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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
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 12.07.2022
3.1A&B S2 Case Management Services 05.16.2022
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 04.26.2022
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
3.2A 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 03.13.2023
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 12.06.2022
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
7.5 Provider Appeals 07.31.2020
CMS Electronic State Plan Sections - Eligibility and Enrollment 01.09.2023
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
Preprint Pages from Front of State Plan 08.29.2022
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
7.4 Medicaid Disaster Relief for the COVID-19 National Emergency 06.03.2022
3.1L 2 Alternative Benefit Plan - Adult Expansion Group 04.21.2022
3.1L 3 Alternative Benefit Plan - Medicaid Works 04.21.2022
7.7A COVID Vaccines, Testing, and Treatment 11.30.2022

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