Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 122 - COMMUNITY WAIVER SRVICES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES › Section 12VAC30-122-60 - Financial eligibility standards for individuals

Current through Register Vol. 40, No. 24, July 15, 2024
A. Individuals receiving services under the
				Family and Individual Supports (FIS) Waiver, Community Living (CL) Waiver, and
				Building Independence (BI) Waiver, which are collectively known as the DD
				Waivers, shall meet the following Medicaid eligibility requirements. The
				Commonwealth shall apply the financial eligibility criteria contained in the
				State Plan for Medical Assistance for the categorically needy and in
				12VAC30-30-10
				and
				12VAC30-40-10.
				The Commonwealth covers the optional categorically needy groups under 42 CFR
				435.211, 42 CFR 435.217, and 42 CFR 435.230.
B. Patient pay methodology.
1. The income level used for 42 CFR 435.211,
				42 CFR 435.217, and 42 CFR 435.230 shall be 300% of the current supplemental
				security income (SSI) payment standard for one person.
2. Under the DD Waivers, the coverage groups
				authorized under § 1902(a)(10)(A)(ii)(VI) of the Social Security Act shall
				be considered as if they were institutionalized for the purpose of applying
				institutional deeming rules. All individuals under the waivers shall meet the
				financial and nonfinancial Medicaid eligibility criteria and meet the
				institutional level-of-care criteria for an ICF/IID. The deeming rules shall be
				applied to waiver eligible individuals as if the individuals were residing in
				an ICF/IID or would require that level of care.
3. The Commonwealth shall reduce its payment
				for home and community-based waiver services provided to an individual who is
				eligible for Medicaid services under 42 CFR 435.217 by that amount of the
				individual's total income, including amounts disregarded in determining
				eligibility, that remains after allowable deductions for personal maintenance
				needs, other dependents, and medical needs have been made according to the
				guidelines in 42 CFR 435.735 and § 1915(c)(3) of the Social Security Act
				as amended by the Consolidated Omnibus Budget Reconciliation Act of 1986 (
				42 USC §
											1395ww ). DMAS shall reduce its payment for
				home and community-based waiver services by the amount that remains after the
				deductions listed in this subdivision:
a. For
				individuals to whom § 1924(d) of the Social Security Act applies and for
				whom the Commonwealth waives the requirement for comparability pursuant to
				§ 1902(a)(10)(B), DMAS shall deduct the following in the respective order:
(1) The basic maintenance needs for an
				individual under the DD Waivers, which shall be equal to 165% of the SSI
				payment for one person. Due to expenses of employment, a working individual
				shall have an additional income allowance. For an individual employed 20 hours
				or more per week, earned income shall be disregarded up to a maximum of both
				earned and unearned income up to 300% of SSI; for an individual employed less
				than 20 hours per week, earned income shall be disregarded up to a maximum of
				both earned and unearned income up to 200% of SSI. If the individual requires a
				guardian or conservator who charges a fee, the fee, not to exceed an amount
				greater than 5.0% of the individual's total monthly income, shall be added to
				the maintenance needs allowance. However, in no case shall the total amount of
				the maintenance needs allowance (basic allowance plus earned income allowance
				plus guardianship fees) for the individual exceed 300% of SSI.
(2) For an individual with only a spouse at
				home, the community spousal income allowance determined in accordance with
				§ 1924(d) of the Social Security Act.
(3) For an individual with a family at home,
				an additional amount for the maintenance needs of the family determined in
				accordance with § 1924(d) of the Social Security Act.
(4) Amounts for incurred expenses for medical
				or remedial care that are not subject to payment by a third party including
				Medicare and other health insurance premiums, deductibles, or coinsurance
				charges, and necessary medical or remedial care recognized under state law but
				not covered under the State Plan for Medical Assistance.
b. For individuals to whom § 1924(d)
				does not apply and for whom the Commonwealth waives the requirement for
				comparability pursuant to § 1902(a)(10)(B), DMAS shall deduct the
				following in the respective order:
(1) The
				basic maintenance needs for an individual under the DD Waivers, which is equal
				to 165% of the SSI payment for one person. Due to expenses of employment, a
				working individual shall have an additional income allowance. For an individual
				employed 20 hours or more per week, earned income shall be disregarded up to a
				maximum of both earned and unearned income up to 300% of SSI; for an individual
				employed less than 20 hours per week, earned income shall be disregarded up to
				a maximum of both earned and unearned income up to 200% of SSI. If the
				individual requires a guardian or conservator who charges a fee, the fee, not
				to exceed an amount greater than 5.0% of the individual's total monthly income,
				shall be added to the maintenance needs allowance. However, in no case shall
				the total amount of the maintenance needs allowance (basic allowance plus
				earned income allowance plus guardianship fees) for the individual exceed 300%
				of SSI.
(2) For an individual with
				a dependent child, an additional amount for the maintenance needs of the child,
				which shall be equal to the Title XIX medically needy income standard based on
				the number of dependent children.
(3) Amounts for incurred expenses for medical
				or remedial care that are not subject to payment by a third party including
				Medicare and other health insurance premiums, deductibles, or coinsurance
				charges, and necessary medical or remedial care recognized under state law but
				not covered under the State Plan for Medical Assistance.