Medicaid funding, which accounts for one-fifth of healthcare spending, is a major source of support for hospitals and physicians, nursing homes, and healthcare jobs. The open-ended guarantee of federal matching funds gives states the flexibility to use Medicaid to address healthcare priorities like the opioid epidemic.
The funding structure also enables states to use Medicaid as a safety net when economic shifts and other factors cause the coverage needs to increase.
Medicaid is a constant source of debate because it plays a large role in both federal and state budgets and is the primary source of coverage for low-income Americans. We’ll be informing you about Medicaid, Medicaid eligibility, and how to apply for Medicaid in Virginia.
What is Medicaid?
Medicaid is a government-funded assistance program. It caters to low-income people of all ages. In most cases, patients are not responsible for any of the costs associated with covered medical expenses. Occasionally, a small co-payment is required. It is a joint federal-state initiative. It differs from one state to the next. Medicaid is administered by state and local governments following federal guidelines.
What is Medicare?
Medicare is a healthcare insurance plan. Medical bills are paid out of trust funds that those who are covered have contributed to. It primarily serves people over the age of 65, regardless of their income, as well as younger disabled people and dialysis patients.
Patients pay a portion of hospital and other costs through deductibles. Non-hospital coverage requires only a small monthly premium. Medicare is a government-funded program. It is administered by the Centers for Medicare & Medicaid Services, a federal agency, and is essentially the same throughout the United States.
What Does Medicaid Cover in Virginia?
Medicaid in Virginia has three levels of benefits.
Full coverage provides members with a complete range of benefits. This includes pharmacy, hospital, and doctor services for qualified individuals.
Time-limited coverage is for people who meet the spend-down or women who get 24 months of services regarding family planning once the Medicaid coverage they had expires at the end of their pregnancy.
Medicare-related coverage is where Medicaid will pay for Medicare premiums. This might also include payments for Medicare coinsurance and deductible.
Medicaid eligibility in Virginia?
Before you find out how to apply for Medicaid in Virginia you should confirm if you are eligible. Medicaid may be able to provide you with free or low-cost care depending on your income and family size.
Eligibility requirements for Medicaid have to be met before you can qualify for the program. To be eligible for Medicaid in Virginia, you have to belong to one of the designated patient groups. Without this qualification, you will not be eligible for the program. Those medical groups are:
- Pregnant women
- Parents or caretakers of relatives
- Adults between the ages of 21 and 64 who suffer from a mental illness
- Other adults who qualify
- Adults between the ages of 18 and 26 who are former foster children
You must also be a resident of Virginia who has a valid state ID. You will also need to provide your Social Security number and have documents proving that you are a US citizen. Aside from these things, if you are a former foster child, suffering from a disability or mental illness, you will need to provide documentation regarding these things.
How Much Does Medicaid Cost in Virginia?
Cost estimates will vary from person to person and the health services needed will also be a factor. If you have a copay, they are typically small and most of the time do not exceed $30. Visits to the clinic, doctor, or eye doctor cost as little as $1.
Things like outpatient hospital visits, home health visits, or rehab cost as little as $3. If you are admitted to the hospital, the cost will be $100.
Cost and Coverage of Medicaid in Virginia – Medicaid services that may be provided include care for babies, dental, durable medical equipment and supplies, early and periodic screening, diagnosis and treatment, family planning and birth control, long-term care, prescription drugs, clinic services, community-based residential services, and mental health services.
10 Things to Know About Medicaid
1. Medicaid is the nation’s public health insurance program for people with low income.
Medicaid is a government-run healthcare program for low-income people in the United States. One out of every five Americans is covered by Medicaid, which includes many people with complex and expensive healthcare needs. The program is the primary source of long-term care insurance in the United States.
The vast majority of Medicaid recipients do not have other affordable health insurance options. Medicaid covers a wide range of health services and keeps out-of-pocket costs to a minimum.
Medicaid accounts for nearly a fifth of all personal healthcare spending in the United States, funding hospitals, community health centers, physicians, nursing homes, and health-care-related jobs.
Title XIX of the Social Security Act and a large body of federal regulations govern the program, defining federal Medicaid requirements and state options and authorities.
The Centers for Medicare and Medicaid Services (CMS) within the Department of Health and Human Services (HHS) is responsible for implementing Medicaid.
2. Medicaid is structured as a federal-state partnership.
States administer Medicaid programs under federal guidelines and have discretion over who is covered, what services are covered, how health care is delivered, and how physicians and hospitals are paid.
