Section 90. Application procedures and waiting list

A. An application for assistance under the Uninsured Medical Catastrophe Fund must be on a form prescribed by DMAS and signed by the applicant. Funds will be committed on behalf of eligible individuals on a first-come, first-served basis based on the date and time the original signed application is received by DMAS or its agent.

B. Applicants must: (i) provide a statement signed by a physician licensed in the state in which he practices who has examined the individual certifying that the individual has a life-threatening illness or injury as defined in this regulation and (ii) submit a treatment plan developed by a potential contracting provider and signed by a physician licensed in the state in which he practices.

C. It is the responsibility of the applicant to provide financial and medical information necessary to determine eligibility and approve the treatment plan. Failure to complete the application, submit the items in subsection B of this section, or provide requested information within 30 days of the date of the original signed application is grounds for denial.

D. Eligibility for Uninsured Medical Catastrophe Funds and approval of the treatment plan shall be determined by DMAS within 45 days of the date the original signed application was received. DMAS will not fully evaluate an application if it has determined that there is at least one cause for disqualification. DMAS shall advise in writing all applicants within 45 days of its determination about their applications.

E. DMAS may establish a waiting list if funds are insufficient to make commitments for all applicants. Applicants will be placed on the waiting list in the order that the original signed application was received by DMAS or its agent. An applicant will be taken off the waiting list if (i) there is an adverse determination regarding eligibility and no expedited appeal has been requested, (ii) the treatment plan is denied, (iii) the applicant requests to be taken off the waiting list, or (iv) the applicant dies. An applicant who prevails on appeal or in circuit court will be restored to the waiting list based on the date of the original signed application, but this action does not affect any contracts signed in the interim.

F. If more than 60 days have elapsed between the date that DMAS initially determines an applicant eligible and approves the treatment plan and the date that funds become available, DMAS may review and revise the eligibility and treatment plan decisions. DMAS may require applicants to update the information provided in the original application.

G. An application may be denied if no provider is willing to contract with DMAS pursuant to 12VAC30-150-70 within 30 days of a favorable determination of eligibility, approval of the treatment plan, and the availability of funds.

H. DMAS may establish additional application procedures as necessary.

Historical Notes

Derived from Volume 18, Issue 17, eff. June 6, 2002; amended, Virginia Register Volume 22, Issue 25, eff. November 6, 2006.

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.