reglab/statecodes huggingface dataset:
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart II - Resource Assessments And Eligibility › Article 3 - Resource Eligibility Determinations for Institutionalized Spouses › Section 12VAC30-110-856 - Revisions to the community spouse resource allowance

Current through Register Vol. 40, No. 24, July 15, 2024
For the purposes of this article, a community spouse
						  resource allowance may be revised if:
1. A department hearing officer determines on
						appeal that the income generated from the community spouse resource allowance
						as originally calculated pursuant to
						12VAC30-110-853 is inadequate to
						raise the community spouse's income to the minimum amount to be deducted as a
						maintenance allowance in the post-eligibility determination made pursuant to
						Article 4 (12VAC30-110-920 et seq.) of this
						subpart;
2. A department hearing
						officer determines on appeal that the original calculation was
						incorrect;
3. The department
						determines that the original information with which the spousal share was
						calculated was incorrect; or
4. An
						institutionalized spouse transfers resources to a community spouse pursuant to
						a court order for spousal support.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart II - Resource Assessments And Eligibility › Article 3 - Resource Eligibility Determinations for Institutionalized Spouses › Section 12VAC30-110-860 - Protected periods of eligibility

Current through Register Vol. 40, No. 24, July 15, 2024
Subject to
						  12VAC30-110-870, for 90 days after
						  an initial determination of eligibility, resources in the institutionalized
						  spouse's name necessary to meet the community spouse resource allowance shall
						  be disregarded in determining continued eligibility of the institutionalized
						  spouse. An institutionalized spouse's eligibility shall be protected to allow
						  him time to legally transfer resources pursuant to
						  12VAC30-110-850 if the
						  institutionalized spouse expressly indicates in writing his intention to effect
						  such a transfer. Absent such an expression of intent, the protected period will
						  not extend beyond the end of the month in which eligibility is being
						  determined. The 90-day protected period shall begin with the date the agency
						  takes action to approve the institutionalized spouse's initial eligibility for
						  medical assistance for institutional, waiver, or hospice services. No extension
						  of the protected period shall be permitted.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart II - Resource Assessments And Eligibility › Article 3 - Resource Eligibility Determinations for Institutionalized Spouses › Section 12VAC30-110-870 - Exception to protected period of eligibility

Current through Register Vol. 40, No. 24, July 15, 2024
If, at the time of an initial determination of
						  eligibility, a community spouse has title to resources equal to or exceeding
						  his spousal protected resource amount, no protected period of eligibility shall
						  exist.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart II - Resource Assessments And Eligibility › Article 3 - Resource Eligibility Determinations for Institutionalized Spouses › Section 12VAC30-110-880 - Additional resources acquired during protected period of eligibility

Current through Register Vol. 40, No. 24, July 15, 2024
If an institutionalized spouse obtains additional
						  resources during a protected period of eligibility, the additional resources
						  shall be exempt during the protected period if:
1. The new resources combined with other
						resources that the institutionalized spouse intends to retain do not exceed the
						appropriate medical assistance resource limit for one person, or
2. The institutionalized spouse intends to
						transfer the new resources to the community spouse during the protected period
						of eligibility, and the total resources to be transferred do not exceed the
						community spouse resource allowance.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart II - Resource Assessments And Eligibility › Article 3 - Resource Eligibility Determinations for Institutionalized Spouses › Section 12VAC30-110-890

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart II - Resource Assessments And Eligibility › Article 3 - Resource Eligibility Determinations for Institutionalized Spouses › Section 12VAC30-110-900 - Resource eligibility determinations in retroactive months

