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Virginia Health Insurance

Virginia Medical Insurance Overview

Virginia offers many health insurance programs to its population that range from state programs, employer group policies, and individual plans.  Despite the availability of these policy options, many residents in Virginia residents are still uninsured, causing the state to perform poorly in terms of health problems like obesity, diabetes, and cancer related deaths.  With the enactment of the Affordable Care Act, Virginia residents can enjoy a wider variety of insurance options.  In addition, it is believed that throughout the year 2020, as many as 30 million U.S. residents will likely have insurance coverage as a result of the ACA coming into play.

Virginia’s Health Care Issues
The United Health Foundation ranks the state of Virginia in 21st place among the standings of the rest of the states in the country.  As such, the state exhibits its share of both strengths and weaknesses as listed below:

Low incidence of infectious disease
Low percentage of children in poverty
Low violent crime rate

Large disparity in health status by education level
High prevalence of smoking
Low per capita public health funding

Understanding Virginia’s Uninsured Population
As of 2014, the Kaiser Family Foundation reports that 10% of the population is without insurance coverage.  Of those numbers, 6% are children up to age 18 and 13% are between the ages of 19 and 64.

The Virginia Health Care Foundation reports the following statistics related to the uninsured population of Virginia in 2015:

Almost 15 % of residents under 65 are without medical insurance , equating to 995,000 uninsured residents of Virginia.

  • 71.1% of the non-elderly uninsured population are part of families that work.
  • 48.6% are part of families with one full-time worker.
  • 22.5% are part of families that have at least one part-time worker.
  • Over 40% of all uninsured residents live below the Federal Poverty Level
  • Over 70% of uninsured adults have incomes at or below 200% of the Federal Poverty Level.

Group Health Plans
In Virginia, companies are not required to offer insurance plans to their employees.  If insurance coverage is available through a group plan, it must be offered to all employees that are eligible.  Many employers operating in Virginia offer this coverage to only full-time employees.  Typically, the company offering the insurance plan can dictate the premium amounts that employees will be required to pay.

Under a group health plan, you can’t be denied coverage because you have a pre-existing condition.  However, you can be subjected to waiting out an exclusion period for the period of six months.  This does not apply to dependents covered under these policies that are under the age of 19.  Insurance companies that cover groups of under 50 participants cannot treat pregnancy as if it is a pre-existing condition.

Insurance companies are required to offer small businesses Small Employer Group Coverage. This is available to employers of small businesses regardless of the past employee group health claims or an employee’s health status.  Managed Care Health Insurance Plans and insurance companies that this coverage covers must also make Standard and Essential Health Benefit plans available.

Continuation Coverage
COBRA coverage allows for people who have lost their insurance coverage to apply for continuation coverage past their dates of employment.  This offers the former employee the ability to retain the same coverage that was provided under the group plan, but the premiums are higher because of the lack of employer contribution.
In order to qualify for COBRA coverage, the company that you’ve worked for must employ over 50 workers.

This is an expensive option for coverage, but it is a cheaper option than purchasing an individual health insurance plan.

Individual Health Plans
The Commonwealth of Virginia State Corporation Commission reveals that individual health insurance plans in Virginia are made available to individuals or their family members based on policy options and levels of coverage.  You can access this option if you are not able to receive coverage through the workplace.  When you purchase this particular plan type, you need to keep the associated costs in mind and you have to show that you are insurable.  When you apply for coverage, the insurance company will evaluate your eligibility during the process of underwriting.

Virginia Health Benefit Exchange
In 2012, the state’s former Governor McDonnell elected to allow the health benefits marketplace to be managed on a federal level while retaining the rights to plan management.  The current Governor McAuliffe is a strong supporter of the Affordable Care Act and has worked to expand Medicaid coverage in the state of Virginia.  Despite including legislation to support the expansion of Medicaid in 2015, lawmakers in the state showed no support.

Virginia State Insurance Programs
There are many publicly funded options for insurance in the state of Virginia.  They are listed below in detail and are offered based on income and other guidelines.

Virginia Medicaid
To get coverage under the Medicaid program, you must be a resident of Virginia, a U.S. citizen, be in need of health insurance assistance, and have a low income.  You must also be either be pregnant or the parent or caretaker of dependent children who are 19 and younger, or under 21 in foster care, are blind, disabled or over the age of 65.  Income requirements vary and depend on which group you fall into.  There are no enrollment fees associated with Medicaid coverage for eligible persons.  You may be charged a low co-payment amount for various services under this program.