States can also get Section 1115 waivers to test and implement approaches that aren’t required by federal law but that the Secretary of HHS determines are necessary to achieve the program’s goals. As a result of this flexibility, state Medicaid programs differ significantly.
The Medicaid entitlement is based on two guarantees: first, all Americans who meet Medicaid eligibility requirements are guaranteed coverage, and second, states are guaranteed federal matching dollars without a cap for qualified services provided to eligible enrollees.
The match rate for most Medicaid enrollees is determined by a formula in the law that provides a match of at least 50% and provides a higher federal match rate for poorer states.
3. Medicaid coverage has evolved.
Medicaid eligibility for parents, children, the poor aged, blind, and people with disabilities was tied to cash assistance (either Aid to Families with Dependent Children (AFDC) or federal Supplemental Security Income (SSI) starting in 1972) under the original 1965 Medicaid law.
States may choose to provide coverage at income levels higher than those eligible for cash assistance.
Congress has gradually increased federal minimum requirements and provided states with new coverage options, particularly for children, pregnant women, and people with disabilities. Congress also mandated that Medicaid assist low-income Medicare beneficiaries with premiums and cost-sharing, as well as allowing states to offer a “buy-in” option to Medicaid for working people with disabilities.
In 1996, the link between Medicaid eligibility and welfare was severed, and in 1997, the Children’s Health Insurance Program (CHIP) was established to cover low-income children above the Medicaid cut-off with an enhanced federal match rate.
States conducted outreach campaigns and simplified enrollment procedures to enroll eligible children in both Medicaid and CHIP for the first time after these policy changes. Expansions in Medicaid coverage of children marked the beginning of later reforms that recast Medicaid as an income-based health coverage program.
In 2010, as part of a broader health coverage initiative, the Affordable Care Act (ACA) expanded Medicaid to nonelderly adults with income up to 138% FPL ($17,236 for an individual in 2019) with enhanced federal matching funds.
Before the ACA, individuals had to be categorically eligible and meet income standards to qualify for Medicaid leaving most low-income adults without coverage options as income eligibility for parents was well below the federal poverty level in most states and federal law excluded adults without dependent children from the program no matter how poor.
The ACA changes effectively eliminated categorical eligibility and allowed adults without dependent children to be covered; however, as a result of a 2012 Supreme Court ruling, the ACA Medicaid expansion is effectively optional for states. Under the ACA, all states were required to modernize and streamline Medicaid eligibility and enrollment processes.
Expansions of Medicaid have resulted in historic reductions in the share of children without coverage and, in the states adopting the ACA Medicaid expansion, sharp declines in the share of adults without coverage. Many Medicaid adults are working, but few have access to employer coverage, and before the ACA had no options for affordable coverage.
4. Medicaid covers 1 in 5 Americans and serves diverse populations
Medicaid serves as a high-risk pool for the private insurance market, providing health and long-term care to millions of America’s poorest and most vulnerable citizens.
It covers over 75 million low-income Americans in the fiscal year 2017. As of February 2019, 37 states had enacted Medicaid expansion legislation.
According to data from FY 2017 (when fewer states had adopted the expansion), 12.6 million people were added to the expansion group. Children make up more than four out of ten (43%) of all Medicaid enrollees, while the elderly and people with disabilities make up about one out of every four enrollees.
Medicaid plays an especially critical role for certain populations covering: nearly half of all births in the typical state; 83% of poor children; 48% of children with special health care needs and 45% of nonelderly adults with disabilities (such as physical disabilities, developmental disabilities such as autism, traumatic brain injury, serious mental illness, and Alzheimer’s disease); and more than six in ten nursing home residents.
States can opt to provide Medicaid for children with significant disabilities in higher-income families to fill gaps in private health insurance and limit out-of-pocket financial burden.
Medicaid also assists nearly 1 in 5 Medicare beneficiaries with their Medicare premiums and cost-sharing and provides many of them with benefits not covered by Medicare, especially long-term care.
5. Medicaid covers a broad range of health and long-term care services
Virginia Medicaid covers a wide range of services to meet the diverse needs of the people it helps. Many states choose to cover optional services such as prescription drugs, physical therapy, eyeglasses, and dental care in addition to the federally mandated services.
The ACA’s ten “essential health benefits,” which include preventive services and expanded mental health and substance use treatment services, are included in coverage for Medicaid expansion adults.
Medicaid plays a critical role in combating the opioid epidemic and in connecting Medicaid beneficiaries to behavioral health services in general. Medicaid provides comprehensive benefits for children, known as Early Periodic Screening Diagnosis and Treatment (EPSDT) services. EPSDT is especially important for children with disabilities because private insurance is often inadequate to meet their needs.
