If you/family member with a disability, are not receiving Supplemental Security Income (SSI), and have
been receiving a Medicaid Waiver prior to age 18, then there will need to be a “disability
determination” done before the 18 th birthday to ensure there is no lapse in Medicaid and Waiver
eligibility and services as you/family member move from Childhood to Adult (18 years old) Medicaid. .
A disability determination for Medicaid is not required for a child who receives SSI. In that case, the
child will have a review of continuing disability and SSI eligibility completed by the Social Security
Administration (SSA) when he or she turns 18.
What is a Medicaid Disability Determination? (key word is Medicaid)
A Medicaid disability determination is the name for the process through which Disability Determination
Services (DDS) and the local Department of Social Services (DSS), which handles Medicaid eligibility,
determines if someone can be eligible for Medicaid as an individual with a disability that qualifies them
for Medicaid. This is done for anyone moving from childhood to adult Medicaid at age 18. (Excluding
those with SSI, per above).
How Do I Start the Process?
If you have Medicaid through a Medicaid Waiver prior to your 18 th birthday, your eligibility worker at the
Department of Social Services where you live, should send you forms in the mail at least 90 days prior to
your birthday. You must complete and return the forms within 10 calendar days. If you do not hear from
your eligibility worker by 90 days prior to your 18 th birthday, contact them directly.
The forms and instructions you should receive are:
1. Social Security Disability Report
2. Authorization to Disclose Information to the Social Security Administration forms
3. Complete and return the forms within 10 days. TIP: MAKE and KEEP a COPY of the forms.
4. Notify the physicians you listed on the Disability Report, that they may be contacted to confirm your
1/2 Relationship to Social Security Benefits
A long-standing requirement for Medicaid eligibility is for individuals to apply for other benefits, such as
Social Security Disability Insurance for dependents or survivors, to which they have the right to receive.
The Social Security application process is still a separate determination from Medicaid. We suggest
keeping a copy of the Disability Report that you completed for Medicaid so that it can help with the
application process for Social Security. During that time, the disability determination made by Medicaid
is applicable to Medicaid eligibility. After Social Security’s determination, their decision, if different,
becomes binding for Medicaid eligibility.
If YOU Need Help
If you are in need of assistance with this process, you can ask for help. Here are some people who may be
able to assist you.
1. Your Community Services Board Support Coordinator ( https://vacsb.org/csb-bha-directory/)
2. Your CCC Plus Care Advocate ( https://elderrightsva.org/ccc.htm)
3. Your local DSS eligibility worker who processes your Medicaid applications and renewals
4. Your DSS Regional Consultant (https://www.dss.virginia.gov/division/regional_offices/index.cgi)
5. Your VA Dept. of Social Services Regional Medical Assistance Consultant (804)726-7363
6. DSS Regional Consultant Supervisor, Sherry Sinkler-Crawley, 804-726-7660 or
Background About this Change
Prior to 2013, Medicaid policy allowed parental income to be disregarded for all children receiving
waiver services. In 2014, Federal Medicaid rules regarding how parental income is counted for children
living with a parent changed. Since that time, Medicaid eligibility requirements cannot allow for parental
income to be disregarded for children in waiver services once they turn age 18 unless the child has been
determined disabled according to SSA criteria.
Medicaid eligibility policy was clarified in a recent Medicaid Transmittal (https://www.dmas.virginia.gov/files/links/3681/TN%20#DMAS-13%20Effective%
It states that anyone with Long Term Care (i.e., Waiver) Medicaid must have a referral
to Disability Determination Services (DDS) specifically for Medicaid eligibility purposes prior to their
18th birthday. According to DMAS, the requirement for a disability determination is not new; rather, the
referral process for having a disability determination has been streamlined to help prevent any
interruptions in waiver services.
The Arc of Virginia appreciates the collaboration and assistance of the Virginia Dept. of Medical
Assistance/DMAS and The Arc of Northern Virginia provide this information..