Virginia Medicaid Application Packet (Long-Term Care / CCC Plus / Nursing Facility)

VIRGINIA MEDICAID APPLICATION PACKET — LONG-TERM CARE / CCC PLUS / NURSING FACILITY

TABLE OF CONTENTS

1. Cover Letter to the Local Department of Social Services
2. Applicant and Household Identification
3. Categorical Eligibility (Aged, Blind, or Disabled)
4. Financial Eligibility — Income
5. Financial Eligibility — Resources
6. Spousal Impoverishment Protections
7. Transfer of Assets and 60-Month Look-Back
8. Primary Residence and Home-Equity Treatment
9. Medically Needy Spend-Down
10. Pre-Admission Screening (UAI) and Level-of-Care Findings
11. CCC Plus Managed Care Enrollment
12. Patient Pay / Patient Liability Calculation
13. Estate Recovery Acknowledgment
14. Authorized Representative and Verifications
15. Document Checklist
16. Applicant / Authorized Representative Signature
17. Virginia Practice Notes
18. Sources and References

1. COVER LETTER TO THE LOCAL DEPARTMENT OF SOCIAL SERVICES

Date: [__/__/____]

[CITY/COUNTY] DEPARTMENT OF SOCIAL SERVICES

ATTN: Long-Term Care / Adult Medicaid Eligibility Unit

[STREET ADDRESS]

[CITY], Virginia [ZIP]

Re: Application for Medical Assistance — Long-Term Care Coverage

Applicant: [APPLICANT FULL LEGAL NAME]

Date of Birth: [__/__/____]

Social Security Number (last 4): [____]

Medicare Claim Number / MBI: [________________________________]

Dear Eligibility Worker:

Enclosed please find the Application for Medical Assistance (Form 032-03-0824) and supporting documentation submitted on behalf of the above-named applicant for Virginia Medicaid long-term care coverage under Cardinal Care, including (☐ check all that apply):

• ☐ Nursing Facility (NF) Medicaid
• ☐ Commonwealth Coordinated Care Plus (CCC Plus) Waiver (HCBS)
• ☐ Aged, Blind, and Disabled (ABD) categorically needy coverage
• ☐ Medically Needy with Spend-Down
• ☐ Medicare Savings Program (QMB / SLMB / QI) — concurrent

The undersigned respectfully requests that all eligibility correspondence, requests for verification, and notices of action be directed to the Authorized Representative identified in Section 14 of this packet.

Sincerely,

[________________________________]

[APPLICANT or AUTHORIZED REPRESENTATIVE NAME]

2. APPLICANT AND HOUSEHOLD IDENTIFICATION

2.1. Applicant. Name: [________________________________]; DOB: [__/__/____]; SSN: [________________________________]; Place of Birth: [________________________________]; Citizenship/Immigration Status: [________________________________].

2.2. Residence. Current physical address: [________________________________] (☐ private residence ☐ assisted living facility ☐ nursing facility — Name: [________________________________]; Date of Admission: [__/__/____]).

2.3. Marital Status. ☐ Single ☐ Married ☐ Widowed ☐ Divorced ☐ Legally Separated. If married, complete Section 6.

2.4. Community Spouse. Name: [________________________________]; DOB: [__/__/____]; SSN: [________________________________]; Address: [________________________________].

2.5. Dependents in the Household. [List names, DOBs, and relationship.]

3. CATEGORICAL ELIGIBILITY (AGED, BLIND, OR DISABLED)

3.1. Applicant qualifies under one or more of the following categories (☐ check all that apply):

• ☐ Aged (65 or older)
• ☐ Blind (meets SSA definition under 42 U.S.C. § 1382c)
• ☐ Disabled (meets SSA definition; Social Security Disability determination attached or pending)

3.2. 209(b) Note. Virginia is a Section 209(b) state under 42 U.S.C. § 1396a(f). Receipt of SSI does not automatically confer Medicaid eligibility; a separate Virginia determination is required and may apply more restrictive criteria than SSI for blindness and disability. The applicant [has / has not] previously been adjudicated disabled by SSA on [__/__/____].

