
1. During the first 90
calendar days of enrollment in a
new or an initial MCO, a member may disenroll from that MCO to
enroll into another MCO for any reason. Such disenrollment shall be effective
no later than the first day of the second month after the month in which the
member requests disenrollment.
2. During the remainder of the enrollment period, the member may only disenroll from one MCO into another MCO upon determination by DMAS that good cause exists as determined under subsection J of this section.
I. The department shall conduct an annual open enrollment for
all Medallion mandatory managed care members with the exception of those
members who live in a designated rural exception area. The open enrollment
period shall be the 60
calendar days before the end of the enrollment
period. Prior to the open enrollment period, DMAS will inform the member of the
opportunity to remain with the current MCO or change to another MCO, without
cause, for the following year. Enrollment selections will be effective on the
first day of the next month following the open enrollment period. Members who
do not make a choice during the open enrollment period will remain with their
current MCO selection.
J. Disenrollment for cause may be requested at any time
and the disenrollment reasons shall be in accordance with 42 CFR 438.56
After the first 90 days of enrollment in an MCO, members
may request disenrollment from DMAS based on cause. The request may be made
orally or in writing to DMAS and shall cite the reason or reasons why the
member wishes to disenroll. Cause for disenrollment shall include be
in accordance with 42 CFR 438.56(d)(2), which includes the following reasons:
a. A member's desire to seek services from a federally qualified health center that is not under contract with the member's current MCO, and the member requests a change to another MCO that subcontracts with the desired federally qualified health center;
b. Performance or nonperformance of service to the member by
an MCO or one or more of its network providers that is deemed by the
DMAS external quality review organizations to be below the generally
accepted community practice of health care. This may include poor quality care;
c. Lack of access to a
PCP primary care physician
or necessary specialty services covered under the State Plan or lack of access
to network providers experienced in dealing with the member's health
d. A member has a combination of complex medical factors that, in the sole discretion of DMAS, would be better served under another contracted MCO;
e. The member moves out of the MCO's service area;
f. The MCO does not, because of moral or religious objections, cover the service the member seeks; or
g. The member needs related services to be performed at the
same time; not all related services are available within the network, and the
member's primary care provider or another provider determines that receiving
the services separately would subject the member to unnecessary risk
; or. h. Other reasons as determined by DMAS through written
2. DMAS shall determine whether cause exists for disenrollment.
Written responses shall be provided within a timeframe set by department policy;
however, the effective date of an approved disenrollment shall be no later than
the first day of the second month following the month in which the member files
, in compliance with 42 CFR 438.56.
3. Cause for disenrollment shall be deemed to exist and the disenrollment shall be granted if DMAS fails to take final action on a valid request prior to the first day of the second month after the request.
4. The DMAS determination concerning cause for disenrollment
may be appealed by the member in accordance with the
client appeals process at 12VAC30-110-10 through 12VAC30-110-370.
5. The current MCO shall provide
, within two working
days of a request from DMAS , information necessary to determine cause.
6. Members enrolled with
a an MCO who
subsequently meet one or more of the exclusions in subsection B of this section
during MCO enrollment shall be excluded from Medallion as determined
appropriate by DMAS , with the exception of those who subsequently become
individuals participating in the IFDDS, ID, EDCD, Day Support, or Alzheimer's
federal waiver programs for home-based and community-based Medicaid coverage.
These members shall receive acute and primary medical services via the MCO and
shall receive waiver services and related transportation to waiver services via
the fee-for-service program.
K. In accordance with 42 CFR 438.3(q)(5) and 42 CFR 438.56(c)(2), a member has the right to disenroll from the contractor's plan without cause at the following times:
1. During the 90 days following the date of the member's initial enrollment into the MCO or during the 90 days following the date DMAS sends the member notice of that enrollment, whichever is later.
2. At least once every 12 months thereafter.
3. Upon automatic reenrollment under subsection G of this section if the temporary loss of Medicaid eligibility has caused the beneficiary to miss the annual disenrollment opportunity.
4. When DMAS imposes the intermediate sanction specified in 42 CFR 438.702(a)(4).
12VAC30-120-380. Medallion MCO responsibilities.
