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State Plan

Medicaid State Plan

The Virginia Medicaid state plan is an agreement between Virginia and the Federal government describing how Virginia administers its Medicaid program. It gives an assurance that a state will abide by Federal rules and may claim Federal matching funds for its program activities. The state plan sets out groups of individuals to be covered, services to be provided, methodologies for providers to be reimbursed and the administrative activities that are underway in Virginia.

Children's Health Insurance Program (CHIP) State Plan

The CHIP State Plan is separate from the Medicaid State Plan. The CHIP State Plan is filed in accordance with Title XXI of the Social Security Act and describes how the state uses both state and federal funds to provide child health assistance to uninsured, low-income children. Virginia's programs administered by DMAS under CHIP State Plan authority are:
  • Family Access to Medical Insurance Security (FAMIS) for children 
  • FAMIS Prenatal Coverage for eligible uninsured pregnant individuals regardless of immigration or citizenship status.

Chapter / Section Title Date
CMS Electronic State Plan Sections - Eligibility and Enrollment   05.01.2024
Preprint Pages from Front of State Plan   08.29.2022
1.1A Designation and Authority   07.31.2020
1.2A Organization and Administration - Single State Agency   07.31.2020
1.2B Organization and Administration - Organizational Chart   07.31.2020
1.2C Organization and Administration - Professional and Medical Supporting Staff   07.31.2020
1.2D Organization and Administration - Central Processing Unit   07.31.2020
2.1A Definition of Medicaid Health Maintenance Organizations   07.31.2020
2.1B HMOs - Quality Control and Utilization Review   07.31.2020
2.2A Groups Covered and Agencies Responsible for Eligibility Determinations   07.31.2020
2.2A S1 Reasonable Classification of Individuals Under the Age of 21, 20, 19, and 18   07.31.2020
2.2A S2 More Restrictive Categorical Eligibility Criteria   07.31.2020
2.6A Eligibility Conditions and Requirements   07.31.2020
2.6A S1 Income Eligibility Levels   07.31.2020
2.6A S2 Categorically Need Groups With Incomes Related to FPL   07.31.2020
2.6A S3 Limits on Amounts for Necessary Care Not Covered Under Medicaid   07.31.2020
2.6A S5 More Restrictive Methods of Treating Resources Than SSI Program   07.31.2020
2.6A S6 Standards for Optional State Supplementary Payments   07.31.2020
2.6A S7 Categorically Needs Covered Under Requirements More Restrictive than SSI   07.31.2020
2.6A S8 Resource Standards, More Liberal Income Disregards, More Liberal Methods of Treating Resources   07.31.2020
2.6A S9 Transfer of Resources   07.31.2020
2.6A S10 Consideration of Medicaid Qualifying Trust   07.31.2020
2.6A S11 Cost Effectiveness Methodology for COBRA Continuation   07.31.2020
2.6A S12 Variations from the Basic Personal Needs Allowance   07.31.2020
2.6A S13 Institutionalized Spouse   07.31.2020
2.6A S14 Eligibility Under Section 1931 of the Act   07.31.2020
2.6A S16 Asset Verification System   07.31.2020
2.6A S18 Adjustments to Newly Eligible Adult Population   07.31.2020
2.6B Standards for Optional State Supplementary Payments   07.31.2020
2.8A Requirements for Advance Directives   07.31.2020
3.1A Amount, Duration, and Scope - Categorically Needy   04.07.2022
3.1A S7 Medication Assisted Treatment   10.14.2021
3.1A&B S1 Amount, Duration, and Scope - Categorically and Medically Needy   05.15.2024
3.1A&B S2 Case Management Services   11.22.2023
3.1A&B S3 Requirements and Limits - Expanded Prenatal Care Services   07.31.2020
3.1A&B S5 Drugs or Drug Categories - Not Covered   07.31.2020
3.1A&B S6 Program of All-Inclusive Care for the Elderly   04.27.2023
3.1B Amount, Duration, and Scope - Medically Needy   04.07.2022
3.1B S1 Medication Assisted Treatment   10.14.2021
