The following words and terms when used in this part shall have the following meanings unless the context clearly indicates otherwise:
"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).
"Appeal" means a request for review of an action, as "action" is defined in this section.
"Area of residence" means the recipient's address in the Medicaid eligibility file.
"Capitation payment" means a payment the department makes periodically to a contractor on behalf of each recipient enrolled under a contract for the provision of medical services under the State Plan, regardless of whether the particular recipient receives services during the period covered by the payment.
"Client," "clients," "recipient," "enrollee," or "participant" means an individual or individuals having current Medicaid eligibility who shall be authorized by DMAS to be a member or members of Medallion II.
"Covered services" means Medicaid services as defined in the State Plan for Medical Assistance.
"Disenrollment" means the process of changing enrollment from one Medallion II Managed Care Organization (MCO) plan to another MCO or to the Primary Care Case Management (PCCM) program, 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.
"Enrollment broker" means an independent contractor that enrolls recipients in the contractor's plan and is responsible for the operation and documentation of a toll-free recipient service helpline. The responsibilities of the enrollment broker include, but shall not be limited to, recipient education and MCO enrollment, assistance with and tracking of recipients' complaints resolutions, and may include recipient marketing and outreach.
"Exclusion from Medallion II" means the removal of an enrollee from the Medallion II program on a temporary or permanent basis.
Quality Review Organization"
(EQRO) is 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 [ EQR
external quality review ] related activities as set forth in 42 CFR
438.358, or both.
"Foster care" is a program in which a child receives either foster care assistance under Title IV-E of the Social Security Act or state and local foster care assistance.
"Grievance" means an expression of dissatisfaction about any matter other than an action, as "action" is defined in this section.
"Health care plan" means any arrangement in which any managed care organization undertakes to provide, arrange for, pay for, or reimburse any part of the cost of any health care services.
"Health care professional" means a provider as defined in 42 CFR 438.2.
"Managed care organization" or "MCO" means an 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 Medallion II program. Covered services for Medallion II individuals must be as accessible (in terms of timeliness, amount, duration, and scope) as compared to other Medicaid recipients served within the area.
"Network" means doctors, hospitals or other health care providers who participate or contract with an MCO and, 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.
"Nonparticipating provider" means a health care entity or health care professional not in the contractor's participating provider network.
"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.
"Post-stabilization care services" means covered services related to an emergency medical condition that are provided after an enrollee is stabilized in order to maintain the stabilized condition or to improve or resolve the enrollee's condition.
"Potential enrollee" means a Medicaid recipient who is subject to mandatory enrollment or may voluntarily elect to enroll in a given managed care program, but is not yet an enrollee of a specific MCO or PCCM.
"Primary care case management" or "PCCM" means a system under which a primary care case manager contracts with the Commonwealth to furnish case management services (which include the location, coordination, and monitoring of primary health care services) to Medicaid recipients.
"Retractions" means the departure of an enrolled managed care organization from any one or more localities as provided for in 12VAC30-120-370.
"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 Medallion II members are mandated to enroll in the one available contracted MCO.
"School health services" means those physical
therapy, occupational therapy, speech therapy, nursing, psychiatric and
psychological services rendered to children who qualify for these services
under the federal Individuals with Disabilities Education Act (20 USC § 1471 et
seq.) by (i) employees of the school divisions or (ii) providers that
subcontract with school divisions, as described in [
"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.
12VAC30-120-370. Medallion II enrollees.
A. DMAS shall determine enrollment in Medallion II. Medicaid eligible persons not meeting the exclusion criteria set out in this section must participate in the Medallion II program. Enrollment in Medallion II is not a guarantee of continuing eligibility for services and benefits under the Virginia Medical Assistance Services Program. DMAS reserves the right to exclude from participation in the Medallion II managed care program any recipient 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. Recipients excluded from Medallion II through this provision may appeal the decision to DMAS.
