Medicaid (and Waivers), MAGI “Expansion,” Medicare & Medicaid Appeals, ABLE Accounts, Va. Auxiliary Grant, & Long Term Care Costs and Insurance Resources

Paying For Long Term Care and Medical Costs in Virginia

National Medicaid Topical News

Apply for Medicaid Application Onl ine– Forms and Information

Medicaid application, Part One (General Information) (All Applicants, Appendices A, B, and C) (2021)
Appendix C, Appointment of Authorized Agent for Medicaid Application and dealing with the Department of Social Services (1 page, 2019)
Persons over 65, Disabled Persons, and Persons Applying for Long Term Care (Nursing Home Care) (Appendix D) (2021)
Appendix F, Long Term Care Needs, 19-64, and Not Enrolled in Medicare (“MAGI” applicants, see below)
Where to apply (Virginia Only)

Broadcasts of interest.

Medicaid beneficiaries Dental Services. Covered dental services for adult Medicaid members with full benefits will include:
– Cleanings, X-rays and exams
– Fillings and root canals
– Dentures
– Gum-related treatment
– Oral surgeries

Members can check with their existing dentist to see if they accept Medicaid, or to find a new dentist by zip code.

CMS: Centers for Medicare and Medicaid Services	To learn about the Medicaid program in your state see pages inside this link. Spousal Impoverishment General Eligibility Income vs resource: what’s the difference (from SSA and Virginia DMAS)? Income defined. Not income: SI 00815.001: What Is Not Income – General SI 00815.050: Medical and Social Services, Related Cash, and In-Kind Items SI BOS00815.050: State Of Connecticut Department Of Mental Retardation – Medical And Social Service Funds SI CHI00815.050: (IL) Illinois Family Assistance Program For Mentally Disabled Children SI KC00815.050: Missouri Blind Pension SI PHI00815.050: Adult Services Program Payments SI BOS00815.051: Medical And Social Services, Related Cash, And In-Kind Items – Massachusetts Catastrophic Illness In Children Relief Fund SI CHI00815.051: (MI) Michigan Family Support Subsidy SI CHI00815.052: Community Integrated Living Arrangements (CILA) – (RTN 410 — 08/2007) SI 00815.100: Food and Shelter Received During a Medical Confinement SI 00815.150: Personal Services SI 00815.200: Conversion or Sale of a Resource SI 00815.250: Rebates and Refunds SI 00815.270: Income Tax Refunds SI 00815.300: Credit Life or Credit Disability Insurance Payments SI 00815.350: Proceeds of a Loan SI DAL00815.350: Proceeds of a Loan SI 00815.400: Bills Paid By a Third Party SI 00815.450: Replacement of Income Already Received SI 00815.460: Return of Erroneous Payments SI 00815.500: Weatherization Assistance SI 00815.550: Receipt of Certain Noncash Items SI 00815.600: Wage-Related Payments Resources defined. SI 01110.600 First-of-the-Month (FOM) Rule for Making Resource Determinations (C)(3). An item of value cannot be income and and a resource in the same month. See also Virginia Medicaid Manual M1110.600 RULE FOR MAKING DETERMINATIONS

