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Virginia Administrative Code (Last Updated: January 10, 2017) |
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Title 12. Health |
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Agency 30. Department of Medical Assistance Services |
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Chapter 141. Family Access to Medical Insurance Security Plan |
Section 150. Application requirements
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A. Availability of program information. DMAS or its designee shall furnish the following information in written form and orally as appropriate to all applicants and to other individuals who request it:
1. The eligibility requirements;
2. Summary of covered benefits;
3. Copayment amounts required; and
4. The rights and responsibilities of applicants and enrollees.
B. Opportunity to apply. DMAS or its designee must afford an individual, wishing to do so, the opportunity to apply for child health insurance. Applications for health insurance will be accepted at a central site designated by DMAS and at local departments of social services throughout the Commonwealth. Applicants may file an application for child health insurance by mail, by fax, or in person at local departments of social services. Applications filed at the FAMIS CPU can be submitted by mail, by fax, via the Internet, or by phone. Face-to-face interviews for the program are not required. Eligibility determinations for FAMIS shall occur at either local departments of social services or at the DMAS designated central site.
C. Right to apply. An individual who is 18 years of age shall not be refused the right to complete an application for health insurance for himself and shall not be discouraged from asking for assistance for himself under any circumstances.
D. Applicant's signature. The applicant must sign state-approved application forms submitted, even if another person fills out the form, unless the application is filed and signed by the applicant's parent, adult relative caretaker, legal guardian or conservator, attorney-in-fact or authorized representative.
E. The authorized representative for an individual 18 years of age or older shall be those individuals as set forth in 12VAC30-110-1380.
F. The authorized representative for children younger than 18 years of age shall be those individuals as set forth in 12VAC30-110-1390.
G. Persons prohibited from signing an application. An employee of, or an entity hired by, a medical service provider who stands to obtain FAMIS payments shall not sign an application for health insurance on behalf of an individual who cannot designate an authorized representative.
H. Written application. DMAS or its designee shall require a written application from the applicant if he is at least 18 years of age or older, or from a parent, adult relative caretaker, guardian, legal custodian, or authorized representative if the applicant is less than 18 years of age or the applicant is incapacitated. The application must be on a form prescribed by DMAS, and must be signed under a penalty of perjury. The application form shall contain information sufficient to determine Medicaid and FAMIS eligibility.
I. Assistance with application. DMAS or its designee shall allow an individual or individuals of the applicant's choice to assist and represent the applicant in the application process, or a redetermination process for eligibility.
J. Timely determination of eligibility. The time processing standards for determining eligibility for child health insurance begin with the date a signed application is received either at a local department of social services or the FAMIS CPU. An application for health insurance received at local departments of social services must have a full Medicaid eligibility determination and, when a child is determined to be ineligible for Medicaid due to excess income, a FAMIS eligibility determination performed, within the same Medicaid case processing time standards.
Except in cases of unusual circumstances as described below, an application for health insurance received at the FAMIS CPU and screened as ineligible for Medicaid, shall have a FAMIS eligibility determination completed within 10 business days of the date the complete application was received at the CPU. Applications that are screened as Medicaid likely will be processed within Medicaid case processing time standards.
1. Unusual circumstances include: administrative or other emergency beyond the agency's control. In such case, DMAS, or its designee, or the LDSS must document, in the applicant's case record, the reasons for delay. DMAS or its designee or the local department of social services must not use the time standards as a waiting period before determining eligibility or as a reason for denying eligibility because it has not determined eligibility within the time standards.
2. Incomplete applications shall be held open for a period of 30 calendar days to enable applicants to provide outstanding information needed for an eligibility determination. Any applicant who fails to provide, within 30 calendar days of the receipt of the initial application, information or verifications necessary to determine eligibility, shall have his application for FAMIS eligibility denied.
K. Notice of DMAS', its designee's or the local department of social services' decision concerning eligibility. DMAS, its designee or the local department of social services must send each applicant a written notice of the agency's/designee's decision on his application, and, if approved, his obligations under the program. If eligibility for FAMIS is denied, notice must be given concerning the reasons for the action and an explanation of the applicant's right to request a review of the adverse actions, as described in 12VAC30-141-50.
L. Case documentation. DMAS, its designee, or the local department of social services must include in each applicant's record all necessary facts to support the decision on his application, and must dispose of each application by a finding of eligibility or ineligibility, unless (i) there is an entry in the case record that the applicant voluntarily withdrew the application and that the agency or its designee sent a notice confirming his decision; or (ii) there is a supporting entry in the case record that the applicant cannot be located.
M. Case maintenance. All cases approved for FAMIS shall be maintained at the FAMIS CPU. Children determined by local departments of social services to be eligible for FAMIS shall have their cases transferred to the FAMIS CPU for ongoing case maintenance. The FAMIS CPU will be responsible for providing newly enrolled recipients with program information, benefits available, how to secure services under the program, a FAMIS handbook, and for processing changes in eligibility and annual renewals within established time frames.
N. Redetermination of eligibility. DMAS or the FAMIS CPU must redetermine the eligibility of enrollees with respect to circumstances that may change at least every 12 months. During the 12-month period of coverage, enrollees must make timely and accurate reports if an enrollee no longer resides in the Commonwealth of Virginia or when changes in income exceed 200% of the federal poverty level. DMAS or the FAMIS CPU must promptly redetermine eligibility when it receives information about changes in a FAMIS enrollee's circumstances that may affect eligibility.
O. Notice of decision concerning eligibility. DMAS or the FAMIS CPU must give enrollees timely notice of proposed action to terminate their eligibility under FAMIS. The notice must meet the requirements of 42 CFR 457.1180.
Historical Notes
Derived from Volume 19, Issue 21, eff. August 1, 2003; amended, Virginia Register Volume 23, Issue 07, eff. January 10, 2007.