Virginia Medicaid Expansion: Eligibility and Benefits
- Virginia expanded Medicaid in 2019, offering coverage to adults with household incomes up to 138% of the Federal Poverty Level (FPL).
- For a single individual in 2026, the income threshold for Virginia Medicaid is approximately $20,783 per year.
- Virginia Medicaid (FAMIS Plus) provides comprehensive health benefits with no monthly premiums or out-of-pocket costs for most eligible members.
- Pregnant women in Virginia can qualify for FAMIS Moms with incomes up to 200% FPL, including 12 months of postpartum care.
- Applications for Virginia Medicaid and FAMIS programs can be submitted online via commonhelp.virginia.gov.
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Understanding Virginia Medicaid Expansion Eligibility
Virginia Medicaid, often referred to as FAMIS Plus for the expansion population, provides comprehensive health coverage for eligible individuals. The primary factor for eligibility under expansion is household income relative to the Federal Poverty Level (FPL). In Virginia, adults aged 19-64 without dependent children can qualify if their Modified Adjusted Gross Income (MAGI) is at or below 138% of the FPL. This threshold is higher than traditional Medicaid programs, significantly broadening access to care. For other populations, Virginia also offers specific Medicaid programs:- FAMIS Moms: Covers pregnant women with household incomes up to 200% FPL, providing prenatal care, delivery, and 12 months of postpartum care.
- FAMIS (Family Access to Medical Insurance Security): Provides low-cost coverage for uninsured children in families with incomes up to 200% FPL. For children between 200% and 400% FPL, FAMIS Select offers affordable options.
- Traditional Medicaid: Covers children, parents/caretakers, and individuals with disabilities who meet specific income and resource limits, which are often lower than the expansion threshold.
Income Thresholds for Virginia Medicaid (2026 FPL)
To determine if you might be eligible for Virginia Medicaid, compare your household income to the Federal Poverty Level (FPL) chart below. The 138% FPL threshold is key for most adults under the expansion program.| Household Size | 100% FPL | 138% FPL (Medicaid Ceiling) | 150% FPL | 200% FPL (Pregnancy/CHIP) |
|---|---|---|---|---|
| 1 person | $15,060 | $20,783 | $22,590 | $30,120 |
| 2 people | $20,440 | $28,207 | $30,660 | $40,880 |
| 3 people | $25,820 | $35,632 | $38,730 | $51,640 |
| 4 people | $31,200 | $43,056 | $46,800 | $62,400 |
| 5 people | $36,580 | $50,480 | $54,870 | $73,160 |
| 6 people | $41,960 | $57,905 | $62,940 | $83,920 |
| +1 additional | +$5,380 | +$7,424 | +$8,070 | +$10,760 |
Based on 2026 Federal Poverty Level (FPL) guidelines. MAGI (Modified Adjusted Gross Income) is used for eligibility determination.
If your income falls below the 138% FPL threshold, you may be eligible for Virginia Medicaid. If your income is above this level but still below 400% FPL, you may qualify for significant subsidies (Premium Tax Credits) to lower your monthly premiums on the Marketplace Virginia.Virginia Medicaid Benefits and Cost Structure
One of the most significant advantages of Virginia Medicaid (FAMIS Plus) is its comprehensive benefits package with virtually no out-of-pocket costs for most members. For eligible individuals, services are typically covered with:- $0 Premiums: There are no monthly premiums to pay for Virginia Medicaid coverage.
- $0 Deductibles: You do not need to meet a deductible before your benefits begin.
- $0 Copayments: Most covered services do not require copayments.
- Doctor visits and preventive care
- Hospital stays and emergency services
- Prescription drugs
- Maternity and newborn care
- Mental health and substance use disorder services
- Laboratory tests and X-rays
- Rehabilitative and habilitative services
- Vision and dental care (specific limits may apply)
Medicaid vs. Marketplace Subsidies: Which Path is Right for You?
For Virginians, the path to affordable health insurance primarily depends on your household income.| Income Level (Single Adult) | FPL % (Approx.) | Recommended Path | Monthly Cost (Approx.) | Why This Path? |
|---|---|---|---|---|
| Under $20,783 | Under 138% FPL | Virginia Medicaid (FAMIS Plus) | $0 | Comprehensive coverage with no costs, designed for low-income adults. |
| $20,783 – $22,590 | 138% – 150% FPL | Marketplace Silver Plan with APTC & CSR Tier 1 | ~$0 – $30 | High subsidies (APTC) and maximum Cost-Sharing Reductions (CSR) make Silver plans very affordable, reducing deductibles and copays significantly. |
| $22,590 – $30,120 | 150% – 200% FPL | Marketplace Silver Plan with APTC & CSR Tier 2 | ~$30 – $100 | Strong subsidies and substantial CSR benefits reduce out-of-pocket costs, making Silver a better value than Bronze. |
| $30,120 – $37,650 | 200% – 250% FPL | Marketplace Silver Plan with APTC & CSR Tier 3 or Gold | ~$100 – $200 | Partial CSR still applies to Silver; Gold plans may be a good option for those with higher expected medical needs. |
| $37,650 – $60,240 | 250% – 400% FPL | Marketplace Gold or HDHP + HSA | Varies | Good subsidies (APTC) continue. Gold plans offer lower out-of-pocket maximums; HDHP with HSA offers tax advantages for healthy individuals. |
| Above $60,240 | Above 400% FPL | Marketplace Gold, Platinum, or HDHP + HSA (on/off-exchange) | Varies | Subsidies may be reduced or absent. HDHP with HSA is often optimal for healthy individuals seeking tax-advantaged savings. |
Net premium after APTC. Single adult, benchmark Silver reference. Actual premium varies by plan and individual circumstances.
