Medicaid Eligibility

The Medical Assistance program (Medicaid) was established under Title XIX of the Social Security Act to enable states to provide medical care for public assistance recipients and medically needy persons (i.e. persons of low income who can meet their maintenance needs but have insufficient income to provide the cost of medical care). The program is financed by state and federal funds.

In Virginia, Children's Health Insurance includes Medicaid and Family Access to Medical Insurance Security (FAMIS) and is available through a single application. Children will be covered by Medicaid if the family's income meets the Medicaid income requirements. Children who are not eligible for Medicaid and who meet the FAMIS eligibility requirements will be covered by FAMIS.

Most Frequently Asked Questions

Who Medicaid Covers

In order to be eligible for Medicaid, applicants must meet the non-financial and financial requirements for Medicaid and must be in one of the groups covered by Medicaid.

The four major groups covered by Medicaid are:

1. Medically Indigent Children and Pregnant Women (MI) - Medicaid generally provides coverage to pregnant women and children with countable family income below 133% of the federal poverty level (FPL) who meet the non-financial requirements. Eligibility under this component is determined without regard to the individual's resources.
2. Low Income Families and Children (LIFC) - Medicaid covers families who meet the non-financial requirements and the income and resource requirements.
3. Aged, Blind and Disabled (ABD) - Medicaid covers individuals over 65 and individuals with disabilities who meet the non-financial requirements and the income and resource requirements. Medicaid covers Supplemental Security Income (SSI) recipients who meet the resource requirements.
4. Long-Term Care (LTC) - Medicaid provides coverage to individuals who require care in a medical facility or whose care can be provided in the home and whose income and resources are insufficient to cover the cost of their care.

What Medicaid Covers

For individuals who meet income and resource limits for full coverage, Medicaid covers a comprehensive range of services, including hospital care, doctor's visits, prescriptions, mental health services, and rehabilitative services. An individual may be covered by other health insurance and be eligible for Medicaid. Medicaid will cover the cost of care not covered by the other plan and may cover the cost of employer-sponsored health insurance for eligible individuals.

Medicaid covers the Medicare premiums, copayments, and deductibles for individuals who are eligible for full Medicaid coverage and who also have Medicare. Individuals with Medicare Part A whose income and resources are over the limit for full Medicaid coverage may still be eligible for limited coverage.

How the Program Works

Virginia law provides that the Medicaid Program be administered by the Department of Medical Assistance Programs (DMAS), whose responsibilities are:

• Development of the state medical assistance plan to cover eligibility criteria and scope of services, in conformity with federal law and regulations
• Provision of medical care covered under the state plan
• Handling of appeals related to medical assistance and
• Handling of fraud in cooperation with the Department of Social Services (VDSS)

Determination of eligibility for medical assistance and the provision of related social services is the responsibility of local social service departments, under the supervision of VDSS. The responsibilities of VDSS are the:

• Determination of initial and continuing eligibility for medical assistance
• Provision of related social services and
• Enrollment of eligible persons in the Medicaid Program (exception: VDSS carries direct responsibility for the determination of eligibility for medical assistance and for the enrollment in the Medicaid Program of certain patients in state owned hospitals and long term facilities)

Steps to Apply

1. Complete screening for potential eligibility
2. Submit application to your local department of social services (you can also pick up an application at your local office or ask them to mail one to you).

Note:

• In order to apply for FAMIS, income verification is required. It is not necessary to be interviewed at the local Department of Social Services. Mail-in applications are accepted.
• In order to apply for Medicaid for Pregnant Women, income and verification of pregnancy are required. It is not necessary to be interviewed at the local Department of Social Services. Mail-in applications are accepted.
• For help with Medicare Costs, income and resource verifications are required. It is not necessary to be interviewed at the local Department of Social Services. Mail-in applications are accepted.