Cardinal Care, Virginia’s combined Medicaid and FAMIS program, covers a broad set of health services at no cost to members: primary and specialist doctor visits, hospital and emergency care, prescription drugs, dental, vision, hearing, behavioral health and addiction treatment, maternity care, long-term services and supports, and rides to medical appointments. There are no copays, premiums, or deductibles for covered services. What follows walks through each category, with the places where coverage differs for children, adults, or pregnant members called out as they come up.
Doctor Visits, Hospital Care, and Prescriptions
Primary care visits are covered with no limit on how many you can have. Preventive care, vaccines, and specialist visits are included, along with emergency and urgent care. Members can also use telehealth for common conditions through secure video visits, and a 24/7 nurse advice line is available.
Virginia permanently eliminated copays for Medicaid and FAMIS members, so there is no out-of-pocket cost for doctor visits, hospital stays, prescriptions, or any other covered service.
Prescription drugs are covered through each health plan’s formulary, the list of approved medications. Because each of the five managed care plans maintains its own formulary, the specific drugs covered can vary. Some medications require prior authorization. You can confirm whether a drug is covered by contacting your health plan or checking the Virginia Medicaid Pharmacy Services website.
Dental Through Cardinal Care Smiles
Dental care is administered separately from medical coverage through Cardinal Care Smiles, run by DentaQuest. Members use their regular Medicaid or managed care ID card at dental appointments and can find participating dentists at DentaQuest.com or by calling 1-888-912-3456.
Children through age 20 get the fullest benefit: checkups, cleanings, fluoride treatments, sealants, X-rays, space maintainers, extractions, root canals, crowns, and braces with approval. Checkups, cleanings, and fluoride are covered every six months.
Adults on Medicaid are covered for X-rays, exams, cleanings, fillings, root canals, gum treatment, and dentures. Pregnant members age 21 and older receive cleanings, exams, fillings, crowns, root canals, X-rays, and anesthesia, but braces are not included. Pregnancy dental benefits end 12 months after the baby is born.
Vision and Hearing
Every Cardinal Care plan covers one annual eye exam and one annual hearing exam. Beyond the exams, the specifics depend on the plan. Allowances for glasses or contacts run from $100 to $200 per year. Hearing aid coverage runs from $1,500 to $2,000 annually, and most plans also cover 60 hearing aid batteries per year.
Children under 21 get more extensive vision and hearing coverage through the EPSDT benefit, which includes diagnosis and treatment of vision and hearing conditions as well as eyeglasses and hearing aids when medically necessary.
Behavioral Health and Substance Use Treatment
Mental health care under Cardinal Care spans outpatient therapy, intensive outpatient programs, partial hospitalization, and psychiatric services. Crisis services are available 24 hours a day, including the 988 Suicide and Crisis Lifeline, mobile crisis response teams, 23-hour crisis stabilization, and residential crisis stabilization units.
Youth ages 11 to 18 can receive multi-systemic therapy and functional family therapy. Adults with serious mental illness can access assertive community treatment, a 24/7 team-based model delivered in the community.
Substance use disorder treatment comes through the Addiction and Recovery Treatment Services benefit, which follows American Society of Addiction Medicine criteria. Coverage runs from early intervention and outpatient care through intensive outpatient, partial hospitalization, residential treatment, and medically managed inpatient care. Peer recovery support and office-based addiction treatment, including opioid treatment programs, are also covered.
For children under 21, applied behavior analysis therapy for autism is covered as part of EPSDT. The initial assessment has to be done in person by a licensed behavior analyst or licensed mental health professional. No physician referral letter is required to start services, though the provider must notify the child’s primary care physician. Requests for more than 20 hours per week require detailed documentation, and family involvement is required at least weekly.
Pregnancy, Postpartum, and Doula Services
Pregnant members receive comprehensive benefits during pregnancy and for 12 months after giving birth. Medicaid may also provide up to three months of retroactive coverage before the application date. Covered services include prenatal and postpartum care, dental benefits through Cardinal Care Smiles, breastfeeding support, and maternal mental health services.
Virginia also covers community doula services. State-certified doulas provide non-clinical support during pregnancy, labor and delivery, and the postpartum period, including childbirth education, lactation help, and referrals to health and social services. Prior authorization is not required, but a recommendation from a licensed practitioner such as a physician, midwife, or nurse practitioner is. Virginia Medicaid reimburses $859 for eight prenatal or postpartum visits plus attendance at delivery, with up to $100 in additional incentive payments for linkage to postpartum and newborn care.
