Administrative Code

Virginia Administrative Code
1/24/2022

Part II. Coverage and Eligibility

12VAC30-10-60. Application; determination of eligibility and furnishing Medicaid.

A. The Medicaid agency meets all requirements of 42 CFR Part 435, Subpart J for processing applications, determining eligibility and furnishing Medicaid.

B. 1. Except as provided in subdivisions 2 and 3 of this subsection, individuals are entitled to Medicaid services under the plan during the three months preceding the month of application, if they were, or on application would have been, eligible. The effective date of prospective and retroactive eligibility is specified in 12VAC30-40-10.

2. For individuals who are eligible for Medicaid cost sharing expenses as qualified Medicare beneficiaries under § 1902(a)(10)(E)(i) of the Act, coverage is available for services furnished after the end of the month in which the individual is first determined to be a qualified Medicare beneficiary. 12VAC30-40-10 specifies the requirements for determination of eligibility for this group.

3. Pregnant women are not entitled to ambulatory prenatal care under the plan during a presumptive eligibility in accordance with § 1920 of the Act. 12VAC30-40-10 specifies the requirements for determination of eligibility of this group.

C. The Medicaid agency elects to enter into a risk contract with an HMO that is qualified under Title XIII of the Public Health Service Act or is provisionally qualified as an HMO pursuant to § 1903(m)(3) of the Social Security Act (42 USC § 1396(m)).

The Medicaid agency elects to enter into a risk contract with an HMO that is not federally qualified, but meets the requirements of 42 CFR 434.20(c) and is defined in 12VAC30-20-60.

D. The Medicaid agency has procedures to take applications, assist applicants, and perform initial processing of applications from those low income pregnant women, infants, and children under age 19, described in § 1902(a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), and (a)(10)(A)(ii)(IX) at locations other than those used by the Title IV-A program including FQHCs and disproportionate share hospitals. Such application forms do not include the ADFC form except as permitted by HCFA instructions.

E. Supplemental Nutrition Assistance Program (SNAP) income will be used to support Medicaid eligibility determinations for individuals currently enrolled in SNAP. The Medicaid agency will not alter SNAP procedures while using the reported income to determine Medicaid eligibility using Medicaid rules. The Medicaid agency will obtain all information necessary for a Medicaid eligibility determination that is not in the case record for SNAP from the Medicaid eligibility application.

Statutory Authority

§ 32.1-325 of the Code of Virginia; 42 USC § 1315 and 42 USC § 1396 et seq.

Historical Notes

Subsection A derived from VR460-01-10, eff. June 16, 1993; subsections B and C derived from VR460-01-11, eff. July 1, 1995; subsection D derived from VR460-01-11.1, eff. June 16, 1993; amended, Virginia Register Volume 11, Issue 18, eff. July 1, 1995; Volume 13, Issue 5, eff. January 1, 1997; Volume 37, Issue 24, eff. September 2, 2021.

12VAC30-10-70. Coverage and conditions of eligibility.

Medicaid is available to the groups specified in 12VAC30-30-10 et seq., that is, the mandatory categorically needy, other required special groups, specified optional groups, and the medically needy.*

The conditions of eligibility that must be met are specified in 12VAC30-40-10.

All applicable requirements of 42 CFR 435 and § 1902(a)(10)(A)(i)(IV), (V), and (VI), 1902(a)(10)(A)(ii)(XI), 1902(a)(10)(E), 1902(l) and (m), 1905(p), (q) and (s), 1920, and 1925 of the Act are met.

*Medicaid is available to the groups as identified in 12VAC30-30-10, except for the following: eligibility will be denied any individual for a period of twelve (12) months following the date of their conviction for fraud against the Program.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-12, eff. June 16, 1993.

12VAC30-10-80. Residence.

Medicaid is furnished to eligible individuals who are residents of the State under 42 CFR 435.403, regardless of whether or not the individuals maintain the residence permanently or maintain it at a fixed address.

See 12VAC30-20-230.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-13, eff. July 1, 1987.

12VAC30-10-90. Blindness.

All of the requirements of 42 CFR 435.530 and 42 CFR 435.531 are met. The more restrictive definition of blindness in terms of ophthalmic measurement used in this plan is specified in 12VAC30-30-10.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-14, eff. July 1, 1987.

12VAC30-10-100. Disability.

All of the requirements of 42 CFR 435.540 and 435.541 are met. The State uses the same definition of disability used under the SSI program unless a more restrictive definition of disability is specified in 12VAC30-30-10 item 13 of this plan.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-15, eff. June 16, 1993.

12VAC30-10-110. Financial eligibility.

The Financial eligibility conditions for Medicaid-only eligibility groups and for persons deemed to be cash assistance recipients are described in 12VAC30-40-10 et seq.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-16 and VR460-01-17, eff. June 16, 1993.

12VAC30-10-120. Medicaid furnished out of state.

Medicaid is furnished under the conditions specified in 42 CFR 431.52 to an eligible individual who is a resident of the State while the individual is in another State, to the same extent that Medicaid is furnished to residents in the State.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-18, eff. January 1, 1987.

12VAC30-10-130. Requirements for advance directives.

An advance directive shall be defined as a written instruction, such as a living will or durable power of attorney for health care, recognized under state law and relating to the provision of medical care when the individual is incapacitated. Each specified provider receiving funds under this Plan must maintain written policies, procedures, and materials concerning advance directives to ensure compliance with the law. The specified providers shall be: hospitals, nursing facilities, providers of home health care or personal care services, hospices, health maintenance organizations and health insuring organizations.

Refer to 12VAC30-20-70 for further requirements.

Statutory Authority

Social Security Act Title XIX; 42 CFR 430 to end; all other applicable statutory and regulatory sections.

Historical Notes

Derived from VR460-01-18.1, eff. December 18, 1991.

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