Cost and Coverage of Medicaid in Virginia

Virginia Medicaid coverage enables low-income individuals and families access to quality health care for free or at a low cost. The program is jointly funded by the State of Virginia and the federal government. Prices for different services and individuals vary greatly.

This section covers the following:

  • How much does Medicaid cost in Virginia?

  • What services are covered by Medicaid in Virginia?

  • What does Medicaid not cover in Virginia?

  • Types of Medicaid insurance in Virginia

How much does Medicaid cost in Virginia?

VA Medicaid cost estimates vary from individual to individual, and the health services sought. Some Medicaid members have to pay copays for various services.

The Medicaid cost estimates in VA for copays are small and mostly range from zero to $30.Eye examinations, physician office visits and clinic visits cost $1 per visit. Rehabilitation service, home health visits, other physician visits and outpatient hospital clinic cost $3. Inpatient hospital admission costs $100 per admission. How much is VA Medicaid for surgeries? Surgeries and other complicated health procedures come with higher copayments, and are based on the surgery.

The estimate Medicaid costs of copays change over time. Applicants can confirm with their health provider the cost of copays for the services needed. If the Medicaid beneficiary cannot afford copayment, a provider cannot deny medical services. However, he or she will still have to pay the copay later.

VA Medicaid services do not require copayments from members living in long-term care facilities, individuals receiving community or institutional-based long-term care services and members that are younger than 21 years of age.

How much is Medicaid in Virginia for primary services? Various health care services in Virginia do not come with copays. These include emergency room services, family planning services, pregnancy-related services and emergency services (including dialysis treatments).

What services are covered by Medicaid in Virginia?

Medicaid services offered in Virginia include:

  1. BabyCare. This is a case management program offered to high-risk pregnant women and infants up to age two. Services covered include substance abuse treatment services, homemaker services for members whose physicians have ordered complete bed rest, nutritional counseling and assessment and prenatal education on various topics, including parenting, preparing of childbirth, tobacco cessation, etc.

  2. Dental care services. VA Medicaid coverage pays for comprehensive dental services, including orthodontics, restorative/surgical procedures, preventive and diagnostics for members below 21 years. Permanent crowns, braces and dentures are also covered for members below 21 years.

  3. Durable medical equipment and Supplies (DME). Virginia Medicaid coverage includes medical equipment and supplies deemed medically necessary. Such equipment may include dialysis supplies and equipment, oxygen and respiratory supplies and equipment and ostomy services.

  4. Early and Periodic Screening, Diagnosis and Treatment (EPSDT). This is a preventive program that covers tests, immunizations and well-child examinations for members up to age 21.

  5. Family planning/Birth control.> VA Medicaid coverage includes services that prevent or delay pregnancy, including diagnosis, certain sterilization procedures, devices, supplies, drugs and treatments.

  6. Long term care. Medicaid Services covered may include care in an institutional setting such as an ICF for the mentally retarded or a nursing facility. Home and community based services waiver programs are also covered.

  7. Prescription drugs. With Medicaid, drugs are only covered when prescribed by a physician. The drugs must be in the Preferred Drug List of Medicaid. Copayments may apply.

  8. Clinic services. Virginia Medicaid services include visits to private or public clinic for diagnosis or treatment of various illnesses.

  9. Community-based residential services. These services are only covered for members that are below 21 years old. The Medicaid services include psychiatric treatment, therapeutic supervision, psycho-education and daily activities identified in the plan of care.

  10. Mental health services. VA Medicaid covers community mental health, including retardation services for members. Services covered include treatment, diagnosis and care of people with mental retardation, substance abuse and mental illness.

VA Medicaid services covered also include case management treatment in foster care, transportation services for medical treatment and care in inpatient psychiatric hospitals for members that are 65 years or older.

What does Medicaid not cover in Virginia?

What does Medicaid not cover in Virginia? Medicaid coverage pays for many services for members below 21 years of age. However, for adults, some services may not be covered, except with prior approval, or under special circumstances. Medicaid coverage in VA excludes the following services:

  • Psychological testing done for school or institution admission, educational diagnosis, school purposes or upon court order.

  • Administrative expenses such as copying records or completion of forms

  • Alcohol and drug abuse therapy (expect if offered to pregnant women through the Community Services Boards and under the BabyCare program, or as provided through EPSDT)

  • Any services meant to promote fertility, e.g. in-vitro fertilization, artificial insemination, etc.

  • Various drugs or treatments that have been proven not to be effective in managing your condition or that are offered by non-participating manufacturers

  • Experimental diagnostic or surgical procedures

  • Sitter services for the elderly or daycare (except in some community- and home-based service waivers)

  • Eyeglasses and dentures for members above 21 years

  • Medical services for items received from providers not enrolled in Virginia Medicaid

To fully answer the question, “What does Medicaid not cover in VA?” applicants must confirm with their health provider. Beneficiaries will have to pay the bill for any health services or items received that are not covered by Medicaid.

Types of Medicaid Insurance in Virginia

There are different types of Medicaid insurance from which applicants can choose. The types of Medicaid insurance chosen determine the premiums which enrollees pay. There are six managed care organizations (MCOs) that provide Medicaid health care services in Virginia. The MCOs include Aetna Better Health of Virginia, Anthem Health Keepers Plus, INTotal Health, Kaiser Permanente, Optima Family Care and VAPremiere.

All VA Medicaid coverage enrollees have to choose a MCO, otherwise one will be chosen for them. The network of providers, physicians and facilities where the medical services covered by Medicaid will be offered will depend on the MCO you choose.



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