Virginia Medicaid Plan for Low Income, Children, Pregnant Women, Parents, Aged, Disabilities, Medically Needy - Medicaid



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Zip Code23464
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Program Details

What is Medicaid?

Medicaid coverage is primarily available to Virginians who are children in low-income families, pregnant women, elderly, individuals with disabilities and parents meeting specific income thresholds.

Who is it for?

Medicaid,Low Income, Children, Pregnant Women, Parents, Aged, Disabilities, Medically Needy

Who is Eligible?

Must be a U.S. citizen. Must be a Virginia resident. Must fall within the following income limits:

  • Children Ages 0-18: 148% (Includes 5% disregard)
  • Pregnant Women: 148% (Includes 5% disregard)
  • Parents/Caretakers: 54% FPL (Includes 5% disregard)
  • Aged (65 years and older), Blind & Disabled: 80% FPL
  • Medically-Needy: 47% FPL (Single), 56% FPL (Married)

What is Covered?

BabyCare (including Prenatal and maternal care); Clinic Services; Community-Based Residential Services for Children and Adolescents under 21; Community Mental Health and Intellectual DisabilityServices; Dental Care Services; Durable Medical Equipment and Supplies (DME); Early and Periodic Screening, Diagnosis, and Treatment (EPSDT); Early Intervention; Eye Examinations; Eyeglasses; Family Planning Services; Glucose Test Strips; Home Health Services; Hospice; Hospital Care -Inpatient/Outpatient; Hospital Emergency Room; Lead Testing; Long-Term Care; Money Follows the Person (MFP) Program; Nursing Facility; Organ Transplants; Personal Care; Physician's Services; Podiatry Services (foot care); Prenatal and Maternity Services; Prescription Drugs when

What is not Covered?

Some services below may be covered for members under age 21 under EPSDT: ; Abortions, unless the pregnancy is life-threatening; Acupuncture; Administrative expenses, such as completion of forms and copying records; Alcohol and drug abuse therapy*; Artificial insemination, in-vitro fertilization, or other services to promote fertility; Broken appointments; Certain drugs not proven effective and those offered by non-participating manufacturers (enrolled doctors, drugstores, and health departments have lists of these drugs); Certain experimental surgical and diagnostic procedures ; Chiropractic services (except as provided through EPSDT*); Cosmetic treatment or surgery ; Daycare, including sitter services for the elderly (except in some home-and community-based service waivers); Dentures for members age 21 and over; Doctor services during non-covered hospital days; Drugs prescribed to treat hair loss or to bleach skin; Eyeglasses or their repairfor members age 21 or older; Hospital charges for days of care not authorized for coverage including Friday or Saturday hospital admission for non-emergency reasons or admission for more than one day prior to surgery; Immunizations if you are age 21 or older (except for flu and pneumonia for those at risk); Inpatient hospital care in an institution for the treatment of mental disease for members under age 65 (unless they are under age 22 and receiving inpatient psychiatric services); Medical care received fromproviders who are not enrolled in or will not accept Virginia Medicaid; Personal care services (except in some home and community-based service waivers or under EPSDT*); Private duty nursing (except in some home and community-based service waivers or under EPSDT*); Psychological testing done for school purposes, educational diagnosis, school, or institution admission and/or placement or upon court order(Psychological tests performed by local education agencies that are in child's Individual Education Plan [IEP] are covered under school-based health services); Remedial education; Routine dental care if you are age 21 or older; Routine school physicals or sports physicals; Sterilization of members younger than age 21; Telephone consultation; Weight loss cl

How much is it?


How to Apply?

  1. Call Cover Virginia at 1-855-242-8282 to apply on the phone Mon - Fri: 8:00 am to 7:00 pm and Sat: 9:00 am to 12:00 pm or
  2. Apply online at or
  3. Print out and complete a paper application and mail it to your local Department of Social Services (* Additional forms or applications may be required) or
  4. Visit your local Department of Social Services in the city or county in which you live

You should have the following information ready when you apply:
  • Full legal name, Date of Birth, Social Security Number, Citizenship or Immigration Status for you and anyone in your household who is applying for health care coverage.
  • Most recent federal tax filing information (if available).
  • Job and income information for members of your household for the month prior or the current month. Having recent pay stubs or W-2s to reference may be helpful.
  • Information about other taxable income for members of your household such as unemployment benefits, Social Security benefits, pensions, retirement income, rental income, alimony received, etc.
  • Policy numbers for any current health insurance

What will I be asked?