B. The following individuals shall be excluded (as defined in
12VAC30-120-360) from participating in Medallion II
or will be disenrolled
from Medallion II if any of the following apply. Individuals not meeting the
exclusion criteria must participate in the Medallion II program. as
defined in the § 1915(b) managed care waiver. Individuals excluded from
Medallion II 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
mentally retarded intellectually disabled ];
3. Individuals who are placed on spend-down;
4. Individuals who are participating in the family planning waiver, or in federal waiver programs for home-based and community-based Medicaid coverage prior to managed care enrollment;
5. Individuals who are participating in foster care or subsidized adoption programs;
6. Individuals under age 21 who are either enrolled in DMAS authorized treatment foster care programs as defined in 12VAC30-60-170 A, or who are approved for DMAS residential facility Level C programs as defined in 12VAC30-130-860;
7. 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 (e.g., physician, hospital, midwife) does not participate with the enrollee's assigned MCO. Exclusion requests made during the third trimester may be made by the recipient, 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;
8. Individuals, other than students, who permanently live outside their area of residence for greater than 60 consecutive days except those individuals placed there for medically necessary services funded by the MCO;
9. Individuals who receive hospice services in accordance with DMAS criteria;
10. 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);
11. 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 recipients admitted to the hospital while already enrolled in a department-contracted MCO;
12. Individuals who request exclusion during preassignment 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 client's physician must certify the life expectancy;
13. Certain individuals between birth and age three certified
by the Department of
Mental Health, Mental Retardation and Substance Abuse
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 Medallion
14. Individuals who have an eligibility period that is less than three months;
15. Individuals who are enrolled in the Commonwealth's Title XXI SCHIP program;
16. Individuals who have an eligibility period that is only retroactive; and
17. 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. Individuals enrolled with a MCO who subsequently meet one
or more of the aforementioned criteria during MCO enrollment shall be excluded
from MCO participation as determined by DMAS, with the exception of those who
subsequently become recipients in the federal long-term care waiver programs,
as otherwise defined elsewhere in this chapter, for home-based and
community-based Medicaid coverage (AIDS, IFDDS, MR, EDCD, Day Support, or
Alzheimer's, or as may be amended from time to time). These individuals
shall receive acute and primary medical services via the MCO and shall receive
waiver services and related transportation to waiver services via the
Individuals excluded from mandatory managed care enrollment shall receive Medicaid services under the current fee-for-service system. When enrollees 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. Recipients 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 mandatory managed care enrollment shall receive Medicaid services under the current fee-for-service system. When enrollees no longer meet the criteria for exclusion, they shall be required to enroll in the appropriate managed care program.
D. E. Medallion II managed care plans shall be
offered to recipients, and recipients shall be enrolled in those plans,
exclusively through an independent enrollment broker under contract to DMAS. E. F. Clients shall be enrolled as follows:
1. All eligible persons, except those meeting one of the exclusions of subsection B of this section, shall be enrolled in Medallion II.
2. Clients shall receive a Medicaid card from DMAS, and shall be provided authorized medical care in accordance with DMAS' 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 a preassigned MCO, determined as provided in subsection F of this section, in which the client will be enrolled if he does not make a selection within a period specified by DMAS of not less than 30 days. Recipients 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 currently assigned MCO, if available. These recipients will receive a notification letter including information regarding their ability to change health plans under the new program.
4. Any newborn whose mother is enrolled with an MCO at the time
of birth shall be considered an enrollee of that same MCO for the newborn
The newborn enrollment period is defined as the birth
month plus two months following the birth month. This requirement does not
preclude the enrollee, once he is assigned a Medicaid identification number,
from disenrolling from one MCO to another in accordance with subdivision G
H 1 of this section.
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. Infants who do not receive a Medicaid identification number prior to the end of the newborn enrollment period will be disenrolled. Newborns who remain eligible for participation in Medallion II will be reenrolled in an MCO through the preassignment process upon receiving a Medicaid identification number.
5. Individuals who lose then regain eligibility for Medallion II within 60 days will be reenrolled into their previous MCO without going through preassignment and selection.
F. G. Clients who do not select an MCO as
described in subdivision E 3 F 3 of this section shall be
assigned to an MCO as follows:
1. Clients are assigned through a system algorithm based upon the client's history with a contracted MCO.
2. Clients not assigned pursuant to subdivision 1 of this subsection shall be assigned to the MCO of another family member, if applicable.
3. Clients who live in rural exception areas as defined in 12VAC30-120-360 must enroll with the one available MCO. These persons shall receive a preassignment 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.
3. 4. All other clients shall be assigned to an
MCO on a basis of approximately equal number by MCO in each locality. 4. In areas where there is only one contracted MCO,
recipients have a choice of enrolling with the contracted MCO or the PCCM
program. All eligible recipients in areas where one contracted MCO
exists, however, are automatically assigned to the contracted MCO. Individuals
are allowed 90 days after the effective date of new or initial enrollment to
change from either the contracted MCO to the PCCM program or vice versa.
5. Recipients in areas where there is only one contracted MCO and the PCCM program are automatically assigned to the contracted MCO, but are allowed 90 days after the effective date of new or initial enrollment to change from either the contracted MCO to the PCCM program, or vice versa. Recipients residing in localities qualifying for rural exception shall not be afforded the 90-day window after initial enrollment during which they may make a health plan or program change.
