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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M03 January 2021 Subchapter Subject Page ending with Page M0310 GENERAL RULES & PROCEDURES M0310.112 26

1. LDSS Referrals to DDS for Non- expedited Cases a. Send the following forms to the applicant for completion immediately, giving the applicant 10 calendar days to return the completed forms:

• a copy of the Frequently Asked Questions—Disability Determinations for Medicaid (form #032-03-0426), available on SPARK at https://fusion.dss.virginia.gov/bp/BP-Home/Medical- Assistance/References, explaining the disability determination process and the individual’s obligations;

• the Disability Report Adult (SSA-3368-BK), available at http://www.socialsecurity.gov/online/ssa-3368.pdf, or the Disability Report Child (SSA-3820-BK), available at http://www.socialsecurity.gov/online/ssa-3820.pdf,

• an Authorization to Disclose Information to the Social Security Administration form (SSA-827), available at http://www.socialsecurity.gov/online/ssa-827.pdf.

b. In most cases, the DDS referral is transmitted electronically to DDS through VaCMS. Form 3368-BK or 3830-BK and SSA-827 are uploaded to VaCMS for submission to DDS. No DDS Referral Form is used for electronic submissions. Follow the instructions in the Quick Reference Guide “Sending a DDS Referral in the VaCMS,” available in VaCMS.

c. If the DDS referral cannot be completed in VaCMS, manually submit the referral. Complete the DDS Referral Form, available at https://fusion.dss.virginia.gov/bp/BP-Home/Medical-Assistance/Forms. Use the DDS Referral Form that corresponds with the DDS Regional Office to which the LDSS has been assigned (#032-03-0095, #032-03- 0096, #032-03-0097, or #032-03-0098). To the form, attach the following: • the completed Disability Report • the signed Authorization to Disclose Information • copies of paystubs, if the applicant is currently working.

If the individual’s application was filed with the assistance of a hospital- based eligibility assistance organization, a copy of the consent to release information to the organization must be included with the referral so DDS staff can communicate with them, if necessary.

Mail the DDS Referral form and attachments to the DDS Central Regional (Richmond) Office. See Appendix 1 to this subchapter for the contact information. Do not send referrals to DDS via the courier.

2. Expedited Referrals for Hospitalized Individuals Awaiting Transfer to a Rehabilitation Facility The 2004 Budget Bill mandated that DDS make a disability determination within seven (7) working days of the receipt of a referral from the LDSS when the Medicaid applicant is hospitalized, needs to be transferred directly to a rehabilitation facility AND the individual does not already have a disability application pending with DDS. To ensure that the DDS is able to make the disability determination within the mandated timeframe, the procedures below shall be followed: