1 Department of Medical Assistance Services Governor’s Access Plan Online Application Process Virginia Department of Medical Assistance Services Department of Medical Assistance Services

2 Department of Medical Assistance Services Finding the Online GAP App GAP SMI Screeners will have access to the online application beginning January 12, 2015 by going to the web address that was provided to the GAP Screening Entity via an notification. The application is only available through this special web address and is NOT posted on Coverva.org. The application will NOT be accessible though the DMAS Web Portal.

3 Department of Medical Assistance Services Logging In At the log in screen you will need to enter the NPI number of the agency and click “Login” If you are unable to log in please contact the GAP Unit of Cover VA by calling

4 Department of Medical Assistance Services Step 0 Next click the pencil icon to edit the green field. Enter the name of the person assisting with the application. By clicking on the pencil icon a pop up box will open. You may need to turn off any popup blockers on your computer.

5 Department of Medical Assistance Services Pop Up 0 In the blank fields enter the name, phone number, and address of the person assisting with the application process. Check the box in order to attest that the applicant is in the room and able to sign the application. Click save.

6 Department of Medical Assistance Services On the next screen click “Start this Step” adjacent to Step 1 to begin entering the applicants information. Starting Steps

7 Department of Medical Assistance Services Step 1 A pop up box for step 1 will open. Enter the demographic information of the person who is applying for the GAP program. The address entered will need to be a place where the applicant can receive mail. This will be where decision notification will be sent.

8 Department of Medical Assistance Services Step 1 Continued Continue completing the information in step 1. Check the box if the person has any form of health insurance. Leave the box blank if not. Check the box if the person is in foster care, pregnant, disabled, incarcerated, or hospitalized. Leave blank if the person is not. Check any of the tax information boxes that apply. Leave blank if they do not apply. Click Save.

9 Department of Medical Assistance Services Step 2 Click on “Start this Step” for Step 2 to generate the pop up box.

10 Department of Medical Assistance Services Step 2 Continued In step 2 enter the information for all adults living in the home, and any children of the individual under the age of 19 living in the home with the person applying. The tax information in Step 2 pertains to the person listed as living in the home with the applicant. Click save and see next slide for entering another individual.

11 Department of Medical Assistance Services Adding/Editing/Deleting in Step 2 To add another person living in the home click the green plus sign and a new pop up box will display. To edit information already added, click the pencil icon located over the information. To delete information already added, click the red X over the information you wish to delete. These icons will have the same function in each area that you see them.

12 Department of Medical Assistance Services To begin each of the remaining steps continue to click on “Start this Step” and fill in the information in the pop up window and click Save. Each area will need to be completed in order to submit the application. Applications cannot be saved and continued at a later time. Remaining Steps

13 Department of Medical Assistance Services Step 3 – Household Relationships Step 3 is tax filing information for each of the individuals entered during Step 2. Since the applicant (Clive Sr.) listed Joy as his wife and a tax filer in Step 2, she is auto listed as a tax payer in Step 3. The children (Hazel and Clive Jr) are auto listed as Household members. Select the drop down choice on the right that describes the household member’s tax status. Click Save.

14 Department of Medical Assistance Services Step 4 – Household Income Step 4 is to enter household income. Enter the name of the person receiving income, the source of the income (work, disability, etc.), how often it is received, and the amount received. In the example above the individual receives $1, monthly. Click save to add more Household members.

15 Department of Medical Assistance Services Step 4 – Adding More Members To add additional household member income click on the green plus sign under Step 4. Household income includes any income from: –The individual; –The individual’s spouse; and –Anyone that claims the individual on his/her taxes.

16 Department of Medical Assistance Services Step 5 – Authorized Representative Step 5 allows for the individual applying for benefits to list an authorized representative. This step is optional and should only be completed for individuals who have an authorized representative or would like for a spouse or family member to act on their behalf. The person assisting with the application should not list the agency as the authorized representative unless the agency has legal standing as the individuals authorized representative.

17 Department of Medical Assistance Services Step 5 – Authorized Representative Fill in the name, organization, if any, address, and phone number of the individual’s authorized representative, or a spouse or family member that the applicant would like to designate as a representative.

18 Department of Medical Assistance Services Step 6 – Digital Signature Step 6 is the digital signature of the individual applying for GAP benefits. Enter the name of the individual and the date. This signature indicates that to the best of the individual’s knowledge all information entered is true and correct. It is also a release of information which needs to be read by the applicant. This should not be entered without the individual present in the room when the signature page is saved.

19 Department of Medical Assistance Services Confirmation Page The final page will list what documents to send to Cover VA as well as the fax and mail in address. It will also give the date by which the documents must be received by Cover VA. Print this page and Give to the applicant. Confirmation pages do not need to be mailed to Cover VA.

20 Department of Medical Assistance Services Verification Documentation Cover VA will need documentation to verify income of the individual applicant and any household income based on tax status. For example: –If the applicant is claimed on another person’s taxes then that person’s income verification will be necessary; or –If the applicant is married and files taxes jointly, then the spouse’s income will need to be verified. Cover VA will need to verify one month of income. There is no resource verification. Verification of citizenship is only necessary when the applicant indicates that they are not a U.S. Citizen. Other documentation may be required in special circumstances. Please assist the individual in reading ALL confirmation notices.

21 Department of Medical Assistance Services Reminders Please note that Cover VA will have 45 days from the date of submission of the online application to determine eligibility. Questions pertaining to the online application can be directed to the GAP Unit of Cover VA by calling Applications can also be submitted telephonically by calling