Medical Assistance Programs in Virginia

With recent ideological debate and partisan politics surrounding the reauthorization of the State Children's Health Insurance Program (SCHIP), you may be understandably confused as to how the government medical assistance programs work and who may be eligible.

Family Access to Medical Insurance Security (FAMIS)

FAMIS:

FAMIS is a joint state-federal assistance program which provides low-cost health insurance for children in families whose income is 133% to 200% Federal Poverty Level (FPL). To be eligible, the child (under age 19) must not currently have or have had health insurance in the past four months (some exceptions apply) and cannot be eligible for a state employee's health insurance plan. No resource (asset) evaluation is required. In 2007, the applicable income range is $18,308-$27,308 for family of 2, $22,837-$34,340 for family of 3, $27,465-$41,300 for family of 4, $32,093-$48,260 for family of 5, $36,722-$55,220 for family of 6.

FAMIS Plus:

FAMIS Plus is the Medicaid program for children in Virginia whose family income is at or below 133% FPL. No resource (asset) evaluation is required. In 2007, family income must be less than $18,308 for family of 2, $22,837 for family of 3, $27,465 for family of 4, $32,093 for family of 5, $36,722 for family of 6.

FAMIS Select:

FAMIS Select is a unique program which helps families pay for private or employer-sponsored health coverage. To be eligible, the family must have at least one child enrolled in a FAMIS program. Families are able to choose between FAMIS or FAMIS Select benefits. The eligible family will receive up to $100 per enrolled child to help pay for family health insurance coverage, although a minimum employer-sponsored premium contribution is required. The premium contribution amount received from FAMIS Select cannot exceed the family's share of health insurance premiums. No resource evaluation is required.

FAMIS MOMS:

FAMIS MOMS is the assistance program for pregnant women whose income is at or below 185% FPL. To be eligible, the pregnant woman must not have access to a state employee's health insurance plan. No resource (asset) evaluation is required. In 2007, family income must be less than $25,327 for you and the unborn child (family of 2), $31,765 for family of 3, $38,203 for family of 4, $44,641 for family of 5. For income eligibility, the unborn child counts as a family member.

Department of Medical Assistance Services (DMAS)

Medicaid:

Full Medicaid coverage is available to enrollees who are age 65 or older, blind, or disabled as determined by the Social Security Administration (SSA), and have an income at or below 80% FPL which is $8168 for an individual and $10,952 for a couple. Or the candidate may be an SSI enrollee with resources less than $4000 for an individual or $6000 for couple.

Limited Medicaid coverage is available to enrollees who are eligible for Medicare Part A and have resources less than $4000 for an individual or $6000 for a couple. If income is below 100% FPL ($10,210 for individual or $13,690 for couple), Medicaid pays Medicare Part A & Part B premiums, as well as coinsurance payments and deductible amounts which medicare doesn't pay. If income is less than 135% FPL ($13,784 for an individual or $18,482 for couple), Medicaid pays Medicare Part B premiums. If enrollee is disabled and employed with income less than 200% FPL ($20,420 for an individual or $27,380 for couple), Medicaid pays Medicare Part A premiums.

The Medicare enrollee whose income is below 135% FPL may be eligible to receive full or partial Medicare Part D Subsidy. For full subsidy, resources must not exceed $6000 for an individual or $9000 for couple. For partial subsidy, resources must not exceed $10,000 for an individual or $20,000 for couple.

Medicaid Works:

Medicaid Works is a Work Incentive (WIN) program available to disabled medicaid enrollees, under age 65, who are employed or wish to be employed. Initial eligibility requires that family income is below 80% FPL and that resources are limited to $2000 for an individual or $3000 for a couple. Continued participation requires that all earned income be deposited into a WIN account, maintaining $2000 minimum balance. This program allows the disabled Medicaid recipient to earn income up to $40,905 and to accumulate resources up to $27,577. Any amounts deposited into IRS-approved accounts do not count against resource limits and will not affect continued eligibility. Examples of IRS-approved accounts include IRA, MSA, MRA, education accounts or independence accounts.

If the Medicaid Works enrollee is unable to continue working, he/she may switch to the traditional Medicaid program. Resources accumulated in WIN accounts will not count against current eligibility and the enrollee will have one year to dispose of excess funds before impacting continued eligibility. Resources accumulated in IRS-approved accounts will not count against current or future eligibility.

Health Insurance Premiums Payment (HIPP):

Health Insurance Premiums Payment Program is a Medicaid program which reimburses some or all of an enrollee's share of employer-sponsored group health insurance premiums when it is determined to be more cost-effective to do so by Virginia DMAS.

Medically Needy Spenddown:

Spenddown - If an applicant meets all other Medicaid requirements, but has excess income, he/she can reduce excess income by incurring medical expenses, placing the applicant in the Medically Needy group. A deductible, or spenddown amount ranging from $1557-$2335 for an individual to $1982-$2815 for a couple, is calculated for a six-month period. Current and some previous unpaid medical bills may be used as deductions against the spenddown amount. Medicaid coverage starts only after the spenddown amount has been reduced to zero and continues through the end of the spenddown period after which the enrollee can reapply for another period of coverage.

Useful Definitions:

Income includes earned income, such as wages, and unearned income, such as Social Security, retirement benefits, veteran's benefits, child support, etc. Here's a handy chart of HHS Federal Poverty Income Limits.

All resources and assets MUST be reported, including money on hand, in the bank, or in a safe deposit box; stocks, bonds, CDs, trusts, and pre-paid burial plans; cars, boats, life insurance policies, and real property. Not all resources are counted against eligibility, including your personal residence, one vehicle, and resources necessary to self-support.