Commonwealth of Virginia Medicaid: Eligibility and Long-Term Care

Virginia Medicaid eligibility and coverage depends on which group you fall into: adults 19 to 64 qualify with household income at or below 138% of the Federal Poverty Level, children and pregnant residents qualify up to 205%, and adults who are 65 or older, blind, or disabled qualify under stricter income and asset rules. Once enrolled, members receive hospital care, doctor visits, prescriptions, behavioral health, preventive care, adult dental, and, for those who need it, long-term services and supports. The program covers more than 1.8 million Virginians and is administered by the Department of Medical Assistance Services (DMAS).

Who Qualifies

Virginia sorts applicants into a handful of categories, and the category decides which income test, asset test, and benefit package applies to you.

Adults aged 19 to 64. This is the expansion group added in 2019. If your household income is at or below 138% of the Federal Poverty Level, you qualify for full coverage. Disability status, whether you have children, and pregnancy do not matter for this pathway.¹
Children under 19. Virginia’s Family Access to Medical Insurance Security (FAMIS) program provides no-cost coverage for children in households up to 205% of the FPL.²
Pregnant residents. Coverage is available up to 205% FPL through Medicaid for Pregnant Women or FAMIS MOMS. Benefits begin the month you apply, run through the pregnancy, and continue for 12 months after the pregnancy ends. A separate FAMIS Prenatal Coverage option provides 60 days of postpartum coverage instead of 12 months.³
Aged, blind, or disabled adults. People 65 and older, people with documented disabilities, and those who are blind qualify through Virginia’s ABD programs, which use different income and asset rules than the expansion group.⁴

2026 Income Limits in Dollars

Most adults and children are measured using Modified Adjusted Gross Income (MAGI), which is essentially the income reported on your federal tax return with a few adjustments.⁵ The 2026 Federal Poverty Level is $15,960 for a single person and $33,000 for a family of four.⁶

For expansion adults, the 138% ceiling works out to about $22,025 per year for one person or $45,540 for a household of four.¹ For children in FAMIS and pregnant residents in FAMIS MOMS, the 205% cutoff comes to roughly $32,718 for one person or $67,650 for a family of four.²

Asset Rules for Older and Disabled Applicants

ABD applicants face both an income test and an asset test. Countable resources generally cannot exceed $2,000 for a single person or $3,000 for a couple.⁴ Countable resources include bank accounts, stocks, bonds, and secondary real estate. Your primary home, one vehicle, and designated burial funds up to a set amount are typically excluded.

Income for ABD applicants is measured against Supplemental Security Income (SSI) standards, not MAGI. Those thresholds are lower, so an applicant under 65 whose income sits above SSI levels but below the expansion cutoff may actually find it easier to qualify through the expansion group.

Spousal Protections for Nursing Home Applicants

When one spouse enters a nursing home and applies for Medicaid, federal law protects the spouse still living at home. The community spouse can keep assets up to the Community Spouse Resource Allowance, which is $162,660 in 2026, and monthly income up to the Maximum Monthly Maintenance Needs Allowance, which is $4,066.50 in 2026. These figures exist so that paying for one spouse’s care does not impoverish the other.

If Your Income Is Too High: The Spend-Down

Virginia offers a medically needy pathway for people whose income exceeds the limit but who have significant medical expenses. You subtract qualifying medical costs from your income until you reach the eligibility threshold. The pathway is open to ABD applicants and certain other groups who meet non-financial requirements and stay within the resource limits.⁷

If you receive long-term services and supports, the spend-down is calculated in one-month periods and coverage starts on the first of the month you meet the threshold. If you do not, the period is six months, and coverage begins on the exact day your accumulated expenses close the gap between your income and the limit, then runs through the end of the six-month window.⁷

Qualifying expenses include hospital bills, prescriptions, doctor visits, behavioral health care, dental work, and health insurance premiums you pay out of pocket. Unpaid bills from earlier periods can also count if they were not already applied to a prior spend-down and you remain responsible for them.

What Virginia Medicaid Covers

Coverage includes the services federal law requires plus several optional benefits Virginia has chosen to add.⁸ In practical terms, members get:

Inpatient and outpatient hospital care
Doctor visits, specialist referrals, and lab work
Prescriptions filled at participating retail pharmacies
Behavioral health, including counseling, psychiatric evaluations, and substance use treatment
Physical, occupational, and speech therapy when medically necessary
Preventive care such as screenings, immunizations, and wellness visits
Emergency room and ambulance services

Children in FAMIS receive additional pediatric benefits including dental, vision, and well-child checkups.⁹ Pregnant members receive all prenatal and delivery services, with postpartum coverage continuing for up to 12 months.¹⁰

Adult Dental

Adult dental benefits are provided through the Cardinal Care Smiles program, managed by DentaQuest. Covered services include X-rays, exams, cleanings, fillings, root canals, gum treatment, dentures, and extractions.¹¹

Rides to Medical Appointments

Virginia Medicaid covers non-emergency medical transportation when you have no other way to get to appointments. The level of service ranges from a standard van or taxi to a wheelchair-accessible vehicle depending on medical need. Rides typically need to be booked at least five days ahead through your managed care plan or the state’s transportation broker. A free escort can ride along but cannot stay during the appointment. Members who have their own transportation may qualify for mileage reimbursement instead.

