Virginia Regulatory Town Hall
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Department of Medical Assistance Services
 
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Board of Medical Assistance Services
 
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10/22/25  10:27 pm
Commenter: Allison Meyer, GPCS

Section 7 CPST Medical Necessity Criteria
 
Under 7.1 Tier One Criteria... 3. Functional Impairment Criteria should read: must meet a and b and at least one....
 
The continued stay criteria indicate that if the individual is not making significant progress after 90 days, then the provider and health plan must develop an alternative ISP.  What constitutes significant progress versus just progress?  Recommend rewording to "making progress" as that is a more reasonable bar in 90 days.  What is the mechanism for the health plan to be involved?  Is this coordination with the MCO Care Coordinator or what?
CommentID: 237520