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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.  \nSECTION 1  Household Information  \n1. Are You?  Married  Single  Divorced  Widowed  Separated  \n\n| 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\u003Cbr>—If yes, please indicate which state or Virginia city or county below: |\n| --- |\n| State or Virginia city or county: |\n\n\n| 3. Is anyone in your household temporarily away from home?  Yes  No |  |\n| --- | --- |\n| Name | Date Left mm/dd/yyyy |\n| Reason for Leaving |  |\n| Where is the person currently staying? | Expected Return Date mm/dd/yyyy |\n\nIf 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) .  \nNEED 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  \nAnswer questions 4-11a if any applicants are under age 65 years.  \n\n| 4. Are you or is anyone for whom you are applying disabled?  Yes  No\u003Cbr>—If yes, please provide the name of the persons: |  |\n| --- | --- |\n| Name of Person | Name of Person |\n\n4a. 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  \n\n| 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\u003Cbr>—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\n| 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\u003Cbr>—If yes, please provide the name of the individual: |  |\n| --- | --- |\n| Name | Name |\n\n\n| 7. If the application for Social Security, SSI or Railroad Retirement benefits was denied, did you file an appeal of the denial?  Yes  No |\n| --- |\n| If yes, please tell us the outcome of the appeal: |\n\n8. Has it been less than 12 months since the most recent application for Social Security, SSI or Railroad Retirement benefits was denied?  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  \n\n| 11. Have you or anyone for whom you are applying ever received SSI, disability benefits from the Social Security Administration or Auxiliary Grant payments?\u003Cbr> Yes  No\u003Cbr>Has the payment stopped?  Yes  No |\n| --- |\n| 11a. If yes, explain why the payments stopped: |\n\nNEED HE","cbCaikbBGpFVUPFd","https://ap.wps.com/l/cbCaikbBGpFVUPFd","pdf",545309,7,"English","# What is Appendix D Used For?\n# SECTION 1 Household Information\n## 1. Are You?\n## 2. Prior Health Care Coverage in Another State\n## 3. Temporarily Away From Home\n## 4. Are You Disabled?\n## 4a. Medicaid Works\n## 5. Social Security/SSI/Railroad Retirement Applications\n## 6. Approvals for Disability Purposes\n## 7. Appeal of Denial Outcome\n## 8. Denial Within 12 Months\n## 9. Condition Change or Worsening\n## 10. New Medical Condition\n## 11. Received SSI/Disability or Auxiliary Grant Payments\n## 11a. Why Payments Stopped\n# SECTION 2 Long-Term Services and Supports\n## 12. Nursing Facility Care or Help at Home","[{\"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 health coverage application.\"},{\"question\":\"Who needs to complete Appendix D?\",\"answer\":\"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.\"},{\"question\":\"Which questions are covered in Section 1 Household Information?\",\"answer\":\"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.\"}]","Application for Health Coverage and Help Paying Costs - Appendix D | PDF",1789840723]