VIRGINIA MEDICAL ASSISTANCE ELIGIBILITY MANUAL

TABLE OF CONTENTS Changes

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TABLE OF CONTENTS

VIRGINIA DEPARTMENT OF MEDICAL ASSISTANCE SERVICES, MEDICAL ASSISTANCE ELIGIBILITY MANUAL

CHAPTER SUBCHAPTER

M01 APPLICATION FOR MEDICAL ASSISTANCE

GENERAL INFORMATION .........................................................M0110 MEDICAL ASSISTANCE APPLICATION .................................M0120 APPLICATION PROCESSING.....................................................M0130 RETENTION OF CASE INFORMATION ..................................M0140

M02 NONFINANCIAL REQUIREMENTS

GENERAL RULES & PROCEDURES.........................................M0210 CITIZENSHIP & ALIEN REQUIREMENTS .............................M0220 VIRGINIA RESIDENCY REQUIREMENTS..............................M0230 SOCIAL SECURITY NUMBER REQUIREMENTS..................M0240 ASSIGNMENT OF RIGHTS AND PURSUIT OF SUPPORT FROM THE ABSENT PARENT REQUIREMENTS............M0250 RESERVED......................................................................................M0260 APPLICATION FOR OTHER BENEFITS ..................................M0270 INSTITUTIONAL STATUS REQUIREMENTS.........................M0280 HIPP REQUIREMENTS ....................................................Removed 08/09

M03 MEDICAID COVERED GROUPS

GENERAL RULES & PROCEDURES.........................................M0310 AGED, BLIND & DISABLED GROUPS .....................................M0320 FAMILIES & CHILDREN GROUPS ...........................................M0330

M04 MODIFIED ADJUSTED GROSS INCOME (MAGI) M05 MEDICAID ASSISTANCE UNIT GENERAL RULES & PROCEDURES.........................................M0510 FAMILIES & CHILDREN (F&C) FAMILY/BUDGET UNIT ........................................................M0520 ABD ASSISTANCE UNIT ..............................................................M0530

M06 FAMILIES AND CHILDREN RESOURCES GENERAL--F&C RESOURCE .....................................................M0610 IDENTIFYING RESOURCES .......................................................M0620 F&C EXCLUDED RESOURCES ..................................................M0630 TYPES OF COUNTABLE RESOURCES ....................................M0640

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M07 FAMILIES AND CHILDREN INCOME

GENERAL--F&C INCOME RULES ............................................M0710 F&C WHAT IS NOT INCOME .....................................................M0715 F&C EARNED INCOME ...............................................................M0720 F&C UNEARNED INCOME .........................................................M0730

M08 ABD INCOME

GENERAL--ABD INCOME RULES............................................M0810 WHAT IS NOT INCOME..............................................................M0815 EARNED INCOME........................................................................M0820 UNEARNEDINCOME ...................................................................M0830

M11 ABD RESOURCES

RESOURCES, GENERAL ............................................................M1110 IDENTIFYING RESOURCES.......................................................M1120 RESOURCES EXCLUSIONS........................................................M1130 TYPES OF COUNTABLE RESOURCES....................................M1140

M13 SPENDDOWN

SPENDDOWN GENERAL PRINCIPLES AND DEFINITIONS .................................................................M1310 SPENDDOWN INFORMATION...................................................M1320 SPENDDOWN BUDGET PERIODS .............................................M1330 SPENDDOWN DEDUCTIONS ......................................................M1340 CHANGES PRIOR TO MEETING SPENDDOWN....................M1350 CHANGES AFTER SPENDDOWN IS MET ...............................M1360 SPENDDOWN - LIMITED BENEFIT ENROLLEES.............................................................................M1370

M14 LONG-TERM CARE

GENERAL RULES .........................................................................M1410 AUTHORIZATION FOR MEDICAID LTSS..................................M1420 FACILITY CARE............................................................................M1430 COMMUNITY-BASED CARE ......................................................M1440 TRANSFER OF ASSETS................................................................M1450 LTC FINANCIAL ELIGIBILITY .................................................M1460 PATIENT PAY - POST-ELIGIBILITY TREATMENT OF INCOME ..............................................................................M1470 MARRIED INSTITUTIONALIZED INDIVIDUALS ELIGIBILITY & PATIENT PAY............................................M1480

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M15 ENTITLEMENT POLICY & PROCEDURES

MEDICAID ENTITLEMENT........................................................M1510 MEDICAL ASSISTANCE ELIGIBILITY REVIEW..................M1520 DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES (DBHDS) FACILITIES ................................................................................M1550

M16 APPEALS PROCESS

M17 MEDICAID FRAUD AND RECOVERY M18 MEDICAL SERVICES M20 EXTRA HELP – MEDICARE PART D LOW-INCOME SUBSIDY

M21 FAMILY ACCESS TO MEDICAL SECURITY INSURANCE PLAN (FAMIS)

M22 FAMIS MOMS

M23 FAMIS PRENATAL COVERAGE

CHAPTER M01

APPLICATION FOR MEDICAL ASSISTANCE

M01 Changes

Changed With Effective Date Pages Changed TN #DMAS-17 7/1/20 Table of Contents, page ii was added. Transmittal (TN) #97 9/1/12 Table of Contents

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M01 APPLICATION FOR MEDICAL ASSISTANCE

SUBCHAPTER Page

General Information M0110

Legal Base and Agency Responsibilities ......................... M0110.100.................................... 1

Definitions ......................................................................... M0110.200.................................... 5

Availability of Information .............................................. M0110.300.................................... 7

Retention of Case Information ........................................ M0110.400.................................. 10

Virginia DSS Strengthening Families Initiative Practice Model.......................................... M0110.500 ................................. 13

Virginia DSS Strengthening Families Initiative Practice Model (Full) ............................................... Appendix 1 .................................. 1

Medical Assistance Application M0120

Right to Apply ................................................................... M0120.100.................................... 1

Who Can Sign the Application ........................................ M0120.200.................................... 1

Medical Assistance Application Forms .......................... M0120.300.................................... 8

Place of Application ......................................................... M0120.400.................................. 11

Receipt of Application ...................................................... M0120.500.................................. 15

When An Application Is Required ................................. M0120.500.................................. 15

Sample Letter Requesting Signature .............................. Appendix 1 ................................. 1

The Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) Medicaid Application, form #032-03-384……………………Appendix 2 ................................. 1

Interstate Compact on Adoption and Medical Assistance (ICAMA) Member States and Reciprocity……..…Appendix 3 ................................ 1

Application Processing M0130

Processing Time Standards ............................................. M0130.100 ................................... 1

Required Information and Verifications ....................... M0130.200 ................................... 3

Eligibility Determination Process ................................... M0130.300 ................................... 8

Applications Denied Under

Special Circumstances .......................................... M0130.400 ................................. 11

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Incarcerated Individuals M0140

General Information ....................................................... M0140.000 ................................... 1

Communication ................................................................ M0140.100 ................................... 2

Application Guidelines ..................................................... M0140.200 ................................... 2

Case Maintenance ............................................................ M0140.300 .................................. 2

CHAPTER M01

APPLICATION FOR MEDICAL ASSISTANCE ____ ________ SUBCHAPTER 10

GENERAL INFORMATION

M0110 Changes

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M0110 GENERAL INFORMATION

M0110.000 GENERAL INFORMATION

Section

Page

Legal Base and Agency Responsibilities ....... . ................... M0110.100 ........................................ 1

Confidentiality .................................... .................... .M0110.110 ....................................... 2a

Address Confidentiality Program ..... .................... .M0110.120 ....................................... 7

Definitions ................................................................................... M0110.200 ........................................ 7

Availability of Information ..................................................... M0110.300 ............................................ 9

Retention of Case Information ............................................. M0110.400 ....................................... 15

Virginia DSS Strengthening Families Initiative Practice Model ................................................. M0110.500 ....................................... 16

Appendices

Virginia DSS Strengthening Families Initiative Practice Model (Full) ................................................... Appendix 1 ...................................... 1

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M01 July 2020 Subchapter Subject Page ending with Page M0110.000 GENERAL INFORMATION M0110.100 1

M0110 General Information

M0110.100 Legal Base and Agency Responsibilities

A. Introduction Virginia’s two medical assistance programs are Medicaid and the Family Access to Medical Insurance Security Plan (FAMIS). Collectively, these programs are referred to as medical assistance (MA). The MA programs pay medical service providers for medical services rendered to eligible individuals. When an individual submits an application for MA, his eligibility is determined for Medicaid first. If he is not eligible for Medicaid due to excess income, his eligibility is determined for FAMIS. The policies and procedures for determining Medicaid eligibility are contained in Chapters 1 through 18 of this manual; the policies and procedures for determining FAMIS eligibility for children and pregnant women (FAMIS MOMS) are contained in Chapters 21 and 22, respectively. The MA eligibility determination consists of an evaluation of an individual's situation that compares each of the individual's circumstances to an established standard. Requests for Virginia MA must be made on an approved electronic or paper application form or telephonically through the Cover Virginia Call Center. All activity of the agency in receiving and acting upon an application must be consistent with the objectives of the MA programs and be conducted in a manner which respects the personal dignity and privacy of the individual. The local agency must provide timely, accurate, and fair service to all applicants and recipients. Each local agency must establish office procedures and operations that accommodate the needs of the populations it serves. The local agency must not establish any polices, regulations, or rules that create a barrier to accessing benefits. Populations with special needs include households with elderly or disabled members, homeless households, and households with members who work during normal office hours. The local agency must provide bilingual staff and interpreter services to households with limited English proficiency. B. Legal Base The Medicaid Program is established under Title XIX of the Federal Social Security Act and is financed by state and federal funds. The State Plan for Medical Assistance (State Plan) is the official body of regulations covering the operation of the Medicaid program in Virginia. The FAMIS program is established under Title XXI of the Social Security Act. Virginia law provides that the MA programs be administered by the Department of Medical Assistance Services (DMAS). Determination of eligibility for medical assistance is the responsibility of local departments of social services under the supervision of the Virginia Department of Social Services (DSS).

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C. Agency Responsibilities 1. DMAS The administrative responsibilities of DMAS are:

• the development of the State Plan to cover eligibility criteria and scope of services, in conformity with federal law and regulation,

• the determination of medical care covered under the State Plan,

• oversight of the Cover Virginia Call Center, the Central Processing Uni (CPU), which handles telephonic applications for MA, and the Cover Virginia Incarcerated Unit (CVIU).

• the handling of appeals related to the MA programs,

• the approval of providers authorized to provide medical care and receive payments under the MA programs,

• the processing of claims and making payments to medical providers, and • the recovery of MA expenditures in appropriate cases. Suspected applicant fraud is a combined responsibility of both DMAS and DSS. 2. DSS The responsibilities of DSS are: • the determination of continuing eligibility for Medicaid and FAMIS,

• the referral of individuals with inappropriate MA payments to the DMAS Recipient Audit Unit, and

• the referral of certain individuals to the Health Insurance Marketplace.

3. DSS/Cover Virginia Certain processes are handled at DSS or at Cover Virginia, with general responsibilities that may include:

• the determination of initial eligibility for Medicaid and FAMIS, including applications referred from the Health Insurance Marketplace,

• the enrollment of eligible persons in the Medicaid or FAMIS programs,

• the maintenance of case records pertaining to the eligibility of MA enrollees for certain populations or aid categories.

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M01 October 2016 Subchapter Subject Page ending with Page M0110.000 GENERAL INFORMATION M0110.110 2a

M0110.110 Confidentiality

A. Confidentiality MA applicants and recipients are protected by federal and state confidentiality regulations, 42 CFR 431.300 and 12VAC30-20-90. These regulations were established to protect the rights of clients to confidentiality of their information. B. Release of Client Information Except as otherwise indicated, no person shall obtain, disclose or use, authorize, or permit the use of any client information that is directly or indirectly derived from the records, files or communications of the agency, except for purposes directly connected with the administration of the MA programs, which include but is not limited to: • establishing eligibility,

• determining the amount of medical assistance,

• providing services for recipients, and

• conducting or assisting in an investigation, prosecution or a civil or criminal proceeding related to the administration of the program.

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C. Use of System Searches Searches of online information systems, including but not limited to the State Online Query-Internet (SOLQ-I),the State Verification Exchange System (SVES), and the Federal Data Hub, are permitted only for applicants and family members whose income and/or resource information is required to determine eligibility for the applicant or patient pay for an enrollee. This includes spouses of applicants and parents of child applicants. Searches of the Asset Verification System (AVS) are permitted only for applicants with a resource test. The Federal Data Hub and AVS are to be accessed only for information necessary to determine eligibility for MA cases processed in the Virginia Case Management System (VaCMS). They may not be used for other public assistance programs. D. Release of Information to Medical Providers Although certain individuals are authorized to receive information about an applicant’s/recipient’s case, only the minimum data necessary to respond to the request is to be released. Federal regulations stipulate that the disclosure of information about an applicant or recipient can only be for purposes related to administration of the Medicaid State Plan. Information in the case record related to an individual’s medical treatment, or method of reimbursement for services may be released to Virginia MA providers by DMAS without the applicant’s/enrollee’s consent. Enrollee consent is not needed for the DSS agency to provide confirmation of an individual’s eligibility, the dates of eligibility, and any patient pay responsibility if the medical provider is unable to obtain that information from the member verification system or from DMAS staff. The provider is not entitled to specific information about an applicant’s/recipient’s income or resources because the provider does not need that information for medical treatment or payment. Provider contractors, such as application assistance companies, operate under the authority of the provider. A patient’s consent is not required for the agency to provide the contractor with information related to reimbursement for services rendered or medical treatment. Providers and their contractors are not entitled to receive detailed financial or income information contained in an applicant’s or recipient’s case record. Information should not be provided from case records unless the release of such information is for purposes directly related to the administration of the MA programs. Local agencies may release MA enrollee identification numbers to medical providers by telephone if the provider cannot contact the DMAS provider/recipient verification telephone number. This procedure does not conflict with federal or State confidentiality regulations, if the local agency is satisfied that the number is being released to an identifiable provider. E. Release to Authorized Representatives and Other Application Assistants

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1. Authorized Represent- atives Individuals not determined to be incapacitated by a court can designate whomever they choose to be their authorized representatives, including a provider or a provider’s contractor (such as an application assistance company). The designation must be in writing, with the applicant or recipient specifying the information to be released to the authorized representative.

It is not sufficient to indicate that any information in the case record may be released; the designation must state the specific information to be released (i.e. notices, the ability to make application or provide information necessary to determine eligibility, and what, if any, other information can be released to the authorized representative). The authorized representative designation is valid until:

• the application is denied; • medical assistance coverage is canceled; or • the individual changes his authorized representative. The authorized representative can file an appeal on behalf of an individual whose application was denied or canceled. The DMAS Appeals Division will determine whether or not the authorized representative can represent the individual during the appeal.

2. Application Assisters Application assisters are authorized under the Affordable Care Act (ACA) to provide assistance with completing the MA application and renewal, and with explaining and helping the individual to meet documentation requirements. They must be authorized by the individual to provide assistance with completing the application and/or renewal. There are two categories of application assisters:

a. Certified Application Counselors (CAC) CAC are individuals authorized to assist individuals with obtaining health insurance coverage, including Medical Assistance. CAC are generally under the supervision of a non-profit organization and do not receive a fee for providing application counseling.

b. Navigators Navigators receive federal funding to assist individuals with obtaining health insurance coverage, including Medical Assistance.

Application assisters cannot sign forms, receive notices or other communications or otherwise act on behalf of the individual and do not have the same CommonHelp system privileges as authorized representatives.

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Certified Application Counselors and Navigators are designated on the MA application and are deemed to have client consent to release information without an additional release of information form. The client may revoke his consent to the release of information at any time by notifying the LDSS verbally or in writing. The revocation of consent or statement is to be documented in the case record. F. Safeguarding Client Information All information associated with an applicant or recipient that could disclose the individual’s identity is confidential and shall be safeguarded. Such information includes but is not limited to: • name, address, and all types of identification numbers assigned to the client; • medical services provided to the client;

• social and economic conditions or circumstances of the client; • agency evaluation of the client's personal information;

• medical data about the client, including diagnoses and past histories of disease or disabilities;

• information received for verifying income, eligibility, and amount of medical assistance payments; • information received in connection with identification of legally liable third party resources; and • information received in connection with processing and rendering decisions of recipient appeals.

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G. Ownership of Records All client information contained in the agency records is the property of the agency, and employees of the agency shall protect and preserve such information from dissemination except as indicated. Original client records are not to be removed from the premises by individuals other than authorized staff of the agency, except by court order. The agency may destroy records pursuant to records retention schedules. H. Release of Client Information with Consent As part of the application process for MA, the client shall be informed of the need to consent to the release of information necessary for verifying eligibility. Whenever a person, agency or organization that is not performing one or more of the functions described in M0110.110 B above requests client information, the agency must obtain written permission to release the information from the client or the person legally responsible for the client whenever possible. A release for information obtained from the client by the requesting agency also satisfies this requirement. Certified Application Counselors and Navigators are designated on the MA application and are deemed to have client consent to release information without an additional release of information. The client may revoke his consent to the release of information at any time by notifying the LDSS verbally or in writing. The revocation of consent is to be documented in the case record. I. Release of Client Information without Consent Information from the applicant/recipient's case record may not be released to other agencies, such as public housing agencies, legal services, private organizations, the U.S. Citizenship and Immigration Services (USCIS), Virginia Employment Commission (VEC), school lunch programs, health departments or elected officials beyond what is specified in interagency agreements as described below without the client's consent. An exception applies to agencies with which there is an agreement for specific types of sharing of information, such as wage information from the VEC, Systematic Alien Verification for Entitlements (SAVE) with USCIS, the State Verification Exchange System (SVES) with the Social Security Administration, etc. Client information may be disclosed without client consent in the following situations: 1. Social Services Employees to employees of state and local departments of social services for the purpose of program administration;

2. Program Staff in Other States to program staff in other states when a client moves or when there is a question of dual participation, or to verify the status of assistance in Virginia for applicants in another state; 3. DMAS & LDSS Staff between state/local department of social services staff and DMAS for the purpose of supervision and reporting;

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4. Auditors to federal, state and local employees for the purposes of auditing, monitoring, and evaluation; and 5. For Recovery Purposes for the purpose of recovery of monies for which third parties are liable for payment of claims. 6. Law Enforcement Agencies when the request is made under a court order, such as a search warrant or subpoena, and the release of information is not prohibited under state or federal law, including the Health Insurance Portability and Accountability Act (HIPAA). Local departments of social services are advised to consult with the agency’s legal counsel prior to releasing information requested by law enforcement agencies. J. Client’s Right of Access to Information Any client has the right to obtain personal information held by the agency. Upon written or verbal request, the client shall be permitted to review or obtain a copy of the information in his record with the following exceptions: • Information that the agency is required to keep confidential from the client pursuant to §2.2-3704 and §2.2-3705, Code of Virginia, Virginia Freedom of Information Act, Public Records to be open to Inspection; and • Information that would breach another individual's right to confidentiality 1. Freedom of Information Act (FOIA) Consistent with the Virginia Freedom of Information Act, §2.2-3704 and §2.2- 3705, Code of Virginia, the agency shall provide access within five working days after the receipt of the request. The agency shall make disclosures to applicants and recipients during normal business hours. Copies of the requested documents shall be provided to the client or a representative at reasonable standard charges for document search and duplication. 2. Client May Be Accompanied The client shall be permitted to be accompanied by a person or persons of the client's choice and may grant permission verbally or in writing to the agency to discuss the client's file in such person's presence. Upon request and proper identification of any client or agent of the client, the agency shall grant to the client or agent the right to review the following: • All personal information about the client except as provided in §2.2-3704 and §2.2-3705, The identity of all individuals and organizations not having regular access authority that request access to the client's personal information. 3. Client May Contest Information Pursuant to the Code of Virginia §2.2-3800, a client may contest the accuracy, completeness or relevancy of the information in his record. Correction of the contested information, but not the deletion of the original information if it is required to support receipt of state or federal financial participation, shall be inserted in the record when the agency concurs that such correction is justified.

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When the agency does not concur, the client shall be allowed to enter a statement in the record refuting such information. Corrections and statements shall be made a permanent part of the record and shall be disclosed to any entity that receives the disputed information.

M0110.120 Address Confidentiality Program (ACP)

A. Purpose The Virginia Attorney General’s Office’s ACP was created to help a victim of domestic violence who has recently moved to a new location that is unknown to the abuser. The victim wants to keep the new address confidential. Effective July 1, 2011, this program was made available statewide. B. All Mail Goes to Richmond P.O. Box Address The ACP offers a substitute mailing address for the individual in a high risk situation. An individual participating in the ACP will have an ACP authorization card that can be used to verify participation in the program; a participant will use a post office box address in Richmond as his address. This address is to be accepted as a mailing address. No locality, FIPS code, or other geographic identification is included on the ACP authorization card. The actual physical address of the participant MUST NOT be entered in into any of the VDSS automated systems. Only the mailing address (which is P.O. Box 1133, Richmond, Virginia, 23218) is entered into the computer systems as the participant’s residence address; no separate mailing address is entered.

C. Accept Participant’s Verbal Statement of Residency Virginia state residency and locality residency is established by the participant’s verbal statement that he is residing in the locality where he is applying for assistance. D. Third Party Liability (TPL)

When an individual in the ACP is covered on the abuser’s private health insurance plan (TPL), do not add the TPL coverage in the enrollment system. For an individual with TPL who is already receiving MA at the time of entry into the ACP, delete the TPL. Notify the DMAS TPL Unit by e-mail at tplunit@dmas.virginia.gov to ensure that the insurance is not billed or added back to the individual’s case record upon a subsequent data match with the insurance company. E. Refer to Local Domestic Violence Program Please refer any victims of domestic violence to the local Domestic Violence Program for consideration of the ACP, for safety planning, and other services. Local domestic violence advocates are currently receiving training about the ACP. In most localities, the applications for the ACP program will be completed with the DV advocates as a part of in depth safety planning.

M0110.200 Definitions

A. Adult Relative means an individual who is age 18 or older, who is not a parent, but who is related to a child by blood or marriage and who lives with and assumes responsibility for day-to-day care of the child in a place of residence maintained as his or their own home. B. Applicant means an individual who has directly or through his authorized representative made written application for MA at the local social services department serving the locality in which he is a resident, or if institutionalized, the locality in which he last resided outside an institution.

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C. Application for Medical Assistance means an official form prescribed by DMAS for requesting medical assistance that is used for initial eligibility determinations and redeterminations. An application for medical assistance is an application for the Medicaid, Family Access to Medical Insurance Security (FAMIS) and FAMIS MOMS programs. D. Attorney-In-Fact (Named in a Power of Attorney Document) means a person authorized by a power of attorney document (also referred to as a “POA”) to act on behalf of another individual, either for some particular purpose or for the transaction of business in general. A power of attorney document does not necessarily authorize the attorney-in-fact to apply for MA on behalf of the applicant. The eligibility worker must read the power of attorney document to determine (1) if the person has the power to act as the applicant in any of the applicant's business and (2) whether or not the document grants durable power of attorney. If the document is a general power of attorney or includes the power to conduct the applicant's financial business, the attorney-in-fact is considered the applicant's authorized representative as long as the person for whom the attorney-in-fact is authorized to act is not legally incapacitated.

If the individual on whose behalf the attorney-in-fact is acting is incapacitated and not able to act on his own behalf, the eligibility worker must examine the document to determine if it grants a durable power of attorney. The contents of the document must indicate that the power of attorney does not stop upon the incapacity of the person. If the power of attorney is not durable, it is no longer valid when the individual on whose behalf it is executed becomes legally incapacitated. E. Authorized Representative An authorized representative is a person age 18 years or older who is authorized to conduct business for an individual. A competent individual age 18 years or older must designate the authorized representative in a written statement (which defines the representative’s responsibilities). The authorized representative statement is valid until: • the application is denied; • medical assistance coverage is canceled; or • the individual changes his authorized representative. The authorized representative can file an appeal on behalf of an individual whose application was denied or canceled. The DMAS Appeals Division will determine whether or not the authorized representative can represent the individual during the appeal. The authorized representative of an incompetent or incapacitated individual is the individual’s spouse, parent, attorney-in-fact (person who has the individual’s power-of-attorney), legally appointed guardian, legally appointed conservator (committee), or family substitute representative. An individual’s spouse is permitted to be an authorized representative for MA purposes as long as the spouse and applicant are living together, or lived together immediately before the applicant’s institutionalization; no written designation is required.

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F. Child means an individual under age 21 years. G. Competent Individual means an individual who has not been judged by a court to be legally incapacitated. H. Conservator means a person appointed by a court of competent jurisdiction to manage the estate and financial affairs of an incapacitated individual. I. Family Substitute Representative means a spouse age 18 or older or designated relative age 18 or older who is willing and able to take responsibility for the individual's personal or financial affairs. Designated relatives other than the spouse who may be substitute representatives are, in this preferred order, the individual's child, parent, sibling, grandchild, niece or nephew, aunt or uncle. J. Guardian means a person appointed by a court of competent jurisdiction to be responsible for the personal affairs of an incapacitated individual, including responsibility for making decisions regarding the person's support, care, health, safety, habilitation, education, and therapeutic treatment, and if not inconsistent with an order of commitment, residence. K. Incapacitated Individual means an individual who, pursuant to an order of a court of competent jurisdiction, has been found to be incapable of receiving and evaluating information effectively or responding to people, events, or environments to such an extent that the individual lacks the capacity to (1) meet the essential requirements of his health, care, safety, or therapeutic needs without the assistance or protection of a guardian; or (2) manage property or financial affairs or provide for his or her support or the support of his legal dependents without the assistance or protection of a conservator. L. Legal Emancipation of a Minor means a minor who has been declared emancipated by a court of competent jurisdiction. A married minor is not emancipated unless a court has declared the married minor emancipated from his parents. M. Incarcerated Individual means an inmate or offender in a Department of Corrections (DOC), local/regional jail, or Department of Juvenile Justice (DJJ) facility. N. Medical Assistance means any program administered by DMAS jointly with the Department of Social Services (DSS) that helps individuals or families pay for medical, dental and related health services. These programs are Medicaid, FAMIS and FAMIS MOMS.

M0110.300 Availability of Information

A. Information Required to be Given to the Applicant

1. Explanation of the Medical Assistance Programs The local agency must furnish the following information in written form, and orally as appropriate, to all applicants and enrollees, and to other individuals upon request:

• the eligibility requirements, • services covered under the MA programs,

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• the rights and responsibilities of applicants and enrollees, and • the appeals process.

When the MA rights and responsibilities are explained verbally, the eligibility worker must document in the case record (electronic or hard copy) that they were explained and the applicant/enrollee’s acknowledgement. The applicant/enrollee’s failure to acknowledge receipt of the rights and responsibilities is not a condition for MA eligibility and cannot be used to deny, delay or terminate MA coverage.

The following materials must be given to the individuals specified below:

• The brochure "Virginia Department of Social Services Division of Benefit Programs,” form # B032-01-0002, contains information about the Medicaid Program and must be given to all applicants;

• The Division of Child Support Enforcement (DCSE)’s booklet "Child Support and You," form #032-01-945 must be given to applicants who are applying on behalf of a child who has an absent parent; and • The Medicaid and FAMIS Handbooks are available online at. https://coverva.org/en/member-handbooks. A printed copy of the handbook corresponding to the individual’s enrollment or request must be given to anyone who requests a hard copy. Applicants may also be given MA Fact Sheets as appropriate.

2. Early Periodic Screening, Diagnosis and Treatment (EPSDT) All Medicaid applicants who are under age 21 are eligible for Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services. Information on the availability and benefits of EPSDT must be provided for all applicants under age 21 within 60 days of the date that eligibility is determined. EPSDT information is included in the booklet "Virginia Social Services Benefit Programs."

3. Voter Registration The National Voter Registration Act of 1993 (NVRA) requires local social services agencies to offer each Temporary Assistance to Needy Families (TANF), Supplemental Nutrition Assistance Program (SNAP), and MA applicant an opportunity to apply to register to vote at initial application and at each review of eligibility. Additionally, voter registration application services must be provided any time a change of address is reported in person to the local agency.

In complying with the requirements of the NVRA, local agency staff must provide each applicant and enrollee the same degree of assistance in completing his/her voter registration application as they do in completing the application for public assistance.

a. Exceptions to Offering Voter Registration

The only exception to offering voter registration application services is when:

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• the individual has previously indicated that he is currently registered to vote where he lives,

• there is a completed agency certification form in the individual’s case record indicating the same, and

• the individual has not moved from the address where he stated that he was registered to vote.

b. Prohibitions Local social services agencies and agency staff are prohibited from the following activities when providing voter registration application services: • seeking to influence an individual’s political preference;

• displaying any political preference or party affiliation;

• making any statement to the or taking any action the purpose or effect of which is to discourage the individual from applying to register to vote; or

• making any statement to an individual or taking any action the purpose of which is to lead the individual to believe that a decision to register or not register has any impact on the individual's eligibility for assistance or the benefit level that they may be entitled to receive. c. Voter Registration Services Each local social services agency must provide the following voter registration services: • distribution of voter registration application forms; • assistance to individuals in completing the registration application form, unless such assistance is refused, and ensuring that all spaces on the form are completed;

• ensuring that the certification statement on the application for benefits or statement of facts is completed; and • acceptance of voter registration application forms for transmittal to the local general registrar.

1) Each completed registration application must be submitted to the local general registrar every Friday (if Friday is a holiday, the forms must be forwarded to the local registrar on the last working day before Friday.) Completed forms are to be forwarded to the local registrar in an envelope, notated with an "A" in the upper left-hand corner and listing the number of completed registration applications included in the envelope.

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1) For split/combined agencies, all voter registration applications are to be transmitted to the general registrar in the locality where the local social services agency is located. 2) If the individual chooses, he may take a voter registration application to be mailed to the State Board of Elections at his own cost. d. Voter Registration Application In Virginia, one voter registration application form will be used to serve a twofold purpose: • the voter registration application will be completed by the individual with necessary assistance from local agency staff during the application/review process and left at the local agency for transmittal to the local general registrar; or

• for individuals who do not wish to complete the voter registration during the application process, they may take a voter registration form for mail- in registration. e. Individuals Required to be Offered Voter Registration Services In order to be offered voter registration services, an individual must: • be a member of the MA household or family unit. • be at least 18 years old by the next general election. General elections are held in all localities on the Tuesday after the first Monday in November or on the first Tuesday in May to fill offices regularly scheduled by law to be filled at those times. If any question arises as to whether the individual will turn 18 before the next general election, complete the registration application and the local registrar will determine if the individual may be registered.

• be present in the office at the time of the application or renewal interview if an interview takes place, or when a change of address is reported in person. If a change of address is not reported in person, a registration application will be sent to the individual upon request. Any change in the household composition that does not occur concurrent with an application, renewal or change of address will be handled at the next scheduled renewal. Any individual accompanying the applicant/enrollee to the local agency who is not a member of the assistance unit (including payees and authorized representatives) will not be offered voter registration services by the local agency. However, a registration application is to be provided to the non-unit member upon request.

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Any request for a mail-in application for assistance must include a mail-in voter registration application. When an authorized representative is applying on another individual's behalf, the local agency is to offer a mail-in voter registration application. In both situations, the bottom of the certification form is to be completed accordingly. f. Voter Registration Application Sites Local social services agencies are required to offer voter registration application services at each local office (including satellite offices) for applicants/recipients of TANF, SNAP, and Medical Assistance. Voter registration application services are also offered by out-stationed staff taking MA applications at hospitals or local health departments and by Medicaid staff at the state's Department of Behavioral Health and Developmental Services’ facilities. B. Information Made Available to the Public in General 1. Availability of Manual Federal regulations require copies of the State Plan and eligibility rules and policies to be available in agency offices and other designated locations. Policy manuals must be made available in agency offices and other designated locations to individuals who ask to see them.

Upon request, copies of program policy materials must be made available without charge or at a charge related to the cost of reproduction. Copies of manual pages may be made at the local departments of social services. The full Medical Assistance Eligibility Manual is available on the DMAS web site at http://www.dmas.virginia.gov/#/assistance.

2. MA Handbooks and Fact Sheets Federal regulation 42 CFR 435.905 requires the state agency to publish bulletins or pamphlets describing eligibility in easy to understand language. The handbooks available for each MA program include basic information about the programs and provide a listing of rights and responsibilities. To supplement the MA handbooks, fact sheets that explain specific policy areas are available to local social services agencies from the state department of social services. A copy of the handbook corresponding to the program in which the individual was enrolled must be given to all recipients after enrollment and must be given to others upon request. The Medicaid handbooks are available on the internet at http://www.dmas.virginia.gov/#/clientservices. The FAMIS Handbook is available at http://www.coverva.org/programs_famis.cfm. C. Inquiries 1. General Inquiries The following information has been developed to give guidance to employees of the State and local departments of social services about how to respond to inquiries:

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• Limit verbal and written information to explaining the written materials provided. Those written materials may include copies of manual pages, MA handbooks, or fact sheets. The individual may also be referred to the Virginia Department of Social Services website at www.dss.virginia.gov and the Virginia Department of Medical Assistance Services website at www.dmas.virginia.gov for additional information. • Do not go beyond the scope of the written materials. Questions about hypothetical situations, such as (but not limited to) "what would happen if a certain value of resources were transferred?" or "what would be the effect on Medicaid if a trust were written in a certain way?" should not be answered. Medicaid rules and policies are applied to the facts of a specific application after an application is received. Prior to receipt, do not give hypothetical advice or answers to hypothetical questions to applicants, their attorneys or anyone applying on behalf of the applicant. Answering hypothetical questions is inappropriate for two reasons: • Until a complete application is received, the local agency cannot be sure it has all the relevant facts. An attempt to be helpful could be futile or lead to incorrect advice. In the event of a dispute, the applicant may then assert that the agency is bound by the incorrect advice. The applicant or other persons affected by the applicant's actions (such as those affected by a property transfer or those otherwise responsible for the care of the applicant) may attempt to hold the agency employee or employees involved individually liable for damages suffered as a result of alleged negligent advice.

• Providing responses to hypothetical questions may under some circumstances constitute the practice of law. The practice of law includes advising another for compensation, direct or indirect, in any matter involving the application of legal principles to facts or purposes or desires. Local agency workers, regional MA consultants, and central office MA employees, even if they are attorneys, are not functioning as legal counsel and must not give legal advice which may affect the rights of applicants, recipients, or others who may not be applying or eligible for MA. All MA staff are bound by these guidelines for the dissemination of information. Do not refer inquiries from attorneys, applicants or others acting on behalf of the applicant to regional or state MA staff. 2. Case Specific Inquiries Send questions that occur as a direct result of the receipt of an application to the regional MA consultant. Do not refer questions from attorneys (or legal questions in general) to the Office of the Attorney General. These attorneys are responsible for providing legal advice to the regional MA consultant and are not authorized to give legal advice to the public.

M0110.400 Retention of Case Information

A. Introduction The agency must maintain case records that contain information necessary to support the facts essential to the determination of initial and continuing eligibility as well as any basis for discontinuing or denying assistance. The case record shall consist of a hard (i.e. paper) record, an electronic record, or a combination of the two. To be stored electronically in the individual’s case record in the Virginia Case Management System (VaCMS), a document is scanned into VaCMS using the Document Management Imaging System (DMIS). Records of active cases must be maintained for as long as the client receives benefits. Closed records must be maintained for a minimum of three years from the date of closure. B. Policy Case records must contain the following elements: • the date of application, • the date of and basis for the disposition of the application, • facts essential to the determination of initial and continuing eligibility, • the provision of medical assistance (i.e. enrollment), • the basis for discontinuing medical assistance, • the disposition of income and eligibility verification information, and • the name of the agency representative taking action on the case and the date of the action. The agency must include in each applicant’s case record documentation to support the agency’s decision on his application and the fact that the agency gave recipients timely and adequate notice of proposed action to terminate, discontinue or suspend their eligibility or to reduce or discontinue services they may receive under the medical assistance programs. Types of documentation that support the agency’s decision include evaluations of eligibility, case narratives, and permanent verifications. Verifications of earned and unearned income, documentation of reasonable compatibility and the current value of resources (if applicable) must be maintained in the record. Notes by the eligibility worker that the verifications were viewed are not sufficient; income reasonable compatibility and electronic verification of income should be documented in case comments. The case record must contain a duplicate, either electronically or in writing, of all notices sent to the client. Copies of the documents used for verification of citizenship and identity, such as birth certificates, must also be maintained within the case record. Active cases may be purged with the exception of documentation that supports the information shown in the paragraphs above. Agencies may wish to retain other information used in future eligibility determinations, such as resource assessments and burial contracts. Closed cases are required to be retained by the agency for a period of no less than three years from the date of closure. The case record shall be organized as to enable audit and program integrity entities to properly discharge their respective responsibilities for reviewing the manner in which the MA programs are being administered.

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M0110.500 VIRGINIA DSS STRENGTHENING FAMILIES INITIATIVE PRACTICE MODEL

A. Introduction The Virginia DSS Strengthening Families Initiative (SFI) Practice Model sets forth standards of professional practice and serves as a values framework to define relationships, guide thinking and decision-making, and structure beliefs about individuals, families, and communities. The Practice Model suggests a desired approach to working with and delivering services to Virginia’s citizens.

B. Practice Model Principles The principles of the Practice Model are:

1. All children, adults and communities deserve to be safe and stable. 2. All individuals deserve a safe, stable and healthy family that supports them through their lifespan. 3. Self‐sufficiency and personal accountability are essential for individual and family well‐being. 4. All individuals know themselves best and should be treated with dignity and respect. 5. When partnering with others to support individual and family success, we use an integrated service approach. 6. How we do our work has a direct impact on the well‐being of the individuals, families, and communities we serve.

M0110, Appendix 1 contains the full SFI Practice Model.

C. Policy Medicaid and other benefit programs are designed to provide supportive benefits to assist families who are unable to provide the necessities of life and maintain minimum standards of health and well-being through their own efforts. Gathering relevant information about a family's situation and evaluating that information against the eligibility criteria for the benefit programs are the basis for making the eligibility determinations. The process of gathering relevant information also includes an assessment of need for service programs and other resources to assist the family. This process includes following the Practice Model described above. If other needs exist, the eligibility worker must refer the family for appropriate services or resources within the agency or community. Eligibility workers may consult with their supervisors and other agency staff as necessary to gather information to facilitate making such referrals.

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Virginia Department of Social Services Strengthening Families Initiative Practice Model

The Virginia Department of Social Services Practice Model sets forth our standards of professional practice and serves as a values framework that defines relationships, guides thinking and decision‐making and structures our beliefs about individuals, families and communities. We approach our work every day based on various personal and professional experiences. While our experiences impact the choices we make, our Practice Model suggest s a desired approach to working with others and provides a clear model of practice, inclusive of all agency programs and services, that outlines how our system successfully practices. Central to our practice is the family. Guided by this model, we strive to continuously improve the ways in which we deliver programs and services to Virginia’s citizens.

1. All children, adults and communities deserve to be safe and stable.

• Every child has the right to live in a safe home, attend a safe school and live in a safe community. Ensuring safety requires a collaborative effort among family, agency staff, and community partners and across all programs and services.

• Every adult has the right to live and work in a safe environment. We value all programs that address domestic and family violence and the abuse, neglect and exploitation of older or incapacitated adults.

• We value individual and family strengths, perspectives, goals and plans as central to creating and maintaining a safe environment. The meaningful engagement and participation of children, adults, extended fa mily and community stakeholders is a necessary component of assuring safety.

• When legal action is necessary to ensure the safety of a child and/or an adult, we use our authority with respect and sensitivity.

• Individuals are best served when services are person‐centered, family‐focused and community‐ based and aim to preserve the family unit and prevent family disruption.

2. All individuals deserve a safe, stable and healthy family that supports them through their lifespan.

• We believe mothers, fathers, and children thrive in safe, stable, healthy families. We value family structures that support the best interests of children; however, we believe that children do best when raised in intact, two‐parent families.

• Both parents should be actively involved in the lives of their children, even if they are not the primary caregiver.

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• Healthy, lifelong family connections are crucial to the development of children, the stability of the family and the support of infirm, dependent or aging adults. Through the services we provide, we seek out, promote and preserve these healthy ties to family members and to others in the community to whom the family is connected or who may provide support.

3. Self‐sufficiency and personal accountability are essential for individual and family well‐being.

• Family members support each other in ways the social services system cannot. We value the intra‐ family resources and supports that are available within the context of any family as a pathway to self‐sufficiency and personal accountability.

• We believe employment, training and education are keys to self‐sufficiency. We believe in employment and training programs that remove barriers and create opportunities for individuals and families.

• Individuals and families face unique challenges that impact their ability to maintain self‐ sufficiency. We value all programs and services that assist individuals and families to regain and maintain self‐sufficiency and achieve personal accountability.

• Both custodial and noncustodial parents should provide necessary financial resources to support their children.

• We believe that parents and caregivers serve as role models in teaching the importance of self‐ sufficiency and personal accountability.

• We support asset development strategies to help individuals and families weather short‐term emergencies and improve long‐term stability.

4. All individuals know themselves best and should be treated with dignity and respect.

• All programs and services should be culturally and linguistically sensitive to all individuals.

• Individuals and families are empowered when they have access to information and resources.

• We support programs for vulnerable populations including children, the elderly and individuals with disabilities.

• The measure of success differs with every individual. We strive to understand children, adults, and families wit hin the context of their own values, traditions, history and culture.

• The voices of children, individuals and families are heard, valued and included in decision‐ making processes related to programs and services.

5. When partnering with others to support individual and family success, we use an integrated service approach.

• Cooperation, coordination and collaboration within and outside of the social services system are essential to providing the most comprehensive services to families. We are committed to working across programs, divisions, agencies, stakeholder groups and communities to improve outcomes for the childre n, individuals, families and communities we serve.

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• Through the development of policies, procedures, standards and agreements across systems, we will share infor mation, solve problems and overcome barriers.

• We value prevention networks that link effective public and private programs and community‐ based organizations that identify individuals and families before they need services.

• We believe in partnering across programs and systems in order to provide a full array of services along the continuum of care. We are committed to working within and outside of the social services system to identify and address service gaps.

6. How we do our work has a direct impact on the well‐being of the individuals, families and communities we serve.

• Children, individuals and families deserve trained, skillful professionals to engage and assist them. We hire, de velop and maintain a workforce that aligns with our practice model.

• Clear expectations, effective supervision, leadership and proper resource supports are critical for the workforce to do their job effectively.

• We believe in creating and maintaining a supportive working and learning environment with accountability at all levels.

• We value the provision of high‐quality, timely, efficient and effective services. We believe relationships and communication should be conducted with honesty, transparency, integrity, empathy and respect within and outside of our social services system.

• The collection and sharing of accurate, outcome‐driven data and evidence‐based information is a critical part of how we continually learn and improve. We use data to inform, manage, improve practice, measure effectiveness and guide decisions.

CHAPTER M01 APPLICATION FOR MEDICAL ASSISTANCE _______________________ SUBCHAPTER 20

MEDICAL ASSISTANCE APPLICATION

M0120 Changes

Changed With Effective Date Pages Changed TN #DMAS-37 1/1/26 Page 17 TN #DMAS-36 10/1/25 M0120.100 TN #DMAS-35 7/1/25 Pages 2 and 5 TN #DMAS-30 1/1/24 Page 17 TN #DMAS-25 10/1/22 Page 7 TN #DMAS-23 4/1/22 Pages 9, 10, 16, 17, 19 TN #DMAS-18 1/1/21 Pages 11, 17 Page 12 is a runover page. Page 12a was added as a runover page. TN #DMAS-17 7/1/20 Pages 2, 2a, 5, 7, 8, 13, 16 Page 6 is a runover page. Page 14 was removed. Pages 15-20 were renumbered. TN #DMAS-14 10/1/2019 Pages 7, 10, 11, 18 Page 20a was deleted. TN #DMAS-12 4/1/19 Pages 2, 12-13,15, 20a TN #DMAS-10 10/1/18 Pages 2, 4, 15, 17-20 Page 20a was added as a runover page. TN #DMAS-8 4/1/18 Page 12 TN #DMAS-6 10/1/17 Page 1 TN #DMAS-5 7/1/17 Page 2a TN #DMAS-4 4/1/17 Pages 2a, 7, 10, 13 TN #DMAS-3 1/1/17 Page 15 TN #DMAS-2 9/1/16 Pages 2, 15 Page 2a is a runover page. TN #DMAS-1 6/1/16 Pages 7, 10, 11, 16-20 TN #100 5/1/15 Table of Contents Pages 1, 2, 15, 20 Page 2a and 16 are runover pages. UP #10 5/1/14 Table of Contents Pages 11, 16-18 Pages 11a and 11b were deleted. Pages 19 and 20 were added. TN #99 1/1/14 Page 11 Pages 11a and b were added. TN #98 10/1/13 Table of Contents Pages 1-17 UP #9 4/1/13 Page 13, 15, 16 UP #7 7/1/12 Pages 1, 10-12 TN #96 10/1/11 Table of Contents Pages 6-18 TN #95 3/1/11 Pages 1, 8, 8a, 14 TN #94 9/1/10 Pages 8, 8a TN #93 1/1/10 Pages 1, 7, 9-16 Update (UP) #1 7/1/09 Page 8 TN #91 5/15/09 Page 10

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TABLE OF CONTENTS

M01 APPLICATION FOR MEDICAL ASSISTANCE

M0120.000 MEDICAL ASSISTANCE APPLICATION

Section Page

Applying for Medical Assistance ............................................. M0120.100.............................. 1

When an Application Is Required .............................................. M0120.150 .............................. 1

Who Can Sign the Application ................................................. M0120.200.............................. 2

Application Forms ..................................................................... M0120.300.............................. 9

Place of Application .................................................................. M0120.400............................ 12

Receipt of Application ............................................................... M0120.500............................ 16

Appendices

Sample Letter Requesting Signature……………………………Appendix 1……………….1

The Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) Medicaid Application, form #032-03-384………………………….…Appendix 2.…………….…1

Interstate Compact on Adoption and Medical Assistance (ICAMA) Member States and Reciprocity………………..Appendix 3…….………….1

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M0120.000 Medical Assistance Application

M0120.100 Applying for Medical Assistance

A. Right to Apply An individual cannot be refused the right to complete an application for medical assistance (MA) for himself (the applicant) or any other individual for whom he is authorized to apply. Under no circumstances can an individual be discouraged from asking for assistance for themselves or any person for whom they are a legally responsible or authorized to represent. An applicant may be assisted with the application by an individual of their choice. A face- to-face or telephone interview is not required but may be requested by the applicant or benefits worker. B. Signed Application Required An application for MA must be signed to be valid. Paper forms must bear the written (not typed) signature of the applicant or an individual authorized to apply on their behalf. Applications submitted electronically or through the approved telephonic process at Cover Virginia, the Enterprise Call Center or the Virginia Insurance Marketplace meet the signature requirement. 1. Unsigned Application A paper application that bears no signature is invalid. Return the application to the applicant with a letter requesting a signature. 2. Invalid Signature An application that is signed by an individual who is not authorized to sign on behalf of the applicant is invalid. For paper applications, return the application with a letter indicating who must sign the application to the individual who filed the application on behalf of the applicant. See M0120, Appendix 1 for a sample letter. If an electronic application does not bear a valid signature, the agency must obtain a valid signature from the applicant or his authorized representative for the case record. The signature page of a paper application form can be used.

M0120.150 When An Application Is Required

A. New Application Required A new application is required when there is: • an initial request for medical assistance, or • a request to add a person to an existing case. When an application is received because there is a new person in the family for whom medical assistance is requested, the annual renewal for the existing enrollees is done using the same application form. See subchapter M1520 for renewal policy and procedures.

B. Application NOT Required A new application is not required when an individual is already an active Medicaid enrollee or is enrolled in another medical assistance program. An application is not needed for a child turning age one when the child was deemed to be eligible based on the mother’s enrollment at the time of birth. A renewal following the procedures in M1520 must be completed when the child turns one. Act on the enrollment of a deemed newborn within seven days when the birth is reported to the local DSS office or to DMAS. Changes in the enrollee’s circumstances do not require a new application. Changes that do not require a new application include, but are not limited to,

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• a change in the case name, • a change in living arrangements, and • a change in income. A change in living arrangements may require a partial review of the individual's eligibility when the change results in a change to the assistance unit. Whenever the change requires verifications that can be used to complete a renewal, the annual renewal should be completed at the time the change is reported.

M0120.200 Who Can Sign the Application

A. Incarcerated Individuals Offenders of any age who are being held in Department of Corrections (DOC) or Department of Juvenile Justice (DJJ) facilities may have applications submitted with the assistance of DOC or DJJ staff. DJJ staff may sign the application and act as Authorized Representatives for individuals under age 18. Offenders of local and regional jails may submit applications for themselves, authorize facility staff to assist, or designate an authorized representative to assist in applying. For new applications, send all notices and correspondence to the mailing address listed on the application (normally the facility address). For re-entry and pre- release applications, send all notices and correspondence to the post-release mailing address of the individual. B. Applicants Age 18 or Older The applicant must sign the application, even if the form is filled out by another person, unless the application is filed and signed by the applicant's legal guardian, conservator (known as the “committee” for persons declared incompetent prior to the 1997 changes in the guardianship section of the Code of Virginia), attorney in fact, or authorized representative. A spouse, aged 18 or older, may sign the application for his spouse when they are living together. EXCEPTION: A parent can submit and sign an application for a child under age 21, when the child is living with the parent. The child does not need to authorize the parent to apply or conduct Medicaid business on his behalf. If the applicant cannot sign his or her name on a paper application but can make a mark, the mark must be correctly designated (the individual's first and last name and the words "his mark" or "her mark" must be printed adjacent to the mark) and witnessed by one person as in the example below: E.g.: (X) John Doe, his mark

Witness's signature:_____________________

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1. Authorized Representative An authorized representative is a person age 18 years or older who is authorized to conduct business for an individual. A competent individual age 18 years or older must designate the authorized representative in a written statement (which defines the representative’s responsibilities). The individual may change or his authorized representative at any time by submitting a new authorized representative statement.

The authorized representative statement is valid while the application is being processed and for as long as the individual is covered, as well as during an appeal related to the denial, reduction of or cancellation of the individual’s coverage. An individual who reapplies after a period of non-coverage must sign another authorized representative statement to designate an authorized representative.

The authorized representative of an incompetent or incapacitated individual is the individual’s spouse, parent, attorney-in-fact (person who has the individual’s power-of-attorney), legally appointed guardian, legally appointed conservator (committee), or family substitute representative.

2. Family Substitute Representative When it is reported that an applicant cannot sign the application and the applicant does not have a guardian, conservator, attorney in fact or designated authorized representative, one of the individuals listed below who is age 18 years or older and is willing to take responsibility for the applicant’s MA business will be the applicant’s “family substitute” representative. The family substitute representative will be, in this preferred order, the applicant’s: • spouse,

• child,

• parent,

• sibling,

• grandchild,

• grandparent,

• niece or nephew, or

• aunt or uncle.

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3. No Individual authorized to sign If the applicant is unable to sign the application and does not have an attorney in fact, authorized representative, or family substitute representative, the applicant’s inability to sign the application must be verified. Verification is by a written statement from the applicant’s doctor that says that the applicant is not able to sign the MA application because of the applicant’s diagnosis or condition. Follow these procedures: a. Determine if anyone has begun the process to have a guardian or conservator appointed for the applicant. b. If action has been initiated to obtain a guardian for the applicant, meaning a court guardianship hearing is scheduled on the court docket, request verification that the action is on the court docket. Give 10 days for this verification to be provided. If the verification is provided within the 10 day period, continue to pend the application until the guardian or conservator is appointed. If the application pends for 45 days, send written notice to the applicant to extend the pending application.

Once the guardian/conservator has been appointed, request verification of the appointment and that the application be signed by the guardian or conservator. Retain a copy of the application and mail the original application to the guardian/conservator. Allow 10 days for the signed application and guardian/conservator papers to be returned. If the application form and guardian/conservator papers are not returned to the agency by the specified date, deny the application because it is invalid. c. If guardianship/conservator procedures have not begun or have not been verified as being on the court docket, refer the applicant to Adult Protective Services (APS) in the local agency.

If the report to APS meets all criteria for a valid report, an investigation will be conducted to learn whether protective services are needed and, if so, what services are needed. The protective services identified will be provided or arranged by APS.

Continue to pend the application until the APS investigation is completed. If the completed APS investigation concludes that guardianship proceedings will not be initiated, the application must be signed by the applicant, or the applicant must sign a statement designating an authorized representative. Give the applicant 10 working days to return the signed application to the agency.

d. If the application form is not signed by the applicant or the authorized representative and returned to the agency by the specified date, deny the application because it is invalid.

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3. Procedure for Who Can Sign the Application When preparing to determine the MA eligibility of an individual age 18 or older, examine the application to determine if the applicant can complete and sign the application form or if the applicant has an authorized representative. Ask the following questions: Has the applicant been judged legally incapacitated by a court of law, as evidenced by a copy of the conservator or guardian certificate of appointment in the record? YES:

The authorized representative is the appointed conservator or guardian. STOP. NO:

The applicant is competent. Does the applicant have an attorney in fact who has the power of attorney to apply for MA for the applicant as evidenced by a copy of the power of attorney document in the record?

YES: The authorized representative is the attorney in fact. STOP.

NO: Has the applicant signed a written statement authorizing a person (or staff of an organization) to apply for MA on his behalf? (Note: a completed authorized representative section on a telephonic application is acceptable)

YES: The authorized representative is the person or organization authorized by the applicant to represent him. STOP.

NO: Is the applicant able to sign or make a mark on a Medicaid application form?

YES: Ask the applicant for his signature or mark on the application form or for a written statement authorizing someone to apply for MA on his behalf. Give the applicant 10 working days to return the completed and signed form(s). If the completed and correctly signed form(s) are not returned by the specified date, DENY MA because of an invalid application.

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NO: Does the applicant have at least one of the following who is age 18 or older: • spouse,

• child,

• parent,

• sibling,

• grandchild, niece or nephew, or

• aunt or uncle?

YES: The authorized representative is the individual identified above who is willing and able to act on the applicant's behalf.

NO: Verify the inability of the applicant to sign the application because of a diagnosis or condition through a written statement from the applicant’s doctor. Refer to APS. Pend the application. At the conclusion of the APS investigation, if APS concludes that guardianship proceedings will not be initiated, the applicant must sign or make a mark on the application or designate an authorized representative in writing. If the signed application form is not received by the specified date, deny MA.

C. Applicants Under Age 18

1. Child Applicant

A child under age 18 years is not legally able to sign his own MA application unless he is legally emancipated from his parents. If the child is not legally emancipated, one of the following individuals who is age 18 or older must sign the application: • his parent (custodial or non-custodial) • legal guardian, • authorized representative (including Department of Juvenile Justice staff for individuals under 18), or • an adult related by blood or marriage with whom the child lives (documentation of the relationship is not required).

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If the child under 18 years of age is married and living with his spouse who is age 18 or older, the child’s spouse may sign the application. a. No Guardian or Legal Custody If the child does not live with a parent or an adult relative and no adult is the child's guardian or has legal custody of the child, whomever the child is living with is responsible for seeking custody or guardianship of the child in the Juvenile and Domestic Relations court. Determine if the person submitting the application, or another person, has begun the process to obtain legal guardianship or custody of the child applicant. b. Action Is Initiated To Appoint Guardian/Award Custody If action has been initiated to appoint a guardian for or seek legal custody of the child, meaning a court guardianship or custody hearing is scheduled on the court docket, request verification that the action is on the court docket. Give 10 calendar days for this verification to be provided.

If the verification is provided within the 10-calendar-day period, continue to pend the application until a guardian is appointed or custody is awarded. If the application pends for 45 calendar days, send a notice to the applicant explaining that the application pending period will be extended. Once the guardian has been appointed or custody awarded, request verification of the appointment or award and that the application be signed by the guardian or adult who was awarded custody. Allow 10 calendar days for the signed application and guardianship or custody papers to be returned. If the court refuses to appoint a guardian or custodian and there is no adult who is legally able to sign an application for the child, deny the application as invalid.

c. Action Not Initiated – Refer to Child Welfare Services If guardianship or custody procedures have not begun or have not been verified as being on the court docket, refer the child to the appropriate Family Services worker.

Continue to pend the application until the service investigation is completed and any court proceedings are completed. Once the guardian has been appointed or custody awarded, request verification of the appointment or award and that the application be signed by the guardian or adult who was awarded custody. Retain a copy of the application and mail the original application to the guardian or custodian. Allow 10 calendar days for the signed application and guardian or custody papers to be returned.

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If the child was emancipated by the court, request the child’s signature on the application. If the application is mailed to the child, allow 10 calendar days for the signed application form to be returned. If the application form is not signed by the applicant, the guardian, the custodial adult, or the emancipated child and returned to the agency by the specified date, deny the application because it is invalid. 2. Non-custodial Parent Applying for Child Eligibility for a child is based on the income of the parent with whom the child lives. If a non-custodial parent applies for his child, he must give written permission for the eligibility worker to contact the custodial parent. The eligibility worker must obtain the custodial parent’s income information, written permission to verify income using available online data sources, and other information necessary to verify and calculate countable income, including Social Security Number and residence address. If either the non- custodial parent or the custodial parent fail to give the necessary permission, the child’s eligibility cannot be determined using the application filed by the non-custodial parent. 3. Minor Parent Applying for Child Parent(s) under age 18 years may apply for MA for their own child because they are the parent of the child. An undocumented minor can apply for FAMIS Prenatal Coverage since the coverage is considered to be for the unborn child. If the individual is eligible, the parent can then be enrolled for the duration of the pregnancy and the 60 day postpartum period. Any future applications filed for the minor prior to turning age 18 would need to be signed by someone who is legally authorized to sign on the individual’s behalf. 4. Foster Care Child a. IV-E The Title IV-E Foster Care & Medicaid Application form, available at https://fusion.dss.virginia.gov/Portals/%5Bdfs%5D/Files/Copy%20of%20032- 03-0636-06-eng.xlsx, is used for the IV-E Foster Care eligibility determination. A separate MA application is not required for a child who has been determined eligible for Title IV-E Foster Care. However, if there is a non-custodial agreement for the IV-E eligible child, the parent or legal guardian must sign an MA application for the child. b. Non-IV-E The Cover Virginia Application for Health Coverage & Help Paying Costs is used for the MA eligibility determination of a non-IV-E Foster Care child. Applications for non-IV-E Foster Care children may also be filed online. The MA application for a non-IV-E child who is in foster care must be signed by an authorized employee of the public or private agency that has custody of the child. Exception: If the child has been placed with and is living with a parent or care-taker relative, the parent or care-taker relative can sign the application. If there is a non-custodial agreement, an MA application form must be filed and the parent or legal guardian must sign the application.