3.3. Functional Eligibility for LTSS. A Uniform Assessment Instrument (UAI) must be completed by the local screening team to confirm Nursing Facility level-of-care criteria under 12 VAC 30-60-300 et seq. Date of UAI: [__/__/____]. Result: [________________________________].

4. FINANCIAL ELIGIBILITY — INCOME

4.1. Special Income Limit (SIL) — 2026. For Nursing Facility and CCC Plus Waiver applicants, gross monthly income must not exceed approximately $2,982 (300% of the SSI Federal Benefit Rate). Confirm the figure in the current DMAS memorandum.

4.2. Applicant Monthly Gross Income. Source-by-source:

4.3. Excess Income Pathway. If gross income exceeds the SIL, applicant pursues coverage through the Medically Needy Spend-Down (see Section 9). Virginia does not use Qualified Income Trusts.

5. FINANCIAL ELIGIBILITY — RESOURCES

5.1. Countable Resource Limit (2026). $2,000 for a single applicant; $4,000 combined for a couple where both spouses are applying. The community-spouse share is governed by the spousal-impoverishment rules in Section 6.

5.2. Countable Resources (Itemize).

5.3. Excluded Resources (typical). One automobile (any value) used for transportation; principal residence (subject to home-equity cap, see Section 8); personal effects and household goods; irrevocable funeral/burial trusts within statutory limits; term life insurance; up to $1,500 face value of non-term life insurance; certain ABLE account balances.

5.4. Five-Year Financial History. Applicant has provided 60 months of statements for each financial account listed above, identifying every withdrawal, transfer, and gift in excess of $[________], consistent with 12 VAC 30-40-300 and DMAS Medicaid Manual M14.

6. SPOUSAL IMPOVERISHMENT PROTECTIONS

6.1. Snapshot Date. The Resource Assessment "snapshot" is taken as of the first continuous 30-day period of institutionalization beginning on or after September 30, 1989. Date of Institutionalization: [__/__/____]. Snapshot countable resources (couple combined): $[________].

6.2. Community Spouse Resource Allowance (CSRA) — 2026.

• Federal maximum CSRA (2026): approximately $162,660.
• Federal minimum CSRA floor (2026): approximately $32,532.
• Virginia formula: 50% of snapshot countable resources, not less than the minimum and not more than the maximum.
• Calculated CSRA for this case: $[________].

6.3. Minimum Monthly Maintenance Needs Allowance (MMMNA) — 2026.

• Floor (2026): approximately $2,643.75/month.
• Ceiling (2026): approximately $4,066.50/month.
• Excess shelter standard / utility standard: per current DMAS table.
• Calculated MMMNA for this case: $[________].

6.4. Income Allocation. From the institutionalized spouse's monthly income, an amount sufficient to bring the community spouse's income up to the MMMNA may be diverted, after applying any personal-needs allowance and health-insurance premium deductions in the patient-pay calculation (see Section 12).

6.5. Fair Hearing / Court-Ordered Increase. The community spouse may request a fair hearing under 12 VAC 30-110 to increase the CSRA or MMMNA on a showing of exceptional circumstances or insufficient income. Court orders for spousal support may also be considered.

7. TRANSFER OF ASSETS AND 60-MONTH LOOK-BACK

7.1. Look-Back Period. Sixty (60) months immediately preceding the later of: (a) the application date, or (b) the date of institutionalization or waiver authorization (42 U.S.C. § 1396p(c)(1)(B); 12 VAC 30-40-300).

7.2. Disclosure of Transfers. Applicant discloses each transfer of resources (including gifts, sales for less than fair market value, and additions/removals from joint accounts) during the look-back period:

7.3. Penalty Divisor. Penalty period = uncompensated transfer ÷ Virginia penalty divisor.

• Northern Virginia divisor (2026, verify): approximately $9,703/month.
• Rest-of-Virginia divisor (2026, verify): approximately $7,324/month.
• Region applicable to this applicant: ☐ Northern Virginia ☐ Rest of Virginia.
• Penalty calculation: $[________] ÷ $[________] = [____] months penalty period beginning on the date applicant is otherwise eligible and receiving NF or waiver services.