Current through Register Vol. 40, No. 24, July 15, 2024
A. First
						application for medical assistance. In each of the three months preceding an
						institutionalized spouse's first application for medical assistance in the
						current continuous period of institutionalization for which resource
						eligibility is to be determined, the community spouse protected resource amount
						shall be deducted from the couple's combined countable resources held on the
						first moment of the first day of each retroactive month.
B. Later applications for medical assistance
						when medical assistance eligibility was established previously. If an
						individual established medical assistance eligibility as an institutionalized
						spouse during a period of institutionalization that began on or after September
						30, 1989, regardless of whether the period of institutionalization is the same
						continuous period covered by the previous application, resources owned by the
						community spouse are not considered in determining the institutionalized
						spouse's medical assistance eligibility.
C. Later applications for medical assistance
						when Virginia medical assistance eligibility was not previously established.
						Regardless of whether previous medical assistance applications have been
						submitted, if an individual has never established medical assistance
						eligibility as an institutionalized spouse, the application shall be treated in
						the same manner as the first application.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart II - Resource Assessments And Eligibility › Article 3 - Resource Eligibility Determinations for Institutionalized Spouses › Section 12VAC30-110-910 - Eligibility for community spouses and other family members

Current through Register Vol. 40, No. 24, July 15, 2024
If a community spouse or other family member applies
						  for medical assistance eligibility on his own behalf, these eligibility
						  regulations will not be used to determine his eligibility for medical
						  assistance.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart II - Resource Assessments And Eligibility › Article 4 - ncome › Section 12VAC30-110-920 - Applicability

Current through Register Vol. 40, No. 24, July 15, 2024
This article shall apply only to the institutional
						  spouse's eligibility for medical assistance.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart II - Resource Assessments And Eligibility › Article 4 - ncome › Section 12VAC30-110-921 - Treatment of income

Current through Register Vol. 40, No. 24, July 15, 2024
During any month in which an institutionalized spouse
						  is an inpatient in a medical institution, is receiving medical assistance
						  community-based waiver services or has elected hospice services, no income of
						  the community spouse shall be deemed available to the institutionalized spouse
						  except as provided in
						  12VAC30-110-930.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart II - Resource Assessments And Eligibility › Article 4 - ncome › Section 12VAC30-110-930 - Determining income

Current through Register Vol. 40, No. 24, July 15, 2024
A couple's income shall be determined as follows,
						  without regard to state laws governing community property or division of
						  marital property:
1. Income from
						nontrust property. Unless a department hearing officer determines that the
						institutionalized spouse has proven to the contrary by a preponderance of the
						evidence:
a. Income paid to one spouse
						belongs to that spouse;
b. Each
						spouse owns one-half of all income paid to both spouses jointly;
c. Each spouse owns one-half of any income
						which has no instrument establishing ownership;
d. Income paid in the name of either spouse,
						or both spouses and at least one other party, shall be considered available to
						each spouse in a proportionate share. When income is paid to both spouses and
						each spouse's individual interest is not specified, one-half of their joint
						interest in the income shall be considered as available to each
						spouse.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart III - Post-Eligibility Process › Section 12VAC30-110-940 - Applicability

Current through Register Vol. 40, No. 24, July 15, 2024
Subpart III
Post-Eligibility Process
After an institutionalized spouse is determined or
						redetermined to be eligible for medical assistance, and after all appropriate
						deductions pursuant to
						12VAC30-110-950 through
						12VAC30-110-970 have been made
						from an institutionalized spouse's gross monthly income pursuant to this
						subpart, the balance shall constitute the maximum amount the institutionalized
						spouse shall pay for medical assistance-covered institutional or waiver
						services.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart III - Post-Eligibility Process › Section 12VAC30-110-950 - Mandatory deductions from institutionalized spouse's income

Current through Register Vol. 40, No. 24, July 15, 2024
The following amounts shall be deducted from the
						institutionalized spouse's gross monthly income:
1. A personal needs allowance of
					 $40;
2. The community spouse
					 monthly income allowance as calculated pursuant to
					 12VAC30-110-960;
3. The family maintenance allowance, if any,
					 as calculated pursuant to
					 12VAC30-110-970; and
4. Incurred medical and remedial care
					 expenses recognized under state law, not covered under the State Plan and not
					 subject to third party payment.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						  Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart III - Post-Eligibility Process › Section 12VAC30-110-960 - Community spouse income allowance

