Medicaid Programs for Children in Virginia



[pic]Medicaid Programs for Children in Virginia

The Department of Medical Assistance Services is the agency that administers Medicaid and the State Children’s Health Insurance Program (CHIP) in Virginia. The CHIP program in Virginia is called Family Access to Medical Insurance Security (FAMIS). Any individual can apply for Medicaid or Famis at their local Department of Social Services or at

I. Medicaid(Famis Plus) and Famis

a. this information is about Virginia Medicaid, also known as FAMIS Plus

Medicaid/Famis Plus… Medicaid was created to assist people with low-income, primarily for low-income children but may also provide assistance to pregnant women, the elderly, individuals with disabilities.

To qualify you must:

• be a resident of the state of Virginia,

• a U.S. national, citizen, permanent resident, or legal alien,

• the household financial situation is characterized as low income or very low income.

• A child under the age of 18

• Other populations considered are a pregnant woman, under age 21 and in foster care, adoption assistance or a nursing facility, blind, disabled, or be 65 years of age or older.

• The Medicaid income limits are different, depending on which group of individuals you fall into.

b. Famis: Family Access to Medical Insurance Security (FAMIS).

FAMIS is Virginia's health insurance program for children. It makes health care affordable for children of eligible families. FAMIS covers all the medical care growing children need to avoid getting sick, plus the medical care that will help them if they do get sick or get hurt.

To qualify you must:

▪ Live in Virginia

▪ Are under age 19

▪ Are a united states citizen or qualified alien

▪ Don't have health insurance now and haven't had it in the past 4 months (There are exceptions to the four month waiting period)

▪ Are not eligible for any Virginia state employee health insurance plan

▪ Are not eligible for FAMIS Plus (also known as Children's Medicaid)

▪ Live in families meeting FAMIS income guidelines. Monthly gross income limit (200% poverty level)

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II. Special Medicaid Populations

a. SSI recipients

Most, if not all, children who receive SSI (Supplemental Security Insurance) via the Social Security Administration are eligible for Medicaid coverage for so long as they are receiving SSI benefits. To be eligible for SSI benefits you must be:

• aged (age 65 or older);

• blind; or

• disabled.

• have limited income; and

• have limited resources; and

• is a U.S. citizen or national, or in one of certain categories of aliens

• once found eligible for SSI by Disability Determination Services of Social Security Administration, an individual can apply for Medicaid benefits at their local Department of Social Services

b. Waiver programs

There are several home and community-based Medicaid “waiver” programs. These waivers provide community-based long-term care services as an alternative to institutionalization. Through Medicaid Waivers, states can “waive” certain requirements including the requirement that individuals live in institutions in order to receive Medicaid funding. The “waiver” is that the parental or household income is “waived” for eligibility criteria if the patient meets the medical level of care criteria:

• Mental Retardation/Intellectual Disability (MR/ID) Waiver

An individual must be age 6 or older and have a diagnosis of MR OR be under age 6 and at developmental risk. The person must be eligible for placement in an intermediate-care facility for persons with mental retardation or other related conditions (ICF-MR). This is established using the “Level of Functioning” survey.

• Day Support Waiver

Persons on the MR/ID waiver Urgent or Non-Urgent Waiting Lists are eligible if they have a MR/ID diagnosis. Individuals are selected according to the date when services were first necessary, regardless of urgency. An individual can remain on the waiting list for the MR/ID Waiver while being served by the Day support Waiver, and transfer to the MR/ID Waiver once a slot becomes available.

• Elderly or Disabled with Consumer-Direction Waiver,

This waiver serves the elderly and persons of all ages with disabilities. An individual must meet nursing facility eligibility criteria, including both medical needs and functional capacity needs (assistance with activities of daily living). An individual can remain on the waiting list for another waiver while being served by the EDCD Waiver and then transfer to the preferred waiver once a slot becomes available.

• Technology Assisted Waiver

Children and adults must require substantial and ongoing skilled nursing care. Children under the age of 21 are eligible if they are dependent on technology to substitute for a vital body function and have exhausted available third-party insurance benefits for private-duty nursing. Tech Waiver services may be limited or denied for individuals who can receive services through a third-party payment source.

• Individual and Family Developmental Disabilities Support Waiver.

The DD Waiver provides services to individuals 6 years of age and older who have a diagnosis of a developmental disability and do not have a diagnosis of mental retardation. Individuals also must require the level of care provided in an intermediate- care facility for persons with mental retardation or other related conditions (ICF/MR). Children who do not have a diagnosis of mental retardation, and have received services through the MR/ID Waiver, become ineligible for the MR/ID Waiver when they reach the age of 6. At that time, they can be screened for eligibility for the DD Waiver; if found eligible they will receive a DD waiver slot without being placed on the DD waiver waiting list.

c. Institutionalized Medicaid (m1410.010)

Children in medical institutions (facilities, hospitals and rehabilitation centers) who have been or are expected to be in the institution for 30 consecutive days or more, are considered NOT living with their parents, therefore can be evaluated for Medicaid without the parental income being considered for Medicaid eligibility purposes.

d. Medicaid Spend Down

A Medicaid spenddown is for people who meet all the Medicaid eligibility requirements except for income. People who have countable income higher than the medically needy income limit for their city or county are placed on a spenddown. Spenddown works like an insurance policy deductible. The amount of the “deductible” is called the “spenddown

liability.” A spend-down is a dollar amount that is figured to help you qualify for Medicaid. If your income is more than the amount the government allows in order to receive Medicaid, you can “spend down” to that level and qualify for assistance. Spend-down amounts are based on a formula that considers your monthly income and medical expenses, and compares the income to pre-determined amounts called income disregard and the Medicaid Need Standard

Medicaid Expansion

Beginning January 2019, adults aged 19 – 64, lawfully residing in the US for at least five years who are 138% or below the poverty level for individual or family (family of 1 = $16,754, family of 3 = $28,677).

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