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5. Adoption Assistance & Special Medical Needs Children a. IV-E A separate MA application is not required for a child who has been determined eligible for Title IV-E Adoption Assistance, regardless of which state has the adoption assistance agreement with the adoptive parents. IV-E Adoption Assistance children who have been placed for adoption through the Interstate Compact for Adoption and Medical Assistance (ICAMA) should have an ICAMA form 6.01 which verifies their Title IV-E eligibility for Medicaid. The ICAMA form 6.01 serves as the MA application form. b. Non-IV-E Non-IV-E Adoption Assistance children include Non-IV-E Special Medical Needs children.

1) Placed by a Virginia agency

An MA application is required for all non-IV-E Adoption Assistance and Non-IV-E Special Medical Needs children whose parents have adoption assistance agreements with a Virginia public or private child-placing agency. The child’s adoptive parent signs and files the application for the child. 2) Placed by another state

Non-IV-E Adoption Assistance children who have been placed for adoption through the Interstate Compact for Adoption and Medical Assistance (ICAMA) should have an ICAMA form 6.01 which verifies their adoption assistance status (IV-E or non-IV-E). The ICAMA form 6.01 serves as the MA application form and a separate application is not required when: • the other state is an ICAMA member state, and • the ICAMA member state reciprocates Medicaid coverage of Virginia Non-Title IV-E Adoption Assistance children. All states and territories EXCEPT Vermont, Wyoming, Puerto Rico and Virgin Islands are members or associate members of ICAMA. A list of the ICAMA member states and whether they reciprocate Medicaid coverage for Non-IV-E Adoption Assistance children is in M0120, Appendix 3. An MA application must be filed for Non-IV-E Adoption Assistance children from non-member states and ICAMA member or associate member states which do NOT reciprocate. The child’s adoptive parent signs and files the MA application for the child. D. Deceased Applicant An application may be made on the behalf of a deceased person within a three-month period subsequent to the month of his death if both of the following conditions were met:

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• the deceased received a Medicaid-covered service on or before the date of death, and • the date of service was within a month covered by the MA application. If the above conditions were met, an application may be made by any of the following:

• his guardian or conservator,

• attorney-in-fact, • executor or administrator of his estate • his surviving spouse, or • his surviving family member, in this order of preference: adult child, parent, adult brother or sister, adult niece or nephew, or aunt or uncle. Under no circumstances can an employee of, or an entity hired by, the medical service provider who stands to obtain MA payment file an MA application on behalf of a deceased individual. Medicaid coverage can begin no earlier than three months prior to the application month. The entitlement rules for retroactive coverage apply to the application's retroactive period. Retroactive FAMIS coverage is available ONLY to an eligible child who was born within the 3 months prior to the FAMIS application month. E. Enrollee Turns 18 When a child who is enrolled in MA Medicaid turns 18, it is not necessary to obtain a new application signed by the enrollee. As long as the enrollee is under age 21, he does not need to authorize a parent with whom he lives for the parent to continue to conduct the enrollee’s MA business.

M0120.300 Medical Assistance Application Forms

A. General Principle – Application Required A signed application for MA is required for all initial requests for medical assistance, except for: • IV-E Foster Care/Adoption Assistance children • Auxiliary Grant (AG) applicants • Newborn children under age 1 born to women eligible for Medicaid, FAMIS, FAMIS MOMS, or FAMIS Prenatal Coverage.

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1. Title IV-E Foster Care & Medicaid Application The Title IV-E Foster Care & Medicaid Application, available at https://fusion.dss.virginia.gov/Portals/%5Bdfs%5D/Files/Copy%20of%20032-03- 0636-06-eng.xlsx, is used for foster care or adoption assistance children who are eligible under Title IV-E of the Social Security Act. If the child requires a resource evaluation for a medically needy spenddown, Appendix E can be used to collect the information. The Appendix must be signed by the applicant’s guardian.

For a IV-E FC child whose custody is held by an LDSS or a private FC agency, or for a IV-E adoption assistance (AA) child, the Title IV-E Foster Care & Medicaid Application is used to determine if the child meets Medicaid IV-E eligibility requirements. This form is also used to determine Medicaid eligibility for IV-E AA children. This form is not used for children in non-custodial agreement cases or non- IV-E FC or AA.

For IV-E FC children in the custody of another state’s social services agency and for IV-E AA children, a separate Medicaid application is not required. The worker must verify the IV-E maintenance payment (for FC) or the IV-E status (for AA). Virginia residency (by declaration) and current third party liability (TPL) information must be obtained. This information may be supplied by the foster/adoptive parent or obtained from the agency that entered into the FC or AA agreement.

For non-IV-E FC children, a separate Medicaid application must be submitted by either the custodial agency or a parent or caretaker relative with whom the child has been placed. When a child enters care through a non-custodial agreement, or when a child is a non-IV-E AA child, a separate Medicaid application must be submitted by the parent or guardian.

2. Auxiliary Grant (AG) An application for AG is also an application for Medicaid. A separate MA application is not required.

3. Exception for Certain Newborns A child born to a mother who was eligible for Medicaid, FAMIS, FAMIS MOMS, or FAMIS Prenatal Coverage at the time of the child’s birth (including a child born to an emergency-services-only alien mother) is deemed to have applied and been found eligible for Medicaid on the date of the child’s birth (see M0320.301). An application for the child is not required. The child’s coverage is subject to renewal when he turns 1 year old. If the child was born to a mother who was covered by Medicaid or the Children’s Health Insurance Program outside Virginia at the time of the child’s birth, verification of the mother’s coverage must be provided or else an application must be filed for the child’s eligibility to be determined in another covered group. 4. Forms that Protect the Application Date a. Low Income Subsidy (LIS) Medicaid Application The Medicare Patient and Provider Improvement Act (MIPPA) requires LIS application data submitted by the Social Security Administration (SSA) to states to be treated as an application for Medicaid, if the LIS applicant agrees. LIS application data is sent to LDSS via the SSA Referral Inbox in VaCMS. The LDSS must generate an LIS Medicaid application and cover sheet and mail them to the individual. The individual must return the application or apply for Medicaid online or by telephone in order for his Medicaid eligibility to be determined. If the individual submits the application, the date of LIS application with the SSA is treated as the date of the Medicaid application.

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b. Model Application for Medicare Premium Assistance Form The Model Application for Medicare Premium Assistance Form was developed by the federal Centers for Medicare & Medicaid Services (CMS) that states can choose to use for the Medicare Savings Program applicants. The model application is NOT a prescribed Virginia Medicaid application form at this time. Should a local department of social services (LDSS) receive a model application form, the agency is to send a valid Virginia MA application to the applicant with a request that it be completed, signed, and returned to the agency within 30 calendar days. The date of application on the model Application for Medicare Premium Assistance is to be preserved as the application date for purposes of Medicaid entitlement. The processing time for the LDSS begins when the agency receives the Virginia application form back from the applicant. If the Virginia application form is not returned within 30 days, no further action is necessary on that application. The agency does not send a Notice of Action because no Virginia application was received. The model application date is not preserved beyond 30 calendar days. Should the person later submit a valid Virginia application, the date the Virginia application is received by the LDSS is the application date. The model application form may be viewed on the SSA web site at: https://www.ssa.gov/forms/ssa-1020b-ocr-sm-inst.pdf. B. Application Forms Medical assistance must be requested using an application method or form approved by the Departments of Medical Assistance Services (DMAS) and Social Services (VDSS). Applications may be made electronically through CommonHelp or the Health Insurance Marketplace. Applications may also be made telephonically through the Cover Virginia Call Center or with a paper application form. The following paper forms have been prescribed as application forms for Medicaid and FAMIS: 1. Streamlined Applications The following forms are used to apply for affordable health insurance, including qualified health plans with the Advance Premium Tax Credit (APTC), through the Health Insurance Marketplace or the local DSS:

• the Cover Virginia Application for Health Coverage & Help Paying Costs and all applicable appendices:

o Appendix D, for applications submitted for aged, blind or disabled (ABD) applicants and ABD applicants who are requesting long-term services and supports (LTSS)

o Appendix E, when a Families and Children (F&C) Medically Needy determination is requested

o Appendix F, for applicants in need of LTSS who are between the ages of 19 and 64 years and who are not eligible for or enrolled in Medicare;

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• the federal Application for Health Coverage & Help Paying Costs for multiple individuals and all applicable appendices; and

• the federal Application for Health Coverage & Help Paying Costs (Short Form) for individuals and all applicable appendices.

2. BCCPTA Medicaid Application The Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) Medicaid Application, form #032-03-384, is used only by individuals screened under the Breast and Cervical Cancer Early Detection Program. This form is not to be given to applicants by the local departments of social services (M0120, Appendix 2 is provided for reference purposes only).

3. Replaced Application Forms The following forms were replaced by the streamlined application forms effective October 1, 2013. While agencies should accept and process any of these forms if they are submitted, additional information, such as tax filing information, may need to be obtained (see M0120.300 B.4 below). • Application for Benefits (#032-03-824)

• The Application/Redetermination for Medicaid for SSI Recipients ( #032-03-091)

• The Medicaid Application/Redetermination for Medically Indigent Pregnant Women (#032-03-040)

• The Health Insurance for Children and Pregnant Women (#FAMIS-1)

• The Application for Adult Medical Assistance form (#032-03-0222)

• The Plan First Application (#DMAS-65E) 4. Renewal Forms Returned After Reconsideration Period Renewal forms filed after the end of the 90-day reconsideration period are treated as reapplications. Accept the form and request any additional information needed to determine the individual’s eligibility. See M1520.200 C for additional information. 5. If Additional Information is Required Applicants may apply for MA on any valid application form. Regardless of which application form is used, if additional information is required to determine an applicant’s eligibility, send the applicant the relevant page(s) of the Cover Virginia Application for Health Coverage & Help Paying Costs, and/or Appendices D or E, as appropriate, along with a checklist asking for the information. Give the applicant at least 10 business days to return the information and any required verifications to the agency.

M0120.400 Place of Application

A. Principle The place of application may be the office of the local social services department serving the locality in which the applicant resides. Verification of locality residence is not required. MA applications are also accepted online, telephonically through Cover Virginia, or at designated hospitals and health clinics (Medicaid outstationed sites). If an applicant is homebound and needs assistance with completing the application, the agency, upon request, must arrange to have the application taken where he resides or is a patient.

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1. Locality of Residence Medical assistance applications that are approved are sent to the LDSS in the applicant’s locality of residence or where the individual last lived outside of an institution. 2. Joint Custody Situations A child whose residence is divided between two custodial parents living in different localities is considered to reside in the locality in which he attends school. If the child is not enrolled in school, the parents must decide which locality is the child’s residence for application/ enrollment purposes.

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B. Foster Care, Adoption Assistance, Department of Juvenile Justice

1. Foster Care Responsibility for taking applications and maintaining the case belongs as follows: a. Title IV-E Foster Care Children in the custody of a Virginia LDSS or private foster care agency who receive Title IV-E maintenance payments apply at the agency that holds custody. Title IV-E foster care children in the custody of another state’s social services agency apply in the Virginia locality where they reside. b. State/Local Foster Care Non-Title IV-E (state/local) children in the custody of a Virginia LDSS or a private child placing agency apply at the LDSS that holds custody. Children in the custody of another state’s social services agency who have been placed with and are living with a parent or caretaker-relative apply at the LDSS where the child is residing. (see M0230). 2. Adoption Assistance Children receiving adoption assistance through a Virginia local department of social services apply at the LDSS that made the adoption assistance agreement. Children receiving adoption assistance through another state’s social services agency apply at the LDSS where the child is residing. 3. Virginia Department of Juvenile Justice/Court (Corrections Children) When a child is in the custody of the Virginia Department of Juvenile Justice (DJJ) or is the responsibility of a court (corrections children), responsibility for processing the application and determining eligibility will be handled either centrally or by the LDSS in the locality in Virginia in which he last resided prior to going into the DJJ system. For a new applicant use the physical address where the person is located. For pre-release and re-entry individuals, use the address where the person will reside after release (post-release).

C. Institutionalized Individual (Not Incarcerated) When an individual of any age is a resident or patient in a medical or residential institution, except a Virginia Veteran’s Care Center, responsibility for processing the application and determining eligibility rests with the department of social services in the locality in Virginia in which he last resided outside of an institution. Exception: If the applicant is applying for or receives SNAP, responsibility for processing the MA application and determining MA eligibility rests with the LDSS in the locality in which the institution where he is receiving care is located. If the individual did not reside in Virginia prior to entering an institution, responsibility for processing the application and determining eligibility rests with the LDSS in the locality in which the institution where he is receiving care is located.

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D. Individuals In Virginia Veteran’s Care Center MA applications for patients in the Virginia Veteran’s Care Center in Roanoke may be filed, processed and maintained at the Roanoke City Department of Social Services. E. Incarcerated Individuals and DJJ Supervisees Inmates of state (DOC), regional and local correctional facilities, and individuals under the age of 21 under the supervision of DJJ (placed in a facility or receiving services from any court services unit or DJJ contractor) may apply for Medicaid. Responsibility for processing the application and determining eligibility will be handled through a centralized process or by the local department of social services (DSS) in the locality where the individual was living prior to incarceration or DJJ/court custody. Applications are not to be refused because an applicant is an inmate of a public institution at the time of application. If the individual did not reside in Virginia prior to becoming incarcerated or committed to DJJ, responsibility for processing the application and determining eligibility will be handled through a centralized process or by DSS in the locality in which correctional facility is located. The physical address on the application should be the address where the individual is currently placed. The mailing address will be the facility address where the individual is currently placed. For pre-release or re-entry individuals, use the address the person provides where they will be located after release. If the individual was homeless prior to being incarcerated, use the physical address of the local DSS or an address the person provides.

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M0120.500 Receipt of Application

A. General Principle An applicant or authorized representative may submit an application for medical assistance only or may apply for MA in addition to other programs. An applicant may be assisted with completing the various aspects of the application by an individual(s) of his choice and may designate in writing (or documented on a telephonic application) that such individual(s) may represent him in subsequent contacts with the agency. B. Application Date The application date is the earliest date the signed application for medical assistance is received by the local agency, an out-stationed site, or an entity contracted with DMAS to accept applications. The application must be on a form prescribed by DMAS and signed by the applicant or person acting on his behalf. The application may be received by mail, fax, hand delivery, electronically or telephonically. The date of receipt by the agency must be recorded. If an application is received after the agency’s business hours, the date of the application is the next business day. Exception: For CommonHelp applications, if the application is received after business hours and the next business day is in the following month, the date of the application is the actual date it was submitted. The date of application for foster care children in the custody of a local department of social services is the date the application is received by the eligibility worker. If an application for a pregnant woman or child is denied due to excess income, the applicant must be given the opportunity to request a medically needy evaluation. If the evaluation is requested within 10 calendar days of the date the notice of denial was mailed, the application date is protected, and the date of application is the date the denied application was received.

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C. Hospital Presumptive Eligibility The Affordable Care Act required states to allow approved hospitals to enroll patients who meet certain Families & Children covered groups in Medicaid for a limited time on the basis of their presumptive eligibility. The Department of Medical Assistance Services (DMAS) is responsible for coordinating the HPE Agreement with approved hospitals, providing training and technical assistance, and monitoring the appropriate use of the HPE enrollments. HPE is not available to individuals who are already actively enrolled in Medicaid or FAMIS. Local eligibility staff do not determine eligibility for HPE. 1. HPE Determination and Enrollment To provide an individual HPE coverage, the hospital staff obtains basic demographic information about the individual, as well as the attestations from the individual regarding Virginia residency (including locality), U.S. citizenship or lawful presence, Social Security number, household size and income, and requirements related to a covered group. As the information is self attested, no verifications or additional proof is required. Hospital staff determines eligibility and enters the approved individual’s data into the HPE webpage located in the provider portal in the Medicaid Enterprise System (MES—formerly the Medicaid Management Information System [MMIS]). This information is electronically transferred to the Cover Virginia Central Processing Unit (CPU) which is responsible for enrolling the individual in the appropriate aid category (AC) in MMIS. The HPE enrollment is not entered in the Virginia Case Management System (VaCMS). HPE recipients are not entered into a managed care organization (MCO). The hospital is responsible for providing immediate notification to the individual of his HPE coverage. They will request that he file a full MA application by the end of the following month so that continued eligibility for Medicaid can be evaluated without an interruption in coverage. The HPE covered groups and the ACs are: • Pregnant Women (AC 035) • Child Under Age 19 (AC 064) • Low Income Families with Children (LIFC) (AC 065) • Former Foster Care Children Under Age 26 (AC 077) • Breast & Cervical Cancer Prevention & Treatment Act (BCCPTA) (AC 067) • Plan First (AC 084) • MAGI Adults (AC 106) ( effective January 1, 2019) Individuals enrolled on the basis of HPE receive a closed period of coverage beginning with the date of the HPE determination through the last day of the following month or the date MA eligibility is determined, whichever comes first. Enrollment in HPE is not based on the date of the hospital admission nor the first day of the month. While enrolled as HPE, individuals in the Child Under Age 19 years, LIFC, Former Foster Care Children Under Age 26, BCCPTA, and MAGI Adults covered groups receive full Medicaid benefits. HPE pregnant women coverage

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(AC 035) is limited to outpatient prenatal services; labor and delivery are not covered under HPE for AC 035. HPE coverage for Plan First enrollees AC084 is limited to family planning services only. Transportation to receive covered medical services is covered for all HPE enrollees. Enrollment as HPE is limited to one HPE period per calendar year for all individuals other than pregnant women. For pregnant women, enrollment is limited to one HPE eligibility period per pregnancy. Children’s 12 month continuous eligibility does not apply to children enrolled as HPE. There are no appeal rights for an HPE determination. 2. Eligibility Procedures – Post HPE Enrollment a) MA Application Not Submitted If the person does not submit an MA application prior to the end of the HPE coverage period, no further worker action or additional notice not required because the enrollment was for a closed period of coverage. b) MA Application Submitted

For MA coverage to continue beyond the initial HPE coverage period, the individual must submit a full MA application. MA applications submitted by HPE enrollees are subject to the standard eligibility and entitlement policies. The 7-calendar day processing standard applies to MA applications submitted by pregnant women. The 10-work day requirement applies to applications submitted by BCCPTA individuals enrolled in HPE.

While the LDSS does not determine eligibility for HPE, if an MA application is received and pended in VaCMS, the individual’s coverage in the HPE AC may need to be extended or reinstated (if HPE coverage will end during the application processing period) while the application is processed. If HPE coverage needs to be extended/reinstated, alert a VDSS Regional Consultant or submit a Coverage Correction Request through the Coverage Correction Portal (CCP) on the MES website., Home | MES. To access the CCP and User Guides, LDSS, VDSS, CoverVA, and DMAS staff must sign into the MES using their current credentials and then sign into the MMIS with their eCode. The enrollment mailbox has been disabled.

Example 1: Mary Smith is enrolled in HPE coverage in AC 065 (LIFC) for the period of 3-5-18 through 4-30-18. On 4-20-18, she submits an MA application; however, the 45th processing day will fall after the HPE end date of 4-30-18. Therefore, the worker must have the HPE coverage reinstated in MES under the same aid category (AC 065), using the MA application date. The effective date of the reinstatement is 5-1-18, the day after the HPE coverage ends. Once the application has been processed. the worker must act to cancel the HPE coverage, and if the individual remains eligible reinstate coverage in the appropriate AC.

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c) Applicant Determined Eligible for MA Coverage

If the individual is determined eligible for MA coverage, coverage under the appropriate MA aid category will includes any day(s) to which he is entitled and not covered by HPE.

If the individual submits a MA application and it is approved in the same month HPE coverage began and HPE began the first day of the month, MA coverage begins the first day of that application month.

If the MA application is approved and HPE began on any day other than the first day of the month, the worker will enroll MA coverage beginning with the first day of the month and end on the day before the HPE begin date. Ongoing coverage will then begin the day after the HPE coverage ends. An exception to this process will be for an approved pregnant woman or Plan First application.

Example 2: Tony is an adult enrolled in HPE coverage (AC106) for the period of 9-6-18 through 10-31-18. He submits an MA application on 9-8- 18 and is approved as a MAGI Adults AC103 on 9-28-18. He did not request retroactive coverage so the AC103 coverage will be for the period 9- 1 thru 9-5 and ongoing AC103 coverage will begin on 11-1-18 (after the HPE coverage ended).

If an individual submits an MA application in the month a full-benefit HPE coverage is to end, and is determined eligible for ongoing MA coverage, the ongoing coverage is entered in the appropriate MA AC beginning the first day of the month after the effective date of the HPE coverage cancellation. An exception to this process will be for an approved pregnant woman application. Example 3: Billy is a child enrolled in HPE coverage (AC 064) for the period of 2-14-18 through 3-31-18. His parent submits an MA application on 3-18-18 and there is no indication of any medical services in a retro period. Billy is determined eligible for Medicaid coverage in AC 092 on 3- 26-18.

The Medicaid entitlement begins after the HPE coverage ends. The worker enrolls the child into AC 092 with ongoing coverage beginning 4-1-18.

d) Applicant Determined Eligible as Pregnant Woman (PW) or for Plan First

The HPE process for a pregnant woman (AC 035) or Plan First (AC 084) follows the same policy as other HPE categories. The exception is for enrollment if an MA application is submitted and approved for a pregnant woman (AC 091 or AC 005) or for Plan First. In those cases, coverage will begin on the first day of the month the MA application was received. Request that HPE coverage be cancelled retroactively. Reinstate in full coverage for the ongoing coverage.

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Example 4 : Jane was enrolled in HPE AC 035 (pregnant women) for the period of 4-13-18 through 5-30-18. She files an MA application on 4-28-18 and is approved for AC 091 coverage. Jane would have coverage as AC 091 for the period beginning 4-1-18. However, based on her expected delivery date found on the application, Jane was pregnant during the months prior to her HPE determination. The worker determines and approves retro coverage. The worker ensures Jane has coverage for AC 091 with a begin date of 1-1-18. In MES, this transaction would be a retro cancel reinstate using Cancel Reason 024.

e) Retroactive Coverage

An individual cannot receive retroactive HPE coverage. An individual’s eligibility for retroactive coverage for the three months prior to the month of the MA application is determined when the individual had a medical service within the three months prior to the month of the full MA application or when MA began. If the individual had full coverage while enrolled as HPE, only enroll him for the portion of the retroactive period that he was not enrolled as HPE.

f) Applicant Determined Not Eligible for ongoing MA coverage

If the applicant is determined to not be eligible for ongoing MA coverage, his entitlement to HPE coverage ends. Unless the HPE coverage was extended, no further action is required by the worker. If cancellation of HPE coverage is needed, request that the effective cancel date be the current date (i.e. day of the eligibility determination), using Cancel Reason 008. Send a Notice of Action indicating that the individual’s MA application was denied and that his HPE coverage was cancelled with the effective date. Because the individual receives notice of the HPE coverage period from the hospital at the time of the HPE enrollment, advance notice of the HPE cancellation is not required. There are no appeal rights for HPE. The individual’s HPE coverage is valid regardless of whether or not the individual is eligible for ongoing coverage; do not refer the case to the DMAS Recipient Audit Unit.

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M01 January 2003 Subchapter Subject

Page M0120 MEDICAL ASSISTANCE APPLICATION Appendix 1 1

Commonwealth of Virginia Department of Social Services

NOTICE REGARDING MEDICAID APPLICATION REQUIREMENTS

A Medicaid application has been filed on the behalf of __________________________________ (name of applicant). However, the application is not valid and cannot be processed because the application must be signed by one of the following persons:

• the parent of a person under age 18,

• the adult who is the legal guardian or has legal custody of a person under age 18,

• any adult related by blood or marriage with whom a person under age 18 lives,

• the person for whom Medicaid is requested if the person is over age 18 or an emancipated minor,

• the authorized representative for the person who is requesting assistance, who may be

- any person to whom he/she has legally given power of attorney, or

- any person who he/she has designated by a signed written statement to apply on his/her behalf for Medicaid or public benefits, or

• the guardian, conservator, or committee of a person over age 18 who has been judged legally incapacitated by a court of law.

Please return the signed application and the authorized representative statement (if needed) by ______________________________ so that the application may be processed. Thank you. (date)

_________________________________________ _________________________ Signature

Date

_________________________________________ Title

_________________________________________ Agency Name

______________________________________ Phone Number

COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) Medicaid Application

AGENCY USE ONLY DATE RECEIVED:

CASE NAME/NUMBER:

LOCALITY:

WORKER

Please complete all sections. If you need assistance, please contact an eligibility worker at your local Department of Social Services. 1. IDENTIFYING INFORMATION LAST NAME:

FIRST NAME:

MI:

SOCIAL SECURITY NUMBER:

ADDRESS:

CITY: STATE:

ZIP: STATE OF RESIDENCE:

MAILING ADDRESS (If different): CITY: STATE:

ZIP: HOME PHONE #: DAYTIME PHONE #:

2. ADDITIONAL INFORMATION RACE:

WHITE AMERICAN INDIAN/ALASKA NATIVE

MARITAL STATUS: NEVER MARRIED

DIVORCED

BLACK ASIAN/PACIFIC ISLANDER

MARRIED

WIDOWED

HISPANIC OTHER

SEPARATED

DATE OF BIRTH:

PLACE OF BIRTH: ________________________________________________________________________ U. S. CITIZEN? YES NO

IF NO, ALIEN NUMBER: DO YOU RECEIVE SSI? YES NO

ARE YOU PREGNANT? YES NO

DO YOU HAVE A CHILD(REN) UNDER AGE 19 LIVING WITH YOU? YES NO

DO YOU HAVE HEALTH INSURANCE? YES NO

IF YES, COMPANY NAME: __________________________________________________________________ POLICY #: EFFECTIVE DATE: TYPE OF COVERAGE: _____________________________________________

DID YOU RECEIVE MEDICAL CARE IN ANY OF THE THREE MONTHS BEFORE THIS APPLICATION? YES NO

IF YES, LIST MONTHS: ___________________________

3. BCCPTA CERTIFICATION

I CERTIFY THAT THE ABOVE NAMED INDIVIDUAL IS A VIRGINIA BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAM (BCCEDP) PARTICIPANT (TITLE XV) AND IS ELIGIBLE FOR MEDICAID UNDER THE BREAST AND CERVICAL CANCER PREVENTION AND TREATMENT ACT OF 2000.

SCREENING DATE: _______________ DIAGNOSIS DATE: _______________ FACILITY/SERVICE SITE: ______________________________ PHONE #: ___________________

SIGNATURE OF BCCEDP CASE MANAGER : ____________ DATE: ______________________________________

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YOUR RIGHTS AND RESPONSIBILITIES

By signing below, I agree to the following: I have the right to: ♦ Be treated fairly and equally regardless of my race, color, religion, national origin, gender, political beliefs or disability consistent with state and federal law and to file a complaint if I feel I have been discriminated against. ♦ Have my eligibility for Medicaid benefits determined within 10 working days of receipt of my application at my local department of social services or be notified of the reason for any delay. ♦ Appeal and have a fair hearing if I am: (1) not notified in writing of the decision regarding my application; (2) denied benefits from the Medicaid program; or (3) dissatisfied with any other decision that affects my receipt of Medicaid benefits.

I have the responsibility to: ♦ Not purposely withhold information, or give false information and understand if I do so my Medicaid coverage may be denied or ended. ♦ Report any changes in information provided on this form within 10 days to my local department of social services. ♦ Cooperate with a review of my Medicaid eligibility by Quality Control and understand that refusing to cooperate will make me ineligible for Medicaid until I cooperate with a review.

I further understand and agree that:

♦ This application is used only to apply for Medicaid under the Breast and Cervical Cancer Prevention and Treatment Act coverage group and that in order to apply under other coverage groups I must complete another application. ♦ The Department of Medical Assistance Services and the Department of Social Services are authorized to obtain any verification necessary to establish my eligibility for Medicaid. ♦ The Department of Medical Assistance Services has the right to receive payments for services and supplies from insurance companies and other liable sources as reimbursement for medical services received by me. ♦ Each provider of medical services may release any medical records pertaining to any services received by me. ♦ I am assigning my rights to medical support and other third party payments to the Department of Medical Assistance Services in order to receive benefits from the Medicaid program.

I declare that all information I have given on this application is true and correct to the best of my knowledge and belief. I understand that if I give false information, withhold information or fail to report a change promptly or on purpose I may be breaking the law and could be prosecuted for perjury, larceny and/or fraud. I understand that my signature on this application signifies, under penalty of perjury, that I am a U.S. citizen or alien in lawful immigration status.

________________________________________________ ______________________ Signature or Mark

Date ___________________________________________________ ________________________ Witness/Authorized Representative

Date

VOTER REGISTRATION Check one of the following:

( ) I am not registered to vote where I currently live now, and I would like to register to vote here today. I certify that a voter registration form was given to me to complete. (If you would like help in filling out the voter registration, we will help you. The decision to have us help you is yours. You also have the right to complete your form in private.) ( ) I am registered to vote at my current address. (If already registered at your current address, you are not eligible to register to vote.) ( ) I do not want to apply to register to vote. ( ) I do want to apply to register to vote, please send me a voter registration form.

Applying to register or declining to register to vote will not affect the assistance or services that you will be provided by this agency. A decision not to apply to register to vote will remain confidential. A decision to apply to register to vote and the office where your application was submitted will also remain confidential and may only be used for voter registration purposes. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register to vote, or your right in applying to register to vote, you may file a complaint with: Secretary of Virginia State Board of Elections, Ninth Street Office Building, 200 North Ninth Street, Richmond, VA 23219-3497. The phone number is (804) 786-6551.

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Page M0120 MEDICAL ASSISTANCE APPLICATION Appendix 3 1

Interstate Compact on Adoption and Medical Assistance (ICAMA) Member States and Reciprocity

STATE COBRA OPTION* RECIPROCITY** COMMENT Alabama Yes Yes Reciprocity with ICAMA member states only Alaska Yes Yes Reciprocity with all states Arizona Yes Yes Reciprocity with all states Arkansas Yes Yes Reciprocity with all states California Yes Yes Reciprocity with all states Colorado Yes Yes Reciprocity with all states Connecticut Yes Yes Reciprocity with ICAMA member states only Delaware Yes Yes Reciprocity with all states District of Columbia Yes No

Florida Yes Yes Reciprocity with ICAMA member states only Georgia Yes Yes Reciprocity with all states Hawaii Yes No

Idaho Yes Yes Reciprocity with all states Illinois Yes No

Indiana Yes Yes Reciprocity with all states Iowa Yes No

Kansas Yes Yes Reciprocity with all states Kentucky Yes Yes Reciprocity with ICAMA member states only Louisiana Yes Yes Reciprocity with all states Maine Yes Yes Reciprocity with all states Maryland Yes Yes Reciprocity with all states Massachusetts Yes Yes Reciprocity with all states Michigan Yes Yes Reciprocity with all states Minnesota Yes Yes Reciprocity with all states Mississippi Yes Yes Reciprocity with all states Missouri Yes Yes Reciprocity with all states Montana Yes Yes Reciprocity with ICAMA member states only Nebraska Yes No

Nevada Yes No

New Hampshire Yes No

New Jersey Yes Yes Reciprocity with ICAMA member states only New Mexico No No

New York *** Yes No

North Carolina Yes Yes Reciprocity with ICAMA member states only North Dakota Yes Yes Reciprocity with ICAMA member states only Ohio Yes Yes Reciprocity with all states Oklahoma Yes Yes Reciprocity with all states Oregon Yes Yes Reciprocity with all states

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STATE COBRA OPTION* RECIPROCITY** COMMENT Pennsylvania Yes Yes Reciprocity with all states Rhode Island Yes Yes Reciprocity with ICAMA member states only South Carolina Yes Yes Reciprocity with all states South Dakota Yes Yes Reciprocity with all states Tennessee Yes Yes Reciprocity with all states Texas Yes Yes Reciprocity with all states Utah Yes Yes Reciprocity with ICAMA member states only Vermont

Virginia Yes Yes Reciprocity with ICAMA member states only Washington Yes Yes Reciprocity with all states West Virginia Yes Yes Reciprocity with all states Wisconsin Yes Yes Reciprocity with all states Wyoming

* per COBRA 1985 law, the ICAMA member state’s Medicaid program covers its own Non-IV-E (state-local) Adoption Assistance [AA] children).

** the ICAMA member state’s Medicaid program covers Non-IV-E AA children who have adoption assistance agreements with another state and move to the state.

*** ICAMA Associate Member State ICAMA Non-Member State (Vermont, Wyoming)

CHAPTER M01 APPLICATION FOR MEDICAL ASSISTANCE _________________________ SUBCHAPTER 30

APPLICATION PROCESSING

M0130 Changes Page 2 of 2

Changed With Effective Date Pages Changed TN #DMAS-37 1/1/26 Page 12 TN #DMAS-36 10/1/25 M0130.500 TN #DMAS-35 7/1/25 Pages 1, 9, 10 and 15 TN #DMAS-34 1/1/25 Page 9 TN #DMAS-33 10/1/24 TOC, Pages 1, 6, 6a, 12-14 Page 15 is added. TN #DMAS-32 7/1/24 Pages 9 and 10 TN #DMAS-29 10/1/23 Page 12 TN #DMAS-27 4/1/23 Page 6a TN #DMAS-25 10/1/22 Pages 9,10 TN #DMAS-23 4/1/22 Pages 5, 12 TN #DMAS-21 10/1/21 Page 14 TN #DMAS-20 7/1/21 Page 2 Page 2a is a runover page. TN #DMAS-18 1/1/21 Pages 4, 8, 13

M0130 Changes Page 1 of 2

TN #DMAS-17 7/1/20 Pages 2, 6, 10 Page 6a was added as a runover page. TN #DMAS-15 1/1/20 Pages 9, 10 TN #DMAS-14 10/1/19 Pages 9, 10 TN #DMAS-11 1/1/19 Page 1 TN #DMAS-10 10/1/18 Table of Contents Pages 1, 2-2b, 9-12 Pages 2c-2e were added as runover pages. TN #DMAS-9 7/1/18 Page 2b TN #DMAS-8 4/1/18 Page 13 TN #DMAS-7 1/1/18 Pages 1, 9 TN #DMAS-5 7/1/17 Pages 1, 10 TN #DMAS-4 4/1/17 Page 6 TN #DMAS-3 1/1/17 Pages 5, 7, 11 TN #DMAS-2 10/1/16 Table of Contents Pages 2. 4, 5, 7-10, 12, 13 Page 2a is a runover page. Page 14 was added as a runover page. TN #DMAS-1 6/1/16 Table of Contents Pages 4, 6, 10, 12 Page 11 is a runover page. Page 13 was added as a runover page. TN #100 5/1/15 Pages 1, 2-2b, 5, 11 Pages 3, 6 and 2c are runover Pages. UP #10 5/1/14 Table of Contents Pages 8-12 Page 13 was added. TN #99 1/1/14 Pages 10-12 Page 13 was added. TN #98 10/1/13 Table of Contents Pages 1-12 UP #9 4/1/13 Page 3, 5 UP #7 7/1/12 Pages 4, 5 TN #96 10/1/11 Pages 6-8 TN #95 3/1/11 Page 8 TN #94 9/1/10 Pages 2-6, 8 TN #93 1/1/10 Pages 4-6, 8 Update (UP) #2 8/24/09 Pages 8, 9

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TABLE OF CONTENTS

M01 APPLICATION FOR MEDICAL ASSISTANCE

Section Page

Medical Assistance

Application Processing Principles……………………M0130.001 .... ……………………...1

Processing Time Standards………………………………M0130.100 .... ……………………...2

Required Information and Verifications………………..M0130.200 .... ……………………....5

Eligibility Determination Process ……………………….M0130.300……………………........11

Applications Denied Under

Special Circumstances ……………………………….M0130.400……………………..…..14

Returned Mail …………………………………………….M0130.500…………………………15

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M01 July 2025 Subchapter Subject Page ending with Page M0130 APPLICATION PROCESSING M0130.001 1

M0130.001 Medical Assistance Application Processing Principles

A. Introduction Under the Affordable Care Act (ACA), the Medicaid and FAMIS medical assistance (MA) programs are part of a continuum of health insurance options available to Virginia residents. MA application processing is based on several principles that are prescribed by the ACA. B. Principles 1. Single Application Applications for affordable health insurance, including qualified health plans with Advance Premium Tax Credit (APTC) assistance and MA, are made on a single, streamlined application. The application gathers information needed to determine eligibility for both APTC and MA. 2. No Wrong Door Individuals may apply for MA through their local department of social services (LDSS), the Virginia Health Insurance Marketplace (VIM), at the CommonHelp website, or the Cover Virginia Call Center. Applications may be routed to either the LDSS or Cover Virginia for processing. Effective 11/1/2018, applications made through the VIM that require MAGI eligibility determinations will have the eligibility determination made by the VIM. If an application is approved, the case will be routed to either the CPU or LDSS, where it should be accepted and enrolled without delay. ABD applications received by the VIM will be routed to the local agencies for processing. 3. Use of Electronic Data Source Verification The eligibility determination process for MA is based on electronic data source verification (EDSV) to the fullest extent possible. The Federally- managed Data Services Hub (the Hub) provides verification of a number of elements related to eligibility for MA applications processed in the Virginia Case Management System (VaCMS). Data from on-line sources including the Virginia Employment Commission (VEC), the Work Number, Asset Verification System (AVS) and the Virginia Department of Motor Vehicles (DMV) are also acceptable for both initial applications and renewals. Electronic sources should be automatically inquired prior to worker evaluation. Information available electronically is considered agency knowledge. Eligibility workers are to request information from the applicant or authorized representative(s) only when it is not available through an approved data source or the information is inconsistent with agency records. Searches of online information systems, including but not limited to the Hub, State Online Query-Internet (SOLQ-I) and the State Verification Exchange System (SVES) are permitted only for applicants and family members whose income and/or resource information is required to determine eligibility for the applicant or patient pay for an enrollee. This includes spouses of applicants and parents of child applicants. 4. Processing Time

Agencies are required by the State Plan to adhere to prescribed standards for the processing of MA applications, including applications processed using the self-directed functionality in VaCMS. The amount of time allowed to process an application is based on the availability of required information and verifications, as well as the covered group under which the application must be evaluated.

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5. Delayed Verifications If requested verifications or other information needed to process the case are delayed in the postal system due to no fault of the applicant’s, accept the documentation, reopen the case if necessary, and complete application processing.

M0130.100 Processing Time Standards

A. Processing Time Standards

1. Expedited Application Requirements a. Pregnant Women Applications for pregnant women must be processed within seven (7) calendar days of the agency's receipt of the signed application. If the pregnant woman also applies for other children or other persons in her family and the agency cannot determine the other persons' eligibility within 7 calendar days, the agency must determine just the MA eligibility of the pregnant woman within the 7 calendar days. The agency must have all necessary verifications within the 7 calendar days in order to determine eligibility. If the agency does not receive the verifications within the 7 calendar days, the worker must send the applicant written notice on the 7th day. The notice must state why action on the application was not taken, specify what documentation is necessary in order to determine eligibility, and give a deadline of at least 10 days by which to submit the documentation. Once all necessary verifications for the pregnant woman are received, an eligibility decision must be made immediately and the applicant must be immediately notified of the decision. If the pregnant woman applied for other persons in the family, and the eligibility determination for those persons has not been completed, the written notice must state that the application is still pending. If all necessary verifications are not received, the application continues to pend until the 45-day processing time limit is reached. b. Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) Medicaid Applications BCCPTA Medicaid applications filed by individuals who do not meet the description of an individual in the Low-income Families with Children (LIFC), Medicaid pregnant women, or SSI recipients covered groups must be processed within 10 working days of the agency’s receipt of the signed application.

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BCCPTA Medicaid applications filed by individuals who meet the description of an individual in the LIFC, pregnant women, or the SSI recipients covered groups must be processed as soon as possible, but no later than 45 days of the agency’s receipt of the signed application. If the BCCPTA Medicaid application is the only application required and no additional information is required, the eligibility decision must be made immediately and the applicant must be notified of the decision within 10 working days of the agency’s receipt of the application.

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If a decision cannot be made within 10 working days of receipt of the BCCPTA application, the worker must send a written notice on the 10th day stating why action has not been taken, specifying what information is needed, and a deadline for submitting the information. If all necessary verifications are not received, the application continues to pend until the 45-calendar-day processing time limit is reached. 2. 45/90 Day Requirement Applications for which information in addition to that provided on the application is required, including requests for retroactive coverage, must be processed within 45 calendar days for all applicants other than pregnant women, women in the BCCPTA covered group, or individuals needing a disability determination. For individuals who require a disability determination to meet the covered group requirement, the time standard for processing an application is 90 calendar days. Other non-financial requirements, however, must be met and verified by the 45th calendar day, or the application must be denied and DDS must be notified to stop action on the disability determination (see M0310.112 G.3). The time standard begins with the date of receipt of a signed application and ends with the date of enrollment or the date the notification of denial of MA is mailed to the applicant. The applicant must be informed of the agency's time standards. The eligibility worker must allow at least 10 calendar days to receive the necessary verifications. If all necessary verifications are not received, the application continues to pend until the 45-day processing time limit is reached. 3. Early Denial Before Deadline Date When the 45-day processing deadline date falls on a weekend or a holiday, the LDSS may deny an individual’s application on the last business day before the deadline date if all necessary verifications have not been received. If the early denial action is taken, however, the LDSS must re-open the application if the individual provides the necessary information on or before the 45th day deadline. If the individual’s application is re-opened and he is determined eligible, the LDSS must enroll the individual and send a notice to the individual notifying him of the approval and the begin date of coverage. 4. Processing Priority Application processing priority must be given to applicants who are in need of Medicaid coverage for nursing facility or community-based long-term care, hospice care, or who are in emergent need of other covered services. These applications must be processed as quickly as possible. 5. Time Standard Exceptions The specified time standards apply unless the agency cannot reach a decision within the time standard because of one of the following reasons: • the applicant's inability to furnish necessary information for a reason beyond his/her control, • a delay in receipt of information from an examining physician, • a delay in the disability determination process, • a delay in receiving DMAS decision on property transfer undue hardship claim, or • an administrative or other emergency beyond the agency's control.

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If action is not taken within the time standard, the case record must show the cause for the delay and the applicant must be notified in writing of the status of his application, the reason for the delay, and his right of appeal. When an application is delayed after 90 days because of a disability decision and the agency has determined that excess resources exist at the time the delay notice is sent, the NOA must inform the applicant that he/she has excess resources and the amount. The notice must also state that: • a final action cannot be taken until the disability decision is made; • if the applicant is determined to be disabled, he/she will not be eligible unless the excess resources are reduced; and • he will be notified when the disability decision is made. B. Application for Retroactive Coverage The retroactive period is based on the month in which the application is filed with the agency. The retroactive period is the three months prior to the application month. Retroactive Medicaid eligibility must be determined when an applicant for medical assistance indicates on the application that he, or anyone for whom he requests assistance, received a covered medical service within the retroactive period. The covered service may be listed by the applicant as an actual medical service on the application, or information on the application may indicate that a service was received, such as the birth of a child or Medicare coverage during the retroactive period. An individual may request retroactive coverage at any time subsequent to an application even if the application was denied or the applicant signed a statement saying he did not want retroactive coverage. The retroactive period is based on the application month regardless of whether the application was denied or approved. There is no administrative finality on determining retroactive eligibility if eligibility for the months in the retroactive period has not been determined. If the application was denied, the application is reopened for determination of eligibility in the entire retroactive period – all three months prior to the application month – even if a covered medical service was received in only one retroactive month. The applicant must provide all verifications necessary to determine eligibility during the retroactive period. If the applicant is found eligible for retroactive coverage and a Medicaid-covered medical service was received over one year prior to the date the retroactive eligibility is determined, the applicant must be given an "Eligibility Delay" letter to give to the medical provider so that Medicaid will pay the claim (see the sample letter on the intranet at https://fusion.dss.virginia.gov/bp/BP- Home/Medical-Assistance/Forms. Once retroactive eligibility is established, Medicaid coverage begins the first day of the earliest retroactive month in which retroactive eligibility exists.

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M0130.200 Required Information and Verifications

A. Identifying Information An application must contain basic identifying information about the applicant. Basic identifying information is the applicant's name, address, Social Security number (SSN) or proof that the individual applied for the SSN, if required for the applicant’s eligibility, and date of birth. 1. Name The name entered in the official case record and computer enrollment systems for an applicant must match the applicant’s name on his Social Security card or Social Security Administration (SSA) records verification. This is important because of the Medicare Buy-in and other computer matches the Medicaid Enterprise System (MES—formerly the Medicaid Management Information System [MMIS]) performs with SSA. At the time of the initial MA application, verify the SSA record of the individual’s name. The Federally managed Data Services Hub verifies the individual’s name and SSN with the SSA for cases processed in VaCMS (see M0130.200 B.1 below). For an individual whose name and SSN cannot be verified in VaCMS and for all individuals whose cases are not processed in VaCMS, either SVES or the State Online Query- Internet system (SOLQ-I) SSA Title II and Title XVI results may be used. If the individual says his name is different from the name on his Social Security card, he must first notify SSA and have his name changed on SSA records. When SSA changes his name and SSA verification of the name change is received, the worker can change his name in the case record and on the eligibility and MES computer systems. For purposes of the case record only, the agency may choose to set up the case in the individual’s alleged name before it is changed on the Social Security card. 2. SSN The SSN of an individual for whom medical assistance is requested and for whom having an SSN or proof of application for one is an eligibility requirement, must be provided by the applicant and verified by the worker through SSA. The Hub or SOLQ-I may be used to verify the individual’s SSN. See M0240.001. B. Required Verifications 1. The Federally- managed Data Services Hub The Hub is a data center that links the following federal systems: • Social Security Administration • Internal Revenue Service (IRS) • Systematic Alien Verification for Entitlements (SAVE).

Income verification by the Hub is acceptable for retroactive eligibility determinations provided that reasonable compatibility is met (see M0420.100 B.9). Information from other sources, such as the Work Number, may become available via the Hub in the future. 2. Other Verification Sources An individual must provide verifications of certain MA eligibility requirements when they cannot be verified through EDSV. Before taking action on the application, the applicant must be notified in writing of the required information. The verification request (checklist) must be sent to the authorized representative, if one has been designated.

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The eligibility worker must allow at least 10 calendar days for receipt of the necessary verifications, but additional time may be allowed depending on the type of information requested. The specific information requested and the deadline for receipt of the verifications must be documented in the case record. If the applicant reports to the EW that he needs help to obtain certain verifications, the EW must attempt to assist the applicant. If the verification cannot be obtained, the application must be denied.

3. Copy or Scan Verification Documents Legal documents and documents that may be needed for future eligibility determinations or audits must be copied or scanned into VaCMS using the Document Management Imaging System (DMIS) and preserved for the record. These include citizenship and identity documents, alien status documentation, verification of legal presence, trusts, annuities, contracts, wills, life insurance policies, the current value of all other countable resources, and verifications of earned and unearned income. Notes by the eligibility worker that the verifications were viewed are not sufficient. 4. Non-custodial Parent Applying for Child Eligibility for a child is based on the income of the parent with whom the child lives. If a non-custodial parent applies for his child, he must give written permission for the eligibility worker to contact the custodial parent. The eligibility worker must obtain the custodial parent’s income information, written permission to verify income using available online data sources, and other information necessary to verify and calculate countable income, including Social Security Number and residence address. If the either the non-custodial parent or the custodial parent fails to give the necessary permission, the child’s eligibility cannot be determined using the application filed by the non-custodial parent.

5. Information Not Provided If information necessary to make an eligibility determination is requested but not provided by the applicant and cannot be obtained from any other source, the application must be denied (or the coverage cancelled) due to the inability to determine eligibility. Individuals whose applications are denied due to the inability to determine eligibility are not referred to the VIM. See M0130.300 D.2. If the Verification Checklist or other mail is returned to the agency, follow the steps in M0130.500 Returned Mail prior to taking negative action. When the deadline date falls on a weekend or holiday, LDSS may choose to deny the application (or cancel coverage) before the deadline date. However, if the early denial or cancel action is taken, LDSS must re-open the application if the individual provides the necessary information on or before the original deadline date. If the individual’s application is re-opened and he/she is determined eligible, the LDSS must send a notice to the individual notifying them of the changed action.

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C. Verification of Nonfinancial Eligibility Requirements 1. Verification Not Required The applicant’s statements on the application may be accepted for the following identifying information and nonfinancial eligibility requirements unless the eligibility worker has reason to question the applicant’s statements: • Virginia state residency; • pregnancy. 2. Verification Required

3. Verification Required for a Case Change of Gender The following information must be verified: • citizenship and identity; • Social Security number (see section D below); • legal presence in the U.S. of applicants; • age of applicants age 65 and older; and • disability and blindness. The worker must attempt to verify all information using Electronic Verification sources prior to requesting proof from the applicant. An individual’s gender is not a factor used to process a determination of Medicaid eligibility and does not have to be verified. The individual’s request to a change the gender listed on the case cannot be accepted verbally and verification of a change is required. Acceptable verification could include a Social Security Administration record, a state driver license, state identification card, or other official document.

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See M0130.200 E below for instructions on the verification of legal presence. See subchapter M0220 for instructions on the verification of identity and citizenship. See subchapter M0310 for instructions on the verification of age and disability. D. Social Security Numbers Applicants must provide the SSN of any person for whom they request Medicaid, if an SSN is required for that individual’s eligibility. An individual who is applying only for others and is not applying for himself is not required to provide an SSN for himself.

1. SSN Verification The Federal Hub, SVES or SOLQ-I may be used to verify the individual’s SSN. 2. Exceptions to SSN Requirements The SSN requirement does not apply to: • an alien who is eligible only for Medicaid payment of emergency services, as defined in subchapter M0220,

• a non-citizen who is only eligible to receive an SSN for a valid non-work reason,

• a child under age one born to a Medicaid-eligible or FAMIS- covered mother (see M0330.301 B. 2 and M2220.100.), or

• an individual who refuses to obtain an SSN because of well-established religious objections.

See M0240 for additional information and verification requirements. 3. SSN Not Yet Issued If an SSN has not been issued, the applicant must cooperate by applying for a number with the local Social Security Administration (SSA) office. Instruct the applicant to submit form SS-5, the Application for Social Security Number, to the SSA and to obtain a receipt from the SSA verifying that the application was submitted. The SS-5 is available online at: https://www.ssa.gov/forms/ss- 5.pdf. The applicant must provide the SSN to the local social services department as soon as it is received and the number must be entered in the eligibility and enrollment system. Applicants who refuse to furnish an SSN or to show proof of application for a number will be ineligible for medical assistance. In the case of a newborn child not eligible in a child under 1 covered group, the applicant can request hospital staff to apply for an SSN for the child through hospital enumeration procedures. Form #SSA-2853 will be given to the applicant as proof of application for an SSN. When entering the individual in the eligibility/enrollment system, use the date the individual applied for an SSN, or the individual’s date of birth, preceded by “999” as the individual’s SSN. For example, an individual applied for an SSN on October 13, 2006, enter “999101306” as the individual’s SSN. E. Legal Presence (Effective January 1, 2006) Effective January 1, 2006, Section 63.2-503.1 of the Code of Virginia requires most applicants for or recipients of public assistance who are age 19 or older to provide proof of citizenship or legal presence in the U.S. Applicants or recipients age 19 or older for whom medical assistance is requested must prove their citizenship or legal presence.

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Individuals who, on June 30, 1997, were Medicaid-eligible and were residing in long-term care facilities or participating in home and community-based waivers, and who continue to maintain that status (eligible for Medicaid and reside in long-term care facilities or participate in home and community-based waivers) are exempt from this requirement. Non-citizens applying for Medicaid payment limited to emergency services are not subject to the legal presence requirement. An individual who is applying on behalf of another and is not requesting assistance for himself is not subject to the legal presence requirement. 2. Documents That Demonstrate Legal Presence An applicant may demonstrate legal presence by presenting one of the following documents: • valid evidence of U.S. citizenship; • valid evidence of legal permanent resident status; • valid evidence of conditional resident alien status; • a valid SSN verified by SSA; • a U.S. non-immigrant visa; • a pending or approved application for legal asylum; • a refugee or temporary protected status document; or • a pending application for an adjustment of residence status. 3. Failure to Provide Proof of Legal Presence An applicant who cannot provide documentation that he is a citizen or legally present at the time of application must sign an affidavit under oath attesting that he is a U.S. citizen or legally present in the U.S. in order to meet the requirement for proof of legal presence for either: • a period of 90 days or until it is determined that he is not legally present in the U.S., whichever is earlier; or • indefinitely if the applicant provides a copy of a completed application for a birth certificate that has been filed and is pending and being actively pursued in accordance with federal or state law. Such extension shall terminate upon the applicant’s receipt of a birth certificate or determination that a birth certificate does not exist because the applicant is not a U.S. citizen. The affidavit form is on the intranet at https://fusion.dss.virginia.gov/bp/BP- Home/Medical-Assistance/Forms. NOTE: The individual’s address on the affidavit form must be the individual’s residence address, not the mailing address. 4. Relationship to Other Medicaid Requirements Providing proof of legal presence or submitting a signed affidavit meets the legal presence eligibility requirement. To be eligible for Medicaid, however, the individual must meet all other state and federal Medicaid eligibility requirements. Submission of the affidavit without proof of application for an SSN as required by M0130.200 D. does NOT meet the SSN requirement. F. Third Party Liability (TPL) Applicants must be asked to provide information about any health insurance they may have. Verification of health insurance information is not required.

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M01 July 2025 Subchapter Subject Page ending with Page M0130 APPLICATION PROCESSING M0130.200 9 If the client is eligible for benefits to be used exclusively for the payment of medical expenses (i.e. an insurance settlement), but there is no TPL code for that benefit, the worker must email the information to the DMAS TPL Unit at TPLUnit@dmas.virginia.gov, or send the information to: DMAS Third Party Liability Section 600 East Broad Street, Suite 1300 Richmond, Virginia 23219 G. Health Insurance Premium Payment (HIPP) Program The HIPP program is a cost-savings program for individuals enrolled in Medicaid which may reimburse some or all of the employee portion of the employer group health insurance premium. Eligibility for HIPP is determined by the HIPP Unit at DMAS. Participation in HIPP is voluntary. The local DSS agency must give each applicant or enrollee who reports that he or someone in his family is employed more than 30 hours each week and is eligible for health insurance coverage under an employer’s group health plan must be given a HIPP Fact Sheet, which provides a brief description of the program and the contact information for the HIPP Unit at DMAS. The HIPP Fact Sheet is available at https://fusion.dss.virginia.gov/Portals/[bp]/Medicaid/Resources%20and%20Job%20A ids/MA%20Fact%20Sheets/HIPP%20Fact%20Sheet%2024_d032_03_0842-04- eng_.doc?ver=2024-07-15-082927-803. Enrollees and other members of the public may contact the HIPP Unit for additional information at hippcustomerservice@dmas.virginia.gov. If the health insurance policy holder lives outside of the home, a HIPP Consent Form must be completed by both the policy holder and the parent/authorized representative so the DMAS HIPP Unit can process the HIPP application. If the form is required, the DMAS HIPP Unit will send it to the applicant for completion. H. Verificatio n of Financial Eligibility Requirem ents The eligibility worker must verify the following financial eligibility requirements: • the value of all countable, non-excluded resources, if the reported values of the resources are not both reasonably compatible with electronic sources AND below the resource limit. In all situations the sources of the resources do not have to match. If the member attests to having resources below the limit and values received from electronic sources are above the limit, additional verification should be requested. Reasonable compatibility for resource evaluation is effective for all case actions as of June 3, 2024. • asset transfer information for individuals in need of long-term care services, including the date of transfer, asset value, and compensation received. • earned and unearned income. For all case actions effective August 26, 2022, if the income attested to by the applicant is within 20% of the income information obtained from electronic sources OR both sources are below the applicable income limit, no additional verification is required. If the attested income is under the income limit and the reasonable compatibility standard is not met, request verification of income and allow a minimum of 10 days to return. If the applicant meets a Medically Needy (MN) covered group, verification of income is required to determine spenddown liability. If the attested income is over the income limit and the individual does not meet a Medically Needy (MN) covered group, deny the application. The agency must utilize online systems information verifications that are available to the agency without requiring verifications from the individual or family. The agency has ready access to Supplemental Nutrition Assistance Program (SNAP) and TANF records, some wage and payment information, and

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information from SSA through SVES or SOLQ-I. Verification of income is valid if the information is less than 6 months old. The agency must include in each applicant’s case record facts to support the agency’s decision on the case.

1. Resources The value of all countable, non-excluded resources must be verified. If an applicant’s attested resources are over the resource limit, the applicant or authorized representative must be given the opportunity to provide verification of the resources. All available resource verification system(s) must be searched prior to requesting information from the applicant. 2. Use of Federal Income Tax Data The Hub provides verification of income reported to the IRS. Income information reported to the IRS may be used for eligibility determinations for Families and Children (F&C), MAGI Adults, and ABD covered groups when IRS information is available. The income reported on the application is compared to the data obtained from the Hub for reasonable compatibility per M0420.100. When IRS verification is used for an ABD individual, reasonable compatibility is acceptable as verification of earned (i.e. taxable) income.

3. SSA Data Social Security and/or Supplemental Security Income must be verified through SSA. The Federal Hub links to SSA data. SOLQ-I may also be used. The State Data Exchange (SDX) system should only be used as an alternate method when the Hub or SOLQ-I is not available. 4. Income For all case actions effective August 26, 2022, the applicant’s attested income, including when the applicant attests to having zero ($0.00) income, is considered the verified income if the income attested to by the applicant is within 20% of the income reported by electronic data sources OR both sources are below the applicable income limit. If the attested income is under the income limit and the reasonable compatibility standard is not met, request verification of income and allow a minimum of 10 days to return. If the applicant meets a MN covered group, verification of income is required to determine spenddown liability based on actual income received. For individuals requesting long-term services and supports (LTSS), verification of income is required to calculate the patient pay. See M1470. If the attested income is over the income limit and the individual does not meet a Medically Needy (MN) covered group, deny the application. If the individual agrees that the discovered countable income was received, determine if the on-line information can be used to evaluate current/ongoing eligibility. If the discovered information is not sufficient to evaluate eligibility, send a written request for needed verifications and allow at least ten calendar days for the return of the verifications. If the individual reports the income has stopped, ask when the income stopped to ensure all income needed to correctly determine prospective and retroactive eligibility (if appropriate) is evaluated. Note the date of termination of income (last pay received) in the record. If the income stopped during a month that is being evaluated for eligibility, the individual must provide verification of the termination of income.