7.4. Exempt Transfers (claimed). ☐ Transfer to spouse; ☐ Transfer to or for the sole benefit of a blind/disabled child; ☐ Transfer to or for the sole benefit of a disabled individual under age 65 in a (d)(4)(A) or (d)(4)(C) trust; ☐ Transfer of home to caregiver child (per 42 U.S.C. § 1396p(c)(2)(A)(iv)); ☐ Transfer of home to sibling with equity interest who resided in the home at least one year before institutionalization; ☐ Undue hardship waiver requested.

7.5. Hardship Waiver. If imposing a transfer penalty would deprive the applicant of medical care necessary to avoid endangering health or life, or food, clothing, shelter, or other necessities of life, applicant requests a hardship waiver under 42 U.S.C. § 1396p(c)(2)(D) and 12 VAC 30-40-300.

8. PRIMARY RESIDENCE AND HOME-EQUITY TREATMENT

8.1. Address of Primary Residence. [________________________________].

8.2. Equity Value. Current FMV: $[________]; outstanding mortgage/lien: $[________]; net equity: $[________].

8.3. Home-Equity Cap (2026). Federal home-equity cap is approximately $752,000 for 2026 (verify current figure). Net equity above the cap renders the applicant ineligible for NF/waiver coverage absent: (a) a community spouse, child under 21, or blind/disabled child residing in the home, or (b) a hardship waiver.

8.4. Intent to Return Home. Applicant ☐ does ☐ does not intend to return to the residence. A signed Statement of Intent to Return is attached at Tab [____].

8.5. Liens and Recovery. The Commonwealth may file a Medicaid lien and pursue estate recovery against the residence after the applicant's death, subject to statutory exceptions (see Section 13).

9. MEDICALLY NEEDY SPEND-DOWN

9.1. Spend-Down Pathway. Virginia operates a Medically Needy program (12 VAC 30-40-220 et seq.). Where countable income exceeds the categorically-needy limit but not the SIL, or where applicant is not seeking institutional/waiver coverage, applicant may "spend down" excess income against incurred medical expenses to reach the Medically Needy Income Limit (MNIL).

9.2. Spend-Down Period. Six (6) months, established by DMAS Manual M13.

9.3. Allowable Expenses. Medical, dental, behavioral-health, and prescription costs; Medicare and other health-insurance premiums; medical equipment and supplies; and previously-incurred unpaid medical bills not previously applied.

9.4. Calculation Worksheet.

• Monthly countable income: $[________].
• MNIL (household size [____]): $[________].
• Excess income per month: $[________].
• Spend-down liability for 6-month period: $[________].

9.5. Submission of Bills. Applicant agrees to submit medical bills to the LDSS as incurred to meet the spend-down obligation.

10. PRE-ADMISSION SCREENING (UAI) AND LEVEL-OF-CARE FINDINGS

10.1. Screening Team. The screening team consists of nursing, social-work, and physician members at the local DSS / Health Department (community screenings) or at an acute-care hospital (hospital-based screenings). 12 VAC 30-60-300 et seq.

10.2. UAI Date / Outcome. Date: [__/__/____]. NF level-of-care criteria ☐ met ☐ not met. Waiver criteria ☐ met ☐ not met. Screening team contact: [________________________________].

10.3. Plan of Care. A person-centered plan of care has been developed with [CCC Plus MCO / NF Director of Nursing] and is attached at Tab [____].

11. CCC PLUS MANAGED CARE ENROLLMENT

11.1. Enrollment. Most LTSS recipients are enrolled in Commonwealth Coordinated Care Plus (CCC Plus) for managed long-term services and supports, including nursing-facility coverage, the CCC Plus Waiver, and behavioral-health and acute services.

11.2. MCO Selection. Applicant ☐ selects ☐ accepts auto-assignment to the following MCO: ☐ Aetna Better Health of Virginia ☐ Anthem HealthKeepers Plus ☐ Humana Healthy Horizons ☐ Sentara Community Plan / Optima Health ☐ UnitedHealthcare Community Plan. (Confirm participating MCOs in the current contract year.)

