Medicaid

Medicaid pays for health and medical care for certain groups of people who have low income. Local Departments of Social Services take applications and make eligibility decisions. The Department of Medical Assistance Services (DMAS) pays the bills. Medicaid is not a type of insurance, though Medicaid benefits may be provided to you through a chosen primary care physician or Health Maintenance Organization (HMO). Medicaid is only available to people who fall into certain categories and who have limited finances.
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 Medical Eligibility Groups

People with low income who belong to one of the groups described below may be eligible for either full or limited Medicaid benefits.

  • Pregnant women - Once eligible for Medicaid, pregnant women remain eligible throughout the pregnancy and up to 60 days after the pregnancy ends.
  • Children younger than age 19.
  • Pregnant women or children under 19 who are over 133% of the federal poverty level may be eligible for FAMIS.
  • Children under age 21 who are in foster care or subsidized adoptions.
  • Infants born to Medicaid-eligible women may remain eligible until their first birthday.
  • Individuals who are 65 or older, blind or have been declared disabled by Social Security.
  • Individuals residing in Long Term Care Facilities, or receiving nursing care in their homes.
  • Hospice

There are several Medical Assistance Programs offered in Virginia. Each program covers different groups of people and each program has different eligibility requirements. When you apply for Medical Assistance, you are screened for all possible programs based on your age, income, financial resources, and other information. To be eligible for a Medical Assistance Program, you must meet the financial and non-financial eligibility conditions for that program.

 Frequently Asked Questions

When am I required to report changes?
The recipient has a responsibility to report any changes in his/her circumstances that may affect his/her eligibility within 10 days of the date the changed occurred.

When are Medicaid Reviews required?
Medicaid reviews are required at least every 12 months.  Reviews may also be done when changes are reported.

What information is required for the review?
Depending on the type of Medicaid you are receiving, you may be asked to complete a review form, provide verification of all gross monthly income, and provide verification of resources.  Your eligibility worker will contact you to request the information that is needed.

What is Medallion?
Medallion is a managed care organization (MCO) established to provide quality health care to Medicaid recipients. 

When should I expect to be enrolled in an MCO?
If you are selected for managed care, you will receive an enrollment package in the mail 15 to 45 days after you have been approved for Medicaid.  Complete this package in the time allotted and return the forms if you want to choose your MCO.  If you fail to return your forms and make a selection by the time indicated, an MCO will be chosen for you.

If I have problems with my MCO, whom do I call?
Call the MCO’s Hotline.  This number should be called first.  If you are not satisfied with the response, call the general Medallion Hotline 1(800) 643-2273.  Your eligibility worker should only be called as a last resort in MCO matters.

What happens if I am disenrolled from Medallion?
If you remain Medicaid eligible, you can receive Medicaid covered services from any approved Medicaid provider.  If your Medicaid case is closed and then reopened and you are again eligible for managed care, your MCO enrollment will be reactivated in 30-60 days from the time your case is reopened.

What is LIFC?
LIFC stands for Low Income Families with Children.  This Medicaid coverage is for parents, caretaker-relatives, and persons essential to the well-being of a dependent child.  These individuals must be living with the dependent child.

What is a Spenddown?
A Medicaid spenddown is for people who meet all the Medicaid eligibility requirements except for income.  People who have countable income higher than the medically needy income limit are placed on a spenddown.  A spenddown works like an insurance policy deductible.  The amount of the deductible is called the “spenddown liability”.  The spenddown is a 6-month period, although it can be shortened under certain conditions.

What is Retro period?
This is the 3- month period that is immediately before the application month.  If you applied in April, your retro period is January, February, and March.  To be evaluated for this period, you will have to verify all income and resources the household had during this period.

Will Medicaid cover bills earlier than 3 months prior (retro period) to the application month?
No.

What is SLH?
SLH stands for State and Local Hospitalization.  It covers In/Out patient services at a hospital, emergency room services, and Health Department Clinic visits.  The certification period is for 6 months.  The certification does not cover doctor visits.

If I am not eligible for any state funded medical program, where can I get medical help?
You can go to the Virginia Beach Health Department located at 4452 Corporation Lane (telephone 518-2700) or the Beach Health Clinic located at 3396 Holland Rd., Suite 102, Virginia Beach, VA 23452 (telephone 428-5601).

What about help with prescription costs?
If you do not have prescription drug coverage through private insurance, Medicare or Medicaid, you may be eligible for obtain medicines at no cost or at a discount through prescription assistance programs.  Additional information is available online at Disability Res​ources and the Virginia Health Care Foundation.  (These programs are not affiliated with our agency.)

