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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M03 January 2023 Subchapter Subject Page ending with Page M0310 GENERAL RULES & PROCEDURES M0310.114 28b

The levels of administrative review are in the following order: a. reconsideration, b. the hearing before an administrative law judge (ALJ), and c. the Appeals Council For example: An individual is enrolled in Medicaid as disabled. However, his SSA claim is denied at the ALJ hearing level. If the individual fails to appeal the ALJ decision to the Appeals Council and the Appeals Council does not decide on its own to review the case, the ALJ decision becomes the final decision once the 60-day deadline for requesting further review has passed. Because the individual no longer meets the disabled definition for another covered group, his Medicaid coverage must be canceled. 6. RRB Denial, Termination and RRB Appeal If RRB denies disability, the disability definition is not met. If the individual has been enrolled in Medicaid as disabled and is not eligible in another covered group, send an advance notice to the recipient to cancel Medicaid. Persons who believe that their claims have not been adjudicated correctly may ask for reconsideration by the Board's Office of Programs. If not satisfied with that review, the applicant may appeal to the Board’s Bureau of Hearings and Appeals. Further, if the individual timely appeals the RRB disability decision, Medicaid coverage must be reinstated until the final decision on the RRB appeal is made. The individual must provide verification that he filed a timely appeal with RRB and must provide verification of the decisions made at all levels of appeal in order for Medicaid to continue during the process. 7. Subsequent SSA/SSI Disability Decisions If the individual appeals a disability denial and the decision is subsequently reversed, reopen and re-evaluate the denied Medicaid application as long as the disability onset month is prior to the month of application or is no later than 90 days after the month of application. If the individual has moved to another locality in Virginia, it is the responsibility of the agency that processed the application to reopen the application and determine eligibility prior to transferring the case. See M1510.104.

M0310.113 RESERVED

M0310.114 FAMILIES & CHILDREN (F&C)

"Families & Children (F&C)" is the group of individuals that consists of • children under 19, • pregnant women, • specified subgroups of children under age 21, • Former Foster Care Children under age 26 (effective January 1, 2014), and • parent/caretakers of dependent children under age 18. Also included in the F&C groups are individuals eligible only for family planning services (Plan First) and participants in BCCPTA.