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M0130.300 Eligibility Determination Process

A. Evaluation of Eligibility Requirements When an MA application is received the worker must determine through a “file clearance” search of the eligibility and enrollment systems whether or not the individual already has Medicaid or FAMIS coverage. With the exception of individuals enrolled on the basis of presumptive eligibility (PE), applications for MA submitted by individuals who already have an application recorded or who are currently active are denied as duplicate applications. See M0130.400.D Applications submitted by individuals currently enrolled as HPE or as Newborn Children are not duplicate applications because they were initially enrolled without filing a full MA application. See M0120.300 A.5 for more information. The eligibility determination process consists of an evaluation of an individual’s situation that compares each of the individual’s circumstances to an established standard or definition. The applicant must be informed of all known factors that affect eligibility. It is crucial that individuals reviewing a case, including auditors, be able to follow the eligibility determination process in VaCMS. Changes and any questionable information must be appropriately documented as comments in the VaCMS case record. The evaluation of eligibility requirements must be documented in writing for cases not processed in VaCMS. The Evaluation of Eligibility (form #032-03-823) may be used. The form is available online at the DSS Fusion website. Agency or CPU created evaluation forms are also acceptable as long as all information needed to determine eligibility is documented on the evaluation form. Eligibility decisions are made following a prescribed sequence: • The applicant must meet all non-financial requirements, including a covered group. • If applicable to the covered group, resource limits must be met. • The income limits appropriate to the covered group must be met. Subchapter M0210 contains the Medicaid non-financial requirements. B. Hierarchy of Covered Group An applicant must be evaluated for eligibility in all potential covered groups and enrolled in the group that is the most beneficial to the applicant. First, evaluate under covered groups offering full coverage and if the applicant is not eligible, evaluate under groups offering limited coverage. Specific instructions regarding the determination of covered group are contained in chapter M03. C. Applicant’s Choice of Covered Group An individual who meets more than one covered group may choose the covered group under which he wishes his eligibility determined. Appropriate policy used is based on that individual's choice. If the choice is not clear on the application/redetermination form, the individual must state his covered group choice in writing. If the applicant does not make a choice, enroll him in the covered group that is the most beneficial.

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D. Application Disposition 1. General Principle Each application must be disposed of by a finding of eligibility or ineligibility as supported by the facts in the case record, unless the application is withdrawn or terminated (see M0130.400). If an applicant dies during the application process, his eligibility can only be established for the period during which he was alive. If an applicant (other than a Medicare beneficiary, HPE, or deceased individual) is ineligible for MA for any reason other than the inability to determine eligibility, a referral to the VIM must be made so that his eligibility for the APTC in conjunction with a Qualified Health Plan (QHP) can be determined. Individuals who have Medicare, who are incarcerated, who are enrolled as HPE, and deceased individuals and are not referred to the VIM. 2. Entitle- ment and Enrollment a. Entitlement Entitlement to medical assistance is based on the application month. However, entitlement cannot begin prior to an individual’s date of birth, and cannot continue after an individual’s date of death. See section M1510.100 for detailed entitlement policy and examples. If applicants indicate that they have been receiving MA (Medicaid or Children’s Health Insurance Program) coverage in another state prior to moving to Virginia, instruct them to contact the eligibility worker there and request that the coverage be cancelled, if they have not already done so. Individuals are no longer considered residents of the other state once they have moved to and intend to reside in Virginia and are not entitled to receive services paid for by the other state’s MA program. Enrollment may begin with the month of application or the earliest month in the application’s retroactive period that they met the residency requirement per M0230. b. Enrollment MA enrollees must be enrolled in the MES, either through the system interface with the eligibility determination system or by submitting a coverage correction request through the Coverage Correction Portal (CCP) on the MES website., Home | MES. Note: The MES was implemented in April 2022. Prior to April 2022, the Medicaid Management Information System (MMIS) was used for enrollment and claims processing. References to MMIS in the Medical Assistance Eligibility Manual will be updated as other policy revisions are made. When an individual who does not have Medicare is eligible for only limited MA benefits, such as Plan First, a referral to the VIM must be made so that eligibility for the APTC in conjunction with a QHP can be determined. 3. Notification to Applicant

Either a Notice of Action generated by the eligibility determination system or the equivalent form #032-03-006 (available at the DSS Fusion website) must be used to notify the applicant of the specific action taken on the application. The notice must be sent to the authorized representative, if one has been designated.

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a. Approvals

As applicable, the notice must state that: • the application has been approved, including the effective date(s) of coverage and the date of the next annual renewal; • retroactive Medicaid coverage was approved, including the effective dates. • For approvals of limited coverage, the notice or a separate system- generated notice must state that the application has been referred to the VIM for determination of eligibility for the APTC. b. Denials

As applicable, the notice must state that: • the application has been denied, including the specific reason for denial cited from policy; • retroactive Medicaid coverage was denied, including the specific reason for denial cited from policy. • When the applicant (other than a Medicare beneficiary or deceased individual) is ineligible for MA for any reason other than the inability to determine eligibility, either the notice or a separate system-generated notice must state that the application has been referred to the VIM for determination of eligibility for the APTC. c. Delays The notice must state that there is a delay in processing the application, including the reason. d. Other Actions Other actions for which a notice must be sent include when a request for re- evaluation of an application in spenddown status has been completed.

e. Advance Health Care Directive An Advance Health Care Directive insert is required to be included with an initial notice of eligibility. The insert (available at https://fusion.dss.virginia.gov/bp/BP-Home/Medical-Assistance/Forms, must be included with the initial approval or denial Notice of Action. This insert is not required when adding a person to an existing case, at redetermination, when a change is reported or when coverage is cancelled.

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E. Notification for Retroactive Entitlement Only There are instances when an applicant is not eligible for ongoing eligibility but is eligible for retroactive benefits or a change in the applicant's situation during the application process results in the applicant being eligible for only a limited period of time. Only one notice is sent to the applicant covering both actions. Statements of the exact dates of eligibility, the date of ineligibility, and the reason(s) for ineligibility must be included on this notice.

M0130.400 Applications Denied Under Special Circumstances

A. General Principle When an application is withdrawn or the applicant cannot be located, the application is denied. The reason for the denial must be recorded in the case record, and a notice must be sent to the applicant's last known address. B. Withdrawal An applicant may withdraw his application at any time. The request can be verbal or written. An applicant may voluntarily withdraw only his application for retroactive coverage by signing a statement or by a verbal statement specifically indicating the wish to withdraw the retroactive coverage part of the application. A written withdrawal request must be placed in the case record. A verbal request for withdrawal can be accepted only from the applicant or case head, or the authorized representative. A verbal request must be documented in the case record with the date and time the withdrawal request was received, the name of the person who made the withdrawal request, and the name and title of the agency staff person who took the call. When the applicant withdraws an application, the eligibility worker must send a notice of action on MA to the applicant. C. Inability to Locate If mail is returned, the worker must follow the returned mail policy in M0130.500. The agency must attempt to contact the applicant by at least two methods in addition to sending a letter to the last known address informing the applicant of the agency's attempt to locate them and asking that they contact the office. For applicants who are documented as homeless and do not provide a mailing address, maintain all correspondence at the local agency. If the applicant does not respond or contact the agency within 45 days of the date of application, deny the application. D. Duplicate Applications The worker will review a duplicate application to verify there are no changes in circumstances, request(s) for coverage, or other actions that need to be acted on. Applications received requesting MA for individuals who already have an application recorded (i.e. pending) or who are currently active and receiving coverage will be denied due to duplication of request. Document current coverage on the notice. For duplicate applications submitted by individuals currently enrolled in coverage, the denial notice must include the member’s coverage status, as appropriate: • the application has been approved for a new level or type of coverage; or

• the application has been denied for new services, but the member remains enrolled in their current level or type of coverage; or

• the requested coverage was denied and the member’s existing coverage is being terminated. Do NOT deny an application for “overlapping coverage” without adding an explanation to the Notice of Action on Medicaid.

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M0130.500 Returned Mail

A. General Principle This policy pertains to all information mailed to the applicant at intake, changes or renewals. Generally, there are three types of recipient mail that could be returned to the Medicaid agency: (1) mail with an in-state forwarding address; (2) mail with an out-of-state forwarding address; and (3) mail that does not include a forwarding address.

Workers must confirm whether the address information on the piece of returned mail is complete and consistent with the address information the agency has on file. The front of the returned mail should be scanned into the case record and all actions to contact the client must be documented. B. Returned Mail With Complete Information Compare the address provided to existing records. If an error is discovered (i.e., missing or incorrect apartment number, etc.), make any necessary corrections and resend the information. If the subsequent mailing to the correct address is not returned, no additional contact is required. The address should be updated in VaCMS and no other action is required. If the subsequent mailing is returned, proceed as indicated below based on whether the returned mail has a forwarding address. C. Returned Mail with no Forwarding Addres The worker must attempt to contact the recipient through two other methods, including phone, text, email, or alternate addresses [including attempting to contact the Authorized representative (AR)]. If only one other method is available, a contact attempt must be made. If no other methods are available, the condition will be met if it has satisfied the up-to-date contact information. D. Returned Mail with Forwarding Address E. Mail Returned from Authorized Representative F. Lack of Alternative Contact Information Sending the VCL or other mail to the new address will represent one contact method. One other method of contact, if available, is required to satisfy the returned mail condition. If mail is not returned from the forwarding address, the returned mail condition no longer applies because the original mailing has been completed and is no longer considered to be returned. The address should be updated in VaCMS and no other action is required. Returned mail from the AR should be investigated. If the address appears correct and no other methods (phone, text, email or alternate addresses) are available, the client should be informed. If after complying with the conditions described above, the only contact information available is the address in the individual’s case record, and the LDSS does not have or cannot find a phone number, email address or other means to contact the individual, no further efforts to contact the individual are necessary. If the applicant does not respond or contact the agency within 45 days of the date of application (30 days for a change) to update their information, deny the application or close the case. See M0130.400 and M1520.200. G. Documentation The case narrative must contain documentation of all methods used for contact attempts. To ensure applicants are able to complete the application process, the worker should ensure that if they successfully contact an individual after receiving returned mail, the recipient receives any necessary verification requests at their correct address and has sufficient time to return the information and complete the application process.

CHAPTER M01

APPLICATION FOR MEDICAL ASSISTANCE SUBCHAPTER 40

INCARCERATED INDIVIDUALS

M0140 Changes

Changed With Effective Date Pages Changed TN #DMAS-34 1/1/25 Page 2 TN #DMAS-30 1/1/24 Page 1 TN #DMAS-25 10/1/22 Page 1, 3, 5 TN #DMAS-24 7/1/22 Page 3, 4 TN #DMAS-21 10/1/21 Page 1 TN #DMAS-18 1/1/21 Pages 3-5 TN #DMAS-14 10/1/19 Pages 4, 5

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TABLE OF CONTENTS

M01 APPLICATION FOR MEDICAL ASSISTANCE

Section Page

Incarcerated Individuals General Information…………M0140.000 .... ……………………...1

Communication ……………………….…………………..M0140.100 .... ……………………...2

Application Guidelines …………………………………...M0140.200 .... ……………………...2

Case Maintenance ……………………………..…………..M0140.300 .. ……………………....4

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M0140.000 Incarcerated Individuals General Information

A. Introduction An incarcerated individual, or offender, is an inmate of a public institution. Inmates include those under the authority of the Virginia Department of Corrections (DOC), held in a regional or local jail, those on work release, and inmates of a Virginia Department of Juvenile Justice (DJJ) facility. For juveniles not in a facility but within the authority of DJJ, see section M0280.300 D. See section M0280.301 regarding an individual who is not considered to be an inmate of a public institution. An individual released from jail under a court probation order due to a medical emergency is NOT an inmate of a public institution because he is no longer incarcerated. B. Policy Principles An individual is not eligible for full benefit Medicaid coverage while incarcerated. These individuals may apply for medical assistance and (if approved) receive coverage limited to inpatient hospitalization services. Inpatient hospitalization may include long-term inpatient services, such as admission to a rehabilitation facility. Children under 19 are eligible for 12 months of continuous in-patient hospitalization coverage.

The offender must meet eligibility requirements for a full-benefit covered group. Medicaid non-financial eligibility requirements include • Virginia residency requirements (see M0230) • Citizenship or immigration status (see M0220) • A Social Security Number (SSN) or proof of application for an SSN (see M0240) • Institutional status requirement of being an inmate in a public institution (see M0280)

Medicaid financial eligibility requirements for the individuals covered group include • Resources (if applicable) within resource limit (Chapter M06 for F&C; Chapter S11 for ABD) • Income within income limit (Chapter M04 & M07 for F&C covered groups; Chapter S08 for ABD covered groups)

C. Covered Group The individual is evaluated for eligibility in the covered group in which they would otherwise be eligible except for being incarcerated. The primary covered groups an offender may meet include: • MAGI Adults (M0330.250) • Pregnant Women (M0330.400) • Child Under Age 19 (M0330.300) • Aged, Blind or Disabled (M0320.300) • Former Foster Care Child Under Age 26 Years (M0330.109) D. Immigration Status Requirements An incarcerated person must meet immigration requirements (see M0220). A non-citizen who meets all Medicaid eligibility requirements except for immigration status and has received an inpatient hospitalization may be evaluated for coverage as an Emergency Services Alien see M0140.200.C.3

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M0140.100 COMMUNICATION

A. Introduction Direct communication between an offender and staff at the Cover Virginia Incarcerated Unit (CVIU) or LDSS may be limited or prohibited depending on the facility. Staff employed by the facility or DOC may assist in coordinating the application process and communicating information to the offender, or to CVIU/LDSS.

B. Policy The facility may designate staff who are permitted to assist with applications. Communication with facility staff is limited only to information related to the case or application. Access to case information by facility staff is terminated when the offender is released and/or no longer incarcerated.

Case assistance for offenders held by the DOC will be coordinated by the Department of Corrections, Medicaid Program Unit, 5511-B Biggs Road, Richmond, Virginia 23224.

Case assistance for offenders in regional and local jails is handled in coordination with the facility, their staff, and any authorized representative(s) (see M0110.110).

Send all notices and other correspondence to the mailing address or via secure email as indicated on the application. If the applicant has designated an authorized representative to act on his behalf and receive notices, send a copy of the correspondence and notices to the authorized representative.

M0140.200 APPLICATION GUIDELINES A. Introduction Any application, renewal, or case review for an offender will be processed in the required time standards following applicable Medicaid eligibility policy (see M0130.100).

B. Policy Offenders may file their own applications. An authorized representative may assist in applying or renewing coverage. An offender may add or change an authorized representative at any time. An authorized representative designation is valid for the life of the application (see M0110.110.E) unless a written statement indicates such designation will cease when incarceration ends. See Broadcast in Fusion dated 3/8/2019 Cover Virginia Incarcerated Unit (CVIU) and 5/19/2019 Updates to Cover Virginia Incarcerated Unit (CVIU) Procedures (https://fusion.dss.virginia.gov/broadcasts) for instructions explaining how to send offender applications received by the local agency to Cover Virginia for processing. If the offender is approved, the Commonwealth of Virginia (COV) Medicaid Card is suppressed (not mailed).

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C. Offender Application Processing An application is not to be refused or denied because an applicant is incarcerated. A person is not required to have had an inpatient hospitalization in order to apply for Medicaid. The agency must evaluate the eligibility of all MA enrollees, with respect to circumstances that may change, at least every 12 months unless the enrollee is pregnant (see M1520.200 p.9).

1. New Application An offender who does not have active Medicaid coverage may apply while incarcerated. Coverage is based on the month of application and can include up to three months of coverage (if requested) prior to the month of application, provided eligibility requirements are met.

Ongoing coverage in AC 108 or AC 109 is effective the first day of the month of application or the date when incarceration begins, whichever is later. 2. Re-entry Process A medical assistance application for an offender with no active Medicaid coverage and an anticipated release date within 45 days is handled as part of a “Re-Entry” process and will follow the same procedure as a New Application (ref M0140.200.C.1). If the offender is approved the case will have a redetermination conducted for ongoing Medicaid coverage. This is a new application and an eligibility determination for Medicaid coverage will be made based on the information as reported or known at the time of release from the facility.

If the person is approved but is unable to or does not provide a post-release address where he will reside (e.g. reports as homeless or moving to a temporary shelter) the case will be transferred to the LDSS of his pre- incarceration, if known. If there is no known address, or the individual lived outside of Virginia prior to incarceration and intends to remain in the state, transfer the case to the LDSS where the correctional facility is physically located.

If the application is approved the worker will confirm that a new Commonwealth of Virginia Medicaid Card has been generated and a copy of the Notice of Action sent to the anticipated post-release address.

3. Emergency Services A non-citizen who meets all Medicaid eligibility requirements except for immigration status, and has received an inpatient hospitalization, may qualify for coverage of emergency medical care. This care must have been provided in a hospital emergency room or as an inpatient in a hospital. Determine eligibility for emergency services using policy in M0220.400 and enroll eligible individuals using the procedures in M0220.600 D. For cases processed at the Cover Virginia Incarcerated Unit (CVIU) the individual will be enrolled in the appropriate AC 112 or AC 113 and the case will be retained at the CVIU for ongoing case maintenance. Emergency Services coverage in AC 112 or AC 113 is effective the first day of the month of application, the first day of the retroactive period, or the date when incarceration begins, whichever is earliest

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M0140.300 CASE MAINTENANCE

A. Ongoing Case Maintenance Case maintenance may include updates such as when the inmate is moved to another facility, change of an authorized representative, updates to demographics, or other changes affecting Medicaid eligibility or coverage.

Update to an offender’s case are handled by the CVIU. Facilities will use a CVIU Communication Form to report changes. Local agencies will use the LDSS to Cover Virginia Communication Form #032-03-0458-00-eng to report changes.

B. Partial Reviews If a change occurs it may be necessary to re-evaluate the offender’s Medicaid coverage. This may include release from incarceration, change of anticipated release date, death, an inmate turning age 65 years old, becoming eligible for Medicare, or end of a pregnancy (see M0140.001 G).

The eligibility worker will handle such changes within 30 days and re-evaluate the offender for continued coverage. For an offender case that involves a spenddown, see M1350.850.

C. Redetermination An offender with ongoing approved Medicaid coverage is subject to an annual (every 12 months) redetermination of coverage. The CVIU processes redeterminations of incarcerated individuals (see M1520.200 A).

Do not initiate a renewal for an individual under 19 before their 12th month of eligibility unless they reach age 19; are no longer Virginia residents; the child or child’s representative requests eligibility be closed; the agency determines that eligibility was incorrectly approved because of agency error or fraud, abuse, or perjury attributed to the child or the child's representative; or the child is deceased. Do not initiate a renewal of eligibility of a pregnant woman during her pregnancy. Eligibility as a pregnant woman ends effective the last day of the 12th month following the month in which her pregnancy ends. When eligibility as a pregnant woman ends, prior to the cancellation of her coverage, determine if the woman meets the definition for another Medicaid covered group (see M0310.002). If the woman meets the definition of a full-benefit covered group, determine if an ex parte renewal can be completed or if a renewal form is required and take appropriate action. Follow Ex Parte Renewal procedure as found in M1520.200 B. 1 if applicable. If unable to process an Ex Parte renewal, see M1520.200 B. 2 and 3 for procedures. D. Pre-Release Review An offender with active Medicaid coverage and a reported release date of 45 days or less requires a “Pre-Release” partial review. Eligibility will be evaluated for ongoing Medicaid coverage and processed based on the information as reported or known at the time of release. If the offender is approved and remains eligible for ongoing Medicaid coverage, the worker will cancel the existing aid category (AC108 or AC109) on the day prior to the actual release date and enter coverage in the new AC as of the date of release. Children under 19 should be given a new 12 month period of continuous eligibility at renewal.

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The worker will confirm a new Commonwealth of Virginia Medicaid Card has been generated and copy of the Notice of Action sent to the post-release address. If eligibility for ongoing Medicaid is denied, cancel existing Medicaid coverage the day prior to actual date of release. An offender with active Medicaid coverage (AC108/109) and released to the community before a Pre-Release Review can be conducted by the CVIU will transfer the offender’s case to the locality for review. The CVIU will send a CPU to LDSS Communication Form to alert the locality for the need to review the member for ongoing Medicaid coverage and any other requested benefits. 1. Release to a Community Living Arrangement An offender entering a household with existing benefits after incarceration may affect Medicaid eligibility for those in the household. The CVIU will process Pre-Release Reviews if approved, the case will be assigned to the locality where the ex-offender plans to reside. If the person is approved but cannot or will not provide an address where he will reside (e.g. reports as homeless or moving to a temporary shelter), the case will be transferred to the LDSS of his pre-incarceration, if known. If there is no known address or the individual lived outside of Virginia prior to incarceration and intends to remain in the state, transfer the case to the LDSS where the correctional facility is physically located.

2. Release to an Institutional Placement, LTSS, or HCBS When an offender is being released and needs to be placed in an institution or receive home and community-based services (HCBS), the CVIU will collaborate with LDSS in the locality where the individual will be residing for processing the application to ensure the eligible individual can receive necessary medical support/services when released.

E. Split Cases For case maintenance, an offender with active Medicaid coverage in aid category 108 or 109 should be placed in his own case in VaCMS and assigned to the CVIU. If the incarcerated individual is the case name and other household members with active coverage are on the case, the local agency will be responsible for removing any other member(s), setting up a new case, and transferring the offender’s case to the CVIU.

CHAPTER M02

NONFINANCIAL ELIGIBILITY REQUIREMENTS

M02 Table of Contents Changes

Changed With Effective Date Pages Changed TN #DMAS-32 7/1/24 Page ii TN #DMAS-24 7/1/22 Page i TN #DMAS-15 1/1/20 Pages i, ii TN #DMAS-10 10/1/18 Page ii TN #95 3/1/11 Page i

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TABLE OF CONTENTS

M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS

M0210.000 GENERAL RULES AND PRINCIPLES

Section Page

Principles of Medicaid Eligibility Determination ...............................M0210.001 .................. 1 Ineligible Persons ...................................................................................M0210.100 .................. 2 Legal Presence ........................................................................................M0210.150 .................. 3 Covered Groups .............................................................................................M0210.200 .................. 4

M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS

General Principles .................................................................................M0220.001 ................. 1 Citizenship and Naturalization .............................................................M0220.100 ................. 2 Alien Immigration Status ......................................................................M0220.200 .................4 Full Benefit Aliens ..................................................................................M0220.300 .................7 Emergency Services Aliens....................................................................M0220.400 .................17 Aliens Eligibility Requirements ............................................................M0220.500 .................20 Aliens Entitlement & Enrollment .........................................................M0220.600 .................22a Appendices

Citizenship & Identity Procedures and Documentation Charts .......Appendix 1 ................1 Sample Letters of Certification/Eligibility for Victims of a Severe Form of Trafficking .............................................................Appendix 2 ................1 SSA Quarters of Coverage Verification Procedures for Lawful Permanent Residents ....................................................Appendix 3 ................1 Emergency Medical Certification (Form 032-03-628) ........................Appendix 4 ................1 Alien Codes Chart ..................................................................................Appendix 5 ................1 Proof of U.S. Citizenship and Identity for Medicaid ..........................Appendix 6 ................1 Typical Documents Used by Lawfully Present Immigrants .........................Appendix 7 ................... 1 Alien Status Reference Guide .........................................................................Appendix 8 ................... 1 Emergency Services Aliens Entitlement & Enrollment

Prior to July 1, 2022 .............................................................................Appendix 9 .................... 1

M0230.000 VIRGINIA RESIDENCY REQUIREMENTS

Policy Principles ....................................................................................M0230.001 ................. 1 Definition of Terms ................................................................................M0230.100 ................. 2 Residency Requirements .......................................................................M0230.200 ................. 3

M0240.000 SOCIAL SECURITY NUMBER REQUIREMENTS

General Principle .................................................................................M0240.001 ................. 1 Application For SSN ..............................................................................M0240.100 ................. 1 Follow-up Requirements For SSN ........................................................M0240.200 ................. 2

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Page M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS TOC ii

M0250.000 ASSIGNMENT OF RIGHTS AND PURSUIT OF SUPPORT

FROM THE ABSENT PARENT REQUIREMENTS

Section Page

General Principles .................................................................................M0250.001 ................. 1 Assignment of Rights ............................................................................M0250.100 ................. 1 Procedures for Assignment of Rights ..................................................M0250.200 ................. 2 Pursuit of Medical Support From the Absent Parent .......................M0250.300 ................. 3

M0260 RESERVED

NOTE: Policy references to M0260 that are still in effect have been moved to

subchapter M0250.

M0270.000 APPLICATION FOR OTHER BENEFITS -Subchapter Removed 07/2024

M0280.000 INSTITUTIONAL STATUS REQUIREMENTS

General Principles .................................................................................M0280.001 ................. 1 Definition of Terms ................................................................................M0280.100 ................. 1 Institutional Status Rule ........................................................................M0280.200 ................. 3 Inmate of A Public Institution ..............................................................M0280.300 ................. 6 Individuals Moving To or From Public Institutions ...........................M0280.500 .................12 Departmental Responsibility.................................................................M0280.600 .................13 Institutional Status Quick Reference Guide ........................................Appendix 1 ................ 1

M0290.000 HIPP REQUIREMENTS—Subchapter Removed 08/2009

CHAPTER M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS

SUBCHAPTER 10

GENERAL RULES AND PROCEDURES

M0210 Changes

Changed With Effective Date Pages Changed TN #DMAS-32 7/1/24 Page 1 TN #DMAS-18 1/1/21 Page 4 TN #DMAS-2 10/1/16 Page 4 TN #98 10/1/13 Pages 1-3 TN #97 9/1/12 Page 3 Update (UP) #2 8/24/09 Pages 1, 2

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 January 2006 Subchapter Subject Page ending with Page M0210 NONFINANCIAL ELIGIBILITY REQUIREMENTS TOC i

TABLE OF CONTENTS

M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS

M0210.000 GENERAL RULES AND PRINCIPLES

Section Page

Principles of Medicaid Eligibility Determination ............. M0210.001 ...................... 1

Ineligible Persons ................................................................. M0210.100 ...................... 2

Legal Presence ..................................................................... M0210.150 ...................... 3

Covered Groups .................................................................... M0210.200 ...................... 4

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 July 2024 Subchapter Subject Page ending with Page M0210 NONFINANCIAL ELIGIBILITY REQUIREMENTS M0210.001 1

M0210.000 GENERAL RULES & PROCEDURES

M0210.001 PRINCIPLES OF MEDICAID ELIGIBILITY DETERMINATION

A. Introduction Medicaid is an assistance program which pays medical service providers for services rendered to eligible needy individuals. An individual's need for medical care, the state of his health, or his coverage by private health insurance, have no effect on his Medicaid eligibility. The eligibility determination consists of an evaluation of an individual's situation which compares each of the individual's circumstances to an established standard or definition. The evaluation provides a structured decision-making process. An individual must be evaluated for eligibility in all covered groups for which he meets the definition, and the applicant/enrollee shall be informed of all known factors that affect eligibility. B. Eligibility Requirements Although all the requirements that follow may not be applicable in a particular individual's situation, they must be looked at and evaluated. 1. Nonfinancial Eligibility Requirements

The Medicaid nonfinancial eligibility requirements are: a. Legal presence in the U.S., effective January 1, 2006 (M0210.150). b. Citizenship/alien status (M0220). c. Virginia residency (M0230). d. Social Security number (SSN) provision/application requirements (M0240).

Assignment of rights to medical benefits and pursuit of support from the absent parent requirements (M0250). f. Institutional status requirements (M0280). g. Covered group requirements (M03).

2. Financial Eligibility Requirements The Medicaid financial eligibility requirements are: a. Asset transfer for individuals who need long-term care (subchapter M1450). b. Resources within resource limit appropriate to the individual's covered group. (Chapter M06 for F&C covered groups; Chapter S11 for ABD covered groups). c. Income within income limit appropriate to the individual's covered group. (Chapters M04 and M07 for F&C covered groups; Chapter S08 for ABD covered groups).

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2013 Subchapter Subject Page ending with Page M0210 NONFINANCIAL ELIGIBILITY REQUIREMENTS M0210.100 2

3. Example EXAMPLE: On January 5, 2006, Mr. H applies for Medicaid. He is in a nursing facility in Virginia, and has been there since July 5, 2005. When evaluating his application, the worker finds that he: • is a U.S. citizen, • is currently a Virginia resident residing in a medical institution in Virginia, • provided his SSN, • refused to provide third party liability and medical support information, • has applied for all benefits to which he is entitled, • meets the institutional status requirements, • is age 67 years and meets a covered group requirement. He currently has $5,000 in the bank. His income is $600 per month Social Security (SS). Since he refused to provide third party liability and medical support information, he does not meet the assignment of right requirements and his application must be denied. He is also informed of the resource limit and that he is ineligible for Medicaid because his resources exceed the limit.

M0210.100 INELIGIBLE PERSONS

A. Introduction The individuals listed in this section are not eligible for Medicaid. However, their income and resources may be considered in determining the eligibility of others in the household who have applied for Medicaid. B. Certain Recipients of General Relief (GR) A recipient of General Relief (GR) maintenance who does not meet a Medicaid covered group is not eligible for Medicaid. An applicant for Medicaid and Supplemental Security Income (SSI) who receives GR from the interim assistance component may become eligible for Medicaid following the establishment of SSI eligibility. Eligibility for an SSI payment is effective the month following the SSI application month. When the Medicaid application is dated in the same month as the SSI application, Medicaid eligibility can be effective the month of application if the applicant meets all Medicaid eligibility requirements and another covered group requirement in the application month. C. Essential Spouse of an ABD Individual An essential spouse of an aged, blind, or disabled person who does not himself/herself meet a covered group is not eligible for Medicaid. D. Individual Who Refuses to Assign Rights By signing the application for medical assistance, an applicant assigns his rights to third party payments. Should the individual for any reason subsequently refuse to assign rights to third-party payments or support for himself or anyone for whom he can legally assign rights, he is not eligible for Medicaid. Failure to assign rights for another person will not affect the eligibility of that other person.

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2013 Subchapter Subject Page ending with Page M0210 NONFINANCIAL ELIGIBILITY REQUIREMENTS M0210.150 3 E. Individual Who Refuses to Pursue Support From an Absent Parent An individual applying for Medicaid for himself and on behalf of a child meets the requirement to cooperate with the pursuit of medical support from an absent parent for the child by signing the application. If DMAS requires the individual, other than a categorically needy pregnant woman, to take further action to cooperate with the pursuit of medical support, the individual must cooperate to continue to be eligible for Medicaid. If the individual refuses to cooperate in the pursuit of medical support, he is not eligible for Medicaid. Eligibility could exist if the individual meets a covered group and the individual chooses not to apply for the child. F. Individual Found Guilty of Medicaid Fraud An individual found guilty by a court of Medicaid fraud is not eligible for Medicaid. Ineligibility will last for a period of 12 months beginning with the month of conviction. G. Individual Who Refuses to Supply or Apply For an SSN Any individual, except a child under age 1 born to a Medicaid or FAMIS eligible mother, or an illegal alien, who does not apply for an SSN account number or who fails or refuses to furnish all SSNs to the Department of Social Services is not eligible for medical assistance coverage.

M0210.150 LEGAL PRESENCE

A. Legal Presence (Effective January 1, 2006) Effective January 1, 2006, Section 63.2-503.1 of the Code of Virginia requires most applicants for or recipients of public assistance who are age 19 or older to provide proof of citizenship or legal presence in the U.S. Applicants or recipients age 19 or older for whom medical assistance is requested must prove their citizenship or legal presence. Individuals who, on June 30, 1997, were Medicaid eligible and were residing in long-term care facilities or participating in home and community-based waivers, and who continue to maintain that status (eligible for Medicaid and reside in long-term care facilities or participate in home and community-based waivers) are exempt from this requirement. Non-citizens applying for Medicaid payment for emergency services are not subject to the legal presence requirement. An individual who is applying on behalf of another and is not requesting assistance for himself is not subject to the legal presence requirement. B. Documents That Demonstrate Legal Presence An applicant may demonstrate legal presence by presenting one of the following documents: • valid evidence of U.S. citizenship; • valid evidence of legal permanent resident status; • valid evidence of conditional resident alien status; • a valid SSN verified by the Social Security Administration (SSA); • a U.S. non-immigrant visa; • a Resident Alien Card, form I-551, showing lawful permanent residence (green card); • a pending or approved application for legal asylum;

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 January 2021 Subchapter Subject Page ending with Page M0210 NONFINANCIAL ELIGIBILITY REQUIREMENTS M0210.200 4

• a refugee or temporary protected status document; or • a pending application for an adjustment of residence status. C. Failure to Provide Proof of Legal Presence At the time of application, an applicant who cannot provide documentation that he is a citizen or legally present must sign an affidavit under oath attesting that he is a U.S. citizen or legally present in the United States in order to meet the requirement for proof of legal presence for either: • a period of 90 days or until it is determined that he is not legally present in the U.S., whichever is earlier; or • indefinitely if the applicant provides a copy of a completed application for a birth certificate within the United States or its territories that has been filed and is pending. The affidavit’s validity shall terminate upon the applicant’s receipt of a birth certificate or determination that a birth certificate does not exist because the applicant is not a citizen of the United States. The Affidavit Of United States Citizenship Or Legal Presence In The United States is available at https://fusion.dss.virginia.gov/bp/BP-Home/Medical-Assistance/Forms. NOTE: The individual’s address on the affidavit form must be the individual’s residence address, not the mailing address. D. Relationship to Other Medicaid Requirements Providing proof of legal presence or submitting a signed affidavit meets the legal presence eligibility requirement. To be eligible for Medicaid, however, the individual must meet all other state and federal Medicaid eligibility requirements. Submission of the affidavit without proof of application for an SSN as required by M0130.200.D does NOT meet the SSN requirement.

M0210.200 COVERED GROUPS

A. Introduction An individual who meets the nonfinancial eligibility requirements must also meet the definition for a Medicaid covered group. Covered groups include individuals who are age 65 or older, blind, disabled, under age 19, pregnant women, and the parent(s) or caretaker-relative of a dependent child. Medicaid financial eligibility requirements vary depending upon the covered group for which eligibility is being determined. See chapter M03 for the covered groups’ definitions, policy and procedures.

CHAPTER M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS SUBCHAPTER 20 CITIZENSHIP & ALIEN REQUIREMENTS

M0220 Changes Page 3 of 3

Changed With Effective Date Pages Changed TN #DMAS-36 10/1/25 Appendix 2, pages 1 and 2 TN #DMAS-35 7/1/25 Pages 4, 4a, 4b and 20 TN #DMAS-33 10/1/24 Pages 14e, 22 TN #DMAS-32 7/1/24 Pages 1, 4-5, 6a; Appendix 1, page 5 Appendix 4, page 2 Appendix 5, page 1 TN #DMAS-30 1/1/24 Page 3; Appendix 4, page 1 TN #DMAS-27 4/1/23 Page 17 Appendix 4, page 1 Appendix 5, page 1 TN #DMAS-25 10/1/22 Table of Contents, Page 14d. Page 22 Appendix 4 added page 2. TN #DMAS-24 7/1/22 Table of Contents Pages 1, 4a, 4b, 5, 6a, 8, 14d, 14e, 15, 17, 18, 21, 22, 23 Page 6b was added as a runover page. Appendix 9 was added. Pages 22a and 24-25 were removed.

M0220 Changes Page 2 of 3

Changed With Effective Date Pages Changed TN #DMAS-22 1/1/22 Table of Contents Pages 7, 12, 14a, 14b, 14d, 14e, 16, 22, 22a, 24 Appendix 5, pages 1, 3 Appendix 8, pages 1, 3 Appendix 4 was added. TN #DMAS-20 7/1/21 Pages 14c, 15, 18, 21, 22a Appendix 5, page 3 Appendix 8, page 3 Page 15 is a runover page. TN #DMAS-19 4/1/21 Table of Contents Pages 7, 14a-14d, 16, 22a, 24 Appendix 3, page 1 Appendix 5, page 1 Appendix 8, pages 1, 3 Page 8 is a runover page. Pages 8a and 14e were added as runover pages. TN #DMAS-18 1/1/21 Page 21 TN #DMAS-17 7/1/20 Table of Contents Page 21 TN #DMAS-14 10/1/19 Table of Contents Pages 3, 4, 23, 24 Page 25 was added as a runover page. Appendix 8 was added. TN #DMAS-13 7/1/19 Page 21 TN #DMAS-12 4/1/19 Pages 20, 21, 23 TN #DMAS-10 10/1/18 Page 1 TN #DMAS-9 7/1/17 Page 1, 2, 14c TN #DMAS-6 10/1/17 Page 15 Appendix 1, page 4 TN #DMAS-5 7/1/17 Pages 18, 19, 23, 24 TN #DMAS-3 1/1/17 Table of Contents Page 22a Appendix 1, page 1 TN #DMAS-2 10/1/16 Pages 13, 19-22, 23, 24 TN #DMAS-1 6/1/16 Pages 4, 4b, 5, 23 TN #100 5/1/15 Table of Contents Pages 4b, 12, 17, 18 Appendix 5, page 3 Page 4 was renumbered for clarity. Page 4a is a runover page. TN #99 1/1/14 Table of Contents Pages19, 23, 24 Appendix 4 was removed.

M0220 Changes Page 1 of 3

Changed With Effective Date Pages Changed TN #98 10/1/13 Pages 2-3b Appendix 1 Pages 1-5 Pages 6-18 were removed. UP #9 4/1/13 Page 3 Appendix 1, pages 3, 17 Appendix 3, pages 3, 4 UP #8 10/1/12 Table of Contents Pages 4, 7-8, 12, 14d-20 Page 17a was deleted. Appendix 5 , page 3 Appendix 7 pages 1-5 UP #7 7/1/12 Table of Contents Pages 14d, 16-19 Appendix 5 , page 3 TN #96 10/1/11 Table of Contents Pages 2, 3, 7, 8, 14d, 18-22a, 23 Appendix 5, page 3 TN #95 3/1/11 Table of Contents Pages 3, 3a, 4-6a, 14a-14c, 17, 19, 20 Pages 22a, 23, 24 Appendices 1-2a removed. Appendix 3 and Appendices 5-8 reordered and renumbered. TN #94 9/1/10 Pages 3-3b, 7-9, 14a-14d, 18, 21, 22a, 23 Appendix 1 Appendix 3, page 3 Update (UP) #3 3/1/10 Pages 1-3a TN #93 1/1/10 Table of Contents Pages 7-8, 14a, 14c-14d, 15-20, 22a Appendix 1 Appendix 3, page 3 Appendix 4, pages 1 and 2 Appendix 6, page 2 TN #92 5/22/09 Table of Contents Pages 1-6a Appendix 8 (18 pages) Pages 4a-4t were removed and not replaced. TN #91 5/15/09 Page 7 Pages 14a, 14b Page 18 Page 20 Appendix 3, page 3

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2022 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS TOC i TABLE OF CONTENTS M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Section Page General Principles .......................................................................................... M0220.001 ..................... 1 Citizenship and Naturalization....................................................................... M0220.100 ..................... 2 Alien Immigration Status................................................................................ M0220.200 ..................... 4a Immigration Status Verification ....................................................... M0220.201 ..................... 4b Systematic Alien Verification for Entitlements (SAVE) ................. M0220.202 ..................... 5 Full Benefit Aliens ........................................................................................... M0220.300 ..................... 7 Aliens Receiving SSI........................................................................... M0220.305 ..................... 8a Certain American Indians ................................................................. M0220.306 ..................... 9 Qualified Aliens Defined .................................................................... M0220.310 ..................... 9 Veteran & Active Military Aliens ..................................................... M0220.311 .................... 12 Qualified Aliens Who Entered U.S. Before 8-22-96......................... M0220.312 .................... 14 Qualified Aliens Who Entered U.S. On/After 8-22-96 .................... M0220.313..................... 14a Lawfully Residing Non-citizen Children under age 19 and Pregnant Women .................................................................... M0220.314 .................... 14e Emergency Services Aliens ............................................................... M0220.400 .................... 15 Emergency-Services-Only Qualified Aliens Who Entered U.S. On/After 8-22-96 ............................................ M0220.410 .................... 16 Unqualified Aliens .............................................................................. M0220.411 .................... 18 Aliens Eligibility Requirements...................................................................... M0220.500 .................... 19 Entitlement & Enrollment .............................................................................. M0220.600 .................... 21 Appendices Citizenship & Identity Procedures................................................................. Appendix 1.................... 1 Sample Letters of Certification/Eligibility for Victims of a Severe Form of Trafficking ...................................................................... Appendix 2 ................... 1 SSA Quarters of Coverage Verification Procedures for Lawful Permanent Residents for Eligibility Determinations for Months Prior to April 1, 2021 ................................................................. Appendix 3 ................... 1 Afghan Special Immigrants or Ukraine Humanitarian Parolees ................. Appendix 4 .................... 1 Alien Status Codes ........................................................................................... Appendix 5 ................... 1 Proof of U.S. Citizenship and Identity for Medicaid .................................... Appendix 6 .................... 1 Typical Documents Used by Lawfully Present Immigrants ........................ Appendix 7 .................... 1 Alien Status Reference Guide ......................................................................... Appendix 8 ................... 1 Emergency Services Aliens Entitlement & Enrollment Prior to July 1, 2022 ........................................................................... Appendix 9 ................... 1

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 July 2024 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS M0220.001 1 M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS M0220.001 GENERAL PRINCIPLES A. Introduction This subchapter explains in detail how to determine if an individual is a citizen or alien eligible for full Medicaid benefits (referred to as “full benefit aliens”) or emergency services only (referred to as “emergency services aliens”). The federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) made major changes to the Medicaid eligibility of non- citizens of the United States. These changes eliminated the “permanently residing under color of law” (PRUCOL) category of aliens. The Medicaid benefits for which an alien is eligible are based upon whether or not the alien is a “qualified” alien as well as the alien’s date of entry into the United States. With some exceptions, the Deficit Reduction Act of 2005 (DRA) required applicants for Medicaid and Medicaid recipients to verify their United States citizenship and identity to be able to qualify for Medicaid benefits. The citizenship and identity (C&I) verification requirements became effective July 1, 2006. The Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) allows additional exemptions from the C&I verification requirements and provides states with the option to verify C&I through the use of an electronic data match with the Social Security Administration (SSA). It also requires states to enroll otherwise eligible individuals prior to providing C&I verification or immigration status, and grant them one or more “reasonable opportunity” periods after enrollment to provide documentation, if necessary. The policy and procedures for determining whether an individual is a citizen or a “full-benefit” or “emergency services” noncitizens are contained in the following sections: M0220.100 Citizenship & Naturalization; M0220.200 Alien Immigration Status M0220.300 Full Benefit Aliens M0220.400 Emergency Services Aliens M0220.500 Aliens Eligibility Requirements M0220.600 Aliens Entitlement & Enrollment M0220, Appendix 9 Emergency Services Aliens Entitlement & Enrollment B. Declaration of Citizenship/Alien Status The Immigration Reform and Control Act (IRCA) requires as a condition of eligibility that the adult applicant who is head of the household (with exceptions below) declare in writing under penalty of perjury whether or not the individual(s) for whom he is applying is a citizen or national of the United States, and if not, that the individual is a lawfully admitted alien. For children under 18 years of age, the declaration is made by an adult family member. The declaration statement is on the application form. EXCEPTION: An individual who is an “unqualified” alien (as defined in section M0220.410) does NOT complete the declaration. Individuals who are required to sign the declaration and who fail or refuse to sign are NOT eligible for any Medicaid services.

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2013 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS M0220.100 2 M0220.100 CITIZENSHIP AND NATURALIZATION

A. Introduction A citizen or naturalized citizen of the United States meets the citizenship requirement for medical assistance (MA) eligibility, and is eligible for all MA services if he meets all other eligibility requirements. B. Citizenship Determination 1. Individual Born in the United States An individual born in the United States, any of its territories (Guam, Puerto Rico, United States Virgin Islands, or Northern Mariana Islands), American Samoa, or Swain's Island is a United States citizen. A child born in the United States to non-citizen parents who are in the United States as employees of a foreign country’s government may not meet the United States citizen requirement. When a child born in the United States to non- citizen parents is a United States citizen by birth, the child may not meet the Virginia residency requirements in M0230.201 because of the parents’ temporary stay in the United States. 2. Individual Born Outside the U.S. a. Individual Born to or Adopted by U.S. Citizen Parents A child or individual born outside the United States to U.S. citizen parents (the mother, if the child was born out-of-wedlock) automatically becomes a citizen by birth. A child under age 18 years who is a lawful permanent resident, who is currently residing permanently in the U.S. in the legal and physical custody of a U.S. citizen parent, and who meets the requirements applicable to adopted children under immigration law automatically becomes a citizen when there is a final adoption of the child, and does not have to apply for citizenship. b. Individual Born to Naturalized Parents A child born outside the United States to alien parents automatically becomes a citizen after birth, if his parents (the mother, if the child was born out-of- wedlock) are naturalized before he becomes 16 years of age. c. Naturalized Individual A child or individual born outside the U.S. and not automatically a citizen as in a) or b) above must have been naturalized to be considered a citizen. C. Verification 1. Requirements The DRA requires that satisfactory documentation of citizenship and identity must be obtained for all enrollees who claim to be U.S. citizens. Enrollees who claim U.S. citizenship must have a declaration of citizenship AND documentary evidence of citizenship and identity in their case records. 2. Exceptions to Verification Requirements The following groups of individuals are NOT required to provide verification of C&I. Document in the case record why an individual is exempt from verifying C&I:

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a. All foster care children and IV-E Adoption Assistance children; b. Individuals born to mothers who were eligible for MA in any state on the date of the individuals’ birth; c. Individuals entitled to or enrolled in Medicare, individuals receiving Social Security benefits on the basis of a disability and SSI recipients currently entitled to SSI payments. Former SSI recipients are not included in the exemption. The local department of social services (LDSS) must have verification from the Social Security Administration (such as a SVES response) of an individual’s Medicare enrollment, benefits entitlement or current SSI recipient status. When an individual loses an exception status and his C&I has not previously been verified, the individual must be given a reasonable opportunity to provide C&I. NOTE: A parent or caretaker who is applying for a child, but who is NOT applying for MA for himself, is NOT required to verify his or her C&I. 3. Verification Required One Time Once verification of C&I has been provided, it is not necessary to obtain verification again. Documentary evidence may be accepted without requiring the individual to appear in person. C&I documentation must be stored in the case record. 4. Enroll Under Good Faith Effort If an individual meets all other eligibility requirements and declares that he is a citizen, he is to be enrolled under a good faith effort. Do not request verification of C&I from the applicant, and do not delay or deny application processing for proof of C&I. If the applicant meets all other eligibility requirements: • Approve the application and enroll the applicant in MA, AND • Specify on the Notice that the individual may have to provide documentation of C&I if it cannot be obtained by other means, OR • Include the Reasonable Opportunity Insert, available at https://fusion.dss.virginia.gov/Portals/[bp]/Files/Medical%20Assistance %20Guidance/medicaid_reasonable_opportunity_insertrev_03-09- 10.pdf?ver=2019-06-04-151050-230 with the Notice. The individual remains eligible for MA while the agency attempts to verify C&I through the data matching process described in M0220.100 D below, or if necessary, requests verification from the individual. The same good faith effort requirements apply should an individual lose his exemption from providing C&I verification. Children enrolled under good faith effort are not eligible for 12 months of continuous eligibility. D. Procedures for Documenting C&I CHIPRA allows the option for verification of C&I for individuals newly enrolled in Medicaid or Family Access to Medical Insurance Security Plan (FAMIS) using a data match with SSA to confirm the consistency of a declaration of citizenship with SSA records in lieu of presentation of original documentation. This option, implemented in March 2010, allows for a monthly exchange of data between the Medicaid Management Information System

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(MMIS) and SSA for the documentation of C&I for individuals enrolled in the Medicaid and FAMIS programs. In order for this process to be used to verify citizenship and identity, the individual’s SSN must be verified by SSA (see M0240). For eligibility determinations processed through VaCMS, the Social Security data match takes place when the individual’s information is sent through the Hub. For cases not processed in VaCMS, the SSA data match will take place after the individual has been enrolled in MMIS. 1. MMIS Data Matches SSA If the information in the MMIS matches the information contained in the SSA files, the MMIS will be updated to reflect the verification of C&I. No further action is needed on the part of the eligibility worker, and the enrollee will not be required to provide any additional documentation, if the SSA match code in MMIS shows that SSA verified the individual’s C&I. 2. MMIS Data Does Not Match SSA If the information in the MMIS does not match the information in the SSA files, a discrepancy report will be generated monthly listing the inconsistent information. Eligibility staff is expected to review the report to see if the report lists any enrollees who were rejected because SSA could not verify the enrollee’s citizenship and identity.

a. SSA Cannot Verify C&I

If the SSA data match result does not verify the individual’s C&I, eligibility workers must review the information in the system to determine if a typographical or other clerical error occurred. If it is determined that the discrepancy was the result of an error, steps must be taken to correct the information in the system so that SSA can verify C&I when a new data match with SSA occurs in the future.

If the inconsistency is not the result of a typographical or other clerical error, the individual must be given a reasonable opportunity period of 90 days to either resolve the issue with SSA or provide verification of C&I. The eligibility worker must send a written notification to the enrollee that informs the enrollee of the discrepancy and gives him 90 calendar days from the date of the notice to either resolve the discrepancy with the SSA and to provide written verification of the correction, OR provide acceptable documentation of C&I to the LDSS.

The notice must specify the date of the 90th day, and must state that, if the requested information is not provided by the 90th day, the individual’s Medicaid coverage will be canceled. Include with the notice the “Birth Certificates and Proof of Citizenship for Medicaid” Fact Sheet available on at https://fusion.dss.virginia.gov/bp/BP- Home/Medical-Assistance/References. Acceptable forms of documentation for C&I are also included in Appendix 1 to this subchapter.

b. Individual Does Not Provide Verification in 90 Days

If the individual does not respond to the request and does not provide the information necessary to meet the C&I documentation requirements by the 90th day, coverage may be canceled. Send an advance notice and cancel coverage at the end of the month in which the 90th day occurs. If the individual provides part of the information or is in the process of getting the information, a new reasonable opportunity period shall be provided. The new reasonable opportunity period begins the day after the first period ended. No more than two reasonable opportunity periods should be granted within a certification period since the case cannot be successfully redetermined without the C&I documentation.

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c. Discrepancy Resolved With SSA Within 90 Days If written verification is received that corrects the SSA discrepancy within the 90 days, update the system accordingly so that the enrollee’s information will be included in a future data match for C&I verification. The individual continues to remain enrolled pending the results of the subsequent data match. If this subsequent data match with SSA results in verified C&I, MMIS will automatically enter code “CV” in the Cit Lvl and Identity fields in the individual’s MMIS record. No further match will be done with the SSA files for C&I verification. d. Verification of C&I Provided Within 90 Days If the individual provides acceptable verification of his C&I within the 90 days, update the appropriate demographic fields in MMIS with the appropriate codes. No further match will be done with the SSA files for C&I verification. 3. Subsequent Applications If the individual who lost coverage for failure to provide C&I documentation files a subsequent application, but still does not provide C&I documentation, a new 90 day reasonable opportunity period should be granted.

M0220.200 ALIEN IMMIGRATION STATUS

A. Introduction An alien’s immigration status is used to determine whether the alien meets the definition of a “full benefit” alien. All aliens who meet the state residency, covered group and all other nonfinancial eligibility requirements (except SSN for illegal aliens), and who meet all financial eligibility requirements are eligible for Medicaid coverage of emergency services. “Full benefit” aliens may be eligible for all Medicaid covered services. “Emergency services” aliens may be eligible for emergency services only. B. Procedure An alien's immigration status must be verified. Use the procedures in sections M0220.201 and 202 below to verify immigration status. After the alien's immigration status is verified, use the policy and procedures in section M0220.300 to determine if the alien is a full benefit alien. If the alien is a full benefit alien and is eligible for Medicaid, use the policy and procedures in section M0220.600 to enroll the alien in Medicaid. If the alien is an emergency services alien who is eligible for Medicaid, use the policy and procedures in section M0220.600 D to enroll an eligible emergency services alien in Medicaid for emergency services only. C. Changes in Immigration Status If a “full benefit” alien who was admitted to the U.S with immigration status in one of the “seven-year” alien groups listed in M0220.313.A becomes a Lawful Permanent Resident, he is considered to have full benefit status for the purposes of Medicaid eligibility for the first seven years of residency in the U.S.

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M0220.201 IMMIGRATION STATUS VERIFICATION

A. Verification Procedures An alien's immigration status is verified by the official document issued by the United States Citizenship and Immigration Services (USCIS) and a comparison with the Systematic Alien Verification for Entitlements (SAVE) system. SAVE interfaces with the Federal Hub for applications processed in VaCMS. The EW does not need to obtain the alien status document when immigration status is verified through the Hub. If immigration status cannot be verified through the Hub, the EW must see the original document or a photocopy; submission of just an alien number is NOT sufficient verification. If the alien has an alien number but no USCIS document, or has no alien number and no USCIS document, use the secondary verification SAVE procedure in M0220.202 below if the alien provides verification of his or her identity. If the agency cannot promptly verify immigration status of an individual in the Hub/SAVE, the agency must provide a 90-calendar-day reasonable opportunity period for the individual’s immigration status to be verified and may not delay, deny, reduce or terminate benefits for an individual whom the agency determines to be otherwise eligible for Medicaid during such reasonable the opportunity period. If the individual does not respond to the request and does not provide the information necessary to meet the C&I documentation requirements by the 90th day, coverage may be canceled. Send an advance notice and cancel coverage at the end of the month in which the 90th day occurs. If the individual provides part of the information or is in the process of getting the information, a new reasonable opportunity period should be provided. The new reasonable opportunity period begins the day after the first period ended. No more than two reasonable opportunity periods should be granted within a certification period since the case cannot be successfully redetermined without the C&I documentation. NOTE: If a noncitizen attests that they do not have a valid immigration status, do not use the verification procedures in this section or the SAVE procedures. Go to section M0220.400 below to determine the noncitizen's eligibility. B. Documents That Verify Status Appendix 7 to this subchapter contains a list of typical immigration documents used by lawfully present noncitizens. Verify lawful permanent resident status by a Resident Alien Card or Permanent Resident Card (Form I-551), or for recent arrivals a temporary I-551 stamp in a foreign passport or on Form I-94. Verify lawful admission by a Resident Alien Card (issued from August 1989 until December 1997) or Permanent Resident Card (Form I-551); a Re-entry Permit; or a Form I-688B with a provision of law section 274A.12(A)(1). Afghan and Iraqi immigrants admitted to the U.S. under a Special Immigrant Visa will have either (1) a Form I-551 or (2) a passport or I-94 form indicating categories SI1, SI2, SI3, SQ1, SQ2, or SQ3 and bearing the Department of Homeland Security stamp or notation. Form I-151 (Alien Registration Receipt Card – the old aka “green card”), Form AR-3 and AR-3a are earlier versions of the Resident Alien Card (Form I-551). An alien with one of the older cards who does not have an I-551should be referred to USCIS to obtain the application forms for the I-551. The forms may be ordered by calling 1- 800-375-5283. When an I-151 is presented, refer the alien to USCIS, but accept the document for further verification (see M0220.201.E below).

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C. Letters that Verify Status The USCIS and the Office of Refugee Resettlement (ORR) issue letters that are used in lieu of or in conjunction with USCIS forms to identify alien status. If the letter is the only document provided, it is necessary to verify the status of the alien. For USCIS letters, contact the USCIS at 1-800-375-5283 for assistance in identifying the alien's status. For ORR letters, contact the toll-free ORR Trafficking Verification Line at 866-401-5510 (see Appendix 2 of this subchapter). Do not verify ORR letters via the SAVE system. D. Local USCIS Office Documents Some USCIS offices have developed their own stamps. Therefore, it is possible that a locally produced stamp or legend will be on an USCIS form. If there is any question as to the veracity or status of the document, contact USCIS. E. Expired or Absent Documentation If an applicant presents an expired USCIS document or is unable to present any document showing his immigration status, refer the individual to the USCIS district office to obtain evidence of status unless he provides an alien registration number. Allow the individual a 90-calendar-day reasonable opportunity period to provide the documentation. If the individual meets all other Medicaid eligibility requirements, do not delay, deny, reduce or terminate the individual’s eligibility for Medicaid on the basis of immigration status. If the individual does not respond to the request and does not provide the information necessary to meet the C&I documentation requirements by the 90th day, coverage may be canceled. Send an advance notice, and cancel coverage at the end of the month in which the 90th day occurs. If the individual provides part of the information or is in the process of getting the information, a new reasonable opportunity period should be provided. If the applicant provides an alien registration number with supporting verification of his identity, use the SAVE procedures in M0220.202 below to verify immigration status. If an applicant presents an expired I-551 or I-151, follow procedures for initiating a primary verification. If the alien presents any expired document other than an expired I-551 or I-151, follow procedures for initiating a secondary verification. If the alien does not provide verification of his identity, his immigration status cannot be determined, and he must be considered an unqualified alien. M0220.202 SYSTEMATIC ALIEN VERIFICATION FOR ENTITLEMENTS (SAVE)

A. SAVE Aliens must submit documentation of immigration status before eligibility for the full package of Medicaid benefits can be determined. SAVE interfaces with the Federal Hub for applications processed in VaCMS. The following procedures are applicable when immigration status cannot fully be verified by the Hub. If the documentation provided appears valid and meets requirements, eligibility is determined based on the documentation provided AND a comparison of the documentation provided with immigration records maintained by the USCIS. The comparison is made by using the SAVE system established by Section 121 of the Immigration Reform and Control Act of 1986 (IRCA). 1. Primary Verification Primary verification is the automated method of accessing the USCIS data bank. SAVE regulations require that automated access be attempted prior to initiating secondary verification. There are some specific instances, however, when the agency will forego the primary verification method and initiate secondary verification (see Secondary Verification).

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SAVE is accessed by the Alien Registration Number. SAVE is accessed directly by the local agency. The alien registration number begins with an "A" and should be displayed on the alien's USCIS document(s). Information obtained through SAVE should be compared with the original USCIS document. If discrepancies are noted, the secondary verification process must be initiated. No negative action may be taken on the basis of the automated verification only. A primary verification document must be initiated prior to case approval. The primary verification document must be filed in the case record. 2. Secondary Verification Secondary verification is required in the following situations: a. The alien has an alien number but no USCIS document, or the alien has no alien number and no USCIS document. b. Primary verification generates the message "Institute Secondary Verification" or "No File Found." c. Discrepancies are revealed when comparing primary verification to the original immigration document. d. Immigration documents have no Alien Registration Number (A-Number). e. Documents contain an A-Number in the A60 000 000 or A80 000 000 series. f. The document presented is an USCIS Fee Receipt. g. The document presented is Form I-181 or I-94 in a foreign passport that is endorsed "Processed for I-551, Temporary Evidence of Lawful Permanent Residence," and the I-181 or I-94 is more than one year old. When secondary verification is required, the agency must complete the top portion of a Document Verification Request (Form G-845) or initiate an on-line request for a secondary verification through SAVE. The G-845 is available at http://www.uscis.gov. Click on “Forms.” B. Document Verification Request (Form G- 845) If the alien has filed an USCIS application for or received a change in status, the application for or change in status in itself is not sufficient basis for determining immigration status. Likewise, any document which raises a question of whether USCIS contemplates enforcing departure is not sufficient basis for determining the alien's status. In such situations, verify the alien's status with USCIS using the Document Verification Request (Form G-845). For an alien who entered the U.S. before 8-22-96 and whose status is adjusted to a qualified status after he entered the U.S. use the Form G-845 Supplement to request the period of continuous presence in the U.S. The G-845 Supplement (S) is available at http://www.uscis.gov. Click on “Forms.” Form G-845 should be completed as fully as possible by the submitting agency. It is essential that the form contain enough information to identify the alien.

