Current through Register Vol. 41, No. 3, September 23, 2024
A.
Enrollees in FAMIS may, but shall not be required to, enroll in a private or
employer-sponsored health plan if DMAS or its designee determines that such
enrollment is cost effective, as defined in this section.
B. Eligibility determination. FAMIS children
may elect to receive coverage under a health plan purchased privately or
through an employer and DMAS may elect to provide coverage by paying all or a
portion of the premium if all of the following conditions are met:
1. The children are determined to be eligible
for FAMIS;
2. The cost of coverage
for the child under FAMIS Select is equal to or less than the Commonwealth's
cost of obtaining coverage under FAMIS only for the eligible targeted
low-income children involved. The cost-effectiveness determination methodology
is described in subsection E of this section;
3. The policyholder agrees to assign rights
to benefits under the private or employer-sponsored health plan to DMAS to
assist the Commonwealth in pursuing these third-party payments for childhood
immunizations. When a child is provided coverage under a private or
employer-sponsored health plan, that plan becomes the payer for all other
services covered under that plan; and
4. The policyholder is not under a court
order to provide medical support for the applicant child.
C. DMAS will continually verify the child's
or coverage under the private or employer-sponsored health plan and will
redetermine the eligibility of the child for the FAMIS Select component when it
receives information concerning an applicant's or enrollee's circumstances that
may affect eligibility.
D.
Application requirements.
1. DMAS shall
furnish the following information in written form and orally, as appropriate,
to the families of FAMIS children who have indicated an interest in FAMIS
Select:
a. The eligibility requirements for
FAMIS Select;
b. A description of
how the program operates, the amount of premium assistance available, and how
children can move from FAMIS Select into FAMIS if requested;
c. A summary of the covered benefits and
cost-sharing requirements available through FAMIS;
d. A guide to help families make an informed
choice by comparing the FAMIS plan to their private or employer-sponsored
health plan. Such guide shall include a notice to the effect that children
covered by FAMIS Select will not receive FAMIS-covered services, but only those
health services covered by their private or employer-sponsored health plan, and
that the FAMIS Select enrollee shall be responsible for any and all costs
associated with their chosen health plan;
e. Information on coverage for childhood
immunizations through FAMIS; and
f.
The rights and responsibilities of applicants and enrollees.
2. DMAS will provide interested
families with applications for FAMIS Select.
3. An electronic or written application for
the FAMIS Select component shall be required from interested
families.
4. DMAS shall determine
eligibility for the FAMIS Select component promptly, within 45 calendar days
from the date of receiving an application that contains all information and
verifications necessary to determine eligibility, except in unusual
circumstances beyond the agency's control. Actual enrollment into the FAMIS
Select component may not occur for extended periods of time, depending on the
ability of the family to enroll in the employer's plan.
5. Incomplete FAMIS Select applications shall
be held for a period of 30 calendar days to enable applicants to provide
outstanding information needed for a FAMIS Select eligibility determination.
Any applicant who, within 30 calendar days of the receipt of the initial
application, fails to provide information or verifications necessary to
determine FAMIS Select eligibility shall have his application denied.
6. DMAS must send each applicant a written
notice of the agency's decision on his application for FAMIS Select and, if
approved, his obligations under the program. If eligibility is denied, notice
will be given concerning the reasons for the denial.
E. Cost effectiveness. DMAS may elect to
provide coverage to FAMIS children by paying all or a portion of the family's
private or employer-sponsored health insurance premium if the cost of such
premium assistance under FAMIS Select is equal to or less than the
Commonwealth's cost of obtaining coverage under FAMIS only for the eligible,
targeted, low-income child involved. Providing premium assistance for the
FAMIS-eligible children may result in the coverage of an adult or other
relative or dependent; however, this coverage shall be solely incidental to
covering the FAMIS child.
1. To ensure that
the FAMIS Select program remains cost effective, DMAS will establish a fixed
premium assistance amount per child that will be paid to a family choosing to
enroll their FAMIS-eligible child in FAMIS Select. The fixed premium assistance
amount will be determined annually by:
a.
Determining the cost of covering a child under FAMIS. The cost will be
determined by using the capitated payment rate paid to MCHIPs, or an average
cost amount developed by DMAS;
b.
Determining the administrative costs associated with the FAMIS Select program;
and
c. Establishing a fixed premium
assistance amount that includes administrative costs and is less than or equal
to the cost of covering the FAMIS child under FAMIS.
DMAS will ensure that the total of the fixed premium
assistance amounts for all the FAMIS-eligible children per family do not exceed
the total cost of the family's health insurance premium payment for the private
or employer-sponsored health plan. If the total fixed premium assistance
amounts do exceed the family's premium payment, then the family premium
assistance will be reduced by an amount necessary to ensure the premium
assistance payment is less than or equal to the family's premium
payment.
F. Enrollment and disenrollment.
1. FAMIS children applying for FAMIS Select
will receive coverage under FAMIS until their eligibility for coverage under
the FAMIS Select component is established and until they are able to enroll in
the private or employer-sponsored health plan.
2. The timing and procedures employed to
transfer FAMIS children's coverage to the FAMIS Select component will be
coordinated between DMAS and the agency managing the case to ensure
continuation of coverage.
3.
Participation by families in the FAMIS Select component shall be voluntary.
Families may disenroll their child from the FAMIS Select component as long as
the proper timing and procedures established by DMAS are followed to ensure
continued health coverage.
G. Premium assistance. When a child is
determined eligible for coverage under the FAMIS Select component, premium
assistance payments shall become effective the month in which the FAMIS child
is enrolled in the employer's plan. Payment of premium assistance shall end:
1. On the last day of the month in which
FAMIS eligibility ends;
2. The last
day of the month in which the child loses eligibility for coverage under the
private or employer-sponsored health plan;
3. The last day of the month in which the
family notifies DMAS that it wishes to disenroll its child from the FAMIS
Select component; or
4. On the next
business day following a request by the family to immediately transfer the
child from FAMIS Select into the FAMIS program. The request must include
notification that the child's private or employer-sponsored health plan has
been terminated as of the date of transfer and an agreement by the family to
return to DMAS the premium assistance payment prorated for that portion of the
month in which the child was not enrolled in the private or employer-sponsored
health plan.
H.
Supplemental health benefits coverage will be provided to ensure that FAMIS
children enrolled in the FAMIS Select component receive all childhood
immunizations available under the FAMIS benefits. FAMIS children can obtain
these supplemental benefits through Medicaid providers.
I. Cost sharing. FAMIS Select families will
be responsible for all copayments, deductibles, coinsurance, fees, or other
cost-sharing requirements of the private or employer-sponsored health plan in
which they enroll their children. There is no Title XXI family cost-sharing cap
applied to families with children enrolled in FAMIS Select.
There is no copayment required for the supplemental
immunization benefits provided through FAMIS.
Statutory Authority: §
32.1-351 of the Code of Virginia; 42 USC §
1396 et
seq.
