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STATE CHILD HEALTH PLAN UNDER TITLE XXI OF THE SOCIAL SECURITY ACT

STATE: Virginia Page 11-1

Effective Date: 07/01/05

73 Approval Date: _____________/06 Section 12. Applicant and enrollee protections (Sections 2101(a))

Check here if the state elects to use funds provided under Title XXI only to provide expanded eligibility under the state’s Medicaid plan.

Eligibility and Enrollment Matters

12.1 Please describe the review process for eligibility and enrollment matters that complies with 42 CFR 457.1120.

For reviews involving adverse eligibility actions taken by the Department of Medical Assistance Services (“DMAS”), the local department of social services, or the Central Processing Unit (“CPU), the following procedures shall apply.

1. DMAS, the local department of social services, and/or the CPU must send written notification of adverse actions affecting an individual’s request for or receipt of FAMIS coverage. Adverse actions include:

a. Denial of eligibility;

b. Failure to make a timely determination;

c. Suspension or termination of enrollment, including disenrollment for failure to pay cost sharing.

2. The written notification must include the reasons for the determination, an explanation of rights to request a review and how to request a review, the standard and expedited time frames for review, and the circumstances under which enrollment may continue pending review. The notice must be sent to applicants/enrollees within 10 days after the date of denial or at least 10 days prior to suspension or termination of enrollment.

3. To be considered timely, a request for review shall be received by DMAS no later than 30 calendar days from the date of the DMAS, the local department of social services, or CPU notice of adverse action.

4. A review shall not be granted if the sole basis for the adverse determination is a state or federal provision requiring an automatic change in eligibility or enrollment that affects all applicants or enrollees or a group of applicants or enrollees without regard to their individual circumstances.

5. A request for review shall be heard and decided by an agent of DMAS who has not been directly involved in the adverse action under review.