Current through Register Vol. 40, No. 24, July 15, 2024
A. Unless the exceptions in subsections B and
					 C of this section apply, a community spouse monthly income allowance shall be
					 deducted from the monthly income of the institutionalized spouse. The community
					 spouse monthly income allowance shall be the amount by which the greater of:
1. The community spouse monthly maintenance
					 needs standard plus the excess shelter allowance, if any; or
2. An amount determined necessary by a
					 department hearing officer because of exceptional circumstances resulting in
					 extreme financial duress;
exceeds the amount of monthly income otherwise available
						to the community spouse (determined without regard to such an
						allowance).
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart III - Post-Eligibility Process › Section 12VAC30-110-970 - Family members maintenance needs allowance

Current through Register Vol. 40, No. 24, July 15, 2024
A. There shall be deducted from the
					 institutionalized spouse's income an allowance for each dependent family
					 member.
B. The amount deducted
					 shall be an amount equal to 1/3 of the community spouse monthly maintenance
					 needs standard, minus each family member's income.
C. This allowance is to be deducted
					 regardless of whether the institutionalized spouse actually makes the allowance
					 available to the family member.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart IV - Appeals › Section 12VAC30-110-980 - Applicability, notices and regulatory authority

Current through Register Vol. 40, No. 24, July 15, 2024
Subpart IV
Appeals
A. The
					 appeals process contained in this subpart shall apply to appeals of resource
					 assessments, initial determinations and redeterminations of resources, and
					 income amounts and allowances made in connection with applications for medical
					 assistance benefits by spouses institutionalized for a continuous period on or
					 after September 30, 1989, or receiving waiver or hospice services for a
					 continuous period on or after September 30, 1989, pursuant to existing Client
					 Appeals regulations (Part I (12VAC30-110-10 et
					 seq.) of this chapter).
B. Written
					 notices are to be provided to the institutionalized spouse and the community
					 spouse advising them of:
1. Resource
					 assessments;
2. The amounts
					 deducted for spousal and family allowances used in the post-eligibility
					 calculation; and
3. Their rights to
					 appeal the amounts deducted in the calculations for determining the spousal and
					 family allowances used in the post-eligibility calculation.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart IV - Appeals › Section 12VAC30-110-1010 - Hearing officer authority

Current through Register Vol. 40, No. 24, July 15, 2024
Through the appeals process applicable as described in
						12VAC30-110-980, hearing officers
						shall prescribe appropriate increases in income or resource allowances in the
						event they determine that exceptional circumstances exist which cause
						significant financial duress to the community spouse.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part V - Married Institutionalized Individuals' Eligibility and Patient Pay › Subpart IV - Appeals › Section 12VAC30-110-1011 - Appealable issues

Current through Register Vol. 40, No. 24, July 15, 2024
Only the following issues shall be appealable under this
						section:
1. Spousal share
					 determinations;
2. Initial resource
					 eligibility determinations and redeterminations;
3. Spousal protected resource
					 amounts;
4. Community spouse
					 resource allowance;
5. Income
					 eligibility determinations and redeterminations; and
6. Patient pay and income allowance
					 calculations.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1030 - Income eligibility

