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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M04 April 2022 Subchapter Subject Page ending with Page M04 MODIFIED ADJUSTED GROSS INCOME (MAGI) M0450.400 32 Dee’s eligibility determination: Potential covered groups: Child < Age 19 FAMIS Monthly Income limits: Child < Age 19 143% FPL for a HH of 2 = $1,962 FAMIS, 200% FPL for HH of 2 = $2,585 5% FPL for 2 = $65 HH monthly income: $300 (Jane’s gross earnings) $300 is less than the Medicaid Child < Age 19 143% FPL income limit for 2 ($1,962) so Dee is eligible for Medicaid in the Child < Age 19 covered group. The 5% disregard is not applied because it is not necessary; her gross HH income is within the Medicaid Child < Age 19 income limit. M0450.400 GAP-FILLING RULE EVALUATION

A. When to Complete Gap- Filling Evaluation Complete a gap-filling evaluation to determine eligibility for Medicaid or FAMIS whenever all of the following conditions apply: • The individual is in a tax filer household (regardless of whether or not a tax dependent exception in M0430.100 B.2 is met). APTC methodology does not apply to non-filer households or if married parents file separately and live in the same home. • Current monthly household income, using Medicaid/FAMIS MAGI- based methods is over the applicable monthly income limit (including the 5% FPL disregard) for the individual’s covered group. • The total of income already received plus projected income for the calendar year in which eligibility is being determined, using MAGI methods applied by the HIM for the purposes of APTC eligibility, is below 100% FPL (i.e. the lower income threshold for APTC eligibility). See M04, Appendix 1. The individual’s prior income for the calendar year, or lack of income, is included in the calculation of annual income when determining financial eligibility. Note: The individual does not need to apply for the APTC prior to applying for Medicaid or having the gap-filling evaluation completed. The gap-filling evaluation is applicable to the eligibility determination for retroactive and ongoing coverage. If the eligibility and enrollment system is unable to determine eligibility using the gap-filling evaluation, the evaluation must be completed outside the system and documented in the electronic record. If the individual is eligible, the coverage must be entered directly into the Medicaid Enterprise System (MES—formerly the Medicaid Management Information System [MMIS]), and the renewal date must be updated for January of the following year.