2006 Code of Virginia § 32.1-351 - Family Access to Medical Insurance Security Plan established

32.1-351. Family Access to Medical Insurance Security Plan established.

A. The Department of Medical Assistance Services shall amend the VirginiaChildren's Medical Security Insurance Plan to be renamed the Family Access toMedical Insurance Security (FAMIS) Plan. The Department of Medical AssistanceServices shall provide coverage under the Family Access to Medical InsuranceSecurity Plan for individuals under the age of 19 when such individuals (i)have family incomes at or below 200 percent of the federal poverty level orwere enrolled on the date of federal approval of Virginia's FAMIS Plan in theChildren's Medical Security Insurance Plan (CMSIP); such individuals shallcontinue to be enrolled in FAMIS for so long as they continue to meet theeligibility requirements of CMSIP; (ii) are not eligible for medicalassistance services pursuant to Title XIX of the Social Security Act, asamended; (iii) are not covered under a group health plan or under healthinsurance coverage, as defined in 2791 of the Public Health Service Act (42U.S.C. 300gg-91(a) and (b) (1)); (iv) have been without health insurancefor at least four months or meet the exceptions as set forth in the VirginiaPlan for Title XXI of the Social Security Act, as amended; and (v) meet boththe requirements of Title XXI of the Social Security Act, as amended, and theFamily Access to Medical Insurance Security Plan. Eligible children, residingin Virginia, whose family income does not exceed 200 percent of the federalpoverty level during the enrollment period shall receive 12 continuous monthsof coverage as permitted by Title XXI of the Social Security Act.

B. Family Access to Medical Insurance Security Plan participants shallparticipate in cost-sharing to the extent allowed under Title XXI of theSocial Security Act, as amended, and as set forth in the Virginia Plan forTitle XXI of the Social Security Act. The annual aggregate cost-sharing forall eligible children in a family above 150 percent of the federal povertylevel shall not exceed five percent of the family's gross income or asallowed by federal law and regulations. The annual aggregate cost-sharing forall eligible children in a family at or below 150 percent of the federalpoverty level shall not exceed 2.5 percent of the family's gross income. Thenominal copayments for all eligible children in a family shall not be lessthan those in effect on January 1, 2003. Cost-sharing shall not be requiredfor well-child and preventive services including age-appropriate childimmunizations.

C. The Family Access to Medical Insurance Security Plan shall providecomprehensive health care benefits to program participants, includingwell-child and preventive services, to the extent required to comply withfederal requirements of Title XXI of the Social Security Act. These benefitsshall include comprehensive medical, dental, vision, mental health, andsubstance abuse services, and physical therapy, occupational therapy,speech-language pathology, and skilled nursing services for special educationstudents. The mental health services required herein shall include intensivein-home services, case management services, day treatment, and 24-houremergency response. The services shall be provided in the same manner andwith the same coverage and service limitations as they are provided tochildren under the State Plan for Medical Assistance Services.

D. The Virginia Plan for Title XXI of the Social Security Act shall include aprovision that participants in the Family Access to Medical InsuranceSecurity Plan who have access to employer-sponsored health insurancecoverage, as defined in 32.1-351.1, may, but shall not be required to,enroll in an employer's health plan, and the Department of Medical AssistanceServices or its designee shall make premium payments to such employer's planon behalf of eligible participants if the Department of Medical AssistanceServices or its designee determines that such enrollment is cost-effective,as defined in 32.1-351.1.

E. The Family Access to Medical Insurance Security Plan shall ensure thatcoverage under this program does not substitute for private health insurancecoverage.

F. The health care benefits provided under the Family Access to MedicalInsurance Security Plan shall be through existing Department of MedicalAssistance Services' contracts with health maintenance organizations andother providers, or through new contracts with health maintenanceorganizations, health insurance plans, other similarly licensed entities, orother entities as deemed appropriate by the Department of Medical AssistanceServices, or through employer-sponsored health insurance. All eligibleindividuals, insofar as feasible, shall be enrolled in health maintenanceorganizations.

