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You must also complete the Application for Health Coverage and Help Paying Costs and submit Appendix D with the application.  \nIf completing Appendix D for someone else, please answer the questions for that person.  \nSECTION 1  Household Information  \n1. Are You?  Married  Never married  Divorced  Widowed  Separated  \n2. Has anyone in your household ever applied for or received any Health Care Coverage from asocial service agency in another state or Virginia city or county?  \n Yes  No  \n—If yes, please indicate which state or Virginia city or county below:  \nState or Virginia city or county  \n3. Is anyone in your household temporarily away from home?  Yes  No  \n—If yes, please provide the following information:  \n\n| Name | Date Left |\n| --- | --- |\n| Reason for Leaving |  |\n| Where is the person currently staying? | Expected Return Date |\n\nAnswer questions 4-11 if any applicants are under age 65 years.  \n4. Are you or is anyone for whom you are applying disabled?  Yes  No  \n—If yes, please provide the name of the persons:  \n\n| Name of Person | Name of Person |\n| --- | --- |\n\n5. Have you or anyone for whom you are applying ever applied for Social Security, Supplemental Security Income (SSI) or Railroad Retirement benefits as a disabled person?  \n Yes  No  \n—If yes, please provide the name of the persons and date of application:  \n\n| Name of Person and Date of Application | Name of Person and Date of Application |\n| --- | --- |\n\n6. Have you or anyone in your household for whom you are applying been approved for disability for Social Security, SSI, Railroad Retirement or Medicaid purposes?  Yes  No  \n—If yes, please provide the name of the individual:  \n\n| Name | Name |\n| --- | --- |\n\n7. If the application for Social Security, SSI or Railroad Retirement benefits was denied, did you file an appeal of the denial?  Yes  No  \n—If yes, please tell us the outcome of the appeal:  \nOutcome  \n8. Has it been less than 12 months since the most recent application for Social Security, SSI or Railroad  \nRetirement benefits was denied?  \n Yes  No  \n9. Has the condition changed or worsened since the most recent application for disability was denied?  Yes  No  \n10. Do you or anyone for whom you are applying have a new medical condition since the most recent application for disability was denied?  Yes  No  \n11. Have you or anyone for whom you are applying ever received SSI, disability benefits from the Social Security Administration or Auxiliary Grant payments?  \n Yes  No  \nHas the payment stopped?  Yes  No  \n—If yes, explain whose payment stopped, when it stopped, and why it stopped.  \nExplain  \nSECTION 2  Long-term Care  \nAnswer questions 12-14 if you are applying for anyone who is in a nursing facility or assisted living facility, or who requires nursing home care or assistance to remain in the home  \n12. Do you or anyone for whom you are applying need nursing facility care or help such as bathing, dressing, toileting, etc., so that you can remain in your own home?  Yes  No  \n—If yes, and there is a spouse who lives somewhere else, what is the name and address of the spouse?(Note: Under Virginia law persons are considered married and legally responsible for each other until they divorce)  \n\n| Name |\n| --- |\n| Address |\n\n13. Do you or anyone for whom you are apply","cbCaibdpnyCjBne8","https://ap.wps.com/l/cbCaibdpnyCjBne8","pdf",133877,8,"English","# SECTION 1 Household Information\n## SECTION 2 Long-term Care\n## SECTION 3 Resources and Assets","[{\"question\":\"What is Appendix D used for?\",\"answer\":\"Appendix D gathers additional information needed to determine eligibility for Health Care Coverage. It is not a stand-alone application and must be submitted with the main Application for Health Coverage and Help Paying Costs.\"},{\"question\":\"Who should complete Appendix D?\",\"answer\":\"Complete Appendix D when applying for Health Care Coverage for someone with disabilities, someone age 65 or over, people needing long-term care services, or someone who is medically needy and wants evaluation based on income, resources, and medical expenses.\"},{\"question\":\"What kinds of questions are included in Appendix D?\",\"answer\":\"Appendix D includes household information, long-term care details (such as nursing facility or assisted living needs), benefits and disability-related questions, and resource and asset questions such as cash on hand and other resources.\"}]","Application for Health Coverage and Help Paying Costs - Appendix D | PDF",1789835667]