A. The MCO shall provide, at a minimum, all medically
necessary covered services provided under the State Plan for Medical Assistance
and further defined by written
DMAS federal and state
regulations, the Medallion contract, policies, and instructions,
except as otherwise modified or excluded in this part.
1. Nonemergency services provided by hospital emergency departments shall be covered by MCOs in accordance with rates negotiated between the MCOs and the hospital emergency departments.
2. Services that shall be provided outside the MCO network
, but are not limited to, those services identified and
defined by the contract between DMAS and the MCO. Services reimbursed by DMAS
include dental and orthodontic services for children up to age younger
than 21 ; for all others years of age, dental services for
others (as described in 12VAC30-50-190 ), and school
health services , community mental health services (12VAC30-50-130 and
12VAC30-50-226); early intervention services provided pursuant to Part C of the
Individuals with Disabilities Education Act (IDEA) of 2004 (as defined in
12VAC30-50-131 and 12VAC30-50-415); and long-term care services provided
under the § 1915(c) home-based and community-based waivers including related
transportation to such authorized waiver services.
3. The MCOs shall pay for emergency services and family planning services and supplies whether such services are provided inside or outside the MCO network.
EPSDT Early and periodic screening, diagnostic,
and treatment (EPSDT) services shall be covered by the MCO and defined by
the contract between DMAS and the MCO. The MCO shall have the authority to
determine the provider of service for EPSDT screenings.
C. The MCOs shall report data to DMAS under the contract requirements, which may include data reports, report cards for members, and ad hoc quality studies performed by the MCO or third parties.
D. Documentation requirements.
1. The MCO shall
maintain records as required by federal and
state law and regulation and by DMAS policy comply with the records
retention requirements as outlined in the contract. The MCO shall furnish
such required information to DMAS, the Attorney General of Virginia or his
authorized representatives, or the State Medicaid Fraud Control Unit on request
and in the form requested.
2. Each MCO shall
have written policies regarding member
rights and shall comply with any applicable federal and state laws that pertain
to member rights and shall ensure that its staff and affiliated providers take
those rights into account when furnishing services to members in accordance
with 42 CFR 438.100. comply with the member rights and protections
stipulated in the contract and as identified in 42 CFR 438 Subpart C.
E. The MCO shall comply with the contract and 42 CFR 438 Subparts E and H to ensure that the health care provided to its members meets all applicable federal and state mandates, community standards for quality, and standards developed pursuant to the DMAS managed care quality program.
F. The MCOs shall promptly provide or arrange for the
provision of all required services as specified in the contract between the
Commonwealth and the MCO. Medical evaluations shall be available within 48
hours for urgent care and within 30
calendar days for routine care.
On-call clinicians shall be available 24 hours per day, seven days per week.
G. The MCOs shall meet the standards specified in 42 CFR 438, Subpart D by DMAS for sufficiency of provider networks as specified in the contract between the Commonwealth and the MCO.
H. Each MCO and its subcontractors shall have in place
and follow , written policies and procedures for processing requests for
initial and continuing authorizations of service. Each MCO and its subcontractors
shall ensure that any decision to deny a service authorization request or to
authorize a service in an amount, duration, or scope that is less than
requested , be made by a health care professional who has appropriate
clinical expertise in treating the member's condition or disease. Each MCO and
its subcontractors shall have in effect mechanisms to ensure consistent
application of review criteria for authorization decisions and shall consult
with the requesting provider when appropriate.
I. In accordance with 42 CFR 447.50 through 42 CFR
447.90, MCOs shall not impose any cost sharing obligations on members
except as set forth in 12VAC30-20-150 and 12VAC30-20-160.
J. An MCO may not prohibit
, or otherwise restrict ,
a health care professional acting within the lawful scope of practice ,
from advising or advocating on behalf of a member who is his patient in
accordance with 42 CFR 438.102.
K. An MCO that would otherwise be required to reimburse for or provide coverage of a counseling or referral service is not required to do so if the MCO objects to the service on moral or religious grounds and furnishes information about the service it does not cover in accordance with 42 CFR 438.102.
12VAC30-120-390. Payment rate for MCOs.
The payment rate to MCOs that participate in the Medallion
mandatory managed care program shall be set by negotiated contracts and in
accordance with 42 CFR
438.6 438.4 through 42 CFR 438.8 and other
pertinent federal regulations.