Unlike commercial health insurance and Medicare, Medicaid also covers long-term care including both nursing home care and many homes and community-based long-term services and supports.
More than half of all Medicaid spending for long-term care is now for services provided in the home or community that enable seniors and people with disabilities to live independently rather than in institutions.
Given that Medicaid and CHIP enrollees have limited ability to pay out-of-pocket costs due to their modest incomes, federal rules prohibit states from charging premiums in Medicaid for beneficiaries with income less than 150% FPL, prohibit or limit cost-sharing for some populations and services, and limit total out-of-pocket costs to no more than 5% of family income.
Some states have obtained waivers to charge higher premiums and cost-sharing than allowed under federal rules. Many of these waivers target expansion adults but some also apply to other groups eligible through traditional eligibility pathways.
6. Most Medicaid enrollees get care through privately managed care plans
Over two-thirds of Medicaid beneficiaries are enrolled in private managed care plans that contract with states to provide comprehensive services, and others receive their care in the fee-for-service system. Managed-care plans are responsible for ensuring access to Medicaid services through their networks of providers and are at financial risk for their costs.
In the past, states limited managed care to children and families, but they are increasingly expanding managed care to individuals with complex needs.
Close to half the states now cover long-term services and support through risk-based managed care arrangements. Most states are engaged in a variety of delivery systems and payment reforms to control costs and improve quality including implementation of patient-centered medical homes, better integration of physical and behavioral health care, and development of “value-based purchasing” approaches that tie Medicaid provider payments to health outcomes and other performance metrics.
Community health centers are a key source of primary care, and safety-net hospitals, including public hospitals and academic medical centers, provide a lot of emergency and inpatient hospital care for Medicaid enrollees.
Medicaid covers a continuum of long-term services and supports ranging from home and community-based services (HCBS) that allow persons to live independently in their own homes or other community settings to institutional care provided in nursing facilities (NFs) and intermediate care facilities for individuals with intellectual disabilities (ICF-IDs).
In FY 2016, HCBS represented 57 percent of total Medicaid expenditures on LTSS while institutional LTSS represented 43 percent. This is a dramatic shift from 1995 (two decades earlier) when institutional settings accounted for 82 percent of national Medicaid LTSS expenditures.
7. Medicaid facilitates access to care
A large body of research shows that Medicaid beneficiaries have far better access to care than the uninsured and are less likely to postpone or go without needed care due to cost. Moreover, rates of access to care and satisfaction with care among Medicaid enrollees are comparable to rates for people with private insurance. Medicaid coverage of low-income pregnant women and children has contributed to dramatic declines in infant and child mortality in the U.S.
A growing body of research indicates that Medicaid eligibility during childhood is associated with reduced teen mortality, improved long-run educational attainment, reduced disability, and lower rates of hospitalization and emergency department visits in later life. Benefits also include second-order fiscal effects such as increased tax collections due to higher earnings in adulthood.
Research findings show that state Medicaid expansions to adults are associated with increased access to care, improved self-reported health, and reduced mortality among adults.
Gaps in access to certain providers, especially psychiatrists, some specialists, and dentists, are ongoing challenges in Medicaid and often in the health system more broadly due to overall provider shortages, and geographic maldistribution of health care providers.
However, low Medicaid payment rates have long been associated with lower physician participation in Medicaid, especially among specialists. Managed-care plans, which now serve most Medicaid beneficiaries, are responsible under their contracts with states for ensuring adequate provider networks.
There is no evidence that physician participation in Medicaid is declining. In a 2015 survey, 4 in 10 primary care providers who accepted Medicaid reported seeing an increased number of Medicaid patients since January 2014, when the coverage expansions in the ACA took full effect.
Medicaid covers people who are struggling with opioid addiction and enhances state capacity to provide access to early interventions and treatment services. The Medicaid expansion, with enhanced federal funding, has provided states with additional resources to cover many adults with addictions who were previously excluded from the program. Medicaid covers 4 in 10 nonelderly adults with opioid addiction.
8. Medicaid is jointly financed by states and the federal government
It is financed jointly by the federal government and states. The federal government matches state Medicaid spending. The federal match rate varies by state based on a federal formula and ranges from a minimum of 50% to nearly 75% in the poorest state. Under the ACA, the federal match rate for adults newly eligible was 100% for 2014-2016, phasing down gradually to 90% in 2020 and thereafter (93% in 2019).
