12 Va. Admin. Code § 30-141-100 - General conditions of eligibility
Current through Register Vol. 38, No. 3, September 27, 2021
Statutory Authority: § 32.1-351 of the Code of Virginia; 42 USC § 1396 et seq.
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12VAC30-141-100. General conditions of eligibility.
A. An LDSS, DMAS, or the CPU determines eligibility for Title XXI services.
B. FAMIS shall be in effect statewide.
D. Each individual covered under the plan shall be:
1. Financially eligible to receive services as established using the methods and standards described in subsection F of this section; and
2. Meet the applicable nonfinancial eligibility conditions.
E. Nonfinancial eligibility conditions.
1. Eligible individuals shall be younger than 19 years of age.
2. Eligible individuals shall be residents of the Commonwealth. A child is considered to be a resident of the Commonwealth under the following conditions:
a. A noninstitutionalized child if capable of indicating intent and who is emancipated or married if the child is living in the state and intends to reside in the state, including without a fixed address;
b. A noninstitutionalized child not described in subdivision E 2 a of this section and who is not in the custody of the state:
(1) Residing in the state, with or without a fixed address; or
(2) The state of residency of the parent or caretaker, in accordance with 42 CFR.435.403(h)(1), with whom the individual resides;
c. An institutionalized child who is not a ward of the state if the state is the state of residence of the child's custodial parent or caretaker at the time of placement;
d. A child who is in the custody of the state regardless of where the child lives; or
e. A child physically located in the state when there is a dispute with one or more states as to the child's actual state of residence.
3. FAMIS eligibility is open to:
a. United States citizens;
b. United States nationals;
c. Qualified noncitizens as defined in § 431 of the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) (8 USC § 1641) or whose eligibility is required by § 402(b) of PRWORA (8 USC § 1612(b)) and is not prohibited by § 403 of PRWORA (8 USC § 1613);
d. Individuals who have declared themselves to be citizens or nationals of the United States or an individual having satisfactory immigration status, during a reasonable opportunity period pending verification of their citizenship, nationality, or satisfactory immigration status consistent with requirements of §§ 1903(x), 1137(d), and 1902(ee) of the Social Security Act and 42 CFR 435.407, 42 CFR 407, 42 CFR 435.956, and 42 CFR 457.380.
(1) The reasonable opportunity period begins on and extends 90 calendar days from the date the notice of reasonable opportunity is received by the individual. "Notice of reasonable opportunity" means the written notice that is sent to the applicant to inform the applicant that the applicant must provide verification of citizenship and identity within 90 calendar days.
(2) An extension of the reasonable opportunity period is allowed if the individual is making a good faith effort to resolve any inconsistencies or obtain any necessary documentation, or the agency determining eligibility needs more time to complete the verification process.
(3) The agency will provide benefits to otherwise eligible individuals during the reasonable opportunity period;
e. Lawfully residing in the United States, as provided in § 2107(e)(1)(J) of the Social Security Act (§ 214 of CHIPRA 2009, P.L. 111-3). An individual is considered to be lawfully residing in the United States if the person is:
(1) A qualified noncitizen as defined in 8 USC § 1641(b) and (c);
(3) A noncitizen who has been paroled into the United States in accordance with 8 USC § 1182(d)(5) for less than one year, except for an individual paroled for prosecution, for deferred inspection, or pending removal proceedings;
(4) A noncitizen who belongs to one of the following classes:
(b) Granted temporary protected status (TPS) in accordance with 8 USC § 1254a and individuals with pending applications for TPS who have been granted employment authorization;
(c) Granted employment authorization under 8 CFR § 274a.12(c);
(d) Family unity beneficiaries in accordance with § 301 of P.L. 101-649, as amended;
(e) Under deferred enforced departure in accordance with a decision made by the President;
(f) Granted deferred action status;
(g) Granted an administrative stay of removal under 8 CFR 241; or
(h) Beneficiary of approved visa petition who has a pending application for adjustment of status;
(a) Has been granted employment authorization; or
(b) Is younger than 14 years of age and has had an application pending for at least 180 calendar days;
(6) Has been granted withholding of removal under the Convention Against Torture;
(7) Is a child who has a pending application for Special Immigrant Juvenile Status as described in 8 USC § 1101(a)(27)(J);
(8) Is lawfully present in American Samoa under the immigration laws of American Samoa; or
(9) Is a victim of severe trafficking in persons, in accordance with the Victims of Trafficking and Violence Protection Act of 2000, P.L. 106-386, as amended (22 USC § 7105(b)).
f. An individual with deferred action under the Department of Homeland Security's deferred action for the childhood arrivals process, as described in the Secretary of Homeland Security's June 15, 2012, memorandum, shall not be considered to be lawfully present with respect to any of the categories in subdivision E 3 e of this section.
4. Eligible individuals shall be uninsured, that is, not have creditable health insurance coverage. "Creditable health insurance coverage" means coverage that meets the definition of 42 CFR 457.10.
a. Individuals eligible for FAMIS shall not be found eligible or potentially eligible for Medicaid under policies of the State Plan determined through the screening process described at 42 CFR 457.350.
b. Any child covered under a group health plan or under health insurance coverage, as defined in § 2791 of the Public Health Services Act (42 USC § 300gg-91(a) and (b)(1)), shall not be eligible for FAMIS.