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				  Individuals and families who otherwise meet the medically needy eligibility
				  requirements, but who have income in excess of the medically needy limit, shall
				  be ineligible for medical assistance unless the excess income is insufficient
				  to meet the total cost of needed medical care and the cost of incurred medical
				  or remedial care recognized under state law has been deducted from excess
				  income.
B. Spenddown applies only
				  to the medically needy. Individuals must meet the medically needy nonfinancial,
				  property transfer and resource requirements in order to be placed on a
				  spenddown.
C. An individual or
				  family shall be determined to be income eligible when countable income is equal
				  to or lower than the medically needy income level for the budget period or when
				  countable income after deduction of specified medical and remedial care
				  expenses is equal to or below the MNIL. Countable income shall be compared to
				  the MNIL for the budget period and incurred medical and remedial care expenses
				  shall be deducted from income in excess of the MNIL.
D. An applicant having income in excess of
				  the MNIL shall be advised that medical expenses incurred prior to the month of
				  application count toward meeting the spenddown if the following conditions are
				  met:
1. The applicant is legally liable to
				  pay the expense.
2. A claim for the
				  expense was submitted to the liable third parties and the applicant provides
				  evidence of the third parties' denial of payment or amount of payment made by
				  the third parties for the expense. Only that portion of the expense which is
				  the applicant's legal responsibility (not the liability of any third party)
				  shall be deducted from countable income.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1040 - Spenddown calculation

Current through Register Vol. 40, No. 24, July 15, 2024
A. When
				  countable income exceeds the Medically Needy Income Level (MNIL) for the budget
				  period, certain medical and remedial care expenses incurred by an individual,
				  family or financially responsible relative that are not subject to payment by a
				  third party unless the third party is a public program of a state or territory
				  or political subdivision of a state or territory shall be deducted from
				  countable income.
B. Medical and
				  remedial care expenses paid by a public program (other than a Medicaid program)
				  of a state or territory shall be deducted from countable income. Once countable
				  income is reduced (by applying these deductions) to an amount equal to the
				  MNIL, the individual or family shall be income eligible.
C. Reasonable measures to determine the legal
				  liability of third parties to pay for incurred expenses shall be taken.
				  However, eligibility determination shall not be forestalled simply because
				  third party liability cannot be ascertained or payment by the third party has
				  not been received.
D. The time
				  standards for reaching decisions on Medicaid eligibility must be met when
				  determining eligibility through spenddown: 90 days for applicants who apply on
				  the basis of disability and 45 days for all other applicants. These limits
				  shall apply for receipt of third party payment or verification of third party
				  intent to pay in order to determine deductible expenses under spenddown.
				  Efforts to determine the liability of a third party shall continue through the
				  last day of this period. If information regarding third party liability is not
				  received by this date, eligibility must be established based upon the
				  information available.
E. If the
				  amount subject to payment by a third party cannot be determined based on
				  information available, the bill in question to which the third party liability
				  applies cannot be used in determining the spenddown. However, if information
				  becomes available at a later date, the spenddown shall be recalculated and the
				  effective date of eligibility revised.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1050 - Required deductions based on kinds of services

Current through Register Vol. 40, No. 24, July 15, 2024
In determining incurred medical expenses to be deducted
					 from income, the medical or remedial care expenses listed below that are not
					 subject to payment by a third party shall be deducted from countable income.
					 Such deductions are allowable even if the expenses are paid by a public program
					 (other than the Medicaid program) of a state or territory if the program is
					 financed by the state or territory.
1.
				  Expenses for Medicare and other health insurance premiums, and deductible or
				  coinsurance charges, including enrollment fees, copayments, or deductibles
				  imposed by the State Plan for Medical Assistance.
2. Expenses incurred by the individual or
				  family or financially responsible relative for necessary medical and remedial
				  services that are recognized under state law but are not included in the State
				  Plan for Medical Assistance.
3.
				  Expenses incurred by the individual or family or by financially responsible
				  relative for necessary medical and remedial services included in the State Plan
				  for Medical Assistance including those that exceed agency limitations on
				  amount, duration and scope of services.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1060 - Required deductions based on the age of bills