Applicants for medical assistance are asked to provide their Social Security number, declare Virginia residency, and may be asked to provide documentation of United States citizenship and identity. If you are not a U.S. Citizen you must provide information and documents about your immigration status. Some immigrants can be eligible for full Medicaid coverage; others can be eligible for Medicaid payment only for emergency services. If you are pregnant, you will be asked how many babies you are expecting and the estimated date of delivery. Medical proof of pregnancy is no longer required.
Income that you receive must be listed on the application. Income includes earned income, such as wages and self-employment, as well as other income such as Social Security, retirement pensions, certain Veteran 's disability benefits, alimony, etc. Child support is generally not counted. Countablesources of income are added together and compared to the income limit to determine eligibility.You will also be asked questions about how you file your taxes to make sure we are counting the right incomeand including the right individualsin your household.

Who makes the decision?

Once a signed application is received, local DSS staff will determine whether you meet a Medicai d covered group (see section on Covered Groups) and if your resources ( if required) and income are within required limits. The amount of income and resources you can have and still be eligible for Medicaid depends on how many family members are living toge ther and the limits established for your covered group.

How to know when a decision has been made?

An eligibility decision will be made on your Medicaid appliction 1) Within 45 calendar days OR 2)Within 10 working days for pregnant women and participants in the Virginia Department of Health's Every Woman's Life Program (BCCPTA) AFTER the signed application is received in the agency. 3) Within 90 calendar days if a disability decision is needed of the date your application is filed with a local DSS.

When does my coverage start?

Families and Children: Medicaid coverage usually starts on the first day of the month in which you apply and are found to be eligible. Coverage can start as early as three months before the month in which you applied if you received a medical service during that time and met all eligibility requirements. Spenddown coverage begins once the spenddown is met and continues until the end of the spenddown period. Contact your local DSS office if you have questions about when your Medicaid coverage starts.
Aged, Blind and Disabled: Medicaid coverage usually starts on the first day of the month in which you apply and are found to be eligible. Medicaid coverage can start as early as three months before the month in which you applied if you received a medical service during that time and met all eligibility requirements. Coverage under the Qualified Medicare Beneficiary (QMB) group alwaysstarts the month after the approval action. Spenddown coverage begins once the spenddown is met and continues until the end of the spenddown period. Contact your local DSS office if you have questions about when your Medicaid coverage starts and ends.

How often do I have to renew?

If you are currently enrolled in Medicaid, FAMIS or Plan First, your health care coverage needs to be renewed annually. You will receive a form in the mail if you need to renew your health coverage.
If you recently received a renewal application for these programs, you may have noticed that the application looks different than before. There's a new process to renewing your coverage. The first time you use this new form to renew, it may take you longer than before to complete. However, you could be automatically renewed for up to 5 years without having to complete a renewal form if nothing has changed and you check a box at the end of the form that allows us to look at your electronic income data each year, including information from tax returns.

  1. Online: Through your account on, or;
  2. By phone: Call Cover Virginia at 1-855-242-8282
  3. By mail: Complete the paper renewal form and return it to your local Department of Social Services.

Where can I report a change? What changes do I need to report?

You must report any change in circumstances (such as achangeofaddressor locality, income, or health insurance coverage)within 10 calendar days of the change on the CommonHelp website or by contacting your local DSS worker.

Will I have to pay co-payments?

See Program Guide

For out-of-state services

Virginia Medicaid will cover emergency medical services you receive while temporarily outside of Virginia if the provider of care agrees to participate in Virginia's Medicaid Program and to bill Medicaid. No payments are made directly to members for services receivedout of state. Rules for out-of-state care may be different if your coverage is through an MCO. If you are enrolled in an MCO, contact MCO stafffor procedures regarding out-of-state treatment.
If you receive emergency medical services out of state from a provider not enrolled in Virginia Medicaid, ask the provider to contact the DMAS Provider Enrollment Unit: Virginia Medicaid Provider Enrollment Services, P.O. Box 26803, Richmond, Virginia 23261, Phone: 1-888-829-5373 or 804-270-5105
Virginia Medicaid does not cover medical care received outside of the United States.

What if I have other medical insurance or other health coverage?

If you already have health insurance you can still be covered by Medicaid. The other insurance plan is always billed first. Having other health insurance does not change the Medicaid co-payment amount (if any) that you pay to providers as a Medicaid enrollee. If you drop private health insurance coverage or enroll in a private health insurance plan, tell your eligibility worker. If you don't, medical bill paymentscould be delayed.

What is a Managed Care Plan?

Members enrolled in Medicaid, will receive a letter requesting that they select a plan and also indicating that they have been preassigned to a contracted MCO.

Contracted Health Plans

For the plans in your county, please refer to

Physicians that accept medicaid assignment

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  • Phone Number
    (757) 523-4589
  • Office Locations
    1212 LAKE JAMES DR

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