Administrative Code

Virginia Administrative Code
6/30/2022

Part III. Financial Eligibility

12VAC30-40-90. Income and resource levels and methods.

Article 1
General

A. For individuals who are AFDC-related medically needy or SSI recipients, the income and resource levels and methods for determining countable income and resources of the AFDC and SSI program apply, unless the plan provides for more restrictive levels and methods than SSI for SSI recipients under § 1902(f) of the Act, or more liberal methods under § 1902(r)(2) of the Act, as specified in this section.

B. For individuals who are not AFDC-related medically needy or SSI recipients in a non-section 1902(f) state and those who are deemed to be cash assistance recipients, the financial eligibility requirements specified in this article apply.

C. 12VAC30-40-100 specifies the methods for determining income for individuals evaluated using modified adjusted gross income (MAGI) methodology.

D. 12VAC30-40-220 specifies the income levels for mandatory and optional categorically needy groups of individuals, including individuals with incomes related to the federal income poverty level, that is pregnant women and infants or children covered under §§ 1902(a)(10)(A)(i)(IV), 1902(a)(10)(A)(i)(VI), 1902(a)(10)(A)(i)(VII), and 1902(a)(10)(A)(ii)(IX) of the Act and aged and disabled individuals covered under § 1902(a)(10)(A)(ii)(X) of the Act, and for mandatory groups of qualified Medicare beneficiaries covered under § 1902(a)(10)(E)(i) of the Act.

E. 12VAC30-40-230 specifies the resource levels for mandatory and optional categorically needy poverty level related groups and for medically needy groups.

F. 12VAC30-40-260 specifies the income levels for categorically needy aged, blind, and disabled persons who are covered under requirements more restrictive than SSI.

G. 12VAC30-40-240 specifies the methods for determining resource eligibility used by states that have more restrictive methods than SSI, permitted under § 1902(f) of the Act.

H. 12VAC30-40-270 specifies the resource standards to be applied for categorically needy individuals in states that have elected to impose more restrictive eligibility requirements than SSI, permitted under § 1902(f) of the Act.

I. 12VAC30-40-280 specifies the methods for determining income eligibility used by states that are more liberal than the methods of the cash assistance programs, permitted under § 1902(r)(2) of the Act.

J. 12VAC30-40-290 specifies the methods for determining resource eligibility used by states that are more liberal than the methods of the cash assistance programs, permitted under § 1902(r)(2) of the Act.

Statutory Authority

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

Historical Notes

Derived from VR460-02-2.6100 C, eff. July 1, 1993; amended, VR460-02-2.6100:1, eff. November 15, 1995; Volume 33, Issue 21, eff. July 27, 2017.

12VAC30-40-100. Methods of determining income.

A. Families and Children Medically Needy individuals.

1. In determining countable income for Families and Children Medically Needy individuals, the methods under the state's July 16, 1996, approved Aid to Families with Dependent Children plan and any more liberal methods described in 12VAC30-40-280 are used.

2. In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to children living with parents until the children become 21 years of age.

3. Agency continues to treat women eligible under the provisions of § 1902(a)(10) of the Act as eligible, without regard to any changes in income of the family of which she is a member, for the 60-day period after her pregnancy ends and any remaining days in the month in which the 60th day falls.

B. Individuals subject to the use of modified adjusted gross income (MAGI) methodology. In determining income eligibility for individuals subject to the use of MAGI-based methodologies, the following shall apply:

1. The Commonwealth shall apply MAGI-based methodologies as described in this subsection, and consistent with 42 CFR 435.603 and § 1902(e)(14) of the Act. Individuals subject to the use of MAGI-based income methodologies include:

a. Parents/caretaker relatives under §§ 1902(a)(10)(A)(i)(l) and 1931 of the Act.

b. Pregnant women under §§ 1902(a)(10)(A)(i)(l), (lll), (IV), (ii)(l), ((IV), (IX) and 1931 of the Act.

c. Children under the age of 19 years under §§ 1902(a)(10)(A)(i)(l), (lll), (IV), (VI), (VII), (ii)((IV), (IX) and 1931 of the Act.

d. Reasonable classifications of children younger than the age of 21 years under §§ 1902(a)(10)(A)(ii)(l) and (IV) of the Act.

e. Individuals younger than the age of 21 years who are under a state adoption assistance agreement under § 1902(a)(10)(A)(ii)(VIII) of the Act.

