Virginia Medicaid, often working with the Family Access to Medical Insurance Security (FAMIS) program, provides comprehensive health coverage for eligible low-income residents of the Commonwealth. Operating under the umbrella of Cardinal Care, the program ensures access to a broad range of medical and support services. Coverage is determined by federal requirements that set a minimum standard, which Virginia expands upon with state-specific optional benefits.
Mandatory Acute Medical Services
Virginia Medicaid provides federally mandated acute medical services to ensure immediate and necessary care is available to members. This includes coverage for both inpatient and outpatient hospital services, covering costs associated with a hospital stay, emergency services, and procedures performed in a hospital setting.
Physician services are a required component of coverage, providing access to primary care doctors and specialists for diagnosis and treatment. Essential diagnostic services, such as laboratory and X-ray services, are also covered. Furthermore, services provided through Federally Qualified Health Centers (FQHCs) are included, offering accessible, community-based primary care, dental, and mental health services.
Behavioral Health and Prescription Coverage
Virginia has enhanced its offerings for mental health and substance use disorder treatment, providing robust behavioral health support. Coverage includes a broad spectrum of services, such as inpatient and outpatient mental health care, individual and group counseling, and specialized therapies. The comprehensive Addiction and Recovery Treatment Services (ARTS) benefit specifically addresses substance use disorders, providing services like detox, residential treatment, and intensive outpatient programs.
The prescription drug benefit is governed by the Virginia Preferred Drug List (PDL), which specifies medications covered without special authorization. Drugs not on the PDL are non-preferred and require prior authorization, where the prescriber must demonstrate medical necessity. Approval may be granted if the member has a documented allergy, a contraindication, or a history of therapeutic failure with at least two preferred drugs in the same class. The program mandates the substitution of a generic drug when an equivalent is available.
Long-Term Services and Community Supports
Long-Term Services and Supports (LTSS) are available for individuals needing ongoing assistance with daily activities due to age, chronic illness, or disability. This coverage encompasses both institutional care, such as nursing facility services, and Home and Community Based Services (HCBS). HCBS allows individuals to receive necessary care in their home or community setting, promoting independence and quality of life.
Access to HCBS is primarily managed through Virginia’s Medicaid Waivers, such as the Commonwealth Coordinated Care Plus (CCC Plus) Waiver. These waivers cover supports including personal care assistance, respite care for caregivers, and assistive technology. To qualify for LTSS, an individual must undergo a screening to confirm they meet functional eligibility criteria, typically demonstrating a need for a Nursing Facility Level of Care. This determination assesses the individual’s dependency in Activities of Daily Living (ADLs) and their medical needs.
Specialized Coverage for Children and Pregnant Individuals
Virginia Medicaid provides enhanced benefits for children and pregnant individuals, recognizing their unique health needs. Children under age 21 enrolled in Medicaid or FAMIS are entitled to the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. This benefit mandates comprehensive coverage of preventive, developmental, and specialty care, ensuring that any health condition is detected and treated early, even if the service is not routinely covered for adults.
The EPSDT benefit often covers services limited for adults, such as comprehensive dental and vision care. For pregnant individuals, Virginia offers full coverage throughout the pregnancy and extends this coverage for a full 12 months postpartum. This extension, provided through programs like Medicaid for Pregnant Women and FAMIS MOMS, is well beyond the standard 60-day period. Continuous coverage includes a full range of benefits, such as behavioral health services, family planning, and community doula services.