What is FAMIS?
This is Family Access to Medical Insurance Security and is for uninsured low-income children from birth to age 19.  The program is designed to provide comprehensive health care coverage for children whose family makes too much to qualify for Medicaid, but has income below 200% of the federal poverty level.  To apply call 1(866) 87FAMIS.  If you have access to a computer, go to the FAMIS Web site for more information or to file an on-line application.    

What is FAMIS Plus?
FAMIS Plus is another name for Medicaid children from birth to age 19 whose family unit has income within 133% of the federal poverty level (FPL).

Does the Virginia Beach Department of Social Services Human Services maintain a list of doctors and dentists that accept Medicaid?
It is up to the customer to locate a physician who accepts Virginia Medicaid.  A Provider Search function is on the Virginia Department of Medical Assistance.

Can anyone obtain case information on my Medicaid case?
Yes, but you have to authorize that individual to have access in writing before the agency can release the information.

Does Sentara Family Care provide dental coverage for adults?
Yes but only for 19 and 20 yr. olds. For more information call 1-800-881-2166.

Will Medicaid or Medallion pay for non-emergency transportation?
You must call 1-866-386-8331 at least 48 hours (2 days) before service is needed.

What is Income?
Income is any money received by you such as SSI, Social Security, cash gifts, wages, etc.

Is a bank account for my Social Security check considered a resource?
Yes, and all resources including bank accounts must be verified.  That includes accounts with zero and negative balances.

What is the Patient Advocate Foundation Virginia Cares Uninsured Program?
This program helps uninsured adults diagnosed with a chronic, life-threatening, or debilitating disease find the healthcare they need.  Call 1(800) 532-5274 or visit Patient Advocate Foundation for more information.

What is Plan First?
Plan First pays for family planning services only for men and women ages 19 to 64 years of age.  Contact us at (757) 437-3200 or the Virginia Department of Medical Assistance (DMAS) for more information.

What is Smiles for Children?
This program provides dental coverage for children enrolled in Medicaid (FAMIS Plus) and FAMIS.  It also covers limited oral surgery for adults enrolled in Medicaid.  Call 1(888) 912-3456 for more information.

Do you have to meet citizenship and identification requirements for Medicaid?
Yes, citizens may be asked to provide proof of citizenship and identity.  Contact our agency at (757) 437-3200 for more information. ​

 Health Insurance Premium Payment

HIPP is a federal requirement that all Medicaid-eligible individuals able to enroll in a cost-effective private health insurance plan through their employer do so. The HIPP program will pay the employee's share of the premium. Individuals who do not enroll will lose their Medicaid benefits. The Department of Medical Assistance Services (DMAS) HIPP Unit will evaluate every plan offered to the employee to determine whether the plan is cost-effective; that is, if it would cost less to buy health insurance to cover medical care or to pay for the care with Medicaid funds.

Applying for HIPP

If you or family members are employed and have access to group health insurance, you are required to complete a HIPP application. Your eligibility worker will forward the application to the Department of Medical Assistance Services (DMAS). You will also be given an Employer Insurance Verification Form, which you are required to give to your employer to complete. The employer must return the completed form to the HIPP Unit at DMAS.

Medicaid will still cover the Medicaid-eligible members of your family as a secondary plan. Medicaid will pay for some services not covered by the insurance including co-pays and deductibles.

Employer Insurance versus Medicaid

The insurance may cover services not covered by Medicaid. Members of your family that are not covered by Medicaid may be covered under the employer's insurance plan. Continued enrollment in private health insurance can help meet your pre-existing waiting periods, deductibles, and out of pocket expenses for the time when you will no longer be covered by Medicaid. If you lose your Medicaid eligibility, you may pay the premiums yourself and keep the private insurance. Using private health insurance helps lower costs to the Medicaid program.

Your Responsibilities under HIPP

Any changes in employment, insurance coverage, or household must be reported to DMAS immediately. Every month, you will be required to send DMAS a copy of your most recent paycheck showing the insurance premium deduction. Incorrect payments will be recovered.

To report changes or if you have questions, call HIPP at (800) 432-5924.

For additional information, contact Phillip White (757) 385-3603

Contact Information

 Family Access to Medical Insurance Security (FAMIS)

FAMIS is Virginia's program that helps families provide health insurance to their children. Health insurance is important to make sure that kids are able to get all the help they need to grow up healthy.