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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M01 January 2021 Subchapter Subject Page ending with Page M0120 MEDICAL ASSISTANCE APPLICATION M0120.300 11

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;