Application for Health Coverage and Help Paying Costs - Appendix D

Sep 19, 2026

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Appendix D collects additional information to determine eligibility for health care coverage in Virginia, specifically for applicants who have disabilities, are age 65 or over, need long-term care services, are enrolled in or eligible for Medicare, or want to apply for Medicaid Works. It is not a stand-alone application and must be submitted with the main health coverage application. The form gathers household details and, where applicable, questions about disability-related benefits, appeals, and long-term services.

LanguageEnglish

CategoryForms

FormatPDF

Pages7

Reading Time3 min

AccessFree to download

What is Appendix D Used For?

SECTION 1 Household Information

1. Are You?

2. Prior Health Care Coverage in Another State

3. Temporarily Away From Home

4. Are You Disabled?

4a. Medicaid Works

5. Social Security/SSI/Railroad Retirement Applications

6. Approvals for Disability Purposes

7. Appeal of Denial Outcome

8. Denial Within 12 Months

9. Condition Change or Worsening

10. New Medical Condition

11. Received SSI/Disability or Auxiliary Grant Payments

11a. Why Payments Stopped

SECTION 2 Long-Term Services and Supports

12. Nursing Facility Care or Help at Home

Name of Applicant: Application for Health Coverage and Help Paying Costs APPENDIX D Complete Appendix D if you are applying for Health Care Coverage for: • Someone who has disabilities • Someone age 65 years or over • All people, including children, in need of Long-term Care Services (nursing facility or community based care) • Someone who is enrolled in or eligible for Medicare • Someone interested in applying for Medicaid Works What is Appendix D Used For? Appendix D gathers additional information needed to determine your eligibility for Health Care Coverage. Appendix D is not a stand-alone application. You must also complete the Application for Health Coverage and Help Paying Costs and submit Appendix D with the application. If completing Appendix D for someone else, please answer the questions for that person. SECTION 1 Household Information 1. Are You? Married Single Divorced Widowed Separated | 2. Has anyone in your household ever applied for or received any Health Care Coverage from a social service agency in another state or Virginia city or county? Yes No
—If yes, please indicate which state or Virginia city or county below: | | --- | | State or Virginia city or county: | | 3. Is anyone in your household temporarily away from home? Yes No | | | --- | --- | | Name | Date Left mm/dd/yyyy | | Reason for Leaving | | | Where is the person currently staying? | Expected Return Date mm/dd/yyyy | If you are visually impaired and need large print or other assistance to access this document, please contact us at 1-855-242-8282 (TTY: 1-888-221-1590) . NEED HELP WITH YOUR APPLICATION? Visit [coverva.dmas.virginia.gov](coverva.dmas.virginia.gov) or call us at 1-855-242-8282. Para obtener una copia de este formulario en Español, llame 1-855-242-8282. If you need help in a language other than English, call 1-855-242-8282 and tell the customer service 7/22/25 representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-221-1590. Page 1 Answer questions 4-11a if any applicants are under age 65 years. | 4. Are you or is anyone for whom you are applying disabled? Yes No
—If yes, please provide the name of the persons: | | | --- | --- | | Name of Person | Name of Person | 4a. Medicaid Works is Virginia's Medicaid program for people with disabilities who are employed or who want to work. Are you interested in applying for Medicaid Works? Yes No | 5. 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? Yes No
—If yes, please provide the name of the persons and date of application: | | | --- | --- | | Name of Person and Date of Application | Name of Person and Date of Application | | 6. 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
—If yes, please provide the name of the individual: | | | --- | --- | | Name | Name | | 7. If the application for Social Security, SSI or Railroad Retirement benefits was denied, did you file an appeal of the denial? Yes No | | --- | | If yes, please tell us the outcome of the appeal: | 8. Has it been less than 12 months since the most recent application for Social Security, SSI or Railroad Retirement benefits was denied? Yes No 9. Has the condition changed or worsened since the most recent application for disability was denied? Yes No 10. 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 | 11. Have you or anyone for whom you are applying ever received SSI, disability benefits from the Social Security Administration or Auxiliary Grant payments?
Yes No
Has the payment stopped? Yes No | | --- | | 11a. If yes, explain why the payments stopped: | NEED HE

FAQs

What is Appendix D used for?

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 health coverage application.

Who needs to complete Appendix D?

Complete Appendix D when applying for health care coverage for someone with disabilities, age 65 or over, anyone needing long-term care services, someone enrolled in or eligible for Medicare, or someone interested in applying for Medicaid Works.

Which questions are covered in Section 1 Household Information?

Section 1 collects household information such as your marital status, prior health care coverage applications in another state or locality, temporary absence from home, and disability-related benefit history questions when relevant.

Sep 19, 2026

Upload by Grenda