{"formats":[{"name":"JSON","format":"json","url":"\/downloads\/2025\/code-json\/32.1-330.01.json"},{"name":"Plain Text","format":"text","url":"\/downloads\/2025\/code-text\/32.1-330.01.txt"},{"name":"XML","format":"xml","url":"\/downloads\/2025\/code-xml\/32.1-330.01.xml"},{"name":"HTML","format":"html","url":"\/downloads\/2025\/code-html\/32.1-330.01.html"}],"law_id":80319,"edition_id":1,"section_id":80319,"structure_id":13276,"section_number":"32.1-330.01","catch_line":"Reports related to long-term services and supports","history":"2017, c. 749; 2020, cc. 304, 365.","full_text":"A\n\nThe Department shall (i) develop a program for the training and certification of individuals who perform long-term services and supports screenings for community and institutional long-term services and supports provided in accordance with the state plan for medical assistance services and ensure that all screeners are trained on and certified in the use of the long-term services and supports screening tool for long-term services and supports screening, (ii) develop guidelines for a standardized long-term services and supports screening process for community and institutional long-term services and supports provided in accordance with the state plan for medical assistance services and ensure that all long-term services and supports screenings are performed in accordance with such guidelines, (iii) establish and monitor performance according to established standards, and (iv) strengthen oversight of the long-term services and supports screening process for community and institutional long-term services and supports to ensure that problems are identified and addressed promptly.B\n\nThe Department shall require managed care organizations that provide managed long-term services and supports in the Commonwealth to develop the portion of the plan of care addressing the type and amount of long-term services and supports for each recipient. For recipients of long-term services and supports, the managed care organization shall participate in and collaborate with the existing interdisciplinary care team planning process already established pursuant to federal law and regulations in the development of the care plan.C\n\nThe Department shall work with its actuary to (i) ensure that trends are consistent with Actuarial Standards of Practice, including consideration of negative historical trends in medical spending by managed care organizations to be carried forward when setting capitation rates paid to managed care organizations through the managed care program where appropriate, and (ii) annually rebase administrative expenses per member per month for projected enrollment changes and future program changes impacting administrative costs beginning in Fiscal Year 2019.D\n\nThe Department shall include additional financial and utilization reporting requirements in contracts with managed care organizations and the Managed Care Technical Manual, including requirements for submission of (i) income statements that show medical services expenditures by service category, (ii) statements of revenues and expenses, (iii) information about related party transactions, and (iv) information about service utilization metrics, and shall monitor data submitted by managed care organizations to identify undesirable trends in spending and service utilization and work with managed care organizations to address such trends.E\n\nThe Department shall (i) establish a compliance enforcement review process and apply consistent and uniform compliance standards in accordance with the Managed Care Technical Manual, managed care contracts, and federal standards; (ii) return all compliance feedback to managed care organizations within the same reporting or auditing period in which such reports were generated; (iii) review the reasons for which the Commonwealth will mitigate or waive sanctions imposed on managed care organizations that fail to fulfill contract requirements and review and consider infractions due to unforeseen circumstances beyond the managed care organization’s control, infractions occurring during the first year of the managed care organization’s operation, infractions occurring for the first time, and infractions that are self-reported by the managed care organization; (iv) when applicable, include guidance in the Managed Care Technical Manual for managed care organizations that state the reasons for which sanctions may be mitigated or waived; (v) include information about the number of sanctions mitigated or waived and the reasons for such mitigation or waiver in its monthly compliance reports; and (vi) annually review the results of its contract compliance enforcement action process and include information about the process and results, including the percentage of points and fines mitigated or waived and the reasons for mitigating them for each managed care organization, in its annual report.F\n\nThe Department shall (i) incrementally increase the amount of performance incentive awards granted to managed care organizations that meet certain performance goals to create a stronger incentive for managed care organizations to improve performance and (ii) retain at least one metric related to chronic conditions in the performance incentive award program.G\n\nThe Department shall work collaboratively with managed care organizations and relevant stakeholders, where appropriate, to annually publish a uniform and agreed-upon managed care organization report card for the Department for the managed care program and shall make such information available to new enrollees as part of the enrollment process.H\n\nUpon the inclusion of behavioral health services in the managed care program and implementation of managed long-term services and supports, the Department shall require all managed care organizations participating in the managed care program to provide to the Department information about (i) the managed care organization’s policies