Effective 04/01/2018 (DMAS TN-#8), the MAGI gap-filling rule became effective to evaluate certain MAGI households. This functionality does not currently exist within VaCMS.

When an individual’s current monthly household income using Medicaid and FAMIS MAGI methodology is over the applicable income limit (including the 5% disregards) agencies will need to evaluate if the individual could receive Medicaid using gap-filling rules. Please see policy in Chapter 4 of the Medical Assistance (MA) Manual for more information about the gap-filling rules and income limit.

Below are the steps to evaluate an individual under the gap-filling rule outside of VaCMS:

• Determine the household composition based on APTC rules (the tax filing household).

• Determine the countable income for that household using the policy in M04 of the MA Manual and send a manual checklist through VaCMS requesting any verifications not already received.

• Compare the income to the limit in M04, Appendix 1. If the individual is income eligible, meaning the calculated income is less than 100% FPL, they are eligible for Medicaid using gap-filling rules.

If the individual is eligible for a MAGI Medicaid covered group using gap-filling rules, enrollment of that individual must occur directly in MMIS. The local agency must manually track each individual enrolled directly in MMIS. Finally, the individual’s eligibility must be denied/closed in VaCMS in one of two ways:

•   If all enrollees are eligible under gap-filling rules, close the case using Program Request and the reason Duplicate Application. Suppress the system generated notice and send a manual notice.

• · If there are other enrollees that should remain open in VaCMS, use the spend-down adjustment screen for those eligible for Medicaid using the gap-filling rules so that they are not evaluated for MN coverage. This allows their Program Request to remain “Yes” for future changes and evaluations. Suppress the system generated notice and send a manual notice.

If the individual is not eligible using gap-filling rules, complete the evaluation in VaCMS to provide the individual the opportunity to be evaluated for and placed on a spend-down.

Regardless of the result, the agency must document their evaluation under the Case Comments in VaCMS, even if the individual was potentially eligible for gap-filling rules but did not meet the criteria (such as failing to provide verifications or the income was over the limit for gap-filling rule evaluation) and upload any documents used in the evaluation, including but not limited to the notice.

TBD

Updated: 11/30/2018