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Virginia's Medicaid Rules Have Changed!

We're excited to report that, as of January 15th, more than 200,000 newly eligible Virginia adults were enrolled in Medicaid coverage that became available to them January 1st! To stay current on enrollment numbers, check out the Expansion Dashboard here .

In this edition, we'll explore the Top 10 FAQs our  SUN training team has encountered. If you have a Medicaid/FAMIS question or topic you'd like us to address in a future  SUN Outreach newsletter, please email .
In this issue:

1. New Adult Health Coverage: Who can qualify?

2. How and when can my client apply? Where can I find more information?

3. What services are covered?

4. Medallion 4.0 and CCC Plus: What's the difference?

5. What dental services are covered?

6. Can non-U.S. citizens qualify for New Adult Health Coverage?

7. What types of income are counted for eligibility? Do assets or resources count?

8. I heard there was a work requirement to stay enrolled in the New Adult Health Coverage. Is that true?

9. When does my client need to complete his/her annual renewal?

10. Where can I find out more about the New Health Coverage for Adults and how to help people apply?

  I heard there was New Health Coverage for Virginia Adults. Who can qualify?
Adults who are Virginia residents and meet the following criteria might now be eligible for Medicaid through the New Health Coverage:
  • Age 19 - 64, and not eligible for Medicare
  • Have qualifying household income (find out more here)
  • Meet citizenship or immigration-related requirements (find out more here)
If you'd like to help someone find out if s/he might qualify for Medicaid under the new rules, check out You'll find the income guidelines and a helpful screening tool to help your clients find out if they might qualify.

From our research on other states that expanded their Medicaid programs, we know that many newly eligible adults will need one-on-one help applying.
How and when can my client apply? Where can I find more information?
Applicants can complete a single, streamlined application by phone, online, or on paper...there is no wrong door!
  • By phone with Cover Virginia at 1-855-242-8282 (TDD: 1-888-221-1590). Cover Virginia is open Mon - Fri from 8am to 7pm, and Saturday from 9am to 12pm.
  • Online at Virginia's CommonHelp portal (
  • Online through The Health Insurance Marketplace ( Reminder: The Health Insurance Marketplace may be able to determine whether a Virginian is eligible for Medicaid/FAMIS in real time.
  • On paper (by mail or drop-off) at your local Department of Social Services (LDSS). Find your LDSS by visiting:
  • By phone with the Virginia Department of Social Services' Enterprise Call Center at 1-855-635-4370, if your client wants to apply for health coverage and other benefits, like energy assistance, child care subsidies, etc.
You or your client can find more information about how to apply at

Unlike many other types of insurance, individuals and families can apply for Medicaid/FAMIS, including the New Adult Coverage, 365 days a year.
Coverage through Medicaid/FAMIS, including the New Health Coverage for Adults, usually begins on the first of the month in which someone applies. In some cases, an applicant can get coverage for up to three months prior to the month of application. So, even if a newly eligible adult applies in April, s/he could still get coverage that begins on January 1! A newly eligible adult's coverage cannot start before January 1, 2019, though, since the program did not formally begin until that day.

Remember: It can take up to 45 calendar days for Virginia to process an application for a non-pregnant adult, or 10 business days for a pregnant woman. It's important to submit any follow-up documentation requested by the local Department of Social Services or by Cover Virginia by the requested due date to make sure an application is complete.
What services are covered?
The New Adult Coverage offers a comprehensive set of benefits, including:
  • Preventive and wellness services, including annual wellness exams, immunizations, smoking cessation and nutritional counseling
  • Doctor, hospital and emergency services
  • Behavioral health services, including addiction and recovery treatment services (ARTS)
  • Prescription drugs, labs, and X-ray services
  • Home health services, medical equipment, and supplies
  • Rehabilitative services (PT, OT, speech)
  • Family planning, maternity, and newborn care
  • Non-emergency transportation
  • Long-term services and supports (LTSS), nursing home and community-based care
  • And more!
For a more complete list, and answers to some Frequently Asked Questions about coverage, check out the Virginia Department of Medical Assistance Services' ( DMAS) fact sheet here.
I've heard people talk about Medallion 4.0 and CCC Plus. What do those terms mean? Are the services different under the two programs?
Medallion 4.0 is the name for the managed care delivery system for most Medicaid enrollees, including the newly eligible adults. Commonwealth Coordinated Care Plus ( also known as CCC Plus) is the name of the managed care delivery system for medically complex individuals. It offers extra support to help with coordinating all of their health care needs. The covered services for all newly eligible adults are the same - it doesn't matter if they are in Medallion 4.0 or CCC Plus.