and processes for identifying behavioral health providers who provide services deemed to be inappropriate to meet the behavioral health needs of the individual receiving services and (ii) the number of such providers that are disenrolled from the managed care provider’s provider network.I\n\nThe Department shall develop a process that allows managed care organizations providing services through the managed care program to determine utilization control measures for services provided but includes monitoring of the impact of utilization controls on utilization rates and spending to assess the effectiveness of each managed care organization’s utilization control measures.J\n\nThe Department shall include language in contracts for managed care long-term services and supports requiring managed care organizations providing services through the managed care program to develop a plan that includes (i) a standardized process to determine the capacity of individuals receiving services to self-direct services received, (ii) criteria for determining when a person receiving services is no longer able to self-direct services received, and (iii) the roles and responsibilities of service facilitators, including requirements to regularly verify that appropriate services are provided.K\n\nFollowing inclusion of managed long-term services and supports in the managed care program, the Department shall (i) review information about utilization and spending on long-term services and supports provided by managed care organizations and work with managed care organizations to make necessary changes to managed care organizations’ prior authorization and quality management review processes when undesirable trends are identified; (ii) include revenue and expense reports, information about related party transactions, and information about service utilization metrics in contracts for managed long-term services and supports and the Managed Care Technical Manual and utilize data and information received from managed long-term services and supports providers to monitor spending and utilization trends for managed long-term services and supports and address problems related to spending and utilization of services through managed long-term services and supports program contracts or the rate-setting process; (iii) include additional requirements for information about metrics related to behavioral health services in the managed long-term services and supports contract and the Managed Care Technical Manual to facilitate identification of undesirable trends in service utilization and enable the Department to address problems identified with managed care organizations participating in the program; and (iv) include additional metrics related to the long-term services and supports in the managed long-term services and supports contract and the Managed Care Technical Manual to facilitate identification of differences between models of care, assessment of progress in and challenges related to keeping service recipients in community-based rather than institutional care, and cooperation with managed care organizations in resolving problems identified.","order_by":null,"text":{"0":{"id":287497,"text":"The Department shall (i) develop a program for the training and certification of individuals who perform long-term services and supports screenings for community and institutional long-term services and supports provided in accordance with the state plan for medical assistance services and ensure that all screeners are trained on and certified in the use of the long-term services and supports screening tool for long-term services and supports screening, (ii) develop guidelines for a standardized long-term services and supports screening process for community and institutional long-term services and supports provided in accordance with the state plan for medical assistance services and ensure that all long-term services and supports screenings are performed in accordance with such guidelines, (iii) establish and monitor performance according to established standards, and (iv) strengthen oversight of the long-term services and supports screening process for community and institutional long-term services and supports to ensure that problems are identified and addressed promptly.","type":"section","prefixes":["A"],"prefix":"A","entire_prefix":"A","prefix_anchor":"A","level":1,"next_prefix":"B"},"1":{"id":287498,"text":"The Department shall require managed care organizations that provide managed long-term services and supports in the Commonwealth to develop the portion of the plan of care addressing the type and amount of long-term services and supports for each recipient. For recipients of long-term services and supports, the managed care organization shall participate in and collaborate with the existing interdisciplinary care team planning process already established pursuant to federal law and regulations in the development of the care plan.","type":"section","prefixes":["B"],"prefix":"B","entire_prefix":"B","prefix_anchor":"B","level":1,"prior_prefix":"A","next_prefix":"C"},"2":{"id":287499,"text":"The Department shall work with its actuary to (i) ensure that trends are consistent with Actuarial Standards of Practice, including consideration of negative historical trends in medical spending by managed care organizations to be carried forward when setting capitation rates paid to managed care organizations through the managed care program where appropriate, and (ii) annually rebase administrative expenses per member per month for projected enrollment changes and future program changes impacting administrative costs beginning in Fiscal Year 2019.","type":"section","prefixes":["C"],"prefix":"C","entire_prefix":"C","prefix_anchor":"C","level":1,"prior_prefix":"B","next_prefix":"D"},"3":{"id":287500,"text":"The Department shall include additional financial and utilization reporting requirements in contracts with managed care organizations