Virginia Health Insurance

Virginia offers its eight million residents the full range of health insurance options: They can get coverage through their employer; buy individual policies under the Affordable Care Act (ACA; aka Obamacare); or find coverage through Medicare, Medicaid or the Children’s Health Insurance Program (CHIP), if they qualify.¹

As of 2019, over half of Virginians were insured through their jobs, one of four were covered by Medicare or Medicaid, and one in 10 either had an individual ACA plan or military coverage. Almost 10% of residents remained uninsured.²

Two important events expanded coverage to more Virginians: Starting in 2013, the ACA lowered the uninsured rate from 12% to 8%.³ Then the state expanded Medicaid coverage to include nearly all low-income adults under age 65.

Read on to learn more about Virginia’s health insurance landscape and to explore your options for coverage as a resident of the state.

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Individual Health Insurance Options (ACA)

The introduction of ACA-compliant plans through Virginia’s Health Insurance Marketplace means that all insurers must provide “essential health benefits” such as inpatient hospital care, prescription drug coverage and free preventive care. For now, the Marketplace, called Cover Virginia, is operated by the federal government, but a state-run Marketplace is expected to open by 2023.⁴ 

You can buy these plans through healthcare.gov, the government’s ACA site. While there, be sure to see if you qualify for subsidies that will help pay your premiums if you qualify. About 88% of Virginia enrollees qualified for help.⁵  

Enrolling in Virginia’s Health Insurance (ACA) Marketplace 

Open enrollment for Virginia’s Health Insurance Marketplace runs from November 1 to January 15 each year and coverage starts the following January 1. To avoid a gap in your insurance, be sure to re-enroll during each year’s Open Enrollment Period (OEP) at healthcare.gov.

If you miss the OEP, you won’t be able to apply until the next one unless you have what’s called a “qualifying life event,” which is any situation that leaves you uninsured or changes the size of your family. In these cases, you’ll have a brief window called a Special Enrollment Period during which you can get insurance through the Marketplace.⁶  

The ACA Marketplace may be the best low-cost health insurance for many families and individuals because of the subsidies (as mentioned above, many Virginians qualify for these). 

Keep in mind, too, that you can access ACA Marketplace plans if you’re self-employed without any employees.

Nearly 262,000 Virginians – about 3.3% of the state’s population – signed up for coverage through Obamacare in 2021. Enrollment has dropped slightly more than one-third since 2018, partly due to the more comprehensive Medicaid coverage in the state.⁷  

Individual Health Insurance Companies in Virginia 

For 2022, 12 health insurance companies offered individual policies to Virginians through healthcare.gov, up from five in 2014.⁸ They include:  

• Aetna Life Insurance Company (new)
• Bright Health Insurance (new)
• CareFirst BlueChoice
• Cigna Health and Life Insurance Company
• Group Hospitalization and Medical Services
• HealthKeepers
• Innovation Health Plan (new)
• Kaiser Foundation Health Plan of the Mid-Atlantic States
• Optima Insurance Company
• Optima Health Plan – HMO
• Optimum Choice
• Oscar Insurance Company
• Piedmont Community Healthcare HMO

The ACA plans offered through healthcare.gov are also available outside the Marketplace and follow the same Open Enrollment Period. However, if you decide to go outside the Marketplace to buy a policy, you would forfeit access to subsidies. 

Virginia Health Insurance Premiums

The Marketplace organizes plans by tiers, each with the name of a metal: bronze, silver and gold. The more valuable the metal, the more the monthly premium will cost you and the more of the shared cost the insurance company will pay. The shared-cost coverage by the insurer is 60% for bronze, 70% for silver and 80% for gold.

While premiums for qualified plans had been rising in recent years, they dropped for 2020. As an example, here are the average costs a 40-year-old Virginian would pay for bronze, silver and gold plans:⁹ 

Average Monthly Premium for Virginia Marketplace Plans, by Metal Tier (for a 40-year-old person)

Plan Type	2019 Plan Year	2020 Plan Year	2021 Plan Year
Least-Expensive Bronze	$410	$380	$358
Least-Expensive Silver	$525	$506	$470
Least-Expensive Gold	$531	$510	$464

Subsidies are calculated on a “benchmark” silver plan, which is the second-lowest-cost for premiums for a silver plan. The benchmark for 2021 is $479, which is $42 per month less than in the previous year.¹⁰

Financial Help Through the ACA Marketplace

Within the Marketplace, your health insurance cost may not exceed 8.5% of your total household income, meaning you may be eligible for a subsidy to help with premiums no matter which metal tier you choose. In 2021, a family of three earning between $21,960 and $87,840 a year, for example, would qualify for subsidies.

Subsidies in Virginia Marketplace plans take the form of Advanced Premium Tax Credits (APTC) which are used to help pay your premium. The monthly APTC averaged $555 for the 87% of enrollees who received them. 

Here are a couple of examples of cost savings with subsidies:

• A 28-year-old living in Richmond who earns $24,000 a year could get a 2022 silver plan for $29 per month after subsidies. The same policy would cost $367 per month without premium tax credits, which cover 98.6% of the cost.¹¹ 

• A family of three living in Charlottesville with an income of $50,000 a year could pay $130 per month after subsidies for a 2022 silver plan. The same policy would cost $992 a month without premium tax credits, which cover 97% of the cost.¹²   

If you earn between 100% and 250% of FPL, purchase a silver plan on the Marketplace, and receive tax credits, you may also be eligible for Cost-Sharing Reductions (CSRs), which lower your out-of-pocket costs. In 2021, 37% of enrollees in Virginia Marketplace plans received CSRs.¹³ 

Help in shopping for and enrolling in the Virginia Health Insurance Marketplace is available by entering your location in the Cover Virginia website. 

