The Virginia Medicaid eligibility manual, officially the Medical Assistance Eligibility Manual published by the Department of Medical Assistance Services (DMAS), is the rulebook every local Department of Social Services caseworker follows when deciding who qualifies for Medicaid, FAMIS, and related programs. Because the same standards bind every caseworker in the Commonwealth, knowing what the manual requires gives you a real advantage when applying, renewing, or appealing a decision.
Who Qualifies for Virginia Medicaid
The manual sorts applicants into eligibility groups. The group you fall into determines whether an asset test applies, how income is counted, and what documentation you have to produce.
Adults Aged 19 to 64
Virginia expanded Medicaid in 2019. Adults between 19 and 64 can qualify based on income alone if their household’s modified adjusted gross income is at or below 138% of the Federal Poverty Level.1Department of Medical Assistance Services. Adults Aged 19-64 For 2026, that works out to roughly $22,025 a year for a single adult and about $45,540 for a family of four.2HHS ASPE. 2026 Poverty Guidelines – 48 Contiguous States There is no asset test for this group, and caseworkers verify income electronically through federal data hubs.
Aged, Blind, or Disabled
If you are 65 or older or meet the Social Security Administration’s definition of blindness or disability, you fall under the Aged, Blind, or Disabled (ABD) classification. ABD applicants face both income and asset tests. The asset limit is $2,000 for a single person and $3,000 for a married couple. Your primary home, one vehicle, and certain burial funds are not counted. If your income is above the standard limit but you have steep medical costs, you may still qualify through a medically needy spend-down, where unpaid medical bills reduce your countable income to the qualifying level for a temporary coverage period.3Department of Medical Assistance Services. Aged, Blind, or Disabled
Children and Pregnant Applicants
Children have two pathways. FAMIS Plus covers children in households with income up to 148% of the Federal Poverty Level under Medicaid, and FAMIS covers children in families earning up to 205% FPL. Both thresholds include a built-in 5% income disregard.4Virginia Health Care Foundation. Virginia Medicaid and FAMIS Income Chart – January 2026 Pregnant individuals can qualify for Medicaid or FAMIS MOMS regardless of immigration status.5CoverVA. Health Coverage for Noncitizens
Noncitizens
Children under 19 must be lawfully residing in the United States to qualify for Medicaid or FAMIS, though children who have applied for asylum or special immigrant juvenile status may also meet the rules. Noncitizens without eligible immigration status who otherwise meet Medicaid requirements can still receive coverage limited to emergency services.5CoverVA. Health Coverage for Noncitizens Virginia’s noncitizen eligibility rules are scheduled to change on October 1, 2026, so check CoverVA for updates as that date approaches.
What Documents You Need
DMAS needs enough information to verify your identity, residency, and finances. The application asks for your full legal name, date of birth, Social Security number (or immigration document number for lawful immigrants), employer and income information such as pay stubs or W-2s, any current health insurance policy numbers, and details about job-based insurance available to your household.6Department of Medical Assistance Services. Applying for Medicaid
Residency can be established with a utility bill, a lease or rental agreement, or a valid Virginia driver’s license.7Virginia Code Commission. Virginia Administrative Code 12VAC5-195-90 – Proof of Residency List every member of your tax-filing household on the application, even those who are not seeking coverage, because household size drives the income threshold. Report gross monthly income accurately; mismatches with federal databases cause delays.
ABD and long-term care applicants face a more intensive documentation process because asset limits apply. Expect to provide bank statements, information on any life insurance policies with cash value, and records of real property beyond your primary home. Expansion-group adults and children do not have an asset test, so income verification alone determines eligibility.
How to Apply and How Long It Takes
You can submit a Virginia Medicaid application through several channels. The CommonHelp portal at commonhelp.virginia.gov handles online applications and gives you a tracking number confirming receipt.8Virginia CommonHelp. Virginia CommonHelp You can also apply by phone through CoverVA at (855) 242-8282, by mail to your local Department of Social Services office, or in person at that office.9CoverVA. How to Apply
Federal regulations cap processing at 45 calendar days for standard applications and 90 calendar days for disability-based applications, which take longer because of the medical review.10eCFR. 42 CFR 435.912 – Timely Determination of Eligibility During that window, a caseworker may ask for additional documents. The manual requires that you be given at least 10 calendar days to return any requested verification.11Department of Medical Assistance Services. Chapter M15 Entitlement Policy and Procedures Miss that deadline and your application can be denied as incomplete.
Once the review finishes, you receive a Notice of Action. An approval tells you the effective date of coverage and which program you have been assigned to. A denial must explain the legal basis for the decision and tell you how to appeal.