Payment Preauthorized, emergency, and
post-stabilization services and payment rate for preauthorized or
emergency care provided by out-of-network providers.
The MCOs shall pay for preauthorized
emergency, and post-stabilization services when provided outside the
MCO network to members in compliance with the contract and 42 CFR
438.114. Preauthorized or, emergency, and post-stabilization
services provided to a managed care member by a provider or facility not
participating in the MCO's network will be reimbursed according to the current
Medicaid fee schedule. This reimbursement shall be considered payment in full
to the provider or facility of emergency services.
12VAC30-120-400. Quality control and utilization review.
A. DMAS shall rigorously monitor the quality of care provided
by the MCOs. DMAS
may contract with one or more external quality review organizations
to perform focused studies on the quality of care provided by the MCOs. The
external organizations may utilize data or other tools to ensure contract
compliance and quality improvement activities. Specifically and the MCOs
shall comply with (i) the contract; (ii) 42 CFR 438 Subpart E, entitled Quality
Measurement and Improvement: External Quality Review; and (iii) the MCO
standards identified in 42 CFR 438 Subpart D, entitled MCO, PIHP, and PAHP
Standards. DMAS shall monitor the MCOs to determine if the MCO:
their compliance with the contract, 42 CFR Subpart A, and all other relevant
sections of 42 CFR Part 438 (Managed Care) as follows:
Fails If the MCO fails substantially to
provide the medically necessary items and services required under law or under
the contract to be provided to an enrolled recipient and the failure has
adversely affected (or has substantial likelihood of adversely affecting )
Engages If the MCO engages in any practice
that discriminates against individuals on the basis of their health status or
requirements for health care services, including expulsion or refusal to
reenroll an individual, or any practice that could reasonably be expected to
have the effect of denying or discouraging enrollment (except as permitted by §
1903(m) of the Social Security Act (42 USC § 1396b(m)) ) by eligible
individuals whose medical conditions or histories indicate a need for
substantial future medical services.
Misrepresents If the MCO misrepresents or
falsifies information that it furnishes, under § 1903(m) of the Social
Security Act (42 USC § 1396b(m)) to CMS, DMAS, an individual, or any other
Fails If the MCO fails to comply with the
requirements of 42 CFR 417.479(d) through 42 CFR 417.479(g) relating to
physician incentive plans , or fails to submit to DMAS its physician
incentive plans as required or requested in 42 CFR 434.70.
Imposes If the MCO imposes on members premiums
or charges that are in excess of the premiums or charges permitted under the Medicaid
B. DMAS shall ensure that data on performance and patient results are collected.
C. DMAS shall ensure that quality outcomes information is
provided to MCOs. DMAS shall ensure that changes
which that are
determined to be needed as a result of quality control or utilization review
A. If DMAS determines that an MCO is not in compliance with
applicable state or federal laws
, or regulations (including but
not limited to the requirements of or pursuant to 12VAC30-120-380 E §
1932(e)(1) of the Social Security Act (the Act), 12VAC30-120-380, or 42 CFR
438 , Subpart I) , or the MCO contract, DMAS may impose sanctions
on the MCO pursuant to § 1932(e) of the Act and this section. The
sanctions may include , but are not limited to:
1. Limiting enrollments in the MCO by freezing voluntary member enrollments;
2. Freezing DMAS assignment of members to the MCO;
3. Limiting MCO enrollment to specific areas;
4. Denying, withholding, or retracting payments to the MCO;
5. Terminating the MCO's contract as provided in § 1932(e)(4) of the Act;
6. Intermediate sanctions including, but not limited to, the
maximum civil money penalties specified in 42 CFR Part 438, Subpart I, for the
violations set forth therein, or in accordance therewith; and 7. 6. Civil monetary penalties as specified in 42
CFR 438.704; and
7. Appointment of temporary management for an MCO as provided in 42 CFR 438.706.
B. In the case of an MCO that has repeatedly failed to meet
the requirements of §§ 1903(m) and
1932 1932(e) of the Social
Security Act, DMAS shall, regardless of what other sanctions are imposed,
impose the following sanctions:
1. Appoint a temporary manager to:
a. Oversee the operation of the Medicaid managed care organization upon a finding by DMAS that there is continued egregious behavior by the organization or there is a substantial risk to the health of members; or
Assure Ensure the health of the
organization's members if there is a need for temporary management while (i)
there is an orderly termination or reorganization of the organization or (ii)
improvements are made to remedy the violations found under subsection A of this
section. Temporary management under this subdivision may not be terminated
until DMAS has determined that the MCO has the capability to ensure that the
violations shall not recur.
