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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 M0120.400 12

• 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.