12VAC30-60-500. Disease management services.
A. The State elects to provide Secretary-approved coverage as appropriate for the population served under Section 1937 of the Social Security Act. Virginia's disease management program is designed to help patients better understand and manage their condition(s) through prevention, education, lifestyle changes, and adherence to their prescribed plan of care (POC). The purpose of the program is not to offer medical advice, but rather to support providers in reinforcing patients' POCs.
1. The State shall provide the alternative benefit package to individuals who voluntarily enroll in the program ("opt-in"). Individuals shall be informed of the available benefit options prior to having the option to voluntarily enroll. Opt-in alternative coverage will be provided as follows:
a. Individuals who choose to participate in the opt-in program maintain eligibility for the regular Medicaid benefits at all times.
b. All individuals in fee-for-service who are determined to have asthma, congestive heart failure and are aged 21 years or older, coronary artery disease and are age 21 years or older, chronic obstructive pulmonary disease (COPD) and are aged 21 years or older, and/or diabetes, except for the following: (i) those who have third party insurance coverage; (ii) those enrolled in a Medicaid managed care organization; and (iii) those who reside in institutional settings.
c. The State shall inform each individual that such enrollment is voluntary, that such individual may opt out of such alternative benefit package at any time and maintain eligibility for the standard Medicaid program under the State plan.
d. Individuals are encouraged to participate in the program through mailings and telephonic outreach by the disease management program administrator.
C. Benchmark Benefits: in addition to all regular Medicaid program benefits, the alternative benefit package includes at least the following disease management services:
1. ongoing condition-specific education;
2. access to a 24 hour nurse call line;
3. regularly scheduled telephonic condition management, support and referrals (for individuals identified by the Agency as having more acute or intensive health care needs);
4. monitoring patient health activity and providing informational feedback to primary care physicians to help facilitate changes to patients' plans of care pursuant to the provision of disease management services (for individuals identified by the Agency as having more acute or intensive health care needs);
5. the opt-in program adds additional chronic condition disease management services for individuals diagnosed with one of the covered conditions.
D. Geographical classification: services under this alternative benefit package are available statewide.
E. Service delivery system: alternative benefits will be offered through a Prepaid Ambulatory Health Plan, under contract with the State. All other Medicaid State Plan services shall be provided on a fee-for-service basis.
F. Additional Assurances
1. The State assures that individuals will have access, through benchmark coverage, benchmark-equivalent coverage, or otherwise, to Rural Health Clinic (RHC) services and Federally Qualified Health Center (FQHC) services as defined in subparagraphs (B) and (C) of section 1905(a)(2).
2. The State assures that payment for Rural Health Clinic (RHC) and Federally Qualified Health Clinic (FQHC) services is made in accordance with the requirements of section 1902(bb).
G. Cost effectiveness of plans: benchmark or benchmark-equivalent coverage and any additional benefits are provided in accordance with economy and efficiency principles.
H. Compliance with the law: The State will continue to comply with all other provisions of the Social Security Act in the administration of the State's disease management program under this chapter.