2. Permit members who are enrolled with the MCO to disenroll without cause. If this sanction is imposed, DMAS shall be responsible for notifying such members of the right to disenroll.
C. Prior to terminating a contract as permitted under
A 5 of this section, § 1932(e)(4) of the Act, DMAS shall provide the
MCO with a hearing. DMAS shall not provide an MCO with a pretermination predetermination
hearing before the appointment of a temporary manager under subdivision B 1 of
D. Prior to imposing any sanction other than termination of the MCO's contract, DMAS shall provide the MCO with notice, develop procedures with which the MCO must comply to eliminate specific sanctions, and provide such other due process protections as the Commonwealth may provide.
E. In accordance with the terms of the contract, MCOs shall
have the right to appeal any adverse action taken by DMAS. For appeal
procedures not addressed by the contract, the MCO shall proceed in accordance
with the appeals provisions of the Virginia Public Procurement Act (§ 2.2-4300
et seq. of the Code of Virginia). Pursuant to §§ 2.2-4364 and 2.2-4365 of the
Code of Virginia, DMAS shall establish an administrative appeals procedure through
which the MCO may elect to appeal decisions on disputes arising during the
performance of its contract. Pursuant to § 2.2-4365 of the Code of Virginia,
such appeal shall be heard by a hearing officer; however, in no event shall the
hearing officer be an employee of DMAS. In conducting the administrative
appeal, the hearing officer shall follow the hearing procedure used in §
2.2-4020 of the Code of Virginia. F. When DMAS determines that an MCO committed one of the
violations specified in 12VAC30-120-400 A, DMAS shall implement the provisions
of 42 CFR 434.67. 1. Any sanction imposed pursuant to this subsection shall be
binding upon the MCO. 2. The MCO shall have the appeals rights for any sanction
imposed pursuant to this subsection as specified in 42 CFR 434.67.
12VAC30-120-420. Member grievances and appeals.
A. The MCOs shall
, whenever a member's request for covered
services is reduced, denied or terminated, or payment for services is denied,
provide a written notice in accordance with the notice provisions specified in
42 CFR 438.404 and 42 CFR 438.210(c), as defined by comply with (i) the
Grievance and Appeal System as identified in 42 CFR 438 Subpart F, (ii) the
Enrollee Rights and Protections requirements in 42 CFR 438 Subpart C, (iii)
the Medallion contract between DMAS and the MCO, and (iv) any
other applicable state or federal statutory or regulatory requirements.
B. MCOs shall
, at (i) the initiation of either
new member enrollment or, (ii) the initiation of new provider/subcontractor
provider or subcontractor contracts, or at (iii) the
request of the member, provide to every member the information described in 42
CFR 438.10(g) concerning grievance/appeal grievance and appeal
rights and procedures.
C. Disputes between the MCO and the member concerning any
aspect of service delivery, including medical necessity and specialist
referral, shall be resolved through a verbal or written
grievance or appeals process operated by the MCO or through the DMAS
appeals process. A provider or other representative who has the member's
written consent may act on behalf of a member in the MCO grievance/appeals
grievance or appeals or the DMAS appeals process.
1. The member, provider, or representative acting on behalf of
the member with the member's written consent may file an oral or written
grievance or internal appeal with the MCO. The MCO must accept
or appeals filed at any time. Internal appeal requests
must be submitted within 30 60 days from the date of the
notice of adverse action benefit determination. Oral requests for
internal appeals must be followed up in writing within 10 business
days by the member, provider, or the representative acting on behalf of the
member with the member's consent, unless the request is for an expedited internal
appeal. The member may also file a written request for a standard or
expedited appeal with the DMAS Appeals Division within 30 days of the member's
receipt of the notice of adverse action, in accordance with 42 CFR 431, Subpart
E; 42 CFR Part 438, Subpart F; and 12VAC30-110-10 through 12VAC30-110-370.