Contact Information for State Medicaid Offices
Medicaid Handbook; Covered Services. Medicaid Providers	Medicaid Handbook. Of special note: Addiction and alcoholism (Addiction and Recovery Treatment Services (ARTS) program). See also Addiction and Alcoholism Supplement. Dental. Virginia’s Smiles For Children program now offers comprehensive dental benefits for the entire family. Mental Health Magellan Behavioral Health, Inc. (Magellan of Virginia) manages Medicaid covered mental health and substance use disorder treatment services. It coordinates benefits with approved managed care organizations. Locate a Virginia Medicaid Provider, I___ and II___.
Virginia Department of Medical Assistance Services (Medicaid)	Resources for Virginia Medicaid issues.
Virginia Medicaid Manual (DMAS) Interim transmittals and updates are incorporated at this link. Transitional: Entire Medicaid Manual (Combined by RSM). Assimilated on June 7, 2023, and current through Medicaid Transmittal #DMAS-27 (Effective 4-1-2023) and including Draft #DMAS 28 (Effective 7 1 2023). Entire Medicaid Manual (Combined by RSM). Assimilated on August 12, 2024, effective July 1, 2024, and current through Medicaid Transmittal #DMAS-32 (Effective 7-1-2024). 138% Poverty Level Medicaid for non-Medicare Recipients between 18 and 64 years of age Virginia “Expansion” (MAGI) Benefits from Cover VA (updated by DMAS) What is MAGI income? The income counted under MAGI rules is the income counted for federal tax purposes with few exceptions. All taxable income sources and some non-taxable income sources are counted for the MA eligibility determinations. See generally, 26 U.S. Code Part III – ITEMS SPECIFICALLY EXCLUDED FROM GROSS INCOME For “income” specifically included, see M0440.100 B 1. For “income” specifically excluded, see M0440.100 B 2. The policy specifically excludes Worker Comp awards and “emergency withdrawals or early” withdrawals from tax qualified plans,. The policy is silent about personal injury proceeds which are obviously excluded, but under both federal law and the general definition in the Medicaid Manual, such proceeds (lump sum or structured payments) are excluded from federal taxation and therefore not includible as income for MAGI purposes. MAGI generally imposes no eligibility resource test; LTC beneficiaries are subject to TOA policy [M1450.002 (F)]. Limits and Indices Resources	The Medicaid Eligibility Manual contains the policy and procedures used by eligibility workers to determine eligibility for the Medicaid program in Virginia. The Medicaid Manual and interim transmittal links (in Adobe .pdf) maintained by the DMAS are the left. Assimilated manual provisions have proven helpful for global word searches. When more than one stitched manual is included, the former is useful for the writer’s published material prior to the most recent assimilation. The writer’s assimilation and bookmarks were engineered with the Foxit portable document format editor. The April 1, 2023 edition of the writer’s Medicaid Highlights remains posted at this site’s outline page, and here. The work cites to the June 7, 2023 assimilation with specific hyperlinks. The July 1, 2024 edition is a work in progress as of August 16, 2024. When complete it will link to the August 12, 2024 assimilation. Readers in the interim should look at the updated Manual links in the August 12 work. Current standards and limits are at this link. Helpful DMAS tables detailing what is new in the materials start at this link and conclude at this link. The writer has highlighted several of most important note to lawyers and financial planners. Links below are to targeted policy often involved in our long term care / worker compensation / personal injury proceeds protection practice, including specifically the writer’s 2023 “Triple Scoop” trusts for MAGI eligible persons that can (a) avoid Medicaid payback, (b) avoid the necessity of disability status, and (c) in cases where benefits are paid for services before age 55, avoid estate recovery claims: Virginia Medicaid Expansion and the Modified Adjusted Gross Income Medicaid Category The Gift of the MAGI MAGI Graphs and Vignettes What is Medicaid MAGI (not real Magi)? 1. MAGI: • is a methodology for how income is counted and how household composition and family size are determined, • is based on federal tax rules for determining adjusted gross income (with some modification), and • has no resource test (Exception: MAGI Adults requesting coverage of Long Term Care services are subject to certain asset/resource requirements). The legal base for Virginia MAGI: • Statute • Virginia Administrative Code • Virginia Medicaid Policy (Medicaid Manual Provisions M0410.100 et seq.) Other States Enacting Expansion (now a majority of States). 2. MAGI Rules: • MAGI has an income disregard equal to 5% of the federal poverty level (FPL) for the Medicaid or FAMIS individual’s household size. The disregard is only given if the individual is not eligible for coverage due to excess income. It is applicable to individuals in both full-benefit and limited-benefit covered groups. • If the individual meets multiple Medicaid covered groups (and/or FAMIS) his gross income is compared first to the income limit of the group with the highest income limit under which the individual could be eligible. • If the income exceeds the limit, the 5% FPL disregard can be allowed, and the income again is compared to the income limit. • When considering tax dependents in the tax filer’s household, the tax dependent may not necessarily live in the tax filer’s home. • Under MAGI counting rules, an individual may be counted in more than one household but is only evaluated for eligibility in his household. • Use non-filer rules when the household does not file taxes. • Use non-filer rules when the applicant is claimed as a tax dependent by someone outside the applicant’s household. • Non-filer rules may be used in multi-generational household. 