Section 40. Review of adverse actions

Part II. Review of Adverse Actions

A. Upon written request, all FAMIS Plan applicants and enrollees shall have the right to a review of an adverse action made by the MCHIP, local department of social services, CPU or DMAS.

B. During review of a suspension or termination of enrollment or a reduction, suspension, or termination of services, the enrollee shall have the right to continuation of coverage if the enrollee requests review prior to the effective date of the suspension or termination of enrollment or suspension, reduction, or termination of services.

C. Review of an adverse action made by the local department of social services, CPU or DMAS shall be heard and decided by an agent of DMAS who has not been directly involved in the adverse action under review.

D. Review of an adverse action made by the MCHIP must be conducted by a person or agent of the MCHIP who has not been directly involved in the adverse action under review.

E. After final review by the MCHIP, there shall also be opportunity for final independent external review by the external quality review organization.

F. There will be no opportunity for review of an adverse action to the extent that such adverse action is based on a determination by the director that funding for FAMIS has been terminated or exhausted. There will be no opportunity for review based on which type of delivery system (i.e., fee-for-service, MCHIP) is assigned. There will be no opportunity for review if the sole basis for the adverse action is a state or federal law or regulation requiring an automatic change that affects all applicants or enrollees or a group of applicants or enrollees without regard to their individual circumstances.

G. The burden of proof shall be upon the applicant or enrollee to show that an adverse action is incorrect.

H. At no time shall the MCHIP's, local department's of social services, the CPU's, or DMAS' failure to meet the time frames set in this chapter or set in the MCHIP's or DMAS' written review procedures constitute a basis for granting the applicant or enrollee the relief sought.

I. Adverse actions related to health benefits covered through the FAMIS Select program shall be resolved between the insurance company or employer's plan and the FAMIS Select enrollee, and are not subject to further review by DMAS or its contractors. Adverse actions made by an MCHIP, the local department of social services, the CPU, or DMAS shall be subject to the review process set forth in Part II (12VAC30-141-40 et seq.) of this chapter.

Historical Notes

Derived from Volume 19, Issue 21, eff. August 1, 2003; amended, Virginia Register Volume 22, Issue 26, eff. October 4, 2006.

Statutory Authority

§ 32.1-351 of the Code of Virginia.