How Does Virginia Medicaid Make a Disability Determination?

When someone under age 65 applies for Virginia Medicaid based on a disability or blindness, the state has up to 90 days to process the application.

The additional time beyond the standard 45 days is used for a formal disability determination.

Who Makes the Disability Decision?

Virginia's Medicaid agency sends the case to Disability Determination Services (DDS).

DDS uses the same evaluation process as the Social Security Administration (SSA). If the applicant already received a disability decision from SSA, DDS reviews that prior determination as part of the file.

What DDS Does During Those 45 Extra Days

1. Medical Records Collection

DDS collects medical records from the providers listed on the application, including:

• Requests to physicians, hospitals, clinics
• Mental health treatment records
• Lab results, imaging, operative reports
• Prior disability determinations (e.g., from Social Security Administration)

Providers can take weeks to respond. We strongly recommend contacting your physicians' offices to ensure the medical documents are transferred efficiently because transfer requests can simply be overlooked and cause significant delays.

2. Disability Forms

DDS reviews detailed disability forms that describe how the condition affects daily functioning. These forms include:

• Detailed function reports
• Work history reports
• Activities of Daily Living (ADL) assessments

Forms are usually completed on paper and returned to DDS. In some cases, DDS conducts a phone interview to clarify answers.

3. Consultative Examinations (If Needed)

If medical records are not sufficient to make a decision, DDS may schedule a consultative examination. This may include:

• A physical exam
• A psychological evaluation

These exams are arranged by the state at no cost to the applicant. They are ordered only when existing evidence is insufficient.

4. Quality Review

Some cases undergo an additional supervisory review before a final approval or denial is issued. This internal review ensures the disability decision follows federal standards.

What This Means for Medicaid

For applicants under 65 applying based on disability or blindness, this process must be completed before Medicaid can approve coverage. That is why the timeline extends to up to 90 days.

Long-term care programs such as CCC+ cannot move forward until the disability determination is finished.

A medical diagnosis alone does not qualify someone. The state must complete this formal disability review.