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A separate form must be completed for each alien. Completely legible copies (front and back) of the alien immigration documents must be stapled to the upper left corner of Form G-845. Copies of other documents used to make the initial alien status determination such as marriage records or court documents must also be attached. Once the requirement to obtain secondary verification is determined, the agency must initiate the request within ten work days. The USCIS mailing address is subject to frequent changes. Obtain the current mailing address from the SAVE web site at http://www.uscis.gov. Click on “Direct Filing Addresses for Form G-845.” A photocopy of the completed G-845 form must be filed in the record as evidence that the form has been forwarded to USCIS. The USCIS maintains a record of arrivals and departures from the United States for most legal entrants, and LDSS can obtain the required information from their USCIS office. The USCIS does not maintain an arrival and departure record for Canadian and Mexican border crossers. For these immigrants, as well as immigrants whose status was adjusted and whose original date of entry cannot be verified by USCIS, LDSS will need to verify continuance presence by requiring the immigrant to provide documentation showing proof of continuous presence. Acceptable documentation includes: • letter from employer • school or medical records • series of pay stubs • shelter expense receipts, such as utility bills in the immigrant’s name that verify continuous presence for the period of time in question. C. Agency Action When the primary verification response requires the eligibility worker to initiate a secondary verification from USCIS, do not delay, deny, reduce or terminate the individual’s eligibility for Medicaid on the basis of alien status. If the applicant meets all other Medicaid eligibility requirements, approve the application and enroll the applicant in Medicaid. Allow 90 calendar days for the secondary verification to be received. If the secondary verification or the individual do not provide the information necessary to meet the documentation requirements by the 90th day, coverage may be canceled. Send an advance notice and cancel coverage at the end of the month in which the 90th day occurs. If the individual provides part of the information or is in the process of getting the information, a new reasonable opportunity period should be provided. Upon receipt of the G-845 or response to the on-line query, compare the information with the case record. Timely notice must be given to the individual when Medicaid benefits are denied or reduced.

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Note: When a secondary verification is requested for an alien with an expired I- 551, the G-845 or response to the on-line SAVE query should indicate that the person continues to have lawful permanent resident status. When a secondary verification is requested for an alien with an expired I-151, the G-845 or response to the on-line SAVE query will indicate that the documentation is expired; however, do not delay, deny, reduce or terminate an individual’s eligibility for Medicaid on the basis of an expired I-151. Once information has been obtained through SAVE, aliens with a permanent status are no longer subject to the SAVE process. Aliens with a temporary or conditional status are subject to SAVE at the time of application and when the temporary or conditional status expires.

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A. Policy A “full benefit” alien is • an alien who receives SSI (M0220.305); • an American Indian born in Canada to whom the provisions of section 289 of the Immigration and Nationality Act (INA) apply, or a member of an Indian tribe (as defined in section 4(e) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450b(e)) (M0220.306); • a “qualified” alien (defined in M0220.310 below) who entered the U.S. before 8-22-96; • a qualified alien refugee; asylee; deportee; Amerasian; Cuban or Haitian entrant; victim of a severe form of trafficking; or a qualified Afghan or Iraqi immigrant admitted to the U.S. on a Special Immigrant Visa or an Afghan special immigrant who meets the criteria in M0220, Appendix 4; who entered the U.S. on or after 8-22-96, but only for the first 7 years of residence in the U.S. (M0220.313.C) unless the criteria in M0220 Appendix 4 are applicable. • effective 12-27-20, a qualified alien who is a Compact of Free Association (COFA) migrant (also referred to as compact citizens). COFA is a compact between the United States and the three Pacific Island sovereign states of Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau—known as the Freely Associated States. • before 4-1-21, a qualified LPR who entered the U.S. on or after 8-22-96 who has at least 40 qualifying quarters of work, but only AFTER 5 years of residence in the U.S. (M0220.313 B). Effective 4-1-21, a qualified LPR who entered the U.S. on or after 8-22-96 and who has resided in the U.S. for at least five years is no longer required to have any qualifying quarters of work to receive full Medicaid benefits; • the following qualified aliens, but only AFTER 5 years of residence in the U.S.: - a parolee under section 212(d)(5) of the Immigration and Nationality Act for a period of at least 1 year; - an alien who is granted conditional entry pursuant to section 203(a)(7) of the Immigration and Nationality Act as in effect prior to April 1, 1980; - an alien, and/or an alien parent of battered children and/or an alien child of a battered parent who is battered or subjected to extreme cruelty while in the U.S. • a qualified alien who meets the veteran or active duty military requirements in M0220.311 below; or • a lawfully residing non-citizen child under age 19 or pregnant woman who meets the requirements in M0220.314 below. A full benefit alien is eligible for full Medicaid benefits if he/she meets all other Medicaid eligibility requirements. Aliens who are not “full benefit” aliens are “emergency services” aliens and may be eligible for emergency Medicaid services only if they meet all other Medicaid eligibility requirements. See section M0220.400 for emergency services aliens.

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B. Procedure 1. Step 1 First, determine if the alien receives SSI. Section M0220.305 describes this group of aliens who receive SSI. If the alien does NOT receive SSI, go to Step 2. If the alien receives SSI, go to Step 6. 2. Step 2 Second, determine if the alien is an American Indian born in Canada or a member of an Indian tribe as defined in section 4(e) of the Indian Self- Determination and Education Assistance Act (25 U.S.C. 450b(e)). Section M0220.306 describes this group of aliens. If NO, go to Step 3. If YES, go to Step 6. 3. Step 3 Third, determine if the alien is a “qualified” alien eligible for full benefits (a full benefit qualified alien). • Section M0220.310 defines “qualified” aliens. • Section M0220.311 defines qualified veteran or active duty military aliens. • Section M0220.312 describes qualified aliens who entered the U.S. before 8- 22-96. • Section M0220.313 describes qualified aliens who entered the U.S. on or after 8-22-96. If the alien is NOT a qualified alien eligible for full benefits, go to step 4. If the alien is a qualified alien eligible for full benefits, go to step 6. 4. Step 4 Fourth, determine if the alien is a lawfully residing non-citizen child under age 19 or pregnant woman. See section M0220.314. If the alien is NOT a lawfully residing non-citizen under age 19 or pregnant woman, go to Step 5. If the alien is a lawfully residing non-citizen child under age 19 or pregnant woman, go to Step 6. 5. Step 5 The alien is an “emergency services” alien. Go to Section M0220.400 which defines emergency services aliens, then to M0220.500 which contains the eligibility requirements applicable to all aliens, then to M0220.600 D, which contains the entitlement and enrollment policy and procedures for emergency services aliens. 6. Step 6 Use Section M0220.500, which contains the Medicaid eligibility requirements applicable to all aliens, to determine the alien’s Medicaid eligibility. Then use Section M0220.600, which contains the entitlement and enrollment procedures for full benefit aliens, to enroll an eligible full benefit alien.

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M0220.305 ALIENS RECEIVING SSI

A. Policy An SSI recipient meets the Medicaid full benefit alien status requirements. Some SSI recipients who are aliens would have lost SSI and Medicaid eligibility. The Balanced Budget Act of 1997 restored SSI eligibility for certain groups of aliens: • a legal alien who was receiving SSI on August 22, 1996, may continue to receive SSI if he/she meets all other SSI eligibility requirements. • an alien who was blind or disabled on August 22, 1996, and who is residing legally in the U.S. may receive SSI in the future if he/she meets all other SSI eligibility requirements. • a legal alien who is receiving SSI for months after July 1996 on the basis of an SSI application filed before January 1, 1979, is exempted from the SSI legal alien requirements, and is eligible for SSI if he/she meets all other SSI eligibility requirements.

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B. SSI Extension for Elderly and Disabled Refugees Act The SSI Extension for Elderly and Disabled Refugees Act (P.L. 110-328), enacted on September 30, 2008, allows elderly or disabled aliens subject to the seven-year time limit for receiving SSI to receive up to two additional years of SSI benefits. Although the Social Security Administration makes the determination of eligibility for the SSI extension, the categories of seven-year aliens to which the SSI extension may apply are listed in M0220.313 A.1 through A.4. Individuals receiving SSI benefits on the basis of the SSI extension also meet the alien status requirement for full-benefit Medicaid eligibility. C. Procedure Verify the alien’s SSI current payment status on the SDX or through SVES. If the alien currently receives SSI, and/or received SSI during the period for which Medicaid coverage is requested, the alien meets the alien status requirements for Medicaid with no further development. Determine the alien SSI recipient’s Medicaid eligibility using the policy and procedures for full benefit aliens in section M0220.600 below. M0220.306 CERTAIN AMERICAN INDIANS

A. Policy An alien who is • an American Indian born in Canada to whom the provisions of section 289 of the Immigration and Nationality Act (INA) apply, or • a member of an Indian tribe (as defined in section 4(e) of the Indian Self- Determination and Education Assistance Act (25 U.S.C. 450b(e)), meets the Medicaid full benefit alien status requirements. B. Procedure Verify the status of an American Indian born in Canada from USCIS documents that the individual presents, or via the SAVE system. Verify the status of a member of an Indian tribe as defined in section 4(e) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450b(e) from official documents that the individual presents. M0220.310 QUALIFIED ALIENS DEFINED

A. Qualified Aliens Defined A qualified alien is an alien who, at the time he applies for, receives or attempts to receive Medicaid is: 1. Lawful Permanent Resident an alien who is lawfully admitted for permanent residence under the Immigration and Nationality Act. 2. Refugee an alien who is admitted to the U.S. under the Immigration and Nationality Act as a refugee under section 207 of the INA, or an alien

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who is admitted to the U.S. as an Amerasian immigrant pursuant to section 584 of the Foreign Operations, Export Financing, and Related Programs Appropriations Act 1988 (as contained in section 101(e) of Public Law 100- 202 and amended by the 9th proviso under MIGRATION AND REFUGEE ASSISTANCE in title II of the Foreign Operations, Export Financing, and Related Programs Appropriations Act, 1989, Public Law 100-461, as amended). The refugee will have a Form I-94 identifying him/her as a refugee under section 207 of the INA. The Amerasian immigrant will have an I-94 coded AM1, AM2, or AM3, or an I-551 coded AM6, AM7, or AM8. 3. Conditional Entrant an alien who is granted conditional entry pursuant to section 203(a)(7) of the Immigration and Nationality Act as in effect prior to April 1, 1980. Aliens admitted to the United States as conditional entrants pursuant to 203(a)(7) of the Immigration and Nationality Act (INA) (8 USC 1153(a)(7)) have an USCIS Form I-94 bearing the stamped legend "Refugee - Conditional Entry" and a citation of the INA section. NOTE: Section 203(a)(7) of the INA was made obsolete by the Refugee Act of 1980 (P.L.96-212) and replaced by section 207 of the INA effective April 1, 1980. 4. Asylee an alien who is granted asylum under section 208 of the Immigration and Nationality Act. Aliens granted asylum will have a Form I-94 and a letter. 5. Parolee an alien who is paroled into the U.S. under section 212(d)(5) of the Immigration and Nationality Act for a period of at least 1 year. Aliens in this group will have a Form I-94 indicating that the bearer has been paroled pursuant to section 212(d)(5) of the INA. 6. Deportee-- Deportation Withheld an alien whose deportation is being withheld under section 243(h) of the INA (as in effect immediately before the effective date of section 307 of division C of Public Law 104-208) or section 241(b)(3) of the INA (as amended by section 305(a)of division C of Public Law 104-208) . These aliens will have an order from an immigration judge showing that deportation has been withheld under section 243(h) or section 241(b)(3) of the INA and/or a Form I-94. 7. Cuban or Haitian Entrant an alien who is a Cuban and Haitian entrant as defined in section 501(e) of the Refugee Education Assistance Act of 1980. A Cuban or Haitian Entrant is a person from Cuba or Haiti who • has been granted parole by USCIS for humanitarian or public interest reasons, unless a final order of deportation or exclusion has been issued; • has an application for asylum pending with USCIS, unless a final order of deportation or exclusion has been issued;

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• is subject to USCIS exclusion or deportation proceedings, unless a final order of deportation or exclusion has been issued. a. Humanitarian, Public Interest, Application for Asylum To meet the humanitarian, public interest or application for asylum status, the Cuban or Haitian entrant must be from Cuba or Haiti and must have an I-94 with one or more of the following notations: • humanitarian parole; • public interest parole; • section 212(d)(5); • parole; or • Form I-589 filed. Contact USCIS if there is reason to believe that a final order of exclusion or deportation has been issued. b. Subject to Exclusion or Deportation To be subject to exclusion or deportation proceedings, the Cuban or Haitian entrant must be from Cuba or Haiti and must have letters or notices which indicate ongoing exclusion or deportation proceedings that apply to the individual. Contact USCIS if there is reason to believe that a final order of exclusion or deportation has been issued. 8. Battered Alien an alien, and/or an alien parent of battered children and/or an alien child of a battered parent who is battered or subjected to extreme cruelty while in the U.S. who meets the following requirements: a. the perpetrator is a spouse, parent or other household member of the spouse or parent’s family who was residing in the home at the time of the incident but is no longer in the home. The alien must not now be residing in the same household as the individual responsible for the battery or extreme cruelty, and • the alien was battered or subjected to extreme cruelty while in the U.S. by a spouse or a parent, or by a member of the spouse or parent’s family residing in the same household as the alien, and the spouse or parent consented to or acquiesced in such battery or cruelty; • the alien’s child was battered or subjected to extreme cruelty while in the U.S. by a spouse or a parent of the alien (without the active participation of the alien in the battery or cruelty), or by a member of the spouse or parent’s family residing in the same household as the alien, and the spouse or parent consented or acquiesced to such battery or cruelty and the alien did not actively participate in such battery or cruelty; or

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• the alien child resides in the same household as a parent who has been battered or subjected to extreme cruelty while in the U.S. by that parent’s spouse, or by a member of the spouse’s family residing in the same household as the parent and the spouse consented or acquiesced to such battery or cruelty. b. the agency providing benefits determines (according to the guidelines to be issued by the U.S. Attorney General) that there is a substantial connection between the battery or cruelty and the need for benefits; and c. the alien has a petition approved by or pending with USCIS for one of the following: • status as an immediate relative (spouse or child) of a U.S. citizen; • classification changed to immigrant; • status as the spouse or child of a lawful permanent resident alien (LPR); or • suspension of deportation and adjustment to LPR status based on battery or extreme cruelty by a spouse or parent who is a U.S. citizen or LPR alien. 9. Afghan or Iraqi Special Immigrant an alien who is lawfully admitted into the U.S. on a Special Immigrant Visa (SIV) for permanent residency or an Afghan special immigrant who meets the criteria in M0220, Appendix 4;. Aliens in this group include the principal SIV holder, his spouse, and his children under age 21 living in the home. Afghan and Iraqi Special Immigrants will have either (1) a Form I-551 or (2) a passport or I-94 form indicating categories SI1, SI2, SI3, SQ1, SQ2, or SQ3 and bearing the Department of Homeland Security stamp or notation. Other qualified Afghan special immigrants will have one of the documents listed in M0220, Appendix 4. 10. Victims of Trafficking an alien who has been granted nonimmigrant status under section 101(a)(15)(T) or who has a pending application that sets forth a prima facie (has sufficient evidence) case for eligibility for such status. M0220.311 VETERAN & ACTIVE DUTY MILITARY ALIENS

A. Veterans or Active Duty Military Aliens An alien lawfully residing in the state (not here illegally) is always eligible for full Medicaid benefits (if he/she meets all other Medicaid eligibility requirements) regardless of the date of entry into the U. S., if he or she meets one of the following conditions: 1. he/she is a qualified alien and is a veteran discharged honorably not on account of alienage, and who fulfills the minimum active-duty service requirements of section 5303A(d) of title 38, United States Code; 2. he/she is a qualified alien and is on active duty (other than active duty for training) in the Armed Forces of the United States (not in the Armed Forces Reserves), 3. he/she is the a) spouse or the unmarried dependent child of a living (not deceased) qualified alien who meets the conditions of 1. or 2. above, or

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b) the unremarried surviving spouse of an individual described in 1. or 2. above who is deceased, if the spouse was married to the veteran • before the expiration of fifteen years after the termination of the period of service in which the injury or disease causing the death of the veteran was incurred or aggravated; or • for one year or more; or • for any period of time if a child was born of the marriage or was born to them before the marriage. A divorced person is not a spouse. A “dependent child” for this section’s purposes is one whom the Veterans Administration (VA) has determined to meet the VA definition of “dependent child.” According to the VA, a dependent child is an unmarried child under age 18, an unmarried child between ages 18 and 23 who is attending a VA-approved school, or a “helpless” child who became disabled before attaining age 18. B. Verification 1. Discharge Status Acceptable verification of honorable discharge or active duty status include the following documents: For discharge status, an original or notarized copy of the veteran’s discharge papers (DD 214) issued by the branch of service in which the alien was a member verifies whether he/she was honorably discharged for a reason other than alien status. Other documentation which is acceptable under the Department of Defense (DOD) or VA guidelines can be substituted for the DD 214 form. A self declaration under penalty of perjury may be accepted pending receipt of acceptable documentation. 2. Active Duty Status For active duty military status, an original or notarized copy of the alien’s current orders showing the individual is on full-time duty in the U.S. Army, Navy, Air Force, Marine Corps, or Coast Guard (full-time National Guard duty is NOT active military status), or a military identification card (DD Form 2 (active)) verifies whether the alien is in active duty military status. Other documentation which is acceptable under the Department of Defense (DOD) or VA guidelines can be substituted for the current orders or military ID card. A self declaration under penalty of perjury may be accepted pending receipt of acceptable documentation.

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C. Services Available To Eligibles A qualified alien who meets the veteran or active duty military requirements above and who meets all other Medicaid eligibility requirements is eligible for the full package of Medicaid covered services available to the alien’s covered group. D. Entitlement & Enrollment of Eligibles The Medicaid entitlement policy and enrollment procedures for eligible veteran/active duty military aliens are found in section M0220.600 below. M0220.312 QUALIFIED ALIENS WHO ENTERED U.S. BEFORE 8-22-96

A. Qualified Aliens-- Entered U.S. Before 8-22-96 Qualified aliens (as defined in M0220.310 above) who were living in the U.S. prior to 8-22-96 and who meet all other Medicaid eligibility requirements are eligible for the full package of Medicaid benefits available to the covered group they meet. 1. Full Benefit Qualified Aliens These “full benefit” qualified aliens who entered the U.S. before 8-22-96 are: • Lawful Permanent Residents, • Refugees under section 207, and Amerasian immigrants, • Conditional Entrants under section 203(a)(7), • Asylees under section 208, • Parolees under section 212(d)(5), • Deportees whose deportation is withheld under section 243(h) or 241(b)(3), • Cuban or Haitian Entrants, and • Battered aliens, alien parents of battered children, and/or alien children of battered parents. NOTE: If the qualified alien is a veteran or in active duty military status, or is the spouse or the unmarried dependent child of a qualified alien who meets the conditions in M0220.311 above, the alien is a full benefit alien. 2. Adjusted Status When an alien entered the U.S. before 8-22-96 with an unqualified alien status and the alien’s status is adjusted to a qualified status after the alien entered the U.S., the alien’s qualified status is considered to be effective back to the date he/she entered the U.S. if: • the alien was physically present in the U.S. before 8-22-96, and • the alien remained physically present in the U.S. from the date of entry to the status adjustment date. The date of entry will be the first day of the verified period of continuous presence in the U.S. (see M0220.202).

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B. Services Available To Eligibles A qualified alien who entered the U.S. before 8-22-96 and who meets all other Medicaid eligibility requirements is eligible for the full package of Medicaid covered services available to the alien’s covered group.

C. Entitlement & Enrollment of Eligibles The Medicaid entitlement policy and enrollment procedures for eligible qualified aliens who entered the U.S. before 8-22-96 are found in section M0220.600 below. M0220.313 QUALIFIED ALIENS WHO ENTERED U.S. ON OR AFTER 8-22-96

A. No Limit on Residency in the U.S. Effective 12-27-20, qualified aliens who are Compact of Free Association (COFA) migrants (also referred to as compact citizens) are full benefit aliens. COFA is a compact between the United States and the three Pacific Island sovereign states of Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau—known as the Freely Associated States. B. First 7 Years of Residence in U.S. During the first seven years of residence in the U.S., six (6) groups of qualified aliens (as defined in M0220.310 above) who entered the U.S. on or after 8-22-96 are eligible for the full package of Medicaid benefits available to the covered group they meet (if they meet all other Medicaid eligibility requirements), even if their status is adjusted later to LPR.. These 6 groups of qualified aliens who entered the U.S. on or after 8-22-96 are: 1. Refugees Refugees under section 207 and Amerasian immigrants are full benefit aliens for 7 years from the date of entry into the U.S. Once 7 years have passed from the date the refugee entered the U.S., the refugee becomes an “emergency services” alien. 2. Asylees Asylees under section 208 are full benefit aliens for 7 years from the date asylum in the U.S. is granted. Once 7 years have passed from the date the alien is granted asylum in the U.S., the asylee becomes an “emergency services” alien. 3. Deportees Deportees whose deportation is withheld under section 243(h) or section 241(b)(3) are full benefit aliens for 7 years from the date withholding is granted. After 7 years have passed from the date the withholding was granted, the deportee becomes an “emergency services” alien. NOTE: If the qualified alien is a veteran or in active duty military status, or is the spouse or the unmarried dependent child of a qualified alien who meets the conditions in M0220.313 above, the alien is a full benefit alien. 4. Cuban or Haitian Entrants Cuban and Haitian entrants as defined in section 501(e) of the Refugee Education Assistance Act of 1980 are full benefit aliens for 7 years from the date they enter the U.S. After 7 years have passed from the date they entered the U.S., a Cuban or Haitian entrant becomes an “emergency services” alien.

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5. Victims of a Severe Form of Trafficking Victims of a severe form of trafficking as defined by the Trafficking Victims Protection Act of 2000, P.L. 106-386 are full benefit aliens for 7 years from the date they are certified or determined eligible by the Office of Refugee Resettlement (ORR). Victims of a severe form of trafficking are identified by either a letter of certification (for adults) or a letter of eligibility (for children under age 18 years) issued by the ORR (see Appendix 5 of this subchapter). The date of certification/eligibility specified in the letter is the date of entry for a victim of a severe form of trafficking. After 7 years have passed from the certification/eligibility date, a victim of a severe form of trafficking becomes an “emergency services” alien unless his status is adjusted. 6. Afghan or Iraqi Immigrant Admitted to the U.S. on a Special Immigrant Visa The Department of Defense Appropriations Act of 2010, enacted on December 19, 2009, provides that Iraqi and Afghan Special Immigrants are eligible for Medicaid benefits to the same extent and for the same time period as refugees. The legislation supersedes prior legislative authority that limited Special Immigrants to benefits for an 8-month time period. Provided that all other eligibility requirements are met, Iraqi and Afghan Special Immigrants are eligible for Medicaid benefits for the first seven years after entry into the United States (U.S.). For Afghan special immigrants who do not hold a Special Immigrant Visa, see M0220, Appendix 4. 7. After 7 Years Residence in U.S. After seven years of residence in the U.S., the qualified refugee, Amerasian, asylee, deportee, Cuban or Haitian entrant, victim of a severe form of trafficking, or Afghan or Iraqi Special Immigrant (as defined in M0220.310 above) who entered the U.S. on or after 8-22-96 is no longer eligible for full Medicaid benefits and becomes an “emergency services” alien. C. AFTER 5 Years of Residence in U.S. The following qualified aliens who entered the U.S. on or after 8-22-96 are eligible for the full package of Medicaid benefits available to the covered group they meet (if they meet all other Medicaid eligibility requirements) after 5 years of residence in the U.S.: • a parolee under section 212(d)(5) of the Immigration and Nationality Act for a period of at least 1 year; • an alien who is granted conditional entry pursuant to section 203(a)(7) of the Immigration and Nationality Act as in effect prior to April 1, 1980; • an alien, and/or an alien parent of battered children and/or an alien child of a battered parent who is battered or subjected to extreme cruelty while in the U.S. • LPRs (as defined in M0220.310 above). For eligibility determinations for months prior to April 2021, an LPR who entered the U.S. on or after 8-22-96 and who has resided in the U.S. for five years must also have at least 40 qualifying quarters of work. Effective 4-1-21, a qualified lawful permanent resident who entered the U.S. on or after 8-22-96 and who has resided in the U.S. for at least five years is no longer required to have any qualifying quarters of work to receive full Medicaid benefits. 1. LPR When an LPR entered the U.S. on or after 8-22-96, the LPR is an “emergency services” alien during the first 5 years the LPR is in the U.S., regardless of work quarters.

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Note: If the LPR had prior immigration status in one of the “seven-year” alien groups listed in M0220.313.A, he is considered to have “seven-year” status for the purposes of Medicaid eligibility for the first seven years of residency in the U.S. To determine former status of a LPR, check the coding on the I-551 for codes RE- 6, RE-7, RE-8, or RE-9. Contact the USCIS at 1-800-375-5283 for assistance in identifying the former status for other seven year aliens. Effective 4-1-21, AFTER 5 years have passed from the date of entry into the U.S., LPRs are “full benefit” aliens. For eligibility determinations for months prior to April 2021, LPRs who DO NOT have at least 40 qualifying quarters of work remain emergency services aliens after 5 years have passed from the date of entry into the U.S. 2. Qualifying Quarter • A qualifying quarter of work means a quarter of coverage as defined under Title II of the Social Security Act which is worked by the alien and/or • all the qualifying quarters worked by the spouse of such alien during their marriage and the alien remains married to such spouse or such spouse is deceased, and all of the qualifying quarters worked by a parent of such alien while the alien was under age 18 years. See Appendix 3 to this subchapter for procedures for verifying quarters of coverage under Title II of the Social Security Act. Any quarter of coverage, beginning after December 31, 1996, in which the alien, spouse or parent of the alien applicant received any federal means-tested public benefit (such as SSI, TANF, Supplemental Nutrition Assistance Program [SNAP] and full-benefit Medicaid) cannot be credited to the alien for purposes of meeting the 40 quarter requirement. Medicaid coverage for emergency services does not impact the 40 quarter requirement. D. Services Available To Eligibles 1. Refugee, Amerasian, Asylee, Deportee, Cuban or Haitian Entrant, Victim of a Severe Form of Trafficking; Afghan or Iraqi Special Immigrant The following immigrants: • qualified refugee, • Amerasian, • asylee, • deportee, • Cuban or Haitian entrant, • victim of a severe form of trafficking, or

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• Afghan or Iraqi Special Immigrant ( as defined in M0220.310 above and in M0220, Appendix 4), • Ukraine Humanitarian Parolees (see Appendix 4) who entered the U.S. on or after 8-22-96 and who meets all other Medicaid eligibility requirements is eligible for the full package of Medicaid covered services available to the alien’s covered group during the first 7 years of residence in the U.S. After 7 years of residence in the U.S., the refugee, Amerasian, asylee, deportee, Cuban or Haitian entrant, victim of a severe form of trafficking, or Afghan or Iraqi Special Immigrant who entered the U.S. on or after 8-22-96 is no longer eligible for full Medicaid benefits and is eligible for emergency services only. 2. LPR Effective 4-1-21, after five years of residence in the U.S., an LPR who entered the U.S. on or after 8-22-96 is eligible for the full package of Medicaid benefits available to the covered group he/she meets if he/she meets all other Medicaid eligibility requirements. For eligibility determinations for months prior to April 2021, LPRs who DO NOT have at least 40 qualifying quarters of work remain emergency services aliens after 5 years have passed from the date of entry into the U.S. E. Entitlement & Enrollment for those Eligible The Medicaid entitlement policy and enrollment procedures for full benefit qualified aliens who entered the U.S. on or after 8-22-96 are found in section M0220.600 below. The Medicaid entitlement policy and enrollment procedures for emergency services qualified aliens who entered the U.S. on or after 8-22-96 are found in section M0220.700 below.

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A. Policy Section 214 of CHIPRA of 2009 gives states the option to provide Medicaid and FAMIS/FAMIS MOMS coverage to certain individuals who are lawfully residing in the United States and are otherwise eligible for assistance. Virginia has elected to cover children under the age of 19 and pregnant women who are lawfully residing in the U.S. Noncitizens are lawfully residing in the U.S. if they have been admitted lawfully into the U.S. and have not overstayed the period for which they were admitted, or they have current permission to stay or live in the U.S. This policy does not apply to individuals who receive temporary relief from removal under the Deferred Action for Childhood Arrivals (DACA) process announced by the U.S. Department of Homeland Security on June 15, 2012. Children born in the U.S. to foreign diplomat parents (i.e. neither parent is a U.S. citizen) must have their own lawful status. They may apply for immediate LPR status. Children under age 19 and pregnant women who are in one of the lawfully residing non-citizen alien groups described below must have their immigration status verified at the time of the initial eligibility determination and at each annual renewal of eligibility to ensure that they are lawfully residing in the U.S. and that their immigration status has not changed. NOTE: All aliens who meet the alien status eligibility requirements for Medicaid and FAMIS/FAMIS MOMS must also meet the Virginia state residency requirements to be eligible for coverage under the programs. For a pregnant woman who is not lawfully residing in the U.S., or has the immigration status of DACA, use Chapter M23 to evaluate her eligibility for FAMIS Prenatal Coverage. If she is not eligible for FAMIS Prenatal Coverage, evaluate her eligibility for the coverage of emergency services using M0220.500. B. Eligible Alien Groups Lawfully residing children under age 19 and pregnant women meet Medicaid and FAMIS/FAMIS MOMS alien requirements without regard to their date of arrival or length of time in the U.S. Children under 19 or pregnant women are lawfully residing aliens if they are: 1. a qualified alien as defined in section 431 of PRWORA (8 U.S.C § 1641). See M0220.310; 2. an alien in a nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission . This group includes individuals with valid visas; 3. an alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and nationality Act (INA) (8 U.S.C § 1182 (d)(5)) for less than I year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings; 4. an alien who belongs to one of the following classes: a. aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C.§§ 1160 or 1255a, respectively),

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b. aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. § 1254a), and pending applicants for TPS who have been granted employment authorization, c. aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24), d. Family Unity beneficiaries pursuant to section 301 of Pub. L. 101-649, as amended, e. aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President, f. aliens currently in deferred action status, except for individuals receiving deferred status as a result of the Deferred Action for Childhood Arrivals (DACA) process, announced by the U.S. Department of Homeland Security on June 15, 2012, or g. aliens whose visa petition has been approved and who have a pending application for adjustment of status. 5. a pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158), or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231), or under the Convention Against Torture who has been granted employment authorization, or such an applicant under the age of 19 who has had an application pending for at least 180 days; 6. an alien who has been granted withholding of removal under the Convention Against Torture; 7. a child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. § 1101(a)(27)(J); 8. an alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806 (e); or 9. an alien who is lawfully present in American Samoa under the immigration laws of American Samoa. M0220.400 EMERGENCY SERVICES ALIENS

A. Policy Any alien who does NOT meet the requirements for full benefits as described in section M0220.300 through 314 above is an “emergency services” alien and is eligible for emergency Medicaid services only, if he or she meets all of the Medicaid nonfinancial and financial eligibility requirements. B. Procedure • Section M0220.410 describes the qualified aliens who entered the U.S. on or after 8-22-96 who are emergency services aliens. • Section M0220.411 defines “unqualified” aliens. • Section M0220.500 contains the Medicaid eligibility requirements applicable to full benefit and emergency services aliens. • Section M0220.600 D contains the entitlement and enrollment procedures for emergency services aliens.

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A. First 5 Years of Residence in U.S. During the first five years of residence in the U.S., four groups of qualified aliens (as defined in M0220.310 above) who entered the U.S. on or after 8-22- 96 are eligible for emergency Medicaid services only provided they meet all other Medicaid eligibility requirements. 1. Lawful Permanent Residents (LPRs) An LPR who enters the U.S. on or after 8-22-96 is an “emergency services” alien during the first 5 years the LPR is in the U.S., regardless of work quarters. Note: If the LPR had prior Refugee status, he may be considered to have Refugee status for the purposes of Medicaid eligibility. To determine former Refugee status of a Lawful Permanent Resident, check the coding on the I-551 for codes RE-6, RE-7, RE-8, or RE-9. Refer to M0220.313.A.1. 2. Conditional Entrants A qualified Conditional Entrant who enters the U.S. on or after 8-22-96 is an “emergency services” alien during the first 5 years the Conditional Entrant is in the U.S. 3. Parolees A qualified parolee who enters the U.S. on or after 8-22-96 is an “emergency services” alien during the first 5 years the parolee is in the U.S. 4. Battered Aliens A qualified battered alien who enters the U.S. on or after 8-22-96 is an “emergency services” alien during the first 5 years the battered alien is in the U.S. B. AFTER 5 Years of Residence in U.S. 1. Lawful Permanent Residents Without 40 Work Quarters For months prior to 4-1-21, Lawful Permanent Residents who DO NOT have at least 40 qualifying quarters of work remain emergency services aliens after residing in the U.S. for 5 years. Effective 4-1-21, Lawful Permanent Residents become full benefit aliens after 5 years of residing in the U.S. with no work requirement. 2. Conditional Entrants A qualified Conditional Entrant who enters the U.S. on or after 8-22-96 and has resided in the U.S. for at least 5 years is a full benefit alien. 3. Parolees A qualified parolee who enters the U.S. on or after 8-22-96 and has resided in the U.S. for at least 5 years is a full benefit alien. 4. Battered Aliens A qualified battered alien who enters the U.S. on or after 8-22-96 and has resided in the U.S. for at least 5 years is a full benefit alien.

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C. AFTER 7 Years of Residence in U.S. 1. Refugees After 7 years of residence in the U.S., a refugee or Amerasian immigrant who entered the U.S. on or after 8-22-96 is no longer eligible for full Medicaid benefits and becomes an “emergency services” alien. 2. Asylees After 7 years have passed since asylum was granted, an asylee who entered the U.S. on or after 8-22-96 is no longer eligible for full Medicaid benefits and becomes an “emergency services” alien. 3. Deportees After 7 years have passed since deportation was withheld, a deportee who entered the U.S. on or after 8-22-96 is no longer eligible for full Medicaid benefits and becomes an “emergency services” alien. 4. Cuban or Haitian Entrants After 7 years of residence in the U.S., a Cuban or Haitian Entrant who entered the U.S. on or after 8-22-96 is no longer eligible for full Medicaid benefits and becomes an “emergency services” alien. 5. Afghan and Iraqi Special Immigrants Medicaid coverage for Afghan and Iraqi Special Immigrants who are eligible in a Medicaid covered group cannot begin earlier than December 26, 2007. After 7 years of residence in the U.S., Afghan and Iraqi Special Immigrants are no longer eligible for full Medicaid benefits and become “emergency services” aliens. After the applicable limited time period expires, individuals become “emergency services” aliens unless the requirements in M0220.313 B or M0220.314 are met. D. Services Available To Eligibles An emergency services alien who meets all Medicaid eligibility requirements is eligible for Medicaid coverage of emergency services only. E. Entitlement & Enrollment of Eligibles F. Public Charge Immigrants The Medicaid entitlement policy and enrollment procedures for emergency services aliens are found in section M0220.600 D below. Effective December 23, 2022, DHS implemented a final rule in regards to immigrants who may become a public charge. USCIS issued policy guidance under section 212(a)(4) of the Immigration and Nationality Act (INA). The eligibility worker will use results from a SAVE system inquiry which will indicate a status if the applicant is inadmissible under the public charge policy. Such an indication would define the individual as an unqualified alien (see M0220.441).

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 July 2022 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS M0220.411 18 M0220.411 UNQUALIFIED ALIENS

A. Unqualified Aliens Aliens who do not meet the qualified alien definition M0220.310 above and who are NOT lawfully residing non-citizen children under age 19 or pregnant women per M0220.314 above are “unqualified” aliens. Unqualified aliens, with the exception of pregnant women who are eligible for FAMIS Prenatal Coverage, are eligible for emergency services only if they meet all other Medicaid eligibility requirements. Unqualified aliens include illegal and non-immigrant aliens. For a pregnant woman who is not lawfully residing in the U.S. per M0220.314, use Chapter M23 to evaluate her eligibility for FAMIS Prenatal Coverage. If she is not eligible for FAMIS Prenatal Coverage, evaluate her eligibility for the coverage of emergency services using M0220.400 and M220.600 D. B. Illegal aliens Illegal aliens were never legally admitted to the U.S. or were legally admitted for a limited period of time and did not leave when that period expired. If an alien remains in the U.S. after his visa expires, he becomes an illegal alien. C. Non-immigrant Aliens Aliens who are lawfully admitted to the U.S. for a temporary or limited period of time, and the limited period has not expired, are non-immigrant aliens. Regardless of the individual’s immigration status, accept declaration of Virginia residency on the application as verification of residency unless the individual resides on the grounds of a foreign embassy. Do NOT require individuals who have been admitted into the U.S. on non-immigrant visas to sign a statement of intended residency. Non-immigrants have the following types of USCIS documentation: • Form I-94 Arrival-Departure Record, • Form I-185 Canadian Border Crossing Card, • Form I-186 Mexican Border Crossing Card, • Form SW-434 Mexican Border Visitor's Permit, • Form I-95A Crewman's Landing Permit. Note: If the alien remains in the U.S. after the limited time period (visa) is over, he becomes an illegal alien. Non-immigrants include: 1. Visitors visitors for business or pleasure, including exchange visitors; 2. Foreign Government Representative foreign government representatives on official business and their families and servants. Note: if the foreign government representative resides on the grounds of a foreign embassy, he does not meet the Virginia residency requirement; 3. Travel Status aliens in travel status while traveling directly through the U.S.; 4. Crewmen Crewmen on shore leave; 5. Treaty Traders treaty traders and investors and their families; 6. Travel Status aliens in travel status while traveling directly through the U.S.;

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 July 2017 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS M0220.500 19

7. Foreign Students foreign students; 8. International Organization international organization representatives and personnel, and their families and servants; 9. Temporary Workers temporary workers including some agricultural contract workers; 10. Foreign Press members of foreign press, radio, film, or other information media and their families. M0220.500 ALIENS ELIGIBILITY REQUIREMENTS

A. Policy An alien must meet all other Medicaid eligibility requirements to be eligible for any Medicaid services. The eligibility requirements are: 1. Residency the Virginia residency requirements (M0230); Regardless of the individual’s immigration status or whether or not his documentation (e.g. visa) has expired, accept declaration of Virginia residency on the application as verification of residency. Do NOT require individuals who have been admitted into the U.S. on non-immigrant visas and other non- immigrants to sign a statement of intended residency. 2. Social Security Number (SSN) the SSN provision/application requirements (M0240); An alien eligible only for Medicaid payment of emergency services is not required to apply for or provide an SSN. This includes emergency services only aliens as defined in M0220.410 and unqualified aliens as defined in M0220. 411. Any non-citizen who is only eligible to receive an SSN for a valid non-work reason is not required to provide or apply for an SSN. These individuals include, but are not limited to, non-citizens admitted to the U.S. on non-immigrant visas and individuals who do not intend to work in the U.S. and would only have needed an SSN for the purposes of receiving public assistance.

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3. Assignment of Rights and Pursuit of Support from Absent Parents the assignment of rights to medical benefits requirements (M0250); 4. Institutional Status the institutional status requirements (M0280); 5. Covered Group the covered group requirements (chapter M03). Individuals who are eligible for Medicaid payment of emergency services are enrolled into the emergency services aid categories, 112 and 113, to ensure proper benefit package assignment; emergency services are not covered for individuals in Plan First or the Medicare Savings Programs (Qualified Medicare Beneficiaries, Special Low Income Medicare Beneficiaries, Qualified Individuals).

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7. Financial Eligibility the asset transfer requirements (see subchapter M1450) apply. Resources must be within the resource limit appropriate to the individual's covered group. (Chapter M06 for F&C covered groups; Chapter S11 for ABD covered groups). Income must be within the income limit appropriate to the individual's covered group (Chapter M04 for Modified Adjusted Gross Income [MAGI] covered groups; Chapter M07 for F&C Medically Needy covered groups, and Chapter S08 for ABD covered groups). Spenddown provisions apply to individuals who meet a Medically Needy covered group. All medical expenses count toward meeting the spenddown, but once an entitlement date is determined after the individual meets the spenddown, only emergency services rendered on or after the entitlement date are covered for emergency services aliens. M0220.600 ENTITLEMENT & ENROLLMENT

A. Policy An alien who is determined eligible for full Medicaid benefits and who meets all Medicaid eligibility requirements (including covered group requirements) is eligible for all Medicaid-covered services available to the recipient's covered group. B. Application & Entitlement 1. Application Processing The eligibility worker must take the application and develop it in the same manner as any other individual's application. All eligibility requirements, including covered group requirements must be met. 2. Entitlement If the applicant is found eligible for Medicaid, ongoing eligibility may exist unless the recipient is on a spenddown. 3. Spenddown Spenddown provisions apply to medically needy individuals who have excess income. 4. Notice Appropriate notice must be sent to the applicant of the status of his application and of his Medicaid eligibility. C. Enrollment Procedures Once a full benefit alien is found eligible for Medicaid, he must be enrolled in VaCMS using the following data: 1. Country In this field, Country, enter the code of the alien's country of origin. 2. Cit Status In this field, Citizenship Status, enter the Citizenship code that applies to the alien. Below, next to the Citizenship code, is the corresponding Alien Code from the Alien Code Chart in Appendix 5 to this subchapter. Eligible alien codes are: R = refugee (Alien Chart codes F1, F2, G1, G2); also used for Afghan and Iraqi Special Immigrants (Alien Chart Code Z1). E = entrant (Alien Chart code D1). P = full benefit qualified aliens (Alien Chart codes A1, A2, A3, B1, B3, C1, CC1, D1, D3, E1, E3, H1, H2, I1, I3, J1, J2, K1); I = legal immigrant children under age 19 only (Alien Chart codes Y1, Y2, Y3)

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3. Entry Date THIS FIELD MUST BE ENTERED. Enter the date on which the alien entered the U.S., except for asylees and deportees. For asylees, enter the date asylum was granted. For deportees, enter the date deportation withholding was granted. 4. Appl Dt In this field, Application Date, enter the date of the alien's Medicaid application upon which the eligibility coverage period is based. 5. Coverage Begin Date In this field, Coverage Begin Date, enter the date the alien's Medicaid entitlement begins. 6. Coverage End Date Enter data in this field only if eligibility is a closed period of eligibility in the past. Enter the date the alien's Medicaid entitlement ended. 7. AC Enter the AC code applicable to the alien's covered group. D. Emergency Services Only Aliens Unqualified aliens, and qualified aliens eligible for emergency services only are eligible for Medicaid coverage of emergency medical care only. This care must be provided in a hospital emergency room or as an inpatient in a hospital. Effective July 1, 2022, an emergency services only alien who meets all other Medicaid eligibility requirements is enrolled in Medicaid with retroactive and/or ongoing coverage. Emergency services are no longer certified by the LDSS or DMAS, and the LDSS does not obtain an emergency services certification. Applications received prior to July 1, 2022, are subject to the policies and procedures in M0220, Appendix 9. For an individual whose certification period begins prior to July 1, 2022 and expires on or after July 1, 2022, re- evaluate the individual’s eligibility for ongoing coverage. An emergency services alien will be assigned to one of the following Aid Categories (AC) by VaCMS: • AC 112 for adults in Modified Adjusted Gross Income (MAGI) based covered groups • AC 113 for children and adults in non-MAGI Families and Children’s (F&C) and all Medically Needy (MN) covered groups. For cases processed at Cover Virginia, the individual will be enrolled in the appropriate AC, and the case will be transferred to the local agency for ongoing case maintenance. For CVIU incarcerated individuals refer to Policy M0140.200.3 C. Once an emergency services alien is found eligible in VaCMS, the enrollment will transfer into the Medicaid enrollment system. Any claims for emergency services will be sent by the provider or treating physician to DMAS for review and reimbursement. Medicaid coverage for emergency services only aliens will be restricted to emergency services (including dialysis). Appropriate notice must be sent to the applicant of the status of his application and the duration of his eligibility. The notice must specify that their Medicaid coverage is limited to emergency services.

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Once an emergency services alien is found eligible in VaCMS, the enrollment will transfer into the Medicaid enrollment system. Any claims for emergency services will be sent by the provider or treating physician to DMAS for review and reimbursement. Medicaid coverage for emergency services only aliens will be restricted to emergency services (including dialysis). Appropriate notice must be sent to the applicant of the status of his application and the duration of his eligibility. The notice must specify that their Medicaid coverage is limited to emergency services. Once an emergency services alien is enrolled, any requests for coverage of emergency services will not require a new Medicaid application. The individual will be subject to an annual renewal following the policies in subchapter M1520.200. Follow the policies in subchapter M1520.100 for any reported change to the alien’s situation. A Medicaid card will not be generated for an individual enrolled as an emergency services alien. The provider or treating physician will be responsible for submitting all claim request for payment of an emergency service for an approved member, including labor & delivery and dialysis. Refer providers to the Virginia Medicaid Hospital Provider Manual, Chapter VI “Documentation Guidelines.” Providers with questions regarding the submission or payment of claims for emergency services may contact DMAS at: Division of Program Operations Department of Medical Assistance Services (DMAS) 600 E. Broad Street, Suite 1300 Richmond, VA 23219

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 January 2017 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 1 1 Citizenship & Identity Procedures Workers are to use the following procedures when citizenship and identity verification is required to determine the individual’s continued eligibility.

A. Documents Establishing U.S. Citizenship and Identity 1. Documents that Verify Citizenship and Identity Both U.S. Citizenship and identity are verified by a: • U.S. Passport, • Certificate of Naturalization, or • Certificate of U. S. Citizenship Documentary evidence issued by a federally recognized Indian tribe which identifies the tribe that issued the document, indentifies the individual by name and confirms membership, enrollment or affiliation with the tribe (tribal enrollment card, certificate of degree of Indian blood, Tribal census. document, documents on Tribal letterhead)If the individual presents one of these documents, he has verified his citizenship and identity. Photocopies of original documents are acceptable. 2. Documents that Verify Identity a. Documents The agency must accept any of the documents listed below as proof of identity, provided such document has a photograph or other identifying information including, but not limited to, name, age, sex, race, height, weight, eye color or address. Photocopies of original documents are acceptable. • Identity documents listed at 8 CFR 274a.2(b)(1)(v)(B)(l), except a driver’s license issued by a Canadian government authority • Driver’s license issued by a State or Territory • School identification card • U.S. military card or draft record • Identification card issued by the Federal, State or local government • Military dependent’s identification card • U.S. Coast Guard Merchant Mariner’s card • For children under age 19, a clinic, doctor, hospital or school record, including preschool or daycare records

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2013 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 1 2

• Two documents containing consistent information that corroborates an applicant’s identity. Such documents include, but are not limited to, employer identification cards, high school and college diplomas (including high school equivalency diplomas), marriage certificates, divorce decrees and property deeds or titles. • Finding of identity from a Federal or State governmental agency. The agency may accept as proof of identity a finding of identify from a Federal agency or another State agency, including but not limited to a public assistance, law enforcement, internal revenue or tax bureau, or corrections agency, if the agency has verified and certified the identity of the individual b. Affidavit If the applicant does not have any document specified above and identity is not verified, the applicant may submit an affidavit signed, under penalty of perjury, by another person who can reasonably attest to the applicant’s identity. Such affidavit must contain the applicant’s name and other identifying information. The affidavit does not have to be notarized. 3. Documents that Verify Citizenship a. Documents The agency must accept any of the documents listed below as proof of U.S. Citizenship. Photocopies of original documents are acceptable. • Civil Service employment by the U.S. government prior to 1976 • Evidence of compliance with the Child Citizen Act of 2000 • Final adoption decree showing U.S. birth, or if adoption is not final, a statement from a State-approved adoption agency that shows the child’s name and U.S. place of birth • Homeland Security’s Systematic Alien Verification for Entitlements Database (used when individual has become a Naturalized Citizen but information did not show up in SSA database) • Northern Mariana Card for individuals born before 11/4/1986 ( I-873) • Office of Vital Records • Official Military Records showing a U.S. birth Report/Certificate of birth abroad of U.S. citizen (dS-1350, FS-240 or FS-545) • U.S. Birth Certificate • U.S. citizen ID card (I-197 or I-179)

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• Medical records, including but not limited to, hospital, clinic or doctor records or admission papers from a nursing facility, skilled care facility or other institution that indicate a U.S. place of birth • Life, health or other insurance records that indicate a U.S. place of birth • Official religious record recorded in the U.S. indicating a U.S. birth • School records, including pre-school, Head Start and day care, showing child’s name and U.S. place of birth • Federal or state census records showing U.S. citizenship or U.S. place of birth • Certification of U.S. birth • A Certification of Report of Birth, issued to U.S. citizens who were born outside the U.S. • A report of Birth Abroad of a U.S. citizen b. Affidavit If no other documentation exists, the individual may submit an affidavit signed, under penalty of perjury, by another person who can reasonably attest to the applicant’s identity. Such affidavit must contact the applicant’s name and other identifying information. The affidavit does not have to be notarized. C. Agency Actions 1. Documen- tation From Case Record and Individual Documentation of citizenship and/or identity may be obtained from a number of different sources, including the sources listed below. Photocopies of original documents are acceptable. • Existing LDSS agency records, as long as the documentation conforms to Medicaid policy for citizenship and identity verification in M0220 of the Medicaid Eligibility Manual. • A federal agency or another State agency. A verification of citizenship made by a federal or state agency is acceptable, as long as the verification was done on or after July 1, 2006. No further documentation of citizenship or identity is required.

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• Applicants and Recipients. All applicants and recipients, except SSI recipients, Medicare beneficiaries, SSDI beneficiaries, individuals born to Medicaid-eligible mothers, all foster care children and IV-E Adoption Assistance children, must provide documents that show proof of United States citizenship and proof of the person’s identity if the local DSS is unable to verify citizenship and identity using a data match with the SSA. Contact information for obtaining the various acceptable documents is available on the VDSS local agency intranet and the DSS public website and may be given to individuals to facilitate their obtaining documentation. • DMAS, for individuals born in Puerto Rico who are unable to provide a birth certificate issued on or after July 1, 2010. Puerto Rico invalidated all birth certificates issued prior to July 1, 2010 and reissued the birth certificates. For individuals born in Puerto Rico who are applying for Medicaid for the first time, only a birth certificate issued on or after July 1, 2010 may be accepted from the individual. Should an individual born in Puerto Rico be unable to present a birth certificate issued on or after July 1, 2010, contact your Regional Medical Assistance Specialist, who will refer the case to DMAS. DMAS will obtain official birth verification on behalf of the local DSS. If the person is reapplying and the agency has a birth certificate issued prior to July 1, 2010 on record, no additional verification is required. 2. Authorized Representative For individuals who have authorized representatives, such as the disabled or individuals who are institutionalized, initiate efforts to assist in securing documentation with the appropriate representative. 3. Individuals Who No Longer Meet Exception When an individual loses the exception status, and his citizenship and identity has not been previously verified, it must be verified for him to remain eligible for Medicaid. If the individual’s eligibility in another covered group must be determined (due to the loss of SSI benefits, for example), obtain the documentation of citizenship and identity at the time of the eligibility review. If the verification is not readily available, the individual must be allowed a reasonable opportunity to obtain the documentation. See M0220.100 A 3. Verify the SSI recipient’s or Medicare beneficiary’s entitlement to benefits through the Federal Hub or SOLQ-I. A copy of the printout must be placed in the case file. 4. Individual NOT Required to Submit Documents in Person Individuals do not have to submit their citizenship and identity to the agency worker in person. They may mail the original document for the agency to copy and mail back to the individual, or they may submit a photocopy of the document(s). 5. Special Populations Needing Assistance The agency shall assist special populations who need additional assistance, such as the homeless, intellectually disabled, or physically incapacitated individual who lacks someone who can act on his behalf, to provide necessary documentation.

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3. Failure to Provide Requested Failure to provide satisfactory evidence of citizenship and identity, after being provided a reasonable opportunity to present such documentation, may result in the termination of MA. Verifications An enrollee who fails to cooperate with the agency in presenting documentary evidence of citizenship may be denied or terminated. Failure to cooperate consists of failure by a recipient or that individual's representative, after being notified, to take a required action within the reasonable opportunity time period. If the individual provides part of the information or is in the process of getting the information, a new reasonable opportunity period should be provided. 4. Notification Requirements Prior to the termination of benefits, the enrollee must be sent written notice at least 10 calendar days (plus one day for mailing) prior to the effective date of the closure. A Notice of Action and appeal rights must be sent to an individual whose application is denied because of failure to provide citizenship and/or identity verification. 5. Maintain Documents in Case Record The agency must maintain copies of the documents used to verify citizenship and identity in the individual’s case record or data base and must make the documents available for state and federal audits. 6. No Reporting Requirements There are no monthly reporting requirements. However, the Medical Assistance Program Consultants may conduct reviews of cases where eligibility was denied or terminated because of lack of citizenship and/or identity verification. 7. Refer Cases of Suspected Fraud to DMAS If documents are determined to be inconsistent with pre-existing information, are counterfeit, or are altered, refer the individual to DMAS for investigation into potential fraud and abuse. See section M1700.200 for fraud referral procedures.

Sample Letters of Certification/Eligibility for Victims of a Severe Form of Trafficking

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2025 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 2 1

[Used For Adults]

HHS Tracking Number

(Address)

CERTIFICATION LETTER

Dear :

This letter confirms that you have been certified by the U.S. Department of Health and Human Services (HHS) pursuant to section 107 (b) of the Trafficking Victims Protection Act of 2000. Your certification date is . Certification does not confer immigration status. With this certification, you are eligible for benefits and services under any Federal or State program or activity funded or administered by any Federal agency to the same extent as an individual who is admitted to the United States as a refugee under section 207 of the Immigration and Nationality Act, provided you meet other eligibility criteria.

You should present this letter when you apply for benefits or services. Benefit-issuing agencies should call the trafficking verification line at (866) 401-5510 to verify the validity of this document and to inform HHS of the benefits for which you have applied.

Sincerely,

[Signed] Director/Acting Director Office of Refugee Resettlement

Sample Letters of Certification/Eligibility for Victims of a Severe Form of Trafficking

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2025 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 2 2

[Used For Children Under Age 18 Years]

HHS Tracking Number

(Address)

Dear :

This letter confirms that pursuant to section 107 (b) of the Trafficking Victims Protection Act of 2000, you are eligible for benefits and services under any Federal or State program or activity funded or administered by any Federal agency to the same extent as an individual who is admitted to the United States as a refugee under section 207 of the Immigration and Nationality Act, provided you meet other eligibility criteria. Your initial eligibility date is . This letter does not confer immigration status. You should present this letter when you apply for benefits or services. Benefit-issuing agencies should call the trafficking verification line at (866) 401-5510 to verify the validity of this document and to inform HHS of the benefits for which you have applied.

Sincerely,

[Signed] Director/Acting Director Office of Refugee Resettlement

SSA Quarters of Coverage Verification Procedures for Lawful Permanent Residents for Eligibility

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 April 2021 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 3 1 Determinations for Months Prior to April 1, 2021 This appendix contains the process for determining the number of qualifying quarters (QQ) with which a lawful permanent resident (LPR) who entered the U.S. on or after 8-22-96 can be credited and is to be used in conjunction with the State Verification Exchange System (SVES) User Guide.

I. Procedures:

A. To determine the number of QQ available to a LPR applicant, ask the applicant the following questions:

1. How many years has the applicant, the applicant's spouse, or the applicant's parents (before the applicant turned 18) lived in this country?

2. How many years has the applicant, the applicant's spouse, or the applicant's parents (before the applicant turned 18) commuted to work in the U.S. from another country before coming to the U.S. to live, or worked abroad for a U.S. company, or worked in self-employment while a legal resident of the U.S.?

(If the total number of years to both questions is less than 10 years, STOP because the applicant cannot meet the 40 QQ requirement.) 3. In how many of the years reported in the answer to question 1 did the applicant, the applicant's spouse, or the applicant's parent earn money through work?

B. To determine whether the applicant's earnings were sufficient to establish "quarters of coverage" in those years, refer to the income chart in section II .

If the answer to question 3 is 10 years or more, verify from INS documents or other documents the date of entry into the country for the applicant, spouse and/or parent. If the dates are consistent with having 10 or more years of work, initiate a SVES inquiry.

C. Complete or obtain from the applicant a completed "Consent for Release of Information" (see page 4 of this appendix) with the full name, social security number and date of birth of each individual (self, spouse, or parent) whose work history is relevant. In addition, the applicant must provide a form signed by each such individual, except deceased persons, giving SSA permission to release information through SVES on that individual to the agency and/or the applicant. Retain the consent form in the case file to document the individual's consent. A consent form is valid for 12 months from the time of the signature.

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 January 2023 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 3 2 D. Information received through SVES will not report earnings for the current year nor possibly the last year's earnings (i.e. the lag period). The SVES report will also not include employment that is not covered under Social Security (i.e. not requiring payment of FICA/Social Security tax). The applicant must provide verification of earnings through pay stubs, W-2 forms, tax records, employer records, or other documents, if quarters of the lag period or non-covered employment are needed to meet the 40-quarter minimum. Use the information contained in section II to determine QQ for lag periods and non-covered earnings.

If the alien believes the information from SSA is inaccurate or incomplete, beyond the current two- year lag period, advise the applicant to provide the verification to SSA to correct the inaccurate income records.

In evaluating the verification received directly from the applicant or through SVES, exclude any quarter, beginning January 1997, in which the person who earned the quarter received benefits from the TANF, SSI, or Medicaid, or SNAP Programs or the food assistance block grant program in Puerto Rico. E. In situations when consent to release information through SVES cannot be obtained from a parent or spouse, other than death, request information about quarters of coverage directly from the Social Security Administration. Complete or obtain from the applicant a Request for Quarters of Coverage (QC) History Based on Relation form, SSA-513. The form specify the period(s) for which the verification is requested. Submit the completed from to:

Social Security Administration P.O. Box 33015 Baltimore, Maryland 21290-3015

F. When the SSA is unable to determine if a quarter should be allowed, the SVES inquiry will show "Z" or "#" codes. The requirement for a 40-quarter work minimum was eliminated effective April 1, 2021. Use Form SSA-512, "Request to Resolve Questionable Quarters of Coverage (QC)," to resolve quarters before 1978. A copy of the SVES report must accompany the completed form. Submit Form SSA-512 to:

Social Security Administration Office of Central Records Operations P.O. Box 33015 Baltimore, Maryland 21290-3015

For questionable quarters for 1978 thru March 31, 2021, the applicant must complete Form SSA- 7008. "Request for Correction of Earnings." This form is available at local SSA offices. At the top of the form write "Welfare Reform." Submit the form and proof of earnings to:

Social Security Administration Office of Central Records Operations P.O. Box 30016 Baltimore, Maryland 21290-3016

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 January 2023 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 3 3 II. Establishing Quarters:

The requirement for a 40-quarter work minimum was eliminated effective April 1, 2021. Use the following information to (1) determine whether the applicant’s earnings as reported in section I.A were sufficient to establish quarters of coverage and (2) to determine the number of QQ during lag periods and when the reported employment is not a covered earning for Social Security reporting purposes:

• A quarter is a period of 3 calendar months ending with March 31, June 30, September 30 and December 31 of any year. • Social Security quarters of coverage are credits earned by working at a job or as a self-employed individual. A maximum of four credits or quarters can be earned each year. • For 1978 and later, credits are based solely on the total yearly amount of earnings. The number of creditable QQ are obtained by dividing the total earned income by the increment amount for the year. All types of earnings follow this rule. The amount of earnings needed to earn a credit increases and is different for each year. The amount of earnings needed for each credit and the amount needed for a year in order to receive four credits are listed below.