2. In the case of determining the ongoing eligibility for individuals determined eligible for Medicaid on or before December 31, 2013, MAGI-based income methodologies shall not be applied until March 31, 2014, or the next regularly scheduled renewal of eligibility, whichever is later, if the applications of such methods should result in determination of ineligibility prior to such date.

C. In determining family size for the eligibility determination of a pregnant woman, the pregnant woman shall be counted as herself plus each of the children she is expected to deliver. In determining family size during the eligibility determination of the other individuals in a household that includes a pregnant woman, the pregnant woman shall be counted as just herself.

D. Financial eligibility shall be determined consistent with the following provisions:

1. Financial eligibility shall be based on current monthly income and family size when determining eligibility for new applicants.

2. Financial eligibility shall be based on current monthly household income and family size when determining eligibility for currently enrolled individuals.

3. Household income shall be the sum of the MAGI-based income of every individual included in the individual's household except as provided at 42 CFR 435.603(d)(2) through 42 CFR 435.603(d)(4).

4. An amount equivalent to five percentage points of the federal poverty level for the applicable family size shall be deducted, in determining eligibility for Medicaid, from the household income in accordance with 42 CFR 435.603(d).

5. The age used for children with respect to 42 CFR 435.603(f)(3)(iv) shall be 19 years of age.

E. Aged individuals. In determining countable income for aged individuals, including aged individuals with incomes up to the federal poverty level described in § 1902(m)(1) of the Act, the following methods are used.

1. The methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

2. For optional state supplement recipients in § 1902(f) states and SSI criteria states without § 1616 or § 1634 agreements, SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

3. In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses.

F. Blind individuals. In determining countable income for blind individuals, only the methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

For optional state supplement recipients in § 1902(f) states and SSI criteria states without § 1616 or § 1634 agreements, the SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses and the income of parents as available to children living with parents until the children become 21 years of age.

G. Disabled individuals. In determining countable income of disabled individuals, including disabled individuals with incomes up to the federal poverty level described in § 1902(m) of the Act, the methods of the SSI program, any more liberal methods described in 12VAC30-40-280, or both apply.

For optional state supplement recipients in § 1902(f) of the Act states and SSI criteria states without § 1616 or § 1634 agreements, the SSI methods, any more liberal methods than SSI described in 12VAC30-40-280, or both apply.

In determining relative financial responsibility, the agency considers only the income of spouses living in the same household as available to spouses and the income of parents as available to children living with parents until the children become 21 years of age.

H. Qualified Medicare beneficiaries. In determining countable income for qualified Medicare beneficiaries covered under § 1902(a)(10)(E)(i) of the Act, the methods of the SSI program, more liberal methods described in 12VAC30-40-280, or both are used.

If an individual receives a Title II benefit, any amounts attributable to the most recent increase in the monthly insurance benefit as a result of a Title II COLA is not counted as income during a "transition period" beginning with January, when the Title II benefit for December is received, and ending with the last day of the month following the month of publication of the revised annual federal poverty level.

For individuals with Title II income, the revised poverty levels are not effective until the first day of the month following the end of the transition period.

For individuals not receiving Title II income, the revised poverty levels are effective no later than the date of publication.

I. Qualified disabled and working individuals. In determining countable income for qualified disabled and working individuals covered under § 1902(a)(10)(E)(ii) of the Act, the methods of the SSI program are used.

Statutory Authority

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

Historical Notes

Derived from VR460-02-2.6100 C, eff. June 16, 1993; amended, Virginia Register Volume 17, Issue 13, eff. April 11, 2001; Volume 20, Issue 4, eff. December 3, 2003; Volume 33, Issue 21, eff. July 27, 2017.