11.3. Dual-Eligible Coordination. If the applicant is also a Medicare beneficiary, Medicare remains primary; CCC Plus coordinates Medicaid-covered services and supplemental benefits, and may pair with a D-SNP for aligned enrollment.

12. PATIENT PAY / PATIENT LIABILITY CALCULATION

12.1. Patient Pay Formula (institutionalized applicants):

Gross monthly income
− Personal Needs Allowance (PNA) (currently $[____] for NF residents; verify)
− Spousal MMMNA diversion (if applicable)
− Family allowance (if applicable)
− Cost of guardian/conservator fees (limited)
− Health-insurance premiums (Medicare Parts B and D, Medigap)
− Incurred medical expenses not covered by Medicaid
= Patient Pay (paid monthly to the NF)

12.2. Worksheet.

13. ESTATE RECOVERY ACKNOWLEDGMENT

13.1. Statutory Authority. 42 U.S.C. § 1396p(b); Va. Code § 32.1-326.1; 12 VAC 30-20-141.

13.2. Recovery Targets. After the death of an applicant who was 55 or older when receiving Medicaid LTSS (or any Medicaid services after age 55 to the extent permitted), the Commonwealth may recover from the probate estate against costs of medical assistance correctly paid.

13.3. Statutory Exceptions / Deferrals. Recovery is barred or deferred during the lifetime of: (a) a surviving spouse; (b) a child under age 21; (c) a blind or disabled child of any age; or where recovery would result in undue hardship, as provided by 12 VAC 30-20-141.

13.4. Acknowledgment. Applicant acknowledges receipt of estate-recovery notice and understands that the Commonwealth's claim does not affect rights of joint tenants with rights of survivorship to the extent permitted under Virginia law, but that DMAS may pursue probate-estate assets and may file a TEFRA lien in limited circumstances.

Initial: [____]

14. AUTHORIZED REPRESENTATIVE AND VERIFICATIONS

14.1. Authorized Representative (AR). Pursuant to 42 C.F.R. § 435.923 and 12 VAC 30-110-1300, applicant designates the following individual as Authorized Representative for purposes of this application, eligibility verification, renewal, and appeals:

Name: [________________________________]

Relationship: [________________________________]

Address: [________________________________]

Telephone: [________________________________]

Email: [________________________________]

Power-of-Attorney / Guardianship documentation attached: ☐ Durable POA ☐ Guardian/Conservator order ☐ Health Care POA ☐ Other: [________].

14.2. Authorization to Disclose. Applicant authorizes DMAS, the LDSS, and any third-party verification source (banks, brokerages, life-insurance companies, employers, SSA, IRS, VA, DMV) to disclose information necessary to determine eligibility and patient pay.

14.3. Asset Verification System (AVS). Applicant consents to use of the federally-mandated Asset Verification System to confirm financial accounts.

15. DOCUMENT CHECKLIST

• ☐ Photo ID and Social Security card (or BENDEX printout)
• ☐ Birth certificate / proof of citizenship or qualified-immigrant status
• ☐ Marriage certificate / divorce decree / death certificate of prior spouse
• ☐ Medicare card / MBI; long-term care insurance policy if any
• ☐ 60 months of statements for every financial account (checking, savings, CDs, brokerage, IRA/401(k))
• ☐ Life-insurance policy declarations (face value and cash surrender value)
• ☐ Real property: deed, current tax assessment, mortgage statement
• ☐ Vehicle title(s) and current valuation
• ☐ Funeral/burial trust documents
• ☐ Five years of tax returns
• ☐ Documentation of every gift or transfer over $[________]
• ☐ Power of Attorney / Guardianship / Conservatorship orders
• ☐ Pre-Admission Screening (UAI) results
• ☐ Nursing facility admission agreement (if institutionalized)
• ☐ Verification of all sources of income (SSA, pension, VA, wages)

16. APPLICANT / AUTHORIZED REPRESENTATIVE SIGNATURE

I declare under penalty of perjury under the laws of the Commonwealth of Virginia that the foregoing application and all attached statements are true and correct to the best of my knowledge. I understand that knowingly providing false information to obtain Medicaid is a violation of Va. Code § 32.1-312 and may subject me to civil and criminal penalties, including recoupment.

