Administrative Code

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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

12VAC30-30-60. Requirements relating to determining eligibility for Medicare Prescription Drug Low-Income Subsidy.

The agency provides for making Medicare Prescription Drug Low-Income Subsidy determinations under § 1935(a) of the Social Security Act;

1. The agency makes determinations of eligibility for premium and cost-sharing subsidies under and in accordance with § 1860 D 14 of the Social Security Act;

a. The Social Security Administration's subsidy application (SSA-1020) will be used as the official application form for individuals to request that the state determine eligibility for the Low-Income Subsidy.

b. The application must be filed at the local department of social services in the city or county where the applicant resides. A face-to-face interview is not required.

c. The applicant may be represented by an individual who is authorized to act on behalf of the applicant; if the applicant is incapacitated or incompetent, someone acting responsibly on his behalf; or an individual of the applicant's choice who is requested by the applicant to act as his representative in the application process. The person acting responsibly on behalf of, or acting as the representative of the applicant is required to attest to the accuracy of the information on the application.

d. Applications must be acted on within 45 days from the date the application is received by the local department of social services. A determination of eligibility or ineligibility must be made and the applicant must be sent written notice of his approval or denial of assistance under the Low-Income Subsidy program as well as the reasons for such findings.

e. Redeterminations of eligibility must be made in the same manner and frequency as redeterminations are required under the state's Medicaid State Plan.

f. Family size. The following persons are counted in the family size: the applicant; the applicant's spouse, if living with the applicant; and any persons who are related by blood, marriage or adoption, who are living with the applicant and spouse and who are dependent on the applicant or spouse for at least one-half of their financial support.

g. Financial requirements. Regulations at 20 CFR Part 416 Subparts K and L are used to evaluate income and resources for subsidy eligibility. Current SSI policy can be found in the online Program Operations Manual System (POMS) at Less restrictive rules the state uses for Medicaid determinations are not used for the Low-Income Subsidy determination.

h. The subsidy applicant may appeal his Low-Income Subsidy determination according to the appeal procedures found in the state's Medicaid State Plan.

2. The agency provides for informing the secretary of such determinations in cases in which such eligibility is established or redetermined;

3. The agency provides for screening of individuals for Medicare cost-sharing described in § 1905(p)(3) of the Act and offering enrollment to eligible individuals under the state plan or under a waiver of the state plan.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 23, Issue 11, eff. March 7, 2007.

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