3.1C Standards Established and Methods Used to Assure High Quality   12.14.2021
3.1C S1 Nursing Facility Critera   07.31.2020
3.1D Methods of Providing Transportation   03.07.2022
3.1E Standards for the Coverage of Transplant Services   07.31.2020
3.1F Commonwealth Coordinated Care   07.31.2020
3.1L 2 Alternative Benefit Plan - Adult Expansion Group   04.21.2022
3.1L 3 Alternative Benefit Plan - Medicaid Works   04.21.2022
3.2A Coordination of Title XIX with Part A and B of Title XVIII   07.31.2020
4.03A Confidentiality and Disclosure of Information - Medicaid Applicants   07.31.2020
4.11A Standards - General & Special Hospitals, Convalescent & Nursing Homes   07.31.2020
4.14G Nursing Facility Resident Drug Utilization Review   07.31.2020
4.16A Cooperation with State Vocational Rehab Agency and Title V Agencies   07.31.2020
4.17A Lien Recoveries   07.31.2020
4.17C Estate Recoveries   07.31.2020
4.18A Cost Sharing - Categorically Needy & QMB   07.31.2020
4.18C Cost Sharing - Medically Needy & QMB   07.31.2020
4.19A Payment Rates - Inpatient Care - General   12.06.2022
4.19A S2 Payment Rates - Inpatient Care - Dispute Resolution for State-Operated Providers   07.31.2020
4.19A S3 Payment Rates - Inpatient Care - Per-Diem Methodology   07.31.2020
4.19A S4 Payment Rates - Inpatient Care - Outlier Payment Methodology   07.31.2020
4.19B Payment Rates - Other Types of Care - General   03.05.2024
4.19B S2 Payment Rates - Other Types of Care - Medicare Part A & B Deductible-Coinsurance   07.31.2020
4.19B S3 Payment Rates - Other Types of Care - Establishment of Rate Per Visit - Part 1   07.31.2020
4.19B S4 Payment Rates - Other Types of Care - Establishment of Rate Per Visit - Part 2   03.13.2023
4.19B S5 Payment Rates - Other Types of Care - Prospective Reimbursement for Rehab Agencies or CORFs   07.31.2020
4.19B S6 Payment Rates - Other Types of Care - Medicare Equivalent of Average Commercial Rate   07.31.2020
4.19B S7 Payment Rates - Other Types of Care - Primary Care Service Payment   07.31.2020
4.19C Reserving Beds During an Absence from an Inpatient Facility   07.31.2020
4.19D Establishing Payment Rates for Long-Term Care - Part 1   07.31.2020
4.19D S1 Establishing Payment Rates for Long-Term Care - Part 2   11.08.2023
4.19E Definition of a Claim by Service   07.31.2020
4.22A Third Party Liability - Identifying Liable Resources   07.31.2020
4.22B Third Party Liability - Payment of Claims   07.26.2022
4.22C Health Insurance Premium Payment for Kids Program   07.31.2020
4.30 Sanctions for Psychiatric Hospitals, MCOs, PCCMs   07.31.2020
4.32A System Procedure Requests to Other State Agencies   07.31.2020
4.33A Issuance of Medicaid Cards to Homeless Individuals   07.31.2020
4.34A Requirements for Advance Directives   07.31.2020
4.35A-K Enforcement of Compliance for Nursing Facilities   07.31.2020
4.39 Definition of Specialized Services   07.31.2020
4.39A Categorical Determinations   07.31.2020
4.40A-E Surveys by Department of Health   07.31.2020
4.42A Enforcement of False Claims Recovery Act   07.31.2020
7.2A Methods of Administration - Civil Rights   07.31.2020
7.4 Medicaid Disaster Relief for the COVID-19 National Emergency   06.03.2022
7.5 Provider Appeals   07.31.2020
Appendix 1 Nursing Home Payment System Appendix 1   07.31.2020
Appendix 2 Nursing Home Payment System Appendix 2   07.31.2020
Appendix 3 Nursing Home Payment System Appendix 3   07.31.2020
Appendix 4 Nursing Home Payment System Appendix 4   07.31.2020
Appendix 5 Nursing Home Payment System Appendix 5   07.31.2020
Appendix 6 Nursing Home Payment System Appendix 6   07.31.2020
Appendix 7 Nursing Home Payment System Appendix 7   07.31.2020
S10 MAGI-Based Income Methodologies   12.13.2013
S59 Individuals Eligible for Family Planning Services   04.01.2015
S88 Non-Financial Eligibility - State Residency   12.19.2013

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