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1999 SESSION

999080760
HOUSE BILL NO. 2360
Offered January 21, 1999
A BILL to amend and reenact §§ 32.1-325, 32.1-326.2, 54.1-2603, and 54.1-3606 of the Code of Virginia and to amend the Code of Virginia by adding a section numbered 22.1-274.02, relating to school division participation in medical assistance services.
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Patrons-- Bloxom, Darner, Puller, Tata and Tate
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Referred to Committee on Education
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Be it enacted by the General Assembly of Virginia:

1. That §§ 32.1-325, 32.1-326.2, 54.1-2603, and 54.1-3606 of the Code of Virginia are amended and reenacted and that the Code of Virginia is amended by adding a section numbered 22.1-274.02 as follows:

§ 22.1-274.02. Certain memorandum of agreement required.

A. The Superintendent of Public Instruction or his designee and the Director of the Department of Medical Assistance Services or his designee shall develop and execute a memorandum of agreement relating to community health centers and special education health services that are delivered by school divisions to public school students. This memorandum of agreement shall be revised on a periodic basis; however, the agreement shall, at a minimum, be revised and executed within six months of the inauguration of a new governor in order to maintain policy integrity.

B. The memorandum of agreement shall include, but need not be limited to, (i) requirements for regular and consistent communications and consultations between the two departments and with school division personnel and officials and school board representatives; (ii) a specific and concise description and history of the federal Individuals with Disabilities Education Act, a summary of school division responsibilities pursuant to the Individuals with Disabilities Education Act, and a summary of any corresponding state law which influences the scope of these responsibilities; (iii) a specific and concise summary of the then-current Department of Medical Assistance Services regulations regarding the community health centers and the special education health services programs; (iv) assignment of the specific responsibilities of the two state departments for the operation of the community health services and special education health services programs; (v) a schedule of issues to be resolved through the regular and consistent communications process, including, but not limited to, ways to ameliorate the impact of managed care on school division participation in medical assistance and mechanisms to integrate or coordinate managed care and other programs administered by the Department of Medical Assistance Services with the community health centers and special education health services programs; (vi) a process for the evaluation of the services which may be delivered by school divisions participating in Medicaid; and (vii) a plan and schedule to reduce the administrative and paperwork burden of Medicaid participation on school divisions in Virginia.

C. The Board of Education shall cooperate with the Board of Medical Assistance Services in developing a form to be included in the individualized education plan (IEP) that shall be accepted by the Department of Medical Assistance as the plan of care (POC) and in collecting the data necessary to establish separate and specific Medicaid rates for the IEP meetings and other services delivered by school divisions to students.

The Board shall also assist in all necessary ways in the development, by the Board of Medical Assistance Services, of mechanisms to reduce the burden on the school divisions of determining eligibility and obtaining physicians’ orders and parental consent to services. Such mechanisms shall include, but need not be limited to, the insertion of a clause in the application forms for medical assistance services and any other programs administered by the Department of Medical Assistance Services providing for parental consent to release, in compliance with the federal Family Education Rights and Privacy Act (FERPA), 20 U.S.C. 1232q, any minor’s record for the purpose of delivery and billing by community health centers and special education health services programs pursuant to the Medicaid program and other programs operated by the Department of Medical Assistance Services. The Department of Medical Assistance Services shall state, in writing, the effect of such clause. School divisions shall, in the implementation of such clause, disclose to the parents, specifically and clearly, this consent mechanism. Such consent shall be maintained by either the Department of Medical Assistance Services or the Department of Education in accordance with the then-current memorandum of agreement.

§ 32.1-325. Board to submit plan for medical assistance services to Secretary of Health and Human Services pursuant to federal law; administration of plan; contracts with health care providers.

