Section 520. Required provider agreement

With respect to agreements between the Medicaid agency and each provider furnishing services under the plan:

A. For all providers, the requirements of 42 CFR 431.107 and 42 CFR Part 442, Subparts A and B (if applicable) are met.

B. For providers of NF services, the requirements of 42 CFR Part 483, Subpart B, and § 1919 of the Act are also met. (*plus additional requirements described below)

C. For providers of ICF/MR services, the requirements of participation in 42 CFR Part 483, Subpart D are also met.

D. Ambulatory prenatal care is not provided to pregnant women during a presumptive eligibility period.

E. For each provider receiving funds under the plan, all the requirements for advance directives of § 1902(w) are met:

1. Hospitals, nursing facilities, providers of home health care or personal care services, hospice programs, health maintenance organizations and health insuring organizations are required to do the following:

a. Maintain written policies and procedures with respect to all adult individuals receiving medical care by or through the provider or organization about their rights under state law to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives;

b. Provide written information to all adult individuals on their policies concerning implementation of such rights;

c. Document in the individual's medical records whether or not the individual has executed an advance directive;

d. Not condition the provision of care or otherwise discriminate against an individual based on whether or not the individual has executed an advance directive;

e. Ensure compliance with requirements of state law (whether statutory or recognized by the courts) concerning advance directives; and

f. Provide (individually or with others) for education for staff and the community on issues concerning advance directives.

2. Providers will furnish the written information described in subdivision E 1 a of this section to all adult individuals at the time specified below:

a. Hospitals at the time an individual is admitted as an inpatient;

b. Nursing facilities when the individual is admitted as a resident;

c. Providers of home health care or personal care services before the individual comes under the care of the provider;

d. Hospice program at the time of initial receipt of hospice care by the individual from the program; and

e. Health maintenance organizations at the time of enrollment of the individual with the organization.

3. 12VAC30-20-240 describes law of the state (whether statutory or as recognized by the courts of the state) concerning advance directives.

As a condition of participation in the Virginia Medical Assistance Program all nursing homes must agree that when a patient is discharged to a hospital, the nursing home from which the patient is discharged shall ensure that the patient shall be given an opportunity to be readmitted to the facility at the time of the next available vacancy.

The only acceptable reasons for failure to readmit a specific patient who has been discharged to a hospital shall be the patient is certified for a level of care not provided by the facility, the patient is judged by a physician to be a danger to himself or others, or the patient, who at the time of readmission has an outstanding payment to the nursing home for which he is responsible in accordance with Medicaid regulations.

F. The Department of Medical Assistance Services (DMAS) shall conduct provider screening according to the requirements of Subpart E of 42 CFR Part 455. DMAS shall terminate or deny enrollment to any provider in accordance with the requirements of 42 CFR 455.416.

Historical Notes

Paragraphs A through D derived from VR460-01-45, eff. June 16, 1993; paragraph E 1 a through E 1 e, derived from VR460-01-45.1, eff. June 16, 1993; paragraph E 1 f, E 2, and E 3 derived from VR460-01-45.2, eff. June 16, 1993; amended, Volume 33, Issue 02, eff. October 19, 2016.

Statutory Authority

. § 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.