Individual health plans add their own pregnancy perks on top of these benefits. Depending on the plan, extras can include free diapers (up to 300 or 500 count), gift cards for completing prenatal visits, car seats or cribs, and monthly allowances for care products at pharmacies such as CVS.
Children’s Coverage Through EPSDT
Children and adolescents under 21 enrolled in Medicaid or FAMIS Plus get Early and Periodic Screening, Diagnostic and Treatment services, which go beyond standard Medicaid coverage. If a screening identifies a health problem, Medicaid must cover all medically necessary treatment to correct or improve the condition, even when that service is not otherwise listed in the state plan.
EPSDT screenings include comprehensive physical exams, developmental and behavioral assessments, autism screening, vision and hearing tests, lead and anemia testing, immunizations, and dental referrals starting at age two. Sick visits cannot be limited, and prior authorization is not required for screenings or sick visits. Specialized services that may be authorized case by case include assistive technology, private duty nursing, personal care, behavioral therapy including ABA, and medical formula and nutritional services.
Long-Term Services and Supports
Cardinal Care covers long-term services and supports for members who need ongoing help with daily activities such as bathing, dressing, and eating, whether that help is delivered in a nursing facility or at home. Accessing these services requires a screening to determine the level of care needed, and applicants must meet specific income and resource limits. Members receiving long-term care may be required to contribute toward the cost, called “patient pay.”
The Commonwealth Coordinated Care Plus waiver provides community-based services as an alternative to a nursing facility. It serves people of all ages and has no waiting list. Covered services include personal care assistance (both agency-directed and consumer-directed options), respite care, adult day health care, private duty nursing, personal emergency response systems, assistive technology, home modifications, and transition services for people moving from a nursing facility back into the community.
Separate waivers serve people with developmental disabilities: the Building Independence waiver, the Family and Individual Supports waiver, and the Community Living waiver. These do have waiting lists, with slots allocated based on urgency of need.
Rides to Appointments
Non-emergency medical transportation is covered for travel to and from Medicaid-covered appointments. The type of ride depends on your location and medical needs and may include public transit passes, volunteer drivers, gas reimbursement, sedans, vans, taxis, wheelchair-accessible vehicles, stretcher vans, or non-emergency ambulances.
If you’re enrolled in a managed care plan, you call your health plan to arrange a ride. Fee-for-service members use ModivCare (formerly LogistiCare) at 1-866-386-8331 at least five business days before an appointment. Urgent trips with shorter notice can be accommodated when verified. Some health plans also offer additional transportation as a value-added benefit, with covered round trips ranging from 12 to 30 per year depending on the plan.
Extra Benefits That Vary by Plan
On top of standard Medicaid coverage, each of the five managed care plans offers its own value-added benefits. These differ by plan, so it’s worth comparing before choosing one. Examples include:
- A debit card loaded with funds for healthy food, for eligible members
- Home-delivered meals after a hospital or skilled nursing stay, ranging from 14 to 56 meals
- A free smartphone with monthly data, from 4.5 GB up to unlimited
- Education support, including GED cost coverage and test vouchers, up to $500 for higher education or trade school, and up to $250 for ESL classes
- Children’s activities such as swimming lessons, sports physicals, and up to $200 for healthy programs
- Up to $20 per month in period products at CVS
- Up to $200 in reimbursement for non-traditional medicine such as acupuncture
- Tenant legal services for members 18 and older
- Nicotine cessation support through the Quit Now Virginia program
Plan-specific benefit charts are available through the Virginia Managed Care website and the Virginia Cardinal Care mobile app.
What’s Changing in 2027
Beginning in January 2027, Medicaid expansion adults ages 19 to 64 will have to meet new community engagement requirements to keep their coverage. Members will need to complete at least 80 hours per month of work, education, job training, or community service, or earn at least $580 per month (equivalent to 80 hours at the federal minimum wage). Eligibility reviews will shift to every six months instead of once a year.
Broad exemptions apply. Parents or caregivers of children age 13 or younger, pregnant members, people with disabilities, former foster care youth age 25 or younger, and individuals with substance use disorders are among those exempt. Members will receive a notice by the end of September 2026 explaining the requirements and how to document an exemption. Anyone whose coverage is denied or terminated for noncompliance can appeal.