and the Managed Care Technical Manual, including requirements for submission of (i) income statements that show medical services expenditures by service category, (ii) statements of revenues and expenses, (iii) information about related party transactions, and (iv) information about service utilization metrics, and shall monitor data submitted by managed care organizations to identify undesirable trends in spending and service utilization and work with managed care organizations to address such trends.","type":"section","prefixes":["D"],"prefix":"D","entire_prefix":"D","prefix_anchor":"D","level":1,"prior_prefix":"C","next_prefix":"E"},"4":{"id":287501,"text":"The Department shall (i) establish a compliance enforcement review process and apply consistent and uniform compliance standards in accordance with the Managed Care Technical Manual, managed care contracts, and federal standards; (ii) return all compliance feedback to managed care organizations within the same reporting or auditing period in which such reports were generated; (iii) review the reasons for which the Commonwealth will mitigate or waive sanctions imposed on managed care organizations that fail to fulfill contract requirements and review and consider infractions due to unforeseen circumstances beyond the managed care organization’s control, infractions occurring during the first year of the managed care organization’s operation, infractions occurring for the first time, and infractions that are self-reported by the managed care organization; (iv) when applicable, include guidance in the Managed Care Technical Manual for managed care organizations that state the reasons for which sanctions may be mitigated or waived; (v) include information about the number of sanctions mitigated or waived and the reasons for such mitigation or waiver in its monthly compliance reports; and (vi) annually review the results of its contract compliance enforcement action process and include information about the process and results, including the percentage of points and fines mitigated or waived and the reasons for mitigating them for each managed care organization, in its annual report.","type":"section","prefixes":["E"],"prefix":"E","entire_prefix":"E","prefix_anchor":"E","level":1,"prior_prefix":"D","next_prefix":"F"},"5":{"id":287502,"text":"The Department shall (i) incrementally increase the amount of performance incentive awards granted to managed care organizations that meet certain performance goals to create a stronger incentive for managed care organizations to improve performance and (ii) retain at least one metric related to chronic conditions in the performance incentive award program.","type":"section","prefixes":["F"],"prefix":"F","entire_prefix":"F","prefix_anchor":"F","level":1,"prior_prefix":"E","next_prefix":"G"},"6":{"id":287503,"text":"The Department shall work collaboratively with managed care organizations and relevant stakeholders, where appropriate, to annually publish a uniform and agreed-upon managed care organization report card for the Department for the managed care program and shall make such information available to new enrollees as part of the enrollment process.","type":"section","prefixes":["G"],"prefix":"G","entire_prefix":"G","prefix_anchor":"G","level":1,"prior_prefix":"F","next_prefix":"H"},"7":{"id":287504,"text":"Upon the inclusion of behavioral health services in the managed care program and implementation of managed long-term services and supports, the Department shall require all managed care organizations participating in the managed care program to provide to the Department information about (i) the managed care organization’s policies and processes for identifying behavioral health providers who provide services deemed to be inappropriate to meet the behavioral health needs of the individual receiving services and (ii) the number of such providers that are disenrolled from the managed care provider’s provider network.","type":"section","prefixes":["H"],"prefix":"H","entire_prefix":"H","prefix_anchor":"H","level":1,"prior_prefix":"G","next_prefix":"I"},"8":{"id":287505,"text":"The Department shall develop a process that allows managed care organizations providing services through the managed care program to determine utilization control measures for services provided but includes monitoring of the impact of utilization controls on utilization rates and spending to assess the effectiveness of each managed care organization’s utilization control measures.","type":"section","prefixes":["I"],"prefix":"I","entire_prefix":"I","prefix_anchor":"I","level":1,"prior_prefix":"H","next_prefix":"J"},"9":{"id":287506,"text":"The Department shall include language in contracts for managed care long-term services and supports requiring managed care organizations providing services through the managed care program to develop a plan that includes (i) a standardized process to determine the capacity of individuals receiving services to self-direct services received, (ii) criteria for determining when a person receiving services is no longer able to self-direct services received, and (iii) the roles and responsibilities of service facilitators, including requirements to regularly verify that appropriate services are provided.","type":"section","prefixes":["J"],"prefix":"J","entire_prefix":"J","prefix_anchor":"J","level":1,"prior_prefix":"I","next_prefix":"K"},"10":{"id":287507,"text":"Following inclusion of managed long-term services and supports in the managed care program, the Department shall (i) review information about utilization and spending on long-term services and supports provided by managed care organizations and work with managed care organizations to make necessary changes to managed care organizations’ prior authorization and quality management review processes when undesirable trends are identified; (ii) include revenue and expense reports, information about related party transactions, and