• A current year quarter may be included in the 40-quarter computation. Use the current year amount as the divisor to determine the number of quarters available. If you need to use quarters before 1978:

• A credit was earned for each calendar quarter in which an individual was paid $50 or more in wages (including agricultural wages for 1951-1955); • Four credits were earned for each taxable year in which an individual's net earnings from self- employment were $400 or more; and/or • A credit was earned for each $100 (limited to a total of 4) of agricultural wages paid during the year for years 1955-1977.

Year Increment Amount Amount Required for 4 QCs 2013 $1,160 $4,640 2012 $1,130 $4,520 2010 – 2011 $1,120 $4,480 2009 $1,090 $4,360 2008 $1,050 $4,200 2007 $1,000 $4,000 2006 $970 $3880

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 April 2013 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 3 4

Year Increment Amount Amount Required for 4 QCs 2005 $920 $3680 2004 $900 $3600 2003 $890 $3560 2002 $870 $3480 2001 $830 $3320 2000 $780 $3120 1999 $740 $2960 1998 $700 $2800 1997 $670 $2680 1996 $640 $2560 1995 $630 $2520 1994 $620 $2480 1993 $590 $2360 1992 $570 $2280 1991 $540 $2160 1990 $520 $2080 1989 $500 $2000 1988 $470 $1880 1987 $460 $1840 1986 $440 $1760 1985 $410 $1640 1984 $390 $1560 1983 $370 $1480 1982 $340 $1360 1981 $310 $1240 1980 $290 $1160 1979 $260 $1040 1978 $250 $1000

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 March 2011 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 3 5

Social Security Administration OMB No. 0960-0567

Consent for Release of Information TO: Social Security Administration

Name Date of Birth Social Security Number I authorize the Social Security Administration to release information or records about me to:

NAME ADDRESS

I want this information released because:

(There may be a charge for releasing information.)

Please release the following information:

Social Security Number

Identifying information (includes date and place of birth, parents’ names)

Monthly Social Security benefit amount

Monthly Supplemental Security Income payment amount

Information about benefits/payments I received from to

Information about my Medicare claim/coverage from to

(specify)

Medical records

Record(s) from my file (specify)

Other (specify)

I am the individual to whom the information/record applies or that person’s parent (if minor) or legal guardian. I know that if I make any representation which I know is false to obtain information from Social Security records, I could be punished by a fine or imprisonment or both. Signature:

(Show signatures, names and addresses of two people if signed by mark.)

Date:

Relationship:

SSA-3288

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 March 2011 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 3 6 OMB NO: 0960-0575 Date of Request

REQUEST TO RESOLVE QUESTIONABLE QUARTERS OF COVERAGE (QC)

Complete the information below when the QC array contains either a (#) pound sign or code “Z” prior to 1978. Mail the form and a copy of the system’s printout to the Social Security Administration, PO Box 17750, Baltimore, MD. 21235-0001.

Print Name:

Last First MI

SSN - -

Date of Birth ---------------------

MM DD YY Request Years 19 , 19 , 19 , 19 , 19 , 19 , 19 , 19 , 19 , 19 , 19 , 19 , 20 , 20 , 20 .

OR

19 thru 19 , 19 thru 19 , 19 , thru 19 ,

20 thru 20 .

State’s Name & Address

Contact Person’s Name & Telephone Number

The Paperwork Reduction Act of 1995 requires us to notify that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. We may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB control number. SSA-512

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 March 2011 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 3 7

Date of Request

QMB NO: 0960-0575

REQUEST FOR QUARTERS OF COVERAGE (QC) HISTORY BASED ON RELATIONSHIP

Complete the information below when requesting QC history for spouse(s) or parent (s) of a lawfully admitted non-citizen applicant. Mail the form to the Social Security Administration, PO Box 17750, Baltimore, MD 21235-0001.

Print Name:

Last First MI

SSN

- -

Date of Birth ----------------------------

MM DD YY Relationship to Applicant

NOTE: COMPLETE THE YEAR COLUMN AND CIRCLE THE PERTINENT QUARTER (S) FOR THE YEAR. SSA WILL PROVIDE INFORMATION ONLY FOR YEARS AND QUARTERS YOU INDICATE.

QC PATTERN QC PATTERN YEAR 1ST Q 2nd Q 3RD Q 4TH Q YEAR 1ST Q 2nd Q 3RD Q 4TH Q

State’s Name

& Address

Contact Person’s Name & Telephone Number

FORM SSA-513 (9/97)

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 January 2024 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 4 1

Afghan Special Immigrants

The United States Congress passed the Continuing Resolution on October 1, 2021. Section 2502 of the Continuing Resolution provides that certain Afghan nationals who receive parole between July 31, 2021 and March 31, 2023 “shall be eligible for resettlement assistance, entitlement programs, and other benefits available to refugees” to include Medicaid, until March 1, 2023 (or until their parole expires). On December 23, 2022 Congress passed the Consolidated Continuing Appropriations Act 2023 which extended the date that parole must have been received by to September 30, 2023 and expanded the groups of eligible for services. Eligibility continues until the parole expires. Afghan parolees who have a pending re-parole application, a pending asylum application, or a pending adjustment of status application with U.S. Citizenship and Immigration Services (USCIS), under the U.S. Department of Homeland Security (DHS) are still eligible for the continuation of Medicaid if they were enrolled prior to the expiration of their initial period of parolee. Eligible Parolees are: 1. Special Immigrant Parolees (SIP), who are individuals granted Special Immigrant (SI/SQ) Parole (per section 602(B)(1) AAPA/Section 1059(a) NDAA 2006) who entered the United States between July 1, 2021 and September 30, 2023, including Unaccompanied Afghan Minors, 2. Humanitarian Parolees entering the United States without SI/SQ parole due to the urgent nature of their arrival (Humanitarian status), who entered the United States between July 1, 2021 and September 30, 2023,

3. Afghan SIPs or Humanitarian Parolees who are the spouses or children of eligible Afghan Parolees who entered between July 1, 2021 and September 30, 2023, even if they entered after September 30, 2023, and 4. Afghan SIPs or Humanitarian Parolees who are the parents or legal guardians unaccompanied Afghan minors who entered between July 1, 2021 and September 30, 2013, even if they entered after September 30, 2023. Afghan nationals who have another Qualifying immigration status, such as refugees, Special Immigrant Visa (SIV) holders, or asylees, are eligible for Medicaid in the standard manner. They are not required to enter within a particular timeframe. Children under 19 years and pregnant women with SIP, or Humanitarian status meet the definition of lawfully residing aliens for Medicaid and FAMIS/FAMIS MOMS coverage.

Afghan Special Immigrant visa holders will have either (1) a passport or I-94 form indicating category SI1, SI2, SI3, SQ1, SQ2, or SQ3 and bearing the Department of Homeland Security stamp or notation or an I-151 (“green card”) indicating SI6, SI7, SI8, SQ6, SQ7, or SQ8. Special Immigrant Parolees will have an I-94 form noting SQ or SI Parole (per section 602(B)(1) AAPA/Sec 1059(a) NDAA 2006). If an individual has attested to eligible immigration status and is found otherwise eligible for Medicaid, but verification of that status cannot be obtained, do not deny or delay coverage. Enroll the individual and provide the 90-day reasonable opportunity period. Exception: Humanitarian Parolees who arrived before July 31, 2021, are eligible only for Medicaid coverage of emergency medical services and Health Insurance Marketplace coverage. Many of these individuals have already been enrolled in subsidized Marketplace coverage or have been granted asylum and are therefore eligible for Medicaid or FAMIS without the 5-year bar.

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 July 2024 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 4 2 Ukraine Humanitarian Parolees The U.S. Department of Homeland Security (DHS) is providing support and humanitarian relief to Ukrainians who have been displaced by Russia’s February 24, 2022 invasion and fled Ukraine. The United States Congress passed the Additional Ukraine Supplemental Appropriations Act (AUSAA) and was signed on May 21, 2022 by President Biden. It was extended by the Ukraine Security Supplemental Appropriations Act, 2024. This measure confers eligibility for all Ukrainian Humanitarian Parolees for mainstream federal benefits as well as resettlement services funded by the Office Refugee Resettlement (ORR). Certain Ukraine nationals entering the U.S. may be eligible for health coverage through Medicaid, the Children’s Health Insurance Program (CHIP), the Health Insurance Marketplace, or Refugee Medical Assistance (RMA). These individuals may be granted a range of lawful non-citizen statuses, including parole, temporary protected status (TPS), immigrant and nonimmigrant visas, and refugee or asylees. The primary non-citizen immigrant statuses include: 1. Parolees: Ukrainian nationals who enter the United States as parolees on or between February 24, 2022 and September 30, 2024 are eligible for Medicaid or CHIP to the same extent as refugees, without a five-year waiting period, if they meet other eligibility requirements. These Ukrainian parolees are considered “qualified non-citizens” for purposes of Medicaid and CHIP eligibility since they are eligible for the same benefits as refugees. Ukrainian nationals who are paroled into the U.S. after September 30, 2023 and are the spouse or child of a parolee described above, or who is the parent, legal guardian, or primary caregiver of a parolee described above who is determined to be an unaccompanied child will also be eligible for Medicaid and CHIP to the same extent as refugees. For eligible Ukrainian parolees who entered the United States with parole between February 24, 2022 – Sept 30, 2023, their date of eligibility is May 21, 2022, or their date of parole, whichever is later. For eligible Ukrainian parolees who enter the United States with parole between October 1, 2023 – Sept 30, 2024, their date of eligibility is April 24, 2024, or their date of parole, whichever is later. 2. Temporary Protected Status (TPS): Ukrainian nationals (and individuals having no nationality who last habitually resided in Ukraine) are eligible to apply for TPS. This includes Ukrainians granted TPS or have pending applications for TPS and who have been granted employment authorization. The TPS designation is effective April 19, 2022 and will remain in effect through October 19, 2023. 3. Refugees: Some Ukrainian nationals may be granted refugee status and resettled into the U.S. are eligible for full Medicaid or CHIP benefits, without application of the five-year waiting period, if they otherwise meet all other Medicaid eligibility requirements. 4. Lawfully Residing individual: Children under age 19 and pregnant women who are in one of the lawfully residing non-citizen alien groups (see M0220.314) and meet the definition of a lawfully residing alien for Medicaid and FAMIS/FAMIS MOMS coverage may be eligible for assistance. 5. Emergency Services: Ukrainian non-citizens who do not qualify for full Medicaid benefits based on their immigration status may be eligible for “emergency services Medicaid” if they meet all other eligibility requirements. An individual eligible only for emergency Medicaid is permitted to enroll in Marketplace coverage if they meet all Marketplace eligibility requirements. Ukrainian parolees will generally have foreign passports with a DHS stamp admitting them with a PAR, DT, or UHP Class of Admission (COA). DHS will be using the existing COA code DT and PAR for some Ukrainians who were paroled into the U.S. Additional COA code(s) will be programmed into Hub logic in early fall of 2022.

If an individual has attested to eligible immigration status and is found otherwise eligible for Medicaid, but verification of that status cannot be obtained, do not deny or delay coverage. Enroll the individual and give a 90- day reasonable opportunity period.

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Code MEDICAID ALIEN CODE CHART QUALIFIED ALIEN GROUPS Arrived Before August 22, 1996 Arrived On or After August 22, 1996 1st 5 years After 5 years A Qualified aliens who are Veterans or Active Military (includes spouses/dependent children); certain American Indians [Form DD 214-veteran] Full Benefit A1 Full Benefit A2 Full Benefit A3 B Permanent Resident Aliens (Aliens lawfully admitted for permanent residence) who have worked 40 qtrs., except Amerasians [I-151; AR-3a; I-551; I-327; I-688B- 274a.12(a)(1)] Full Benefit B1 Emergency Only B2 Full Benefit (40 quarter work requirement ended effective 4-1-21) B3 C Permanent Resident Aliens (Aliens lawfully admitted for permanent residence) who have NOT worked 40 qtrs., except Amerasians and citizens of Micronesia, Marshall Islands, Palau [I-327; I-151; AR-3a; I-551; I688B-274 a.12(a)(1)] Full Benefit C1 Emergency Only C2 Full Benefit effective 4-1-21 C1; Emergency Only for months prior to 4-21 C2 CC Compact of Free Association (COFA) migrants who are citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau. Full Benefit CC1 Full Benefits effective 12-27-20. CC1; Emergency Only for months prior to 12-20. CC2 Full Benefit effective 12-27-20. CC1; Emergency Only prior to 12-20. CC2 D Conditional entrants-aliens admitted pursuant to 8 U.S.C. 1153(a)(7), section 203(a)(7) of the INA [I-94] Full Benefit D1 Emergency Only D2 Full Benefit D3 E Aliens, other than Cuban or Haitian Entrants, paroled in the US pursuant to 8 U.S.C. 1182(d)(5) section 212(d)(5) of INA [I-94; I-688B – 274a(12)(c)(11)] Afghan Special Immigrant Parolees paroled into the United States between July 31, 2021, and September 30, 2023 will have an I-94 form noting SQ or SI Parole (per section 602(B)(1) AAPA/Sec 1059(a) NDAA 2006). They are eligible for full coverage without a 5-year waiting period. See Appendix 4. Ukraine Humanitarian Parolees. See Appendix 4. Full Benefit E1 Emergency Only E2 Full Benefit E3 I Battered aliens, alien parents of battered children, alien children of battered parents [U.S. Attorney General] Full Benefit I1 Emergency Only I2 Full Benefit I3 QUALIFIED ALIEN GROUPS 1st 7 years After 7 years F Aliens granted asylum pursuant to section 208 of the INA [I-94; I-688B – 274a.12(a)(5)] Full Benefit F1 Full Benefit F2 Emergency Only F3 G Aliens admitted as refugees pursuant to section 207 of the INA, or as Cuban or Haitian Entrants as defined in section 501(e) of Refugee Education Assistance Act of 1980 {including those under section 212(d)(5)}, or Amerasians [I-551; I-94; I-688B] Full Benefit G1 Full Benefit G2 Emergency Only G3 H Aliens whose deportation has been withheld pursuant to Section 243(h) or 241(b)(3) of the INA [I-688B – 274a.12(a)(10); Immigration Judge’s Order] Full Benefit H1 Full Benefit H2 Emergency Only H3

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2022 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 5 2

UNQUALIFIED ALIEN GROUPS Arrived Before 8-22-96 Arrived On or After 8-22-96 J Victims of a Severe Form of Trafficking pursuant to the Trafficking Victims Protection Act of 2000, P.L. 106-386 [ORR Certification/eligibility Letter] N/A J1 Full Benefit J2 Emergency Only J3 K Aliens residing in the US pursuant to an indefinite stay of deportation [I-94; Immigration Letter] Emergency Only K1 Emergency Only K2 Emergency Only K3 L Aliens residing in the US pursuant to an indefinite voluntary departure [I-94; Immigration Letter] Emergency Only L1 Emergency Only L2 Emergency Only L3 M Aliens on whose behalf an immediate relative petition has been approved and their families covered by the petition who are entitled to voluntary departure under 8 CFR 242.5(a)(2)(vi) and whose departure the INS does not contemplate enforcing [I-94; I-210] Emergency Only M1 Emergency Only M2 Emergency Only M3 N Aliens who have filed an application for adjustment of status pursuant to §245 INA that the INS has accepted as properly filed and whose departure the INS does not contemplate enforcing [I-181; Endorsed Passport] Emergency Only N1 Emergency Only N2 Emergency Only N3 O Aliens granted stay of deportation by court order, statute or regulation, or by individual determination of the INS whose departure the agency does not contemplate enforcing [I-94; Court Order; INS Letter] Emergency Only O1 Emergency Only O2 Emergency Only O3 P Aliens granted voluntary departure pursuant to section 242(b) of the INA whose departure the INS does not contemplate enforcing [I-94; I-210; I-688B – 247a.12(a)(11) or (13)] Emergency Only P1 Emergency Only P2 Emergency Only P3 Q Aliens granted deferred action status pursuant to INS Operations Instruction 103.1(a)(ii) prior to 6/15/84 or 242.1a22 issued 6/15/84 and later [I-210; INS Letter] Emergency Only Q1 Emergency Only Q2 Emergency Only Q3 R Aliens residing in the U.S. under orders of supervision [I-220B] Emergency Only R1 Emergency Only R2 Emergency Only R3 S Aliens who entered before January 1972 and have continuously resided in the U.S. since January 1972 [Case Record] Emergency Only S1 Emergency Only S2 Emergency Only S3

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UNQUALIFIED ALIEN GROUPS (cont.) Arrived Before 8-22-96 Arrived On or After 8-22-96 T Aliens granted suspension of deportation pursuant to Section 244 of the INA and whose deportation the USCIS does not contemplate enforcing [Immigration Judge Court Order] Emergency Only T1 Emergency Only T2 Emergency Only T3 U Any other aliens living in the US with the knowledge and permission of the USCIS whose departure the agency does not contemplate enforcing [USCIS Contact] Emergency Only U1 Emergency Only U2 Emergency Only U3 V Aliens not lawfully admitted or whose lawful admission status has expired* *For a pregnant woman who is not lawfully residing in the U.S., go to Chapter M23. Emergency Only V1 Emergency Only V2 Emergency Only V3 W Visitors (non-immigrants): tourists, diplomas, foreign students, temp. workers, etc. [I-688B – 274a.12(b)(1)-(20); I-94; I-185: I- I186; SW-434; I-95A] Emergency Only W1 Emergency Only W2 Emergency Only W3

LAWFULLY RESIDING NON-CITIZENS Effective 1/1/10 Effective 7/1/12 Y Non-citizen (alien) children under the age of 19 and pregnant women lawfully residing in the U.S. who meet the requirements in M0220.314. Full Benefits for Medicaid children under age 19 (FAMIS Plus) Full Benefits for Medicaid (FAMIS Plus), Medicaid pregnant women, FAMIS and FAMIS MOMS

AFGHAN AND IRAQI SPECIAL IMMIGRANTS First 7 Years after Entry into U.S. After 7 Years Z Afghan and Iraqi Special Immigrants admitted on a Special Immigrant Visa (SIV), including the spouse and children under age 21 living in the home with the principal visa holder. [I-551 or passport/ I-94 indicating categories SI1, SI2, SI3, SQ1, SQ2, or SQ3 and bearing Department of Homeland Security stamp or notation] For Afghan special immigrants admitted prior to being granted a Special Immigrant Visa, see M0220, Appendix 4. Full Benefits Z1 Emergency Only Z2

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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 March 2011 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 6 2

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 March 2011 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 6 3

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2012 Subchapter Subject Page ending with Page M0220.000 CITIZENSHIP & ALIEN REQUIREMENTS Appendix 7 1 TYPICAL DOCUMENTS USED BY LAWFULLY PRESENT IMMIGRANTS

STATUS TYPICAL DOCUMENTS Lawful Permanent Resident (LPR) • “Green card” (Form I-551) or earlier versions: I-151, AR-2 and AR-3; • Reentry permit (I-327); • Foreign passport stamped to show temporary evidence of LPR or “I- 551” status; • Receipt from USCIS (U.S. Citizenship and Immigration Services) indicating that an I-90 application to replace LPR card has been filed; • Memorandum of Creation of Lawful Permanent Residence with approval stamp (I-181); • I-94 or I-94A with stamp indicating admission for lawful permanent residence; • Order issued by the INS/DHS (Immigration and Naturalization Service/Dept. of Homeland Security), an immigration judge, the BIA (Board of Immigration Appeals), or a federal court granting registry, suspension of deportation, cancellation of removal, or adjustment of status; or • Any verification from the INS, DHS, or other authoritative document. Amerasian LPR NOTE: The codes listed here pertain only to the particular Vietnamese Amerasians who qualify for the “Refugee Exemption.” • Any of the LPR documents listed above with one of the following codes: AM-1, AM-2, AM-3, AM-6, AM-7, or AM-8; or • Any verification from the INS, DHS, or other authoritative document Applicant for Adjustment to LPR Status • Receipt or notice showing filing or pending status of Form I-485 Application to Register Permanent Residence or Adjust Status; • Form I-797 ASC Appointment Notice with Case Type “I-485 Application to Register Permanent Residence or Adjust Status”; • Form I-688B or I-766 employment authorization document (EAD) coded 274a.12(c)(9) or C9 or C9P; • I-797 receipt for Application for Employment Authorization based on C09; • I-512 authorization for parole, indicating applicant for adjustment of status; or • Any verification from the INS, DHS, or other authoritative document. Refugee • Form I-94 or I-94A Arrival/Departure Record or passport stamped “refugee” or “§ 207”; • Form I-688B or I-766 EAD coded 274a.12(a)(3) or A3; or (a)(4) or “A4” (paroled as a refugee); • Refugee travel document (I-571); or • Any verification from the INS, DHS or other authoritative document. • NOTE: If adjusted to LPR status, I-551 may be coded R8-6, RE-6, RE-7, RE-8, or RE-9. Conditional Entrant • Form I-94, I-94A, or other document indicating status as “conditional entrant,” “Seventh Preference,” § 203(a)(7), or P7; or • Any verification from the INS, DHS, or other authoritative document.

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Asylee • Form I-94, I-94A, or passport stamped “asylee” or “§ 208”; • Order granting asylum issued by the INS, DHS, an immigration judge, the BIA, or a federal court; • Form I-688B or I-766 EAD coded 274a.12(a)(5) or A5; • Refugee travel document (I-571); or • Any verification from the INS, DHS, or other authoritative document. NOTE: If adjusted to LPR status, I-551 may be coded AS-6, AS-7, or AS-8. Granted Withholding of Deportation or Withholding of Removal • Order granting withholding of deportation or removal issued by the INS, DHS, an immigration judge, the BIA, or a federal court; • Form I-688B or I-766 EAD coded 274a.12(a)(10) or A10; or • Any verification from the INS, DHS, or other authoritative document. Granted Withholding of Deportation/Removal under the Convention Against Torture (CAT) • Order granting withholding of deportation or removal under CAT, issued by an immigration judge, the BIA, or a federal court; • Form I-688B or I-766 EAD coded 274a.12(a)(10) or A10; or • Any verification from the INS, DHS, or other authoritative document Applicant for Asylum or Withholding of Deportation/Removal, including Applicant for Withholding of Deportation/Removal under CAT, with employment authorization if > 14 years, or application for asylum/withholding pending for 180 days if < 14 years • Receipt or notice showing filing or pending status of Form I-589 Application for Asylum and Withholding or CAT; • Form I-688B or I-766 EAD coded 274a.12(c)(8) or C8; or • Any verification from the INS, DHS, or other authoritative document. Cuban or Haitian Entrant • Form I-94 with a stamp indicating “Cuban/Haitian entrant” (this may be rare, as it has not been used since 1980) or any other notation indicating “parole,” any documents indicating pending exclusion or deportation proceedings; • Any documents indicating a pending asylum application, including a receipt from an INS Asylum Office indicating filing of Form I-589 application for asylum; • Form I-688B or I-766 EAD coded 274a.12(c)(8) or C8, or 274a.12(c)(11) or C11; or • Any verification from the INS, DHS, or other authoritative document. NOTE: Individuals who have adjusted to LPR status may have I-551 cards or temporary I-551 stamps in foreign passports coded CAA66, CB1, CB2, CB6, CB7, CH6, CNP, CU6, CU7, CU8, CU9, CUO, CUP, NC6, NC7, NC8, NC9, HA6, HA7, HA8, HA9, HB6, HB7, HB8, HB9, HC6, HC7, HC8, HC9, HD6, HD7, HD8, HD9, HE6, HE7, HE8, HE9. In addition, Cubans or Haitians with the codes LB1, LB2, LB6, or LB7 may also qualify. These codes were used for individuals granted LPR status under any of the 1986 legalization provisions including Cuban/Haitian entrants.

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Paroled into the U.S. • Form I-94 or I-94A indicating “parole” or “PIP” or “212(d)(5),” or other language indicating parole status; • Form I-688B or I-766 EAD coded 274a.12(a)(4), 274a.12(c)(11), A4, or C11; or • Any verification from the INS, DHS, or other authoritative document. NOTE: If subsequently adjusted to LPR status, may have I-551 card (for Lautenberg parolees, these may be coded LA). Granted Temporary Protected Status (TPS) • Form I-688B or I-766 EAD coded 274a.12(a)(12) or A12; • Form I-797 Notice of Action showing grant of TPS status; or • Any verification from the INS, DHS, or other authoritative document. Applicant for TPS, with employment authorization • Receipt or notice showing filing or pending status of Form I-821 (Application for Temporary Protected Status); • Form I-688B or I-766 EAD coded 274a.12(c)(19) or C19; or • Any verification from the INS, DHS, or other authoritative document. Granted Deferred Enforced Departure (DED) • Form I-688B or I-766 EAD coded 274a.12(a)(11) or A11; or • Any verification from the INS, DHS, or other authoritative document. Granted Deferred Action Status • Form I-797 Notice of Action or other form showing approval of deferred action status; • Form I-688B or I-766 EAD coded 274a.12(c)(14) or C14; or • Any verification from the INS, DHS, or other authoritative document. Applicant for Special Immigrant Juvenile Status • Form I-797 Notice of Action Special Immigrant Juvenile Approval Notice; • Form I-797 Welcome Notice/Approval of I-485, “Other Basis of Adjustment SL6”; • I-551 coded “SL6”; or • Any verification from the INS, DHS, or other authoritative document. “Qualified” Domestic Violence Survivor Must have a pending petition for an immigrant visa, either filed by a spouse or a self-petition under the Violence Against Women Act (VAWA), or an application for suspension of deportation or cancellation of removal. The petition or application must either be approved or, if not yet approved, must present a prima facie case. • Receipt or other proof of filing I-130 (visa petition) under immediate relative (IR) or 2nd family preference (P-2) showing status as a spouse or child; • Form I-360 (application to qualify as abused spouse, child, or parent under the VAWA); • Form I-797 Notice of Action referencing pending I-130 or I-360 or finding establishment of a prima facie case; • Receipt or other proof of filing I-485Application for Adjustment of Status on basis of an immediate relative or family 2nd preference petition or VAWA application; • Any documents indicating a pending suspension of deportation or cancellation of removal case, including a receipt from an immigration court indicating filing of Form EOIR-40 (Application for Suspension of Deportation) or EOIR-42 (Application for Cancellation of Removal); Form I-688B or I-766 EAD coded 274a.12(a)(10) or A10 (applicant for suspension of deportation) or 274a.12(c)(14) or C14 (individual granted deferred action status); or • Any verification from the INS, DHS, or other authoritative document.

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Victim of Trafficking • Certification from U.S. Dept. of Health and Human Services (HHS) Office of Refugee Resettlement (ORR); • ORR eligibility letter (if under 18); • Certification status verified through HHS Trafficking Verification Line 202-401-5510 or 866-401-5510 ; • I-914 (T status application); • I-766 coded (a)(16); • Form I-797 approval notice for “CP” (continued presence); • Form I-797 indicating approval of T-1 Status; • Bona fide case determination on a T status application; or • Form I-797 “Extension of T or U Nonimmigrant Status”; • I-512 authorization for parole, indicating T-1 status; • I-551 coded ST6; or • Any verification from HHS, INS, DHS, or other authoritative document. Derivative Beneficiary of Trafficking Survivor • Proof of approved I-914A petition (derivative T status); • I-94 or passport stamped T-2, T-3, T-4, or T-5; • Form I-797 Notice of Action indicating approval of T-2, T-3, T-4 or T-5 status; • I-766 EAD coded (c)(25); • Form I-797 “Extension of T or U Nonimmigrant Status”; • I-512 authorization for parole, indicating T-2, T-3, T-4 or T-5 status; • I-551 card coded ST7, ST8, ST9, or ST0; or • Any verification from HHS, INS, DHS, or other authoritative document. Nonimmigrant • Form I-94 or I-94A Arrival/Departure Record or passport indicating admission to U.S. with nonimmigrant visa; • Receipt for Form I-102 Application for Replacement/Initial Nonimmigrant Arrival-Departure Document; • I-797 approving application to extend/change nonimmigrant status; • I-797 approving application for S, T, U, or V nonimmigrant status; • Form I-688B or I-766 EAD or other INS/DHS document indicating nonimmigrant status; or • Any verification from the INS, DHS, or other authoritative document. Citizen of Micronesia, the Marshall Islands, and Palau • Form I-94 or passport noted as “CFA/RMI” or “CFA/FSM” or “CFA/PAL”; • Form I-766 coded (a)(8); or • Any verification from the INS, DHS, or other authoritative document. Lawful Temporary Resident • Form I-688 Temporary Resident Card; • Form I-688A EAD; • Form I-688B or I-766 EAD coded 274a.12(a)(2) or A2; or with other evidence indicating eligibility under INA §§210 or 245A ; • Form I-698 Application to Adjust from Temporary to Permanent Residence under INA § 245A; or • Any verification from the INS, DHS, or other authoritative document.

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Applicant for Legalization under IRCA or the LIFE Act, with employment authorization • Form I-688B or I-766 EAD coded 274a.12(c)(20), (c)(22), or (c)(24); • Form I-687 Application for Temporary Residence under INA § 245A; • Passport, with stamp or writing by INS/DHS officer, indicating pending §245 application; or • Any verification from the INS, DHS, or other authoritative document. Family Unity • Form I-797 Notice of Action showing approval of I-817 Application for Family Unity; • Form I-688B or I-766 EAD coded 274a.12(a)(13) or A13; or • Any verification from the INS, DHS, or other authoritative document. Applicant for Cancellation of Removal or Suspension of Deportation, with employment authorization • Receipt or notice showing filing Form EOIR-40 (Application for Suspension of Deportation), EOIR-42 (Application for Cancellation of Removal), or I-881 (Application for Suspension of Deportation or Special Rule Cancellation of Removal); • I-256A (former suspension application); • Form I-688B or I-766 EAD coded 274a.12(c)(10) or C10; or • Any verification from the INS, DHS, or other authoritative document. Order of Supervision, with employment authorization • Notice or form showing release under order of supervision; • Form I-688B or I-766 EAD coded 274a.12(c)(18) or C18; or • Any verification from the INS, DHS, or other authoritative document. Registry Applicant, with employment authorization • Receipt or notice showing filing Form I-485 Application to Register Permanent Resident or Adjust Status; • Form I-688B or I-766 EAD coded 274a.12(c)(16) or C16; or • Any verification from the INS, DHS or other authoritative document. Abbreviations BIA - Board of Immigration Appeals CAT - Convention Against Torture CMS - Centers for Medicare and Medicaid Services CP – continued presence DHS - U.S. Dept. of Homeland Security EAD - employment authorization document EOIR - Executive Office for Immigration Review HHS - U.S. Dept. of Health and Human Services INS - Immigration and Naturalization Service IR - immediate relative LPR - lawful permanent resident ORR - Office of Refugee Resettlement USCIS - U.S. Citizenship and Immigration Services VAWA - Violence Against Women Act

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Alien Status Reference Guide

Immigration Status Eligible for Full Medicaid Benefits? MMIS Code Qualified Non-Citizen Arrived in U.S. before 8/22/1996 Exempt from 5 year waiting period and no time limit on eligibility Lawful Permanent Resident Yes P Refugee under section 207 Yes R Amerasian Immigrant Yes P Conditional Entrant Under Section 303(a)(7) Yes P Asylee Under Section 208 Yes P Parolee under section 212(d)(5) Yes P Deportee whose deportation is withheld under section 243(h) or 241(b)(3) Yes P Cuban or Haitian Entrant Yes P Battered alien, alien parent of a battered child, and/or alien child of a battered parent Yes P Alien who arrived prior to 8/22/96 with unqualified status and who remained physically present in U.S. from date of entry to date of adjustment to a status listed above Yes See above

Arrived in U.S. on or after 8/22/1996 Has resided in the U.S. for 7 years or less; exempt from 5 year waiting period Refugee Yes R Asylee Yes P Deportee Yes P Cuban or Haitian Entrant Yes P Victim of a severe form of trafficking Yes P Afghan or Iraqi immigrant admitted on a Special Immigrant Visa Yes P

Arrived in U.S. on or after 8/22/1996 Has resided in the U.S. for more than 7 years Refugee No—Eligible A Asylee for Emergency Services Coverage Only A Deportee A Cuban or Haitian Entrant A Victim of a severe form of trafficking A Afghan or Iraqi immigrant admitted on a Special Immigrant Visa A

Arrived in U.S. on or after 8/22/1996 Has resided in the U.S. for at least 5 years Effective 4-1-21, Lawful Permanent Resident Yes P Conditional Entrants Parolees, other than Cuban or Haitian Entrants Battered aliens, alien parents of battered children, alien children of battered parents Yes P

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Immigration Status Eligible for Full Medicaid Benefits? MMIS Code Lawfully Residing Non-Citizen Children Under Age 19 Years and Pregnant Women No limitation on date of arrival to the U.S. No time limitation on eligibility as long as covered group requirements are met A qualified alien as defined in section 431 of PRWORA (8 U.S.C § 1641) (see M0220.310) Yes <19 I Pregnant P An alien in a nonimmigrant status who has not violated the terms of the status under which he or she was admitted or to which he or she has changed after admission, including individuals with valid visas. Yes <19 I Pregnant P An alien who has been paroled into the United States pursuant to section 212(d)(5) of the Immigration and nationality Act (INA) (8 U.S.C § 1182 (d)(5)) for less than I year, except for an alien paroled for prosecution, for deferred inspection or pending removal proceedings Yes <19 I Pregnant P An alien who belongs to one of the following classes: Yes <19 I Pregnant P • aliens currently in temporary resident status pursuant to section 210 or 245A of the INA (8 U.S.C.§§ 1160 or 1255a, respectively) Yes <19 I Pregnant P • aliens currently under Temporary Protected Status (TPS) pursuant to section 244 of the INA (8 U.S.C. § 1254a), and pending applicants for TPS who have been granted employment authorization Yes <19 I Pregnant P • aliens who have been granted employment authorization under 8 CFR 274a.12(c)(9), (10), (16), (18), (20), (22), or (24) Yes <19 I Pregnant P • Family Unity beneficiaries pursuant to section 301 of Pub. L. 101- 649, as amended Yes <19 I Pregnant P • aliens currently under Deferred Enforced Departure (DED) pursuant to a decision made by the President Yes <19 I Pregnant P • aliens currently in deferred action status, except for individuals receiving deferred status as a result of the Deferred Action for Childhood Arrivals (DACA) process, announced by the U.S. Department of Homeland Security on June 15, 2012 Yes <19 I Pregnant P • aliens whose visa petition has been approved and who have a pending application for adjustment of status Yes <19 I Pregnant P A pending applicant for asylum under section 208(a) of the INA (8 U.S.C. § 1158), or for withholding of removal under section 241(b)(3) of the INA (8 U.S.C. § 1231), or under the Convention Against Torture who has been granted employment authorization, or such an applicant under the age of 19 who has had an application pending for at least 180 days Yes <19 I Pregnant P An alien who has been granted withholding of removal under the Convention Against Torture Yes <19 I Pregnant P A child who has a pending application for Special Immigrant Juvenile status as described in section 101(a)(27)(J) of the INA (8 U.S.C. § 1101(a)(27)(J) Yes <19 I Pregnant P An alien who is lawfully present in the Commonwealth of the Northern Mariana Islands under 48 U.S.C. § 1806 (e) Yes <19 I Pregnant P An alien who is lawfully present in American Samoa under the immigration laws of American Samoa Yes <19 I Pregnant P

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Immigration Status Eligible for Full Medicaid Benefits? MMIS Code Non-Citizen No limitation on date of arrival to the U.S. No time limitation on eligibility as long as covered group requirements are met a. A qualified alien and veteran who was discharged honorably not on account of alienage, and who fulfills the minimum active-duty service requirements of section 5303A(d) of title 38, United States Code Yes P b. A qualified alien on active duty (other than active duty for training) in the Armed Forces of the United States (not in the Armed Forces Reserves) Yes R The spouse or the unmarried dependent child (see M0220.311 A) of a living (not deceased) qualified alien who meets the conditions in a. or b. above Yes P The unremarried surviving spouse of an individual described in a. or b. above who is deceased, if the spouse was married to the veteran • before the expiration of fifteen years after the termination of the period of service in which the injury or disease causing the death of the veteran was incurred or aggravated; or • for one year or more; or • for any period of time if a child was born of the marriage or was born to them before the marriage. Yes P Recipients of Supplemental Security Income (SSI) Yes P An alien who is • an American Indian born in Canada to whom the provisions of section 289 of the Immigration and Nationality Act (INA) apply, or • a member of an Indian tribe (as defined in section 4(e) of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450b(e)), Yes P Compact of Free Association (COFA) migrants who are citizens of the Federated States of Micronesia, the Republic of the Marshall Islands, or the Republic of Palau. Yes Effective 12/27/20 P

Arrived in U.S. on or after 8/22/1996 Regardless of length of residency in U.S. Individuals other than pregnant women with no immigration documents (undocumented) For a pregnant woman who is not lawfully residing in the U.S., go to Chapter M23. No—Eligible for Emergency Services Coverage Only A Deferred Action Childhood Arrivals (DACA) No—Eligible for Emergency Services Coverage Only A Individuals whose immigration status has expired and who do not meet any other immigration status No—Eligible for Emergency Services Coverage Only A Lawful Permanent Resident who has resided in the U.S. for fewer than 5 years, and/or prior to 4-1-21, without at least 40 qualify quarters of work coverage on record with the Social Security Administration. Effective 4-1- 21, there is no longer a work requirement. The 5 year residency requirement remains in effect. No—Eligible for Emergency Services Coverage Only A

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A. Policy Unqualified aliens, and qualified aliens eligible for emergency services only are eligible for Medicaid coverage of emergency medical care only. This care must be provided in a hospital emergency room or as an inpatient in a hospital. B. Entitlement- Enrollment Period If the applicant is found eligible and is certified for emergency services, eligibility exists only for the period of coverage certified by the eligibility worker or DMAS staff on the Emergency Medical Certification form #DMAS Form 2019NR. Once an eligibility period is established, additional requests for coverage of emergency services within 6 months will not require a new Medicaid application. However, each request for Medicaid coverage of an emergency service or treatment requires a new, separate certification and a review of the alien’s income and resources and any change in situation that the alien reports. With the exception of dialysis patients, an emergency services alien must file a new Medicaid application after the 6-month eligibility period is over if the individual receives an emergency service and wants Medicaid coverage for that service. DMAS will certify dialysis patients for up to a one year period of services without the need for a new Medicaid application. However, due to edits in MMIS, only one six-month certification period at a time can be entered. The worker must manually enter the second certification period of up to six months (as certified by DMAS) after the first period expires. The dialysis patient must reapply for Medicaid after his full certification period expires. C. Enrollment Procedures Once an emergency services alien is found eligible for coverage of emergency services, enroll the individual in the eligibility and enrollment system using the following data: In this field, Country of Origin, enter the code of the client’s country of origin. 2. Citizenship Status In this field, Citizenship Status code, enter : A = Emergency services alien (Alien Chart codes B2, C2, C3, CC2, D2, E2, F3, G3, H3, I2, codes J3 through V3, Z2) other than dialysis patient. D = Emergency services alien who receives dialysis. V = Visitor, non-immigrant alien (Alien Chart codes W1, W2, W3). The Alien Codes Chart is found in Appendix 5 to this subchapter.

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NOTE: Foreign visitors are not usually eligible for Medicaid because usually they do not meet the Virginia state residency requirement. 3. Entry date THIS FIELD MUST BE ENTERED. Enter the date on which the alien entered the U.S., except for asylees and deportees. For asylees, enter the date asylum was granted. For deportees, enter the date deportation withholding was granted. 4. App Dt In this field, application date, enter the date of the alien's Medicaid application upon which the eligibility coverage period is based. 5. Covered Dates Begin In this field, coverage begin date, enter the begin date of the emergency service(s). 6. Covered Dates End In this field, coverage end date, enter the date when the alien's emergency service(s) ends. When the emergency service(s) received was related to labor and delivery, the end date includes the day of discharge even though it is not counted to determine the length of stay for certification purposes. 7. AC Enter the code applicable to the alien’s covered group. D. Notices Appropriate notice must be sent to the applicant of the status of his application and the duration of his eligibility. The USCIS requires that all benefit applicants who are denied benefits based solely or in part on the SAVE response be provided with adequate written notice of the denial as well as the information necessary to contact USCIS, so that the individual may correct his records in a timely manner, if necessary. The fact sheet, “Information for Applicants: Verification of Immigration Status and How to Correct Your Record with USCIS” (Form # 032-03-0427-00) must be included with the Notice of Action when benefits are denied, including the approval of emergency-services-only Medicaid coverage, and with the Advance Notice of Proposed Action when benefits are subsequently cancelled based on the results of a SAVE inquiry. The fact sheet is available at https://fusion.dss.virginia.gov/Portals/[bp]/Files/SAVE/Inform%20for%20Applic ants%20Verification%20of%20Immigration%20Status.pdf?ver=2019-05-29- 135745-363. A Medicaid card will not be generated for an individual enrolled as an emergency services alien. The agency must contact the provider(s) and supply the eligibility dates and Medicaid number for billing purposes by sending a copy of the completed Emergency Medical Certification #DMAS Form 2019NR, to the provider(s).

CHAPTER M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS

SUBCHAPTER 30

VIRGINIA RESIDENCY REQUIREMENTS

M0230 Changes

Changed With Effective Date Pages Changed TN #DMAS-32 7/1/24 Page 3 TN #DMAS-2 10/1/16 Pages 1, 6 TN #100 5/1/15 Pages 3, 4 TN #98 10/1/13 Table of Contents pages 3-6 Page 7 was deleted. TN #97 9/1/12 Page 4 TN #95 3/3/11 Pages 1, 2 TN #93 1/1/10 Page 2

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TABLE OF CONTENTS

M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS

M0230.000 VIRGINIA RESIDENCY REQUIREMENTS

Section Page

Policy Principles ................................................................................... M0230.001 ................ 1

Definition of Terms ............................................................................... M0230.100 ................ 2

Residency Requirements ....................................................................... M0230.200 ................ 3

Individuals Under Age 21 ......................................................... M0230.201 ................ 3

Individuals Age 21 and Older .................................................. M0230.202 ................ 5

State Placement In Institution ................................................. M0230.203 ................ 5

Cash Assistance Program Recipients ...................................... M0230.204 ................ 6

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M0230.000 VIRGINIA RESIDENCY REQUIREMENTS

M0230.001 POLICY PRINCIPLES

A. Policy An individual must be a Virginia resident in order to be eligible for Medicaid, but is not required to have a fixed address. This subchapter, M0230, explains in detail how to determine if an individual is a Virginia resident. An individual placed by a Virginia government agency in an institution is considered a Virginia resident for Medicaid purposes even when the institution is in another state (section M0230.203 below). For all other individuals, Virginia residency is dependent on whether the individual is under age 21 years or is age 21 or older (sections M0230.201 and 202 below). B. Retention of Residency Residence is retained until abandoned. Temporary absence from Virginia with subsequent return to the state, or intent to return when the purposes of the absence have been accomplished, does not interrupt continuity of Virginia residence. C. Non-immigrant Aliens Regardless of an individual’s immigration status, accept declaration of Virginia residency on the application as verification of residency. Do NOT require individuals who have been admitted into the U.S. on non-immigrant visas and other non-immigrants to sign a statement of intended residency. D. Cross-Reference to Intra-State Transfer Procedures for handling cases where individuals who are Virginia residents move from one Virginia locality to another are described in subchapter M1520. E. No Fixed Address The agency cannot deny Medicaid to an eligible Virginia resident just because the resident has no fixed address. A Virginia resident is not required to have a fixed address in order to receive Medicaid. For an eligible Virginia resident who does not have a fixed address, use the local social services department's address for the Medicaid card and inform the resident that he must come to the social services department to receive his card until he obtains a fixed address. F. Length of Residency The agency may not deny Medicaid eligibility because an individual has not resided in Virginia for a specified period of time.

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G. Residency in Virginia Prior to Admission to Institution The agency may not deny Medicaid eligibility to an individual in an institution who meets the Virginia residency requirements previously identified in this subchapter, because the individual did not establish residence in Virginia before entering the institution. H. Temporary Absence The agency may not deny or terminate Medicaid eligibility because of that individual's temporary absence from Virginia if the individual intends to return to Virginia when the purpose of the absence has been accomplished, UNLESS another state has determined that the individual is a resident there for Medicaid purposes. I. Disputed or Un- clear Residency If state residency is unclear or is in dispute, contact the regional specialist for help in resolution. When two or more states cannot resolve the residency, the state where the individual is physically located becomes the state of residence.

M0230.100 DEFINITION OF TERMS

A. Introduction For purposes of this subchapter only, the terms in this section have the following meanings: B. Institution An establishment that furnishes (in single or multiple facilities) food, shelter, and some treatment or services to four or more persons unrelated to the proprietor is an institution. For purposes of state placement of an individual, the term "institution" also includes foster care homes approved by the state and providing food, shelter and supportive services to one or more persons unrelated to the proprietor. C. In An Institution "In an institution" refers to an individual who is admitted to live in an institution and receives treatment or services provided there that are appropriate to his requirements. D. Incapable of Indicating Intent An individual is incapable of declaring his intent to reside in Virginia or any state if the individual: • has an I.Q. of 49 or less or has a mental age of 7 or less, based on tests acceptable to the Virginia Department of Behavioral Health and Developmental Services (DBHDS);

• is judged legally incompetent; or

• is found incapable of declaring intent to reside in a specific state based on medical documentation obtained from a physician, psychologist, or other professional licensed by the State in the field of mental retardation.

E. Virginia Government Agency A Virginia government agency is any state or local government agency, and any entity recognized by State law as being under contract with a Virginia state or local government agency.

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M0230.200 RESIDENCY REQUIREMENTS

M0230.201 INDIVIDUALS UNDER AGE 21

A. Under Age 21 NOT In An Institution

An individual under age 21 is considered a resident of Virginia if he: a. is married or emancipated from his parents, is capable of indicating intent and is residing in Virginia with the intent to reside Virginia. b. is not emancipated but is not living with a parent or caretaker and is presently residing in Virginia with the intent to reside in Virginia; c. lives with a parent or caretaker who is presently residing in Virginia with the intent to reside in Virginia;

d. is a non-IV-E (state/local) foster care child whose custody is held by Virginia (see M230.204 C. and D.);

e. is a non-IV-E foster care child whose custody is held by another state but who has been placed with and is residing in Virginia with a parent or care- taker relative; f. is a non-IV-E child adopted under an adoption assistance agreement with Virginia (see M230.204 C. and D.); g. is a non-IV-E foster care child whose custody is held by a licensed, private foster care agency in Virginia, regardless of the state in which the child physically resides; h. is under age 21 and is residing in another state for temporary period (for reasons such as medical care, education or training, vacation, (or visit) but is still in the custody of his/her parent(s) who reside in Virginia. i. is living with a parent(s) who is a non-immigrant alien (admitted to the U.S. for a temporary or limited time) when the parent has declared his intent to reside in Virginia permanently or for an indefinite period of time, and no other information is contrary to the stated intent. j. Is placed out of state for a trial home visit with parents (while custody is retained by Virginia). B. Under Age 21 In An Institution If the individual was placed in the institution by a state government agent, go to section M0230.203 below. An institutionalized individual (who was not placed in the institution by a state government) who is under age 21 and is not married or emancipated, is a resident of Virginia if: 1. the individual's parent or legal guardian was a Virginia resident at the time of the individual's institutional placement; 2. the individual's parent or legal guardian who applies for Medicaid is a Virginia resident and the individual is institutionalized in Virginia; or

3. the individual's parent(s) has abandoned the individual, no legal guardian has been appointed, and the individual is institutionalized in Virginia.

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C. Under Age 21, Custody or Adoption Agreement with Another State When another state’s child-placing agency has custody of a child who lives in Virginia with a foster family, the child is NOT a Virginia resident unless the child is eligible as a IV-E Foster Care child and receives a IV-E Foster Care maintenance payment. 1. IV-E Eligible Children A Title IV-E Foster Care child who lives in Virginia and who receives a Title IV-E maintenance payment from another state meets the Virginia residency requirements for Medicaid. A Title IV-E Adoption Assistance child who lives in Virginia and has a Title IV-E Adoption Assistance agreement in effect with another state’s child- placing agency meets the Virginia residency requirements for Medicaid. 2. Non-IV-E Foster Care Children A non-IV-E Foster Care child placed in Virginia from another state does NOT meet the Virginia residency requirements for Medicaid unless placed with and residing in Virginia with a parent or caretaker-relative. 3. Foster Care Children with SSI A foster care child who receives Supplemental Security Income (SSI) benefits meets the Virginia residency requirement regardless of which state’s child- placing agency maintains custody. 4. Non-IV-E Adoption Assistance and Adoptive Placement Children A child who lives in Virginia with an adoptive family is considered to be living with a parent, regardless of whether a final order of adoption has been entered in court. When his adoptive parent is a Virginia resident, the child is a Virginia resident for Medicaid eligibility purposes. A Non-IV-E Adoption Assistance child whose adoption assistance agreement is signed by another state’s child- placing agency is a Virginia resident when the child lives in Virginia with the adoptive parent(s).

M0230.202 INDIVIDUALS AGE 21 OR OLDER

A. Introduction For an individual age 21 or older, the determination of state residency depends on • whether or not the individual is in an institution, and

• whether or not the individual is capable of indicating his or her intent to reside in the state. B. Age 21 Or Older NOT In An Institution For any individual age 21 or older NOT residing in an institution, the state of residence is Virginia when: • the individual is living in Virginia with or without a fixed address with the intention to reside in Virginia;

• the individual is living in Virginia and entered the state with a job commitment or seeking employment (whether or not currently employed).

• the individual is incapable of indicating intent and the individual is living in Virginia.

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C. Age 21 Or Older In An Institution If the individual was placed in the institution by a state government agent, go to section M0230.203 below. 1. Capable of Stating Intent An individual in an institution who is age 21 or over and who is capable of declaring his intent to reside in Virginia, is a resident of Virginia if the individual is in an institution in Virginia with the intent to remain permanently or for an indefinite period.

2. Incapable of Stating Intent An individual in an institution who is age 21 or over and who became incapable of stating intent at or after age 21 is a Virginia resident if he or she is residing in Virginia.

M0230.203 STATE PLACEMENT IN INSTITUTION

A. Policy Any agency of the state, including an entity recognized under state law as being under contract with the state for such purposes, that arranges for an individual to be placed in an institution located in another state, is recognized as acting on behalf of the state in making the placement. The state arranging or actually making the placement is considered the individual's state of residence. When an individual is placed by state or local government in an institution in another state, the individual remains the responsibility of the placing state unless the state or local government agency in the other state assumes responsibility for the individual's care or Medicaid eligibility. When an individual is placed by a Virginia government agency in an institution in another state, the individual remains the responsibility of Virginia unless • a state or local government agency in the other state assumes responsibility for the individual's care or Medicaid eligibility, • the individual is a child who receives a IV-E foster care or adoption assistance payment, or

• the individual is a child who receives non-IV-E adoption assistance and the state in which he is placed is a reciprocal state under the interstate compact, verified by the central office Deputy Compact Administrator, Adoption Unit, Division of Family Services, Virginia Department of Social Services (DSS). B. State Placement Placement by a state government agency is any action taken by the agency, beyond providing general information to the individual and his family, to arrange admission to an institution for the individual. The following actions do not constitute state placement: • providing basic information to individuals about other states' Medicaid programs or about the availability of health care services and facilities in other states; • assisting an individual, who is capable of declaring intent and who independently decides to move out-of-state, in locating an institution in another state.

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2016 Subchapter Subject Page ending with Page M0230 VIRGINIA RESIDENCY REQUIREMENTS M0230.204 6

1. Lack Of Facilities When a placement is initiated by a state because the state lacks a sufficient number of appropriate facilities to provide services to its residents, the state making the placement is the individual's state of residence for Medicaid purposes. 2. Individual Leaves Facility When a competent individual leaves the facility in which he was placed by a state, that individual's state of residence for Medicaid purposes is the state where the individual is physically located. C. Individual Placed Out-of-State by Virginia Government An individual can leave Virginia and retain Virginia residency if he is placed in an institution outside Virginia by a Virginia government agency. Out-of-state placement into a long-term care facility must be preauthorized by the Director of the Virginia Department of Medical Assistance Services for Virginia Medicaid to pay for the institutional care. When a competent individual voluntarily leaves the facility in which Virginia placed him, he becomes a resident of the state where he is physically located.

M0230.204 CASH ASSISTANCE PROGRAM RECIPIENTS

A. Introduction Certain individuals are considered residents of Virginia for Medicaid purposes if they live in Virginia and receive a cash assistance payment specified below in this section. Some recipients of cash assistance from a Virginia social services agency who do NOT reside in Virginia are considered residents of Virginia for Medicaid purposes, as specified below. B. Auxiliary Grants Recipients An individual receiving an Auxiliary Grants (AG) payment from a locality in Virginia is considered a Virginia resident. An individual who receives a State Supplement of SSI payment from another state is considered a resident of the state making the State Supplement payment. C. IV-E Payment Recipients For an individual of any age who receives federal foster care or adoption assistance payments under Title IV-E of the Social Security Act, the state of residence for Medicaid eligibility is the state where the child lives. D. Non-IV-E Foster Care Payment Recipients A child in foster care receiving a non-IV-E (state and local) payment whose custody is held by another state but who has been placed with and is residing in Virginia with a parent or care-taker relative is considered a resident of Virginia. If the child is not living with a parent or care-taker relative, the child is a resident of the state that is making the non IV-E payment. E. Non-IV-E Adoption Assistance Payment Recipients The non IV-E (state/local) Adoption Assistance recipient is a resident of the state in which the child’s adoptive parent(s) resides, regardless of whether a final order of adoption has been entered in court.

CHAPTER M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS

SUBCHAPTER 40

SOCIAL SECURITY NUMBER REQUIREMENTS

M0240 Changes

Changed With Effective Date Pages Changed TN #DMAS-32 7/1/24 Pages 3 and 5 TN #DMAS-24 7/1/22 Pages 3-6 TN #DMAS-21 10/1/21 Pages 1, 3, 5 TN #DMAS-20 7/1/21 Table of Contents Pages 1, 3, 5 Page 6a was renumbered to Page 7. Pages 2, 4, 6 and 7 are runover pages. TN #DMAS-13 7/1/19 Page 1 Pages 2 and 3 are runover pages. TN #DMAS-10 10/1/18 Pages 3, 4 TN #DMAS-9 7/1/18 Table of Contents Page 6 Page 6a is a runover page TN #DMAS-2 10/1/16 Pages 1, 4 Page 2 is a runover page. TN #100 5/1/15 Page 2 TN #98 10/1/13 Table of Contents Pages 1-5 Page 6 was deleted. TN #96 10/1/11 Pages 2-4 TN #94 9/1/10 Pages 1-6 TN #93 1/1/10 Pages 1-4 Update (UP) #1 7/1/09 Pages 1, 2 TN #91 5/15/09 Pages 1, 2

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 July 2021 Subchapter Subject Page ending with Page M0240 SOCIAL SECURITY NUMBER REQUIREMENTS TOC i

TABLE OF CONTENTS

M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS

M0240.000 SOCIAL SECURITY NUMBER REQUIREMENTS

Section Page

General Principles ..............................................................M0240.001 ...................................1

Application For SSN ............................................................M0240.100 ...................................3

Follow-up Requirements For SSN Applications ...............M0240.200 ...................................3

SSN Verification Requirements ..........................................M0240.300 ...................................5

SSN Discrepancies ................................................................M0240.400 ...................................6

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2021 Subchapter Subject Page ending with Page M0240 SOCIAL SECURITY NUMBER REQUIREMENTS M0240.001 1

M0240.000 SOCIAL SECURITY NUMBER REQUIREMENTS

M0240.001 GENERAL PRINCIPLES

A. Policy To be eligible for medical assistance (MA), an individual must provide his Social Security number (SSN) as well as the SSN of any person for whom MA is requested, or must provide proof of application for an SSN. This requirement applies to both the Medicaid and FAMIS Programs. Exceptions – the SSN requirement does not apply to: • an alien who is eligible only for Medicaid payment of emergency services, as defined in subchapter M0220,

• a non-citizen who is only eligible to receive an SSN for a valid non-work reason,

• a child under age one born to a Medicaid-eligible or FAMIS- covered mother (see M0330.301 B. 2 and M2220.100.), or

• an individual who refuses to obtain an SSN because of well-established religious objections. An individual who is applying only for others and is not applying for himself is not required to provide an SSN for himself. B. Failure to Meet SSN Requirement Any individual for whom an application for an SSN has not been filed or for whom the SSN is not furnished is not eligible for MA EXCEPT for the following individuals. 1. Child Under Age 1 A child under age one born to a Medicaid-eligible or to a FAMIS-covered mother is deemed to have applied and been found eligible for MA, whether or not the eligibility requirements, including SSN, have actually been met. This includes an infant born to a mother in FAMIS Prenatal Coverage who is assigned to Aid Category 110 AND who is NOT in managed care. An infant born to a mother in FAMIS Prenatal Coverage who is assigned to AC 110 and who IS in managed care OR who is assigned to in AC 111 is not a deemed newborn; however, the infant is not required to provide an SSN or proof of application for an SSN in order to be enrolled. See M0240.200 C. 2. Individual With Religious Objections An individual who refuses to obtain an SSN due to well-established religious objections must provide documentation of (1) membership of a recognized religious sect of division of the sect and (2) adherence to the tenets or teachings of the sect or division of the sect and for that reason being conscientiously opposed to applying for or using a national identification number.