For more information about CCC Plus, or what it means to be medically complex, go to
My client needs dental services. Are those covered by the New Health Coverage for Adults?
Although dental services are not among the core services of Virginia's Medicaid coverage for adults, some of the six Medicaid managed care organizations are offering some limited dental benefits to their members. For more information about covered benefits provided by the MCOs, please see the charts here .

The Smiles For Children program is Virginia's Medicaid and FAMIS/FAMIS MOMS dental program. This program provides varying levels of coverage for its members.
  • Members under 21 years of age receive comprehensive dental benefits.
  • Pregnant members 21 years of age and older receive additional dental benefits for the duration of their pregnancy and for 60 days postpartum.
  • Members 21 years of age or older that are not pregnant receive limited dental benefits including medically necessary extractions and associated diagnostic services.
Can non-U.S. citizens qualify for the New Health Coverage for Adults?
Some non-U.S. citizens can qualify! Check out the DMAS fact sheet here for additional details.
What types of income are counted when determining if someone is eligible? Do assets or resources count?
Income eligibility is based on someone's household size ( determined by federal tax filing rules ) and counting certain types of income for the people in that household. This method is known as Modified Adjusted Gross Income, or "MAGI." It adds together someone's taxable income, plus any tax-exempt interest, Social Security payments, and foreign-earned income.

Assets or resources are not counted  when considering whether someone qualifies for the New Adult Coverage. Financial eligibility is based only on household income for the month prior to application.
I heard there is a work requirement in order to be eligible for Medicaid's New Adult Health Coverage. Is that true?
Not at this time. Virginia has submitted a request to the federal government to add a requirement that some individuals who are not already employed must work, volunteer, or participate in an education or training program for a certain number of hours each month to be eligible for Medicaid.

This requirement will be implemented after the state's request is approved at the federal level and the state develops systems for implementing it. This is a lengthy process, and it will take time. Meanwhile, anyone enrolled in coverage before the changes are approved will not be subject to them until their next renewal (at the earliest). It's another good reason to help people apply now!

The majority of Virginians enrolled in Medicaid are already working. Many others will be exempt from the work requirement, because they are caretakers, are disabled, or are in a situation where participation will be a hardship.
When does my client need to complete his/her annual renewal?
To remain enrolled in coverage, Virginians must renew annually. Whenever possible, a Local Department of Social Services ( LDSS) will attempt to renew an enrollee administratively, without any effort on the part of the enrollee ( called an "ex parte" renewal).

For the New Adult Coverage, there are some special things to consider about annual renewal:
  • Virginians eligible for the new coverage who were previously enrolled in other limited-benefit Medicaid programs (the Governor's Access Plan, or "GAP" program, and Plan First) and were automatically transitioned to the new coverage will maintain the annual renewal date from their prior program. For example: a person who enrolled in GAP on June 20, 2018, will have a June renewal date (and should expect a renewal notice in April).

  • Virginians enrolled in SNAP, or who have children enrolled in FAMIS Plus, were offered the opportunity to complete an Express Application, since Virginia already had some of the information it needed to complete their enrollment into Medicaid. Those who got enrolled by completing an Express Application will have a renewal date that matches up with their children's (if a parent of a FAMIS Plus-enrolled child) or to one of their SNAP recertification dates (if a SNAP enrollee).

  • Those who completed the full application should expect to receive their renewal packet around 10 months after their coverage became active. Many newly-eligible adults may find that their local DSS is able to complete their annual renewal administratively ex parte, and that they do not need to complete any paperwork at renewal time.
Where can I find out more about the New Health Coverage for Adults, and how to help individuals and families apply for Medicaid/FAMIS?
If you want to help families or individuals apply, come to a SignUpNow workshop! Check out to find a workshop in a location near you.
SignUpNow teaches the "ins and outs" of the eligibility requirements, application procedures, and post-enrollment information for Virginia's Medicaid/FAMIS programs, including:
  • New Adult Health Coverage
  • Programs for children and pregnant women
  • Plan First
  • Low Income Families and Children (LIFC) program
We will continue to add workshops to our schedule, so be sure to check back often!