information about service utilization metrics in contracts for managed long-term services and supports and the Managed Care Technical Manual and utilize data and information received from managed long-term services and supports providers to monitor spending and utilization trends for managed long-term services and supports and address problems related to spending and utilization of services through managed long-term services and supports program contracts or the rate-setting process; (iii) include additional requirements for information about metrics related to behavioral health services in the managed long-term services and supports contract and the Managed Care Technical Manual to facilitate identification of undesirable trends in service utilization and enable the Department to address problems identified with managed care organizations participating in the program; and (iv) include additional metrics related to the long-term services and supports in the managed long-term services and supports contract and the Managed Care Technical Manual to facilitate identification of differences between models of care, assessment of progress in and challenges related to keeping service recipients in community-based rather than institutional care, and cooperation with managed care organizations in resolving problems identified.","type":"section","prefixes":["K"],"prefix":"K","entire_prefix":"K","prefix_anchor":"K","level":1,"prior_prefix":"J"}},"ancestry":[{"id":13276,"edition_id":1,"name":"General Provisions","identifier":"1","label":"article","depth":3,"order_by":1,"parent_id":13275,"metadata":{},"date_created":"2026-06-26 03:44:33","date_modified":"2026-06-26 03:44:33","permalink":{"id":201355,"object_type":"structure","relational_id":13276,"identifier":"1","token":"32.1\/10\/1","url":"\/32.1\/10\/1\/","edition_id":1,"permalink":0,"preferred":1}},{"id":13275,"edition_id":1,"name":"Department of Medical Assistance Services","identifier":"10","label":"chapter","depth":2,"order_by":1,"parent_id":12727,"metadata":{},"date_created":"2026-06-26 03:44:33","date_modified":"2026-06-26 03:44:33","permalink":{"id":201353,"object_type":"structure","relational_id":13275,"identifier":"10","token":"32.1\/10","url":"\/32.1\/10\/","edition_id":1,"permalink":0,"preferred":1}},{"id":12727,"edition_id":1,"name":"Health","identifier":"32.1","label":"title","depth":1,"order_by":1,"parent_id":null,"metadata":{},"date_created":"2026-06-26 03:43:50","date_modified":"2026-06-26 03:43:50","permalink":{"id":201099,"object_type":"structure","relational_id":12727,"identifier":"32.1","token":"32.1","url":"\/32.1\/","edition_id":1,"permalink":0,"preferred":1}}],"structure_contents":[{"id":75748,"structure_id":13276,"section_number":"32.1-323","catch_line":"Department of Medical Assistance Services","url":"\/32.1-323\/","token":"32.1\/10\/1\/32.1-323","metadata":false},{"id":73079,"structure_id":13276,"section_number":"32.1-323.1","catch_line":"Department to submit forecast of expenditures","url":"\/32.1-323.1\/","token":"32.1\/10\/1\/32.1-323.1","metadata":false},{"id":78209,"structure_id":13276,"section_number":"32.1-323.2","catch_line":"Elimination of waiting lists for certain waivers","url":"\/32.1-323.2\/","token":"32.1\/10\/1\/32.1-323.2","metadata":false},{"id":65434,"structure_id":13276,"section_number":"32.1-323.3","catch_line":"Dependents of foreign service members; waiting lists for certain waivers","url":"\/32.1-323.3\/","token":"32.1\/10\/1\/32.1-323.3","metadata":false},{"id":74370,"structure_id":13276,"section_number":"32.1-323.4","catch_line":"Department to facilitate transition of persons between certain waiver programs","url":"\/32.1-323.4\/","token":"32.1\/10\/1\/32.1-323.4","metadata":false},{"id":56444,"structure_id":13276,"section_number":"32.1-324","catch_line":"Board of Medical Assistance Services","url":"\/32.1-324\/","token":"32.1\/10\/1\/32.1-324","metadata":false},{"id":82951,"structure_id":13276,"section_number":"32.1-324.1","catch_line":"Authority to administer oaths, conduct hearings; obtaining relevant documents and other information","url":"\/32.1-324.1\/","token":"32.1\/10\/1\/32.1-324.1","metadata":false},{"id":68172,"structure_id":13276,"section_number":"32.1-324.2","catch_line":"Director to facilitate communication","url":"\/32.1-324.2\/","token":"32.1\/10\/1\/32.1-324.2","metadata":false},{"id":75151,"structure_id":13276,"section_number":"32.1-324.3","catch_line":"Uninsured Medical Catastrophe Fund established","url":"\/32.1-324.3\/","token":"32.1\/10\/1\/32.1-324.3","metadata":false},{"id":77747,"structure_id":13276,"section_number":"32.1-325","catch_line":"Board to submit plan for medical assistance services to U.S. Secretary of Health and Human Services pursuant to federal law; administration of plan; contracts with health care providers","url":"\/32.1-325\/","token":"32.1\/10\/1\/32.1-325","metadata":false},{"id":76231,"structure_id":13276,"section_number":"32.1-325.001","catch_line":"Repealed","url":"\/32.1-325.001\/","token":"32.1\/10\/1\/32.1-325.001","metadata":false},{"id":83706,"structure_id":13276,"section_number":"32.1-325.01","catch_line":"Certain term life insurance considered resources","url":"\/32.1-325.01\/","token":"32.1\/10\/1\/32.1-325.01","metadata":false},{"id":54270,"structure_id":13276,"section_number":"32.1-325.02","catch_line":"Determinations of assets; disclaimers of interests to be considered uncompensated transfers of assets for Medicaid eligibility purposes under certain circumstances","url":"\/32.1-325.02\/","token":"32.1\/10\/1\/32.1-325.02","metadata":false},{"id":73332,"structure_id":13276,"section_number":"32.1-325.03","catch_line":"Legal presence required for certain state and local public benefits; exceptions; definitions; proof of legal presence","url":"\/32.1-325.03\/","token":"32.1\/10\/1\/32.1-325.03","metadata":false},{"id":83713,"structure_id":13276,"section_number":"32.1-325.04","catch_line":"Eligibility for medical assistance; individuals