(1) FAMIS shall not be a substitution for private insurance.
(2) Only uninsured children shall be eligible for FAMIS. A child is not considered to be insured if the health insurance plan covering the child does not have a network of providers in the area where the child resides. Each application for child health insurance shall include an inquiry about health insurance. Each redetermination of eligibility shall also document inquiry about current health insurance.
(3) Health insurance does not include Medicare, Medicaid, FAMIS, or insurance for which DMAS paid premiums under Title XIX through the Health Insurance Premium Payment Program or under Title XXI through the state children's health insurance program premium assistance program known as FAMIS Select.
5. Residents of an institution. Eligible individuals may not be an inpatient in an institution for mental diseases or an inmate in a public institution that is not a medical facility at the time of the initial eligibility determination or redetermination.
6. Social Security Number.
a. All eligible individuals shall furnish their Social Security Numbers (SSNs), with the following exceptions: (i) individuals refusing to obtain a SSN because of well-established religious objections, (ii) individuals who are not eligible for a SSN, or (iii) individuals who are issued a SSN only for a valid nonwork purpose.
b. DMAS or its designee shall:
(1) Assist individuals who are required to provide their SSN to apply for or obtain an SSN from the Social Security Administration if the individuals do not have or forgot their SSNs;
(2) Inform individuals required to provide their SSNs (i) by what statutory authority the number is required to be provided; and (ii) how the Commonwealth will use the SSN;
(3) Verify each SSN furnished by applicants or beneficiaries with the Social Security Administration; and
(4) Not deny or delay services to an otherwise eligible applicant pending issuance or verification of the individual's SSN by the Social Security Administration.
c. The utilization of the SSN is consistent with §§ 205 and 1137 of the Social Security Act and the Privacy Act of 1974.
d. DMAS requests nonapplicant household members to voluntarily provide their SSNs. When requesting an SSN for nonapplicant household members, DMAS (i) informs the nonapplicant that this information is voluntary and provides information regarding how the SSN will be used and (ii) uses the SSN for determination of eligibility for Children's Health Insurance Program (CHIP) or other insurance affordability programs or for a purpose directly connected with the administration of the state plan.
F. Financial eligibility.
1. Screening. All applications shall have a Medicaid income eligibility screen completed. Children determined to be ineligible for Medicaid due to excess income will have their eligibility for FAMIS determined.
a. The Commonwealth shall apply modified adjusted gross income (MAGI) methodologies for all separate CHIP covered groups, consistent with 42 CFR 457.315 and 435.603(b) through (i). FAMIS shall be available for targeted low-income children. Income standards shall be applied statewide. Children from birth to age 19 years who have income above the Medicaid-eligible limit at or below 200% of the federal poverty level, with a 5% income disregard, shall be income eligible to participate in FAMIS.
b. In determining family size for the eligibility determination of other individuals in the household that includes a pregnant woman, the pregnant woman is counted just as herself.
c. Financial eligibility is determined consistent with the following provisions:
(1) For new applicants, financial eligibility is based on the monthly income and family size.
(2) When determining eligibility for current beneficiaries, financial eligibility is based on current monthly household income and family size.
(3) In determining current household income, the agency will use reasonable methods to account for current income and reasonable prediction of changes in future income or family size.
d. Unless an exception exists, as provided at 42 CFR 457.315 and 42 CFR 435.603(d)(2) through (d)(4), household income is the sum of the MAGI-based income for every person counted in the individual's MAGI household.
3. Spenddown. The Commonwealth shall not apply a spenddown process for FAMIS where household income exceeds the income eligibility limit for FAMIS.
G. Eligibility of newborns.
1. If a child otherwise eligible for FAMIS is born within the three months prior to the month in which a signed application is received, the eligibility for coverage is effective retroactive to the child's date of birth if the child would have met all eligibility criteria during that time.
2. A child born to a targeted low-income pregnant woman is deemed to have applied for and be eligible for FAMIS or Medicaid until the child turns age one year in accordance with § 2112 of the Social Security Act. "Targeted low-income pregnant woman" means an uninsured pregnant woman whose household income is within the Medicaid or FAMIS MOMS eligibility standards established by the Commonwealth.
a. The child is deemed to have applied for and been found eligible for FAMIS or Medicaid, as appropriate, as of the date of the child's birth and remains eligible without regard to changes in circumstances until the child's first birthday.
b. DMAS shall cover as a deemed newborn a child born to a mother who is covered under Medicaid or CHIP through the authority of the state's § 1115 demonstration on the date of the newborn's birth.
§ 32.1-325 of the Code of Virginia; 42 USC § 1396 et seq.
Derived from Volume 19, Issue 21, eff. August 1, 2003; amended, Virginia Register Volume 22, Issue 26, eff. October 4, 2006; Volume 23, Issue 07, eff. January 10, 2007; Volume 26, Issue 06, eff. January 1, 2010; Volume 26, Issue 12, eff. March 17, 2010; Volume 27, Issue 07, eff. January 5, 2011; Volume 29, Issue 21, eff. July 17, 2013; Volume 30, Issue 20, eff. July 3, 2014; Volume 32, Issue 20, eff. June 29, 2016; Volume 35, Issue 20, eff. June 26, 2019.