Current through Register Vol. 40, No. 24, July 15, 2024
In determining incurred medical expenses to be deducted
					 from income, the agency must include the following:
1. For the retroactive budget period for
				  medical assistance (the three months prior to the month of application), on
				  expenses incurred during such period, whether paid or unpaid and "old bills"
				  (unpaid expenses which remain a liability to the individual incurred prior to
				  the period), to the extent that the expenses have not been deducted previously
				  in establishing eligibility;
2. For
				  the first prospective budget period, expenses incurred during such budget
				  period and any of the three preceding months, whether paid or unpaid, to the
				  extent that the expenses have not been deducted previously in establishing
				  eligibility;
3. Current payments
				  (that is, payments made in the current budget period) on expenses incurred
				  before the current budget period and not previously deducted from income in any
				  budget period in establishing eligibility for such period; and
4. If the individual's eligibility for
				  medical assistance was established in each such budget period preceding the
				  current budget period, expenses incurred before the current budget period but
				  not previously deducted from income in establishing eligibility, to the extent
				  that such expenses are unpaid and are:
a.
				  Described in
				  12VAC30-110-1050; and
b. Carried over from the preceding budget
				  period or periods because the individual had a spenddown liability in each such
				  preceding period that was met without deducting all such incurred, unpaid
				  expenses.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1070 - Projection of expenses

Current through Register Vol. 40, No. 24, July 15, 2024
Medical and remedial care expenses that are not for
					 institutional care services (excluding acute care facility services) shall not
					 be projected. For example, insurance premiums are not an institutional service,
					 therefore, such expenses shall not be projected. Nor shall expenses that are
					 included in a prepaid package of service be deducted prior to the date the
					 services are rendered (e.g., charge for prenatal care and delivery services and
					 orthodontia).
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1080 - Projection of institutional care expenses

Current through Register Vol. 40, No. 24, July 15, 2024
Institutional care expenses, except for expenses for
					 services rendered in an acute care facility, shall be projected. The amount of
					 the projected expenses shall be based on the Medicaid per diem rate or a
					 combination of actual incurred institutional expenses and projected expenses at
					 the Medicaid per diem rate. Projection of institutional care expenses does not
					 preclude deduction of actually incurred expenses and in some instances requires
					 the use of a combination of actually incurred expenses and projected expenses.
					 Those circumstances are:
1. When the
				  projected institutional care expense is less than the individual's spenddown
				  liability for the budget period; and
2. When there is current liability for bills
				  from a period prior to the current retroactive and prospective budget periods.
				  A bill written off as a bad debt is not a current liability.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1090 - Reserved

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1100 - Individuals and families with income below the MNIL

Current through Register Vol. 40, No. 24, July 15, 2024
Cases which have only regular income that is below the
					 MNIL do not have to spenddown to become income eligible. Such cases shall be
					 maintained in the same manner as categorically needy cases; however, effective
					 the month that income exceeds the MNIL or the first month following the timely
					 notification period, the case must be treated as all other spenddown cases.
					 When a monthly budget period is used, increases in income shall be counted
					 beginning the month the change occurs, unless a Medicaid card has already been
					 issued for that month and a change in circumstances occurs too late in the
					 month to provide "timely" notice under
					 42 CFR
					 435.919 prior to suspending Medicaid
					 benefits.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1110 - Reserved

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1120 - Reconciliation

Current through Register Vol. 40, No. 24, July 15, 2024
At the end of the first prospective budget period and any
					 subsequent prospective budget period, or if earlier when any significant change
					 occurs, the agency must reconcile any projected amounts with the actual amounts
					 incurred, or with changes in circumstances to determine if the adjusted
					 deduction of incurred expenses reduces countable income to the income
					 standard.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1130 - Eligibility

Current through Register Vol. 40, No. 24, July 15, 2024
Except as provided in
					 12VAC30-110-1120, an individual is
					 eligible on the first day of the month in which spenddown liability is met.
					 However, expenses used to meet spenddown liability are not reimbursable under
					 Medicaid. The amount paid by Medicaid will be reduced to the extent necessary
					 to prevent the transfer of an individual's spenddown liability to the Medicaid
					 program.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1140 - Spenddown entitlement