12VAC30-40-105. Financial eligibility.

Working Individuals with Disabilities; Basic Coverage Group (Ticket to Work and Work Incentive Improvement Act (TWWIIA)).

The following standards and methods shall be applied in determining financial eligibility:

1. The agency applies the following income and resource standards to applicants of this program:

a. The individual's total countable income shall not exceed 80% of the current federal poverty income guidelines; and

b. The individual's total countable assets shall not exceed $2,000.

2. Income methodologies. In determining whether an individual meets the income standard described in subdivision 1 of this section, the agency uses more liberal income methodologies than the SSI program as further described in 12VAC30-40-280.

3. Resource methodologies. The agency uses resource methodologies in addition to any indicated in subdivisions 1 and 2 of this section that are more liberal than those used by the SSI program as described in 12VAC30-40-290.

Statutory Authority

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

Historical Notes

Derived from Virginia Register Volume 25, Issue 21, eff. July 23, 2009.

12VAC30-40-110. Medicaid qualifying trusts.

In the case of a Medicaid qualifying trust described in § 1902(k)(2) of the Act, the amount from the trust that is deemed available to the individual who established the trust (or whose spouse established the trust) is the maximum amount that the trustee(s) is permitted under the trust to distribute to the individual. This amount is deemed available to the individual, whether or not the distribution is actually made. This provision does not apply to any trust or initial trust decree established before April 7, 1986, solely for the benefit of a mentally retarded individual who resides in an intermediate care facility for the mentally retarded.

The policy for qualifying trusts which is effective for trusts established or assets disposed of after August 10, 1993, is located in 12VAC30-40-300.

Statutory Authority

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

Historical Notes

Derived from VR460-02-2.6100 C, eff. April 20, 1994.

12VAC30-40-120. Medically needy income levels (MNILs) based on family size.

Medically needy income levels (MNILs) are based on family size.

12VAC30-40-220 specifies the MNILs for all covered medically needy groups. If the agency chooses more restrictive levels under § 1902(f) of the Act, 12VAC30-40-220 so indicates.

Statutory Authority

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

Historical Notes

Derived from VR460-02-2.6100 C, eff. April 20, 1994.

12VAC30-40-130. Handling of excess income; spend-down.

Handling of excess income - Spend-down for the medically needy in all states and the categorically needy in 1902(f) states only.

a. Medically Needy

(1) Income in excess of MNIL is considered as available for payment of medical care and services. The Medicaid agency measures available income for periods of either 1 or 6 month(s) (not to exceed 6 months) to determine the amount of excess countable income applicable to the cost of medical care and services.

(2) If countable income exceeds the MNIL standard, the agency deducts the following incurred expenses in the following order:

(a) Health insurance premiums, deductibles, and coinsurance charges.

(b) Expenses for necessary medical and remedial care not included in the plan.

(c) Expenses for necessary medical and remedial care included in the plan.

Incurred expenses that are subject to payment by a third party are not deducted unless the expenses are subject to payment by a third party that is a publicly funded program (other than Medicaid) of a State or local government.

b. Categorically Needy - § 1902(f) states:

The agency applies the following policy under the provisions of § 1902(f) of the Act. The following amounts are deducted from income to determine the individual's countable income:

(1) Any SSI benefit received.

(2) Any State supplement received that is within the scope of an agreement described in § 1616 or 1634 of the Act, or a State supplement within the scope of § 1902(a)(10)(A)(ii)(XI) of the Act.

(3) Increases in OASDI that are deducted under §§ 435.134 and 435.135 for individuals specified in that section, in the manner elected by the State under than section.

(4) Incurred expenses for necessary medical and remedial services recognized under State law.

Incurred expenses that are subject to payment by a third party are not deducted unless the expenses are subject to payment by a third party that is a publicly funded program (other than Medicaid) of a State or local government.

