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Virginia Medicaid and FAMIS are healthcare plans that operate on the state and federal levels. The programs aim to provide qualifying Virginia residents with access to affordable healthcare, including coverage for children, pregnant women, medically needy individuals, and low-income families or caregivers who are U.S. citizens or permanent residents. As of June 2023, 2,008,101 Virginians were enrolled in Medicaid.
With countless healthcare options available, it can be challenging to find an affordable one that still offers you broad access to healthcare services. However, if you live in Virginia, you could start by exploring the many benefits of Virginia Medicaid. Their FAMIS program might be a good option for your children, and their FAMIS Prenatal program covers expectant mothers.
If these programs don’t seem like enough coverage for you or your family, you can also consider extending your options with third-party health insurance. Virginia Medicaid already has excellent healthcare benefits. Still, the right gap coverage could give you peace of mind about your family’s access to the healthcare they need. To prevent shouldering the debt of unexpected medical expenses, many Virginians extend their Medicaid coverage to include a more comprehensive range of benefits and services by way of private health insurance.
To help you assess what’s on offer, the guide below shares more about FAMIS and Virginia Medicaid. Read on for how to apply, what both plans cover, and how private healthcare can complement your state medical plan if needed.
What is FAMIS in terms of Virginia's Medicaid program? This branch of the state’s health insurance program for children—Family Access to Medical Insurance Security—applies to family members under 19.
Medicaid for Children and FAMIS Prenatal are healthcare plans for children under 19 and expectant mothers within a specific income bracket, respectively. Coverage for children under age 21 who are in foster care or subsidized adoptions may also be available.
Virginia's Department of Medical Assistance Services and the United States Department of Health and Human Services manage and fund Virginia’s Medicaid, as well as FAMIS. These programs provide access to free or more affordable healthcare to vulnerable and low-income Virginians. The healthcare plans differ but generally pay for doctor visits, emergency care, and prescriptions.
Under these Medicaid programs in Virginia, you won't pay to enroll or manage monthly premiums. Sometimes, a small copayment may be necessary to receive services. However, the majority of the services covered will be free as long as you and your family qualify.
You will get a FAMIS Plus or Virginia Medicaid card once you receive approval, depending on which program you have applied to enter. The cards include your name or the name of your eligible child, with a corresponding identification number.
You must present the card to medical care providers or a pharmacy you visit in order to use the healthcare program’s benefits. The program also recommends checking that your healthcare provider accepts Virginia’s Medicaid coverage for payment before you receive any services.
If you lose your Medicaid eligibility at any time, maybe due to a relocation or exceeding the income restrictions, don't throw away your FAMIS Plus or Medicaid card. Should you become eligible for the benefits again, these cards will become active as soon as the government reinstates you.
(Please note that the card shown may differ depending on the carrier from which you are covered.)
Eligible Virginia residents can apply to join the Virginia Medicaid program or its related programs in several ways:
When applying for Virginia Medicaid or FAMIS, you'll need to provide the following information:
Qualifying for FAMIS is relatively straightforward. Children must live in Virginia, be 19 or younger, and be United States citizens or lawful residing immigrants. Your household must also meet certain income rules to be eligible.
Virginia Medicaid’s benefits fall under two tiers: full coverage and limited coverage. Full coverage Medicaid offers a wide range of medical benefits like hospital and doctor services for Virginians who aren't participating in Medicare.
Limited coverage often requires you to meet a spend down for time-limited coverage. An adult whose income is within 200% of the Federal Poverty Level may also qualify. Medicaid spend down applies to medically needy children, adults, and families who meet the non-financial eligibility requirements but exceed the income limits.
Let's take a closer look at Virginia Medicaid eligibility requirements for full coverage:
After you apply to join FAMIS or Virginia Medicaid, the staff at the local Department of Social Services will review your application and documents to determine your eligibility. Medicaid decisions typically occur within:
If you receive approval, your medical insurance coverage will start on the first day of the month in which you applied. Everyone in your household who qualifies for healthcare coverage will receive a FAMIS Plus card or Virginia Medicaid card, which the program will send to your current mailing address.
All Virginia Medicaid members will get the blue and white Medicaid card. However, in this state, some members will receive coverage through a managed care organization. In this case, there will be a separate ID card sent in the mail, which you will present with your Medicaid card to receive care, medications, and so on.
If your benefits change but then you can enroll in this program again, you won't have to request a new card. The LDSS will reinstate your existing Medicaid card. However, you will need to request a replacement from the LDSS if you lose your card or someone steals or damages it.
Once you and your family receive your Medicaid coverage in Virginia, you will have 12 months of coverage if you meet all the eligibility requirements for the entire period. The LDSS staff will review your case annually and reinstate your coverage if you still qualify for Medicaid healthcare coverage for the next 12 months.
A notice arrives in the mail when it's time for your plan renewal. You'll then complete another form and provide proof of income and other resources. Sometimes, the LDSS staff can use available information to renew your family’s Medicaid coverage without additional information from you, but you risk losing coverage if you don't provide the requested information.