A. The Board, subject to the approval of the Governor, is authorized to prepare, amend from time to time and submit to the Secretary of the United States Department of Health and Human Services a state plan for medical assistance services pursuant to Title XIX of the United States Social Security Act and any amendments thereto. The Board shall include in such plan:

1. A provision for payment of medical assistance on behalf of individuals, up to the age of twenty-one, placed in foster homes or private institutions by private, nonprofit agencies licensed as child-placing agencies by the Department of Social Services or placed through state and local subsidized adoptions to the extent permitted under federal statute;

2. A provision for determining eligibility for benefits for medically needy individuals which disregards from countable resources an amount not in excess of $2,500 for the individual and an amount not in excess of $2,500 for his spouse when such resources have been set aside to meet the burial expenses of the individual or his spouse. The amount disregarded shall be reduced by (i) the face value of life insurance on the life of an individual owned by the individual or his spouse if the cash surrender value of such policies has been excluded from countable resources and (ii) the amount of any other revocable or irrevocable trust, contract, or other arrangement specifically designated for the purpose of meeting the individual's or his spouse's burial expenses;

3. A requirement that, in determining eligibility, a home shall be disregarded. For those medically needy persons whose eligibility for medical assistance is required by federal law to be dependent on the budget methodology for Aid to Families with Dependent Children, a home means the house and lot used as the principal residence and all contiguous property. For all other persons, a home shall mean the house and lot used as the principal residence, as well as all contiguous property, as long as the value of the land, exclusive of the lot occupied by the house, does not exceed $5,000. In any case in which the definition of home as provided here is more restrictive than that provided in the state plan for medical assistance in Virginia as it was in effect on January 1, 1972, then a home means the house and lot used as the principal residence and all contiguous property essential to the operation of the home regardless of value;

4. A provision for payment of medical assistance on behalf of individuals up to the age of twenty-one, who are Medicaid eligible, for medically necessary stays in acute care facilities in excess of twenty-one days per admission;

5. A provision for deducting from an institutionalized recipient's income an amount for the maintenance of the individual's spouse at home;

6. A provision for payment of medical assistance on behalf of pregnant women which provides for payment for inpatient postpartum treatment in accordance with the medical criteria, outlined in the most current version of or an official update to the "Guidelines for Perinatal Care" prepared by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists or the "Standards for Obstetric-Gynecologic Services" prepared by the American College of Obstetricians and Gynecologists. Payment shall be made for any postpartum home visit or visits for the mothers and the children which are within the time periods recommended by the attending physicians in accordance with and as indicated by such Guidelines or Standards. For the purposes of this subdivision, such Guidelines or Standards shall include any changes thereto within six months of the publication of such Guidelines or Standards or any official amendment thereto;

7. A provision for payment of medical assistance for high-dose chemotherapy and bone marrow transplants on behalf of individuals over the age of twenty-one who have been diagnosed with lymphoma or breast cancer and have been determined by the treating health care provider to have a performance status sufficient to proceed with such high-dose chemotherapy and bone marrow transplant. Appeals of these cases shall be handled in accordance with the Department's expedited appeals process;

8. A provision identifying entities approved by the Board to receive applications and to determine eligibility for medical assistance;

9. A provision for breast reconstructive surgery following the medically necessary removal of a breast for any medical reason. Breast reductions shall be covered, if prior authorization has been obtained, for all medically necessary indications. Such procedures shall be considered noncosmetic;

10. A provision for payment of medical assistance for annual pap smears;

11. A provision for payment of medical assistance services for prostheses following the medically necessary complete or partial removal of a breast for any medical reason;

12. A provision for payment of medical assistance which provides for payment for forty-eight hours of inpatient treatment for a patient following a radical or modified radical mastectomy and twenty-four hours of inpatient care following a total mastectomy or a partial mastectomy with lymph node dissection for treatment of disease or trauma of the breast. Nothing in this subdivision shall be construed as requiring the provision of inpatient coverage where the attending physician in consultation with the patient determines that a shorter period of hospital stay is appropriate;

13. A requirement that certificates of medical necessity for durable medical equipment and any supporting verifiable documentation shall be signed, dated, and returned by the physician and in the durable medical equipment provider's possession within sixty days from the time the ordered durable medical equipment and supplies are first furnished by the durable medical equipment provider;

