Expanded Medicaid Coverage for Adults

Some Virginia residents who previously exceeded Medicaid income limits, but did not earn enough to qualify for subsidies through the Exchange will now have access to quality, low cost health insurance. Many within this population work in industries, such as construction, child care or retail, that don’t typically offer health insurance coverage.

Medicaid is expanding to provide coverage for:

   Childless Adults    Parent (Family of 3)    Person With Disability
Currently: Not Eligible Eligible with annual income at or below $6,900 Eligible with annual income at or below $9,700
Beginning 2019: Eligible with annual income at or below $17,237 Eligible with annual income at or below $29,436 Eligible with annual income at or below $17,237

Key Initiatives:

  1. Health and Wellness Incentives
  2. Referrals to Workforce Solutions
  3. Appropriate Utilization of ER services

Individuals must meet income requirements which vary by the number of people in their household. For example, a single adult living alone may be eligible if her or his annual income is at or below $16,754 dollars. A parent living with a spouse and a child may be eligible if the total annual income for everyone in the household is at or below $28,677 dollars.

Family Size* Yearly Monthly
(1) $17,237 $1,438
(2) $23,337 $1,946
(3) $29,436 $2,454
(4) $35,536 $2,962
(5) $41,636 $3,470
(6) $47,735 $3,979
(7) $53,835 $4,487
(8) $59,934 $4,995
Additional persons $6,100 $509

* Income requirements vary by household size. Up to 133% of the Federal Poverty Level, including 5% Federal Poverty Disregard.

Optima Health Medicaid XP and Enrollment

Optima Health has branded our expansion population as Optima Health Medicaid XP. However, it’s important to understand that Optima Medicaid Product lines will not change. Those who become members through expansion will be enrolled in the existing Optima Family Care (OFC) or Optima Health Community Care (OHCC).

Upon selecting Optima Health as their MCO, 90% of the new members will be enrolled into OFC. The rest, having preliminarily been categorized as Medically Complex, will be enrolled into OHCC.

Medically Complex Identification

Most enrollees identified as Medically Complex are under a temporary status based upon their response to a Yes/No question during their initial Medicaid application. These members will be enrolled into OHCC.

Medically Complex Confirmation

A health screening will be conducted within 90 days of enrollment to validate the Medically Complex status. Those members who are confirmed as Medically Complex will remain in OHCC and receive enhanced case management services. If they are NOT deemed Medically Complex, they will be reassigned to OFC effective the first of the next month.

Through the Governor’s Access Plan (GAP), adults ages 21-64 with Severe Mental Illness (SMI) will be directly enrolled into OHCC. No application or additional screening will be required.

Your Network Status is Important!

If you are currently in-network for OFC and OHCC, you are already a participating provider for all XP members. No action required.

If you are currently in-network with only one Optima Health Medicaid product, you are only a participating provider for XP members who are enrolled in that specific plan. We encourage you to join both networks to avoid any impact to your reimbursement.

If you do not currently participate in any Optima Health Medicaid products, and want to become a network provider:

  1. Enroll as a DMAS fee-for-service provider at: virginiamedicaid.dmas.virginia.gov
  2. Join the OFC and OHCC Networks

Important: Providers must be in-network with your patient’s originally assigned plan to be reimbursed for services, even if their plan assignment changes after initial enrollment.

Identifying an Optima Health Medicaid XP Member

You can identify members covered under Optima Health Medicaid XP by looking for the following information on the Member ID card:

  1. "MEDICAID XP" is displayed under the plan name, and
  2. "OFC" or "OHCC" is appended to the Group Number, and
  3. The "Cover Virginia" logo is present on the card.
An example of a Member ID card for OFC. Hover your mouse over the image to see the identifying information.
Optima Family Care card with Medicaid XP, Group Number and Cover Virginia logo highlighted.

Medicaid XP Benefits

New enrollees will receive ALL Medicaid standard covered services, including preventive and ARTs program services.

The following added benefits have been mandated through expansion, but were always covered through Optima Health Medicaid plans:

  • Preventive and wellness services
  • Annual wellness exams for adults and children
  • Immunizations
  • Smoking cessation
  • Nutritional counseling
  • See each plan for applicable Added Benefits (OFC)

Take Advantage of the Opportunity to Add New Patients Through Medicaid Expansion!

  • Contract with both OFC and OHCC.  (To confirm your current participation, please contact Optima Health Provider Relations.)
  • Ensure your OFC and OHCC panels are open as soon as possible! To update or confirm your panel status, contact your Network Educator today at 877-865-9075, Option 2.
  • Inform patients who could benefit from Medicaid expansion that Optima Health Medicaid XP may now be available to them.

Common Core Formulary (CCF)

The DMAS Common Core Formulary is the list of preferred drugs all Medicaid health plans are required to cover.

  • Includes 90 common drug classes
  • No additional authorization or restrictions can be required
  • Same set of requirements across all plans, easing provider administrative burden

All Optima Health Medicaid plan formularies adhere to the Common Core Formulary. Access the OFC and OHCC formularies.

Emergency Department Care Coordination (EDCC)

  • Integrates with all hospitals electronic health records statewide
  • Real-time communication and collaboration
  • Providers receive alerts for hospital admissions, discharges, transfers, and care coordination plans
  • HIPAA-compliant
  • Integrated with the Prescription Monitoring Program and the Advance Health Care Directive Registry

Website: https://connectvirginia.org/

Future Initiatives*

  1. Health and Wellness Accounts
  2. Cost-sharing including copayments
  3. Training, Enrollment, Education, Employment and Opportunity Program (TEEOP)
  4. Supportive Employment and Housing Benefit

*Federal approval of § 1115 Demonstration Waiver required.

Need More Information?

Call Optima Health Provider Relations
Medical: 800-229-8822
Behavioral Health: 800-648-8420

Virginia Medicaid Expansion

female doctor and male patient discussing medical information

Access the tools below for detailed provider information about Optima Health Medicaid XP.