Virginia Medicaid is a health care program that covers about one out of every 14 adults, one out of every four children, three out of every five nursing home residents, three out of every ten disabled persons, and one out of every eight Medicare beneficiaries. Most Medicaid spending in Virginia goes to disabled and elderly residents, who often qualify for Medicare as well. You may qualify for more benefits and not even know it!
Virginia holds one of the strictest Medicaid programs in the country, but that does not mean you don’t qualify. For the most part, childless adults cannot qualify. Children (under 18) and pregnant woman can qualify with an income at 133% of the federal poverty level or lower, elderly and disabled people can qualify at 80% of the federal poverty level or lower, and working parents can qualify at 30% of the federal poverty level or lower. The federal poverty level depends on your family size and yearly income and can change every year. The 2018 Federal Poverty Level is $12,140 per year for single adults, $16,460 for a family of 2, $20,780 for a family of 3, etc.
You can apply for VA Medicaid either online, over the phone, by mail, or in person. To apply by phone, call Cover Virginia at 1-855-242-8282 (TDD: 1-888-221-1590). To apply online, visit commonhelp.virginia.gov. To apply in person or by mail, complete the Virginia Medicaid Application and mail or bring it into your nearest Department of Social Services.
When you apply, you will need your Social Security Number, immigration status (if applicable), recent pay stubs or W-2s, and any policy numbers or benefit information (like unemployment, pensions, etc.) you may have.
VA Medicaid has three coverage levels: full, time-limited, and Medicare-related. Full coverage includes prescription drugs, hospital services, and doctor visits. Time-limited is for pregnant women and those who are eligible due to high medical spending. Medicare-related is for Medicare beneficiaries who also qualify for Medicaid. Medicare-related coverage handles out-of-pocket Medicare costs like premiums, deductibles, and coinsurance.
To find Virginia Medicaid providers near you, use this search tool. You can search by name, provider type, and/or location. Aside from doctors and providers who accept VA Medicaid, you can also visit free and low-cost clinics in your area. Use this search tool to find a free clinic and this map to find a Community Health Center.
Virginia adults can only get Medicaid coverage for medically necessary dental services, like oral surgery, extractions, and diagnostic services. Preventative services like cleanings, fillings, root canals, and dentures are generally only covered for kids, under the Smiles For Children program. Adult services will be paid through Dentaquest, so use the Dentaquest search tool to find a dentist near you who accepts VA Medicaid. You can also use one of these free and affordable clinics who you may be able to see for cleanings and preventative benefits.
Medicaid always pays for medically necessary vision care, like surgeries and procedures for common diseases (amblyopia, cataracts, Retinopathy, dry eye, Glaucoma, Macular Degeneration, Retinal Tears). It will also cover one vision exam every two years, which can help you catch these diseases. If glasses or contacts are required, Medicaid may cover them. However, Medicaid will most often not cover contacts as a cosmetic choice - only as medically necessary.
The VA Medicaid program does include prescription drug coverage. However, there is a specific Preferred Drug List (like a formulary) that doctors and pharmacists should adhere to. If you need a prescription that is not on the preferred list, you will need to seek prior approval with a Service Authorization, which you can request by calling or faxing 800-932-6648 or submitting through the member portal. Usually, if two other preferred drugs have failed, or if the requested drug is a generic form of another drug, it will be approved. However, it’s always best to start with the Virginia Medicaid Preferred Drug List.
The Virginia Health Insurance Program is called FAMIS, for “Family Access to Medical Insurance Security.” FAMIS covers doctor visits and checkups, hospital visits, vaccinations and prescriptions, test and x-rays, dental and vision, mental health, and emergency care. The only costs involved are occasional copayments (no more than $5). You can apply using the Virginia Medicaid application. To be eligible, household income must meet the following:
Virginia also has a FAMIS Plus program. It is the same as FAMIS, but kids can qualify for FAMIS Plus even if they have another form of health insurance. FAMIS Plus would then act as secondary insurance. Kids with alternative coverage cannot qualify for regular FAMIS.
FAMIS Moms is similar to the FAMIS program, but for pregnant women. You can qualify if you are within sixty days of your pregnancy end date or still pregnant and you meet the FAMIS income limits (above). FAMIS Moms covers comprehensive health care, including dental through Smiles For Children. Breast pumps and breastfeeding support are also included. There are no copayments for FAMIS Moms. Once your baby is born, he or she can enroll in FAMIS or FAMIS Plus for the first year of life.
If you qualify for Medicare, we at Medicare Plan Finder can help you navigate your coverage options. If you qualify for both Medicare and Medicaid in Virginia, you can even get a DSNP (dual eligible special needs plan), which combines the benefits of the two programs.
To speak with a licensed benefits advisor in your area, complete this form or call us at 833-438-3676.
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