Date: [__/__/____]

[________________________________]

[APPLICANT NAME]

[________________________________]

[AUTHORIZED REPRESENTATIVE NAME, if signing on behalf of applicant]

Capacity: ☐ Agent under Durable POA ☐ Guardian/Conservator ☐ Spouse ☐ Other: [________]

17. VIRGINIA PRACTICE NOTES

• 209(b) State. Virginia exercises the option under 42 U.S.C. § 1396a(f) to apply more restrictive eligibility criteria than SSI. SSI receipt does not confer automatic Medicaid eligibility — a Virginia-specific determination is required.
• Medically Needy / Spend-Down (No Miller Trust). Virginia covers the medically needy and uses a six-month spend-down. It does not authorize Qualified Income Trusts ("Miller Trusts"); applicants with income above the Medically Needy Income Limit but at or below the Special Income Limit qualify under the institutional pathway directly.
• CCC Plus Delivery System. Long-term services and supports for adults 65+ and disabled adults are delivered through the Commonwealth Coordinated Care Plus (CCC Plus) managed-care program. NF residents and CCC Plus Waiver participants enroll with one of the contracted MCOs.
• Penalty Divisors — Two Regions. Virginia uses two penalty divisors: a higher Northern Virginia divisor (Arlington, Fairfax, Loudoun, Prince William, etc., and the cities of Alexandria, Fairfax, Falls Church, Manassas, Manassas Park) and a Rest-of-Virginia divisor. Confirm region and current divisor in the most recent DMAS Medicaid Memorandum.
• Annual Indexing. The CSRA, MMMNA, home-equity cap, and Special Income Limit are indexed annually. Always pull the operative-year figures from the CMS Spousal Impoverishment Standards and Virginia DMAS memoranda before signing.
• Pre-Admission Screening. A current UAI must be on file. Hospital screenings are valid for limited periods; a stale screening may require re-screening before NF or waiver authorization.
• Estate Recovery and TEFRA Lien. Estate recovery applies to the probate estate under Virginia law. Pre-death TEFRA liens are limited to permanently institutionalized recipients without protected family members.
• Appeals. Adverse eligibility determinations may be appealed to the DMAS Appeals Division within 30 days (12 VAC 30-110). Continued benefits may be available upon timely appeal.

18. SOURCES AND REFERENCES

• Virginia Department of Medical Assistance Services (DMAS) — https://www.dmas.virginia.gov/
• Cardinal Care (Virginia Medicaid) member portal — https://coverva.dmas.virginia.gov/
• CommonHelp online application — https://commonhelp.virginia.gov/
• DMAS Medicaid Manual M01–M22 (eligibility, resources, transfers, spend-down) — https://www.dmas.virginia.gov/
• 12 VAC 30-40 (Eligibility Conditions and Requirements) — https://law.lis.virginia.gov/admincode/title12/agency30/chapter40/
• 12 VAC 30-110 (Eligibility and Appeals) — https://law.lis.virginia.gov/admincode/title12/agency30/chapter110/
• 12 VAC 30-120 (Waivered Services, including CCC Plus) — https://law.lis.virginia.gov/admincode/title12/agency30/chapter120/
• Va. Code Title 32.1, Chapter 10 (Medical Assistance Services) — https://law.lis.virginia.gov/vacodefull/title32.1/chapter10/
• 42 U.S.C. § 1396p (transfers, liens, estate recovery) — https://www.govinfo.gov/
• 42 U.S.C. § 1396r-5 (spousal impoverishment) — https://www.govinfo.gov/
• CMS Spousal Impoverishment Standards (annual update) — https://www.medicaid.gov/medicaid/eligibility-policy/medicaid-eligibility-spouses-institutionalized-individuals/index.html
• DMAS Spend-Down Fact Sheet — https://coverva.dmas.virginia.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Medicaid eligibility figures and policy memoranda are updated annually. An attorney licensed in Virginia, ideally an elder-law specialist, must review and customize this packet before submission. Verify all dollar amounts, divisor values, and citations against current DMAS guidance.