The federal matching structure provides states with resources for coverage of their low-income residents and also permits state Medicaid programs to respond to demographic and economic shifts, changing coverage needs, technological innovations, public health emergencies such as the opioid addiction crisis, and disasters, and other events beyond states’ control.
The guaranteed availability of federal Medicaid matching funds eases budgetary pressures on states during recessionary periods when enrollment rises. Federal matching rates do not automatically adjust to economic shifts but Congress has twice raised them temporarily during downturns to strengthen support for states.
Total federal and state Medicaid spending was $577 billion in FY 2017. Medicaid is the third-largest domestic program in the federal budget, after Social Security and Medicare, accounting for 9.5% of federal spending in FY 2017. In 2017, Medicaid was the second-largest item in state budgets, after elementary and secondary education.
Federal Medicaid matching funds are the largest source of federal revenue (55.1%) in state budgets. Accounting for state and federal funds, Medicaid accounts for 26.5% of total state spending. Because Medicaid plays a large role in state budgets, states have an interest in cost containment and program integrity.
Enrollment and spending increased significantly following the implementation of the ACA, but have moderated in more recent years. While slower caseload growth helped to mitigate Medicaid spending growth in FYs 2018 and 2019, higher costs for prescription drugs, long-term services and supports and behavioral health services, and policy decisions to implement targeted provider rate increases were cited as factors putting upward pressures on Medicaid spending.
9. Medicaid spending is concentrated on the elderly and people with disabilities
Seniors and people with disabilities makeup Medicaid 1 in 4 beneficiaries but account for almost two-thirds of Medicaid spending, reflecting high per enrollee costs for both acute and long-term care. Medicaid is the primary payer for institutional and community-based long-term services and support – as there is limited coverage under Medicare and few affordable options in the private insurance market.
Over half of Medicaid spending is attributable to the highest-cost five percent of enrollees. However, on a per-enrollee basis, Medicaid is low-cost compared to private insurance, largely due to lower Medicaid payment rates for providers.
Analysis shows that if adult Medicaid enrollees had job-based coverage instead, their average health care costs would be more than 25% higher. Medicaid spending per enrollee has also been growing more slowly than private insurance premiums and other health spending benchmarks.
The majority of the public holds favorable views of Medicaid.
Public opinion polling suggests that Medicaid has broad support. Seven in ten Americans say they have ever had a connection with Medicaid including three in ten who were ever covered themselves. Even across political parties, majorities have a favorable opinion of Medicaid and say that the program is working well.
In addition, polling shows that few Americans want decreases in federal Medicaid funding. In addition to broad-based support, Medicaid has very strong support among those who are disproportionately served by Medicaid including children with special health care needs, seniors, and people with disabilities.
How to apply for Medicaid in Virginia?
There are a variety of ways to enroll in Medicaid in Virginia. You can:
Apply online via healthcare.gov, which is Virginia’s health insurance marketplace.
Fill out the online application at www.commonhelp.virginia.gov
Apply over the phone by calling the Cover Virginia Call Center at 1-855-242-8282 (TDD: 1-888-221-1590). Help is available Monday to Friday, 8:00 am to 7:00 pm, and Saturday, 9:00 am to 12:00 pm.
Complete a paper application (English version; Spanish version) and mail it in or drop it off at your local Department of Social Services Office.
If you also want to apply for other benefits, you can call the Virginia Department of Social Services Enterprise Call Center at 1-855-635-4370.
Medicaid covers Emergency Ambulance services when provided by providers licensed by the state. The patient must be transported in an appropriate vehicle that has been inspected and issued a permit by the state.
Dental services are a required service for most Medicaid-eligible individuals under the age of 21. States may elect to provide dental services to their adult Medicaid patients.
Medicare is a medical insurance program for people over 65 and younger disabled people and dialysis patients. Medicaid is an assistance program for low-income patients’ medical expenses.
Medicaid is a health coverage assistance program for children, adults, pregnant women, people with disabilities, and seniors who qualify due to low income or other criteria.
To find a doctor that accepts Medicare and Medicaid payments, you may want to visit the Centers For Medicare and Medicaid Services’ Physician Compare. You can search by State, County, City, Zip Code, and doctor’s name and by the name of a Group Practice.
Millions of Americans, the majority of whom are working families, benefit from Medicaid’s comprehensive coverage and financial protection. Medicaid enrollees have access to care at rates comparable to those of people with private insurance, despite their low income.
So, if you live in Virginia and are eligible for Medicaid, this will show you how to apply for Medicaid in Virginia.