Can You Have Medicaid and Private Insurance in Virginia?

You can have both Medicaid and private insurance in Virginia at the same time. Federal law treats Medicaid as the payer of last resort, so your private plan pays first on every claim and Medicaid covers what’s left for services it would normally pay for.¹ Carrying an employer plan does not disqualify you, and in some situations Virginia will actually pay your share of the private premium for you.

How the Two Plans Pay Together

Your private insurer is always the primary payer. Providers must bill that insurer first, and Virginia’s Medicaid system will not process a claim until the invoice shows the private insurer has either paid or denied it.² Once the private payment or denial comes back, Medicaid steps in as the secondary payer and can cover the remaining balance up to its own payment schedule, including the deductibles, copays, and coinsurance your private plan would otherwise leave you owing.

If your private plan denies a service entirely but Medicaid covers it, such as certain behavioral health treatments or durable medical equipment, Medicaid pays as if it were the primary insurer for that service. There are also two carve-outs where Virginia pays on its own schedule without waiting on the private insurer: preventive pediatric services under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit, and situations involving child support enforcement, where Medicaid will pay after 100 days if the parent’s private insurer has not responded.²

A provider who takes Medicaid cannot refuse to treat you just because a third party might also owe payment for the service.¹

Does Having Private Insurance Affect Medicaid Eligibility?

Owning a private policy does not count against you. Eligibility turns on your category and your income, not on whether you also carry other coverage. How premiums factor into that income calculation depends on which group you fall into.

Most Adults and Children (MAGI)

Expansion adults ages 19 to 64, children, pregnant individuals, and parents or caretakers have income counted using Modified Adjusted Gross Income. Under MAGI, allowable deductions are limited to things like student loan interest, IRA contributions, HSA contributions, and certain self-employment expenses. Private health insurance premiums are not deductible.³ Paying for an employer plan will not lower the income Medicaid counts.

For expansion adults in 2026, Virginia’s limit is 138 percent of the federal poverty level: $22,025 per year ($1,836 per month) for one person, or $45,540 per year ($3,795 per month) for a family of four. Those figures already include a 5 percent FPL disregard.⁴ If your income is under the threshold for your household size, you qualify whether or not you also carry private insurance.

Aged, Blind, or Disabled Applicants (Non-MAGI)

If you qualify based on age 65 or older, blindness, or disability, Virginia uses a different income calculation that does let you subtract health insurance premiums, Medicare premiums, deductibles, coinsurance, and copayments from your countable income.⁵ For someone just over the income limit, those deductions can be what qualifies you.

Virginia also runs a Medically Needy Spenddown program for aged, blind, or disabled applicants whose income is too high for full Medicaid. You accumulate medical bills, including insurance premiums, up to a threshold, and coverage then kicks in for the rest of the coverage period.⁶ Report any premium increase promptly, since it may lower your countable income further.

HIPP: When Virginia Pays Your Private Premiums

If you qualify for Medicaid and also have access to employer-sponsored insurance, Virginia may pay all or part of your share of the premium through the Health Insurance Premium Payment program. DMAS runs two versions: HIPP for Kids and standard HIPP. Every application is evaluated for HIPP for Kids first, then for standard HIPP if the applicant does not qualify for the children’s version.⁷

HIPP for Kids requires that a family member under 19 be enrolled in full-coverage Medicaid, that the employer pay at least 40 percent of the premium, and that the plan’s deductibles stay below IRS high-deductible health plan limits. Standard HIPP has similar requirements but replaces the age rule with a cost-effectiveness test: Medicaid must find that paying your employer premium costs less than covering your care directly.⁸

Once you’re enrolled in HIPP, the employer plan becomes the first source of payment for your care, up to that plan’s limits, before Medicaid pays anything.⁹ You can apply through the HIPP Online Portal or call DMAS at 1-800-432-5924. Documents can also be emailed to HIPPcustomerservice@dmas.virginia.gov, faxed to 1-804-452-5447, or mailed to DMAS at 600 East Broad Street, Suite 1300, Richmond, VA 23219.

Reporting Your Private Coverage to Medicaid

You must tell Virginia about your private insurance within 10 days of any change, whether you’ve gained coverage, lost it, or switched plans.¹⁰ The state needs:

The insurance carrier’s name
Policy and group numbers from your card
The policyholder’s name
The effective date of the coverage or change

You can report through the Virginia CommonHelp portal or contact your caseworker by phone, mail, or in person.¹¹ Once Virginia updates the third-party liability file, future claims flow through the correct primary-then-secondary order.

Miss the 10-day deadline and claims can be delayed or rejected because the system doesn’t match your current coverage. A provider who cannot bill correctly may try to collect from you directly. If your employer switches carriers during open enrollment, that still counts as a change you need to report, even though you didn’t actively pick a new plan.

If Medicaid Denies a Claim or Decision

You can appeal. Because most Virginia Medicaid members are in managed care, the process runs in two stages.

First, file an internal appeal with your managed care organization. The MCO must issue a written decision explaining its findings and telling you how to request a state fair hearing. You or an authorized representative can file by mail, fax, phone, email, or in person. Any communication asking for the case to be reviewed counts as an appeal request.¹²

After the MCO’s final internal decision, you can request a state fair hearing through the DMAS Appeals Division. To keep benefits running during the appeal, file within 10 calendar days of the mail date on the MCO’s decision.¹² If your treating provider finds that the standard timeline could seriously harm your health or ability to function, you can request an expedited appeal, which the MCO must resolve within 72 hours. You have the right to legal representation at both stages.

1
Office of the Law Revision Counsel. 42 U.S. Code 1396a – State Plans for Medical Assistance
2
Virginia Code Commission. Virginia Administrative Code 12VAC30-20-200 – Requirements for Third Party Liability; Payment of Claims
3
Virginia Department of Medical Assistance Services. Chapter M04 Modified Adjusted Gross Income
4
CoverVA. Adults 19-64 Years Old
5
Virginia Code Commission. Virginia Administrative Code 12VAC30-110-1050 – Required Deductions Based on Kinds of Services
6
Virginia Department of Medical Assistance Services. Programs and Guidelines
7
CoverVA. Health Insurance Premium Payment (HIPP) Programs
8
Virginia Department of Medical Assistance Services. Health Insurance Premium Program
9
Virginia Code Commission. Virginia Administrative Code 12VAC30-20-205 – Health Insurance Premium Payment for Kids
10
Virginia Department of Social Services. Benefits – Your Responsibilities
11
Commonwealth of Virginia. Virginia CommonHelp
12
Virginia Code Commission. Virginia Administrative Code 12VAC30-120-640 – State Fair Hearing Process