confined in state correctional facilities","url":"\/32.1-325.04\/","token":"32.1\/10\/1\/32.1-325.04","metadata":false},{"id":75066,"structure_id":13276,"section_number":"32.1-325.1","catch_line":"Appeals of agency determinations","url":"\/32.1-325.1\/","token":"32.1\/10\/1\/32.1-325.1","metadata":false},{"id":87103,"structure_id":13276,"section_number":"32.1-325.1:1","catch_line":"Definitions; recovery of overpayment for medical assistance services","url":"\/32.1-325.1_1\/","token":"32.1\/10\/1\/32.1-325.1_1","metadata":false},{"id":56047,"structure_id":13276,"section_number":"32.1-325.2","catch_line":"Department is payor of last resort","url":"\/32.1-325.2\/","token":"32.1\/10\/1\/32.1-325.2","metadata":false},{"id":60758,"structure_id":13276,"section_number":"32.1-325.3","catch_line":"Disclosure or use of information for purpose not connected with medical assistance program; Department not subject to certain disclosure","url":"\/32.1-325.3\/","token":"32.1\/10\/1\/32.1-325.3","metadata":false},{"id":55595,"structure_id":13276,"section_number":"32.1-325.4","catch_line":"Penalty for violation","url":"\/32.1-325.4\/","token":"32.1\/10\/1\/32.1-325.4","metadata":false},{"id":60835,"structure_id":13276,"section_number":"32.1-325.5","catch_line":"State pharmacy benefits manager","url":"\/32.1-325.5\/","token":"32.1\/10\/1\/32.1-325.5","metadata":false},{"id":62094,"structure_id":13276,"section_number":"32.1-326","catch_line":"Director may make payments to or for eligible persons in state-owned medical facilities","url":"\/32.1-326\/","token":"32.1\/10\/1\/32.1-326","metadata":false},{"id":75399,"structure_id":13276,"section_number":"32.1-326.1","catch_line":"Department to operate program of estate recovery","url":"\/32.1-326.1\/","token":"32.1\/10\/1\/32.1-326.1","metadata":false},{"id":86309,"structure_id":13276,"section_number":"32.1-326.2","catch_line":"Pilot school\/community health centers","url":"\/32.1-326.2\/","token":"32.1\/10\/1\/32.1-326.2","metadata":false},{"id":69227,"structure_id":13276,"section_number":"32.1-326.3","catch_line":"Special education health services; memorandum of agreement between the Department of Education and the Department of Medical Assistance Services","url":"\/32.1-326.3\/","token":"32.1\/10\/1\/32.1-326.3","metadata":false},{"id":81598,"structure_id":13276,"section_number":"32.1-327","catch_line":"Claim against indigent's estate for payments made","url":"\/32.1-327\/","token":"32.1\/10\/1\/32.1-327","metadata":false},{"id":59946,"structure_id":13276,"section_number":"32.1-328","catch_line":"Repealed","url":"\/32.1-328\/","token":"32.1\/10\/1\/32.1-328","metadata":false},{"id":74371,"structure_id":13276,"section_number":"32.1-329","catch_line":"Repealed","url":"\/32.1-329\/","token":"32.1\/10\/1\/32.1-329","metadata":false},{"id":85726,"structure_id":13276,"section_number":"32.1-330","catch_line":"Long-term services and supports screening required","url":"\/32.1-330\/","token":"32.1\/10\/1\/32.1-330","metadata":false},{"id":80319,"structure_id":13276,"section_number":"32.1-330.01","catch_line":"Reports related to long-term services and supports","url":"\/32.1-330.01\/","token":"32.1\/10\/1\/32.1-330.01","metadata":false},{"id":56351,"structure_id":13276,"section_number":"32.1-330.02","catch_line":"Average hourly payment rates; 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orientation program","url":"\/32.1-331.04\/","token":"32.1\/10\/1\/32.1-331.04","metadata":false},{"id":84036,"structure_id":13276,"section_number":"32.1-331.05","catch_line":"Coordinated specialty care; work group","url":"\/32.1-331.05\/","token":"32.1\/10\/1\/32.1-331.05","metadata":false},{"id":77511,"structure_id":13276,"section_number":"32.1-331.06","catch_line":"Annual review of medications and treatment for sickle cell disease; report","url":"\/32.1-331.06\/","token":"32.1\/10\/1\/32.1-331.06","metadata":false}],"previous_section":{"id":85726,"structure_id":13276,"section_number":"32.1-330","catch_line":"Long-term services and supports screening required","url":"\/32.1-330\/","token":"32.1\/10\/1\/32.1-330","metadata":false},"next_section":{"id":56351,"structure_id":13276,"section_number":"32.1-330.02","catch_line":"Average hourly payment rates; publication","url":"\/32.1-330.02\/","token":"32.1\/10\/1\/32.1-330.02","metadata":false},"metadata":false,"official_url":"https:\/\/law.lis.virginia.gov\/vacode\/32.1-330.01\/","history_text":"

This law was first created in 2017. The record of its establishment is cataloged in chapter 749<\/a> of that year\u2019s edition of \u201cActs of Assembly,\u201d the annual state publication listing all changes made to the Code of Virginia in that year. It has been modified 1 time. Those modifications are cataloged by \u201cThe Acts of Assembly,\u201d a state publication, by year and chapter. Those modifications that can be read on the General Assembly\u2019s website will be linked accordingly. That modification is as follows: in 2020, chapters 304<\/a> and 365<\/a>.<\/p>","references":false,"refers_to":false,"permalink":{"id":201473,"object_type":"law","relational_id":80319,"identifier":"32.1-330.01","token":"32.1\/10\/1\/32.1-330.01","url":"\/32.1-330.01\/","edition_id":1,"permalink":0,"preferred":1},"url":"\/32.1-330.01\/","token":"32.1\/10\/1\/32.1-330.01","dublin_core":{"Title":"Reports related to long-term services and supports","Type":"Text","Format":"text\/html","Identifier":"\u00a7 32.1-330.01","Relation":"Code of Virginia"},"html":"\n\t\t\t\t\t\t