5. 6. DMAS shall have the discretion to utilize
an alternate strategy for enrollment or transition of enrollment from the
method described in this section for expansions, retractions, or changes
to new client populations, new geographical areas, expansion
through procurement procurements, or any or all of these; such
alternate strategy shall comply with federal waiver requirements. G. H. Following their initial enrollment into an
MCO or PCCM program, recipients shall be restricted to the MCO or PCCM program
until the next open enrollment period, unless appropriately disenrolled or
excluded by the department (as defined in 12VAC30-120-360).
1. During the first 90 calendar days of enrollment in a new or initial MCO, a client may disenroll from that MCO to enroll into another MCO or into PCCM, if applicable, for any reason. Such disenrollment shall be effective no later than the first day of the second month after the month in which the client requests disenrollment.
2. During the remainder of the enrollment period, the client may only disenroll from one MCO into another MCO or PCCM, if applicable, upon determination by DMAS that good cause exists as determined under subsection I of this section.
H. I. The department shall conduct an annual
open enrollment for all Medallion II participants with the exception of
those clients 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 recipient of
the opportunity to remain with the current MCO or change to another MCO,
without cause, for the following year. In areas with only one contracted MCO and
where the PCCM program is available, recipients will be given the
opportunity to select either the MCO or the PCCM program. Enrollment selections
will be effective on the first day of the next month following the open
enrollment period. Recipients who do not make a choice during the open
enrollment period will remain with their current MCO selection. I. J. Disenrollment for cause may be requested
at any time.
1. After the first 90 days of enrollment in an MCO, clients must request disenrollment from DMAS based on cause. The request may be made orally or in writing to DMAS and must cite the reasons why the client wishes to disenroll. Cause for disenrollment shall include the following:
a. A recipient's desire to seek services from a federally qualified health center which is not under contract with the recipient's current MCO, and the recipient (i) requests a change to another MCO that subcontracts with the desired federally qualified health center or (ii) requests a change to the PCCM, if the federally qualified health center is contracting directly with DMAS as a PCCM;
b. Performance or nonperformance of service to the recipient by an MCO or one or more of its providers which is deemed by the department's 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 or necessary specialty services covered under the State Plan or lack of access to providers experienced in dealing with the enrollee's health care needs;
d. A client has a combination of complex medical factors that, in the sole discretion of DMAS, would be better served under another contracted MCO or PCCM program, if applicable, or provider;
e. The enrollee moves out of the MCO's service area;
f. The MCO does not, because of moral or religious objections, cover the service the enrollee seeks;
g. The enrollee needs related services to be performed at the same time; not all related services are available within the network, and the enrollee's primary care provider or another provider determines that receiving the services separately would subject the enrollee to unnecessary risk; or
h. Other reasons as determined by DMAS through written policy directives.
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 enrollee files the request, 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 client in accordance with the department's client appeals process at 12VAC30-110-10 through 12VAC30-110-380.
5. The current MCO shall provide, within two working days of a request from DMAS, information necessary to determine cause.
6. Individuals enrolled with a MCO who subsequently meet one or
more of the exclusions in subsection B of this section during MCO enrollment
disenrolled excluded as appropriate by DMAS, with the
exception of those who subsequently become recipients into the AIDS, IFDDS, MR
MR/ID, EDCD, Day Support, or Alzheimer's federal waiver programs for
home-based and community-based Medicaid coverage. These individuals 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
enrollees no longer meet the criteria for exclusion, they shall be required to
enroll in the appropriate managed care program.
12VAC30-120-380. Medallion II 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 regulations, 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 emergency departments.
2. Services that shall be provided outside the MCO network shall include, but are not limited to, those services identified and defined by the contract between DMAS and the MCO. Services reimbursed by DMAS include, but shall not be limited to, dental and orthodontic services for children up to age 21; for all others, dental services (as described in 12VAC30-50-190), school health services (as defined in 12VAC30-120-360), community mental health services (rehabilitative, targeted case management and the following substance abuse treatment services: emergency services (crisis); intensive outpatient services; day treatment services; substance abuse case management services; and opioid treatment services), as defined in 12VAC30-50-228 and 12VAC30-50-491, EPSDT 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 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 they are provided inside or outside the MCO network.
Except for those services specifically carved out in
subsection A of this section, 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 clients, 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. 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 enrollee rights and shall comply with any applicable federal and state laws that pertain to enrollee rights and shall ensure that its staff and affiliated providers take those rights into account when furnishing services to enrollees in accordance with 42 CFR 438.100.
E. The MCO shall ensure that the health care provided to its clients 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 state and the contractor. 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 must meet standards specified by DMAS for sufficiency of provider networks as specified in the contract between the state and the contractor.
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 enrollee'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 447.60, MCOs shall not impose any cost sharing obligations on enrollees 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 an enrollee 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.