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West Virginia Income Maintenance Manual Chapter 1

West Virginia Income Maintenance Manual Page 39 Chapter 1 Application/Redetermination Process

1.3.4.A.2 Submission Format The SLA can be submitted by mail, phone, electronically through the Federally Facilitated Marketplace (FFM) or WV PATH, or in person for all health coverage and insurance affordability programs. 1.3.4.A.3 Related Forms ➢ Supplement to Application for Health Coverage DFA-SLA-S1 The DFA-SLA-S1 is the supplement used in addition to the DFA-SLA-1 or DFA- SLA-2 to collect additional information required to determine eligibility for Medicaid coverage groups on a basis other than MAGI. The DFA-SLA-S1 is a supplement only and is not used as an application. 1.3.4.B Medical Assistance Application DFA-MA-1 The DFA-MA-1 is a shelf document that can only be used to apply for the following Long Term Care (LTC) Medicaid categories: Nursing Facilities Services, Intermediate Care Facilities (ICF) for Individuals with Intellectual Disabilities, Aged and Disabled Waiver (ADW), Intellectual Disabilities and Developmental Disabilities (IDD) Waiver, Traumatic Brain Injury (TBI) Waiver, and Children with Disabilities Community Service Program (CDCSP). The DFA-MA-1 can also be used to apply for Qualified Medicare Beneficiaries (QMB), Specified Low-Income Medicare Beneficiaries (SLMB), and Qualified Medicare Individuals (QI-1). The DFA-RR-1 is not required. The DFA-MA-1 must only be used for applicants that are not eligible for Medicaid coverage using the Modified Adjusted Gross Income (MAGI) methodology, otherwise the DFA-SLA-1 and DFA-SLA-S1 or DFA-2 must be used as the Medicaid application. 1.3.4.C QMB/SLIMB/QI-1 Application DFA-QSQ-1