Low-Cost and Free Healthcare Coverage Through Medicaid and CHIP (FAMIS)

Almost one-quarter of Virginia’s residents earn less than twice the federal poverty level (FPL).¹⁴ This makes them eligible to receive healthcare assistance through Medicaid and FAMIS (Family Access to Medical Insurance Security), the state’s programs designed to help low-income adults and their children. As of April 2021, some 1.5 million Virginians were enrolled in Medicaid, with more than 165,000 enrolled in CHIP.¹⁵ 

You’ll need to meet some income requirements to qualify for any of Virginia’s Medicaid programs. These are calculated as a percentage of the federal poverty level and will vary for different groups:¹⁶ 

• Parents: 138%
• Childless adults: 138%
• Pregnant women: 148%
• Children: 205%
• Seniors: 81%
• People with a disability: 81%

Cover Virginia has information about the state’s Medicaid and FAMIS programs for children, pregnant women and adults who qualify for the program; visit their website or call (855) 242-8282 to learn more.

Medicaid

Most Virginians covered by Medicaid are served through two managed care programs: Medallion 4.0 and Commonwealth Coordinated Care Plus. You must meet income limit requirements mentioned above to qualify.

If you’re an adult between the ages of 19 and 64, or a parent or caretaking adult relative living with a child under 19, you may pay no enrollment costs or monthly premiums for Medicaid coverage. For example, for a parent in a family of three, your household would have to earn less than 138% of the FPL to qualify; that FPL is $21,960, so household income must be less than $30,304. 

Pregnant women may qualify for Medicaid or the state’s FAMIS MOMS program. If you are eligible, you’ll receive full coverage during your pregnancy and delivery and for two months following your baby’s birth. Your baby is automatically eligible upon birth for health insurance for the first year of life. 

If you’re between 18 and 26 and a former foster youth who was still in foster care on your 18^th birthday and receiving Medicaid, you may continue to access Medicaid, no matter what your income.

Those who are age 65 or older, disabled and/or blind may qualify for full Medicaid coverage. Virginia’s medically needy spend-down program is available if your income exceeds the usual thresholds to qualify. It factors in medical bills compared to household size and income. Call Cover Virginia at (855) 242-8282 to learn more.

Children’s Health Insurance Program (CHIP)

In Virginia, two health coverage programs are available for children who qualify.¹⁷ The state’s Children’s Health Insurance Program (CHIP) is called Family Access to Medical Insurance Security (FAMIS) and covers children under age 19 who are uninsured and whose family income is between 133% and 200% of the federal poverty level. 

Children’s coverage under Medicaid is called FAMIS Plus. It covers children under age 19 who might have insurance and whose family has income under 133% of the federal poverty level. These programs have no enrollment costs or monthly premiums.

Under FAMIS PLUS, a family of four would qualify up to an income of $3,158 per month. Under FAMIS, a family of four with a monthly income of $4,528 could still qualify.

FAMIS has a $2 to $5 copayment for certain services, a $25 maximum for any service a child receives, and a $350 maximum per year. Members of FAMIS Plus never have copays.

Virginia Medicare Plans for Seniors and Disabled Individuals 

If you are over age 65, younger with a long-term disability, or have ALS (also known as Lou Gehrig’s disease) or end-stage renal disease, you can receive coverage through Medicare, the federal health insurance program.

Each year, the Open Enrollment Period for Medicare runs from October 15 through January 15. Nearly one in five Virginia residents receives Medicare benefits. Enrollees qualify by age (87%) or, before age 65, because of a disability (13%). In 2018, over 13% of Medicare beneficiaries in the state were also enrolled in Medicaid.¹⁸ 

Of Virginia’s 1.5 million Medicare beneficiaries, four out of five opt to receive their benefits from the federal government’s Original Medicare program, which includes Medicare Part A (hospital insurance) and Medicare Part B (medical insurance).¹⁹ 

The remaining beneficiaries prefer private Medicare Advantage plans. Medicare Advantage (also called Medicare Part C) offers additional benefits, such as Part D prescription drug coverage. (With Original Medicare, you would have to purchase a standalone Part D plan.) In 2020, about a dozen companies offer Medicare Advantage plans in Virginia.²⁰ 

Over 900,000 Virginians bought standalone Medicare Part D drug plans.²¹ In 2022, monthly plan premiums offered through 12 insurers range from $7.10 to $97.30, with an average of $45.70 per month.²² Nearly one-third had help with premiums and other costs.²³  

If you have Original Medicare, you can also choose from dozens of plans for Medicare Supplement Insurance (what’s called a Medigap policy) to cover costs that Medicare doesn’t pay.

The 10 available Medigap policy plans are standardized. The benefits for a plan are the same regardless of which insurer you choose, but premiums vary by company. Plans are lettered from A through N.

If you need help, the Virginia Insurance Counseling and Assistance Program (VICAP) can provide free orientation and assistance including access to Extra Help and Medicare Savings Programs that help with premiums. Call (800) 552-3402 for more information.

Buying Short-Term Health Insurance in Virginia 

Short-term health insurance can help fill a temporary gap in coverage, such as when you’ve missed the window to enroll in an ACA plan or find yourself between jobs.

Plans are currently available with initial terms up to 364 days, with possible renewals.²⁵ However, after July 1, 2021, new policies in Virginia will be restricted to a maximum of three months.

Keep in mind, that short-term health insurance plans — currently available from eight insurers — may not all be available throughout Virginia. Also, they aren’t subject to ACA’s rules regarding essential health benefits, so you may find that a policy doesn’t include all of these services. As you weigh up which policy is right for you, be sure to check all disclosures carefully to see what coverage is guaranteed.