Medicaid is a health insurance program for people who do not make a lot of money. If you qualify, this program pays for your doctor visits, hospital stays, and prescription drugs. In Virginia, health coverage through Medicaid is completely free or costs very little. If you need health insurance and you meet the income rules, applying for Medicaid is the single best step you can take for your health and your wallet.
Health insurance can be hard to understand. Usually, you have to pay a large amount of money every month just to have a health insurance plan. This monthly bill is called a premium. You also have to pay money when you actually go to the doctor.
Medicaid is different. Medicaid is a public health insurance program created to help people who cannot afford regular insurance. It is meant to make sure everyone can see a doctor when they are sick. When you have Medicaid, the government pays the health insurance company for you. You do not have to pay a large monthly premium. When you go to the doctor, you pay almost nothing.
The program is very large. In fact, millions of people in the United States get their health care this way. In the state of Virginia alone, about two million people use Medicaid to stay healthy. It is a normal, safe, and highly trusted way to get health care.
Medicaid is run by a partnership. It is run by both the federal government (the national government in Washington, D.C.) and your local state government.
The federal government writes the main rules. It also provides a lot of the money. You can read the broad, national rules about the program on the federal website at medicaid.gov.
However, every single state runs its own specific program. This means Medicaid in Virginia works a little differently than Medicaid in Maryland or North Carolina. The state gets to choose exactly how to run the day-to-day details.
In Virginia, the state agency that runs the program is called the Virginia Department of Medical Assistance Services. You will often see this name on official letters. Virginia also uses a service called Cover Virginia. Cover Virginia is the public-facing system where you actually go to apply and learn about your benefits. When looking for help, you should always check the Cover Virginia website and the Virginia Department of Medical Assistance Services website for the most accurate state details.
If you tried to get Medicaid many years ago and were told no, you should try again now. The rules have changed in a very big way.
Before the year 2019, Virginia had very strict rules about who could get Medicaid. Mostly, it was only for children, pregnant women, people with severe disabilities, and older adults. If you were a healthy adult between the ages of 19 and 64, and you did not have any children, you could not get Medicaid. It did not matter how little money you made.
In 2019, Virginia changed this law. This change is called “Medicaid expansion.” The state expanded the rules so that more people could get help. Today, single adults without children can get Medicaid. You just need to have an income below a certain amount. Because of this change, more than 700,000 new people in Virginia were able to get health coverage.
Because of Medicaid expansion, the rules are simpler now than they used to be. The state looks at your age, your family size, and your income. They group people into a few different categories to see if they qualify.
Check to see if you meet the main rules for Virginia Medicaid.
| Group | Who is included? |
|---|---|
| Adults (Ages 19 to 64) | Single adults, married couples, parents, and people without children. |
| Children (Under Age 19) | Kids and teens. The income limits for kids are much higher than for adults. |
| Pregnant Individuals | Anyone who is currently pregnant or recently had a baby. |
| Seniors (Age 65 and older) | Older adults who need extra help paying for Medicare or nursing home care. |
| People with Disabilities | Anyone who is blind or has a recognized, long-term disability. |
This is now the largest group of people who get Medicaid in Virginia. If you are between the ages of 19 and 64, you can get Medicaid as long as your income is low enough. It does not matter if you are single or married. It does not matter if you work full-time, work part-time, or do not work at all. The only thing that matters is how much money you make in total.
Children under the age of 19 have a very easy time getting health coverage in Virginia. The state wants to make sure all kids can see a doctor. Because of this, the income limits for children are much higher than the limits for adults. Many families find that the parents make too much money to get Medicaid for themselves, but their children still easily qualify.
Getting medical care while you are pregnant is very important for both the parent and the baby. Virginia makes it easy for pregnant women to get Medicaid. The income limits are higher for pregnant people. Also, when you apply, the state counts your unborn baby as a family member. This increases your family size, which makes it even easier to meet the income rules. Once the baby is born, your Medicaid coverage continues for a full 12 months after the birth, giving you time to heal and care for your newborn.
Children who grow up in the foster care system face a lot of challenges when they turn 18. Virginia helps by providing free health insurance. If you were in foster care in Virginia and you were receiving Medicaid when you turned 18, you are allowed to keep your Medicaid coverage until you turn 26 years old. For this group, your income does not matter at all.
Older adults (age 65 and older) and people who are blind or have a disability fall into a special category. The rules for this group are slightly different. The state will look at your income, but they may also look at your “assets.” Assets are things you own, like money in a savings account or property. This part of Medicaid helps seniors pay for things that regular Medicare does not cover, like staying in a nursing home for a long time.
To get Medicaid, your income must be below a certain limit. This limit is based on something called the Federal Poverty Level, or FPL. The federal government sets these numbers every single year based on the cost of living.
When Virginia looks at your application, they compare your income to the FPL. For most adults ages 19 to 64, your income must be at or below 138% of the Federal Poverty Level.