A.<\/span> The Department<\/span> shall (i) develop a program for the training and certification of individuals who perform long-term services and supports screenings for community and institutional long-term services and supports provided in accordance with the state plan for medical assistance services and ensure that all screeners are trained on and certified in the use of the long-term services and supports screening tool for long-term services and supports screening, (ii) develop guidelines for a standardized long-term services and supports screening process for community and institutional long-term services and supports provided in accordance with the state plan for medical assistance services and ensure that all long-term services and supports screenings are performed in accordance with such guidelines, (iii) establish and monitor performance according to established standards, and (iv) strengthen oversight of the long-term services and supports screening process for community and institutional long-term services and supports to ensure that problems are identified and addressed promptly. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

B.<\/span> The Department<\/span> shall require managed care organizations that provide managed long-term services and supports in the Commonwealth to develop the portion of the plan of care addressing the type and amount of long-term services and supports for each recipient. For recipients of long-term services and supports, the managed care organization shall participate in and collaborate with the existing interdisciplinary care team planning process already established pursuant to federal law<\/span> and regulations in the development of the care plan. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

C.<\/span> The Department<\/span> shall work with its actuary to (i) ensure that trends are consistent with Actuarial Standards of Practice, including consideration of negative historical trends in medical spending by managed care organizations to be carried forward when setting capitation rates paid to managed care organizations through the managed care program where appropriate, and (ii) annually rebase administrative expenses per member per month for projected enrollment changes and future program changes impacting administrative costs beginning in Fiscal Year 2019. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

D.<\/span> The Department<\/span> shall include additional financial and utilization reporting requirements in contracts<\/span> with managed care organizations and the Managed Care Technical Manual, including requirements for submission of (i) income statements that show medical services expenditures by service category, (ii) statements of revenues and expenses, (iii) information about related party<\/span> transactions, and (iv) information about service utilization metrics, and shall monitor data submitted by managed care organizations to identify undesirable trends in spending and service utilization and work with managed care organizations to address such trends. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

E.<\/span> The Department<\/span> shall (i) establish a compliance enforcement review process and apply consistent and uniform compliance standards in accordance with the Managed Care Technical Manual, managed care contracts<\/span>, and federal standards; (ii) return all compliance feedback to managed care organizations within the same reporting or auditing period in which such reports were generated; (iii) review the reasons for which the Commonwealth will mitigate or waive<\/span> sanctions<\/span> imposed on managed care organizations that fail to fulfill contract<\/span> requirements and review and consider infractions due to unforeseen circumstances beyond the managed care organization’s control, infractions occurring during the first year of the managed care organization’s operation, infractions occurring for the first time, and infractions that are self-reported by the managed care organization; (iv) when applicable, include guidance in the Managed Care Technical Manual for managed care organizations that state the reasons for which sanctions<\/span> may be mitigated or waived; (v) include information about the number of sanctions<\/span> mitigated or waived and the reasons for such mitigation or waiver<\/span> in its monthly compliance reports; and (vi) annually review the results of its contract<\/span> compliance enforcement action process and include information about the process and results, including the percentage of points and fines mitigated or waived and the reasons for mitigating them for each managed care organization, in its annual report. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

F.<\/span> The Department<\/span> shall (i) incrementally increase the amount of performance incentive awards granted to managed care organizations that meet certain performance goals to create a stronger incentive for managed care organizations to improve performance and (ii) retain at least one metric related to chronic conditions in the performance incentive award program. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

G.<\/span> The Department<\/span> shall work collaboratively with managed care organizations and relevant stakeholders, where appropriate, to annually publish a uniform and agreed-upon managed care organization report card for the Department<\/span> for the managed care program and shall make such information available to new enrollees as part of the enrollment process. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

H.<\/span> Upon the inclusion of behavioral health services in the managed care program and implementation of managed long-term services and supports, the Department<\/span> shall require all managed care organizations participating in the managed care program to provide to the Department<\/span> information about (i) the managed care organization’s policies and processes for identifying behavioral health providers who provide services deemed to be inappropriate to meet the behavioral health needs of the individual receiving services and (ii) the number of such providers that are disenrolled from the managed care provider’s provider network. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