Family Access to Medical Insurance Security (FAMIS)
This program is Virginia’s health insurance plan for children.  It provides affordable health care for kids in the state to keep them from becoming ill and provides care in the event they do become ill.

Covered services include:
Doctor’s visits
Dental care
Hospital stays
Emergency care services
Vision care
Labs and x-rays
Mental health care
Well child checkups

There are no enrollment fees to sign up and very small co-payments may be required for services.  Eligibility for this program is based on income guidelines located on the FAMIS website.

Family Access to Medical Insurance Security (FAMIS) MOMS
Under this program, pregnant women can receive health insurance coverage up to sixty days following the end of their pregnancy.  To be eligible, you must meet certain income guidelines as listed on the FAMIS MOMS website and be a resident of the state of Virginia and a U.S. citizen.

Under this program, there are no enrollment fees or associated costs for services provided to pregnant women and new moms up to two months following their child’s birth.

Family Access to Medical Insurance Security (FAMIS) Select
This program offers financial assistance for people who need help in paying for their group health insurance through their employer.  Before the family can enroll in this program, at least one dependent child must already be enrolled under the FAMIS program.  When using this program, you can see special health care providers that may otherwise be unavailable or out of the employer’s network of providers.  For more information on the benefits provided and the associated costs, see the FAMIS Select website.

Program of All-Inclusive Care for the Elderly (PACE)
PACE manages all the medical, social, and rehabilitative services to help residents 55 and older who should be placed in nursing care facilities to remain in their homes.

Health Insurance Premium Payment (HIPP)
In order to get HIPP coverage, you or a family member must be enrolled in the Medicaid program and receiving benefits.  This program provides reimbursements for family members who are covered under employer-sponsored health insurance plans.

Health Insurance Premium Payment (HIPP) for Kids
HIPP for Kids is similar to HIPP, but offers dependents aged 19 and under the availability of various benefits as long as they are covered under a parent’s group health plan.

Other Programs
The below programs are also available to residents of Virginia depending on income, citizenship, and other requirements:

Mental Health Case Management Program
Under this program, services are available to people who are eligible for Medicaid and have severe emotional or mental disorders that can impair their ability to function normally.  Eligible people are provided with a case manager who will work to determine their needs, help find healthcare providers and make appointments.

Smiles for Children
For children enrolled in FAMIS or FAMIS Plus, the Smiles for Children program offers an array of dental services.  This encourages regular dental checkups and there are no costs associated with the benefits provided.  Those using this program can only use dentists that are included.

DRS Personal Assistance Services (PAS) Program
This program helps pay for non-medical personal assistance services for people who have physical disabilities and are over the age of 18.  Under this program, individuals can receive help with services related to daily living that include getting dressed, bathing, eating and more.

Alzheimer’s Assisted Living Waiver
This plan covers persons who have been diagnosed with Alzheimer’s disease and are over the age of 55.  Those who are eligible for this program cannot be diagnosed with a serious mental illness or intellectual disability.

Day Support Waiver
This program covers people with intellectual disabilities and offers services to those persons who are six years old or younger and are at developmental risk.  It also covers individuals over the age of six who have been diagnosed with an intellectual disability.

Virginia High Risk Pool
Despite not having a high risk pool, Virginia does offer a pre-existing condition insurance plan (PCIP) that offers coverage to people who have been denied insurance coverage because of such a condition.  In order to qualify, you must be a United States citizen, have a pre-existing condition and have not had insurance coverage for six months prior to the application.

You will be ineligible for coverage under PCIP if you meet any of the following criteria:

  • Enrolled in a high risk pool in the state of Virginia
  • Have an insurance plan that offers limited benefits
  • Are otherwise covered by an insurance policy
  • Have coverage through Medicaid, Medicare or any other state-funded program
  • Have coverage through your workplace or through COBRA

The PCIP plan covers many different health care benefits, including primary and specialty care services along with hospital stays and prescription drug coverage.  This program also covers pre-existing conditions and preventative care services.  Monthly premium costs can differ depending on the applicant’s age and discounts on premiums or subsidies are not available.

Health Insurance Portability and Accountability Act (HIPAA)
Residents looking for should be aware of the significance of the Health Insurance Portability and Accountability Act (HIPAA) and the effect it has on health insurance companies. HIPAA brought many restrictions on insurance companies; especially with regard to their ability to reject coverage for people seeking to join a group health plan due to a pre-existing health condition. HIPAA puts limits on exclusion periods a group health provider can impose, and it also poses limitations on an insurance company’s ability to look back into the medical history of a new applicant.  HIPAA has made many strides forward in securing health insurance for many residents, but it does not require companies to offer a group health insurance plan to their workers.