Current through Register Vol. 40, No. 24, July 15, 2024
A. When
				  excess income has been spent or incurred, the applicant must request
				  reinstatement of his application, submitting the "Record of Medical Expenses -
				  Medicaid" together with bills or receipts for medical services either paid or
				  incurred, and evidence of third party payment or denial of payment if
				  applicable. No new application form is completed at that time. If there has
				  been no change which renders him ineligible, he becomes eligible for the
				  remainder of the six-month period.
B. The request for reinstatement must be
				  processed in the same manner as an application, with notice to the client of
				  the disposition of his request.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1150 - Qualified Medicaid Beneficiaries

Current through Register Vol. 40, No. 24, July 15, 2024
A. When an enrolled medically indigent
				  Medicare beneficiary meets the medically needy spenddown, he continues to be
				  eligible for Medicaid as a Qualified Medicare Beneficiary (QMB) but is also
				  eligible for Medicaid as medically needy beginning the date the spenddown was
				  met, and ending the last day of the six-month spenddown period.
B. No new application for QMB shall be
				  required to continue entitlement as a QMB at the end of the budget period;
				  however, the individual must file a new application in order for eligibility
				  for full Medicaid benefits in subsequent budget periods.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1160 - Retroactive spenddown; countable income; entitlement date

Current through Register Vol. 40, No. 24, July 15, 2024
A. Eligibility for retroactive Medicaid
				  entitlement must be determined in all cases in which an individual reports
				  receiving a Medicaid-covered service during the three-month period prior to the
				  month of application, whether the individual is applying for Aid to Families
				  with Dependent Children, auxiliary grant or Medicaid. Eligibility for
				  retroactive coverage shall be determined at the same time as the ongoing
				  eligibility is determined, using the same application.
B. The amount of countable income available
				  to the applicant's family or budget unit is determined for the three-month
				  period prior to application if none of the three months was included in a prior
				  Medicaid coverage or spenddown period, and all other eligibility factors were
				  met. Countable income for the period shall be applied to the appropriate income
				  limit for the period (1/4 the annual income limit).
If any of the months in the retroactive period were
					 included in a previous coverage or spenddown period, those months cannot be
					 included in the retroactive period. Only the income received in the retroactive
					 months not included in previous periods are counted in determining retroactive
					 eligibility. Countable income is applied to the appropriate income limit for
					 the number of months actually included in the retroactive period.
C. When the retroactive spenddown
				  is met by medical expenses incurred before the retroactive period, eligibility
				  will begin the first day of the retroactive period.
When the retroactive spenddown is met be expenses incurred
					 during the retroactive period, eligibility will begin the date the spenddown
					 was met.
Eligibility will exist for the remainder of the
					 retroactive period.
When the spenddown is not met, retroactive eligibility
					 does not exist.
If an applicant states that a covered service was received
					 in any one of the three retroactive months, eligibility is to be determined for
					 all three retroactive months, regardless of the service date.
D. The Medicaid application shall be
				  processed to determine both retroactive and prospective Medicaid eligibility
				  beginning with the month of application. Notice of both determinations must be
				  provided in written form to the applicant.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VI - Deduction of Incurred Medical Expenses in Determining Countable Income(Spenddown) › Section 12VAC30-110-1170 to 12VAC30-110-1190 - Reserved