I.<\/span> The Department<\/span> shall develop a process that allows managed care organizations providing services through the managed care program to determine utilization control measures for services provided but includes monitoring of the impact of utilization controls on utilization rates and spending to assess the effectiveness of each managed care organization’s utilization control measures. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

J.<\/span> The Department<\/span> shall include language in contracts<\/span> for managed care long-term services and supports requiring managed care organizations providing services through the managed care program to develop a plan that includes (i) a standardized process to determine the capacity of individuals receiving services to self-direct services received, (ii) criteria for determining when a person<\/span> receiving services is no longer able to self-direct services received, and (iii) the roles and responsibilities of service facilitators, including requirements to regularly verify that appropriate services are provided. <\/i><\/a><\/p><\/section>\n\t\t\t\t\t\t

K.<\/span> Following inclusion of managed long-term services and supports in the managed care program, the Department<\/span> shall (i) review information about utilization and spending on long-term services and supports provided by managed care organizations and work with managed care organizations to make necessary changes to managed care organizations’ prior authorization and quality management review processes when undesirable trends are identified; (ii) include revenue and expense reports, information about related party<\/span> transactions, and information about service utilization metrics in contracts<\/span> for managed long-term services and supports and the Managed Care Technical Manual and utilize data and information received from managed long-term services and supports providers to monitor spending and utilization trends for managed long-term services and supports and address problems related to spending and utilization of services through managed long-term services and supports program contracts<\/span> or the rate-setting process; (iii) include additional requirements for information about metrics related to behavioral health services in the managed long-term services and supports contract<\/span> and the Managed Care Technical Manual to facilitate identification of undesirable trends in service utilization and enable the Department<\/span> to address problems identified with managed care organizations participating in the program; and (iv) include additional metrics related to the long-term services and supports in the managed long-term services and supports contract<\/span> and the Managed Care Technical Manual to facilitate identification of differences between models of care, assessment of progress in and challenges related to keeping service recipients in community-based rather than institutional care, and cooperation with managed care organizations in resolving problems identified. <\/i><\/a><\/p><\/section>","plain_text":" CODE OF VIRGINIA\n\nREPORTS RELATED TO LONG-TERM SERVICES AND SUPPORTS (\u00a7 32.1-330.01)\n\nA. The Department shall (i) develop a program for the training and certification\nof individuals who perform long-term services and supports screenings for\ncommunity and institutional long-term services and supports provided in\naccordance with the state plan for medical assistance services and ensure that\nall screeners are trained on and certified in the use of the long-term services\nand supports screening tool for long-term services and supports screening, (ii)\ndevelop guidelines for a standardized long-term services and supports screening\nprocess for community and institutional long-term services and supports provided\nin accordance with the state plan for medical assistance services and ensure\nthat all long-term services and supports screenings are performed in accordance\nwith such guidelines, (iii) establish and monitor performance according to\nestablished standards, and (iv) strengthen oversight of the long-term services\nand supports screening process for community and institutional long-term\nservices and supports to ensure that problems are identified and addressed\npromptly.\n\nB. The Department shall require managed care organizations that provide managed\nlong-term services and supports in the Commonwealth to develop the portion of\nthe plan of care addressing the type and amount of long-term services and\nsupports for each recipient. For recipients of long-term services and supports,\nthe managed care organization shall participate in and collaborate with the\nexisting interdisciplinary care team planning process already established\npursuant to federal law and regulations in the development of the care plan.\n\nC. The Department shall work with its actuary to (i) ensure that trends are\nconsistent with Actuarial Standards of Practice, including consideration of\nnegative historical trends in medical spending by managed care organizations to\nbe carried forward when setting capitation rates paid to managed care\norganizations through the managed care program where appropriate, and (ii)\nannually rebase administrative expenses per member per month for projected\nenrollment changes and future program changes impacting administrative costs\nbeginning in Fiscal Year 2019.\n\nD. The Department shall include additional financial and utilization reporting\nrequirements in contracts with managed care organizations and the Managed Care\nTechnical Manual, including requirements for submission of (i) income statements\nthat show medical services expenditures by service category, (ii) statements of\nrevenues and expenses, (iii) information about related party transactions, and\n(iv) information about service utilization metrics, and shall monitor data\nsubmitted by managed care organizations to identify undesirable trends in\nspending and service utilization and work with managed care organizations to\naddress such trends.