If your income is above the Medicaid threshold, you won't fall into a coverage gap in Virginia. Instead, you'll transition to qualifying for Advanced Premium Tax Credits (APTC) on the state's health insurance marketplace, Marketplace Virginia. These subsidies lower your monthly premiums, making plans more affordable. Many individuals between 100% and 250% FPL also qualify for Cost-Sharing Reductions (CSRs), which are only available on Silver tier plans and significantly reduce deductibles, copayments, and out-of-pocket maximums.Health Insurance in Virginia: What Virginians Need to Know
Virginia operates its own state-based marketplace using the federal platform, known as Marketplace Virginia. This means that while Virginians apply through HealthCare.gov, the state manages its own plan offerings and consumer assistance. For those not eligible for Virginia Medicaid, the marketplace is the primary pathway to subsidized coverage. In Virginia, marketplace shoppers have access to a variety of plan types, including Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), and Exclusive Provider Organization (EPO) plans. This provides flexibility in choosing a plan structure that best fits your needs for doctor and hospital access. Carriers such as HealthKeepers Plus, Cigna, and United Healthcare offer plans on the Marketplace Virginia, providing a range of choices across different metal tiers (Bronze, Silver, Gold, Platinum). The annual Open Enrollment Period is the main time to enroll in a marketplace plan. However, if you lose your Virginia Medicaid eligibility due to an increase in income, this would trigger a Special Enrollment Period (SEP), allowing you to enroll in a marketplace plan outside of Open Enrollment. It's crucial to report income changes promptly to avoid any gaps in coverage.How to Apply for Virginia Medicaid or Marketplace Coverage
Navigating the application process for health insurance can seem complex, but help is available. Here are the steps to secure coverage in Virginia:- Estimate Your Household Income: Accurately calculate your projected Modified Adjusted Gross Income (MAGI) for the upcoming year. This is the key factor in determining eligibility for both Virginia Medicaid and marketplace subsidies.
- Check Virginia Medicaid Eligibility: If your income is at or below 138% FPL (for most adults) or 200% FPL (for pregnant women or children), you should first apply for Virginia Medicaid (FAMIS Plus or FAMIS Moms).
- Apply Through the Correct Portal:
- For Virginia Medicaid and FAMIS programs, apply online at commonhelp.virginia.gov.
- For marketplace plans with subsidies, apply through HealthCare.gov, which serves as the platform for Marketplace Virginia.
- Review Plan Options (if on Marketplace): If you qualify for marketplace subsidies, carefully compare Bronze, Silver, and Gold plans. Remember that Cost-Sharing Reductions (CSRs) are only available on Silver plans and can significantly lower your out-of-pocket costs if your income is below 250% FPL.
- Enroll and Report Changes: Once you've selected a plan, complete your enrollment. It is critical to report any changes in your income, household size, or other circumstances to the Virginia Department of Medical Assistance Services (for Medicaid) or HealthCare.gov (for marketplace plans) to ensure your eligibility and subsidies remain accurate.
Frequently Asked Questions
When did Virginia expand Medicaid?
Virginia expanded its Medicaid program in 2019, extending eligibility to more low-income adults across the state.
What is the income limit for Virginia Medicaid Expansion?
Adults in Virginia may qualify for Medicaid if their household income is up to 138% of the Federal Poverty Level (FPL). For a single person in 2026, this means an income of approximately $20,783 or less per year.
Is Medicaid free in Virginia?
Yes, for most eligible individuals, Virginia Medicaid (FAMIS Plus) provides comprehensive health coverage with no monthly premiums, deductibles, or copayments. There are typically no out-of-pocket costs for covered services.
How do pregnant women qualify for Medicaid in Virginia?
Pregnant women in Virginia can qualify for Virginia Medicaid (FAMIS Moms) with household incomes up to 200% of the Federal Poverty Level. This coverage includes prenatal care, labor and delivery, and 12 months of postpartum care. You can apply through commonhelp.virginia.gov.
Where can I apply for Virginia Medicaid?
You can apply for Virginia Medicaid or FAMIS Plus online through commonhelp.virginia.gov. You can also apply by phone, mail, or in person at your local Department of Social Services. If your income is too high for Medicaid, you can apply for subsidized marketplace coverage via HealthCare.gov.