End of Flexibilities Under Section 1902(e)(14)(A)

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Bulletin

May 19, 2025, 11:44AM

To:

All Providers and Managed Care Organizations (MCOs) Participating in the Virginia Medicaid and FAMIS Programs

From:

Cheryl J. Roberts, Director Department of Medical Assistance Services (DMAS)

The purpose of this bulletin is to notify providers that, effective June 30, 2025, the Centers for Medicare and Medicaid Services (CMS) is ending the remaining flexibilities in place under 1902(e)(14)(A) of the Social Security Act. For Virginia, that means that the following flexibilities will no longer be used from July 1, 2025 forward:

Appeals

For all appeals filed, Medicaid members will automatically keep their coverage.

These flexibilities will no longer be applied to appeals filed on and after July 1, 2025.

In order for benefits to continue during an appeal filed after July 1, 2025, the continued coverage must be requested and the appeal must be filed before the date that coverage ends or within 10 days of the date of the notice of action. Repayment for coverage provided during an appeal may be sought if the appeal is lost.

For more information, visit:

https://dmas.virginia.gov/appeals/applicant-member-appeals-resources/

There will be no financial recovery for continued coverage during an appeal.

Delay scheduling of fair hearings and issuing fair hearing decisions due to an emergency beyond the state’s control.

The state may offer to continue benefits to individuals who are

requesting a fair hearing if the request comes later than the date of the action under 42 CFR 431.230.

Authorized Representative Designation

Permit the designation of an authorized representative for the purposes of signing an application or renewal form via the telephone, documented by the use of the Acknowledgment of Receipt of Verbal Consent form, without a signed designation from the applicant or beneficiary.

This flexibility will no longer be applied to applications and renewals filed on and after July 1, 2025.

To avoid disruption to claims payment through FFS and the MCOs providers must periodically check the DMAS provider portal, also known as the Provider Services Solution (PRSS), to ensure that the provider's enrollment, contact information, and license information is up to date, for all of the provider's respective service locations. Under federal rules, MCOs and DMAS are prohibited from paying claims to network providers who are not enrolled in PRSS. Additional information is provided on the MCO Provider Network Resources webpage and includes links to resources, tutorials and contact information to reach Gainwell with any provider enrollment or revalidation related questions. Dental providers should continue to enroll directly through the DMAS Dental Benefits Administrator, DentaQuest.

PROVIDER CONTACT INFORMATION & RESOURCES

Virginia Medicaid Web Portal Automated Response System (ARS)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

https://vamedicaid.dmas.virginia.gov/

Medicall (Audio Response System)

Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice.

1-800-884-9730 or 1-800-772-9996

Provider Appeals

DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal.

https://www.dmas.virginia.gov/appeals/

Managed Care Programs

Cardinal Care Managed Care and Program of All-Inclusive Care for the Elderly (PACE). In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider. The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals.

Cardinal Care Managed Care

https://www.dmas.virginia.gov/for-providers/managed-care/cardinal-care-…

PACE

Program of All-inclusive Care (virginia.gov)

Provider Enrollment

In-State: 804-270-5105

Out of State Toll Free: 888-829-5373

Email: VAMedicaidProviderEnrollment@gainwelltechnologies.com

Provider HELPLINE

Monday–Friday 8:00 a.m.-5:00 p.m. For provider use only, have Medicaid Provider ID Number available.

1-804-786-6273

1-800-552-8627