\n\nE. The Department shall (i) establish a compliance enforcement review process\nand apply consistent and uniform compliance standards in accordance with the\nManaged Care Technical Manual, managed care contracts, and federal standards;\n(ii) return all compliance feedback to managed care organizations within the\nsame reporting or auditing period in which such reports were generated; (iii)\nreview the reasons for which the Commonwealth will mitigate or waive sanctions\nimposed on managed care organizations that fail to fulfill contract requirements\nand review and consider infractions due to unforeseen circumstances beyond the\nmanaged care organization’s control, infractions occurring during the\nfirst year of the managed care organization’s operation, infractions\noccurring for the first time, and infractions that are self-reported by the\nmanaged care organization; (iv) when applicable, include guidance in the Managed\nCare Technical Manual for managed care organizations that state the reasons for\nwhich sanctions may be mitigated or waived; (v) include information about the\nnumber of sanctions mitigated or waived and the reasons for such mitigation or\nwaiver in its monthly compliance reports; and (vi) annually review the results\nof its contract compliance enforcement action process and include information\nabout the process and results, including the percentage of points and fines\nmitigated or waived and the reasons for mitigating them for each managed care\norganization, in its annual report.\n\nF. The Department shall (i) incrementally increase the amount of performance\nincentive awards granted to managed care organizations that meet certain\nperformance goals to create a stronger incentive for managed care organizations\nto improve performance and (ii) retain at least one metric related to chronic\nconditions in the performance incentive award program.\n\nG. The Department shall work collaboratively with managed care organizations and\nrelevant stakeholders, where appropriate, to annually publish a uniform and\nagreed-upon managed care organization report card for the Department for the\nmanaged care program and shall make such information available to new enrollees\nas part of the enrollment process.\n\nH. Upon the inclusion of behavioral health services in the managed care program\nand implementation of managed long-term services and supports, the Department\nshall require all managed care organizations participating in the managed care\nprogram to provide to the Department information about (i) the managed care\norganization’s policies and processes for identifying behavioral health\nproviders who provide services deemed to be inappropriate to meet the behavioral\nhealth needs of the individual receiving services and (ii) the number of such\nproviders that are disenrolled from the managed care provider’s provider\nnetwork.\n\nI. The Department shall develop a process that allows managed care organizations\nproviding services through the managed care program to determine utilization\ncontrol measures for services provided but includes monitoring of the impact of\nutilization controls on utilization rates and spending to assess the\neffectiveness of each managed care organization’s utilization control\nmeasures.\n\nJ. The Department shall include language in contracts for managed care long-term\nservices and supports requiring managed care organizations providing services\nthrough the managed care program to develop a plan that includes (i) a\nstandardized process to determine the capacity of individuals receiving services\nto self-direct services received, (ii) criteria for determining when a person\nreceiving services is no longer able to self-direct services received, and (iii)\nthe roles and responsibilities of service facilitators, including requirements\nto regularly verify that appropriate services are provided.\n\nK. Following inclusion of managed long-term services and supports in the managed\ncare program, the Department shall (i) review information about utilization and\nspending on long-term services and supports provided by managed care\norganizations and work with managed care organizations to make necessary changes\nto managed care organizations’ prior authorization and quality management\nreview processes when undesirable trends are identified; (ii) include revenue\nand expense reports, information about related party transactions, and\ninformation about service utilization metrics in contracts for managed long-term\nservices and supports and the Managed Care Technical Manual and utilize data and\ninformation received from managed long-term services and supports providers to\nmonitor spending and utilization trends for managed long-term services and\nsupports and address problems related to spending and utilization of services\nthrough managed long-term services and supports program contracts or the\nrate-setting process; (iii) include additional requirements for information\nabout metrics related to behavioral health services in the managed long-term\nservices and supports contract and the Managed Care Technical Manual to\nfacilitate identification of undesirable trends in service utilization and\nenable the Department to address problems identified with managed care\norganizations participating in the program; and (iv) include additional metrics\nrelated to the long-term services and supports in the managed long-term services\nand supports contract and the Managed Care Technical Manual to facilitate\nidentification of differences between models of care, assessment of progress in\nand challenges related to keeping service recipients in community-based rather\nthan institutional care, and cooperation with managed care organizations in\nresolving problems identified.\n\nHISTORY: 2017, c. 749; 2020, cc. 304, 365.","edition":{"id":1,"name":"2025","slug":"2025","date_created":"2026-06-21 22:39:22","date_modified":"2026-06-21 22:39:22","current":1,"order_by":1,"last_import":null}}