G. The Department of Medical Assistance Services may establish a centralizedprocessing site for the administration of the program to include respondingto inquiries, distributing applications and program information, andreceiving and processing applications. The Family Access to Medical InsuranceSecurity Plan shall include a provision allowing a child's application to befiled by a parent, legal guardian, authorized representative or any otheradult caretaker relative with whom the child lives. The Department of MedicalAssistance Services may contract with third-party administrators to provideany additional administrative services. Duties of the third-partyadministrators may include, but shall not be limited to, enrollment,outreach, eligibility determination, data collection, premium payment andcollection, financial oversight and reporting, and such other servicesnecessary for the administration of the Family Access to Medical InsuranceSecurity Plan. Any centralized processing site shall determine a child'seligibility for either Title XIX or Title XXI and shall enroll eligiblechildren in Title XIX or Title XXI. A single application form shall be usedto determine eligibility for Title XIX or Title XXI of the Social SecurityAct, as amended, and outreach, enrollment, re-enrollment and servicesdelivery shall be coordinated with the FAMIS Plus program pursuant to 32.1-325. In the event that an application is denied, the applicant shall benotified of any services available in his locality that can be accessed bycontacting the local department of social services.

H. The Virginia Plan for Title XXI of the Social Security Act, as amended,shall include a provision that, in addition to any centralized processingsite, local social services agencies shall provide and accept applicationsfor the Family Access to Medical Insurance Security Plan and shall assistfamilies in the completion of applications. Contracting health plans,providers, and others may also provide applications for the Family Access toMedical Insurance Security Plan and may assist families in completion of theapplications.

I. The Department of Medical Assistance Services shall develop and submit tothe federal Secretary of Health and Human Services an amended Title XXI planfor the Family Access to Medical Insurance Security Plan and may revise suchplan as may be necessary. Such plan and any subsequent revisions shall complywith the requirements of federal law, this chapter, and any conditions setforth in the appropriation act. In addition, the plan shall provide forcoordinated implementation of publicity, enrollment, and service deliverywith existing local programs throughout the Commonwealth that provide healthcare services, educational services, and case management services tochildren. In developing and revising the plan, the Department of MedicalAssistance Services shall advise and consult with the Joint Commission onHealth Care and shall provide quarterly reports on enrollment, policiesaffecting enrollment, such as the exceptions that apply to the four months'prior coverage limitation referenced in subsection A of this section, benefitlevels, outreach efforts, including efforts to enroll uninsured children offormer Temporary Assistance to Needy Families (TANF) recipients, and othertopics.

J. Funding for the Family Access to Medical Insurance Security Plan shall beprovided through state and federal appropriations and shall includeappropriations of any funds that may be generated through the Virginia FamilyAccess to Medical Insurance Security Plan Trust Fund.

K. The Board of Medical Assistance Services, or the Director, as the case maybe, shall adopt, promulgate, and enforce such regulations pursuant to theAdministrative Process Act ( 2.2-4000 et seq.) as may be necessary for theimplementation and administration of the Family Access to Medical InsuranceSecurity Plan.

L. Children enrolled in the Virginia Plan for Title XXI of the SocialSecurity Act prior to implementation of these amendments shall continue theireligibility under the Family Access to Medical Insurance Security Plan andshall be given reasonable notice of any changes in their benefit packages.Continuing eligibility in the Family Access to Medical Insurance SecurityPlan for children enrolled in the Virginia Plan for Title XXI of the SocialSecurity Act prior to implementation of these amendments shall be determinedin accordance with their regularly scheduled review dates or pursuant tochanges in income status. Families may select among the options availablepursuant to subsections D and F of this section.

M. The provisions of Chapter 9 ( 32.1-310 et seq.) of this title relating tothe regulation of medical assistance shall apply, mutatis mutandis, to theFamily Access to Medical Insurance Security Plan.

N. In addition, in any case in which any provision set forth in Title 38.2excludes, exempts or does not apply to the Virginia plan for medicalassistance services established pursuant to Title XIX of the Social SecurityAct, 42 U.S.C. 1396 et seq. (Medicaid), such exclusion, exemption or carveout of application to Title XIX of the Social Security Act (Medicaid) shallbe deemed to subsume and thus to include the Family Access to MedicalInsurance Security (FAMIS) Plan, established pursuant to Title XXI of theSocial Security Act, upon approval of FAMIS by the federal Centers forMedicare & Medicaid Services as Virginia's State Children's Health InsuranceProgram.

(1997, c. 679; 1999, c. 1034; 2000, cc. 824, 848; 2001, cc. 238, 735, 756;2002, c. 640; 2003, cc. 66, 71, 521; 2005, c. 584; 2006, c. 428.)