Regarding 12VAC30-120-380, Medallion MCO responsibilities:

• (B) 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.
  • OUR COMMENT:  As per the 2017 EPSDT Manual on the DMAS Portal, page 17, under Service initiation, our position is that the EPSDT paperwork process remain as stated:  "The individual/guardian or case manager with consent from the individual/guardian may request that an EPSDT screener (physician, physician assistant or nurse practitioner) complete the EPSDT Functional Assessment Form (DMAS-7). The screener may bill for an inter-periodic screening if the screening is in excess of the periodicity schedule.  The EPSDT screener forwards the completed DMAS-7 to the selected Personal Care agency or CD Service Facilitator."

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Regarding 12VAC30-120-370. Mandatory Medallion mandatory managed care members.

• Section B - Managed Care Waiver and Family Planning Waiver
  • OUR COMMENT: Using the word Waiver is misleading.  Who is it that is being referred to here? There is no Waiver for Managed Care and/or Family Planning
• Section B - Subsection 8
  • OUR COMMENT:  Individuals do not purchase insurance through HIPP. They get reimbursed for insurance they purchase through their employer through HIPP.
• Section F, Subsection 4 & c:
  • 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.
  • 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
    • OUR COMMENT: Details of the timeframe (length/duration) need to be written and clear.
• Section J, subsection 2:
  • 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 the request, in compliance with 42 CFR 438.56.
    • OUR COMMENT:  Someone making this request at the beginning of the month would be waiting almost 2 months to disenroll. This may put the individual in jeopardy if the reason they are disenrolling has to do with medication coverage, or specifically lack thereof.

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Regarding 12VAC30-120-420. Member grievances and appeals.

• Section C, 1:
  • OUR COMMENT:  Member grievances and appeals are conflicting and unclear.  C1 indicates the member "may" file an oral or written grievance or internal appeal with the MCO. It also says they "may" file a written request with DMAS Appeals Division. However, C2 says they "must" exhaust the MCO's internal appeals process before appealing to the DMAS Appeals Division. These two statements seem to conflict with one another.
• Section C, 4:
  • OUR COMMENT: Language should be included here to state who will be responsible for monitoring this.
• Section C, 5 & 6:
  • “sufficiently in advance of the resolution timeframe for”
    • OUR COMMENT: This language makes the timeframe unclear.
• Section F, 1, 2, & 3:
  • OUR COMMENT: These three statements seem to conflict with one another. In bullet 1 the member "may" appeal to the MCO. In bullet 2, they have the right to go directly to DMAS. But then in bullet 3, they "shall exhaust" the MCO appeal process before going to DMAS.

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General Comments:

• The MCO appeal process for Members is unreasonably long and difficult.
• After a denial is issued, if a member appeals within the current 10-day window of opportunity, who is overseeing that the services are maintained during the appeals process
• The 10-day window of appeals (from date of appeal letter to receipt of an appeal letter by member) is not long enough to take necessary action by the Member.