Retroactive Coverage
Virginia Medicaid can pay for services you received up to three months before your application date, as long as you would have qualified in those earlier months. The coverage is not automatic. You request it by answering the appropriate question on the application.12Virginia Code Commission. Virginia Administrative Code 12VAC30-110-1160 – Retroactive Spenddown and Countable Income If you apply in April and are enrolled, outstanding bills from January, February, and March may be covered if you met eligibility during those months. The caseworker decides retroactive and prospective eligibility together and must provide written notice of both.
Keeping Coverage: Annual Renewals and Reported Changes
Coverage renews annually. DMAS first tries to renew your eligibility automatically using data it already has. If the local office can confirm you still qualify without needing anything from you, your coverage continues for another year and you get a notice in the mail confirming it.13Department of Medical Assistance Services. Renew Coverage or Report a Change
If the automatic check cannot confirm eligibility, you receive a paper renewal form by mail. Fill it out and return it, or complete the renewal online through CoverVA. Ignoring a renewal form is one of the most common reasons people lose Medicaid even when they still qualify. Separately, you must report changes in income, household size, or address within 10 calendar days of the change, no matter where you are in the renewal cycle.
Long-Term Care Rules That Catch Families Off Guard
Two rules in the manual apply only if you are seeking nursing home Medicaid or home and community-based waiver services. They do not apply to the expansion group or regular Medicaid, but families often assume they do, so it is worth knowing where the lines are drawn.
The 60-Month Look-Back
Virginia examines every asset transfer you made during the 60 months before applying for long-term care Medicaid. The point is to identify gifts, below-market sales, or other transfers that reduced your assets to meet the eligibility limit. When the state finds a disqualifying transfer, it calculates a penalty period during which you are ineligible for long-term care coverage. The penalty length equals the value of the transferred asset divided by a regional average daily private-pay nursing home cost. The monthly divisor is higher in Northern Virginia (localities such as Fairfax, Loudoun, and Prince William) than in the rest of the state, so the same transfer produces a shorter penalty in Northern Virginia and a longer one elsewhere.
Giving assets to children or moving money into someone else’s name within five years of a long-term care application can backfire, leaving you ineligible for Medicaid during a period when you no longer have assets to pay privately.
Estate Recovery After Death
Virginia does not place liens on the homes of living Medicaid recipients, but it does recover costs from the estates of deceased members who were 55 or older when they received Medicaid services.14Virginia Code Commission. Virginia Administrative Code 12VAC30-20-141 – Estate Recoveries “Estate” is defined broadly to include all real and personal property in which the person held any legal interest at death.
Recovery cannot begin until after the death of the surviving spouse, and only when there is no surviving child who is under 21, blind, or disabled. Several other exceptions apply:
- Medicare premiums, deductibles, and copayments paid for dual-eligible members on or after January 1, 2010 are not recovered.
- If you purchased a qualifying long-term care partnership insurance policy, assets equal to the benefits paid by that policy are shielded.
- Recovery is not pursued when administrative costs would exceed the amount recovered.
- DMAS may waive recovery for undue hardship to heirs or dependents.
If You’re Denied: Appeals and Fair Hearings
If your application is denied, your benefits are reduced, or a service is terminated, you can appeal. The deadline is tight. You must submit an appeal request to DMAS within 30 days of the date on the Notice of Action, plus 5 days for mailing. If the decision came from your managed care organization, you have to exhaust the MCO’s internal appeal first. After the MCO’s final decision, you have 120 days to request a state fair hearing with DMAS.15Department of Medical Assistance Services. Virginia Medicaid Client Appeals Process At A Glance
Appeals can be filed by mail, fax, phone, email, or in person with the DMAS Appeals Division. At the fair hearing, you or your authorized representative can examine witnesses and documents, give testimony, submit evidence, and make arguments. You have the right to an attorney or other representative, though one is not required.16Virginia Code Commission. Virginia Administrative Code 12VAC30-120-640 – State Fair Hearing Process
One rule trips people up constantly. If your appeal involves the termination or reduction of a service you were already receiving, you can ask that benefits continue during the hearing. That request has to be filed within 10 calendar days of the MCO’s final appeal decision mail date. Miss the window and your benefits stop while the appeal proceeds, which can leave you without critical services for weeks.16Virginia Code Commission. Virginia Administrative Code 12VAC30-120-640 – State Fair Hearing Process
If your situation is urgent, you can request an expedited appeal when a treating provider certifies that standard timelines could jeopardize your life, health, or ability to function. Expedited appeals must be resolved within 72 hours of receipt.16Virginia Code Commission. Virginia Administrative Code 12VAC30-120-640 – State Fair Hearing Process