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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M01 April 2022 Subchapter Subject Page ending with Page M0120 MEDICAL ASSISTANCE APPLICATION M0120.300 10

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.