14. A provision for payment of medical assistance to (i) persons age fifty and over and (ii) persons age forty and over who are at high risk for prostate cancer, according to the most recent published guidelines of the American Cancer Society, for one PSA test in a twelve-month period and digital rectal examinations, all in accordance with American Cancer Society guidelines. For the purpose of this subdivision, "PSA testing" means the analysis of a blood sample to determine the level of prostate specific antigen; and

15. A provision for payment of medical assistance for low-dose screening mammograms for determining the presence of occult breast cancer. Such coverage shall make available one screening mammogram to persons age thirty-five through thirty-nine, one such mammogram biennially to persons age forty through forty-nine, and one such mammogram annually to persons age fifty and over. The term "mammogram" means an X-ray examination of the breast using equipment dedicated specifically for mammography, including but not limited to the X-ray tube, filter, compression device, screens, film and cassettes, with an average radiation exposure of less than one rad mid-breast, two views of each breast.

16. A provision for payment of medical assistance services delivered to students with disabilities who are eligible for both medical assistance and special education when such services are provided by school divisions pursuant to the special education health services programs or when such services are delivered to students eligible for medical assistance pursuant to a community health services program operated by a school division; such provision shall establish a school division participating in Medicaid through the community health centers and special education health services programs as a separate and stand-alone category of provider, with appropriate rates and professional credentials for providing medical assistance services within school divisions solely to students.

In preparing the plan, the Board shall work cooperatively with the State Board of Health to ensure that quality patient care is provided and that the health, safety, security, rights and welfare of patients are ensured. The Board shall also initiate such cost containment or other measures as are set forth in the appropriations act. The Board may make, adopt, promulgate and enforce such regulations as may be necessary to carry out the provisions of this chapter.

Before the Board acts on a regulation to be published in the Virginia Register of Regulations pursuant to § 9-6.14:7.1, the Board shall examine the potential fiscal impact of such regulation on local boards of social services. For regulations with potential fiscal impact, the Board shall share copies of the fiscal impact analysis with local boards of social services prior to submission to the Registrar. The fiscal impact analysis shall include the projected costs/savings to the local boards of social services to implement or comply with such regulation and, where applicable, sources of potential funds to implement or comply with such regulation.

The Board's regulations shall incorporate sanctions and remedies for certified nursing facilities established by state law, in accordance with 42 C.F.R. § 488.400 et seq. "Enforcement of Compliance for Long-Term Care Facilities With Deficiencies."

In order to enable the Commonwealth to continue to receive federal grants or reimbursement for medical assistance or related services, the Board, subject to the approval of the Governor, may adopt, regardless of any other provision of this chapter, such amendments to the state plan for medical assistance services as may be necessary to conform such plan with amendments to the United States Social Security Act or other relevant federal law and their implementing regulations or constructions of these laws and regulations by courts of competent jurisdiction or the United States Secretary of Health and Human Services.

In the event conforming amendments to the state plan for medical assistance services are adopted, the Board shall not be required to comply with the requirements of Article 2 (§ 9-6.14:7.1 et seq.) of Chapter 1.1:1 of Title 9. However, the Board shall, pursuant to the requirements of § 9-6.14:4.1, (i) notify the Registrar of Regulations that such amendment is necessary to meet the requirements of federal law or regulations or because of the order of any state or federal court, or (ii) certify to the Governor that the regulations are necessitated by an emergency situation. Any such amendments which are in conflict with the Code of Virginia shall only remain in effect until July 1 following adjournment of the next regular session of the General Assembly unless enacted into law.

B. The Director of Medical Assistance Services is authorized to administer such state plan and to receive and expend federal funds therefor in accordance with applicable federal and state laws and regulations; and to enter into all contracts necessary or incidental to the performance of the Department's duties and the execution of its powers as provided by law.

C. The Director of Medical Assistance Services is authorized to enter into agreements and contracts with medical care facilities, physicians, dentists and other health care providers where necessary to carry out the provisions of such state plan. Any such agreement or contract shall terminate upon conviction of the provider of a felony. In the event such conviction is reversed upon appeal, the provider may apply to the Director of Medical Assistance Services for a new agreement or contract. Such provider may also apply to the Director for reconsideration of the agreement or contract termination if the conviction is not appealed, or if it is not reversed upon appeal.