When you apply, the state wants to know your “household income.” This means they look at everyone who lives with you and is part of your tax family. If you are married, they count your spouse’s income too.
| Family Size | Medicaid Income Limit for Adults (Approximate Yearly) | Medicaid Income Limit for Adults (Approximate Monthly) |
|---|---|---|
| 1 Person | $20,780 | $1,732 |
| 2 People | $28,200 | $2,350 |
| 3 People | $35,630 | $2,969 |
| 4 People | $43,050 | $3,588 |
Note: The exact numbers change a little bit every spring when the federal government updates the math. The state of Virginia will always use the newest math when you apply. You do not have to do the math yourself. The state will calculate it for you.
For most people, the state uses a math formula called MAGI (Modified Adjusted Gross Income). This is just a fancy way of saying they look at the money you make before taxes are taken out.
They count money from your job (your wages). They count money you make if you run your own business. They count money you get from unemployment checks.
They do not count everything, though. For example, they usually do not count child support money that you receive. They do not count money you get from local charities. They also do not look at how much money you have saved in the bank, as long as you are applying in the regular adult, child, or pregnant categories. (Remember, they only look at savings accounts if you are applying as a senior over age 65 or a person with a severe disability).
Your income is the biggest rule, but there are a few other rules you must meet to get Medicaid in Virginia.
You can only get Virginia Medicaid if you live in Virginia. This is called residency. If you are just visiting the state on vacation, you cannot get coverage here. However, you do not have to have lived in Virginia for a certain number of years. As long as you live in the state right now and you plan to stay, you are a resident.
You must be a citizen of the United States to get full Medicaid benefits. If you are not a citizen, you might still qualify if you are a “qualified immigrant” who has lived in the country with legal status for at least five years. Refugees and people who have been granted asylum can often get Medicaid right away without waiting five years.
If you are an immigrant who does not have legal status, you cannot get full Medicaid. However, Virginia will still pay for emergency medical care if you have a life-threatening emergency and you meet the income rules. Also, Virginia has special rules that allow pregnant women and children to get health coverage even if they do not meet the five-year waiting period.
A common myth is that Medicaid is “bad” insurance that does not pay for much. This is completely false. Medicaid is one of the most comprehensive health insurance programs in the country. It pays for almost any medical service you need to stay healthy or get better when you are sick.
When you have Medicaid in Virginia, these are the main things the state will pay for:
If you get a cold, break a bone, or just need a yearly checkup, Medicaid pays for it. You can see a primary care doctor for general health. If you have a specific problem, like a heart issue, Medicaid pays for you to see a specialist, like a heart doctor.
Hospital bills can cost tens of thousands of dollars. If you are admitted to the hospital, Medicaid pays the bill. It covers your room, your bed, the doctors who treat you in the hospital, and the food you eat while you are there.
If you have an emergency, you can go to the emergency room, and Medicaid will pay for the visit. It also pays for trips in an ambulance if you are too sick or hurt to drive yourself to the hospital.
When the doctor writes you a prescription for medicine, you take it to the pharmacy. Medicaid will pay for the medicine. Usually, Medicaid requires the pharmacy to give you the “generic” version of a drug. Generic drugs are exactly the same as name-brand drugs, but they cost less.
Having a baby is fully covered. Medicaid pays for your doctor visits while you are pregnant. It pays for the ultrasounds. It pays for the hospital stay when you give birth. After the baby is born, it pays for your checkups and the baby’s checkups.
This is a very big benefit. Many private health insurance plans do not pay for teeth. Virginia Medicaid does. For children, the state has a program called Smiles For Children. It pays for exams, cleanings, and fixing cavities. Recently, Virginia added full dental coverage for adults on Medicaid, too. Adults can now go to the dentist to get cleanings, X-rays, fillings, and even have teeth pulled if necessary.
Medicaid pays for eye exams. If you have a child on Medicaid, the program will also pay for the child to get glasses if they need them.
Health is not just about your physical body; it is also about your mind. Virginia Medicaid pays for mental health care. You can see a therapist, a counselor, or a psychiatrist. It covers treatments for depression, anxiety, and other mental health conditions. It also pays for treatment programs if you need help stopping the use of drugs or alcohol.
One of the most unique things about Medicaid is that it helps you actually get to the doctor. If you do not have a car, and you cannot get a ride, Medicaid will pay for a ride to your doctor’s appointment. You usually have to set this up ahead of time, but it ensures you never have to miss a checkup just because you do not have a way to travel.
The best part about Medicaid is the price.
Premiums: Most people on Virginia Medicaid pay a premium of $0. You do not get a monthly bill.
Copays: A copay is a small amount of money you pay at the front desk when you walk into the doctor’s office. In Virginia, copays are incredibly low, and often they are entirely free. If you do have a copay, it might be something very small, like $1 or $3 for a prescription. Also, the rules say that a doctor or pharmacy cannot refuse to treat you just because you cannot afford the $1 copay that day. For children and pregnant women, there are strictly no copays at all. Everything is absolutely free.
You might hear the word FAMIS when you read about Virginia Medicaid. FAMIS stands for Family Access to Medical Insurance Security.
FAMIS is Virginia’s version of a federal program called CHIP (the Children’s Health Insurance Program).
