Administrative Code

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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 141. Family Access to Medical Insurance Security Plan

12VAC30-141-740. General conditions of eligibility.

A. This section shall be used to determine eligibility of pregnant women for FAMIS MOMS.

B. FAMIS MOMS shall be in effect statewide.

C. Eligible pregnant women must:

1. Be determined ineligible for Medicaid due to excess income by LDSS, by DMAS, or by the CPU;

2. Be a pregnant woman at the time of application;

3. Be a resident of the Commonwealth as described in 12VAC30-141-100 E;

4. Be either a United States citizen, United States national, lawfully residing, or a qualified noncitizen as described in 12VAC30-141-100 E;

5. Be uninsured, that is, not have creditable health insurance coverage; and

6. Not be an inpatient in an institution for mental diseases, or an inmate in a public institution that is not a medical facility.

"Lawfully residing" means the individual is lawfully present in the United States and meets state residency requirements. "Creditable health insurance coverage" means coverage that meets the definition at 42 CFR 457.10.

D. Financial eligibility.

1. Screening. All applications for FAMIS MOMS coverage shall have a Medicaid income eligibility screen completed. Pregnant women determined to be ineligible for Medicaid due to excess income shall have their eligibility for FAMIS MOMS determined.

2. Standards. Income standards for FAMIS MOMS are the same as those described at 12VAC30-141-100 F 2, applied to pregnant women. For purposes of income determination, the family size of the pregnant woman will count the unborn child.

3. Spenddown. DMAS does not apply a spenddown process for FAMIS MOMS where household income exceeds the income eligibility limit for FAMIS MOMS.

E. Coverage under other health plans.

1. Any pregnant woman covered under a group health plan or under health insurance coverage, as defined in § 2791 of the Public Health Services Act (42 USC § 300gg-91(a) and (b)(1)), shall not be eligible for FAMIS MOMS.

2. FAMIS MOMS shall not be a substitution for private insurance.

a. Only uninsured pregnant women shall be eligible for FAMIS MOMS. A pregnant woman is not considered to be insured if the health insurance plan covering the pregnant woman does not have a network of providers in the area where the pregnant woman resides. Each application for FAMIS MOMS coverage shall include an inquiry about health insurance the pregnant woman has at the time of application.

b. Health insurance does not include Medicare, Medicaid, FAMIS or insurance for which DMAS paid premiums under Title XIX through the Health Insurance Premium Payment (HIPP) Program or under Title XXI through the SCHIP premium assistance program.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.

Historical Notes

Derived from Virginia Register Volume 23, Issue 7, eff. January 10, 2007; amended, Virginia Register Volume 23, Issue 19, eff. July 1, 2007; Volume 25, Issue 19, eff. July 1, 2009; Volume 26, Issue 6, eff. January 1, 2010; Volume 29, Issue 21, eff. July 17, 2013; Volume 34, Issue 9, eff. January 24, 2018; Volume 35, Issue 20, eff. June 26, 2019.

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