The Director may refuse to enter into or renew an agreement or contract with any provider which has been convicted of a felony. In addition, the Director may refuse to enter into or renew an agreement or contract with a provider who is or has been a principal in a professional or other corporation when such corporation has been convicted of a felony.

In any case in which a Medicaid agreement or contract is denied to a provider on the basis of his interest in a convicted professional or other corporation, the Director shall, upon request, conduct a hearing in accordance with the Administrative Process Act (§ 9-6.14:1 et seq.) regarding the provider's participation in the conduct resulting in the conviction.

The Director's decision upon reconsideration shall be consistent with federal and state laws. The Director may consider the nature and extent of any adverse impact the agreement or contract denial or termination may have on the medical care provided to Virginia Medicaid recipients.

When the services provided for by such plan are services which a clinical psychologist or a clinical social worker or licensed professional counselor or clinical nurse specialist is licensed to render in Virginia, the Director shall contract with any duly licensed clinical psychologist or licensed clinical social worker or licensed professional counselor or licensed clinical nurse specialist who makes application to be a provider of such services, and thereafter shall pay for covered services as provided in the state plan. The Board shall promulgate regulations which reimburse licensed clinical psychologists, licensed clinical social workers, licensed professional counselors and licensed clinical nurse specialists at rates based upon reasonable criteria, including the professional credentials required for licensure.

D. The Board shall prepare and submit to the Secretary of the United States Department of Health and Human Services such amendments to the state plan for medical assistance as may be permitted by federal law to establish a program of family assistance whereby children over the age of eighteen years shall make reasonable contributions, as determined by regulations of the Board, toward the cost of providing medical assistance under the plan to their parents.

E. The Department shall include in its provider networks and all of its health maintenance organization contracts a provision for the payment of medical assistance on behalf of individuals up to the age of twenty-one who have special needs and who are Medicaid eligible, including individuals who have been victims of child abuse and neglect, for medically necessary assessment and treatment services, when such services are delivered by a provider which specializes solely in the diagnosis and treatment of child abuse and neglect, or a provider with comparable expertise, as determined by the Director.

F. The Director is authorized to negotiate and enter into agreements for services rendered to eligible recipients with special needs. The Board shall promulgate regulations regarding these special needs patients, to include persons with AIDS, ventilator-dependent patients, and other recipients with special needs as defined by the Board.

Except as provided in subsection I of § 11-45, the provisions of the Virginia Public Procurement Act (§ 11-35 et seq.) shall not apply to the activities of the Director authorized by this subsection. Agreements made pursuant to this subsection shall comply with federal law and regulation.

§ 32.1-326.2. Community health centers; special education health services for children with disabilities; memorandum of agreement between the Department of Education and the Department of Medical Assistance Services.

A. The Department of Medical Assistance Services, in cooperation with the Department of Education, shall, consistent with the biennium budget cycle, examine and may revise the regulations relating to the funding and components of the pilot school/community health centers and special education health services programs.

Any revisions shall be designed to maximize access to health care for poor children, and to improve the funding by making use of every possible, cost-effective means, Medicaid reimbursement or other program administered by the Department of Medical Assistance, including, but not limited to, the State Children’s Health Insurance Plan pursuant to Title XXI of the United States Social Security Act, as approved by the federal Health Care Financing Administration at the time. Any revisions shall be based on the flexibility allowed to the states in the provision of services, focused on prevention avoidance of large costs for acute or medical care and increasing children’s access to health care, and may shall include, but need not be limited to:

1. Funding sources and means of distribution for the state match which will clearly demonstrate that local governments are not funding the state match for these the community health centers or special education health services operated by school divisions.

2. The benefits and drawbacks of allowing school divisions to provide services to disabled students as Medicaid providers.

3. The appropriate credentials of the providers of care in the school community health centers and special education health services programs, e.g., including licensure by the Board of Education and compliance with federal requirements or, when the relevant professional is not licensed by the Board of Education, the licensure required to practice such profession by a the appropriate health regulatory board within the Department of Health Professions.