Sometimes, parents make a little bit too much money to get Medicaid for themselves, and their income is also just a tiny bit too high for the kids to get regular Medicaid. FAMIS is a safety net for exactly these families. The income limits for FAMIS are higher than regular Medicaid. It provides the exact same high-quality coverage for children—doctor visits, hospital stays, dental, and glasses—but it allows families with slightly higher incomes to get help.
When you fill out one single application with the state, they will check to see if your kids qualify for regular Medicaid. If they don’t, the state automatically checks if they qualify for FAMIS instead. You do not have to fill out a separate form.
Applying for Medicaid is free. You do not need to pay anyone to help you apply. You can apply on any day of the year. If you lose your job today, you can apply today.
There are several different ways to submit your application. You can pick the way that is easiest for you.
The fastest way to apply is on a computer or a smartphone. Virginia has an official website called CommonHelp. You can go to the CommonHelp website, create an account, and fill out the form. The system will guide you through all the questions. It will ask for your name, your address, who lives with you, and how much money you make.
If you do not like using computers, you can apply by talking to a real person. You can call the Cover Virginia call center. A worker will stay on the line with you, ask you the questions out loud, and type the answers into the computer for you. (Note: You can find the direct phone number by searching for Cover Virginia online).
You can print a paper application from the Cover Virginia website. You fill it out with a pen and mail it to your local Department of Social Services office.
Every county and city in Virginia has a local Department of Social Services (DSS) office. You can walk into the building, ask for a paper form, fill it out in the waiting room, and hand it right back to a worker.
To make the application go smoothly, you should gather some basic information before you start. You will need:
Once you hand in your application, you have to wait for the state to review it. By law, the state has up to 45 days to give you an answer. If you are applying based on a severe disability, it can take up to 90 days.
While you are waiting, the state workers will check the information you gave them. They will look at electronic databases to verify your income and your citizenship. If they cannot verify something, they will send you a letter in the mail asking for “verification.” This means they might need you to mail them a copy of a pay stub or a birth certificate. If you get a letter asking for proof, you must send it back as quickly as possible, or your application will be denied.
If you are approved, you will get a thick envelope in the mail. It will contain an approval letter and your new Medicaid ID card.
The coverage usually starts on the very first day of the month that you applied. This means if you apply on June 20th and get approved in July, your coverage is backdated to June 1st. Any doctor bills you got between June 1st and your approval date can often be paid by Medicaid.
Once you are approved for Medicaid, there is one more step. Virginia uses a system called Cardinal Care.
Cardinal Care is the name for Virginia’s Medicaid managed care program. This means the state does not pay the doctors directly. Instead, the state hires private health insurance companies to manage your care. These companies are called Managed Care Organizations (MCOs).
When you get approved, you will be asked to pick one of these health plans. Some of the common health plans in Virginia include Sentara Health Plans, Anthem, Aetna, Molina, and UnitedHealthcare.
All of these plans must provide the exact same basic health benefits. The difference is the “network.” A network is a list of doctors and hospitals that have agreed to work with that specific insurance company.
When you pick your plan, you need to make sure your favorite doctors are in that plan’s network. If you do not pick a plan yourself, the state will randomly pick one for you. If they pick one you do not like, you have 90 days to call and switch to a different one.
Once you are in a plan, you will choose a Primary Care Provider (PCP). This is your main doctor. Any time you have a normal sickness or need a checkup, you will call this doctor first.
Medicaid is not a lifetime guarantee. Because your income can change, the state needs to check on you once a year to make sure you still meet the rules. This yearly check is called a renewal or a redetermination.
When it is time for your renewal, the state will first try to check your income using electronic databases. If they can see that your income is still low, they will automatically renew your coverage for another year and send you a letter telling you that you are good to go.
If they cannot verify your income automatically, they will mail you a renewal packet. Do not throw this packet away. It will come in an envelope marked with important state logos. You must open it, fill out the form inside, attach any required proof of income, and send it back before the deadline. If you do not send the form back, the state will cancel your health insurance, even if you are still poor enough to qualify.
Because the state uses the mail for this, the most important thing you can do to keep your Medicaid is to tell the state if you move. If you move to a new apartment and do not update your address with the state, your renewal packet will go to your old house. You will miss the deadline and lose your insurance. Always report a new address to Cover Virginia or your local social services office right away.
Sometimes, life gets better. You might get a better job or a raise at work. If your new income pushes you over the limit, you will no longer qualify for Medicaid.
When this happens, you must report your new income to the state. They will stop your Medicaid coverage. However, losing Medicaid is not the end of the road.
If you make too much money for Medicaid, you can usually buy health insurance through the federal Marketplace (Healthcare.gov). Because you lost Medicaid, you are granted a Special Enrollment Period. This means you do not have to wait for the normal winter sign-up dates; you can buy a Marketplace plan right away. Furthermore, because your income is still likely on the lower side, the federal government will give you a tax credit. This tax credit acts like a huge discount, making the Marketplace insurance very cheap every month.
The system is designed so that you always have a path to health coverage. If your income is very low, Medicaid is there to protect you. If your income goes up, the Marketplace is there to help you transition into private insurance without going broke.