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3. Emergency- Services Aliens and other Non- Citizens An alien eligible for Medicaid payment of emergency services only, as defined in M0220.410 and M0220.41, is not required to provide or apply for an SSN. Any non-citizen who is only eligible to receive an SSN for a valid non-work reason is not required to provide or apply for an SSN. These individuals include, but are not limited to, undocumented aliens, non-citizens admitted to the U.S. on non-immigrant visas and individuals who do not intend to work in the U.S. and would only have needed an SSN for the purposes of receiving public assistance. C. Relationship to Other Medicaid Requirements An applicant who cannot provide documentation that he is a citizen or legally present at the time of application must sign an affidavit under oath attesting that he is a U.S. citizen or legally present in the U.S. in order to temporarily meet the requirement for proof of legal presence (see M0210.150). Submission of the affidavit without proof of application for an SSN does NOT meet the SSN requirement. D. Verification 1. Name The name entered in the official case record and computer enrollment systems for an applicant must match the applicant’s name on his Social Security card or Social Security Administration (SSA) records verification. It is important to spell the name correctly so that when the Medicaid Management Information System (MMIS) sends the enrollee information to SSA for the Medicare Buy-in or the citizenship and identity match, the enrollee can be matched to SSA records. The Federally managed Data Services Hub verifies the individual’s name and SSN with the SSA for cases processed in the Virginia Case Management System (VaCMS). For an individual whose name and SSN cannot be verified in VaCMS and for all individuals whose cases are not processed in VaCMS, either the State Verification Exchange System (SVES) or the State Online Query-Internet system (SOLQ-I) SSA Title II and Title XVI results may be used. 2. SSN The individual’s SSN must be verified. The worker may use the SOLQ-I or SVES to verify an individual’s SSN. 3. Verification Systems - SVES & SOLQ-I SVES verifies the individual’s SSN, name spelling, entitlement to SSA benefits and the amount of the benefit, entitlement to SSI and the amount, and entitlement to Medicare & the Medicare premium amounts. SVES tells the worker what is wrong with the name, if the name is incorrectly spelled. The SOLQ-I verifies the individual’s SSN, entitlement to SSA benefits and the amount of the benefit, entitlement to SSI and the amount, and entitlement to Medicare & the Medicare premium amounts. SOLQ-I does not verify the individual’s name according to the SSA records. E. Procedure Section M0240.100 below explains in detail how to determine if an individual meets the SSN requirements when the individual or child does not have an SSN.

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M0240.100 APPLICATION FOR SSN

A. Policy If an SSN has not been issued for the individual or the individual’s child(ren), the applicant must cooperate in applying for a number with the local Social Security Administration Office (SSA). Instruct the applicant to submit form SS-5, the Application for Social Security Number, to the SSA and to obtain a receipt from SSA verifying that the application was submitted. The SS-5 is available online at: http://www.socialsecurity.gov/ssnumber/ss5.htm.

The agency must provide at least one 90-calendar-day reasonable opportunity period for the individual to obtain and provide an SSN and may not delay, deny, reduce or terminate benefits for an individual whom the agency determines to be otherwise eligible for Medicaid during such reasonable the opportunity period. If the application for an SSN was made through hospital enumeration, the agency must allow 120 calendar days for the SSN to be obtained and provided.

The applicant must provide the SSN to the local social services department as soon as it is received and the number must be verified and entered in the eligibility/enrollment system. 1. Newborns In the case of a newborn child, the applicant/recipient may satisfy this requirement by requesting that an SSN be applied for by hospital staff in conjunction with the filing of the birth record at the time of the child's birth. Form SSA-2853 will be given to the mother by hospital staff as verification of application for the child’s SSN. For an infant born to a mother in FAMIS Prenatal Coverage who is assigned to AC 110 and who is in managed care OR who is enrolled in AC 111, see M0240.200 C.

2. Failure to Apply for SSN Applicants who refuse to furnish an SSN or to show proof of application for a number are ineligible for Medicaid.

3. Retroactive Eligibility An individual who provides proof of application for an SSN after he applies for medical assistance, meets the application for SSN requirement in the three months retroactive to his medical assistance application.

M0240.200 FOLLOW-UP REQUIREMENTS FOR SSN APPLICATION

A. Applicant Applied for SSN When an applicant who has applied for an SSN is determined eligible for medical assistance, he is enrolled with a pseudo-SSN. The worker must obtain the enrollee’s SSN when it is assigned and enter it into the enrollee’s records. For an infant born to a mother in FAMIS Prenatal Coverage who is assigned to AC 110 and who is in managed care OR who is assigned to AC 111, see M0240.200 C.

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B. Follow-Up Procedures for Individuals Who Are Not Infants Born to Women Enrolled in FAMIS Prenatal Coverage The follow-up procedures below do not apply to individuals listed in M0240.100 B.

1. Documentation If the applicant does not have an SSN, the agency must document in the record the date he applied for an SSN.

2. Entering Computer Systems If a date is necessary when entering the individual the eligibility/enrollment system, use the date the individual applied for an SSN, or the individual’s date of birth, preceded by “000” as the individual’s SSN. For example, an individual applied for an SSN on October 13, 2006. Enter “000101306” as the individual’s SSN in the eligibility/enrollment system. 3. Follow-up a. Follow-up in 90 Calendar Days After enrollment of the eligible individual, the agency must follow-up within 90 calendar days of the Social Security number application date or 120 calendar days if application was made through hospital enumeration. b. Check for Receipt of SSN Check the system records for the enrollee’s SSN. If the SSN still has “000” the first 3 digits, contact the enrollee to obtain the enrollee’s SSN verbally or by mail. If the individual has not applied for an SSN, send advance notice that the individual is no longer eligible for coverage and cancel coverage. c. Verify SSN by a computer system inquiry of the SSA records. d. Enter Verified SSN in the eligibility/enrollment system.

4. Renewal Action If the enrollee’s SSN has not been assigned by the 90-day follow-up, the worker must follow-up no later than the enrollee’s annual renewal, by checking the systems for the enrollee’s SSN and by contacting the enrollee if necessary. a. Check for Receipt of SSN Before or at renewal, the SSN must be entered into the eligibility/enrollment system. Check the system records for the enrollee’s SSN. If the SSN has “000”as the first 3 digits, contact the enrollee to obtain the enrollee’s SSN verbally or by mail, or on the renewal form if a renewal form is required. b. Verify SSN by a computer system inquiry of the SSA records. c. Enter Verified SSN in the eligibility/enrollment system.

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d. SSN Not Provided by Renewal Deadline The worker must assist the enrollee in obtaining the applied-for SSN. The worker will ask the enrollee for the assigned SSN at the first renewal, and give a deadline date for the enrollee to provide the SSN. If the enrollee does not provide the SSN by the deadline, the worker will ask the enrollee why it was not provided to the worker: • Did the enrollee ever receive the SSN from SSA? • If not, why not? If the problem is not an SSA administrative problem, the worker must cancel MA coverage for the enrollee whose SSN is not provided. C. Follow-Up Procedures For an Infant Born to a Woman Enrolled in FAMIS Prenatal Coverage An infants born to a mother enrolled in FAMIS Prenatal Coverage assigned to Aid Category (AC) 110 and who is NOT in managed care is a deemed newborn. Follow up on the SSN is not required until the time of the newborn’s first renewal during the month or after turning one. An infant born to a mother in FAMIS Prenatal Coverage who is assigned to AC 110 and who IS in managed care OR who is assigned to AC 111 is not a deemed newborn; however, the infant is not required to provide an SSN or proof of application for an SSN in order to be enrolled. Follow the procedures in M0240.200 B.3 above 90 days following the infant’s enrollment to determine if an SSN has been assigned. If the SSN number has not yet been issued at 90 days, obtain the SSN or proof of application for an SSN at the first renewal of the infant’s coverage during the month or after turning one.

M0240.300 SSN Verification Requirements

A. SSN Provided By Individual The individual’s SSN must be verified. When the individual provides his SSN, the worker may use the SOLQ-I or SVES to verify the individual’s SSN. The individual is not eligible for MA and cannot be enrolled in the eligibility/enrollment system if his SSN is not verified. B. Procedures 1. Enter Verified SSN in Systems Enter the eligible enrollee’s verified SSN in the eligibility/enrollment system. 2. Resolving Unverified SSN Discrepancies a. Data Entry Error Caused Discrepancy If it is determined that the discrepancy was the result of an error made while entering the SSN in the system, steps must be taken to correct the information in the eligibility/enrollment system so that a new data match with SSA can occur in the next month.

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 July 2022 Subchapter Subject Page ending with Page M0240 SOCIAL SECURITY NUMBER REQUIREMENTS M0240.400 6

b. Discrepancy Not Caused by Data Entry Error If the discrepancy is not the result of a typographical or other data entry error, the individual must be given a period of 10 calendar days to resolve the issue or provide written verification from SSA of the individual’s correct SSN. The eligibility worker must send a written notification to the enrollee that informs the enrollee of the SSN discrepancy and gives him 10 calendar days from the date of the notice to either resolve the discrepancy with the SSN or to provide written verification of his correct SSN to the worker. The notice must inform the individual that if he does not verify his SSN by the deadline, his Medicaid coverage will be canceled. c. Individual Provides SSN Verification If verification of the SSN is received within the 10 calendar days, update the eligibility/enrollment system accordingly so that the enrollee’s information will be included in a future data match. d. SSN Verification Not Provided If verification of the SSN is NOT received within the 10 calendar days, send the individual an advanced notice of proposed cancellation and cancel the individual‘s coverage in the eligibility/enrollment system.

M0240.400 SOCIAL SECURITY NUMBER DISCREPANCIES

A. Policy To be eligible for medical assistance (MA), an individual must provide his Social Security number (SSN) as well as the SSN of any person for whom MA is requested, or must provide proof of application for an SSN.

As required by 42 CFR 435.910(g), “the agency must verify each SSN of each applicant and recipient with the SSA [Social Security Administration], as prescribed by the Commissioner, to insure that each SSN was furnished to that individual, and to determine whether any others were issued.”

In addition, 42 CFR 435.920 states, “In redetermining eligibility, the agency must review case records to determine whether they contain the recipient’s SSN or, in the case of families, each family member’s SSN.”

The Medical Assistance enrollment system generates a Social Security number and citizenship report (RS-O-485-A) and makes the report available to the local departments of social services (LDSS) on a monthly basis. LDSS agencies are responsible for reviewing the monthly report and correcting any discrepancies. If the agency is not able to resolve SSN discrepancies in a timely manner, an ineligible individual should not receive Medicaid services. Refer to Medicaid Policy M0240.300 regarding SSN Verification Requirements.

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Staff at the Department of Medical Assistance Services will oversee and monitor the process of SSN resolution on a monthly basis to ensure that action has been taken to correct Social Security Numbers in the system.

B. Process 1. Generation of the RS-O- 485-A Report The RS-O-485-A Report is produced monthly and posted for LDSS review.

2. VDSS Requirements It is the responsibility of the LDSS to review the report and research each entry to resolve any discrepancies concerning an individual’s social security number. An ineligible individual should not receive Medicaid services. VDSS is responsible for implementing the necessary procedures to ensure that all corrections or changes will be made within a 30-day period and updated in the MMIS system accordingly. Policy guidelines are located in the Medicaid Policy Manual. See Policy M0240.300

3. DMAS Review DMAS staff will concurrently review an internal report showing how long each individual discrepancy continues to appear. The number of new (first time) and repeat (not first time on report) occurrences will be noted. Repeat occurrences will be further broken down by those that have appeared from prior month, in the prior two months, in the prior three months, and the total that have been on the report for four or more months.

4. Forward List to VDSS DMAS will provide a monthly outcome report of the number of discrepancies reported and the individuals with discrepancies that remain on the report after 90 days.

This report will be forwarded to the VDSS Medical Assistance Programs Manager and to the VDSS Regional Medicaid consultants for review. VDSS will review the report and provide to DMAS a corrective action plan for resolving the discrepancies. All discrepancies must be resolved within 30 days of receiving the report from DMAS.

CHAPTER M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS

SUBCHAPTER 50

ASSIGNMENT OF RIGHTS AND PURSUIT OF SUPPORT FROM THE ABSENT PARENT REQUIREMENTS

M0250 Changes

Changed With Effective Date Pages Changed TN #DMAS-18 1/1/21 Page 4 TN #98 10/1/13 Pages 1-4 Page 5 was deleted. TN #97 9/1/12 Page 5 TN #96 10/1/11 Page 3 TN #94 9/1/10 Pages 3-5

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 January 2007 Subchapter Subject Page ending with Page M0250 ASSIGNMENT OF RIGHTS AND PURSUIT OF SUPPORT TOC i

TABLE OF CONTENTS

M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS

M0250.000 ASSIGNMENT OF RIGHTS AND PURSUIT OF SUPPORT

FROM ABSENT PARENT REQUIREMENTS

Section Page

General Principles ................................................................. M0250.001 ............................... 1

Assignment of Rights .............................................................. M0250.100 ............................... 1

Procedures for Assignment of Rights .................................. M0250.200 ............................... 2

Pursuit of Medical Support From the Absent Parent ........ M0250.300 ............................... 3

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2013 Subchapter Subject Page ending with Page M0250 ASSIGNMENT OF RIGHTS AND PURSUIT OF SUPPORT M0250.100 1

M0250.000 ASSIGNMENT OF RIGHTS AND PURSUIT OF SUPPORT

FROM THE ABSENT PARENT REQUIREMENTS

M0250.001 GENERAL PRINCIPLES

A. Introduction The assignment of rights to medical support and the pursuit of support from absent parent(s) are Medicaid nonfinancial requirements that must be met as a condition of Medicaid eligibility. The assignment of rights to medical support requirement also applies to children eligible for the Family Access to Medical Insurance Security Plan (FAMIS). B. Policy and Procedures The policy and procedures for the local agency to follow in determining if an individual has met the Medicaid assignment of rights and pursuit of support from absent legally responsible relatives are contained in the following sections: • M0250.100 Assignment of Rights.

• M0250.200 Procedures for the Assignment of Rights.

• M0250.300 Pursuit of Medical Support From the Absent Parent.

M0250.100 ASSIGNMENT OF RIGHTS

A. Assignment of Rights Policy To be eligible for Medicaid, a Medicaid applicant or recipient must: • assign his rights to medical support and payment for medical care from any third party to the Department of Medical Assistance Services (DMAS) if he is applying for himself; • assign the rights of any other individual for whom he applies and can make an assignment of rights to support and third party payments; • cooperate with the agency in identifying (to the extent he is able) potentially liable insurers and other third parties who may be liable to pay for the individual's, and any other individual for whom he applies and can assign rights for care and medical services. B. Individual Unable To Assign Rights If the individual is unable to his assign rights, a spouse, legally appointed guardian or conservator, attorney-in-fact (person who has the individual’s power-of-attorney), or the authorized representative can make such an assignment. If the individual is a child, the parent, legal custodian, authorized representative, or the adult relative with whom the child lives and who signed the application can assign rights. If the person who has the authority to assign the applicant’s/recipient’s rights refuses to assign the rights, the person who has the authority to assign the rights will be ineligible for Medicaid. However, the applicant/recipient will meet the assignment of rights requirement and can be eligible for Medicaid if he meets all other eligibility requirements.

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2013 Subchapter Subject Page ending with Page M0250 ASSIGNMENT OF RIGHTS AND PURSUIT OF SUPPORT M0250.200 2

M0250.200 PROCEDURES FOR ASSIGNMENT OF RIGHTS

A. Forms The assignment of rights information is incorporated into the online and paper applications for medical assistance (MA). By signing the application for MA, the individual assigns his/her own rights and the rights of anyone for whom the individual has applied and can assign rights. B. Refusal To Assign Rights Or Cooperate An individual who is able to assign rights but who refuses or fails to meet the assignment of rights requirements in this subchapter is not eligible for Medicaid. Deny or cancel Medicaid coverage to an individual who:

• refuses to assign his own rights if he applies for himself,

• refuses to assign the rights of any other applicant for whom he can make an assignment, or

• refuses to cooperate in identifying and providing liable third party information, unless cooperation has been waived for good cause. C. Cooperation – Assignment of Rights Cooperation in assisting the agency in securing medical support and payments includes requiring the individual to: • provide identifying information about liable third parties, such as the liable person’s insurance company and policy number, the medical services covered by the insurance policy, etc.;

• appear as a witness at a court or other proceeding; • provide information, or attest to lack of information, under penalty of perjury;

• pay to the agency any medical care funds received that are covered by the assignment of rights; and

• take any other reasonable steps to assist the state in pursuing any liable third party. Should DMAS or the local agency request information from the individual, including information about third party liability, or otherwise require cooperation with the pursuit of medical support and/or third party liability as outlined in M0250.200 C. above, the individual must cooperate with the pursuit of medical support in order for the individual’s eligibility to continue. 1. Waiver of Cooperation A waiver of the cooperation requirement in identifying and providing liable third party information is allowed if the agency finds that cooperation is against the best interests of the individual, or other person for whom he/she can assign rights, because the agency anticipates that cooperation will result in reprisal against or cause physical or emotional harm to the individual or other person.

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2013 Subchapter Subject Page ending with Page M0250 ASSIGNMENT OF RIGHTS AND PURSUIT OF SUPPORT M0250.300 3

2. Documentation Document the case record with the reason(s) the individual refuses to cooperate in identifying and providing liable third party information and the reason(s) the agency finds that cooperation is against the best interests of the individual or other person for whom he/she can assign rights.

M0250.300 PURSUIT OF MEDICAL SUPPORT FROM THE ABSENT PARENT

A. Policy To be eligible for Medicaid, an individual applicant or recipient must cooperate with the agency in obtaining medical support and payments from, or derived from, the absent parent(s) of a child for whom the individual is applying, unless the individual establishes good cause for not cooperating. The individual’s non-cooperation does NOT affect the individual’s Plan First eligibility, nor the individual’s child(ren)’s Medicaid eligibility. A pregnant woman is not required to cooperate with DCSE when requesting assistance for herself and her child(ren) born out of wedlock. If she is or was married, she is required to cooperate in pursuing medical support for her legitimate child(ren) from the legitimate child(ren)’s absent father. A married pregnant woman who meets the medical assistance support requirement cannot be denied medical assistance for failure to cooperate in pursuing support even when ineligible for another program because of failure to cooperate with pursuit of support. B. Definition of Cooperation 1. Application By signing the application for Medicaid, the individual meets the eligibility requirement to cooperate in pursuing support from the absent parent(s) of the child for whom the individual is applying. No further action by the applicant is required at the time of application. The individual is not required to contact DCSE about pursuing support from the absent parent. If the individual chooses to request DCSE services, the individual’s continued cooperation with DCSE is required for the individual to remain eligible for Medicaid. 2. Ongoing After the individual’s application has been approved, if DCSE, DMAS or the local agency requests information from the individual about the absent parent, or otherwise requires the individual’s cooperation with the pursuit of medical support from the absent parent, the individual must cooperate in order for the individual’s eligibility to continue. Medicaid enrollees who were approved for Medicaid before January 1, 2007, and who were referred to DCSE, must continue to cooperate with DCSE in the pursuit of medical support from the absent parent to remain eligible for Medicaid. C. Local DSS Agency Responsibility

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 January 2021 Subchapter Subject Page ending with Page M0250 ASSIGNMENT OF RIGHTS AND PURSUIT OF SUPPORT M0250.300 4

1. Applicants Explain and offer the Division of Child Support Enforcement (DCSE) services to all Medicaid applicants who apply for Medicaid for themselves and/or on behalf of children who have an absent parent. A child’s parent is not considered absent if the absence is due to death, single parent adoption, artificial insemination, or termination of parental rights. Give the applicant the DCSE Fact Sheet available on the intranet at https://fusion.dss.virginia.gov/bp/BP-Home/Medical-Assistance/References. 2. Enrollees If the local agency or DMAS requires from the enrollee information related to medical support from the absent parent, such as the policy number of the health insurance policy the absent parent has that covers the child, and the enrollee refuses to give it to the requesting agency but does not have good cause for refusing, the enrollee is no longer eligible for Medicaid because of failure to cooperate in pursuing medical support and third party liability. The child(ren) remain eligible for Medicaid. a. Enrollees who were approved before January 1, 2007 For a Medicaid enrollee who was approved for Medicaid before January 1, 2007, and was referred to DCSE, the local agency must take action when notified by DCSE that the enrollee is not cooperating in the pursuit of medical support from the absent parent. The child(ren)’s eligibility for Medicaid is NOT affected. b. Enrollees who applied on or after January 1, 2007 If the enrollee who applied for Medicaid on/after January 1, 2007, chooses to apply for DCSE services and DCSE opens a case for the applicant, the enrollee must cooperate with DCSE in the pursuit of medical support from the absent parent, unless there is good cause for not cooperating. If the agency is notified by DCSE that the enrollee is not cooperating, the agency worker must take appropriate action on the enrollee’s Medicaid coverage; the child(ren)’s eligibility for Medicaid is NOT affected. If the recipient wants to claim good cause for not cooperating, contact a Medical Assistance Program Consultant for instructions. 3. TANF Recipients If an applicant for or recipient of Temporary Assistance for Needy Families (TANF) fails to cooperate with DCSE, the individual’s eligibility for Medicaid is not impacted unless the individual previously requested assistance from DSCE for Medicaid purposes per M0250.300 C.2.b above. D. DCSE DCSE District Offices have the responsibility of pursuing support from absent legally responsible parent(s), establishing paternity when the alleged father is absent from the home, and notifying the local DSS when the enrollee does not cooperate. This responsibility entails locating the parent(s), determining ability to support, collecting support from legally responsible parent(s), establishing medical support and/or health insurance covering the applicant child(ren), and court action to secure support from the absent legally responsible parent. The booklet, "Child Support and You", form #032-01-945, gives an overview of DCSE services and the addresses for the district offices.

CHAPTER M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS SUBCHAPTER 60

RESERVED

NOTE: Policy references to M0260 that are still in effect have been moved to

subchapter M0250.

CHAPTER M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS

SUBCHAPTER 70

APPLICATION FOR OTHER BENEFITS

Reserved

M0270 Changes

Changed With Effective Date Pages Changed TN #DMAS-32 7/1/24 Subchapter removed TN #DMAS-20 7/1/21 Page 2 TN #DMAS-16 4/1/20 Page 3 Page 4 was added. Update (UP) #9 4/1/13 page 3

CHAPTER M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS

SUBCHAPTER 80

INSTITUTIONAL STATUS REQUIREMENTS

M0280 Changes

Changed With Effective Date Pages Changed TN #DMAS-36 10/1/25 Pages 6,7 and 10 TN #DMAS-32 7/1/24 Page 7 TN #DMAS-20 7/1/21 Table of Contents Page 1 Appendix 2 was added. TN #DMAS-19 4/1/21 Pages 3, 4 Appendix 1 Page 4a was added. TN #DMAS-17 7/1/20 Pages 7, 9, 10 Page 11 was deleted. TN #DMAS-15 1/1/20 Page 9 Appendix 1 TN #DMAS-14 10/1/19 Pages 6, 7, 9, 11 TN #DMAS-2 10/1/16 Pages 7, 9 TN #100 5/1/15 Table of Contents Pages 1-11 Appendix 1 was added Pages 12 and 13 were deleted. UP #9 4/1/13 Page 5 Update (UP) #7 7/1/12 Table of Contents Page 8 Appendix 1 was deleted. TN #94 9/1/10 Page 1 TN #93 1/1/10 Page 13

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 May 2015 Subchapter Subject Page ending with Page M0280 INSTITUTIONAL STATUS REQUIREMENTS TOC i

TABLE OF CONTENTS

M02 NONFINANCIAL ELIGIBILITY REQUIREMENTS

M0280.000 INSTITUTIONAL STATUS REQUIREMENTS

Section Page

General Principles ................................................................................ M0280.001 ................ 1

Definition of Terms ............................................................................... M0280.100 ................ 1

Institutional Status Rule ....................................................................... M0280.200 ................ 3

Individuals In Medical Facilities .............................................. M0280.201 ................ 4 Individuals In Residential Facilities ........................................ M0280.202 ................ 5

Inmate of A Public Institution .............................................................. M0280.300 ................ 6

Who Is NOT An Inmate of A Public Institution .................... M0280.301 ................ 8

Individuals Moving To or From Public Institutions .......................... M0280.500 ................ 10

Departmental Responsibility ................................................................ M0280.600 ................ 10

Appendix

Institutional Status Quick Reference Guide ...................................... Appendix 1 ............... 1 Institutions for the Treatment of Mental Diseases in Virginia ........... Appendix 2 ................ 1

.

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 July 1, 2021 Subchapter Subject Page ending with Page M0280 INSTITUTIONAL STATUS REQUIREMENTS M0280.100 1

M0280.000 INSTITUTIONAL STATUS REQUIREMENTS

M0280.001 GENERAL PRINCIPLES

A. Introduction To be eligible for Medicaid, an institutionalized individual must meet the institutional status requirement. An individual does not necessarily have to live in an institution (facility) to be considered an "inmate of a public institution." While inmates of public institutions are generally NOT eligible for Medicaid, incarcerated individuals may be eligible for Medicaid payment limited to inpatient hospitalization, provided they meet all other eligibility requirements. B. Procedure This subchapter, M0280, contains the Medicaid institutional status policy, inmate of a public institution policy and procedures for determining whether an individual meets the Medicaid institutional status eligibility requirement.

M0280.100 DEFINITION OF TERMS

A. Child Care Institution A child care institution is a • non-profit private child-care institution, or • a public child care institution that accommodates no more than 25 children which has been licensed by the state in which it is located or has been approved by the agency of the state responsible for licensing or approval of institutions of this type, as meeting the standards established for licensing. The term "child care institution" does NOT include detention facilities, forestry camps, training schools or any other facility operated primarily for the detention of children who are determined to be delinquent. B. Inpatient Inpatient means a patient who has been admitted to a medical institution as an inpatient on recommendation of a physician or dentist and who is admitted and receives room, board and professional services in the institution for a 24 hour period or longer, or is expected by the institution to receive room, board and professional services in the institution for a 24 hour period or longer even though it later develops that the patient dies, is discharged or is transferred to another medical facility and does not actually stay in the institution for 24 hours. C. Institution An institution is an establishment that furnishes (in single or multiple facilities) food, shelter and some treatment or services to four or more persons unrelated to the proprietor. D. Institution for the Treatment of Mental Diseases (IMD) An IMD is a hospital, nursing facility or other institution with more than 16 beds that is primarily engaged in providing diagnosis, treatment or care, including medical attention, nursing care and related services, to persons with mental diseases. A psychiatric residential treatment facility for children and adolescents is an IMD. An institution for individuals with intellectual disabilities is NOT an IMD. A list of IMDs in Virginia is contained in M0280, Appendix 2

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E. Institution for Individuals with Intellectual Disabilities An “institution for individuals with intellectual disabilities” means an institution that is primarily for the diagnosis, treatment, or rehabilitation of individuals with Intellectual Disabilities or persons with related conditions that provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination , and integration of health or rehabilitative services to help each individual function at his greatest ability. An intermediate care facility for individuals with intellectual disabilities (ICF-ID) is not an IMD. Therefore, an individual under age 65 who is in an ICF-ID meets the institutional status eligibility requirement. F. Medical Facility A medical facility is an institution that: • is organized to provide medical care, including nursing and convalescent care,

• has the necessary professional personnel, equipment, and facilities to manage the medical, nursing and other health needs of patients, • is authorized under state law to provide medical care, and • is staffed by professional personnel who are responsible to the institution for professional medical and nursing services. G. Public Institution (Facility) A public institution is an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control, and which is NOT a medical facility. The following are NOT public facilities for this section's purposes: • a medical facility, including a nursing facility; • a publicly operated community residence (serves no more than 16 residents); • a child care institution, for children who receive foster care payments under Title IV-E, that accommodates no more than 25 children; • an institution certified as an ICF-ID for individuals with mental retardation or related conditions. H. Publicly Operated Community Residence A publicly operated community residence is a public residential facility (institution) with 16 beds or less, that provides some services beyond food and shelter such as social services, help with personal living activities or training in socialization and life skills. Occasional medical or remedial care may also be provided. Publicly operated community residences do NOT include the following facilities even though these facilities have 16 or fewer beds:

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 April 2021 Subchapter Subject Page ending with Page M0280 INSTITUTIONAL STATUS REQUIREMENTS M0280.200 3

• residential facilities located on the grounds of, or adjacent to, any large (more than 16 beds) institution; • correctional or holding facilities for individuals who are prisoners, who have been arrested or detained pending disposition of charges, or who are held under court order as material witnesses or juveniles

• educational or vocational training institutions that primarily provide an approved, accredited or recognized program to individuals residing there

• hospitals, nursing facilities, and intermediate care facilities for individuals with intellectual disabilities. NOTE: An individual residing in a public educational or vocational training institution for purposes of securing education or vocational training is NOT an inmate of a public institution, and therefore may be eligible for Medicaid, even though the educational or training facility is not a publicly operated community residence. I. Residential Institution An institution that does not meet the definition of a “medical facility.”

M0280.200 INSTITUTIONAL STATUS RULE

A. Introduction Federal regulations in 42 CFR 435.1008 prohibit federal financial participation (FFP) for individuals who are inmates of a public institution, with certain exceptions for patients in an IMD. Federal regulations limit FFP for individuals who are age 22 years or over but under age 65 years and who are patients in an institution for the treatment of mental diseases (IMD). An individual who is age 22 or over, but under age 65 and who is enrolled in Medicaid at the time of admission to an IMD may remain enrolled in Medicaid. The Department of Medical Assistance Services (DMAS) will coordinate with the Centers for Medicare and Medicaid Services (CMS) to ensure that no unauthorized FFP occurs. There is no prohibition on FFP for individuals under age 22 years if they are receiving inpatient psychiatric services.

NOTE: an ICF-ID is not an IMD.

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B. Procedures The policy and procedures for determining whether an individual is in an IMD are contained in subchapter M1430. The policy and procedures for determining whether an individual is an inmate of a public institution are contained in the following sections: • M0280.201 Individuals in Medical Facilities • M0280.202 Individuals in Residential Facilities • M0280.300 Inmate of A Public Institution • M0280.301 Who Is NOT An Inmate of A Public Institution • M0280.400 Procedures For Determining Institutional Status • M0280.500 Individuals Moving To or From Public Institutions • M0280.600 Departmental Responsibility. See Appendix 1 to this subchapter for an Institutional Status Quick Reference Guide.

M0280.201 INDIVIDUALS IN MEDICAL FACILITIES

A. Public or Private The public or private ownership or administration of a medical facility is irrelevant because a medical facility is not a public institution as defined in this subchapter. B. Individuals in IMDs The following individuals in public or private IMDs are NOT eligible for enrollment into Medicaid because they do not meet the institutional status requirement: • an individual who is age 22 or over, but under age 65; • an individual who is under age 22 who is NOT receiving inpatient psychiatric services in the IMD. An individual who is age 22 or over, but under age 65 and who is enrolled in Medicaid at the time of admission to an IMD may remain enrolled in Medicaid. The Department of Medical Assistance Services (DMAS) will coordinate with the Centers for Medicare and Medicaid Services (CMS) to ensure that no unauthorized FFP occurs.

1. Patient Under Age 22 or 65 Years and Older in an IMD An individual is in an IMD when he/she is admitted to live there and receive treatment or services provided there that are appropriate to his/her requirements. A patient in an IMD is an individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward maintenance, improvement, or protection of health or lessening of illness, disability, or pain. An individual is considered to be in an IMD from the date of admission to the IMD until discharge from the IMD. An individual who is age 65 or older and who is a patient in a public or private IMD meets the institutional status requirement for Medicaid. An individual who is under age 22, who is a patient in a public or private IMD and who is receiving inpatient psychiatric services in the IMD meets the institutional status requirement for Medicaid.

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 April 2021 Subchapter Subject Page ending with Page M0280 INSTITUTIONAL STATUS REQUIREMENTS M0280.201 4a

2. Patient Age 22- 65 Years An individual who is age 22 or over, but under age 65 and who is enrolled in a Medicaid at the time of admission to an IMD may remain enrolled in Medicaid. Do not cancel coverage. The Department of Medical Assistance Services (DMAS) will coordinate with the Centers for Medicare and Medicaid Services (CMS) to ensure that no unauthorized FFP occurs.

For an individual age 22 or over, but under age 65 and who is a patient residing in an IMD at the time of application, follow the policy and procedures in M1510.102 A.5.

3. Conditional Release From IMD A patient in an IMD who is transferred or discharged to a medical facility that is not an IMD, including a patient under conditional release or convalescent leave from the IMD, meets the institutional status requirement and may be eligible for Medicaid. C. ICF-ID

An ICF-ID is not an IMD. Therefore, an individual under age 65 who is in an ICF-ID meets the institutional status eligibility requirement. D. Residential Facilities With Certified Medical Beds Some institutions have both medical and residential sections. Individuals in the residential section (or beds) are residents of a residential facility. If the resident receives Medicaid Community-based Care (CBC) waiver services, use chapter M14 to determine the individual’s eligibility. If the resident does not receive Medicaid CBC, he is not in long-term care; use the Medicaid eligibility requirements for non institutionalized individuals. Individuals in the medical certified portion (or beds) of an institution are patients in a medical facility. Use chapter M14 in determining their Medicaid eligibility.

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E. Cross Reference If the individual has been, or is expected to be, in the medical facility or medical section of the facility for 30 or more consecutive days, the individual is receiving long-term care. Chapter 14 contains additional eligibility policy for individual in long term care.

M0280.202 INDIVIDUALS IN RESIDENTIAL FACILITIES

A. Institutions With Medical and Residential Sections Some institutions have both medical and residential sections. An individual in the medical certified section (or beds) of the institution is a patient in a medical facility. If the individual has been, or is expected to be, in the medical facility for 30 or more consecutive days, the individual is receiving long-term care. Go to chapter M14 to determine the individual's eligibility. An individual in the residential portion (or beds) of the institution is a resident of a residential facility. Use this subchapter to determine the resident's institutional status. B. Private Residence or Group Home An individual who lives in a private residence in the community that is not an institution (it is an establishment that provides food, shelter and some services to three or less persons unrelated to the proprietor) is not living in an institution. A group home that has a capacity of no more than three residents is not an institution. C. Private Residential Facility A resident of any age in a private residential facility meets the institutional status requirement for Medicaid UNLESS the individual is incarcerated, as defined below. D. Public Residential Facility A resident of any age in a PUBLIC residential facility meets the institutional status requirement for Medicaid UNLESS: • the public residential facility has more than 16 beds, or • the individual is an inmate - an incarcerated adult or a juvenile in detention - as described in section M0280.300 below, and is not an individual listed in M0280.301 below.

Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M02 October 2025 Subchapter Subject Page ending with Page M0280 INSTITUTIONAL STATUS REQUIREMENTS M0280.300 6

M0280.300 INMATE OF A PUBLIC INSTITUTION

A. Policy Inmates of public institutions fall into three groups: • individuals living in ineligible public institutions; • incarcerated adults; and • juveniles in detention. An individual is an inmate of a public institution from the date of admission to the public institution until discharge, or from the date of actual incarceration in a prison, county or city jail or juvenile detention facility and considered incarcerated until permanent release, bail, probation or parole. An offender sentenced to the Community Corrections Alternative Program (CCAP) is confined in a DOC facility is not considered released, and is not a parolee or probationer.

Incarcerated individuals (adults and juveniles) who are hospitalized can be eligible for Medicaid payment limited to services received during an inpatient hospitalization, provided they meet all other Medicaid eligibility requirements. An individual released from jail under a court probation order due to a medical emergency is NOT an inmate of a public institution because he is no longer incarcerated. B. Public Residential Facility Residents An individual who lives in a public residential facility that serves more than 16 residents is NOT eligible for Medicaid.

A public residential facility that does not meet the definition of a “publicly operated community residence” in section M0280.100 above, is an “ineligible public institution.” The following are ineligible public institutions: • public residential institutions with more than 16 beds

• residential facilities located on the grounds of, or adjacent to, a public institution with more than 16 beds:

C. Incarcerated Adults Offenders can be eligible for Medicaid payment limited to services received during an inpatient hospitalization of 24 hours or longer. Offenders include: • individuals under the authority of the Department of Corrections (DOC)

• individuals held in regional and local jails, including those on work release

Individuals are not eligible for full benefit Medicaid coverage while they are living in a correctional facility, regional or local jail. For a juvenile in a facility, refer to M0280.300.D below and Appendix 1.

Virginia Medical Assistance Eligibility M02 October 2025 Subchapter Subject Page ending with Page M0280 INSTITUTIONAL STATUS REQUIREMENTS M0280.300 7

An offender who transfers temporarily to a halfway house, residential re- entry center (RRC), or residential treatment facility prior to a formal probation release order is still an inmate of a public institution and can only be eligible for Medicaid payment limited to services received during an inpatient hospitalization. Note: some drug or alcohol rehabilitation centers may be referred to as a “halfway house”; the eligibility worker should confirm the individual is not an inmate or incarcerated. Once an incarcerated individual who is enrolled in Medicaid is released from the correctional facility, he may be eligible for all benefits available under the Medicaid covered group he meets. D. Juveniles in Detention In determining whether a juvenile (individual under age 21 years) is incarcerated, the federal Medicaid regulations distinguish between the nature of the detention, pre- and post- disposition situations, and types of facilities. 1. Held for Care, Protection or Best Interest A juvenile who is in a detention center due to care, protection or in the best interest of the child can be eligible for full benefit Medicaid or Family Access to Medical Insurance Security (FAMIS) coverage. A child who is incarcerated in a Department of Juvenile Justice Facility is considered to be temporarily absent from home. 2. Held for Criminal Activity a. Prior to Court Disposition

The following juveniles can be eligible for Medicaid payment limited to services received during an inpatient hospitalization. • juvenile who is in a detention center due to criminal activity • juvenile who has criminal charges pending (no court disposition has been made) who is ordered by the judge to go to a treatment facility, then come back to court for disposition when the treatment is completed

b. After Court Disposition Juveniles who are on probation with a plan of release which includes residence in a detention center are inmates of a public institution. If they go to any of the secure juvenile correctional facilities, they are inmates of a public institution and can only be eligible for Medicaid payment limited to inpatient hospitalization. A list of secure detention facilities in Virginia is available on the Department of Juvenile Justice’s web site at Juvenile- Detention-Centers-and-Homes-Contacts.pdf (virginia.gov). Because this list is subject to change, consult the list whenever eligibility must be evaluated for a juvenile who is reportedly in a detention center. If the juvenile goes to a non-secure group home, he can be eligible for Medicaid or FAMIS because a non-secure group home is not a detention center.

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3. Type of Facility The type of facility, whether it is residential or medical and whether it is public or private must be determined. A juvenile is not eligible for full- benefit Medicaid if he/she is a resident of an ineligible public residential facility. He can be eligible for Medicaid coverage limited to inpatient hospitalization if he is admitted to a medical facility for inpatient services. EXAMPLE #1: A juvenile is detained for criminal activity. He is placed on probation with specific conditions of release, including a stay of 30 days or longer at a detention facility. The facility is identified as a juvenile detention center, not a treatment center. Upon release from the detention center, he will be placed on probation and will live with his mother. Because of the nature of his custody (criminal activity) and the nature of the facility (a detention center is a public institution) he is not eligible for full-benefit Medicaid/FAMIS during the period of incarceration, but can be eligible for Medicaid coverage for inpatient hospitalization. After he is released from the detention center and while he is on probation, he is NOT an inmate of a public institution and may be eligible for full benefit Medicaid/FAMIS.

M0280.301 WHO IS NOT AN INMATE OF A PUBLIC INSTITUTION

A. Who Is NOT An Inmate of a Public Institution An individual is NOT an inmate of a public institution if: • he is in a public educational or vocational training institution for purposes of securing education or vocational training OR • he is in a public institution for a temporary period pending other arrangements appropriate to his needs.

B. Educational or Vocational Institution An individual residing in a public educational or vocational training institution for purposes of securing education or vocational training is NOT an inmate of a public institution, and therefore may be eligible for Medicaid. C. Temporary Stay An individual residing in a public institution for a temporary period pending other arrangements appropriate to his needs is NOT an inmate of a public institution, and therefore may be eligible for Medicaid. D. Admitted Under TDO An individual over age 18 who was arrested or detained, but did not reside overnight in a prison or jail before being admitted to a public institution under a temporary detention order (TDO) is NOT an inmate of a public institution because he did not reside in the jail or prison immediately before admission to the treatment facility. E. Arrested Then Admitted to Medical Facility An individual who, after arrest but before booking, is escorted by police to a hospital for medical treatment and held under guard is NOT an inmate of a public institution and may be eligible for Medicaid. He is not an inmate of a public institution because he did not reside in a jail, prison or secure detention facility immediately prior to admission to the medical facility. F. Inmate Out On Bail An inmate in a prison or jail prior to arraignment, conviction, or sentencing is not eligible for Medicaid unless he/she is out on bail or released on his/her own recognizance.

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G. Probation, Parole, Conditional Release, Furlough An individual released from prison or jail on probation, parole, or release order, with a condition of: • home arrest • community services • outpatient treatment • inpatient treatment (not inpatient hospitalization) is not an inmate of a public institution and may be eligible for Medicaid. An individual released from prison or jail under a court order due to a medical emergency, medical treatment, or pregnancy is NOT an inmate of a public institution and may be eligible for Medicaid. An individual released from a correctional facility on furlough, for example during a pregnancy, is not an inmate of a public institution while furloughed and may be eligible for Medicaid. For an offender sentenced to the DOC Community Corrections Alternative Program (CCAP) refer to M0280.140.A H. Juvenile in Detention Center Due to Care, Protection, Best Interest A minor in a juvenile detention center prior to disposition (judgment) due to care, protection or the best interest of the child (e.g., Child Protective Services [CPS]), if there is a specific plan for that child that makes the detention center stay temporary, is NOT an inmate of a public institution and may be eligible for Medicaid. This could include a juvenile awaiting placement but who is still physically present in the juvenile detention center. I. Juvenile on Probation in Secure Treatment Center A minor placed on probation by a juvenile court and placed in a secure treatment facility is NOT an inmate of a public institution and may be eligible for Medicaid.

J. Juvenile On Conditional Probation A minor placed on probation by a juvenile court with, as a condition of probation, treatment in a psychiatric hospital or a residential treatment center, or treatment as an outpatient may be eligible for Medicaid. However, if the minor is NOT on probation but is ordered to the treatment facility, he remains an inmate of a public institution and not eligible for full benefit Medicaid. He may be eligible for Medicaid coverage limited to inpatient hospitalization. K. Juvenile On Probation in Secure Treatment Center A minor placed on probation by a juvenile court and placed in a secure treatment facility may be eligible for Medicaid.

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M0280.500 INDIVIDUALS MOVING TO OR FROM PUBLIC INSTITUTIONS

A. Moves To Public Institution If a currently eligible individual enters a public institution, a partial review must be completed to determine if he continues to meet institutional status requirements for continued coverage, as well as all other Medicaid eligibility requirements. Outstanding bills for covered medical services incurred prior to his admission and during his Medicaid coverage period will be paid. B. Moving From Public Institution Although a person may not be eligible for Medicaid while living in a specified public institution or part thereof, he may apply for such assistance as a part of prerelease planning. If he is found eligible (except for institutional status), do not enroll until he leaves the institution to live elsewhere. C. Resident Admitted to Medical Facility A resident of an ineligible public institution may be eligible for Medicaid coverage limited to inpatient hospitalization when admitted to a medical institution (general hospital) for inpatient care.

M0280.600 DEPARTMENTAL RESPONSIBILITY

A. Incarcerated Individuals The Cover Virginia Incarcerated Unit (CVIU) is responsible for case management of incarcerated individuals with active Medicaid coverage enrolled in aid categories 108 and 109, regardless of the facility where the offender resides. See M0140 for additional information. B. All Other Institutions Local social services departments are responsible for the Medicaid eligibility determination and enrollment of individuals in institutions EXCEPT for incarcerated individuals in aid category 108 or 109. The local DSS agency in the Virginia locality where the individual last resided outside of an institution is the responsible DSS agency. If the individual resided outside of Virginia immediately before admission to the institution, the responsible local DSS is the DSS agency serving the locality where the institution is located. When a local department carries responsibility for eligibility determination and enrollment of an individual living in an institution, the department is also responsible for: • advising the institution of the individual's eligibility for Medicaid and enrollment in the program;

• submitting a DMAS-225 form to the institution to indicate the patient’s eligibility and availability of current patient pay information in the Medicaid Management Information System (MMIS), if applicable; and

• seeing that the Medicaid card is forwarded to the institution for the enrollee’s use.

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Institutional Status Quick Reference Guide

Placement or living arrangement Full Benefit Inpatient Only Ineligible

IMDs

age 22-65, Medicaid open at time of admission Medicaid Remains Open

age 22-65, Medicaid not open at time of admission

X

under age 22 and receiving inpatient psychiatric

treatment X

age 65 and older X

conditional release X

ICF-ID – all ages X

Residential

medical section X

private group home with no more than 3 beds X

private residential

X

public residential

less than 16 beds

X

16 or more beds

X

educational or vocational Institution X

Correctional Facilities

adults

DOC

X

regional jails

X

local jails

X

juveniles (DJJ) in secure facilities

held for care, protection, best, interest X

on probation X

held for criminal activity

X

juvenile on probation placed in psychiatric

hospital or residential treatment center

X

juvenile not on probation ordered to treatment

in a psychiatric hospital/residential treatment facility

X

Adult arrested, but not held in corrections

in medical facility prior to correctional facility

placement X

in regional or local jail prior to medical facility

X

TDO

not in jail prior to hospitalization X

in jail prior to hospitalization

X

Individual out on bail/released on own recognizance X

Adult on probation, parole, conditional release, or furlough X

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Institutions for the Treatment of Mental Diseases in Virginia

Facility Location State Facilities Catawba Hospital*

Central State Hospital Petersburg Commonwealth Center (for children and adolescents) Staunton Eastern State Hospital* Williamsburg Northern Virginia State Mental Health Hospital Falls Church Piedmont Geriatric Hospital*

Southern Virginia Mental Health Institute Danville Southwestern Virginia Mental Health Institute Marion Western State Hospital Staunton *Not covered by Medicaid Private Freestanding Psychiatric Hospitals Dominion Hospital Falls Church Kempsville Center for Behavioral Health Norfolk Keystone Newport News LLC Newport News North Spring Behavioral Health Inc. Leesburg Poplar Springs Hospital Petersburg Virginia Beach Psychiatric Center Virginia Beach

Contact VaMedicaidQuestions@dmas.virginia.gov for guidance regarding other types of facilities, such as crisis stabilization units, psychiatric residential facilities, or Addiction and Recovery Treatment Services (ARTS) facilities.

CHAPTER M03

COVERED GROUPS REQUIREMENTS

M03 Table of Contents Changes

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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M03 June 2016 Subchapter Subject

Page M03 COVERED GROUPS REQUIREMENTS TOC i

TABLE OF CONTENTS

M03 COVERED GROUPS REQUIREMENTS

SUBCHAPTER Page

GENERAL RULES & PROCEDURES .................... M0310.000

General Principles of Covered Groups .......................... M0310.001 ..............................1 List of Medicaid Covered Groups .................................. M0310.002 ............................2a Definitions of Terms ........................................................ M0310.100 ..............................5 Cover Sheet for Expedited Referral to DDS.................. Appendix 1 ..............................1 DDS Regional Offices ...................................................... Appendix 2 ..............................1

AGED, BLIND & DISABLED GROUPS .................. M0320.000

Aged, Blind & Disabled General Policy Principles ....... M0320.001 ............................... 1 ABD Cash Assistance Groups ......................................... M0320.100 ............................... 2 Protected Covered Groups .............................................. M0320.200 ............................... 5 ABD with Income < 80% FPL ........................................ M0320.300 ............................. 23 MEDICAID WORKS ...................................................... M0320.400 ............................. 24 300% of SSI Income Limit Groups ................................ M0320.500 ............................. 30 Medicare Savings Plan (MSP) Groups .......................... M0320.600 ............................. 38 Medically Needy Groups ................................................. M0320.700 ............................. 53

FAMILIES & CHILDREN GROUPS ....................... M0330.000

General Policy Principles ................................................ M0330.001 ..............................1 Families & Children Categorically Needy Groups ....... M0330.100 ..............................2 Low Income Families with Children (LIFC) ................. M0330.200 ..............................9 Child Under Age 19 (FAMIS Plus)................................. M0330.300 ............................10 Pregnant Women & Newborn Children ........................ M0330.400 ............................13 300% of SSI Income Limit Groups ................................ M0330.500 ............................16 Plan First – Family Planning Services ........................... M0330.600 ............................24 Breast and Cervical Cancer Prevention Treatment Act (BCCPTA) ........................................................................... M0330.700 ............................26 Families & Children Medically Needy Groups ............. M0330.800 ............................29

CHAPTER M03 MEDICAID COVERED GROUPS

SUBCHAPTER 10

GENERAL RULES & PROCEDURES

M0310 Changes Page 2 of 2

Changed With Effective Date Pages Changed TN #DMAS-36 10/1/25 Page 30a ; Appendix 1 TN #DMAS-35 7/1/25 Pages 5 and 28, Appendix 1 TN #DMAS-33 10/1/24 Page 28 TN #DMAS-29 10/1/23 Page 5 TN #DMAS-26 1/1/23 Pages 2, 28b Appendix 1 TN #DMAS-24 7/1/22 Page 36 Page 37 is a runover page. TN #DMAS-23 4/1/22 Pages 2, 5, 6, 6a TN #DMAS-22 1/1/22 Page 28 TN #DMAS-20 7/1/21 Page 6 Pages 5 and 5a are runover pages. TN #DMAS-18 1/1/21 Table of Contents, page ii Pages 26, 27 Appendix 1 was removed. Appendix 2 was renumbered to Appendix 1. TN #DMAS-17 7/1/20 Page 7 Pages 8 and 9 are runover pages. TN #DMAS-15 1/1/20 Pages 29, 30 TN #DMAS-14 10/1/19 Pages 24, 26, 27, 40 TN #DMAS-13 7/1/19 Pages 24 Page 24a is a runover page. TN #DMAS-12 4/1/19 Pages 8, 9, 13 TN #DMAS-10 10/1/18 Table of Contents, page ii Pages 1-4 Page 40 was added. TN #DMAS-9 7/1/18 Page 35 Appendix 2, Page 1 TN #DMAS-8 4/1/18 Page 9 TN #DMAS-7 1/1/18 Pages 34, Appendix 2, page 1 TN #DMAS-5 7/1/17 Pages 13, 37, 38 TN #DMAS-4 4/1/17 Pages 24, 30a Page 23 is a runover page. Page 24a was added as a runover page.

M0310 Changes Page 1 of 2

TN #DMAS-3 1/1/17 Pages 8, 13, 28b TN #DMAS-2 10/1/16 Pages 4, 7, 29 Page 30 is a runover page. Appendix 2, page 1 TN #DMAS-1 6/1/16 Table of Contents, page ii Pages 13, 26, 28 Appendix 2, page 1 TN #100 5/1/15 Table of Contents, pages i, ii Pages 11, 23, 28b, Pages 27a-27c were renumbered to 28-28a for clarity. Page 10 is a runover page. Appendix 2 UP #10 5/1/14 Pages 29, 30 TN #99 1/1/14 Pages 6, 7, 21, 24, 25, 27a, 39 TN #98 10/1/13 Pages 2, 4, 27a, 27b, 28, 35, 36, 39 UP #9 4/1/13 Pages 24-27 Appendix 2 TN #97 9/1/12 Table of Contents, page i Pages 1-5a, 10-13 Pages 23, 28, 29, 30a, 31 Pages 33, 36, 38, 39 UP #7 7/1/12 Table of Contents, page ii Pages 23, 26, 27 Appendices 1-3 were removed. Appendices 3 and 4 were renumbered and are now Appendices 1 and 2, respectively. TN #96 10/1/11 Appendix 4 TN #95 3/1/11 Pages 30, 30a TN #94 9/1/10 Pages 21-27c, 28 TN #93 1/1/10 Page 35 Appendix 5, page 1 Update (UP) #2 8/24/09 Table of Contents Page 39 TN #91 5/15/09 Pages 23-25 Appendix 4, page 1 Appendix 5, page 1

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TABLE OF CONTENTS

M03 MEDICAID COVERED GROUPS

M0310.000 GENERAL RULES & PROCEDURES Section Page

General Principles of Medicaid Covered Groups .............................. M0310.001 ................ 1

List of Medicaid Covered Groups ........................................................ M0310.002 ................ 2a

Definitions of Terms .............................................................................. M0310.100 ................ 5

ABD .................................................................................................. M0310.101 ................ 5

Adoption Assistance ........................................................................ M0310.102 ................ 5

AFDC ................................................................................................ M0310.103 ................ 6

AG .................................................................................................... M0310.104 ................ 6a

Age & Aged ...................................................................................... M0310.105 ................ 7

*BCCPTA .......................................................................................... M0310.133 ................ 39

Blind .................................................................................................. M0310.106 ................ 7

Caretaker-Relative .......................................................................... M0310.107 ................ 8

Categorically Needy (CN) ............................................................... M0310.108 ................ 10

Covered Group ................................................................................ M0310.109 ................ 10

Child ................................................................................................. M0310.110 ................ 11

Dependent Child .............................................................................. M0310.111 ................ 11

Disabled ............................................................................................ M0310.112 ................ 21

Reserved ............................................................................................ M0310.113 ................ 28b

Families & Children (F&C) ........................................................... M0310.114 ................ 28b

Foster Care ....................................................................................... M0310.115 ................ 29

*HIPP Program ............................................................................... M0310.135 ................ 39

* out of numerical order

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Hospice ............................................................................................. M0310.116 ................ 30a

Institution ........................................................................................ M0310.117 ................ 31

LIFC ................................................................................................. M0310.118 ................ 31

*MAGI Adult ................................................................................... M0310.136 ................ 40

Medically Needy (MN) .................................................................... M0310.120 ................ 32

Medicare Beneficiary ...................................................................... M0310.121 ................ 32

OASDI .............................................................................................. M0310.122 ................ 34

Parent ............................................................................................... M0310.123 ................ 35

Pregnant Woman ............................................................................. M0310.124 ................ 35

QDWI ............................................................................................... M0310.125 ................ 36

QI . .................................................................................................... M0310.126 ................ 37

QMB ................................................................................................. M0310.127 ................ 37

RSDI ................................................................................................. M0310.128 ................ 37

SLMB ................................................................................................ M0310.129 ................ 38

SSI ..................................................................................................... M0310.130 ................ 38

State Plan ......................................................................................... M0310.131 ................ 38

TANF ................................................................................................ M0310.132 ................ 39

VIEW PARTICIPANT ................................................................... M0310.134 ................ 39

* out of numerical order

Appendices

Disability Determination Services (DDS)

Contact Information ....................................................... Appendix 1................................ 1

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M0310.000 GENERAL RULES & PROCEDURES

M0310.001 GENERAL PRINCIPLES OF MEDICAID COVERED GROUPS

A. Introduction An individual who meets all the non-financial eligibility requirements in Chapter M02 and who is not an ineligible person listed in M0210.100, must meet a Medicaid covered group in order to be eligible for Medicaid. Chapter M03 explains in detail each of the Medicaid covered groups and how to determine if an individual meets the covered group requirements. The Medicaid covered groups are divided into two classifications: the categorically needy (CN) and the medically needy (MN). CN individuals meet all Medicaid non-financial requirements (see M02) and the definition for a covered group. MN individuals meet all Medicaid non-financial requirements and resource requirements, but have income in excess of the Medicaid limits. MN individuals may be placed on a spenddown (SD). The covered groups are also divided into Aged, Blind and Disabled (ABD) and Families & Children (F&C) covered groups. Within some covered groups are several definitions of eligible individuals. Some individuals may meet the requirements of more than one group. The agency must verify the individual meets a definition for a covered group and the group’s financial requirements. B. Refugees If the Medicaid applicant is a refugee, first determine if the refugee meets the requirements in a Medicaid covered group using the policy and procedures in this chapter. If the refugee does not meet the requirements of a Medicaid covered group, the refugee is not eligible for Medicaid under a Medicaid covered group. Go to the Refugee Resettlement Program Manual Volume XVIII to determine the refugee's eligibility for assistance under the Refugee Resettlement Program. The requirements for the Refugee Other (Cash Assistance) and Refugee Medicaid Other and Refugee Medicaid Unaccompanied Minors programs are found in another manual: the Refugee Resettlement Program Manual Volume XVIII. C. Covered Group Information This subchapter contains the general principles for determining if the individual meets a definition and covered group(s). • M0310.002 contains the list of Covered Groups; • M0310.100 - M0310.134 contains the Definitions; • M0320 contains the detailed policy and covered group requirements for the Aged, Blind and Disabled Groups; • M0330 contains the detailed policy and covered group requirements for the Families & Children Groups, and includes the Modified Adjusted Gross Income (MAGI) Adults covered group, effective January 1, 2019.

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M0310.002 LIST OF MEDICAID COVERED GROUPS

Group and Description Mandatory = required under federal regulations Optional = State Plan Option Categorically Needy (CN) Medically Needy(MN)

Aged, Blind, or Disabled (ABD) SSI – mandatory X

AG – mandatory X

Protected – mandatory X

≤ 80% FPL – optional X

≤ 300% of SSI – optional (institutionalized only) X

Medicaid Works – optional X

Medicare Savings Programs (QMB, SLMB, QI, QDWI) --all mandatory X

Aged Blind Disabled --all optional

X

Families & Children (F&C)

` IV-E Foster Care or Adoption Assistance - mandatory X

LIFC Parent/Caretaker Relatives - mandatory X

Pregnant woman/newborn child – mandatory X mandatory X optional Child under age 19 – mandatory X

BCCPTA – optional X

Plan First – optional X

Child under 18 – optional

X Individuals under age 21, Adoption Assistance Children with Special Needs for Medical or Rehabilitative Care Adoption Assistance X optional X optional Former Foster Care Children under age 26 – mandatory (effective January 1, 2014) X

MAGI Adults – optional (effective January 1, 2019) X

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A. Categorically Needy (CN) The ABD, and F&C (including the MAGI Adults) covered groups in the CN classification are listed below. 1. ABD Groups a. SSI cash assistance recipients who meet more restrictive Medicaid resource eligibility requirements. b. Auxiliary Grants (AG) cash assistance recipients. c. ABD individuals who are institutionalized in a medical institution, who meet all Medicaid eligibility requirements and have income before exclusions that is less than 300% of the SSI individual payment limit. d. ABD individuals who receive or are applying for Medicaid-approved community-based care services, who meet all Medicaid eligibility requirements and who have income before exclusions that is less than 300% of the SSI individual payment limit. e. ABD individuals who have a “protected” status: 1) individuals who received OAA, AB, APTD, or ADC as of August 1972, and meet specified requirements. 2) individuals who are former SSI/AG recipients and meet specified requirements. 3) individuals who are widows(ers) and meet specified requirements. 4) individuals who are classified as 1619(b) by Social Security and meet specified requirements. 5) individuals who are adult disabled children and meet specified requirements

f. Hospice--a hospice patient is a person who is terminally ill and has elected to receive hospice care; if the individual is not aged, presume that the individual is disabled. g. Qualified Medicare Beneficiaries (QMBs). h. Special Low-income Medicare Beneficiaries (SLMBs). i. Qualified Disabled and Working Individuals (QDWIs). j. Qualified Individuals (QIs). k. ABD With Income  80% Federal Poverty Limit (ABD 80% FPL). l. MEDICAID WORKS.

