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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 30. Groups Covered and Agencies Responsible for Eligibility Determination |
Section 20. Optional groups other than the medically needy
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The Title IV A agency determines eligibility for Title XIX services.
1. Caretakers and pregnant women who meet the income and resource requirements of AFDC but who do not receive cash assistance.
2. Individuals who would be eligible for AFDC, SSI or an optional state supplement as specified in 42 CFR 435.230, if they were not in a medical institution.
3. A group or groups of individuals who would be eligible for Medicaid under the plan if they were in a NF or an ICF/MR, who but for the provision of home and community-based services under a waiver granted under 42 CFR Part 441, Subpart G would require institutionalization, and who will receive home and community-based services under the waiver. The group or groups covered are listed in the waiver request. This option is effective on the effective date of the state's § 1915(c) waiver under which this group(s) is covered. In the event an existing § 1915(c) waiver is amended to cover this group(s), this option is effective on the effective date of the amendment.
4. Individuals who would be eligible for Medicaid under the plan if they were in a medical institution, who are terminally ill, and who receive hospice care in accordance with a voluntary election described in § 1905(o) of the Act.
5. The state does not cover all individuals who are not described in § 1902(a)(10)(A)(i) of the Act, who meet the income and resource requirements of the AFDC state plan and who are under the age of 21. The state does cover reasonable classifications of these individuals as follows:
a. Individuals for whom public agencies are assuming full or partial financial responsibility and who are:
(1) In foster homes (and are under the age of 21).
(2) In private institutions (and are under the age of 21).
(3) In addition to the group under subdivisions 5 a (1) and (2) of this section, individuals placed in foster homes or private institutions by private nonprofit agencies (and are under the age of 21).
b. Individuals in adoptions subsidized in full or part by a public agency (who are under the age of 21).
c. Individuals in NFs (who are under the age of 21). NF services are provided under this plan.
d. In addition to the group under subdivision 5 c of this section, individuals in ICFs/MR (who are under the age of 21).
6. A child for whom there is in effect a state adoption assistance agreement (other than under Title IV-E of the Act), who, as determined by the state adoption agency, cannot be placed for adoption without medical assistance because the child has special care needs for medical or rehabilitative care, and who before execution of the agreement:
a. Was eligible for Medicaid under the state's approved Medicaid plan; or
b. Would have been eligible for Medicaid if the standards and methodologies of the Title IV-E foster care program were applied rather than the AFDC standards and methodologies.
The state covers individuals under the age of 21.
7. Section 1902(f) states and SSI criteria states without agreements under §§ 1616 and 1634 of the Act.
The following groups of individuals who receive a state supplementary payment under an approved optional state supplementary payment program that meets the following conditions. The supplement is:
a. Based on need and paid in cash on a regular basis.
b. Equal to the difference between the individual's countable income and the income standard used to determine eligibility for the supplement.
c. Available to all individuals in each classification and available on a statewide basis.
d. Paid to one or more of the following classifications of individuals:
(1) Aged individuals in domiciliary facilities or other group living arrangements as defined under SSI.
(2) Blind individuals in domiciliary facilities or other group living arrangements as defined under SSI.
(3) Disabled individuals in domiciliary facilities or other group living arrangements as defined under SSI.
(4) Individuals receiving a state administered optional state supplement that meets the conditions specified in 42 CFR 435.230.
The supplement varies in income standard by political subdivisions according to cost-of-living differences.
The standards for optional state supplementary payments are listed in 12VAC30-40-250.
8. Individuals who are in institutions for at least 30 consecutive days and who are eligible under a special income level. Eligibility begins on the first day of the 30-day period. These individuals meet the income standards specified in 12VAC30-40-220.
The state covers all individuals as described above.
9. Individuals who are 65 years of age or older or who are disabled as determined under § 1614(a)(3) of the Act, whose income does not exceed the income level specified in 12VAC30-40-220 for a family of the same size, and whose resources do not exceed the maximum amount allowed under SSI.
10. Individuals required to enroll in cost-effective employer-based group health plans remain eligible for a minimum enrollment period of one month.
11. Women who have been screened for breast or cervical cancer under the Centers for Disease Control and Prevention Breast and Cervical Cancer Early Detection Program established under Title XV of the Public Health Service Act in accordance with § 1504 of the Act and need treatment for breast or cervical cancer, including a pre-cancerous condition of the breast or cervix. These women are not otherwise covered under creditable coverage, as defined in § 2701(c) of the Public Health Services Act, are not eligible for Medicaid under any mandatory categorically needy eligibility group, and have not attained age 65.
12. Individuals who may qualify for the Medicaid Buy-In program under § 1902(a)(10)(A)(ii)(XV) of the Social Security Act (Ticket to Work Act) if they meet the requirements for the 80% eligibility group described in 12VAC30-40-220, as well as the requirements described in 12VAC30-40-105 and 12VAC30-110-1500.
Historical Notes
Derived from VR460-02-2.2100:1, eff. June 16, 1993; amended, Volume 11, Issue 10, eff. March 9, 1995; Volume 17, Issue 13, eff. April 11, 2001; Volume 17, Issue 18, eff. July 1, 2001; Errata, 17:21 VA.R. July 2, 2001; amended, Virginia Register Volume 25, Issue 21, eff. July 23, 2009.