NOTE: FFP will be reduced to the extent a State is paid a spenddown payment by the individual.

Statutory Authority

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

Historical Notes

Derived from VR460-02-2.6100 C, eff. June 16, 1993.

12VAC30-40-140. Methods for determining resources.

a. AFDC-related individuals (except for poverty level related pregnant women, infants, and children).

(1) In determining countable resources for AFDC-related individuals, the following methods are used:

(a) The methods under the state's approved AFDC plan; and/or

(b) Any more liberal methods described in 12VAC30-40-290.

(2) In determining relative financial responsibility, the agency considers only the resources of spouses living in the same household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

b. Aged individuals. For aged individuals covered under § 1902(a)(10)(A)(ii)(X) of the Act, the agency used methods that are more restrictive (except for individuals described in § 1902(m)(1) of the Act) and/or more liberal than those of the SSI program for the treatment of resources. 12VAC30-40-240 describes the more restrictive methods and 12VAC30-40-290 specifies the more liberal methods.

In determining relative financial responsibility, the agency considers only the resources of spouses living in the same household as available to spouses.

c. Blind individuals. For blind individuals the agency uses methods that are more restrictive and/or more liberal than those of the SSI program for the treatment of resources. 12VAC30-40-240 describes the more restrictive methods and 12VAC30-40-290 specifies the more liberal methods.

In determining relative financial responsibility, the agency considers only the resources of spouses living in the same household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

d. Disabled individuals, including individuals covered under § 1902(a)(10)(A)(ii)(X) of the Act. The agency used methods that are more restrictive (except for individuals described in § 1902(m)(1) of the Act) and/or more liberal than those of the SSI program for the treatment of resources. More restrictive methods are described in 12VAC30-40-240 and more liberal methods are specified in 12VAC30-40-290.

In determining relative financial responsibility, the agency considers only the resources of spouses living in the same household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

e. Poverty level pregnant women covered under § 1902(a)(10)(A)(i)(IV) and § 1902(a)(10)(A)(ii)(IX)(A) of the Act.

The agency does not consider resources in determining eligibility.

In determining relative financial responsibility, the agency considers only the resources of spouses living in the same household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

f. Poverty level infants covered under § 1902(a)(10)(A)(i)(IV) of the Act.

The agency does not consider resources in determining eligibility.

g. Poverty level children covered under § 1902(a)(10)(A)(i)(VI) of the Act.

(1) The agency does not consider resources in determining eligibility. In determining relative financial responsibility, the agency considers only the resources of spouses living in the same household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

(2) Poverty level children under § 1902(a)(10)(A)(i)(VIII). The agency does not consider resources in determining eligibility.

In determining relative responsibility, the agency considers only the resources of spouses living in the same household as available to spouses and the resources of parents as available to children living with parents until the children become 21.

h. For Qualified Medicare beneficiaries covered under § 1902(a)(10)(E)(i) of the Act the agency uses methods that are more liberal than those of the SSI program for the treatment of resources. More liberal methods are specified in 12VAC30-40-290.

i. For qualified disabled and working individuals covered under § 1902(a)(10)(E)(ii) of the Act, the agency uses SSI program methods for the treatment of resources.

j. Reserved.

k. Specified low-income Medicare beneficiaries covered under § 1902(a)(10)(E)(iii) of the Act. The agency uses the same method as in subsection (h) of this section.

Statutory Authority

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

Historical Notes

Derived from VR460-02-2.6100 C, eff. June 16, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995; Volume 20, Issue 4, eff. December 3, 2003.

12VAC30-40-150. Resource standard; categorically needy.

A. Section 1902(f) states (except as specified under subsections C and D of this section) for aged, blind and disabled individuals: same as SSI resource standards. The resource standards for other individuals are the same as those in the related cash assistance program.

B. Non-1902(f) states (except as specified under subsections C and D of this section).

1. The resource standards are the same as those in the related cash assistance program.

2. 12VAC30-40-270 specifies for 1902(f) states the categorically needy resource levels for all covered categorically needy groups.