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2. F&C Groups, Including the MAGI Adult Group a. foster care children receiving IV-E and adoption assistance children receiving IV-E. b. Low income families with children (LIFC) eligible children, parents, non-parent caretaker-relatives, and EWBs (essential to the well-being applications submitted prior to October 1, 2013). c. Children under age 1 born to mothers who were eligible for and receiving MA at the time of the child's birth. d. Individuals under age 21 1. Title IV-E Eligible Foster Care children who do not receive a Title IV-E maintenance payment 2. Non-IV-E Foster Care 3. Juvenile Justice Department children 4. Non-IV-E Adoption Assistance children 4. Individuals in an ICF or ICF-MR e. Former foster care children under age 26 years (Effective January 1, 2014) f. Pregnant women g. Plan First; Family Planning Services h. Children under age 19 years i. Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA). Women and men screened and diagnosed with breast or cervical cancer under the Centers for Disease Control and Prevention's (CDC) Breast and Cervical Cancer Early Detection Program (BCCEDP) and eligible to receive Medicaid under the BCCPTA.

j. MAGI Adults, 19 – 64 years of age (Effective January 1, 2019)

B. Medically Needy (MN) The ABD and the F&C covered groups in the MN classification are listed below. 1. ABD Groups a. Aged - age 65 years or older. b. Blind - meets the blind definition c. Disabled - meets the disability definition. d. Individuals who received Medicaid in December 1973 as AB/APTD- related MN and who continue to meet the December 1973 eligibility requirements.

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2. F&C Groups a. Children under age 18 b. Children under age 1

c. Pregnant Women d. Children with Special Needs for Medical or Rehabilitative Care

e. Individuals under age 21 E. Refugees “Refugees” are a special group of individuals who have an alien status of “refugee” and are eligible for Medicaid under a different federal funding source. Virginia receives full federal funding with no state matching funds for the medical assistance provided to these individuals during the first 4 months they are in the U.S who entered as of 10/1/2021. There are two aid categories (ACs) for this group. AC 078 is used for Refugee Other and Refugee Medicaid Other and AC 079 is used for Refugee Medicaid Unaccompanied Minors. The policy and procedures used to determine whether an individual is eligible in this group are found in the Refugee Resettlement Program Manual, Volume XVIII.

M0310.100 DEFINITION OF TERMS

A. Introduction The terms used in the covered groups policy and procedures and the procedures for determining if an individual meets a definition are stated in sections M0310.101 through 131 below.

M0310.101 ABD

A. ABD Definition "ABD" is the short name used to refer to aged, blind or disabled individuals. B. Procedures See the following sections for the procedures to use to determine if an individual meets an ABD definition: • M0310.105 Age and Aged • M0310.106 Blind • M0310.112 Disabled

M0310.102 ADOPTION ASSISTANCE

A. Definition Adoption Assistance is a Title XX of the Social Security Act social services program that provides cash assistance and/or social services to adoptive parents who adopt "hard to place" foster care children who were in the custody of a local department of social services or a child placing agency licensed by the state of Virginia. 1. Residing in Virginia Adoption assistance children are children who reside in Virginia who are adopted under a Title IV-E or Non-IV-E (state-local) adoption assistance agreement with a department of social services or in conjunction with a child- placing agency.

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2. Special Medical Needs Children with special needs for medical or rehabilitative care adopted under a Non IV- E Adoption Assistance agreement with a Virginia local department of social services or a Virginia private, non-profit child placement agency in conjunction with a local department of social services, in accordance with policies established by the State Board of Social Services are considered to be residing in Virginia.

a. Documentation must indicate that the child has special needs for medical or rehabilitative care One of the following documents must indicate the child’s special needs for medical or rehabilitative care: • an adoption assistance agreement specifying that the child has a special need for medical or rehabilitative care; the agreement does NOT need to specify a particular diagnosis or condition.

• an amendment to the adoption assistance agreement specifying that the child has a special need for medical or rehabilitative care.

• a signed letter on official letterhead from the state that facilitated the adoption assistance agreement confirming that the child has a special need for medical or rehabilitative care.

b. Virginia Medicaid coverage for children with special needs for medical or rehabilitative care Medicaid coverage is to be provided to any child who has been determined to be a Non-IV-E Adoption Assistance Child with special needs for medical or rehabilitative care for whom there is in effect an adoption assistance agreement between a local Virginia department of social services (LDSS) or a Virginia child-placing agency and an adoptive parent(s). Virginia Medicaid coverage MAY be provided to a child with special needs for medical or rehabilitative care for whom there is in effect an adoption assistance agreement between another state’s child-placing agency and an adoptive parent(s) IF the other state reciprocates with Virginia per the Interstate Compact on Adoption and Medical Assistance (ICAMA).

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3. Verification a. Adoption assistance agreement with Virginia agency A child’s status as an adoption assistance child is verified by the LDSS agency foster care/adoption assistance worker. Documentation of the child’s IV-E or Non-IV-E adoption assistance eligibility must be part of the Medicaid case record. Verification of a child’s status as a Virginia IV-E, Non-IV-E, or adoption assistance child with special needs for medical or rehabilitative care is obtained through the local agency’s Service Programs Division. b. IV-E adoption assistance agreement with another state When the IV-E adoption assistance agreement is with another state and the IV-E child resides in Virginia, verification of the child’s status as a Title IV-E adoption assistance recipient is verified through the Deputy Compact Administrator, Adoption Unit, Division of Family Services, Virginia Department of Social Services. c. Non-IV-E adoption assistance agreement with another state Verification of the child’s Non-IV-E adoption assistance status with another state, and the state’s reciprocal agreement under the Interstate Compact on Adoption and Medical Assistance (ICAMA), is obtained through the Deputy Compact Administrator, Adoption Unit, Division of Family Services, Virginia Department of Social Services. If the state that signed the non-IV-E adoption assistance agreement does NOT reciprocate Non-IV-E adoption assistance eligibility with Virginia, then the Non-IV-E Adoption Assistance child is not eligible for Virginia Medicaid in the Adoption Assistance classification of the “Individuals Under Age 21” covered group.

M0310.103 AFDC

A. Aid To Families With Dependent Children (AFDC) AFDC is the short name of the Aid to Families With Dependent Children cash assistance program that was operated in Virginia prior to the February 1, 1997, implementation of TANF (Temporary Assistance to Needy Families). It was a federally funded assistance program under Title IV-A of the Social Security Act. In Virginia, AFDC was replaced by TANF on February 1, 1997. B. Procedure AFDC is defined here because of the occasional references in Medicaid policy to the AFDC program that was in effect on July 16, 1996. There are no current recipients of AFDC because the AFDC program no longer exists.

M0310.104 AG

A. Auxiliary Grants (AG) “AG” is the short name for the Auxiliary Grants Program. AG is Virginia's assistance program that supplements the federal Supplemental Security Income (SSI) assistance program. AG is Virginia's "State Supplementation of SSI." AG is available only to ABD financially eligible individuals who reside in licensed Adult Care Residences (ACRs). B. Procedure Check the local agency records of AG recipients. If the individual is eligible for and receiving an AG payment, he is an AG recipient for Medicaid purposes.

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M0310.105 AGE and AGED

A. Age “Age” is the individual's age reached on the anniversary of birth. If the year but not the month and day of the individual's birth is known, July 1 is assigned for both eligibility determination and enrollment. For covered groups with a maximum age requirement, an individual meets the age requirement for the month of his birthday unless his birthday falls on the first day of the month. Examples: Gracie has been enrolled in the Child Under 19 covered group. She turns 19 on August 15. She continues to be eligible in the Child Under 19 covered group through the month of August. Oliver has been enrolled in the MAGI Adults covered group. He turns 65 on July 1. Therefore, he is no longer eligible for the MAGI Adults covered group for the month of July. B. Aged “Aged,” means age 65 years or older. C. Procedures For individuals under age 21, accept the date of birth provided on the application/redetermination form. No verification is required. For aged individuals, verify the individual’s age by Social Security records or documents in the individual’s possession. Acceptable documents include: • birth certificate or notification of birth; • hospital or physician’s record; • court record of adoption; • baptismal record; • midwife’s record of birth; • form VS95 from state Bureau of Vital Statistics; or • marriage records.

M0310.106 BLIND

A. Definition The Medicaid blindness definition is the same as that of the Supplemental Security Income (SSI) blindness definition. Blindness is defined by using one of two criteria. The first criteria indicates that blindness is defined as having best corrected central visual acuity of 20/200 or less in the better eye. The second criteria indicates that blindness is defined as the contraction of the visual field in the better eye with the widest diameter subtending an angle around the point of fixation no greater than 20 degrees.

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B. Procedures An SSI recipient who receives SSI as blind meets the blindness definition for Medicaid. Verify the SSI recipient’s SSI eligibility via SVES (State Verification Exchange System). Virginia no longer maintains a central registry of individuals who have been certified as blind or visually impaired. For an individual who alleges blindness or a visual impairment but does not receive SSI or Social Security Disability Income benefits, refer to section M0310.112 B to establish whether or not the individual requires a referral to the Disability Determination Services (DDS). If the individual requires a determination of blindness, refer the individual to the DDS using the procedure in M0310.112 E. 1.

M0310.107 CARETAKER-RELATIVE

A. Definitions 1. Caretaker- relative A "caretaker-relative" is an individual who is not a parent, but who • is a relative, of a specified degree, of a dependent child (as defined in M0310.111) and • is living with and assuming continuous responsibility for day to day care of the dependent child (as defined in M0310.111) in a place of residence maintained as his or their own home. A caretaker-relative is also referred to as a “non-parent caretaker” to distinguish the caretaker-relative from the parent. 2. Specified Degree A relative of specified degree of the dependent child is • any blood relative, including those of half-blood and including first cousins, nephews or nieces and persons of preceding generations as denoted by prefixes of grand, great, or great-great; • a stepfather, stepmother, stepbrother, and stepsister; • a relative by adoption following entry of the interlocutory or final order, whichever is first; the same relatives by adoption as listed above: including first cousins, nephews or nieces and persons of preceding generations as denoted by prefixes of grand, great, or great-great, and stepfather, stepmother, stepbrother, and stepsister. • spouses of any persons named in the above groups even after the marriage is terminated by death or divorce. Neither severance of parental rights nor adoption terminates the relationship to biological relatives.

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B. Procedures 1. Relationship The relationship as declared on the application/redetermination form is used to determine the caretaker-relative’s relationship to the child. No verification is required. 2. Child Living in the Home A child’s presence in the home as declared on the application/ redetermination form is used to determine if the child is living in the home with a parent or a caretaker-relative. No verification is required. 3. Parent and Stepparent in Home The presence of a parent in the home does not impact a stepparent’s eligibility in the Low Income Families with Children (LIFC) covered group. Both the parent and stepparent may be eligible in the LIFC covered group. See M0330.300. 4. Parent and Other Relative in Home When a parent is in the home, no relative other than a stepparent can be eligible for Medicaid in the LIFC covered group. See M0330.300. 2. Caretaker- Relative Living in the Home A caretaker-relative who is absent from the home is considered living with a child in the household if the absence is temporary and the caretaker-relative intends to return home when the purpose of the absence (such as military service, vacation, education, medical care or rehabilitation) is complete.

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M0310.108 CATEGORICALLY NEEDY (CN)

A. CN Definition "CN" is the short name for "categorically needy." CN is a federal classification of a Medicaid covered group. The CN covered groups include both the mandatory categorically needy groups listed in the federal Medicaid regulations as well as the optional groups Virginia has chosen to cover in the Medicaid State Plan. B. Procedures See subchapter M0320 for the policy and procedures to use to determine if an individual meets an ABD CN covered group. See subchapter M0330 for the policy and procedures to use to determine if an individual meets a F&C CN covered group.

M0310.109 COVERED GROUP

A. Definition The federal Medicaid law and the State Plan for Medicaid describe the groups of individuals who may be eligible for Medicaid benefits. These groups of individuals are the Medicaid covered groups. The individuals in the covered groups must meet specified definitions, such as age or disability, and other specified requirements such as living in a medical facility. The covered groups are classified in Virginia as CN and MN. The covered groups are divided into the ABD and F&C covered groups for financial eligibility purposes. B. Procedure The covered groups are listed in section M0310.002. The detailed requirements of the covered groups are in subchapters M0320 and M0330.

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M0310.110 CHILD

A. Definition The definition of “child” that is applicable depends on the individual’s covered group. 1. Covered Groups to Which Modified Adjusted Gross a. Tax-filer Household A child is an individual of any age who is claimed as a tax dependent by a biological or adopted parent or step-parent.

Income (MAGI)

Is Applicable b. Non-filer Household A child is an individual under age 19. 2. F&C Non-MAGI, ABD and MN covered groups

A child is an individual under age 21 years who has not been legally emancipated from his/her parent(s). A married individual under age 21 is a child unless he/she has been legally emancipated from his/her parents by a court. Marriage of a child does not emancipate a child from his/her parents and does not relieve the parents of their legal responsibility to support the child.

M0310.111 DEPENDENT CHILD

A. Definition The definition of "dependent child" is the definition in section 406(a) of the Social Security Act: the term "dependent child" means a child who is:

• under the age of 18, OR

• under the age of 19 and is a full-time student in a secondary school or in the equivalent level of vocational or technical training, or in a General Educational Development (GED) program IF he may be reasonably expected to complete the secondary school, training or program before or in the month he attains age 19; AND NOTE: The above definition of a full-time student does NOT apply when determining student status for the student earned income exclusion. See sections M0720.500 B.2 and M0720.510 for the student income exclusion requirements. • living in the home of a parent or a caretaker-relative of the first, second, third, fourth or fifth degree of relationship in a place of residence maintained by one or more of such relatives as his or their own home. See section M0310.107 for the definition of a caretaker- relative.

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B. Age & School Enrollment 1. Age The child's date of birth declared on the application/redetermination form is used to determine if the child meets the age requirement. No verification is required. A child who becomes 18 after the first day of his birth month meets the age requirement in the month of his 18th birthday; he is still considered under age 18 during his birth month. If he becomes age 18 on the first day of his birth month, he is age 18 for the whole birth month. An 18 year old child does not meet the age requirement in the month following the month in which his 18th birthday occurs unless the child is enrolled full-time in a secondary school or vocational/technical school of secondary equivalency, AND the child is reasonably expected to complete the program of secondary school or vocational/technical training before or in the month he attains age 19. 2. School Enrollment Accept the declaration of school enrollment.

C. Living With a Parent or Caretaker-Relative

1. Relationship The child’s relationship to the parent or caretaker-relative with whom he lives as declared on the application or redetermination document is used to determine if the child is living with a relative. No verification is required. For the purpose of determining a relationship, neither death, divorce, nor adoption terminates relationship to the biological relatives. 3. Child’s Father Virginia law considers a man who is legally married to the mother of a child on the date of the child’s birth to be the legal father of the child UNLESS DCSE or a court has determined that another man is the child’s father. NOTE: The mother’s marriage at the time of the child’s birth does not require verification; the mother’s declaration is sufficient. The man listed on the application form as the child’s father is considered the father when: • the mother was not married to another man on the child’s birth date, or • the mother was married to another man on the child’s birth date but DCSE or a court determined that the man listed on the application is the child’s father unless documentation, such as the child’s birth certificate, shows that another man is the child’s father. See M0310.123 for the definition of a parent.

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4. Child Living in the Home A child’s presence in the home as declared on the application/ redetermination is used to determine if the child is living in the home with a parent or caretaker-relative. No verification is required unless the information contained in the application does not clearly establish whether or not the child is living with the parent or care-taker relative.

A dependent child is considered living with only one parent for Medicaid eligibility purposes When separated/divorced parents who claim to have equal physical custody of the child both apply for Medicaid and neither spouse has other children under age 18 in the home, obtain a copy of the custody agreement and verify the custody arrangements. If the custody is divided exactly equally between both parents, the parents must decide which parent the dependent child lives with for Medicaid purposes.

A child who is living away from the home is considered living with his parents in the household if: • the child is not emancipated, and

• the absence is temporary and the child intends to return to the parent’s home when the purpose of the absence (such as vacation, visit, education, rehabilitation, placement in a facility for less than 30 days) is complete. NOTE: If the stay in the medical facility has been or is expected to be 30 days or more, go to M1410.010 to determine if the child is institutionalized in long-term care.

Children living in foster homes or medical institutions are NOT temporarily absent from the home. They are indefinitely absent from home and are NOT living with their parents or siblings for Medicaid purpose.

Children placed in Level C psychiatric residential treatment facilities (PRTF) are considered absent from their home if their stay in the facility has been 30 days or more. A child who is placed in a Level C PRTF is considered NOT living with his parents for Medicaid eligibility purposes as of the first day of the month in which the 30th day of residential placement occurs. Modified Adjusted Gross Income (MAGI) methodology contained in Chapter M04 is applicable to children in PRTFs; long-term care rules do not apply to these children.

5. Parent Living in the Home A parent who is absent from the home is considered living with his child in the household if the absence is temporary and the parent intends to return home when the purpose of the absence (such as military service, vacation, education, medical care or rehabilitation) is complete.

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PAGES 15 – 20 WERE INTENTIONALLY REMOVED FROM THIS SUBCHAPTER

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M0310.112 DISABLED

A. Introduction For individuals who meet no other full-benefit covered group and claim to have a disabling condition, Medicaid eligibility uses the same definition of “being disabled” that the Social Security Administration (SSA) uses. 1. Definition of a Disabled Individual

For an individual 18 or older, the SSA defines “being disabled” as an individual’s inability to do any substantial gainful activity (SGA) or work because of a severe, medically determinable physical or mental impairment or combination of impairments. This impairment(s) has lasted or is expected to last for a continuous period of not less than 12 months, or the impairment is expected to result in death. For a child under 18, the SSA defines “being disabled” as having a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations. These limitations must have lasted or be expected to last for a period of not less than 12 continuous months, or the impairment is expected to result in death. However, a child cannot be found disabled if, at application, the child is performing SGA and is not currently entitled to Supplemental Security Income (SSI) benefits. 2. Disability Determination Services Disability Determination Services (DDS) is a division of the Virginia Department for Aging and Rehabilitative Services (DARS) DDS is charged with making disability determinations for individuals who allege they are disabled for the purpose of qualifying for Social Security Disability Insurance (SSDI) and/or Supplemental Security Income (SSI) disability or blindness benefits, and/or Medicaid. An individual must file separate applications for SSDI/SSI benefits with SSA and for Medicaid with LDSS. The Department of Medical Assistance Services (DMAS) contracts with DARS to have DDS process disability and blindness claims and make determinations of “disabled” or “not disabled” based upon federal regulations. DDS uses the same definitions of disability and blindness and the same evaluation criteria for all three programs. See M0310.106 for the definition of blindness. 3. Factors Involved in a Disability Decision The LDSS does not determine whether or not an individual meets the disability requirements. DDS determines whether or not an individual is disabled as defined by the SSA by evaluating a series of factors in sequential order. The following information is intended to provide a general overview for the LDSS worker of this sequential process and does not provide a complete explanation of the disability determination process: a. Engaged in Substantial Gainful Activity (SGA)?

Is the individual currently engaged in substantial gainful activity (SGA)? SGA means work that: (1) involves doing significant and productive physical or mental duties and (2) is done (or intended) for pay or profit and (3) earnings are above a certain amount. If an individual is working and earning SGA, a finding must be made that the person is not disabled, and no medical evaluation is done. If the individual is not earning SGA, DDS proceeds to the next step.

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b. Severe Impairment?

Does the individual have a severe impairment, as defined by SSA, that meets the durational requirement (i.e. has lasted or is expected to last for a continuous period of not less than 12 months, or which is expected to result in death)? If no, the person is not disabled. If yes, DDS will proceed to the next step. c. Impairment Equals Severity Requirements?

Does the individual have an impairment that meets or equals the severity requirements of a medical condition contained in the Social Security Listing of Impairments? If yes, a finding of disability is made. If no, DDS will proceed to the next step. d. Prevents Performing Past Relevant Work? Does the individual have an impairment that prevents him from performing past relevant work? If the individual can perform past relevant work, the person will be found not disabled. If the individual cannot perform past relevant work, DDS will proceed to the next step. e. Prevents Performing Any Work?

Does the individual have an impairment that prevents him from performing any substantial gainful employment? If the individual cannot perform any work, the person will be found disabled. If the person has the capacity to adjust to other types of work, the person will be found not disabled. Age, education, training and skills acquired in past work are considered in making this determination. 4. Other Benefits Related to Disability a. Benefits Administered by the SSA The SSA uses the SSA disability definition in the determination of eligibility for SDDI and SSI benefits. b. Benefits Administered by the Railroad Retirement Board (RRB) The RRB makes disability determinations for railroad employees who have applied for the Railroad Retirement (RR) disability benefits. A determination of “total” disability means the individual is disabled for all regular work. “Occupational” disability means the individual is disabled for regular railroad occupation, but is not “totally” disabled. Individuals who receive a “total” disability determination are disabled using the SSA criteria. B. Policy The following individuals meet the definition of being disabled for the purposes of meeting a Medicaid covered group and are not to be referred to DDS:

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• individuals who received SSDI or SSI disability benefits or RR total disability benefits in one or more of the 12 months preceding the Medicaid application and whose benefits were terminated for a reason other than no longer meeting the disability or blindness requirements.

• individuals who have been determined disabled or blind by DDS for Medicaid or for SSA, without a subsequent decision by SSA reversing the disability determination, and

• individuals who have been determined “totally” disabled by the RRB. C. Procedures for Verifying Disability Status

1. Receives SSDI/SSI Disability Benefits Verify SSDI/SSI disability status through a SVES (State Verification Exchange System) or SOLQ (State Online Verification Query) request or through documentation provided to the applicant by the SSA.

2. Receives RRB Disability Benefits Verify RRB disability by contacting the RRB National Telephone Service at 1-877-772-5772 or through documentation provided to the applicant by the RRB. 3. Determined Disabled by DDS If disability status cannot be ascertained after reviewing SVES or SOLQ, contact your regional DDS office to verify disability status. Contact information for the regional DDS offices is contained in Appendix 2 of this subchapter.

4. Incarcerated Disabled Individual Although benefits administered by the Social Security Administration are suspended while an individual is incarcerated, a disabled individual continues to meet the definition of a disabled individual while incarcerated.

D. When a DDS Disability Determination is Required • The DDS makes a disability determination for Medicaid when the individual alleges a disabling condition and has never applied for disability benefits from SSA or has not been denied disability within the past 12 months; or

• the individual alleges a disabling condition and SSA has not yet made a determination on a pending SSDI/SSI claim; or

• the individual alleges a disabling condition which is different from that considered by SSA or is in addition to that considered by SSA.

An individual must have his disability determined by DDS if he: • is claiming to have a disabling condition but does not receive SS/SSI disability benefits or RR total disability benefits, and

• has not been denied SSDI or SSI disability benefits in the past 12 months.

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1. Individual Under Age 19 and Not Receiving Long-term Care A child under age 19 who is not receiving LTC services and who is claiming to have a disabling condition must have his disability determined by DDS if: • he is not eligible for FAMIS Plus or FAMIS, or • it is 90 calendar days prior to his 19th birthday.

Do NOT refer a disabled child under age 19 to DDS for the sole purpose of participation in the Health Insurance Premium Payment (HIPP) program 2. Individual Under 21 in LTC a. Facility-based Care

An individual under age 21 in a nursing facility or intermediate care facility for the intellectually disabled (ICF-ID) must have his disability determined if • he is not eligible in the Individuals Under 21 covered group, or • it is 90 calendar days prior to his 21st birthday. b. Home and Community-based Services (HCBS)

A child who is receiving HCBS waiver services and has not previously had a disability determination must have his disability determined prior to his 18th birthday because he will no longer be eligible in the F&C 300% SSI covered group (under which parental income is not counted), once he turns 18. The child must be evaluated for coverage as a blind or disabled individual using the income and resource rules applicable to blind/disabled institutionalized individuals. For a child under 19 who is not disabled, MAGI income counting rules require that parental income be included in the eligibility determination.

Ninety days (90) prior to the child turning age 18, the eligibility worker must contact the parent or responsible party and send a verification checklist to request the required documents to start the DDS referral process. Follow the procedure in M0310.112 G below to make a referral to DDS.

Note: The local DSS is not responsible for initiating a DDS referral for a child turning 18 who receives SSI. The child will have a review of continuing disability and SSI eligibility completed by the SSA. The child remains disabled for Medicaid purposes unless and until his disability status is discontinued by SSA. E. When an LDSS Referral to DDS is Required 1. Disability Determination Has Not Been Made The DDS must make a determination of disability when the applicant alleges a disability and a disability determination has not been made by SSA or the RRB. The DDS must make a disability determination within a time frame that will allow the LDSS to process the application within 90 days, provided all medical information has been submitted.

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2. SSA Denied Disability Within the Past 12 Months

SSA decisions made within the past 12 months are final decisions for Medicaid purposes unless: a) The applicant alleges a condition that is new or in addition to the condition(s) already considered by SSA,

OR

b) The applicant alleges his condition has changed or deteriorated causing a new period of disability AND he requested SSA reopen or reconsider his claim AND SSA has refused to do so or denied it for non-medical reasons. Proof of the decision made by SSA is required.

If the applicant indicates that one of the above exceptions applies, the Medicaid referral should be documented appropriately and sent to the DDS. After reviewing the Medicaid referral and Social Security decision, the DDS may determine that the SSA decision addressed all the conditions reported to Medicaid. In this situation, the DDS will determine that no exception applies and that the SSA decision is still binding. In this situation, the DDS will not make an independent disability determination for Medicaid. Instead, the DDS will document that an exception does not apply and that the SSA determination is still binding until the end of the 12-month period.

If the conditions in a or b above do not exist, the SSA denial of disability is final for Medicaid purposes. DO NOT make a referral to DDS for a disability determination.

3. SSA Denied Disability More Than 12 Months Ago If the applicant alleges a disability and SSA denied the disability more than 12 months ago, follow the procedure in M0310.112 G below to make a referral to DDS. DDS will accept and fully develop the Medicaid referral if more than 12 months have passed since the most recent SSA medical determination, regardless of appeal status with SSA, and for any reason.

F. Decision Pathway for DDS Referrals When determining whether or not a referral to DDS is required, the worker should ask the following questions:

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Has the individual applied for SSDI or SSI? If no, refer to DDS.

If yes and a decision has not been made, refer to DDS.

If yes and a decision has been made, was the disability allowed or denied? If allowed, refer to M0310.112 B, because another determination of disability may not be necessary. If denied, look at the date of the last determination.

If the last SSA denial determination was made more than 12 months in the past, refer to DDS regardless of whether or not the decision is in an appeal with SSA. If the last SSA denial determination was made less than 12 months in the past, and there is a new condition that has not been evaluated by SSA, refer to DDS.

If the last SSA denial determination was made less than 12 months in the past, and there has not been a worsening of a condition already evaluated by SSA, do not refer to DDS.

If the last SSA denial determination was made less than 12 months in the past, but there is a worsening of a condition already evaluated by SSA, ask if the individual has filed for a reconsideration or reopening of his case with SSA. If yes and the case is currently under reconsideration, do not refer to DDS. The SSA decision remains binding unless SSA reverses the decision. If yes and the SSA refused to reconsider his case because he does not meet the SSI eligibility requirements, refer to DDS.

If no, do NOT refer to DDS. The individual must initiate an appeal of his denial with SSA. Unless SSA refuses the appeal request or turns it down for non-disability related reasons, the disability determination remains binding for 12 months. G. LDSS Procedures When a Disability Determination is Required There are two types of DDS referrals for the purposes of Medicaid eligibility: non-expedited and expedited. Most referrals are non-expedited. Expedited referrals are limited to individuals who are hospitalized and require a Medicaid disability determination so they can be transitioned directly from the hospital to a rehabilitation facility For both types of referrals, the eligibility worker must request the necessary verifications needed to determine eligibility so that the application can be processed when the disability determination is received.

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1. LDSS Referrals to DDS for Non- expedited Cases a. Send the following forms to the applicant for completion immediately, giving the applicant 10 calendar days to return the completed forms:

• a copy of the Frequently Asked Questions—Disability Determinations for Medicaid (form #032-03-0426), available on SPARK at https://fusion.dss.virginia.gov/bp/BP-Home/Medical- Assistance/References, explaining the disability determination process and the individual’s obligations;

• the Disability Report Adult (SSA-3368-BK), available at http://www.socialsecurity.gov/online/ssa-3368.pdf, or the Disability Report Child (SSA-3820-BK), available at http://www.socialsecurity.gov/online/ssa-3820.pdf,

• an Authorization to Disclose Information to the Social Security Administration form (SSA-827), available at http://www.socialsecurity.gov/online/ssa-827.pdf.

b. In most cases, the DDS referral is transmitted electronically to DDS through VaCMS. Form 3368-BK or 3830-BK and SSA-827 are uploaded to VaCMS for submission to DDS. No DDS Referral Form is used for electronic submissions. Follow the instructions in the Quick Reference Guide “Sending a DDS Referral in the VaCMS,” available in VaCMS.

c. If the DDS referral cannot be completed in VaCMS, manually submit the referral. Complete the DDS Referral Form, available at https://fusion.dss.virginia.gov/bp/BP-Home/Medical-Assistance/Forms. Use the DDS Referral Form that corresponds with the DDS Regional Office to which the LDSS has been assigned (#032-03-0095, #032-03- 0096, #032-03-0097, or #032-03-0098). To the form, attach the following: • the completed Disability Report • the signed Authorization to Disclose Information • copies of paystubs, if the applicant is currently working.

If the individual’s application was filed with the assistance of a hospital- based eligibility assistance organization, a copy of the consent to release information to the organization must be included with the referral so DDS staff can communicate with them, if necessary.

Mail the DDS Referral form and attachments to the DDS Central Regional (Richmond) Office. See Appendix 1 to this subchapter for the contact information. Do not send referrals to DDS via the courier.

2. Expedited Referrals for Hospitalized Individuals Awaiting Transfer to a Rehabilitation Facility The 2004 Budget Bill mandated that DDS make a disability determination within seven (7) working days of the receipt of a referral from the LDSS when the Medicaid applicant is hospitalized, needs to be transferred directly to a rehabilitation facility AND the individual does not already have a disability application pending with DDS. To ensure that the DDS is able to make the disability determination within the mandated timeframe, the procedures below shall be followed:

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a. Hospital staff shall simultaneously send: • the Medicaid application and a cover sheet, available on Fusion at to the LDSS or the hospital outstationed eligibility worker

• the medical documentation (disability report, authorizations to release information and medical records) and cover sheet to the DDS. b. LDSS shall immediately upon receipt of the Medicaid application: • fax a completed DDS Referral Form (#032-03-0095, #032-03-0096, #032-03-0097, or #032-03-0098) available at https://fusion.dss.virginia.gov/bp/BP-Home/Medical-Assistance/Forms, to the DDS Central Regional Office at 804- 527-4518 to verify receipt of the Medicaid application unless it is known to the agency that the individual already has a pending disability claim with DDS. If the individual already has a pending disability claim with DDS, the claim cannot be treated as an expedited referral. • give priority to processing the applications and immediately request any verifications needed; and

• process the application as soon as the DDS disability determination and all necessary verifications are received; and

• notify the hospital contact identified on the cover sheet of the action on the application and provide the Medicaid enrollee number, if eligible.

c. DDS shall make a disability determination within seven (7) working days and fax the result of the disability decision to the LDSS. DDS is not responsible for notifying either the applicant or the hospital of the outcome of the disability determination. If DDS is unable to render a decision within 7 working days, DDS will send a communication to the LDSS advising that the disability determination has been delayed. 3. Application Processing When DDS Referral is Pending If the completed forms are not returned by the applicant within 45 calendar days from the date of application, the applicant is considered not to meet the covered group and the application must be denied. Individuals who require a disability determination must meet all non-financial requirements other than covered group, within 45 calendar days or the application must be denied. If these requirements are met, the application timeframe may be extended to 90 days while DDS is making the disability determination. If any non-financial requirement other than covered group is not met by the 45th calendar day, his application must be denied and DDS must be notified of the denial. DDS does NOT stop the disability determination process when the individual meets all non-financial requirements, but has excess resources (see M0130.100 B.4) because he might reduce his resources while the

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application is pending for the disability determination. DDS does NOT stop the disability determination when the individual has excess income because of possible spenddown eligibility

4. LDSS Responsibilities for Communication with DDS The LDSS must make every effort to provide DDS with complete and accurate information and shall report all changes in address, medical condition, and earnings to the DDS on pending applications. 5. Evaluation for Plan First and Referral to Health Insurance Marketplace While an individual’s application is pending during the non-expedited disability determination process, evaluate his eligibility in non-ABD covered groups (e.g. MAGI Adults, and Plan First if requested). If the individual is not eligible for full Medicaid coverage, refer the individual to the Virginia Health Insurance Marketplace (VIM) for evaluation for the Advance Premium Tax Credit (APTC). H. Notification of DDS Decision to LDSS 1. Hospitalized Individuals

The DDS will advise the agency of the applicant’s disability status as soon as it is determined by either SSA or the DDS. For hospitalized individuals who meet the requirements for an expedited disability determination, DDS will fax the outcome of the disability determination directly to the LDSS responsible for processing the application and enrolling the eligible individual.

2. Individuals Not Hospitalized For all other disability determinations, DDS will notify the LDSS responsible for processing the application and enrolling the eligible individual will fax the outcome of the disability determination directly to the LDSS responsible for processing the application and enrolling the eligible individual. If the claim is denied, DDS will also include a personalized denial notice to be sent to the applicant explaining the outcome of his disability determination.

3. Disability Cannot Be Determined Timely A disability determination cannot be completed within the allotted time when there is missing or incomplete medical information. DDS will notify the applicant about 75 days from the application date of the delay. DDS will notify the LDSS with a delay letter to the worker and the client. Upon receipt of the delay letter the LDSS must send the applicant a Notice of Action to extend the pending application. 4. DDS Rescinds Disability Denial DDS will notify the agency if it rescinds its denial of an applicant’s disability to continue an evaluation of the individual’s medical evidence. If the Medicaid application has been denied, the agency must reopen the application and notify the applicant of the action. The application continues to pend until notification is received from DDS of the disability determination. If an appeal has been filed with DMAS, the agency must notify the DMAS Appeals Division so that the appeal may be closed (see M1650.100). I. LDSS Action & Notice to the Applicant The eligibility worker must complete the Medicaid eligibility determination immediately after receiving notice of the applicant’s disability status and send the applicant a Notice of Action regarding the disability determination and the agency’s decision on the Medicaid application.

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J. Applicant is Deceased When a Medicaid applicant who has been referred to DDS dies or when the applicant is deceased at the time of the Medicaid application, DDS will determine if the disability requirement for Medicaid eligibility was met. The LDSS must immediately notify DDS of the individual’s death and make every effort to provide a copy of the death certificate. K. Subsequent SSA or RRB Disability Decisions When SSA or the RRB make a disability decision subsequent to the DDS (Medicaid) decision which differs from the DDS decision, the SSA or RRB decision must be followed in determining Medicaid eligibility unless one of the conditions in M0310.112 E.2 above applies. 1. SSA/RRB Approval If SSA approves disability or the RRB approves total disability, the disability definition is met. If DDS initially denied disability and the decision is reversed, re-evaluate the denied Medicaid application. The individual’s Medicaid entitlement is based on the Medicaid application date, including the retroactive period, if all eligibility requirements were met during the retroactive period. However, eligibility as a disabled individual cannot begin prior to the disability onset date (month) established by SSA. Do not send the claim back to DDS for an earlier onset date. Disability Approved More Than 12 Months Past If, based upon the re-evaluation, the individual is determined to be eligible and more than 12 months have passed since the application was filed, complete an eligibility renewal to determine whether or not the individual remains eligible. Spenddown If, based upon the re-evaluation, the individual is determined not eligible for Medicaid but met the requirements in Chapter M13 for placement on a spenddown, a first prospective and additional 6 month spenddown budget periods may be established to cover the period of time between the date of application and the date action is taken on his case. A new application is not required for each 6 month spenddown budget period leading up to the date of processing, however, verification of all income and resources for those time periods must be obtained.

2. SSA Denial or Termination And Appeal If SSA denies disability, the disability definition is not met. If the individual has been enrolled in Medicaid as disabled and is not eligible in another covered group, send an advance notice to the enrollee to cancel Medicaid. If the individual appeals the SSA’s disability decision timely (within 60 calendar days from the SSA notification or with good cause for exceeding 60 days) and SSA agrees to reconsider the decision, the Medicaid coverage must be reinstated until the final decision on the SSA appeal is made. The individual must provide verification that he filed the appeal and SSA agreed to reconsider the case. The individual must also provide verification of the decisions made at all levels of appeal in order for Medicaid to continue during the process. The Medicaid coverage will continue until a final decision is made and the individual has no right to further SSA appeals.

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The levels of administrative review are in the following order: a. reconsideration, b. the hearing before an administrative law judge (ALJ), and c. the Appeals Council For example: An individual is enrolled in Medicaid as disabled. However, his SSA claim is denied at the ALJ hearing level. If the individual fails to appeal the ALJ decision to the Appeals Council and the Appeals Council does not decide on its own to review the case, the ALJ decision becomes the final decision once the 60-day deadline for requesting further review has passed. Because the individual no longer meets the disabled definition for another covered group, his Medicaid coverage must be canceled. 6. RRB Denial, Termination and RRB Appeal If RRB denies disability, the disability definition is not met. If the individual has been enrolled in Medicaid as disabled and is not eligible in another covered group, send an advance notice to the recipient to cancel Medicaid. Persons who believe that their claims have not been adjudicated correctly may ask for reconsideration by the Board's Office of Programs. If not satisfied with that review, the applicant may appeal to the Board’s Bureau of Hearings and Appeals. Further, if the individual timely appeals the RRB disability decision, Medicaid coverage must be reinstated until the final decision on the RRB appeal is made. The individual must provide verification that he filed a timely appeal with RRB and must provide verification of the decisions made at all levels of appeal in order for Medicaid to continue during the process. 7. Subsequent SSA/SSI Disability Decisions If the individual appeals a disability denial and the decision is subsequently reversed, reopen and re-evaluate the denied Medicaid application as long as the disability onset month is prior to the month of application or is no later than 90 days after the month of application. If the individual has moved to another locality in Virginia, it is the responsibility of the agency that processed the application to reopen the application and determine eligibility prior to transferring the case. See M1510.104.

M0310.113 RESERVED

M0310.114 FAMILIES & CHILDREN (F&C)

"Families & Children (F&C)" is the group of individuals that consists of • children under 19, • pregnant women, • specified subgroups of children under age 21, • Former Foster Care Children under age 26 (effective January 1, 2014), and • parent/caretakers of dependent children under age 18. Also included in the F&C groups are individuals eligible only for family planning services (Plan First) and participants in BCCPTA.

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M0310.115 FOSTER CARE

A. Definition Foster Care provides maintenance and care for children whose custody is held by: • a local board of social services; • a licensed private, non-profit child placement agency; • the Department of Juvenile Justice; or • the child’s parent(s), under a non-custodial agreement. Federal regulations define “foster care” as “24-hour substitute care for children placed away from their parents or guardians and for whom the State agency has placement and care responsibility” (45 C.F.R. §1355.20). Transfer of the legal custody of the child is not a component when determining if a child is considered to be in foster care. The federal definition is based upon the child being placed outside of the home and who has placement and care responsibility for the child. If a child is placed outside of the home and LDSS is the case manager with placement and care responsibility, then the federal government considers the child to be in foster care. For the federal government, the term “placement and care” means that LDSS is legally accountable for the day-to-day care and protection of the child through either a court order or a voluntary placement agreement. 1. Custody Custody may be given to an agency by the court or may be retained by the parent(s) or guardian when a non-custodial agreement is involved. If custody is retained by the parent under a parental agreement with the Community Policy and Management Team (CPMT), the child is NOT in foster care. 2. Child Placing Agency A child placing agency is an agency that is licensed by the State Department of Social Services for child placing services. Not all child placing agencies provide adoption services; some may provide foster home placement. The services offered must be identified in the description given for the license. The foster care service unit of the local department of social services should be familiar with the function of the child placing agency, and whether or not it is licensed.

3. Independent Living and Fostering Futures A foster care child who is under age 18 who is in an Independent Living arrangement and receives full or partial support from a local social services agency, continues to meet the foster care definition and may be eligible in the covered group of Individuals Under Age 21. A child age 18 and over who is in an Independent Living arrangement with a local department of social services or in the Fostering Futures Program is considered a former foster care child and may be eligible in the Former Foster Care Child Under Age 26 covered group.

4. Kinship Guardianship Payments Kinship Guardianship Payments are not income. These payments are a stipend paid to a relative caregiver who has assumed custody of a child as an alternative to that child remaining in foster care. Children who are eligible for Title IV-E KinGAP (federal funds) Payments are categorically eligible for Medicaid.

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5. Independent Living A foster care child who is under age 21, who is in an Independent Living arrangement and receives full or partial support from a local social services agency, continues to meet the foster care definition and may be eligible in the covered group of Individuals Under Age 21.

6. Non-custodial and Parental Agreements a. Non-custodial Agreement A non-custodial agreement is an agreement between the child’s parent or guardian and the local Board of Social Services. The parent(s) or guardian retains legal custody of the child. The social services agency agrees to provide financial assistance and/or services to the child, such as placement in and payment for residential facility services.

Non-custodial agreements are used when LDSS serves as the case manager and has placement and care responsibilities to place a child outside of his home for treatment.

Children with non-custodial agreements are considered to be in foster care for Medicaid eligibility purposes. b. Parental Agreement A parental agreement is an agreement between the child’s parent or guardian and an agency other than DSS which is designated by the CPMT. The other agency designated by the CPMT has placement and care responsibility for the child and agrees to provide financial assistance and/or services to the child, such as placement in and payment for residential facility services. Parental agreements are used when an agency other than LDSS is designated by the CPMT as case manager and the child is placed outside of the home for treatment. Children with parental agreements ARE NOT considered to be in foster care for Medicaid eligibility purposes. c. Placement Federal Title IV-E funds can only be claimed if LDSS has placement and care responsibility for the child and the child is placed by LDSS outside the child’s home. If the LDSS has placement and care responsibility for the child and the child is placed in the child’s home, the child is not eligible for Title IV-E funds and is a Non-IV-E foster child for Medicaid eligibility purposes. 7. Department of Juvenile Justice A child in the custody of the Virginia Department of Juvenile Justice or who is the responsibility of a court is a “Department of Juvenile Justice (DJJ) child.” B. Procedures 1. IV-E Foster Care Children who are eligible for and receive Title IV-E (AFDC-FC) foster care maintenance payments or Title IV-E KinGAP payments are IV-E Foster Care for Medicaid eligibility purposes. A child of a IV-E foster care child is also considered to be a IV-E foster care child when the mother’s IV-E payment includes an allocation for her child.

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A child who is eligible for IV-E Foster Care but who does not receive a IV-E Foster Care maintenance payment is considered a “Non-IV-E Foster Care” child for Medicaid eligibility purposes. Children in the custody of another state’s social services agency, who are eligible for and receive Title IV-E Foster Care maintenance payments and who now reside in Virginia, are IV-E Foster Care for Medicaid eligibility purposes. Verify the child’s IV-E eligibility from the other state’s department of social services which makes the IV-E payment. 2. Non IV-E Foster Care Children who are eligible for but do not receive IV-E maintenance payments or who are eligible for Non-IV-E (state/local) Foster Care (whether or not they receive a Non-IV-E payment), and who reside in Virginia are Non-IV-E Foster Care for Medicaid eligibility purposes.

3. Non-IV-E Children in Another State’s Custody A child in the custody of another state’s social services agency who is not receiving IV-E foster care maintenance or SSI payments, does NOT meet the Virginia residency requirement for Medicaid (M0230) and is not eligible for Virginia Medicaid UNLESS the child has been placed with and is residing in Virginia with a parent or care-taker relative. 4. Trial Home Visits A foster care or DJJ child continues to meet the foster care definition (either IV-E or non-IV-E) when placed by the agency in the child’s own home for a trial period, if the child continues to be in the agency’s custody or remains the financial responsibility of DJJ or the court. If a Medicaid renewal is due during the trial home visit, continue to treat the child as a foster care or DJJ child.

M0310.116 HOSPICE

A. Definition "Hospice" is a covered group of terminally ill individuals whose life expectancy is 6 months or less and who have voluntarily elected to receive hospice care. The term “hospice” is also used to refer to the covered service for a terminally ill Medicaid recipient, regardless of his covered group. Hospice services can be provided in the individual’s home or in a medical facility, including a nursing facility. 1. Hospice Care "Hospice care" means items and services are provided to a terminally ill individual by, or by others under arrangements made by, a hospice program under a written plan of care for the individual that is established and periodically reviewed by the individual's attending physician and the hospice program's medical director: 2. Hospice Program A "hospice program" is a public agency or private organization which • is primarily engaged in providing hospice care, makes hospice care services available as needed on a 24-hour basis, and provides bereavement counseling for the terminally ill individual's immediate family; • provides hospice care in individuals' homes or in medical facilities on a short-term inpatient basis; • meets federal and state staffing, record-keeping and licensing requirements.

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B. Procedure The individual must elect hospice care in a non-institutional setting. Election of hospice care is verified either verbally or in writing from the hospice care provider. If verification is verbal, document the case record.

M0310.117 INSTITUTION

A. Definition An institution is an establishment that furnishes (in single or multiple facilities) food, shelter, and some treatment or services to four or more persons unrelated to the proprietor. B. Medical Institution (Facility) A medical institution is an institution that: • is organized to provide medical care, including nursing and convalescent care, • has the necessary professional personnel, equipment, and facilities to manage the medical, nursing and other health needs of patients, • is authorized under state law to provide medical care, and • is staffed by professional personnel who are responsible to the institution for professional medical and nursing services. C. Procedures The procedures used to determine if an individual meets a covered group of individuals in institutions are contained in subchapters M0320 and M0330.

M0310.118 LIFC

A. Low Income Families with Children (LIFC) Low Income Families with Children (LIFC) is a covered group of individuals in families who have a dependent child(ren) living in the home, and whose income is within the Medicaid F&C income limits. B. Procedure Section M0330.200 contains the detailed requirements for the LIFC covered group.

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M0310.120 MEDICALLY NEEDY (MN)

A. Definition "MN" is the short name for "medically needy." MN is one of the two federal classifications of Medicaid covered groups. All MN covered groups are optional; the state can choose whether or not to cover MN individuals in its State Plan. However, if the state chooses to cover MN individuals, it must at least cover children under age 18, pregnant women and the protected group of individuals who were eligible as MN blind or disabled in December 1973 and continue to meet the December 1973 eligibility criteria. The state may choose to cover additional groups of individuals as MN. The MN individual is one who has income and resources enough to meet his maintenance needs, but not enough to meet his medical needs. MN individuals whose income exceeds the MN income limit may be placed on a spenddown (SD) and establish eligibility when incurred medical and/or remedial expenses equal or exceed the SD amount. B. Procedure The procedures used to determine if an individual meets a MN covered group are in subchapter M0320 for ABD and M0330 for F&C.

M0310.121 MEDICARE BENEFICIARY

A. Definition A Medicare beneficiary is an individual who is entitled to Medicare (Title XVIII of the Social Security Act). Medicare is a federally funded and administered health insurance program and consists of hospital insurance (Part A), medical insurance (Part B) and, beginning January 1, 2006, prescription drug coverage (Part D). 1. Part A A person is entitled to Medicare Part A if he a. is age 65 or older and: • eligible for monthly Social Security benefits on the basis of covered work under the Social Security Act, • a qualified Railroad Retirement beneficiary, • not eligible for Social Security or Railroad Retirement benefits but meets the requirements of a special transitional provision, • not eligible for Social Security or Railroad Retirement benefits but voluntarily enrolls and pays a monthly premium, or

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• would be eligible for Social Security benefits if his governmental employment were covered work under the Social Security Act; OR b. is under age 65, disabled and • entitled to or deemed entitled to Social Security disability benefits for more than 24 months, • would be entitled to Social Security disability benefits for more than 24 months if his governmental employment were covered work under the Social Security Act, • under specified circumstances, entitled to Railroad Retirement benefits because of disability, • loses his entitlement to disability benefits and Medicare Part A solely because he is engaging in substantial gainful employment but voluntarily elects to enroll and pay a monthly premium; OR c. is any age and has end-stage renal disease treated by a kidney transplant or a regular course of kidney dialysis and meets the special insured status requirements. 2. Part B A person is eligible to enroll in Medicare Part B if he a. is entitled to premium-free Medicare Part A or pays a premium for Medicare Part A, OR b. is age 65 or older, a resident of the U.S., and either • a citizen of the U.S., or • an alien lawfully admitted for permanent residence who has resided in the U.S. continuously during the 5 years immediately prior to the month in which he or she applies for enrollment.

3. Part D A person is eligible to enroll in Medicare Part D if he: a. is entitled to Medicare Part A and/or enrolled in Medicare Part B; and b. is a resident of the United States. B. Procedures A Medicare beneficiary may be eligible for Medicaid if he meets all of the Medicaid eligibility requirements including any one or more of the covered groups. Four of the Medicaid covered groups are specifically for Medicare beneficiaries and provide a limited benefit package that pays costs related to Medicare, such as premiums, copays, and deductibles. These groups include Qualified Medicare Beneficiaries (QMBs), Special Low- income Medicare Beneficiaries (SLMBs), Qualified Disabled and Working Individuals (QDWIs) and Qualified Individuals (QI). QMBs, SLMBs, and QIs are also referred to as Medicare Savings Programs (MSP).

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See sections M0320.601 (QMB), M0320.602 (SLMB), and M0320.603 (QI) for the procedures to use to determine if an individual meets an MSP covered group. See section M0320.604 for the procedures to use to determine if an individual meets the QDWI covered group.

M0310.122 OASDI

A. Old Age, Survivors & Disability Insurance (OASDI) Old Age, Survivors & Disability Insurance (OASDI) is the federal insurance benefit program under Title II of the Social Security Act that provides cash benefits to workers and their families when the workers retire, become disabled or die. OASDI is sometimes called RSDI - Retirement, Survivors & Disability Insurance. Because Title II of the Social Security Act is still officially called “Old Age, Survivors & Disability Insurance”, the Medicaid manual uses the abbreviation “OASDI” interchangeably with “Title II” to refer to Title II Social Security benefits. B. Entitlement An individual is fully insured if he has at least 1 credit for each calendar year after 1950, or if later, after the year in which he attained age 21, and prior to the year in which he or she attains age 62 or dies or becomes disabled, whichever occurs earlier. A worker is entitled to retirement insurance benefits if he is at least age 62, is fully insured and files an application for retirement insurance benefits. A claimant who is the worker's spouse is entitled to spouse's benefits on the worker's record if the claimant is age 62 or over, has in care a child under age 16 or disabled who is entitled to benefits on the worker's record, and the claimant has been married to the worker for at least 1 year before filing the claim or the claimant is the natural mother or father of the worker's biological child. A child is entitled to child's insurance benefits on a parent's work record if an application for child's benefits is filed, the child is or was dependent on the parent, the child is unmarried, the child is under age 18 or is age 18-19 and a full-time elementary or secondary school student or age 18 or over and under a disability which began before the child attained age 22; and the parent is entitled to retirement or disability insurance benefits, or died and was either fully or currently insured at the time of death. When an insured worker dies, monthly cash benefits may be paid to eligible survivors as follows: widow(er)'s benefits, surviving child's benefits, mother's or father's benefits, and parent's benefits. C. Procedures Verify an individual’s entitlement to OASDI by inquiring the MMIS computer system or entering the required data into the State Verification Exchange System (SVES). The individual’s award letter from SSA is acceptable verification of OASDI entitlement.

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M0310.123 PARENT

A. Definition Under federal regulations, a parent means either the mother or the father, married or unmarried, natural or adoptive following entry of the interlocutory or final adoption order, whichever comes first. 1. Mother Married on Child’s Birth Date A mother who was married at the time of her child's birth may name on the application someone other than her husband as the child’s father. The man to whom she was married at the time of the child’s birth, however, is considered the child’s father unless DCSE or a court determines otherwise. DCSE or the court must exclude the mother’s husband, considered the legal father, as the child’s father before the paternity status of the man named on the application is determined. 2. Mother NOT Married on Child’s Birth Date If the mother was NOT married when the child was born, the man who is living in the home and who is listed on the application as the child’s father is the child’s acknowledged father, unless the agency receives evidence that contradicts the application, such as the child’s birth certificate that has another man named as the child’s father. 3. Paternity Evidence If evidence of paternity is required to establish eligibility or ineligibility, such evidence must be entered in the eligibility case record. B. Procedures NOTE: The mother’s marital status at the time of the child’s birth does not require verification; her declaration of her marital status is sufficient. Section M0330.200 contains the detailed requirements for the LIFC covered group in which a parent of a dependent child can be eligible for Medicaid.

M0310.124 PREGNANT WOMAN

A. Definition A woman of any age who attests that she is pregnant meets the definition of a pregnant woman. At the time of application, applicants are asked if they are pregnant and if so, how many babies are expected. The pregnant woman definition is met the first day of the month in which the woman attests she is pregnant. She meets the definition of a pregnant woman for the retroactive period if she was pregnant during the retroactive months.

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The definition of “pregnant woman” for the purposes of the eligibility determination and covered group designation is met for 12 months following the last day the woman was pregnant regardless of the reason the pregnancy ended, and continues to be met until the last day of the month in which the 12th month occurs. After a woman’s eligibility as a pregnant woman is established for Medicaid or FAMIS MOMS, her entitlement continues for 12 months following the end of the month in which her pregnancy ends, regardless of income changes. Medicaid and FAMIS MOMS coverage ends the last day of the 12th month. B. Procedures 1. No Further Verification of Pregnancy Required If the woman has indicated on the application that she is pregnant or subsequently reports a pregnancy, no further information regarding her pregnancy is to be requested nor verification is to be required unless the agency has reason to question the applicant’s statement that she is pregnant. If a woman is applying after the end of a pregnancy, her report of the birth or pregnancy end date is sufficient to establish (1) for purposes of retroactive coverage, her pregnancy in the three months prior to the child’s birth month or pregnancy end date, or (2) for purposes of new, prospective coverage through the end of the 12-month postpartum period, her pregnancy in the twelve months prior. 2. Covered Groups Eligibility A pregnant woman may be eligible for Medicaid if she meets all of the Medicaid eligibility requirements including any one or more of the covered groups. Once eligibility is established in any covered group, changes in income do not affect her eligibility as long as she continues to meet the definition of a pregnant woman and all non-financial eligibility requirements. See section M0330.400 for the pregnant woman covered group requirements and M0330.801 for the MN Pregnant Woman requirements.

M0310.125 QDWI

A. Qualified Disabled & Working Individuals (QDWI) QDWI is the short name used to designate the Medicaid covered group of Medicare beneficiaries who are "Qualified Disabled and Working Individuals." A qualified disabled and working individual means an individual • who is entitled to enroll for Medicare Part A, • whose resources do not exceed twice the maximum amount of resources that an individual or couple may have and be eligible for SSI, • whose income does not exceed 200% of the federal poverty limit, • who is NOT otherwise eligible for Medicaid.

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B. Procedure QDWI is a mandatory covered group that the state plan must cover for the purpose of paying the beneficiary’s Medicare Part A premium. See section M0320.604 for the procedures to use to determine if an individual meets the QDWI covered group.

M0310.126 Qualified Individuals

A. Qualified Individuals (QI)

QI is the short name used to designate the Medicaid covered group of “Qualified Individuals.” A qualified individual means a Medicare beneficiary • who is entitled to Medicare Part A, • who has resources that are within the resource limits for the Medicare Savings Programs (MSPs). See chapter section M1110.003 for the current resource limits; and

• whose income is equal to or more than 120% of the federal poverty level (FPL) and is less than 135% FPL. B. Procedure QI is a mandatory covered group that the State Plan must cover for the purpose of paying the Medicare Part B premium for the QI. See section M0320.603 for the procedures used to determine if an individual meets the QI covered group.

M0310.127 QMB

A. Qualified Medicare Beneficiary (QMB) QMB is the short name used to designate the Medicaid covered group of "Qualified Medicare Beneficiary." A qualified Medicare beneficiary means an individual • who is entitled to enroll for Medicare Part A, • who has resources that are within the resource limits for the Medicare Savings Programs (MSPs). See chapter section M1110.003 for the current resource limits; and

• whose income does not exceed 100% of the FPL. B. Procedure QMB is a mandatory covered group that the state plan must cover for the purpose of paying the beneficiary’s Medicare premiums and cost sharing expenses. See section M0320.601 for the procedures to use to determine if an individual meets the QMB covered group.

M0310.128 RSDI

A. Retirement, Survivors & Disability Insurance (RSDI) Retirement, Survivors & Disability Insurance (RSDI) is another name for Old Age, Survivors & Disability Insurance (OASDI) - the federal insurance benefit program under Title II of the Social Security Act that provides cash benefits to workers and their families when the workers retire, become disabled or die.

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B. Procedure RSDI Is not used in the Medicaid manual. Because Title II of the Social Security Act is still officially called “Old Age, Survivors & Disability Insurance”, the Medicaid manual uses the abbreviation “OASDI” interchangeably with “Title II” to refer to Title II Social Security benefits.

M0310.129 SLMB

A. Special Low-income Medicare Beneficiary (SLMB) SLMB is the short name used to designate the Medicaid covered group of “Special Low-income Medicare Beneficiary”. A special low-income Medicare beneficiary means an individual • who is entitled to enroll for Medicare Part A, • who has resources that are within the resource limits for the Medicare Savings Programs (MSPs). See chapter section M1110.003 for the current resource limits; and

• whose income exceeds the QMB income limit (100% of the FPL) but does NOT exceed the higher SLMB income limit, which is 120% of the FPL. B. Procedure SLMB is a mandatory covered group that the state plan must cover for the purpose of paying the beneficiary’s Medicare Part B premium. See section M0320.602 for the procedures to use to determine if an individual meets the SLMB covered group.

M0310.130 SSI

A. Supplemental Security Income (SSI) Supplemental Security Income (SSI) is the federal cash assistance benefit program under Title XVI of the Social Security Act that provides cash assistance to eligible aged, blind or disabled individuals to meet their shelter, food and clothing needs. B. Procedures Individuals who receive SSI (SSI recipients) are not “automatically” eligible for Medicaid in Virginia. SSI recipients must meet all of the Medicaid nonfinancial eligibility requirements and must meet the Medicaid resource eligibility requirements that are more restrictive than SSI’s resource requirements. See section M0320.101 for the procedures to use to determine if an SSI recipient meets a covered group.

M0310.131 STATE PLAN

A. Definition The State Plan for Medical Assistance is a comprehensive written statement submitted by the Department of Medical Assistance Services (DMAS) describing the nature and scope of Virginia’s Medicaid program. It contains all the information necessary for the federal Centers for Medicare and Medicaid Services (CMS) to determine whether the state plan can be approved for federal financial participation (FFP) in the state’s Medicaid program expenses.

