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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M01 July 2019 Subchapter Subject Page ending with Page M0130 APPLICATION PROCESSING M0130.300 11

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.