4. Utilization of a form which can be incorporated into the individualized education plan, and, when signed by a physician or other appropriate practitioner, be accepted as the plan of care authorizing services.

5. Delivery of medically necessary services, such as rehabilitation, outreach administrative services, speech therapy, physical therapy, occupational therapy, and psychiatric and psychological evaluations and therapy, including such services when delivered by school psychologists licensed by the Board of Education; transportation,; and skilled nursing services, such as case management or care coordination, health assessments, screening activities, nursing appraisals, nursing assessments, medication assessment, medication monitoring, medication administration, immunizations, student health instruction, and emergency care.

6. Payment for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services, with proper medical oversight, in consultation with the students' primary care physicians.

7. The role of the Medallion and, Medallion II, Options or other managed care programs in regard to the school health centers and flexibility for school divisions regarding any required referrals.

In revising the community health centers and special education health services for students with disabilities programs, the Department shall take due consideration of the important role of school divisions in conducting outreach for its various programs.

Any funds necessary to support revisions to the school/community health center projects or special education health services programs shall be included in the budget estimates for the departments, as appropriate.

B. The Director of the Department of Medical Assistance Services or his designee and the Superintendent of Public Instruction or his designee shall develop and execute a memorandum of agreement relating to special education health services for children with disabilities. This memorandum of agreement shall be revised on a periodic basis; however, the agreement shall, at a minimum, be revised and executed within six months of the inauguration of a new governor in order to maintain policy integrity.

C. The agreement shall include, but need not be limited to, (i) requirements for regular and consistent communications and consultations between the two departments and with school division personnel and officials and school board representatives; (ii) a specific and concise description and history of the federal Individuals with Disabilities Education Act, a summary of school division responsibilities pursuant to the Individuals with Disabilities Education Act, and a summary of any corresponding state law which influences the scope of these responsibilities; (iii) a specific and concise summary of the then-current Department of Medical Assistance Services regulations regarding the community health centers and the special education health services programs; (iv) assignment of specific responsibilities of the two departments for the operation of the community health services and special education health services programs; (v) a schedule of issues to be resolved through the regular and consistent communications process, including, but not limited to, ways to ameliorate the impact of managed care on school division participation in medical assistance and mechanisms to integrate or coordinate managed care and other programs administered by the Department of Medical Assistance Services with the community health centers and special education health services; (vi) a process for the evaluation of the services which may be delivered by school division participating in Medicaid; and (vii) a plan and schedule to reduce the administrative and paperwork burden of Medicaid participation on school divisions in Virginia.

D. The Board shall develop, with the cooperation of the Board of Education, mechanisms to reduce the burden on the school divisions of determining eligibility and obtaining physicians’ orders and parental consent to services; such mechanisms shall include a clause which shall be inserted in the application forms for medical assistance services and any other programs administered by the Department of Medical Assistance Services providing for parental consent to release, in compliance with the federal Family Education Rights and Privacy Act (FERPA), 20 U.S.C. 1232q, any minor’s record for the purpose of delivery and billing by community health centers and special education health services programs pursuant to the Medicaid program. The Department of Medical Assistance Services shall state, in writing, the effect of such clause. School divisions shall, in the implementation of such clause, disclose to the parents, specifically and clearly, this consent mechanism. Such consent shall be maintained by either the Department of Medical Assistance Services or the Department of Education in accordance with the then-current memorandum of agreement.