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B. State Plan Governs Medicaid Eligibility Rules The State Plan consists of preprinted material that covers the basic Medicaid requirements and individualized material written by DMAS that reflects the particular requirements and choices made by Virginia for its Medicaid program. The State Plan is included in DMAS’ state regulations promulgated according to the Virginia Administrative Process Act (APA). The State Plan is kept and updated by DMAS. The State Plan shows the eligibility requirements for Virginia Medicaid, including the mandatory and optional groups of individuals covered by Virginia Medicaid and the medical services covered by Medicaid for those groups. The covered groups eligibility requirements in this chapter are based on the State Plan.

M0310.132 TANF

A. Temporary Assistance for Needy Families (TANF) TANF is the federally-funded (with matching funds from the states) block grant program in Title IV Part A of the Social Security Act that provides temporary cash assistance to needy families. In Virginia, TANF replaced the previous Title IV-A program called Aid to Families With Dependent Children (AFDC) on February 1, 1997.

M0310.133 BCCPTA

A. Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) The BCCPTA created a Medicaid covered group for women and men age 18 through 64 who have been identified by the Centers for Disease Control and Prevention's (CDC) Breast and Cervical Cancer Early Detection Program (BCCEDP) as being in need of treatment for breast or cervical cancer. B. Procedures Section M0330.700 contains the detailed requirements for the BCCPTA covered group.

M0310.134 VIEW PARTICIPANT

A. Virginia Initiative for Employment not Welfare (VIEW) Participants A VIEW participant is an individual who has signed the TANF Agreement of Personal Responsibility. For renewals completed and changes reported prior to April 1, 2014, VIEW participants have a higher earned income limit than non-VIEW participants. An individual under a TANF VIEW sanction is a VIEW participant for Medicaid purposes. An individual only receiving TANF transitional support services is not a VIEW participant for Medicaid purposes. Modified Adjusted Gross Income (MAGI) methodology does not differ between VIEW participants and other individuals.

M0310.135 HIPP PROGRAM

A. Health Insurance Premium Payment (HIPP) Program HIPP is a cost savings program administered by the DMAS for Medicaid enrollees which reimburses some or all of the employee portion of group health insurance premiums. HIPP is available to Medicaid enrollees when a family member is employed at least 30 hours per week and is enrolled in an employer’s group health plan. Eligibility for HIPP is determined by the HIPP Unit at DMAS. Participation in HIPP is voluntary. B. Procedures M0130.200 G contains additional information about HIPP.

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M0310.136 MAGI ADULT

A. Definition A MAGI Adult is a person who is not defined as a “child” (see M0310.110). The 2018 Appropriations Act mandated that Medicaid in Virginia be expanded effective January 1, 2019. This new expanded coverage group is called MAGI Adults and covers individuals ages 19-64 who are not eligible for or enrolled in Medicare and who have income at or below 138% of FPL. Several new aid categories have been added for the MAGI Adults covered group. • Childless adults, income less than 100% FPL;

• Childless adults, income less than 138% FPL (133% + 5% income disregard);

• Parent/Caretaker adult relatives, above current LIFC income limit and at or below 100% FPL;

• Parent/Caretaker adult relatives, above 100% FPL and at or below 138% FPL (133% + 5% income disregard);

• Presumptive eligible adult, income at or below 138% FPL (133% + 5% income disregard);

• Incarcerated adult who otherwise meet a Medicaid MAGI Adult aid category but not enrolled due to incarceration. B. Procedure The procedures used to determine if an individual meets the MAGI Adults covered group are contained in subchapters M0320 and M0330.

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Disability Determination Services (DDS) Contact Information

Send ALL expedited and non-expedited disability referrals to the DDS Central District Office.

DDS District Office Hearing Contacts

Central District Office Disability Determination Services 9960 Mayland Drive. Suite 200 Henrico, Virginia 23233

Phone: 855-445-3938

FAX: 804-527-4523

Operations Manager: Talya Brown

Professional Relations Officer: Bonita Jones

District Director: Elliot Duncan

Primary Contact for Scheduling a hearing: Bonita Jones (804) 367-4707

Backup: Shawnelle Martin 804-367-3292

CHAPTER M03 MEDICAID COVERED GROUPS

SUBCHAPTER 20

AGED, BLIND & DISABLED GROUPS

M0320 Changes

Changed With Effective Date Pages Changed TN #DMAS-38 4/1/26 Section M0320.400; M0320.502 TN #DMAS-37 1/1/26 Page 11 TN #DMAS-35 7/1/25 Sections .400 and .500 TN #DMAS-34 1/1/25 Pages 11, 27, 32, 34 Pages 32a and 34a are added TN #DMAS-33 10/1/24 Pages 1, 5, 27, 37 TN #DMAS-32 7/1/24 Pages 24-26a, 29 TN #DMAS-29 10/1/23 Pages 1, 25, 26, 26a, 27, 28 TN #DMAS-27 4/1/23 Pages 11, 24, 25, 27 TN #DMAS-26 1/1/23 Page 11 TN #DMAS-24 7/1/22 Pages 2, 30, 31, 33 TN #DMAS-23 4/1/22 Page 27 TN #DMAS-22 1/1/22 Pages 11, 26a, 27 TN #DMAS-20 7/1/21 Pages 24, 26-29 TN #DMAS-19 4/1/21 Pages 26a, 29 TN #DMAS-18 1/1/21 Pages 11, 22, 26, 27 TN #DMAS-17 7/1/20 Pages 24. 25. 26, 27 Page 26a was added as a runover page. TN #DMAS-15 1/1/20 Pages 11, 26, 27, 29 TN #DMAS-14 10/1/19 Page 40 TN #DMAS-13 7/1/19 Pages 1, 24-27 TN #DMAS-11 1/1/19 Pages 2a, 11, 35, 37 TN #DMAS-10 10/1/18 Page 1; 1a added as a runover page TN #DMAS-9 7/1/18 Page 2, 17 TN #DMAS-7 1/1/18 Page 2, 3, 4, 11, 26-27. TN #DMAS-4 4/1/17 Page 26 TN #DMAS-3 1/1/17 Pages 11, 27, 29, 40, 41, 44, 45, 52 TN #DMAS-2 10/1/16 Pages 4, 15, 16, 18, 20, 22, 30, 33, Pages 39- 41, 43-45, 48, 51, 52, 55 TN #DMAS-1 6/1/16 Table of Contents, page i Pages 1, 11, 25-27, 46-49;Page 50 is a runover page. TN #100 5/1/15 Pages 6, 11, 24, 25-27, 29-30 TN #99 1/1/14 Page 11 TN #98 10/1/13 Pages 1, 54, 55. UP #9 4/1/12 Pages 11, 26, 32, 34-37, 45, 46, 55 TN #97 9/1/12 Table of Contents; Pages 1-56 (all pages) UP #6 4/1/12 Pages 11, 12, 46a TN #96 10/1/11 Table of Contents; Pages 46f-50b; Page 50c deleted TN #95 3/1/10 Pages 11, 12, 42c, 42d, 50, 53, 69 Pages 70, 71; Page 72 added. TN #94 9/1/10 Pages 49-50b UP #3 3/1/10 Pages 34, 35, 38, 40, 42a, Pages 42b, 42f TN #93 1/1/10 Pages 11-12, 18, 34-35, 38 Pages 40, 42a-42d, 42f-44, 49 Pages 50c, 69-71 UP #2 8/24/09 Pages 26, 28, 32, 61, 63, 66 Update (UP) #1 7/1/09 Pages 46f-48 TN #91 5/15/09 Pages 31-34 Pages 65-68

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TABLE OF CONTENTS

M03 MEDICAID COVERED GROUPS

M0320.000 AGED, BLIND & DISABLED GROUPS

Section

Page

Aged, Blind & Disabled (ABD) General Policy Principles ....... M0320.000......................... .1

Categorically Needy Groups ....................................................... M0320.001.......................... 2

ABD Cash Assistance Groups ............................................... M0320.100.......................... 2 SSI Recipients ................................................................... M0320.101.......................... 2a AG Recipients ................................................................... M0320.102.......................... 5

Protected Covered Groups ................................................... M0320.200.......................... 5 Former Money Payment Recipients -August 1972 ........ M0320.201.......................... 5 Conversion Cases .............................................................. M0320.202.......................... 6 Former SSI/AG Recipients .............................................. M0320.203.......................... 7 Protected Widows or Widowers ..................................... M0320.204.......................... 12 Qualified Severely Impaired Individuals (QSII) 1619(b) ............................................................................... M0320.205.......................... 17 Protected Adult Disabled Children ................................ M0320.206.......................... 19 Protected SSI Disabled Children .................................... M0320.207.......................... 21

ABD With Income ≤ 80% FPL ............................................. M0320.300.......................... 23

MEDICAID WORKS ............................................................ M0320.400.......................... 24

300% of SSI Income Limit Groups ..................................... M0320.500.......................... 30

ABD In Medical Institution, Income ≤ 300% SSI ........ M0320. 501 ......................... 31 ABD Receiving Waiver Services (CBC) ........................ M0320. 502 ......................... 33 ABD Hospice ..................................................................... M0320.503.......................... 35

Medicare Savings Plan (MSP) Groups……………………M0320.600 ........................... 38

QMB (Qualified Medicare Beneficiary) ......................... M0320.601.......................... 38 SLMB (Special Low-income Medicare Beneficiary) ..... M0320.602.......................... 38 QI (Qualified Individual) ................................................. M0320.603.......................... 46 QDWI (Qualified Disabled & Working Individual) ..... M0320.604.......................... 50

Medically Needy Covered Groups .............................................. M0320.700.......................... 53

ABD Individuals ............................................................ M0320.701 ........................... 54

December 1973 Eligibles ............................................... M0320.702 ........................... 55

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M0320.000 AGED, BLIND & DISABLED (ABD) GENERAL POLICY PRINCIPLES

A. Overview A State Plan for Medicaid must include the mandatory federal categorically needy (CN) groups of individuals as well as the optional groups a state has elected to cover. This subchapter divides the ABD covered groups into categorically needy and medically needy (MN) groups. B. Procedure Determine an individual’s eligibility first in a CN covered group. This includes eligibility in the Modified Adjusted Gross Income (MAGI) Adults covered group (see M0330.250). If the individual is not eligible in a full-benefit CN covered group, determine the individual’s eligibility as MN (on a spenddown). An evaluation of eligibility for an aged, blind or disabled individual should follow this hierarchy: 1. If the individual is a current SSI/AG recipient, evaluate in this covered group. Exception-- if the individual requests MEDICAID WORKS, go to 5 below.

2. If the individual is a former SSI or AG recipient, evaluate first in the protected covered groups. Exception-- if the individual requests MEDICAID WORKS, go to 5 below.

3. If the individual does not meet the criteria for SSI/AG or protected, is between ages 19 and 64, and is not eligible for or enrolled in Medicare, evaluate next in the MAGI Adults covered group.

4. If the individual is aged and/or is eligible for or has Medicare, evaluate next in the ABD with income < 80% FPL covered group.

5. If a disabled individual has income at or below 138% FPL (including SSI recipients and 1619(b) individuals) and is going back to work, evaluate the individual in the MEDICAID WORKS covered group.

6. If the individual does not meet the requirements for MAGI Adults, 80% FPL group or MEDICAID WORKS, but meets the definition of an institutionalized individual, evaluate in the 300% of SSI covered groups.

7. If the individual is a Medicare beneficiary with income or resources in excess of the full-benefit Medicaid covered groups, evaluate in the Medicare Savings Programs (MSP) groups (QMB, SLMB, QI, QDWI).

8. If the individual is not eligible for Medicaid coverage in an MSP group AND a Plan First evaluation is requested, evaluate in the Plan First covered group.

9. If the individual meets all the requirements, other than income, for coverage in a full benefit Medicaid group, evaluate as MN. C. Referral to Health Insurance Marketplace Unless an individual is incarcerated, an ABD individual who does not have Medicare and is not for eligible for full Medicaid coverage must be referred to the Virginia Health Insurance Marketplace (VIM) so the applicant’s eligibility for the APTC can be determined. Incarcerated individuals and those with Medicare are not referred to the VIM.

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D. Aid Categories Aid Categories (ACs) are used in the eligibility and enrollment systems to denote covered group. Some covered groups have multiple ACs for designating disability status, age, income, and other demographic information. These ACs may be used for reporting and funding purposes. The policy sections for each ABD covered group in this subchapter contain the assigned ACs Exception–ABD individuals of any age who have been determined to be eligible for Medicaid coverage of emergency services based on the alien status requirement policies in subchapter M0220 will be assigned to AC 113 regardless of their covered group.

M0320.001 ABD CATEGORICALLY NEEDY

A. Introduction To be eligible in an ABD covered group, the individual must meet all Medicaid non-financial requirements in chapter M02 and an “Aged,” “Blind” or “Disabled” definition in subchapter M0310. If he does not, then go to the Families & Children covered groups in subchapter M0330. B. Procedures The policy and procedures for determining whether an individual meets an ABD CN covered group are contained in the following sections: • M0320.202 Conversion Cases • M0320.203 Former SSI/AG Recipients • M0320.206 Protected Adult Disabled Children • M0320.207 Protected SSI Disabled Children • M0320.300 ABD with Income ≤ 80% FPL • M0320.400 MEDICAID WORKS • M0320.501 ABD In Medical Institution, Income ≤ 300% SSI • M0320.502 ABD Receiving CBC Services • M0320.503 ABD Hospice • M0320.601 Qualified Medicare Beneficiary (QMB) • M0320.602 Special Low-income Medicare Beneficiary (SLMB) • M0320.603 Qualified Individuals (QI) • M0320.604 Qualified Disabled & Working Individual (QDWI))

M0320.100 ABD CASH ASSISTANCE COVERED GROUPS

A. Legal base Medicaid eligibility for certain individuals is based on their receipt of cash assistance from another benefit program that has a cash assistance component. B. Procedure The policy and procedures for cash assistance recipients are found in the following sections: • M0320.101 SSI Recipients • M0320.102 AG Recipients

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M0320.101 SSI RECIPIENTS

A. Introduction 42 CFR 435.121 - SSI recipients are a mandatory CN Medicaid covered group. Many states automatically enroll an individual in Medicaid when the individual is approved for SSI. However, in Virginia, not all SSI recipients are eligible for Medicaid. Virginia has chosen to impose real property eligibility requirements that are more restrictive than the federal SSI real property eligibility requirements. SSI recipients living in Virginia must apply separately for Medicaid because they are subject to a resource evaluation. The Social Security Administration may approve an SSI applicant as conditionally or presumptively eligible for SSI. Conditionally-eligible SSI recipients are being allowed time to dispose of excess resources. Presumptively blind or disabled SSI recipients are presumed to be blind or disabled; no final blindness or disability determination has been made. An individual who has been conditionally or presumptively approved for SSI is NOT eligible for Medicaid in the SSI Recipients covered group. Evaluate the individual’s eligibility in the MAGI Adults covered group. SSI payments for eligible individuals are effective the first day of the month following the month in which the SSI application was filed. When the Medicaid application is filed in the same month as the SSI application, the applicant is not eligible for Medicaid as an SSI recipient until the month for which he receives his first SSI payment. See policy M0320.101.C. When the SSA record indicates a payment code(s) of “C01” and no payment amount is shown, the individual is considered to be a SSI recipient for Medicaid purposes. If the SSA record indicates a code of EO1 or E02 and no SSI payment has been received in more than twelve months, the individual’s SSI status must be confirmed. Eligibility for months prior to SSI entitlement must be evaluated in the MAGI Adults covered group.

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B. Financial Eligibility 1. Resources Determine if the SSI recipient has the following real property resource(s): 1) equity in non-exempt property contiguous to the individual’s home which exceeds $5,000 and none of the real property exclusions in sections M1130.100, M1130.140, S1130.150, or M1130.160 are applicable to the property; 2) interest in undivided heir property and the equity value of the individual’s share that, when added to all other countable resources, exceeds the appropriate Medicaid resource limit. (The interest in the estate must be legally available.) If a partition suit is necessary to sell the interest, costs of partition and individual’s (recipient/applicant) attorneys' fees may be deducted as described in M1120.215; 3) ownership (equity value) of the individual’s former residence when the SSI recipient is in an institution for longer than 6 months. Determine if the former residence is excluded under policy in section M1130.100 D; 4) equity value in property owned jointly by the SSI recipient with another person in who is not the individual’s spouse as tenants in common or joint tenants with the right of survivorship at common law. Determine if any of the real property exclusions in sections M1130.100, M1130.140, S1130.150, or M1130.160 apply to the property;

5) other real property; determine if any of the real property exclusions in sections M1130.100, M1130.140, S1130.150, or M1130.160 apply to the property. When an SSI recipient has any of the real property listed in 1) through 5) above, ALL of the recipient's resources must be verified, evaluated, and counted together to determine if the SSI recipient meets the Medicaid resource requirements. Calculate resources according to the assistance unit policy in chapter M05. If current resources are within the limit, go on to determine income eligibility. If current resources are NOT within the limit, the individual is NOT eligible in this covered group; he may be eligible as MSP (which has more liberal resource methods and standards).

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When an SSI recipient has no real property resource listed in 1) through 5) above, do NOT determine the SSI recipient’s resources. The SSI recipient meets the Medicaid resource requirements because he receives SSI and does not have a real property resource listed above.

2. Income Verify the SSI recipient's eligibility for SSI payments by an SSI awards notice and inquiring the State On-line Query-Internet (SOLQ-I) system, SDX (State Data Exchange) or SVES (State Verification Exchange System). If the recipient is eligible for SSI, he meets the Medicaid income eligibility requirement. C. Entitlement & Enrollment Eligible individuals in this group are entitled to full Medicaid coverage beginning the first day of the individual’s application month if all eligibility requirements are met in that month, including the receipt of, or entitlement to, an SSI payment in that month. When the SSA record indicates a payment code(s) of “C01” and no payment amount is shown, the individual is considered to be an SSI recipient for Medicaid purposes. If the SSA record indicates a code of EO1 or E02 and no SSI payment has been received in more than twelve months, the individual’s SSI status must be confirmed. Retroactive coverage is applicable to this covered group. However, if the individual did not receive, or was not entitled to, an SSI payment in the retroactiv period, the individual is not eligible for retroactive Medicaid in the SSI recipients covered group. His retroactive eligibility must be evaluated in another Medicaid covered group. The ACs are: • 011 for an aged SSI recipient; • 031 for a blind SSI recipient; • 051 for a disabled SSI recipient. D. Ineligible as SSI Recipient If a non-institutionalized SSI recipient is ineligible for Medicaid because of resources, evaluate the individual’s eligibility in all other Medicaid covered groups including, but not limited to, the ABD with Income ≤ 80% FPL and the MSP covered groups.

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M0320.102 AG RECIPIENTS

A. Policy 42 CFR 435.234 - An Auxiliary Grants (AG) recipient is eligible for Medicaid if he meets the assignment of rights to medical support and third party payments requirements (see M0250). AG eligibility is determined using the AG eligibility policy in the Auxiliary Grant Eligibility Manual. B. Financial Eligibility Verify the AG recipient’s eligibility for AG by agency records. Individuals who receive AG as “Conditional” SSI recipients do not meet the requirements for this covered group. C. Entitlement & Enrollment Eligible individuals in this group are entitled to full Medicaid coverage beginning the first day of the individual’s application month if all eligibility requirements are met in that month. Retroactive coverage is applicable to this covered group. If the person is already eligible for Medicaid as a LTSS recipient, they are eligible as an AG recipient the first day they reside in the Adult Home. The AC should be changed as of that date. If they leave the AH to receive LTSS, the AC should be changed as of the day they leave the AH. The ACs are: • 012 for an aged AG recipient; • 032 for a blind AG recipient; • 052 for a disabled AG recipient.

M0320.200 PROTECTED COVERED GROUPS

A. Legal base Federal law and regulations require that the Medicaid eligibility status of certain groups of persons be protected even though they may not meet current eligibility requirements. These groups, and the applicable eligibility requirements, are described in this section. B. Procedure • M0320.201 Former Money Payment Recipients August 1972 • M0320.202 Conversion Cases • M0320.203 Former SSI/AG Recipients • M0320.204 Protected Widows or Widowers • M0320.205 Qualified Severely Impaired Individuals (QSII)-1619(b) • M0320.206 Protected Adult Disabled Children • M0320.207 Protected SSI Disabled Children.

M0320.201 FORMER MONEY PAYMENT RECIPIENTS AUGUST 1972

A. Policy 42 CFR 435.114 and 42 CFR 435.134--The agency must provide Medicaid to individuals who meet the following conditions: 1. Entitled to OASDI In August 1972 & Received Cash Assistance In August 1972, the individual was entitled to OASDI and • he was receiving AFDC, Old Age Assistance (OAA), Aid to the Blind (AB), or Aid to the Permanently and Totally Disabled (APTD); or • he would have been eligible for one of those programs if he had applied and the Medicaid plan covered this optional group. The Virginia plan covered this group; or

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• he would have been eligible for one of those programs if he was not in a medical institution or intermediate care facility and the Medicaid plan covered this optional group. The Virginia plan covered this group. 2. Would Currently Be Eligible If Increase Were Excluded The individual would meet the F&C income limits for LIFC or currently eligible for SSI or AG except that the increase in OASDI under P.L. 92-336 raised his income over the F&C income limits or SSI. This includes an individual who • meets all LIFC requirements or current SSI requirements except for the requirement to file an application; or • would meet all current LIFC or SSI requirements if he were not in a medical institution or intermediate care facility and the Medicaid plan covers this optional group. The Virginia plan covers this group B. Nonfinancial Requirements The protected individual must meet all of the following criteria: • he was a recipient of OAA, AB, APTD, or AFDC cash assistance as of August, 1972; • his money payment was subsequently discontinued as a result of the 20% increase in Social Security benefits received in October, 1972; • his current countable resources are less than or equal to the current resource limit for Medicaid; and • his current countable income is less than or equal to the F&C income limit or the current SSI income limit, as appropriate, after excluding the 20% increase amount received in 1972. The current SSI standards are in subchapter S0810; the F&C income limit is available from a Regional Medical Assistance Program consultant.

Contact a Medicaid Assistance Consultant if you have an applicant you believe meets this covered group.

M0320.202 CONVERSION CASES

A. Policy 42 CFR 435.131, 435.133--Conversion cases are classified as categorically needy and consist of the following individuals: • blind or disabled individuals eligible in December 1973; • individuals eligible as essential spouses of aged, blind or disabled individuals in December 1973. B. Eligibility Determination The agency must continue the individual’s Medicaid if • the ABD individual continues to meet the December 1973

eligibility requirements of the applicable cash assistance program;

and

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• the essential spouse continues to meet the conditions that were in effect in December 1973 under the applicable cash assistance plan for having his needs included in computing the payment to the ABD individual. C. Essential Spouse The agency must provide Medicaid to any person who was eligible for Medicaid in December 1973 as an essential spouse of an aged, blind or disabled individual who was receiving cash assistance, if the conditions below are met. An “essential spouse” is defined as one who is living with the individual, whose needs were included in determining the amount of cash payment to the individual under OAA, AB, or APTD in December 1973, and who is determined essential to the individual’s well-being. The spouse of the protected conversion person is included in the conversion case if: • his/her needs were included in the OAA, AB, or APTD grant as of December, 1973, and • he/she continues to live in the home of the protected individual D. Blind or Disabled In December 1973 The agency must provide Medicaid to individuals who: • meet all current Medicaid eligibility requirements except the

criteria for blindness or disability; • were eligible for Medicaid in December 1973 as blind or disabled individuals; and for each consecutive month after December 1973, continue to meet the criteria for blindness or disability and the other eligibility requirements used under the Medicaid plan in December 1973. Contact your Regional Medical Assistance Program Consultant if you have an applicant you believe meets this covered group.

M0320.203 FORMER SSI/AG RECIPIENTS

A. Policy 1. Nonfinancial Requirements The protected former SSI/AG recipient must meet the nonfinancial eligibility requirements in chapter M02. The protected former SSI recipient is one who was eligible for and received either: • SSA and SSI, or • SSA and AG, or • SSA, SSI, and AG concurrently, but who became ineligible for SSI or AG due to any reason on or after April 1, 1977. The individual did not have to be receiving Medicaid at that time.

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An individual who concurrently received these benefits does not meet this covered group’s requirements if one of the benefit payments was later recouped because the individual was not entitled to the payment. 2. Financial Requirements The former SSI/AG recipient is eligible for Medicaid if: a. the individual meets the Medicaid resource requirements currently in effect, and the individual's income, less all SSA cost-of-living adjustments (COLAs) received since the most recent month SSI or AG was cancelled (including the COLA received in the month SSI or AG was cancelled) is within the current SSI income limit; OR

b. the individual meets the AG requirements in effect at the time of application or redetermination, including residing in an approved AG home, and the individual's income less the amount of all SSA COLAs received since the most recent month SSI or AG was cancelled (including the COLA received in the month SSI or AG was cancelled) is within the current AG income limit applicable to a resident of that home. c. Any change in SSA benefits other than cost-of-living increases are not excluded, such as an increase due to change from disability benefits to widow's benefits. EXAMPLE #1: Ms. C is age 71. She has never been enrolled in Medicaid before. She applied for Medicaid on February 12, 1997. She received SSA on her own record, in the amount of $280, until March 1, 1994 when she began receiving widow's benefits of $410. She received SSI until March 1, 1994, when SSI was cancelled due to her increased SSA benefit. She received COLA increases in her SSA in January of 1995, 1996, and 1997. Her current SSA is $537. Her countable resources are less than the current Medicaid resource limit. Ms. C meets the former SSI recipient protected individual criteria because she was eligible for and received SSA and SSI concurrently. Her countable income is her SSA amount prior to the January 1, 1995 COLA - $410 - less the $20 disregard. The result, $390, is compared to the current SSI individual limit. Because her resources are within the Medicaid limit, and her countable income of $390 is within the current SSI limit, she is eligible for Medicaid as a protected former SSI recipient. B. Eligibility Procedures 1. Assistance Unit Use the assistance unit composition and resource deeming procedures policy in chapter M05 to determine when a spouse's resources or income are counted or deemed in determining the individual's eligibility. If the protected individual lives with his/her spouse (or parent in the case of a blind/disabled child) whose resources and income would be counted or deemed in determining the individual's SSI or AG eligibility, the SSA cost-of-

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living increase(s) (COLAs) received by the spouse (or parent) since the individual lost SSI or AG eligibility is also excluded in determining the protected individual's income eligibility under this section.

2. Resource Eligibility Resource eligibility is determined by comparing the former SSI recipient’s resources to the current Medicaid resource limit. Determine resources using policy in Chapter S11 (including the real property requirements that are more restrictive than SSI). Calculate resources according to the assistance unit policy in chapter M05. If current resources are within the limit, go on to determine income eligibility. If current resources are NOT within the limit, the individual is NOT eligible in this protected covered group.

3. Income Eligibility a. Countable Income In figuring income to compare to the current SSI or AG income limit, the income exclusions in chapter S08 are applicable including the $20 exclusion. When the individual meets the above criteria for a protected case and the individual’s assistance unit’s resources are within the Medicaid resource limit: 1) Identify the individual's, and the individual's spouse's (or parent's when applicable), amount of Social Security Title II benefits at the time of SSI termination. If this amount is unknown and cannot be obtained, see item 4. below. 2) When the amount of Social Security Title II benefits at the time of SSI termination is determined: • add the Medicare premium amount to the Title II check amount if only the check amount is known (see item 5. below for Medicare premium amounts); • determine if any change in benefit had occurred between loss of SSI and the point of application. If questionable, multiply the prior Title II amount by the COLA percentages and compare to current entitlement. If the figures are significantly different, use the procedures in 4. below to obtain the amount of Title II at the time SSI was terminated; • if there were no changes, count the Title II amount at the time of SSI loss. Subtract the $20 general exclusion; • count all other current sources of income, apply appropriate exclusions, total countable income. b. Allocation For NBD Child(ren) When determining the amount of a spouse's or parent's deemable income, the allocation for a non blind or disabled (NBD) child(ren) in the home is the same regardless of locality (see M0530, Appendix 1). On the income worksheet, insert the SSI individual payment limit whenever the worksheet calls for the Medicaid income limit.

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c. Income Limit Countable income is compared to the AG or SSI income limit for an individual or couple, as appropriate. The SSI limit for a couple is used whenever evaluating a couple when both meet an ABD definition and both request Medicaid. The SSI limit for an individual is used when only one member of a couple applies or meets an ABD definition. The SSI income limit reduced by one-third is used whenever an applicant/recipient lives in the home of another person throughout a month and does not pay his/her pro rata share of food and shelter expenses. Compare total countable income to current appropriate SSI or AG income limit/payment amount as follows: 1) for a protected individual living with a protected or aged, blind, disabled (ABD) spouse who applies for Medicaid, compare the countable income to the current SSI payment limit for a couple. The SSI couple limit is reduced by one-third only if both members of the couple have their shelter and food provided by another person. If income is within the appropriate limit, the individual spouse who meets the protected group criteria is eligible. If both spouses meet the protected group criteria, each is eligible as a former SSI recipient. The non-protected spouse's eligibility is evaluated in another covered group. 2) for an individual living with a spouse and/or minor dependent children who meet a families and children category or do not apply for Medicaid, count only the individual's income and the spouse's deemed income (as determined by deeming procedures in chapter M05) and compare it to the SSI limit for an individual or couple as appropriate. If all food and shelter needs are provided by the spouse or someone else, compare the countable income to the SSI limit for an individual, reduced by one-third. 3) for a blind or disabled child living with a parent, calculate the parent's income (as determined by deeming procedures in chapter M05) and compare the child's countable income to the SSI payment limit for an individual. If all food and shelter needs are provided by the child's parent(s) or someone else, compare the total countable income to the SSI limit for an individual, reduced by one-third. 4. COLA Formula If only the current Title II benefit amount is known OR the benefit was changed or recalculated after loss of SSI, use the formula below to figure the base Title II amount to use in determining financial eligibility. Divide the current Title II entitlement amount by the percentages given. Then follow the steps in item B.3.b. above to determine income eligibility.

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Note: There was no COLA in 2010, 2011 or 2016. The Cost-of-living calculation formula (The formula is the current Title II Benefit divided by the percentage increase to equal the benefit amount before the COLA change):

a. Current Title II Benefit = Benefits before 1/25 COLA 2.8% (1/25 increase) b. Current Title II Benefit= Benefit Before 1/24 COLA 2.5% (1/24 Increase) c. Current Title II Benefit= Benefit Before 1/23 COLA 3.2% (1/23 Increase) d. Current Title II Benefit = Benefit Before 1/22 COLA 1.059 (1/22 Increase) e. Benefit Before 1/22 COLA = Benefit Before 1/21 COLA 1.013 (1/21 Increase)

f. Benefit Before 1/21/ COLA = Benefit Before 1/20 COLA 1.016 (1/20 Increase)

5. Medicare Premiums a. Medicare Part B premium amounts:

1-1-26 $202.90 1-1-25 $185.00 1-1-24 $174.70 1-1-23 $164.90 1-1-22 $170.10 Note: These figures are based on the individual becoming entitled to Medicare during the year listed. The individual’s actual Medicare Part B premium may differ depending on when he became entitled to Medicare. Verify the individual’s Medicare Part B premium in SVES or SOLQ-I if it is necessary to know the premium amount for Medicaid eligibility or post-eligibility purposes. b. Medicare Part A premium amount:

1-1-26 $565.00 1-1-25 $518.00 1-1-24 $505.00 1-1-23 $506.00 1-1-22 $499.00

Contact a Medical Assistance Program Consultant for amounts for years prior to 2022. 6. Evaluation Individuals who are eligible when a cost-of-living increase is excluded are eligible.

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Individuals who are ineligible because of excess income after the cost-of- living increase(s) is excluded can only become Medicaid-eligible in another covered group. If they do not meet an F&C covered group, are not institutionalized, are not receiving CBC or do not have Medicare Part A, they must be determined eligible in a medically needy covered group. The cost-of-living increase(s) is not excluded when determining income eligibility in ANY other covered group. However, these individuals must be identified for possible future protection as the SSI and AG income limits increase. C. Entitlement & Enrollment Eligible individuals in this group are entitled to full Medicaid coverage beginning the first day of the individual’s application month if all eligibility requirements are met in that month. Retroactive coverage is applicable to this covered group. The ACs are: • 021 for an aged individual; • 041 for a blind individual; • 061 for a disabled individual. D. Eligibility for Non- Protected Family Members The amount of an SSA cost-of-living increase that must be excluded when determining eligibility for a former SSI recipient cannot be excluded when determining Medicaid eligibility of the individual’s non-protected spouse and/or children living with the former SSI recipient. The former SSI recipient is included in his/her non-protected spouse's unit if the non-protected spouse is aged, blind, or disabled. The former SSI recipient is included as a member of the family unit when determining a child’s eligibility in an F&C covered group. All of the protected recipient's income, including the cost-of-living increase(s), is counted.

M0320.204 PROTECTED WIDOWS OR WIDOWERS

A. Policy Two groups of disabled widow(er)s who lost SSI eligibility because of receipt of or increase in Title II disabled widow(er)s’ or Title II widow(er)'s benefits have their Medicaid categorically needy eligibility protected. The first group consists of disabled widow(er)s who would be eligible for SSI except for the increase in disability benefits resulting from elimination of the reduction factor under P.L. 98-21 in January 1984. The second group consists of (1) disabled widow(er)s age 60 through 64 years and (2) disabled widow(er)s age 50 through 59 years who would be eligible for SSI except for early receipt of Social Security benefits. B. July 1989 Protected Widow(er)s 42 CFR 435.137 - A “July 1989 protected widow(er)” is an individual who became entitled to SSA benefits when he/she had attained age 50 but not age 60 years, and

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• who applied for Medicaid before July 1, 1989,

• was entitled to monthly OASDI benefits under Title II of the

Social Security Act for December 1983, • was entitled to and received widow’s or widower’s disability benefits under section 202(e) or 202(f) of the Social Security Act for January 1984, • lost SSI and/or AG because of the January 1984 increase in disabled widow(er)'s benefits due to elimination of the reduction factor, • has been continuously entitled to an SSA widow(er)’s disability benefit under section 202(e) or 202(f) of the Social Security Act since the first month that increase was received, and • would be eligible for SSI or AG if the amount of the increase and any subsequent COLAs in the widow(er)s’ SSA benefits were excluded. 1. Nonfinancial Eligibility Determine the widow(er)’s eligibility using the procedures below. The widow(er): a. applied for Medicaid as a protected individual prior to July 1, 1989; b. was entitled to and received a widow's or widower's benefit based on a disability under Section 202 (e) or (f) of the Social Security Act, for January 1984; c. became ineligible for SSI and/or AG payments because of the increase in the amount of his/her widow(er)'s benefit and: • the increase resulted from the elimination of the reduction factor for disabled widow(er)s entitled before age 60, • he/she became ineligible for SSI and/or AG payments in the first month in which that increase was paid to him/her, and • a retroactive payment of that increase for prior months was not made in that month; d. has been continuously entitled to a widow(er)'s disability benefit under Section 202 (e) or (f) of the Social Security Act from the first month tha the increase in his/her widow(er)'s benefit was received; e. would be eligible for SSI or AG if the amount of that increase, and any subsequent cost-of-living adjustments (COLAs) in the widow(er)'s benefits, were deducted from his/her income.

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2. Financial Eligibility a. Assistance Unit Determine whose resources and income will be counted or deemed available according to the assistance unit policy in chapter M05. b. Resource Eligibility Resource eligibility is determined by comparing the widow(er)'s resources to the current Medicaid resource limit. Determine resources using policy in Chapter S11 (including the real property requirements that are more restrictive than SSI). If current resources are within the limit, go on to determine income eligibility. If current resources are NOT within the limit, the individual is NOT eligible in this protected group; he/she may be eligible as an MSP (which has more liberal resource methods and standards). c. Income Eligibility 1) If the individual received SSI (or SSI and AG) and is not currently residing in an approved AG home, the individual's gross SSA benefit amount that was effective in December 1983 plus other current countable income must be within the current SSI individual limit, or couple limit if the individual is married and living with his/her spouse. Calculate income according to the assistance unit policy in chapter M05. Instead of the protected individual’s current SSA benefit amount, use the amount effective in December 1983. Compare the total countable income to the appropriate SSI income limit. If countable income is within the SSI limit, the protected individual is eligible for Medicaid in this protected covered group.

2) If the individual received AG (or AG and SSI) and is currently residing in an approved AG home, the individual's income must be within the current AG limit (home's rate plus personal care allowance). Instead of the protected individual’s current SSA benefit amount, use the amount effective in December 1983. Compare the total countable income to the current AG limit (home's rate plus personal care allowance). If countable income is within that limit, the protected individual is eligible for Medicaid in this protected covered group.

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3) If the individual is not income-eligible, Medicaid eligibility may exist in another covered group. However, when determining eligibility in another covered group, count all current income including the current SSA benefit amount. If the individual does not meet an F&C covered group, is not institutionalized, is not receiving CBC or does not have Medicare Part A, he/she must be determined eligible in a medically needy covered group. C. Protected Disabled Widow(er) 42 CFR § 435.138 specifies that categorically needy eligibility for Medicaid is protected for the group of disabled widow(er)s age 60 through 64 years who meet the criteria specified below. Under 42 USC § 1383c(d), Medicaid protected status was extended to the group of disabled widower(er)s age 50 through 59 years who meet the same criteria. A protected disabled widow(er) is an individual who: • is at least age 50 years (and has not attained age 65); • is not eligible for Medicare Part A hospital insurance; • becomes ineligible for SSI and/or AG because of mandatory application for and receipt of SSA Title II widow(er)'s disability benefits under section 202(e) or 202(f) of the Social Security Act (or any other provision of section 202 if they are also eligible for benefits under subsections (e) or (f) of the Act). • would be eligible for SSI or AG if the SSA widow(er)’s benefit were excluded from income. 1. Nonfinancial Eligibility The protected disabled widow(er) must: a. have received SSI and/or AG for the month before the month in which he/she began receiving SSA Title II disabled widow(er)'s benefits or widow(er)'s benefits; b. be eligible for SSI or AG if the SSA widow(er)s disability benefit were not counted as income.

2. Financial Eligibility a. Assistance Unit Determine whose resources and income will be counted or deemed available according to the assistance unit policy in chapter M05. b. Resource Eligibility Financial eligibility is determined by comparing the widow(er)'s resources to the current Medicaid resource limit. Determine resources using policy in Chapter S11 (including the real property requirements that are more restrictive than SSI). If current resources are within the limit, go on to determine income eligibility.

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If current resources are NOT within the limit, the individual is NOT eligible in this protected group; he/she may be eligible in an MSP covered group (which has more liberal resource methods and standards). c. Income Eligibility When determining a protected widow(er)’s eligibility in this covered group, the agency must deduct from the individual’s income all of the Social Security benefits that made him or her ineligible for SSI. 1) If the individual received SSI (or SSI and AG) and is not currently residing in an approved AG home, the individual's SSA benefit that made him/her ineligible for SSI must be excluded. Other current countable income must be within the current SSI individual limit, or couple limit if the individual is married and living with his/her spouse. Exclude the protected individual’s current SSA widow(er)’s benefit amount. Compare the total countable income to the appropriate SSI income limit. If countable income is within the SSI limit, the protected individual is eligible for Medicaid in this protected covered group. 2) If the individual received AG (or AG and SSI) and is currently residing in an approved AG home, the individual's countable income must be within the current AG limit (home's rate plus personal care allowance). Exclude the protected individual’s current SSA widow(er)’s benefit amount.

Compare the total countable income to the current AG limit (home's rate plus personal care allowance). If countable income is within that limit, the protected individual is eligible for Medicaid in this protected group. 3) If the individual is not income eligible, the individual must be evaluated for Medicaid eligibility in other covered groups. However, when determining eligibility in another covered group, count all current income including the current SSA benefit amount.

D. Entitlement & Enrollment Eligible individuals in this group are entitled to full Medicaid coverage beginning the first day of the individual’s application month if all eligibility requirements are met in that month. Retroactive coverage is applicable to this covered group. The ACs are: • 021 for an aged individual; • 041 for a blind individual; • 061 for a disabled individual.

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M0320.205 QUALIFIED SEVERELY IMPAIRED INDIVIDUALS (QSII)-

1619(B) STATUS

A. Introduction 42 CFR 435.121 - Under Section 1619(a) of the Social Security Act, a disabled individual who would otherwise lose SSI because of work and the demonstration of the ability to perform substantial gainful activity but continues to have a disabling impairment can continue to receive special SSI benefits if he continues to be financially eligible for SSI benefits based on income.

Section 1619(b) of the Act allows a disabled individual whose income is too high to retain financial eligibility for the special SSI benefit under Section 1619(a) and a blind individual who lost regular SSI payments to continue to receive Medicaid benefits under certain criteria specified in Section 1619(b).

The Social Security Administration (SSA) determines whether an individual who lost SSI because of earned income is eligible for 1619(b) status. The local department of social services determines whether an individual who has a 1619(b) status continues to be Medicaid eligible. B. Identifying QSII Individuals To identify a QSII individual, check the "Medicaid Test Indicator" field on the State Verification Exchange System (SVES) WMVE9068 screen or the SOLQ-I screen. If there is a code of A, B, or F, the individual has 1619(b) status.

Since eligibility for 1619(b) can change, check the SVES or SOLQ-I at each redetermination and when there is an indication that a change may have occurred.

C. Determining Eligibility 1. Nonfinancial Eligibility

The QSII individual must have been eligible for and receiving Medicaid coverage as an SSI recipient (must have met the more restrictive real property requirement) in the month immediately preceding the first month of the 1619(b) status. The "Current Pay Status Effective Date" field on the SVES WMVE9065 screen shows the first month of the 1619(b) status.

NOTE: If you cannot determine the first month of 1619(b) status,

contact SSA.

2. Financial Eligibility a. Resource Eligibility Use the following to determine if the QSII recipient has real property resource(s):

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1) equity in non-exempt property contiguous to the individual’s home which exceeds $5,000 and none of the real property exclusions in sections M1130.100, M1130.140, S1130.150, or M1130.160 are applicable to the property; 2) an interest in undivided heir property and the equity value of the individual’s share that, when added to all other countable resources exceeds the appropriate Medicaid resource limit. (The interest in the estate must be legally available. If a partition suit is necessary to sell the interest, costs of partition and attorneys' fees may be deducted as described in M1120.215; 3) ownership (equity value) of an individual’s former residence when the QSII recipient is in an institution for longer than 6 months. Determine if the former residence is excluded under policy in section M1130.100 D; 4) equity value in property owned jointly by the QSII recipient and another person who is not the individual‘s spouse as tenants in common or joint tenants with the right of survivorship at common law. Determine if any of the real property exclusions in sections M1130.100, M1130.140, S1130.150, or M1130.160 apply to the property; 5) other real property; determine if any of the real property exclusions in sections M1130.100, M1130.140, S1130.150, or M1130.160 apply to the property.

When a QSII recipient has any of the real property listed in 1) through 5) previously, ALL of the recipient's resources must be verified, evaluated, and counted together to determine if the recipient meets the Medicaid resource requirements. Calculate resources according to the assistance unit policy in chapter M05. If current resources are NOT within the limit, the individual is NOT eligible in this covered group; he/she may be eligible for Medicare Savings Program (MSP) limited-benefit Medicaid (which has more liberal resource methods and standards). When a QSII recipient has no real property resource listed in 1) through 5) previously, do NOT determine the recipient’s resources. The QSII recipient meets the Medicaid resource requirements because his resource eligibility for QSII has been determined by SSA and he does not have a real property resource as listed previously. b. Income Eligibility There are no income eligibility requirements for QSII individuals once they have been determined eligible as 1619(b).

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D. Entitlement & Enrollment Eligible individuals are entitled to full Medicaid coverage. The ACs are: • 21 for an aged individual; • 41 for a blind individual; or • 61 for a disabled individual. E. Individuals Ineligible as QSII Individuals who are ineligible as QSII because they: • did not receive Medicaid in the month immediately preceding the month in which SSA first determined them eligible under 1619(b) or • lost 1619(b) status must be evaluated for Medicaid eligibility in other covered groups. NOTE: An individual who has 1619(b) status continues to meet the disabled definition. An individual who no longer has 1619(b) status may not meet the disabled definition.

M0320.206 PROTECTED ADULT DISABLED CHILDREN

A. Policy Section 1634(c) of the Social Security Act was amended in 1987 (P.L. 99- 643 §6(b)) to state that if any individual who has attained the age of 18 and is receiving benefits under Title XVI (the Supplemental Security Income program) on the basis of blindness or a disability which began before he or she attained the age of 22 • becomes entitled, on or after the effective date of this subsection (July 1, 1987), to child’s insurance benefits which are payable under section 202(d) on the basis of such disability or to an increase in the amount of the child’s insurance benefits which are so payable; and • ceases to be eligible for SSI because of such child’s insurance benefits under the title or because of the increase in such child’s insurance benefits, shall be treated as receiving SSI benefits for Medicaid eligibility purposes so long as he/she would be eligible for SSI in the absence of such child’s insurance benefits or such increase. B. Nonfinancial Eligibility A protected adult disabled child is one who: • has reached the age of 18 years and receives SSI payments on the basis of blindness or a disability which began before he or she reached the age of 22 years;

• on or after July 1, 1987, becomes entitled to SSA Title II disabled child's insurance benefits on the basis of such disability, or receives an increase in Title II disabled child's insurance benefits;

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• becomes ineligible for SSI on or after July 1, 1987 because of the receipt of, or increase in, Title II disabled child's benefits; • has resources within the current Medicaid resource limit; and • has income which, in the absence of the Title II disabled child's benefit, or in the absence of the increase in such benefit, is within the current SSI income limit.

C. Financial Eligibility Determine whose resources and income will be counted or deemed available according to the assistance unit policy in chapter M05. 1. Resources Financial eligibility is determined by comparing the protected individual’s resources to the current Medicaid resource limit. Determine resources using policy in Chapter S11 (including the real property requirements that are more restrictive than SSI). Calculate resources according to the assistance unit policy in chapter M05. If current resources are within the limit, go on to determine income eligibility. If current resources are NOT within the limit, the individual is NOT eligible in this protected covered group; he/she may be eligible in an MSP covered group (which has more liberal resource methods and standards). 2. Income a. Receipt of SSA Child’s Benefits Causes SSI Ineligibility If the individual began receiving adult disabled child's benefits and this receipt caused SSI ineligibility, then the entire adult disabled child's benefit amount and any subsequent increases in the benefit are excluded when determining the individual's countable income. In determining whether the adult disabled child's income, in absence of the Title II adult disabled child's benefit is within the current SSI income limit, all of the adult disabled child’s other current countable income must be within the current SSI individual limit, or couple limit if the individual is married and living with his/her spouse. Calculate income according to the assistance unit policy in chapter M05, including deeming of parent(s)’ income when the individual is under age 21 and living with a parent(s). Exclude all of the protected individual’s current SSA adult disabled child’s benefit amount. Compare the total countable income to the appropriate SSI income limit. If countable income is within the SSI limit, the protected individual is eligible for Medicaid in this protected covered group. If countable income exceeds the SSI limit, determine the individual’s eligibility in another Medicaid covered group. b. Increase In SSA Child’s Benefits Causes SSI Ineligibility If the individual received an increase in disabled child's benefits and this increase caused SSI ineligibility, only the increase which caused SSI

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ineligibility is excluded when determining the individual's countable income. Calculate income according to the assistance unit policy in chapter M05, including deeming of parent(s)’ income when the individual is under age 21 and living with a parent(s). Exclude the amount of the increase which caused SSI ineligibility.

1) Compare the total countable income to the appropriate SSI

income limit. If countable income is within the SSI limit, the

protected individual is eligible for Medicaid in this protected covered group.

In this situation, the adult disabled child received SSI and SSA concurrently, and lost SSI because of an increase in SSA disabled child's benefits. The amount of the increase that caused SSI ineligibility is excluded. No subsequent increases in the disabled child's benefit are excluded when reviewing the individual's eligibility as a protected adult disabled child. However, if the protected adult disabled child becomes ineligible for Medicaid, evaluate his/her Medicaid eligibility as a protected former SSI recipient using the policy and procedures in Section M0320.201 of this chapter. 2) If countable income exceeds the SSI limit, determine the

individual’s eligibility in another covered group. If the individual

does not meet an F&C MI covered group, is not institutionalized,

is not receiving CBC or does not have Medicare Part A, he/she

must be evaluated in a medically needy covered group. D. Entitlement & Enrollment Eligible individuals in this group are entitled to full Medicaid coverage beginning the first day of the individual’s application month if all eligibility requirements are met in that month. Retroactive coverage is applicable to this covered group. The ACs are: • 021 for an aged individual; • 041 for a blind individual; • 061 for a disabled individual.

M0320.207 PROTECTED SSI DISABLED CHILDREN

A. Introduction The Balanced Budget Act of 1997 (P.L. #105-33) created a new covered group which protects Medicaid eligibility for disabled children who received SSI, whose SSI is canceled solely because the children do not meet the SSI definition of childhood disability (revised per section 211(a) of the Personal Responsibility and Work Opportunity Act of 1996), and who would be paid SSI but for the change in the childhood disability definition. Note: The group of Protected SSI Disabled Children is no longer applicable as all affected children are over age 18; however, it remains in federal regulations.

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B. Nonfinancial Eligibility Requirements To be eligible in this protected covered group, the protected SSI disabled child must • have had his/her SSI canceled solely because he/she does not meet

the SSI definition of childhood disability (revised per section 211(a)

of the Personal Responsibility and Work Opportunity Act of 1996);

• continue to meet the SSI childhood disability definition and regulations that were in effect prior to the effective date of the

change in the disability definition (August 22, 1996); and • be under age 18 years. Note: All affected children are now over age 18 years. 1. Disability Determination Referral to Disability Determination Services (DDS) An SSI disabled child is presumed to meet the childhood disability definition in effect prior to August 22, 1996, until he/she reaches age 18 years, unless there is an improvement in the child’s condition. If the child’s condition improves, complete • DDS Referral Form, available on SPARK at https://fusion.dss.virginia.gov/bp/BP-Home/Medical- Assistance/Forms

• the Disability Report Child (SSA-3820-BK), available at http://www.socialsecurity.gov/online/ssa-3820.pdf and • a minimum of 3 signed, original Authorization to Disclose Information to the Social Security Administration forms (SSA-827), available at http://www.socialsecurity.gov/online/ssa-827.pdf or a form for each medical provider if more than 3. “General Authorization for Medical Information” (form #032-03-311) for each medical practitioner reported by the individual on the report. Send the report(s) and authorization forms to the DDS. 2. DDS Decision If the DDS decides that the child continues to meet the childhood disability definition in effect prior to August 22, 1996, the child continues eligible in the protected group of SSI disabled children, provided the child meets the financial eligibility requirements in item C. below. If the DDS decides that the child no longer meets the childhood disability definition in effect prior to August 22, 1996, the child no longer meets the protected group of SSI disabled children. Determine the child’s eligibility in another covered group. If the child is not eligible in any covered group, send an advance notice to the authorized representative and take action to cancel the child’s Medicaid coverage.

C. Financial Eligibility Procedures

1. Assistance Unit Follow the policy and procedures in M0530.

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2. Resource Eligibility Resource eligibility is determined by comparing the SSI disabled child’s countable resources to the current ABD Medicaid resource limit. Determine resources using policy in Chapter S11 (including the real property requirements that are more restrictive than SSI). Calculate resources according to the assistance unit policy in subchapter M0530. If current resources are within the limit, go on to determine income eligibility. If current resources are NOT within the limit, the child is NOT eligible in the protected SSI disabled children covered group; he/she may be eligible as FAMIS Plus (see M0330.300) if he/she is under age 19 years. 3. Income Eligibility Income eligibility is determined by comparing the SSI disabled child’s income to the current SSI payment limit for an individual. Determine countable income using policy in Chapter S08. Calculate income according to the assistance unit policy in subchapter M0530. If countable income is within the SSI payment limit, the child is eligible for Medicaid in the covered group of protected SSI disabled children. D. Entitlement & Enrollment Children eligible for Medicaid in the covered group of protected SSI disabled children are entitled to full Medicaid coverage beginning the first day of the individual’s application month if all eligibility requirements are met in that month. Retroactive coverage is applicable to this covered group. Eligible protected SSI disabled children are enrolled with program designation “61.”

M0320.300 ABD WITH INCOME ≤ 80% FEDERAL POVERTY LIMIT (FPL)

A. Policy Section 1902(m) of the Social Security Act allows a State to provide full Medicaid benefits to the categorically needy covered group of aged, blind and disabled individuals whose income is less than or equal to a percentage of the federal poverty limit (FPL). The 2000 Appropriations Act mandated that effective July 1, 2001, the State Plan for Medical Assistance be amended to add the covered group of aged, blind and disabled individuals with income less than or equal to 80% FPL. An eligible individual's resources must be within the SSI resource limits.

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B. Financial Eligibility 1. Assistance Unit The assistance unit policy and procedures in chapter M05 apply to ABD individuals with income less than or equal to 80% FPL. If not institutionalized, deem or count any resources and income from the individual’s spouse with whom he lives. If institutionalized with a community spouse, go to subchapter M1480. 2. Resources The resource limit is $2,000 for an individual and $3,000 for a couple. The resource requirements in chapter S11 and Appendix 2 to chapter S11 apply to this covered group. All of the individual’s resources must be verified and evaluated. All nonexempt resources must be added together to determine if the individual meets the Medicaid resource requirements. 3. Income The income limits are < 80% of the FPL and are in section M0810.002. The income requirements in chapter S08 must be met. 4. Income Exceeds 80% FPL Spenddown does not apply to this covered group. If the individual’s income exceeds the 80% FPL limit, he is not eligible in this covered group. Determine the individual’s eligibility in all other Medicaid covered groups. D. Entitlement

If all eligibility factors are met in the application month, entitlement to full Medicaid coverage in this covered group begins the first day of the application month. ABD individuals in this covered group are entitled to retroactive coverage if they meet all the requirements in the retroactive period. E. Enrollment The ABD 80% group AC is: • 029 for an aged individual; • 039 for a blind individual; • 049 for a disabled individual; or • 109 for all incarcerated individuals.

Pages 25 – 30 converted July 1, 2025

M0320 Changes

Changed With Effective Date Sections Changed TN #DMAS-38 4/1/26 M0320.400 TN #DMAS-35 7/1/25 M0320.400 M0320.500 (formatting only)

Virginia Medical Assistance Eligibility Manual

Chapter M03 Section Revision Date July 2025 M0320.000 AGED, BLIND & DISABLED GROUPS M0320.400 MEDICAID WORKS A. Policy

The Appropriations Act of 2006 authorized an amendment to the Virginia State Plan for Medical Assistance that allows disabled (including blind) individuals to work and earn higher income while retaining Medicaid coverage. This program is called MEDICAID WORKS and includes individuals: • at least age 16 and are under age 65, and • who have countable income less than or equal to 138% FPL and • who have countable resources less than or equal to $2,000 for an individual and $3,000 for a couple; and • who are working or have a documented date for employment to begin in the future. • Current participation in the Social Security Administration (SSA) programs Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) will satisfy the condition for disability. Any applicant without SSA documentation of disability should be evaluated by the state’s Disability Determination Services program before eligibility can be established. These individuals can retain Medicaid coverage as long as they remain employed, and their Countable earned income is less than or equal to $6,250 per month. MEDICAID WORKS is Virginia’s Medicaid Buy-In (MBI) program. B. Relationship Between MEDICAID WORKS and 1619(b) Status An individual with SSI or eligible for Medicaid as a Qualified Severely Impaired Individual (QSII) (1619(b)) must meet the 138% FPL income requirement for entry into MEDICAID WORKS and should not be discouraged from enrolling in MEDICAID WORKS. An individual who meets the criteria for 1619(b) status and the 138% income limit may choose to participate in MEDICAID

WORKS because of the higher resource limit. SSI or eligible for Medicaid as a Qualified Severely Impaired Individual (QSII) (1619(b)) individuals are not automatically enrolled in Medicaid Works. They must be evaluated according to the non-financial and financial requirements used for all MEDICAID WORKS applicants and enrollees. Individuals may have their Social Security payments stop when their earnings are above the SSI threshold or SGA level. If the client would otherwise be eligible for a cash benefit if not for their earnings and has not had a determination of medical improvement following a Continuing Disability Review (CDR), they are still considered disabled for Medicaid Works purposes. Individuals receiving 1619(b) Medicaid protections who request enrollment in Medicaid Works are considered disabled but must have their income and resources evaluated according to the guidelines for initial eligibility.

C. Nonfinancial Eligibility The individual must also meet the following additional non-financial criteria: • The individual must be competitively employed in an integrated setting. Work must occur in a work setting in the community or in a personal business alongside people who do not have disabilities. Work performed in a supervised sheltered workshop designed to provide employment opportunities for individuals with disabilities or similar setting is not considered competitive employment in an integrated setting. Contact a Regional Medical Assistance Program Consultant if there is a question about whether the employment meets the criteria for MEDICAID WORKS. • The individual must receive pay at the minimum wage or at the prevailing wage or “going rate” in the community, and the individual must provide documentation that payroll taxes are withheld. Self-employment must be documented according to the policy contained in S0820.210. • The individual must establish a Work Incentive (WIN) Account at a bank or other financial institution, such as a checking or savings account which can be established prior to the application date. The individual must provide documentation for the case record designating the account(s) as a WIN Account. The account must either be a new account or an existing account with only earned income deposited into it. Increases in an enrollee’s Social Security Disability benefits resulting from employment as a MEDICAID WORKS participant OR because of a COLA adjustment to the Social Security Disability benefits may also be deposited into the WIN account and will be excluded as described in M0320.400 D.3.b.3) if the increase is regularly deposited upon receipt into the WIN account. The WIN account cannot contain the individual’s other Social Security benefits. The individual must provide statements from the institution where the account is held at application and renewal. • If there is only one disabled individual on a jointly held account, we presume that all the funds in the account belong to that individual. A previously established ABLE account can be used as a WIN account.

D. Financial Eligibility 1. Assistance Unit a. Initial eligibility determination To qualify for MEDICAID WORKS, the individual must meet the assistance unit policy and procedures in chapter M05 that apply to ABD non-institutionalized individuals. Individuals receiving SSI or who have 1619(b) status must also meet the income requirement for entry into MEDICAID WORKS. Income from a non-ABD spouse, non-applicant/member ABD spouse, or parents is not considered deemable income and is not counted for the initial eligibility determination for individuals requesting to participate in MEDICAID WORKS. Resources from the individual's spouse with whom he lives or, if under age 21, the individual’s parents with whom he lives, must be deemed available. b. Ongoing eligibility

Once the individual is enrolled in MEDICAID WORKS, the individual is treated as an assistance unit of one. Spousal and parental resources and income are disregarded for ongoing enrollee eligibility.