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Virginia Administrative Code
Title 12. Health
Agency 30. Department Of Medical Assistance Services
Chapter 30. Groups Covered and Agencies Responsible for Eligibility Determination
12/2/2020

12VAC30-30-20. Optional groups other than the medically needy.

The Title IV-A agency determines eligibility for Title XIX services. The following groups are eligible:

1. Individuals who would be eligible for SSI or an optional state supplement as specified in 42 CFR 435.230 if they were not in a medical institution.

2. A group or groups of individuals who would be eligible for Medicaid under the plan if they were in a nursing facility (NF) or an intermediate care facility for individuals with intellectual disabilities (ICF/IID), 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 is or these groups are covered. In the event an existing § 1915(c) waiver is amended to cover this group or these groups, this option is effective on the effective date of the amendment.

3. 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.

4. The Commonwealth 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 state plan and who are younger than the age of 21 years. The Commonwealth 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 younger than the age of 21 years).

(2) In private institutions (and are younger than the age of 21 years).

(3) In addition to the group under subdivisions 4 a (1) and 4 a (2) of this section, individuals placed in foster homes or private institutions by private nonprofit agencies (and are younger than the age of 21 years).

b. Individuals in adoptions subsidized in full or part by a public agency (who are younger than the age of 21 years).

c. Individuals in NFs (who are younger than the age of 21 years). NF services are provided under this plan.

d. In addition to the group under subdivision 4 c of this section, individuals in ICF/IIDs (who are younger than the age of 21 years).

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

5. 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 was eligible for Medicaid under the state's approved Medicaid plan.

The Commonwealth covers individuals younger than the age of 21 years.

MAGI-based income methodologies in 12VAC30-40-100 shall be used in calculating household income.

6. 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.

7. 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 Commonwealth covers all individuals as described in this subdivision.

8. 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.

9. Individuals required to enroll in cost-effective employer-based group health plans remain eligible for a minimum enrollment period of one month.

10. Individuals 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 Public Health Service Act and need treatment for breast or cervical cancer, including a pre-cancerous condition of the breast or cervix. These individuals 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.

11. 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.

12. Individuals under the State Eligibility Option of P.L. 111-148 § 2303 who are not pregnant and whose income does not exceed the state established income standard for pregnant women in the Virginia Medicaid and CHIP State Plan and related waivers, which is 200% of the federal poverty level, shall be eligible for the family planning program. Services are limited to family planning services as described in 12VAC30-50-130 D.

Statutory Authority

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

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. 3124 July 2, 2001; amended, Virginia Register Volume 25, Issue 21, eff. July 23, 2009; Volume 33, Issue 11, eff. February 22, 2017; Volume 33, Issue 21, eff. July 27, 2017; Errata, 34:6 VA.R. 718 November 13, 2017.

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