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VA Medicaid Covered Groups

Federal and State laws describe the groups of individuals who may be eligible for Medicaid in Virginia. These groups of individuals are called Medicaid covered groups. The eligibility rules and medical services available are different for different covered groups. Individuals who are in one of the covered groups may be eligible for Medicaid coverage if their income is within the Medicaid Income Limits and their resources are within the required Medicaid Resource Limits of the covered group. The Medicaid covered groups are:

ABD Groups (Aged, Blind and Disabled)

·             Supplemental Security Income (SSI) recipients who are aged 65 or older, blind or disabled and who meet Medicaid resource limits of $2,000 for an individual or $3,000 for a couple.

·             Auxiliary Grant (AG) recipients who meet Medicaid resource limits of $2,000 for an individual or $3,000 for a couple.

·             ABD Individuals with Income that does not Exceed 80% FPL and who meet the Medicaid resource limits of $2,000 for an individual or $3,000 for a couple.

·             Recipients of Medicaid Waiver Services: Individuals who meet the non-financial requirements for any of the Waiver Services and who have Gross Income that does not exceed 300% of the SSI individual payment limit. They must also meet the Medicaid Resource Limits of $2,000 for an individual in any ABD group. Resource limits for married individuals depends on whether or not the spouses live in the community.

·             ABD Individuals residing in Medical Institutions who have Gross Income that does not exceed 300% of the SSI individual payment limit. They must also meet the Medicaid Resource Limits of $2,000 for an individual. Resource limits for married individuals depends on whether or not the spouses live in the community.

·             Persons who are terminally ill and have elected to receive hospice care.

·             VA Medicare Related Covered Groups: Individuals who are eligible for Medicare and who meet certain income and resource limits may receive limited Medicaid coverage. Medicaid pays a portion of the Medicare premium or deductible on behalf of these Medicare beneficiaries. Income limits are based on percentages of the Federal Poverty Limit (FPL). Medicaid Resource Limits are $4,000 for an individual and $6,000 for a couple in the Qualified Disabled and Working Individuals (QDWI) group, and (effective 1/1/2010) must be not more than $6,600 for a single person and $9,910 for a couple in the Qualified Medicare Beneficiaries (QMB), Special Low-Income Medicare Beneficiaries (SLMB), and Qualified Disabled and Working Individuals (QI) groups.

·             MEDICAID WORKS: Individuals with a disability (including blindness) who initially either have income that does not exceed 80% FPL or are current Supplemental Security Income (SSI) recipients, meet the Medicaid resource limits of $2,000 for an individual or $3,000 for a couple, are at least 16 and less than 65 years old, and are or will be self-employed or competitively employed in an integrated setting. This buy-in program enables workers, once enrolled, to have higher income and retain more in savings, or resources, than is usually allowed by Medicaid.

Protected Groups

·             Former Money Payment Recipients August 1972

·             Conversion Cases

·             Former SSI/AG Recipients

·             Protected Widows or Widowers

·             Qualified Severely Impaired Individuals (QSII) 1619(b)

·             Protected Adult Disabled Children

·             Protected SSI Disabled Children

F & C Groups (Families and Children)

·             Pregnant women (single or married) whose family income is at or below 133% of the Federal Poverty Level (FPL). There are no resource limits for this group.

·             Infants born to Medicaid-eligible women. There are no resource limits for this group.

·             Children younger than age 6 whose family income is at or below 133% of the Federal Poverty Level (FPL). There are no resource limits for this group.

·             Children ages 6 to 19, whose family income is at or below 133% of the Federal Poverty Level (FPL). There are no resource limits for this group.

·             Low Income Families with Children (LIFC). Medicaid Resource Limits (previously $1,000 for the assistance unit.) have been eliminated. There are no resource limits for this group.

·             Extended LIFC: This is not really a separate covered group, but is actually an extension of up to a year for LIFC recipients who lose their LIFC eligibility because of increased earned income or child/spousal support.

·             Children under age 21 who are in foster care or subsidized adoptions.

Special Categories

·             FAMIS (Family Access to Medical Insurance Security Plan): FAMIS is not Medicaid; rather, it is health insurance that covers uninsured low-income children under age 19 who are not eligible for Medicaid and whose gross family income does not exceed 200% of the Federal Poverty Level (FPL). There are no resource limits. FAMIS is not an entitlement, which means that when the funds that are allocated for it are exhausted, no additional families will be added.

·             Women screened by the Centers for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program who have been diagnosed and need treatment for breast or cervical cancer, with income below 200% of the Federal Poverty Level (FPL) and

·             Certain refugees for a limited time period.

Two Categories that include some ABD and some F&C

·             Medically Needy: The Medically Needy group consists of those who are in certain of the above covered groups except that their income or resources exceed the limits for their group. They are subject to a spenddown to the Medically Needy Income Levels. They must meet the Medicaid Resource Limits of $2,000 for an individual, $3,000 for a couple, and $100 for each additional member of the assistance unit. (Note that for ABD groups the assistance unit is always either the individual or couple.)

·             Medically Indigent: The Medically Indigent groups have either no Resource Limits or less restrictive resource limits. See: Medicaid Resource Limits.

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VA Medicaid Overview

VA Benefit Information System Welcome and Introduction

Source:

Information for this topic was drawn from Chapters M03 and M1460.500 of the Department of Social Services (DSS) Medicaid Manual.

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