2. The member must exhaust the MCO's internal appeals process before appealing to the DMAS Appeals Division. The member may also file a written request for a standard or expedited internal appeal of the MCO's adverse benefit determination with the DMAS Appeals Division within 120 days of the member's receipt of the MCO's internal appeal decision, in accordance with 42 CFR 431 Subpart E; 42 CFR Part 438 Subpart F; and 12VAC30-110-10 through 12VAC30-110-370.
3. As specified in 12VAC30-110-100, pending the
resolution of a grievance, internal appeal, or appeal filed by a member
or his representative (including a provider acting on behalf of the member) prior
to the effective date of the adverse benefit determination, coverage shall
not be terminated or reduced for the member for any reason
is the subject of the grievance or appeal. 3. 4. The MCO shall ensure that the employees
or agents who make decisions on MCO grievances and appeals were not involved in
any previous level of review or decision making, and neither the
individuals nor agents, nor a subordinate of any such individual, who makes
decisions on grievances and internal appeals were involved in any previous
level of review or decision making. Additionally, where the reason for the
grievance or internal appeal involves clinical issues , or
relates to a denial or of a request for an expedited appeal, or
where the appeal is based on a lack of medical necessity, the MCO shall
ensure that the decision makers are health care professionals with the
appropriate clinical expertise in treating the member's condition or disease.
5. The MCO shall provide the member and any representative a reasonable opportunity in person and in writing to present evidence and testimony and to make legal and factual arguments in accordance with 42 CFR 438.406(b)(4). The MCO shall inform the member of the limited time available for this sufficiently in advance of the resolution timeframe for appeals in accordance with 42 CFR 438.406(b)(4).
6. The MCO shall provide the member and any representative the member's case file, including medical records, and any new or additional evidence considered, relied upon, or generated by the MCO in connection with the appeal of the adverse benefit determination. This information must be provided free of charge and sufficiently in advance of the resolution timeframe for appeals in accordance with 42 CFR 438.406(b)(5).
D. The MCO shall develop written materials describing the
grievance or appeals system and its procedures and operation.
E. The MCO shall maintain a recordkeeping, reporting,
and tracking system for complaints, grievances, and appeals that
complies with the Medallion contract between DMAS and the MCO. The system
shall include a copy of the original complaint, grievance, or internal
appeal; the decision; and the nature of the decision; and data on the
number of internal appeals filed, the average time to resolve internal appeals,
and the total number of internal appeals open as of the reporting date.
This system shall distinguish Medicaid from commercial members , if the
MCO does not have a separate system for Medicaid members.
F. At the time of enrollment and at the time of any adverse
benefit determination, the MCO shall notify the member , in
writing , that:
Medical necessity, specialist referral or other service
delivery issues An adverse benefit determination may be resolved
through a system of grievances and appeals, first within the MCO or
and then through the DMAS client appeals process;
2. Members have the right to request an expedited internal
directly to DMAS;
3. Members shall exhaust their internal appeals with the MCO before being given the right to appeal to DMAS; and
4. The MCO shall promptly provide grievance or appeal forms, reasonable assistance, and written procedures to members who wish to register written grievances or appeals, including auxiliary aids and services upon request such as providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability.
G. The MCO shall issue
grievance/appeal grievance or
internal appeal decisions as defined by 42 CFR 438.408 and the
contract between DMAS and the MCO. Oral grievance decisions are not required to
be in writing.
H. The MCO shall issue standard internal appeal
decisions within 30 days from the date of initial receipt of the internal
appeal in accordance with 42 CFR 438.408 and as defined by the Medallion
contract between DMAS and the MCO. This timeframe may be extended by up to
14 days under the requirements of 42 CFR 438.408. The internal
appeal decision shall be in writing and shall include
, but shall not be
limited to, the following:
1. The decision reached, the results, and the date of the decision reached by the MCO;
2. The reasons for the decision;
3. The policies or procedures that provide the basis for the decision;
A clear explanation of further appeal rights and a
timeframe for filing an appeal; and For internal appeals not resolved
wholly in favor of the member:
a. A clear explanation of further appeal rights and a timeframe for filing an internal appeal; and
b. The right to continue to receive benefits in accordance with 42 CFR 438.420 pending a hearing and how to request continuation of benefits.
