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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M03 October 2024 Subchapter Subject Page ending with Page M0320.000 AGED, BLIND & DISABLED GROUPS M0320.000 1

M0320.000 AGED, BLIND & DISABLED (ABD) GENERAL POLICY PRINCIPLES

A. Overview A State Plan for Medicaid must include the mandatory federal categorically needy (CN) groups of individuals as well as the optional groups a state has elected to cover. This subchapter divides the ABD covered groups into categorically needy and medically needy (MN) groups. B. Procedure Determine an individual’s eligibility first in a CN covered group. This includes eligibility in the Modified Adjusted Gross Income (MAGI) Adults covered group (see M0330.250). If the individual is not eligible in a full-benefit CN covered group, determine the individual’s eligibility as MN (on a spenddown). An evaluation of eligibility for an aged, blind or disabled individual should follow this hierarchy: 1. If the individual is a current SSI/AG recipient, evaluate in this covered group. Exception-- if the individual requests MEDICAID WORKS, go to 5 below.

2. If the individual is a former SSI or AG recipient, evaluate first in the protected covered groups. Exception-- if the individual requests MEDICAID WORKS, go to 5 below.

3. If the individual does not meet the criteria for SSI/AG or protected, is between ages 19 and 64, and is not eligible for or enrolled in Medicare, evaluate next in the MAGI Adults covered group.

4. If the individual is aged and/or is eligible for or has Medicare, evaluate next in the ABD with income < 80% FPL covered group.

5. If a disabled individual has income at or below 138% FPL (including SSI recipients and 1619(b) individuals) and is going back to work, evaluate the individual in the MEDICAID WORKS covered group.

6. If the individual does not meet the requirements for MAGI Adults, 80% FPL group or MEDICAID WORKS, but meets the definition of an institutionalized individual, evaluate in the 300% of SSI covered groups.

7. If the individual is a Medicare beneficiary with income or resources in excess of the full-benefit Medicaid covered groups, evaluate in the Medicare Savings Programs (MSP) groups (QMB, SLMB, QI, QDWI).

8. If the individual is not eligible for Medicaid coverage in an MSP group AND a Plan First evaluation is requested, evaluate in the Plan First covered group.

9. If the individual meets all the requirements, other than income, for coverage in a full benefit Medicaid group, evaluate as MN. C. Referral to Health Insurance Marketplace Unless an individual is incarcerated, an ABD individual who does not have Medicare and is not for eligible for full Medicaid coverage must be referred to the Virginia Health Insurance Marketplace (VIM) so the applicant’s eligibility for the APTC can be determined. Incarcerated individuals and those with Medicare are not referred to the VIM.