What is FAMIS coverage under Virginia’s Medicaid offering to its members? The children’s program and adult program have very similar benefits and services through these state and federally-funded healthcare plans. You’ll be able to get everything from visits with a primary care physician to medical transportation, depending on the Medicaid plan your family joins.
Here is a deeper look into the types of coverage FAMIS and Virginia Medicaid have to offer:
All children with FAMIS Medicaid coverage will receive dental care through Smiles for Children, the official dental program. As a member of the program, services are free (without copayments). That means children, adults, and pregnant women can receive comprehensive dental care from their respective plans.
For example, dental services for children in Virginia typically include the following:
Pregnant women and adults can receive coverage for X-rays, cleanings, fillings, periodontal treatment, partial or complete dentures, extractions, and medically necessary oral surgeries.
For those who have more serious dental issues and anticipate requiring more visits to the dentists, investing in private dental plans in Virginia is advisable.
Prescription drug coverage is a benefit of Virginia’s Medicaid and MCOs, which put out a list of preferred drugs or formularies that they'd want your doctors to use. The reasons stated are that these medications are FDA-approved to be safe and effective and because they're cheaper. As such, your physician may need pre-authorization to ensure your pharmacy will fill your prescription.
Fortunately, you won't have to pay for medications—Virginia’s Medicaid pays for all covered drugs.
Virginia’s Medicaid plans offer additional healthcare services for children with special needs or disabilities. You can check for access to The Developmental Disability Waiver and Commonwealth Coordinated Care Plus Waiver, both of which may be available through Medicaid, LDSS, or your local Department of Health.
Virginia’s DD Waiver offers support and services, aiming to promote physical and behavioral health, learning, employment, and community inclusion. The CCC Plus Waiver is for qualifying members of all ages for respite, nursing, environmental modifications, and assistive technology.
Another important factor to consider is what happens to your finances should a temporary or permanent illness occur? Those who qualify for Virginia Medicaid will receive assistance for the drugs and equipment required to manage, however not to replace your finances. Investing in quality disability insurance is an excellent way to assist with some of the costs incurred with not being able to work either temporarily or permanently, and to help with the cost of medical needs.
If you travel out of Virginia for a short period and face a medical emergency, Virginia Medicaid will cover your medical services. However, the provider of care must participate in the state's Medicaid program and bill Medicaid. If not, Virginia’s Medicaid will neither pay providers nor reimburse members directly for services that occur beyond Virginia's borders.
Unfortunately, many medical providers don't participate in Virginia's Medicaid program, which can make it tough on you during an out-of-state medical emergency. However, you can ask emergency services to contact the DMAS Provider Enrollment Unit at 888-829-5273 for more information (or mail them at P.O. Box 26803, Richmond, Virginia 23261).
Of course, if your Virginia Medicaid benefits come from an MCO, they might have different rules concerning out-of-state coverage. You'd have to contact them for further details.
It’s also great to know your options regarding medical transportation to and from appointments in Virginia. For example, your Medicaid plan will typically cover the cost to and from your doctor’s appointments or medically necessary transportation through ModivCare. The contact information to reserve a ride or speak to transport customer service depends on your specific Medicaid plan.
If you intend on traveling outside of Virginia or outside of the U.S.A. for leisure, always invest in proper travelers insurance.
With FAMIS or Virginia Medicaid, eligible children who receive services within an Individualized Education Program can participate in health-related services through the public school division, including the following:
Special benefits are also available to seniors over 65 in Virginia. The coverage relates to nursing facilities, private or specialized nursing care, inpatient psychiatric hospital services, and home health services, which come with 32 yearly visits. Long-term care is also available for institutional settings and at home through the Home and Community-Based Services Waiver.
Besides children, seniors, and low-income families, Virginia’s Medicaid also provides affordable healthcare coverage to other groups, which you can learn about below.
Virginia’s Native Americans who are members of an Indian tribe defined by the Indian Self-Determination and Education Assistance Act can participate in FAMIS and Virginia Medicaid if they meet the eligibility requirements. American Indians born in Canada could also qualify and get full healthcare benefits through Medicaid.
Military veterans may qualify for healthcare through the U.S. Department of Veterans Affairs. For example, many active duty and retired military members and their immediate family members can receive affordable healthcare through TRICARE.
Still, Virginia’s Medicaid programs are available for veterans and active duty personnel if they qualify for them. In some cases, you can combine your healthcare plans to provide optimal coverage for yourself and your household.
Despite so many benefits, Virginia’s Medicaid plans won't cover all healthcare-related services or products, including the following:
For funerals, limited coverage is available. Securing your family with comprehensive funeral insurance can save thousands of dollars in final costs.
Other services are only available to children under 21 through Early Periodic Screening Diagnosis and Treatment.