Current through Register Vol. 40, No. 24, July 15, 2024
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VII - Medical Assistance Eligibility Resulting from Welfare Reform › Section 12VAC30-110-1200 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
The following words and terms, when used in this part,
					 shall have the following meanings unless the context indicates
					 otherwise:
"Aid to Families with Dependent Children" or "AFDC" means
					 the public assistance programs authorized in §§ 406 and 407 of the
					 Social Security Act ( 42 USC §§ 606 and 607 ), and administered by
					 the Virginia Department of Social Services. The term "AFDC" as used in this
					 part includes Aid to Families with Dependent Children - Unemployed Parent
					 (AFDC-UP).
"Assistance unit" means those persons who have been
					 determined categorically and financially eligible to receive assistance as
					 defined in the Virginia Department of Social Services' Virginia Independence
					 Program regulations (22VAC40-35-5 et seq.).
"Caretaker-relative" means the natural or adoptive parent
					 or other relative, as specified in
					 45 CFR
					 233.90(c)(1)(v), who is
					 responsible for supervision and care of the needy child.
"Child" means an individual who would be considered a child
					 under the AFDC State Plan.
"Family" means those individuals living in the household
					 whose needs and income were included in determining the AFDC eligibility of the
					 assistance unit at the time that the AFDC benefits were terminated and
					 individuals under AFDC sanction whose income but not needs were included. It
					 also includes those individuals whose needs and income would be taken into
					 account in determining the AFDC eligibility of the caretaker-relative's
					 assistance unit under the AFDC State Plan if the family were applying in the
					 current month.
"Family income" means all the earned income, as defined in
					 the AFDC State Plan, of all the members of the family without application of
					 any disregards except the family's cost of child care necessary for the
					 employment of the caretaker-relative or those disregards required by another
					 federal statute.
"Transitional medical assistance" means extended medical
					 assistance to participants in VIEW whose AFDC has been terminated voluntarily
					 or involuntarily.
"Virginia Initiative for Employment not Welfare" or "VIEW"
					 means the Job Opportunities and Basic Skills Training Program as implemented in
					 the Commonwealth.
Statutory Authority
§§ 32.1-325 and 63.1-133.46 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VII - Medical Assistance Eligibility Resulting from Welfare Reform › Section 12VAC30-110-1220 - Scope of coverage

Current through Register Vol. 40, No. 24, July 15, 2024
A. Subject
				  to subsection B of this section, during the 12-month extension period, the
				  amount, duration, and scope of medical assistance made available to a family
				  shall be the same as if the family were still receiving AFDC.
B. The Department of Medical Assistance
				  Services (DMAS), at its option may, pursuant to the requirements of the Health
				  Insurance Premium Payment Program (HIPP) in Part XII (12VAC30-130-740 et seq.) of
				  12VAC30-130, pay a family's expenses for premiums, deductibles, coinsurance,
				  and similar costs for health insurance or other health care coverage offered by
				  an employer of the caretaker-relative or by an employer of the absent parent of
				  a dependent child. If an employer offers such coverage to the
				  caretaker-relative:
1. To receive
				  transitional medical assistance coverage for himself and his family, the
				  caretaker-relative shall make application for such employer coverage, but only
				  if:
a. The employer does not require the
				  caretaker-relative to make financial contributions for the coverage (whether
				  through payroll deduction, payment of deductibles, coinsurance, or similar
				  costs, or otherwise); and
b. DMAS
				  provides, directly or otherwise, payment of any of the premium amount,
				  deductible, coinsurance, or similar expense that the employee is otherwise
				  required to pay; and
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VII - Medical Assistance Eligibility Resulting from Welfare Reform › Section 12VAC30-110-1230 - Written notice and reporting requirements

Current through Register Vol. 40, No. 24, July 15, 2024
A. Notices. During the third, sixth and ninth
				  months of any transitional assistance DMAS shall notify the family of the
				  reporting requirements.
B.
				  Reporting requirements. To receive continued transitional medical assistance, a
				  family shall report the following to the local department of social services,
				  not later than the 21st day of the fourth, seventh, and tenth month in the
				  period of transitional assistance: the family's gross monthly earnings and the
				  family's costs for child care necessary for the employment of the
				  caretaker-relative in each month of the preceding three-month period. The local
				  department of social services may permit continued transitional medical
				  assistance, notwithstanding a failure to report, if the family has established
				  good cause for the failure to report on a timely basis.
C. Good cause. The local department of social
				  services may grant an extension regarding the reporting requirements for good
				  cause shown, pursuant to the Medicaid Client Appeals regulations at Part I
				  (12VAC30-110-10 et seq.) of this
				  chapter.
D. Frequency of reporting.
				  A family receiving transitional assistance shall not be required to report more
				  frequently than as required under subsection B of this section.
E. Notice before termination. No termination
				  of assistance shall become effective until the local department of social
				  services provides the family with notice of the grounds for the termination. No
				  termination shall be effective earlier than 10 days after the date of mailing
				  of the notice.
Statutory Authority
§§ 32.1-325 and 63.1-133.46 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VII - Medical Assistance Eligibility Resulting from Welfare Reform › Section 12VAC30-110-1240 - Appeals

