Medicaid and FAMIS Plus (Medicaid coverage for children) are programs that help pay for medical care. To be eligible for Medicaid or FAMIS Plus you must have limited income and resources (things that you or someone in your household own) and you must be in one of the groups of people covered by Medicaid. Some groups covered by Medicaid are: pregnant women, children, parents who have children under age 18 in the home, people with disabilities, and people age 65 and older. Each group has its own eligibility rules but all people within the same group are treated the same. Medicaid is not designed to help everyone with every medical expense.
Medicaid and FAMIS Plus are programs paid for by the state and federal governments. In Virginia, the Department of Medical Assistance Services (DMAS) manages the Medicaid and FAMIS Plus programs. The local Department of Social Services (DSS) agencies take applications and determine eligibility for Medicaid and FAMIS Plus.
Medicaid has three types of benefits:
• Full coverage – Provides all of the Medicaid benefits including doctor, hospital, and pharmacy services. Individuals enrolled in Medicare Part A and or Part B receive pharmacy coverage through Medicare Part D.
• Limited coverage – Provides coverage for either a limited time period or coverage of limited services. Time limited coverage may include people who have to meet a Medicaid “spenddown” to be eligible for Medicaid. Coverage of limited services includes the Plan First program which covers family planning services only for individuals who are not eligible for full Medicaid coverage.
• Medicare Savings Programs – Provides Medicaid payment of Medicare premiums; may also include payment of Medicare’s deductible and coinsurance, up to Medicaid’s maximum payments.
How Do I Apply?
To apply for Medicaid and FAMIS Plus, contact the local DSS agency in the city or county where you live to request an application. The phone number for your local DSS can be found in the blue pages of your phone book, by contacting the Virginia Information and Referral hotline by dialing 211 or on-line at www.dss.virginia.gov/localagency. In addition, some hospitals have a Medicaid office where applications can be turned in.
An application must be signed by the person who needs assistance unless it is completed and signed by the applicant’s legal guardian, conservator, attorney-in-fact, or authorized representative. A parent, guardian, authorized adult representative, or adult relative with whom the child lives must sign applications for children under the age of 18. Children under the age of 18 cannot apply for themselves unless they are emancipated. However, parents who are under age 18 may apply for their own children. A face-to-face interview is not required.
Medicaid, FAMIS Plus and Plan First applications are available online and can be downloaded at www.dss.virginia.gov/benefit/me_famis/forms.cgi. FAMIS Plus applications may also be downloaded from www.famis.org and Plan First applications downloaded from www.planfirst.org. An online Application for Adult Medical Assistance is available on the web at https://jupiter.dss.state.va.us/VDAMedicaid/info/info.faces.
You may use the screening tool on the DSS website to help find out whether you may be eligible for Medicaid or FAMIS Plus, at www.dssiad.dss.state.va.us/EligibilityScreening, but the final decision must be made by an eligibility worker at your local DSS.
What Will I Be Asked?
If you are applying for Medicaid and FAMIS Plus you will be asked to give your Social Security number, declare that you live in Virginia, show proof of your identity and that you are a citizen of the U.S.. If you are not a U.S. citizen you must provide information and documents about your immigration status. Some immigrants can get full Medicaid coverage. Others can get only emergency services (see page 7). If you claim to be unable to work due to a disability, you will be asked whether you have applied for disability benefits. If you have not, you may be asked further information about your medical condition. If you claim to be pregnant, you will be asked to provide proof of pregnancy from a medical provider, such as the written medical results of your pregnancy test.
You must tell DSS about all income that you receive. Income includes earned income, such as wages, net profit from self-employment, as well as unearned income such as Social Security benefits, retirement pensions, veteran’s benefits, and child support. All of your income is added together and compared to the appropriate income limit set by the federal government to determine if you are income eligible for Medicaid or FAMIS Plus.
The income limits vary according to the covered group, the type of coverage and for some groups depending on the county or city where you live. Total “gross income” is used to determine income eligibility for Medicaid or FAMIS Plus. “Gross income” is the amount before taxes or any deductions are taken from your income. The amount of your debts or bills that you owe cannot be used in determining whether your income is within the Medicaid or FAMIS Plus income limits.
Pregnant women, children, aged, blind, and disabled individuals whose family income is above the established income limit may be eligible for a limited period of time in the Medically Needy group. The Medically Needy group allows you to use incurred/unpaid medical bills to “spend down” the difference between your income and the income limit, to become income eligible for
Medicaid or FAMIS Plus.
Children and pregnant women who have income over the Medicaid or FAMIS Plus income limits may qualify for the Family Access to Medical Insurance Security (FAMIS) or FAMIS MOMS program. For more information, call FAMIS toll free at 1-886-87FAMIS, (1-866-873-2647), or visit www.famis.org.Resources (Assets)
You may be required to tell the local DSS about all your resources (things that you or someone in your household own). There is no resource review for FAMIS Plus, certain pregnant women or Plan First. Resources include money on hand and in the bank, stocks, bonds, certificates of deposit, trusts, or pre-paid burial plans. Resources also include cars, boats, life insurance policies, and real property. If you are required to report resources, all resources must be reported; however, not all resources are counted in deciding eligibility for Medicaid. For
example, you must report all vehicles you own; however, one vehicle that you own is not counted as a resource for Medicaid purposes.
If your resources are worth more than the Medicaid resource limit when you apply for Medicaid coverage, you may become eligible for Medicaid by lowering the amount of your resources to or below the limit. A resource that is sold or given away for less than what it is worth may cause you to be found ineligible for Medicaid coverage of long-term care services for a certain period of time.