Understanding the full scope of what Virginia’s Medicaid will and won't cover can be confusing when you start exploring specific medical procedures. Take a look at the breakdown of common medical services below to see what to expect.
| Dental | |
|---|---|
| X-Rays and exams | Children and adults with FAMIS and Virginia Medicaid memberships can get dental X-rays to identify oral and dental problems beyond what the eye can see. While children receive regular dental checkups, pregnant women and other adults only qualify for annual exams. |
| Wisdom teeth | Do you have an infected or impacted wisdom tooth that causes pain and discomfort? You can get an extraction, which Medicaid will cover. |
| Vision | |
|---|---|
| Eye Exams | Visioncare is available through Virginia's Medicaid program. However, eye exams are limited to once every two years. |
| Glasses | Virginia’s Medicaid members under 21 are eligible to receive eyeglasses for free or for a small charge. The programs won't cover these expenses for adults over 21. |
| Laser Eye Surgery | Laser eye surgeries are usually elective procedures, so Medicaid doesn't typically cover them. However, there could be an exception if the service is medically necessary to correct an injury or treat an illness. |
| Surgery | |
|---|---|
| Rhinoplasty | Generally, Medicaid won't cover rhinoplasty surgeries (nose jobs) because they are cosmetic procedures that alter the shape and appearance of the nose. The program might cover the surgery if it's medically necessary to fix a deviated septum and improve your breathing, though. |
| Breast Reduction | Breast reduction surgeries are also cosmetic. Still, Medicaid will provide benefits to cover treatment if the procedure is medically necessary and the surgeon receives prior authorization. |
| Hospital | |
|---|---|
| Hospital stays | Both FAMIS and Virginia Medicaid benefits extend to inpatient hospital admissions. If your doctor wants to admit you or your child to a hospital, they must get pre-authorization before doing so or within 24 hours of an emergency admission. |
| Ambulance transportation | In the event of a potentially life-threatening medical emergency, like a heart attack or severe injury, Virginia’s Medicaid will cover ambulatory expenses. Unfortunately, the program won't cover minor problems, which include typical labor pains, bruises, headaches, intoxication, or fevers. |
| Giving birth | The maternity program for Virginia Medicaid or FAMIS MOMS includes a health insurance program for uninsured pregnant women that will cover prenatal and delivery services. The program pays for emergency care, doctor visits, prescription medicine, and other services relating to pregnancy and birth. |
With your Virginia Medicaid healthcare plan, you can access community-based residential services for children and adolescents under 21. The program offers therapeutic services in a residential setting. However, children who participate in these services must also get psychotherapy services.
For adults, Medicaid will cover up to 26 mental health or substance abuse psychiatric or psychological service visits without pre-authorization. Sessions beyond the original 26 must have pre-authorization for Virginia’s Medicaid to extend coverage.
| Sexual Health | |
|---|---|
| Gynecologist | Women can receive care from their gynecologist on Medicaid in Virginia, even if they aren't pregnant. |
| Erectile Dysfunction | Prescription medication for erectile dysfunction receives no coverage in Virginia. |
| Birth Control | Virginia Medicaid will cover FDA-approved birth control products and services like IUDs, the pill, and birth control patches or shots. |
| Fertility Treatment | There are no benefits available for infertility treatments or fertility services through Virginia Medicaid. |
| Specialists | |
|---|---|
| Dermatologist | Some medically necessary dermatology services may have Medicaid coverage if your dermatologist participates in Virginia's Medicaid program. |
| Physiotherapy | Physical therapy and occupational therapy coverage is available, but services may need pre-approval. |
| Massage therapy | Do you require massage therapy as a treatment for a medical condition? Medicaid in Virginia may cover this service, but not always. |
| Podiatrist and footcare | You can get medically necessary podiatry or footcare services with your Medicaid plan in Virginia. |
| Allergist and allergy testing | Virginia’s Medicaid will cover allergy testing if medically necessary. |
| Sleep physician and CPAP machines | Sleep studies and CPAP devices may have Medicaid coverage in Virginia, subject to strict conditions. |
FAMIS and Virginia Medicaid are excellent options to consider if you live in the state and need affordable healthcare. Will the benefits be enough to accommodate the needs of your household? If not, a private healthcare plan can provide more comprehensive coverage by supplementing your benefits. Other types of private insurance, such as life insurance, can help pay for medical costs Medicaid will not cover, especially in the event of your passing.
Consider adding an additional policy to your Medicaid coverage to enjoy these potential benefits:
Are you ready to explore supplemental healthcare on top of FAMIS, FAMIS prenatal coverage, Virginia Medicaid, or FAMIS MOMS benefits? A premier comparison platform like Insurdinary makes it easy to explore multiple products and quotes for the most affordable policies and benefits you need.
Insurdinary, and its network of partners offer many different types of insurance. In addition to health, dental, disability, life, funeral and travel insurance as discussed on this page, you may also be interested to explore the following:
Take advantage of Insurdinary’s easy-to-navigate website and helpful customer service team today! Compare Virginia Medicaid plans with private insurance policies through our free quotes form, or get in touch with us to learn more.
