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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M03 July 2025 Subchapter Subject Page ending with Page M0310 GENERAL RULES & PROCEDURES M0310.112 28

application is pending for the disability determination. DDS does NOT stop the disability determination when the individual has excess income because of possible spenddown eligibility

4. LDSS Responsibilities for Communication with DDS The LDSS must make every effort to provide DDS with complete and accurate information and shall report all changes in address, medical condition, and earnings to the DDS on pending applications. 5. Evaluation for Plan First and Referral to Health Insurance Marketplace While an individual’s application is pending during the non-expedited disability determination process, evaluate his eligibility in non-ABD covered groups (e.g. MAGI Adults, and Plan First if requested). If the individual is not eligible for full Medicaid coverage, refer the individual to the Virginia Health Insurance Marketplace (VIM) for evaluation for the Advance Premium Tax Credit (APTC). H. Notification of DDS Decision to LDSS 1. Hospitalized Individuals

The DDS will advise the agency of the applicant’s disability status as soon as it is determined by either SSA or the DDS. For hospitalized individuals who meet the requirements for an expedited disability determination, DDS will fax the outcome of the disability determination directly to the LDSS responsible for processing the application and enrolling the eligible individual.

2. Individuals Not Hospitalized For all other disability determinations, DDS will notify the LDSS responsible for processing the application and enrolling the eligible individual will fax the outcome of the disability determination directly to the LDSS responsible for processing the application and enrolling the eligible individual. If the claim is denied, DDS will also include a personalized denial notice to be sent to the applicant explaining the outcome of his disability determination.

3. Disability Cannot Be Determined Timely A disability determination cannot be completed within the allotted time when there is missing or incomplete medical information. DDS will notify the applicant about 75 days from the application date of the delay. DDS will notify the LDSS with a delay letter to the worker and the client. Upon receipt of the delay letter the LDSS must send the applicant a Notice of Action to extend the pending application. 4. DDS Rescinds Disability Denial DDS will notify the agency if it rescinds its denial of an applicant’s disability to continue an evaluation of the individual’s medical evidence. If the Medicaid application has been denied, the agency must reopen the application and notify the applicant of the action. The application continues to pend until notification is received from DDS of the disability determination. If an appeal has been filed with DMAS, the agency must notify the DMAS Appeals Division so that the appeal may be closed (see M1650.100). I. LDSS Action & Notice to the Applicant The eligibility worker must complete the Medicaid eligibility determination immediately after receiving notice of the applicant’s disability status and send the applicant a Notice of Action regarding the disability determination and the agency’s decision on the Medicaid application.