3. Eligibility Based on MAGI MAGI methodology is used for eligibility determinations for insurance affordability programs including Medicaid, FAMIS, the Advance Premium Tax Credit (APTC) and cost sharing reductions through the Health Insurance Marketplace for the following individuals: a. Children under 19 b. Parent/caretaker relatives of children under the age of 18 – Low Income Families With Children (LIFC) c. Pregnant women, including FAMIS MOMS and FAMIS Prenatal Coverage d. Individuals Under Age 21 e. Adults between the ages of 19 and 64 not eligible or Enrolled in Medicare (effective January 1,2019)” M410.100 (C) “Effective January 1, 2019, determination of eligibility for adults age 19-64 without Medicare will be evaluated using MAGI income methodology. These newly eligible individuals are referred to as MAGI Adults, see also. [MAGI Adults Defined] LTSS (nursing home coverage) is included. ” The MAGI income policy in Chapter M04 is used to determine countable income for MAGI Adults. The income limit is 138% FPL (133% FPL plus a 5% FPL income disregard if needed).” M1460.200 (B)(1) (erratum, should be 2, October, 2018 transmission) There is no patient pay. A. “’Patient pay’ is the amount of the long-term care (LTC) patient’s income which must be paid as his share of the LTC services cost. This subchapter provides basic rules regarding the post-eligibility determination of the amount of the LTC patient’s income which must be paid toward the cost of his care. MAGI Adults have no responsibility for patient pay. If an individual receiving LTC, also called long-term supports and services (LTSS), loses eligibility in the MAGI Adults [M1510 (A)(7)] covered group and is eligible in another full coverage group, patient pay policy will apply.” M1470.001 OVERVIEW …. For all case actions effective October 26, 2019, verification of earned and unearned income will be evaluated using attested income and reasonable compatibility rules. Whenever possible, income reported on the application will be verified through electronic data sources.” Elements of Income Included in MAGI: – Va. Medicaid Manual M0410.100 A. – Va. Medicaid Manual M0410.100 C. APPLICATIONS AND FORMS SSI, SSDI (SGA) Limits Federal Poverty Level Limits (Current Year) Spousal Impoverishment Protected Income (MMNA) and Protected Resource Amounts (PRA) See here and go to the chapters on income, resources, and transfer of resources Miscellany Provider Manuals (Generally) Virginia Medicaid Nursing Home Manual Medicaid Facility Reimbursement Rates DMAS Open Data “Dashboards”
Centralized Common Help Benefit Application	CommonHelp is an electronic application for multiple programs. By establishing an account, it allows an applicant or recipient to check and benefits, link a private account to a case record (in the Department of Social Services), report changes in circumstances, and update a case record.
Virginia Medicaid Application – Paper Versions for Download	Basic Application (required) Voter Registration (required) Long-Term Care Application (Appx. D) )(Aged, Blind, Disabled, for someone who has disabilities, or who is at least 65 years old, everyone, including children, in need of Long-term Care Services (nursing facility or community based care), and anyone who has more income than Medicaid allows but would like to be considered for “spenddown” of their “excess” income. Long-Term Care Application (Appx F) (nursing facility or community-based care, between 19 and 64, not eligible for or Enrolled in Medicare) All Medicaid Forms
Undue Hardship Claim Form	Asset Transfer Undue Hardship Claim
Pre-Screening Assessments	DMAS Checklist for Virginia Hospital Case Managers tasked with Discharge Planning for Hospitalized Individuals receiving Virginia Medicaid May, 2023 DMAS Screening Connections: Guidance for UAI and references. July, 2023: Changes to Screening Requirements, VCA 32.1-330 provides “that if an individual is admitted to a skilled nursing facility for skilled nursing services and such individual was not screened but is subsequently determined to have been required to be screened prior to admission to the skilled nursing facility, then the screening may be conducted after admission. Coverage by the Commonwealth for such persons who have not been prescreened shall not begin until six months after the initial admission to the skilled nursing facility. During this six-month period, the nursing home in which the individual resides shall be responsible for all costs indicated for institutional long-term services and supports, without accessing the patient’s funds.” When sufficient evidence (?) proves the admission without screening was not the fault of the skilled nursing facility, DMAS is to begin coverage of institutional long-term services and supports immediately upon the completion of the functional screening indicating skilled nursing facility level of care pending the financial eligibility determination. A Screeners’ Reference Guide for Long-Term Care Services in Virginia The Long Term Care Assessment Instrument Form is also linked as a downloadable form with other forms at this site. Medicaid Funded Long-Term Services and Supports Authorization Form is the Medicaid approval document for the screening test. Community-Based Care Recipient Assessment Report The Long Term Care Assessment Manual (2015, DSS – APS) User’s Manual: Virginia Uniform Assessment Instrument (UAI) (2005) Skilled Nursing Facility (SNF) Long Term Services And Supports (LTSS) Screening Teams (2020 DMAS Training)
Virginia Medicaid Waivers Virginia Medicaid Manual Provisions for All Waivers Virginia Medicaid Waiver Manual (3/1/22)	The Virginia CCC Plus and Virginia’s waiver programs. Basic coverage description, long term care details. Plan comparisons by Jurisdiction DMAS Waivers and Consumer Directed Services (2020, 2021 CCC+ Rates) Providers by type. For in-home nursing services: Click the above link. In “provider type,” select “Case Management – Waiver and Service Facilitation” Narrow scope by city or zip Waiver payment rates for consumer directed nursing services (here (2019) and here (2020)), scroll to “SFY [YEAR] Waiver Rates,” for example, for 2021, here. Nursing Home Reimbursement Rates. DMAS rate for each participating facility. (Current, 3-30-2023). DMAS’ 2020 General Fact Sheet and Guide, Manual for Employer of Record (the person receiving services), this text explains who can serve and suggests strategies for finding someone in the community to serve. ARC of Northern Virginia’s useful guide and especially useful set of .pdf tables.
Appeals	Medicaid Virginia DMAS Appeal Regulations. Virginia Medicaid Manual Appeals Provisions DMAS Appeal Information Management System Log In Medicare How to file a Medicare appeal.
Life Tables	Life Expectancy – Virginia Medicaid Table. M1450, Long Term Care, for Appendix 2, “LIFE EXPECTANCY TABLE.” Compare: United States SSA Table Life Expectancy.