The member may be held liable for the cost of those benefits if the hearing decision upholds the contractor's adverse benefit determination.
5. For appeals that involve the termination, suspension, or
reduction of a previously authorized course of treatment, the right to continue
to receive benefits in accordance with 42 CFR 438.420 pending a hearing, and
how to request continuation of benefits.
I. An expedited appeal decision shall be issued as
expeditiously as the member's condition requires and within
days 72 hours from receipt of the internal appeal request in cases
of medical emergencies in which delay could result in death or serious injury
to a member. Extensions to these timeframes shall be allowed in accordance with
42 CFR 438.408 and as defined by the Medallion contract between DMAS and
the MCO. Written confirmation of the decision shall promptly follow the verbal
notice of the expedited decision.
J. If the MCO fails to adhere to the internal appeals notice and timing requirements of this section, the member is deemed to have exhausted the MCO's internal appeals process and may file an internal appeal with DMAS.
K. Any adverse benefit determination upheld in whole
or in part by the internal appeal decision issued by the MCO may be
appealed by the member to DMAS in accordance with the
Appeals DMAS appeals regulations at 12VAC30-110-10 through 12VAC30-110-370.
DMAS shall conduct an evidentiary hearing in accordance with the Client Appeals
regulations at 12VAC30-110-10 through 12VAC30-110-370 and shall not base any
appealed decision on the record established by any internal appeal decision
of the MCO. The MCO shall comply with the DMAS appeal decision. The DMAS
decision in these matters shall be final and shall not be subject to appeal by
the MCO. K. L. The MCO shall provide information
necessary for any DMAS appeal within timeframes established by DMAS.
to 12VAC30-120-440. [Reserved] Provider
grievances, reconsiderations, and appeals.
A. The MCOs shall comply with the requirements of the Administrative Process Act (§§ 2.2-4000 et seq. of the Code of Virginia), the provider appeals regulations at 12VAC30-20-500 through 12VAC30-20-560, the Medallion contract between DMAS and the MCO, and any other applicable state or federal statutory or regulatory requirements.
B. The MCOs shall have a grievance system established to respond to grievances made by network providers. Network provider grievances are not appealable to the DMAS Appeals Division.
C. MCOs shall, at the initiation of new network provider contracts, provide to every network provider the information described in this section concerning grievance, reconsideration, and appeal rights and procedures.
D. Disputes between the MCO and the network provider concerning any aspect of reimbursement shall be resolved through a verbal or written grievance or reconsideration process operated by the MCO or through the DMAS appeals process. A network provider or representative that is authorized by the network provider may act on behalf of a network provider in the MCO grievance or reconsideration or the DMAS appeals process.
E. Disputes arising solely from the MCO's denial or termination of a provider's enrollment in the MCO's network are not appealable to the DMAS Appeals Division.
F. If a network provider has rendered services to a member and has been denied authorization or reimbursement for the services or has received reduced authorization or reimbursement, that provider may request a reconsideration of the denied or reduced authorization or reimbursement. Before appealing to DMAS, network providers must first exhaust all MCO reconsideration processes. The MCO's final denial letter must include a statement that the provider has exhausted its reconsideration rights with the MCO and that the next level of appeal is with DMAS. The final denial letter must include the appeal rights to DMAS in accordance with the provider appeals regulations at 12VAC30-20-500 through 12VAC30-20-560.
G. All network provider appeals to DMAS must be submitted to the DMAS Appeals Division in writing and within 30 days of the MCO's last date of denial.
H. The MCO shall provide information necessary for any DMAS appeal within timeframes established by DMAS.
I. The MCO shall comply with the DMAS appeal decision. A DMAS appeal decision is not appealable by the MCO.
J. The MCO shall maintain a recordkeeping, reporting, and tracking system for complaints, grievances, and reconsiderations that complies with the Medallion contract between DMAS and the MCO. The system shall include a copy of the original complaint, grievance, or reconsideration; the decision; the nature of the decision; and data on the number of reconsiderations filed, the average time to resolve reconsiderations, and the total number of reconsiderations open as of the reporting date.