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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.