Current Official Virginia Medicaid Position for Long Term Support Services (LTC)	The official web page of the Virginia Department of Medical Assistance Services relating to long term care services and supports (LTSS). Links to the FOE officer for DMAS. See the CMS “State Medicaid Manual” for the Federal perspective on what Medicaid policy should be.
Virginia DMAS Medicaid Plan Search Page for Virginia Register	Virginia Administrative Code Regulations constitute the official Virginia Medical Assistance Plan. The Virginia Register is the official publication for Virginia administrative regulations, including Medicaid plan regulations, 12VAC-30-XXX-XXXX. The link to the left is the search page for all issues of the Register.
Medicaid and Medicare Resources Current Medicaid Planning Outlines	Income and Resource Guidelines; ABLE Accounts Centers for Medicare & Medicaid Services Notice of Non-Coverage for Medicare Skilled Care and Therapy Services; Premature Termination of Medicare Skilled Coverage and QIO Appeals: Toolbox Jimmo Settlement CMS The Medical Perspective of Medicaid in nursing facilities: Medicaid rules governing who qualifies for assistance and for how much are often characterized as among the most complicated of any program administered by the Federal Government. Up to 60% of residents are impoverished by the costs of long term care and convert to Medicaid Spousal Impoverishment Federal Statute Virginia Rules Sizick v. DHHS ( Mich App Unpbl. LC No. 21-141789-PO, May 26, 2022) Support Order Varying Community Spouse Resource Allowance Premature When Issued Before Medicaid Resource Assessment Completed, in accord with Virginia Medicaid policy, Va. Medicaid Manual 1480.000 et seq. and Majette Medicaid Planning Highlights). Transfer of Assets Federal Rules Virginia Rules Failure of Widow(er) To Claim The Elective Share Treated As A Transfer of Assets – Va. Code § 64.1-13 et seq Miller v. Kansas Department of Social Services Annuity Regulations Medicaid Manual M 1450.400 F. Testamentary Trust Established by Spouse Does Not Violate the Medicaid TOA Rule Short Term Annuities and the Zahner case Federal – Virginia Medicaid Estate Recovery Think it won’t happen to you? Click here, here, and here. Virginia Statute Prohibiting Medicaid Liens, Va. Code §63.2-409. Virginia Regulation Governing Estate Recovery Virginia Regulation Prohibiting Liens Revocable Transfers of Real Estate – Virginia’s “Lady Bird” Deed Statute Filial Responsibility: From Medieval to Modern, Going Around and Coming Around What happens when Medicaid can’t (or won’t) pay for Mom and Dad’s medical and nursing care? Kids, meet Uncle Filial Responsibility, then, now and tomorrow? Personal Injury Lien Reduction Good Faith Lien Waiver Negotiation Guidelines Special Needs Trusts Virginia Department of Social Services Letter Regarding Pooled Income Trusts and Transfer of Assets Policy Related to FUNDING Such Trusts ABLE Accounts Generally. SSI: SI 01130.740 Achieving a Better Life Experience (ABLE) Accounts Medicaid: Virginia Medicaid Manual M 1130.740 (C) allows distributions from a special needs trust to the ABLE account. See page 1065. ABLE accounts are not subject to estate recovery. See page 1824.
Auxiliary Grant, Generally Assembled Auxiliary Grant Manual: All chapters in one searchable document (compiled on 12-28-2020)	The Virginia Auxiliary Grant supplements income for Supplemental Security Income (SSI) and some other aged, blind, or disabled individuals living licensed assisted living facilities, or certain adult foster care homes. The Grant is “to maintain a standard of living that meets a basic level of need.” This link contains the Virginia AG Manual and a listing of all facilities which accept the AG, arrayed by jurisdiction. Detailed information about the facilities (licensure, inspection reports, etc.) is available here.

