LIS

Administrative Code

Creating a Report: Check the sections you'd like to appear in the report, then use the "Create Report" button at the bottom of the page to generate your report. Once the report is generated you'll then have the option to download it as a pdf, print or email the report.

Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 110. Eligibility and Appeals
10/15/2024

12VAC30-110-1160. Retroactive spenddown; countable income; entitlement date.

A. Eligibility for retroactive Medicaid entitlement must be determined in all cases in which an individual reports receiving a Medicaid-covered service during the three-month period prior to the month of application, whether the individual is applying for Aid to Families with Dependent Children, auxiliary grant or Medicaid. Eligibility for retroactive coverage shall be determined at the same time as the ongoing eligibility is determined, using the same application.

B. The amount of countable income available to the applicant's family or budget unit is determined for the three-month period prior to application if none of the three months was included in a prior Medicaid coverage or spenddown period, and all other eligibility factors were met. Countable income for the period shall be applied to the appropriate income limit for the period (¼ the annual income limit).

If any of the months in the retroactive period were included in a previous coverage or spenddown period, those months cannot be included in the retroactive period. Only the income received in the retroactive months not included in previous periods are counted in determining retroactive eligibility. Countable income is applied to the appropriate income limit for the number of months actually included in the retroactive period.

C. When the retroactive spenddown is met by medical expenses incurred before the retroactive period, eligibility will begin the first day of the retroactive period.

When the retroactive spenddown is met be expenses incurred during the retroactive period, eligibility will begin the date the spenddown was met.

Eligibility will exist for the remainder of the retroactive period.

When the spenddown is not met, retroactive eligibility does not exist.

If an applicant states that a covered service was received in any one of the three retroactive months, eligibility is to be determined for all three retroactive months, regardless of the service date.

D. The Medicaid application shall be processed to determine both retroactive and prospective Medicaid eligibility beginning with the month of application. Notice of both determinations must be provided in written form to the applicant.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-10-8.2600 § 15, eff. April 30, 1995.

Website addresses provided in the Virginia Administrative Code to documents incorporated by reference are for the reader's convenience only, may not necessarily be active or current, and should not be relied upon. To ensure the information incorporated by reference is accurate, the reader is encouraged to use the source document described in the regulation.

As a service to the public, the Virginia Administrative Code is provided online by the Virginia General Assembly. We are unable to answer legal questions or respond to requests for legal advice, including application of law to specific fact. To understand and protect your legal rights, you should consult an attorney.