E. The Board of Medical Assistance Services shall also (i) include, in its regulations which provide for reimbursement of mental health services, e.g., 12 VAC 30-80-30, a requirement that mental health services shall include community mental health services, services of a licensed clinical psychologist, services of a licensed school psychologist, and mental health services provided by a physician as well as licensed clinical social workers and licensed professional counselors; however, this provision shall not authorize any school psychologist licensed by the Board of Education or deemed to be licensed for purposes of medical assistance services by the Board of Psychology to practice outside the school setting unless such school psychologist is also licensed through the usual process utilized by the Board of Psychology within the Department of Health Professions; (ii) revise the limitations on services established pursuant to 12 VAC 30-50-200, any other relevant regulations, and Virginia’s plan for medical assistance services, for physical therapy, occupational therapy, and speech, hearing, and language disorders when rendered to children who are eligible for special education services by school divisions when the Individualized Education Plan (IEP) establishes the need for services beyond the limitations in effect on January 1, 1999; (iii) cooperate with the Board of Education in developing a form to be included in the IEP that shall be accepted by the Department of Medical Assistance as the plan of care when signed by a professional nurse, nurse practitioner or physician; (iv) cooperate with the Board of Education in collecting the data necessary to establish separate and specific rates for the IEP services delivered by school divisions to students with disabilities who are eligible for special education; (v) analyze the data necessary for such rates and establish new rates for reimbursement of IEP meetings based on such data; (vi) evaluate the policy relating to implementation of the IEP and reimbursement for the meeting(s) to establish the IEP to ameliorate the impact of delays between Spring meetings and Fall school openings and, therefore, implementation of IEPs; and (vii) implement a separate and distinct provider category for school divisions delivering services to children with disabilities who are eligible for special education or delivering services to children eligible for medical assistance through community health centers by revising its regulations and the Virginia state plan for medical assistance services and submitting such revised plan to the Health Care Financing Administration.

E. Services delivered by school divisions as participating providers in the Medicaid program or any other program operated by the Department of Medical Assistance Services shall not include any family planning, pregnancy or abortion services.

§ 54.1-2603. License required.

In order to practice audiology or speech pathology, it shall be necessary to hold a valid license.

Notwithstanding the provisions of subdivision 2 of § 54.1-2601 or any Board regulation, the Board of Audiology and Speech-Language Pathology shall license, as school speech-language pathologists, persons licensed as speech-language pathologists by the Board of Education. The Board of Audiology and Speech-Language Pathology shall issue licenses to such speech-language pathologists, upon presentation of a valid license from the Board of Education. The Board’s regulations shall provide for licensure of school speech-language pathologists using the same credentials and criteria for such licensure promulgated by the Board of Education.

Persons holding such dual licenses shall practice solely in public school divisions; holding a license as a school speech-language pathologist pursuant to this section shall not authorize such persons to practice outside the school setting or in any setting other than the public schools of the Commonwealth, unless such individuals are licensed by the Board of Audiology and Speech Pathology to offer to the public the services defined in § 54.1-2600.

The Board shall issue persons holding dual licenses from the Board of Education and from the Board of Audiology and Speech Pathology a license which notes the limitations on practice set forth in this section.

§ 54.1-3606. License required. In order to engage in the practice of applied psychology, school psychology, or clinical psychology, it shall be necessary to hold a license.

Notwithstanding the provisions of subdivision 4 of § 54.1-3601 or any Board regulation, the Board of shall license, as school psychologists, persons licensed as school psychologists by the Board of Education. The Board of Psychology shall issue licenses to such school psychologists, upon presentation of a valid license from the Board of Education. The Board’s regulations shall provide for licensure of school psychologists, using the same credentials and criteria for such licensure promulgated by the Board of Education.

Persons holding such dual licenses shall practice solely in public school divisions; holding a license as a school psychologist pursuant to this section shall not authorize such persons to practice outside the school setting or in any setting other than the public schools of the Commonwealth, unless such individuals are licensed by the Board of Psychology to offer to the public the services defined in § 54.1-3600.

The Board shall issue persons holding dual licenses from the Board of Education and from the Board of Psychology a license which notes the limitations on practice set forth in this section.

2. That the Boards of Education and Medical Assistance Services shall promulgate all necessary regulations to implement the provisions of this act within 280 days of its enactment.

3. That the Departments of Education and Medical Assistance Services shall report on or before December 1 of each year to the chairmen of the Senate Committees on Education and Health and Finance, and the House Committees on Education, Health, Welfare and Institutions, Finance, and Appropriations on the status of the community health services and special education health services programs and any issues which may arise. Such report may be delivered in writing or orally, upon the agreement of the relevant chairmen.