Current through Register Vol. 40, No. 24, July 15, 2024
All appeals regarding the provision of services under this
					 part shall be conducted pursuant to the Medicaid Client Appeals regulations at
					 Part I (12VAC30-110-10 et seq.) of this
					 chapter.
Statutory Authority
§§ 32.1-325 and 63.1-133.46 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VII - Medical Assistance Eligibility Resulting from Welfare Reform › Section 12VAC30-110-1300

Current through Register Vol. 40, No. 24, July 15, 2024
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VIII - Applications for Medicaid › Section 12VAC30-110-1350 - Definitions

Current through Register Vol. 40, No. 24, July 15, 2024
"Applicant" means a person who has directly or through his
					 authorized representative made written application for Medicaid at the
					 Department of Medical Assistance Services' Central Processing Unit or at the
					 local social services department serving the locality in which he is a resident
					 or, if institutionalized, the locality in which he last resided outside an
					 institution.
"Authorized representative" means a person who is
					 authorized to conduct the personal or financial affairs for an individual who
					 is age 18 or older.
"Caretaker relative" means an individual who is age 18 or
					 older, who is not a parent, but who is related to a child by blood or marriage
					 and who lives with and assumes responsibility for day-to-day care of the child
					 in a place of residence maintained as his or their own home.
"Competent individual" means a person who has not been
					 judged by a court to be legally incapacitated.
"Conservator" means a person appointed by a court of
					 competent jurisdiction to manage the estate and financial affairs of an
					 incapacitated individual.
"Family substitute representative" means a spouse or
					 designated relative who is willing and able to take responsibility for the
					 individual's personal or financial affairs. The relatives who may be substitute
					 representatives are, in this preferred order, the individual's adult child,
					 parent, adult sibling, adult grandchild, adult niece or nephew, aunt or
					 uncle.
"Guardian" means a person appointed by a court of competent
					 jurisdiction to be responsible for the personal affairs of an incapacitated
					 individual, including responsibility for making decisions regarding the
					 person's support, care, health, safety, habilitation, education, therapeutic
					 treatment, and, if not inconsistent with an order of commitment,
					 residence.
"Incapacitated individual" means a person who, pursuant to
					 an order of a court of competent jurisdiction, has been found to be incapable
					 of receiving and evaluating information effectively or responding to people,
					 events, or environments to such an extent that the individual lacks the
					 capacity to (i) meet the essential requirements of his health, care, safety, or
					 therapeutic needs without the assistance or protection of a guardian or (ii)
					 manage property or financial affairs or provide for his support or for the
					 support of his legal dependents without the assistance or protection of a
					 conservator.
"Legal emancipation" means the minor has been declared
					 emancipated by a court of competent jurisdiction. A married minor is not
					 emancipated unless a court has declared the married minor emancipated from his
					 parents.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part VIII - Applications for Medicaid › Section 12VAC30-110-1360 - Right to apply

Current through Register Vol. 40, No. 24, July 15, 2024
A competent individual who is at least 18 years of age
					 cannot be refused the right to complete an application for himself and cannot
					 be discouraged from asking for assistance for himself under any
					 circumstances.
Statutory Authority
§§ 32.1-324 and 32.1-325 of the Code of
						Virginia; 42 CFR
						435.906 and
						435.907.