How to Apply

Applications are accepted through several channels:¹²

Online at commonhelp.virginia.gov¹³
By phone at the Cover Virginia Call Center, 833-522-5582, Monday through Friday 8 a.m. to 7 p.m. and Saturday 9 a.m. to noon
By mail or in person at your local Department of Social Services

Before starting, gather proof of U.S. citizenship or lawful immigration status such as a birth certificate, passport, or naturalization certificate.¹⁴ You will need a Social Security number for every household member applying, proof of Virginia residency such as utility bills or a lease, and income documentation such as recent pay stubs, W-2s, or tax returns. Self-employed applicants should have profit-and-loss statements or business records showing net income.

Federal rules require Virginia to process most applications within 45 days, or up to 90 days for applications involving a disability determination.¹⁵ Complete documentation up front is the single best way to avoid delays.

Annual Renewal

Coverage is reviewed every year, and missing a renewal is one of the most common reasons Virginians who still qualify lose their Medicaid.¹⁶ If DSS already has enough information on file, your renewal may be processed automatically and you will get a letter confirming continued coverage. If not, a paper renewal form arrives in the mail. You can respond online through CommonHelp, by phone at Cover Virginia at 1-855-242-8282, or by mailing the form to your local DSS office.

If you are found no longer eligible, the state must send a notice with the end date of your coverage, appeal instructions, and a referral to the federal Marketplace so you can look into other insurance.

Long-Term Care and Nursing Home Coverage

Virginia Medicaid pays for nursing home care and home-based alternatives for people who meet both financial and medical eligibility. It is the most expensive category of Medicaid spending and comes with the strictest rules.

Medical eligibility requires that you need the level of care a nursing facility provides. Virginia uses the Uniform Assessment Instrument to evaluate whether you can perform daily activities such as bathing, dressing, eating, and managing medications, and reviews your diagnoses, medications, and whether your home can safely support your care.

The Five-Year Look-Back

When you apply for long-term care Medicaid, the state reviews every asset transfer you made during the 60 months before your application. Anything you gave away or sold below fair market value is presumed to have been transferred to qualify for Medicaid, and the burden is on you to prove otherwise.¹⁷

A disqualifying transfer triggers a penalty period of ineligibility. The length is calculated by dividing the value of the transferred assets by the average monthly cost of private nursing home care in Virginia. Give away $100,000 in a state where the average is $10,000 per month, and you face roughly a 10-month penalty. An undue hardship waiver exists for cases where denying eligibility would cause severe financial harm, but these are not easy to obtain.¹⁷

Care at Home Instead of a Facility

Virginia’s CCC Plus Waiver funds home and community-based services for people who would otherwise need a nursing home. Covered services include personal care (agency-based or consumer-directed, meaning you hire and manage your own attendant), respite care for family caregivers, home modifications, assistive technology, and personal emergency response systems.¹⁸

Estate Recovery After Death

Federal law requires Virginia to recover Medicaid costs from the estates of deceased members who received certain services after turning 55, primarily long-term care in a nursing home or through a home-based waiver. The state can file a claim against the estate up to the total value of the Medicaid payments made.¹⁹

Recovery is blocked while a surviving spouse is alive, and also when the deceased leaves a surviving child under 21 or a child who is blind or disabled.²⁰ The state also will not pursue recovery if the administrative cost would exceed the amount recovered. An undue hardship waiver is available where recovery would cause substantial financial harm to the heirs or dependents.

If you purchased a qualified long-term care partnership insurance policy before needing Medicaid, Virginia will not seek recovery for costs the policy covered, which is why long-term care insurance bought well ahead of eligibility can meaningfully protect what you leave behind.²⁰

1
Department of Medical Assistance Services. Adults Aged 19-64
2
CoverVA. Medicaid for Children and FAMIS
3
CoverVA. Cardinal Care Pregnancy and Postpartum Coverage
4
CoverVA. Medicaid for Persons who are Aged, Blind, or Disabled
5
Centers for Medicare & Medicaid Services. Income Eligibility Using MAGI Rules
6
HHS ASPE. 2026 Poverty Guidelines – 48 Contiguous States
7
Cover Virginia. Cardinal Care Fact Sheet – Medically Needy Spenddown
8
Virginia Code Commission. 12VAC30-10-140 – Amount, Duration, and Scope of Services – Categorically Needy
9
Virginia Medicaid. FAMIS
10
Virginia Medicaid. Maternal and Child Health
11
Virginia Medicaid. Dental – Adults
12
Department of Medical Assistance Services. Applying for Medicaid
13
Virginia CommonHelp. Welcome to CommonHelp
14
Centers for Medicare & Medicaid Services. Medicaid Citizenship Guidelines
15
Department of Medical Assistance Services. Commonly Asked Questions
16
CoverVA. Renew My Coverage
17
Virginia Code Commission. 12VAC30-40-300 – Transfer of Resources
18
Virginia Medicaid. CCC Plus Waiver
19
Virginia Department of Medical Assistance Services. Estate Recovery Fact Sheet
20
Virginia Code Commission. 12VAC30-20-141 – Estate Recoveries