Gen Worth State by State Survey of Nursing Costs Long Term Care Insurance (LTCI)	Annualized Costs of Care. Generally. National Association of State Insurance Commissioners LTCI Links Virginia Insurance Bureau, LTCI Division: Forms Personal Worksheet, which suggests that “[i]f you are buying this policy to protect your assets and your assets are less than $30,000, you may wish to consider other options for financing your long-term care.” 2015 Virginia State Corporation Commission Report, stating at page 40 (Adobe .pdf page 43) that “[a]s various filings made in this docket have demonstrated, significant premium rate increases have continued to impact long-term care insurance policyholders in Virginia. The Commission has sought over the last several years to identify more clearly the drivers of these increases and to clarify if, and to what extent, the current regulatory framework applicable to long-term care insurance rate review may have become insufficient to address effectively the numerous consumer complaints the Bureau has received. The Commission recognizes the extremely difficult nature of this issue and the need to consider numerous factors – including the significant premium rate increases experienced by long-term care insurance policyholders, the ability of the insurers issuing long-term care insurance policies to pay claims in the future and meet their contractual obligations, the equitable and fair treatment of all policyholders, both new and existing, and the sustainability of the long-term care insurance market in Virginia – in adopting changes to the current regulatory framework. The Commission finds that the amendments proposed by the Bureau address many of the concerns expressed not only by consumers, but by the Commission as well, regarding long-term care insurance premium rate increases in Virginia. These proposed amendments, which are discussed in more detail in the Bureau’s Response and Reply and attached as Exhibit A, strive to both protect consumers and place heightened scrutiny on long-term care insurers seeking to raise premium rates. In addition, as discussed above, the Bureau’s proposed amendments to the Rules are substantially similar to certain revisions to the NAIC Model Regulation or contained in the NAIC Model Bulletin,P28F9P which the NAIC spent a considerable amount of time and effort developing based on extensive national discussion and collaboration with a broad set of stakeholders, including state insurance regulators, industry groups and consumer groups. The Commission finds that while the Bureau’s proposed amendments to the Rules will not eliminate long-term care insurance premium rate increases, such proposed amendments adopt a more conservative approach for the initial pricing of long-term care policies, require insurers to take a more active role in managing long-term care insurance rates, and provide additional and necessary protections to long-term care insurance policyholders in Virginia.” Virginia Code Provisions Virginia Administrative Regulations LTCI Shut Down By Pennsylvania State Insurance Commission: – Does Everyone Lose Everything In Their Policies?
Federal Income Tax Deductions	When there are appreciated assets and especially when accessing tax qualified (deferred) plan or account funds (IRA, 401 K, etc.), payments for medical care / expenses may be made more tax efficient by determining the source of the payments. Whether it is better to pay from cash or proceeds of high basis investments or tax qualified (deferred) plans (e.g., 401, IRA, etc.) will depend to some degree upon the availability of deductible medical expenses, which can include long term care expenses incurred and paid by either spouse if filing jointly. Click for link to nursing home services deductibility as a medical expense; click for discussion of the heading, “How Much of the Expenses Can You Deduct?”
© Majette.net Updated J4 11 2023