Section-2-Eligibility-and-Application-5-2025 - Eligibility & Application

Sep 19, 2026

Eligibility & Application outlines non-financial and financial requirements for Virginia state-sponsored health insurance programs, including rules tied to age groups, Virginia residency, and assignment of third-party payment rights. It explains how eligibility is assessed through household size and income comparisons against program guidelines, then details application procedures by telephone, online via CommonHelp, and by paper. It also covers hospital presumptive eligibility, required verification documents, processing timelines, and case dispositions, plus notices for approvals and denials and related appeal materials.

LanguageEnglish

CategoryForms

FormatPDF

Pages52

Reading Time18 min

AccessFree to download

Eligibility & Application

Non-Financial Requirements

Financial Requirements

Application Procedures

Eligibility & Application Non-Financial Requirements Age .................................................................... 2.1 Virginia Residence ................................................ 2.1 Assignment of Third Party Payment Rights ......... 2.1-2.2 Social Security Number ......................................... 2.2 US Citizenship or Alien Status Requirements ...... 2.2-2.3 Other Insurance ................................................... 2.3 Residents of Institutions ....................................... 2.4 Cooperation with Child Support Enforcement ........... 2.4 Living with a Dependent Child ................................ 2.4 Financial Requirements Determining Household Size ............................ 2.5-2.8 Determining Household Income ......................2.8-2.10 Comparing Household Size and Income to Program Guidelines .............................................2.10-2.13 Application Procedures Who Can Apply .................................................. 2.14 How to Apply: By Telephone .........................................2.14-2.15 Online Via CommonHelp ..........................2.15-2.17 Virginia Insurance Marketplace.................2.17-2.18 By Paper ...............................................2.18-2.24 Hospital Presumptive Eligibility ........................ 2.25 Verification Documents ....................................... 2.26 Application Processing Timeframes ....................... 2.27 Disposition of the Case ....................................... 2.27 What Happens if the Application is Denied .....2.28-2.29 Application Step 5 .......................................2.31-2.32 LDSS Request for Verifications ......................2.33-2.34 • • • • • • SignUpNow Tool Kit Application Procedures(continued) Notice of Action-Approval ........................... 2.35-2.40 Notice of Action-Denial...............................2.41-2.43 HPE Approval Notice ........................................... 2.44 Medicaid/FAMIS Appeal Request Form ............2.45-2.47 Medicaid Manual Alien Code Chart .................2.48-2.50 SignUpNow Tool Kit• • • • • • Non-Financial Requirements In addition to financial requirements that must be met to qualify for Virginia’s state-sponsored health insurance programs, several non-financial requirements must also be met. An asterisk ( * ) indicates a rule that differs between the programs in the following list of non-financial eligibility requirements. A . Age FAMIS and FAMIS Plus are for children from birth up to their 19th birthday. Note: a pregnant individual under age 19 will be screened for the pregnancy programs (Medicaid for Pregnant Women, FAMIS MOMS or FAMIS Prenatal) not the children’s programs. Medicaid for Pregnant Women, FAMIS MOMS, and FAMIS Prenatal Coverage are for pregnant individuals of any age. Medicaid Expansion for Adults is for non-pregnant adults ages 19 to 64. Low Income Families With Children (LIFC) is for parents, or a caretaker relative of any age, who have the care of a dependent child under age 18 in their household. If they do have an 18 year old, they may still be eligible if that child is in a secondary school or equivalent level of vocational or technical training or GED program and is reasonably expected to complete the schooling/training before or in the month he/she attains age 19. A person applying for Medicaid for Former Foster Care (FFC) Youth must be between the ages of 19 and 26. They have to have aged out of statesponsored foster care and Medicaid in Virginia or another state. Plan First is primarily for men and women of child bearing age (19-64), but any age person may be eligible. B . Virginia Residence Applicants must be residents of Virginia. This means that they must live in, and intend to remain living in, Virginia. Self-declaration of residency is all that is required. (“Regardless of the individual’s immigration

FAQs

What non-financial requirements must applicants meet?

Applicants must meet non-financial eligibility requirements in addition to financial requirements, including age-related program rules, Virginia residency, and assignment of third-party payment rights.

How does the application determine household size and income eligibility?

The process determines household size and household income and compares both to program guidelines to establish eligibility.

What are the available ways to apply and what documents are needed?

Applicants can apply by telephone, online via CommonHelp, through the Virginia Insurance Marketplace, or by paper. Verification documents are required, and processing timelines and case dispositions are provided as part of the application process.

Sep 19, 2026

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