C. The agency does not apply a resource standard for pregnant women or infants covered under the provisions of §§ 1902(a)(10)(A)(i)(IV) and 1902(a)(10)(A)(ii)(IX) of the Act.

D. The agency does not apply a resource standard for parent/caretaker relatives or children covered under the provisions of § 1902(a)(10)(A)(i)(VI), 1902(a)(10)(A)(i)(l), or 1931 of the Act.

E. For aged and disabled individuals described in § 1902(m)(1) of the Act who are covered under § 1902(a)(10)(A)(ii)(X) of the Act, 12VAC30-40-230 specifies the resource levels for these individuals.

Statutory Authority

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

Historical Notes

Derived from VR460-02-2.6100 C, eff. June 16, 1993; amended, Virginia Register Volume 33, Issue 21, eff. July 27, 2017.

12VAC30-40-160. Resource standard; medically needy.

a. Resource standards are based on family size.

b. A single standard is employed in determining resource eligibility for all groups.

12VAC30-40-230 specifies the resource standards for all covered medically needy groups. If the agency chooses more restrictive levels under this subsection, 12VAC30-40-230 so indicates.

Statutory Authority

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

Historical Notes

Derived from VR460-02-2.6100 C, eff. June 16, 1993.

12VAC30-40-170. Resource standard; qualified Medicare beneficiaries and specified low-income Medicare beneficiaries.

For qualified Medicare beneficiaries covered under § 1902(a)(10)(E)(i) of the Act, and specified low-income Medicare beneficiaries covered under § 1902(a)(10)(E)(iii) of the Act, the resource standard is twice the SSI standard or, effective January 1, 2010, the resource limit set for the Medicare Part D Low Income Subsidy Program.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-02-2.6100 C, eff. June 16, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995; Volume 26, Issue 14, eff. April 14, 2010.

12VAC30-40-180. Qualified disabled and working individuals.

For qualified disabled and working individuals covered under 1902(a)(10)(E)(ii) of the Act, the resource standard for an individual or a couple (in the case of an individual with a spouse) is twice the SSI standard.

Statutory Authority

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

Historical Notes

Derived from VR460-02-2.6100 C, eff. June 16, 1993.

12VAC30-40-190. Excess resources.

a. Categorically Needy, Qualified Medicare Beneficiaries, Qualified Disabled and Working Individuals, and Specified Low-Income Medicare Beneficiaries. Any excess resources make the individual ineligible.

b. Medically Needy. Any excess resources make the individual ineligible.

Statutory Authority

§ 32.1-325 of the Code of Virginia.

Historical Notes

Derived from VR460-02-2.6100 C, eff. June 16, 1993; amended, Virginia Register Volume 12, Issue 2, eff. November 15, 1995.

12VAC30-40-200. Effective date of eligibility.

a. Groups Other Than Qualified Medicare Beneficiaries.

(1) For the prospective period. Coverage is available for the full month if aged, blind, disabled or AFDC-related individuals are eligible at any time during the month.

(2) For the retroactive period. Coverage is available for three months before the date of application if aged, blind, disabled or AFDC-related individuals would have been eligible had they applied.

b. For qualified Medicare beneficiaries defined in § 1905(p)(1) of the Act, coverage is available beginning with the first day of the month after the month in which the individual is first determined to be a qualified Medicare beneficiary under § 1905(p)(1). The eligibility determination is valid for 12 months.

Statutory Authority

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

Historical Notes

Derived from VR460-02-2.6100 C, eff. June 16, 1993.

12VAC30-40-210. Transfer of resources - categorically and medically needy, qualified Medicare beneficiaries, and qualified disabled and working individuals.

The agency complies with the provisions of § 1917 of the Act with respect to the transfer of resources.

Disposal of resources at less than fair market value affect eligibility for certain services as detailed in 12VAC30-40-300.

Statutory Authority

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

Historical Notes

Derived from VR460-02-2.6100:1, eff. June 16, 1993.

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